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Beyond Intent, Plan, and Access to Means: Basic

Interventions for Advanced Assessments

REAL LIFE CRISIS WORKERS WITH A NERDY STREAK

SUICIDE/DEPRESSION SCREENING TOOLS

! ACORN

! COLUMBIA SUICIDE SCREENING

! SAFE-T ! PHQ-9

! ASQ

! SAD PERSONS

! Beck Hopelessness Scale

! AND MORE

ALERT TO RISK BUT DON’T RESOLVE SITUATION

Our focus today is to introduce or review interventions that will aid the clinician in

having a collaborative conversation with the client. These conversations are vital in understanding the critical details of an

individual’s suicidal crisis and leading to an appropriate and safe outcome.

GOALS FOR SUICIDE ASSESSMENTS

! We have found that most suicide assessments in our world have two goals: ! Determining the current degree of risk based on history, current symptoms/

behaviors, and demographics ▪ Static verses dynamic risk factors

! Swiftly building a therapeutic alliance with the client that may provide enough short-term relief from their pain to avoid hospitalization and safely carry them to the next stage of treatment

Barriers to Suicide Assessments

! The assessor’s mental state

! Arousal

! Vicarious trauma

! Countertransference

! The Suicidal Patient and Countertransference Hate by John Malsberger and Daniel Buie (1974)

! Sparse information

! Little is known about the client due to a lack of records or people to interview

! Client, friends, or family can have a difficult time remembering details

! Because they weren’t important, memory loss due to trauma (physical or emotional), due to natural forgetting, due to an individual being “activated” (mid-brain vs. frontal lobe)


! Secondary Gains

! Clients, their friends, and their family can have secondary gains, such as:

! Emotional needs

! Physical needs

! Protectiveness (client’s protecting someone and vice versa)

! Client is guarded or misrepresenting information

! Due to shame

! Stigma

! Cultural attitudes

! Psychosis and paranoia

! High intent to suicide

Interventions with the client – The fluidity of the assessment.

Rapport building, assessing, and moving at the same time.

“I believe the greatest gift I can conceive of having from anyone is to be seen by them, heard by them, to be understood and touched by them” – Virginia Satir

“In my early professional years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth?”

– Carl Rogers

3:00 am in the Emergency Room

Assessor’s Attitude and Presentation

! Cash Metaphor – Build credit to spend later ! Gentle and unconditional positive regard vs. detached

information gathering ! Calm demeanor, calm voice

! Acknowledging the client’s experience while advocating for change

Relationship Building Interventions

! Slow it down! Time is your friend. ! Reflective listening/empathic reflection ! Affirming for change. Acknowledge the difficulty of the

client’s situation and affirm feelings but then advocate for change

! Genuineness ! Open ended questions

Information Gathering and Clinical Conceptualization Interventions

! Shame Attenuation

! Phrasing questions, the answers to which, help to alleviate any possible judgement. The question is asked from the client’s own framework and rationale

! Example: “That sounds really lonely. With all those feelings of loneliness, have you ever considered killing yourself?”

! Gentle Assumptions

! Asking as if a given behavior has occurred as opposed to asking whether or not it has occurred

! Example: “How many times have you tried to suicide in the past?” vs. “Have you ever tried to suicide?”

! Also, looking for subtle assumptions the client may be making (“The last time this happened, it never got this out of hand”)


! Normalization

! Helping the client feel “normal” by placing their experience in perspective with others who have had similar experiences

! Example: “Sometimes when people talk about feeling hopeless or about death, they are thinking about suicide. Are you having thoughts of suicide?”

! Symptom Amplification

! Limiting a client’s tendency to minimize certain behaviors by setting an overstated upper limit

! Example: “How much alcohol do you drink daily? A fifth? A half-gallon?”

! Setting the upper limit helps to address possible reluctance to share information due to fear of judgement and helps to make the conversation seem like it’s more commonplace


! Denial of Specific

! Soliciting information which can only have a binary (yes/no) response

! Example: “How many drugs have you used?” vs “Have you ever used THC? Meth? Heroin?”

! Behavioral Incident

! Ask the client about the concrete details of the suicide attempt while avoiding emotional or interpretive accounts

! Focus on the concrete events and drilling down to the specifics of what happened ! At what point did you decide you were going to kill yourself ! What thoughts did you have when you decided to kill yourself? ! Did you harm yourself with the intention of killing yourself? What was your goal in trying to harm yourself? ! How were you discovered/who called for help? ! How long had you been thinking about killing yourself? Have you been thinking about doing this for a while

or was this something you thought of in the moment? ! Was anyone else with you when you tried to kill yourself? ! What was the means by which you tried to kill yourself? Exactly how and in what way?

! Identify the number of pills, the speed of the car, the height of the bridge, the strength of the rope/the hanging apparatus, or the depth/extent of the cuts

! Lesser lethality means DOES NOT necessarily mean lower level risk of suicide ! “and then what happened?”


! Identifying Causal Factors

! Determining the events and circumstances which have initiated the crisis

! Example: “What happened TODAY that brought you in to the Emergency Department?” “When did you decide to kill yourself?”

! Shae’s CASE Model: Chronological Assessment of Suicide Events


! Cross Referencing Information

! Comparing information from all sources, including:

! Client and collateral reports

! HIPAA

! https://www.hhs.gov/hipaa/for-professionals/faq/505/what-does-the-privacy-rule-allow-covered-entities-to-disclose-to-law-enforcement-officials/index.html

! Historical records

! Verbal and non-verbal clues

! Finding discrepancy and determining validity

! Internal Validity – The client’s account makes sense with other elements of their account

! External Validity – The client’s account makes sense with other known facts and accounts about the case

https://www.hhs.gov/hipaa/for-professionals/faq/505/what-does-the-privacy-rule-allow-covered-entities-to-disclose-to-law-enforcement-officials/index.html




Internal Validity – Does the article make sense with itself? External Validity – Does the article make sense with other articles?


! Leveling with the Client

! Helping the client make an informed decision by giving them an account of the current situation, possible choices, and the impact of their choices

! Can be helpful if client is “stonewalling” or not providing any information

! Example: “I want to help you but if we’re not able to figure out what happened then we might be obligated to hold you in the emergency department until we can make sure you’re safe”

!NO THREATENING!!!

! Non-Confrontational Resolution of Discrepancy

! Making sense of facts which seem inconsistent or contradictory while maintaining therapeutic rapport

! Example: “Help me understand” or “I’m confused”

Information Gathering and Clinical Conceptualization Skills


! Scaling Questions

! Assertive Consultation

! Consult, consult, consult, then document

! Wake ‘em up, interrupt the meeting, make the phone call

! Consultation is like looking at the blind spot in your car. If you’re only looking through your own vantage point without changing your perspective, it’s more likely something will be missed in your blind spot

! Observe Countertransference

! Countertransference is evidence.

! Does something feel off? Not adding up? Look into it.

Interventions to Promote Client Change

!Compliments/encouragement

!Reducing cognitive constriction by helping the client to envision alternatives besides suicide

!Reducing cognitive fusion

! You are not your thoughts

!Miracle Question

!Coping Question

! How do you cope?

!Find exceptions to the problem

!Have there ever been times when the problem was less difficult than it is now?

!Eliciting change talk

!Eliciting self-motivating statements to build self-efficacy

!Develop discrepancy and highlight ambivalence

!Part of you wants to be done but I also sense that part of you…


10 Commonalities in the Majority of Suicides (Shneidman)

! The common goal of suicide is cessation of consciousness

! The common purpose of suicide is to seek a solution

! The common stimulus of suicide is unbearable psychological pain

! The common stressor in suicide is frustrated psychological needs

! The common emotion in suicide is hopelessness-helplessness

! The common cognitive state in suicide is ambivalence

! The common perceptual state in suicide is constriction

! The common action in suicide is escape

! The common interpersonal act in suicide is communication of intention

! The common pattern in suicide is consistency of lifelong styles

! General psychoeducation about distress tolerance and coping skills

! Accepting distressing emotions or sensations

! Example: “You don’t have to like it but that’s the way it is” or “It doesn’t make it right, it makes it real”

! Grounding techniques

! Counting tiles on the floor, listing as many states as they can remember, finding colors in the room, etc.

! Regulation of the nervous system

! Diaphragmatic breathing, progressive muscle relaxation, guided meditation, yoga, a warm bath, exercise, etc.

! Distraction techniques

! Focusing on “no emotion lasts forever”

! Watch TV, read a book, listen to music, play a board game, talk to a friend, go shopping, etc.


Interventions with the System

! Advocacy for the client

! With police, with the hospital, with inpatient treatment, with family, etc.

! Find resources within community ! Navigating systems with/for the client

! Insurance coverage and programs

! OHP presumptive Advocacy does not require knowing it all.

! Psychoeducation about suicide, educating individuals about suicide, planning with family and friends about suicidal risk, etc

Selected Bibliography

! AMSR Task Force (2014). Assessing and Managing Suicidal Risk: Core Competencies for Behavioral Health Professionals [Training Manual]. Developed by the Suicide Prevention Resource Center Education Development Center

! Linehan, M. (1993). Special Treatment Strategies for Crisis and Suicidal Behaviors. In Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: The Guilford Press.

! Malsberger, J., & Buie, D. (1974). The Suicidal Patient and Countertransference Hate. Archive of General Psychiatry, 30(5), 625-633.

! Pisani, A. R., Murrie, D. C., & Silverman, M. M. (2015). Reformulating Suicide Risk Formulation: From Prediction to Prevention. Academic Psychiatry.

! Podolak, E. (2015). Suicide Risk Assessment: Searching for True Positive. International Journal of Adolescent Medicine and Health, 27(2).

! Roos, L., Sareen, J., & Bolton, J. M. (2013). Suicide Risk Assessment Tools, Predictive Validity Findings and Utility Today: Time for a Revamp? Neuropsychiatry, 3(5).

Selected Bibliography

! Shea, S. C. (2011). The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors. Lexington, KY: Mental Health Presses.

! Shea, S. C. (2017). Psychiatric Interviewing: The Art of Understanding: A Practical Guide for Psychiatrists, Psychologists, Counselors, Social Workers, Nurses, and Other Mental Health Professionals. New York: Elsevier

! Shea, S. C. (2009). Uncovering Suicidal Intent: A Sophisticated Art and Using the Chronological Assessment of Suicide Events (CASE Approach). Psychiatric Times, 26(12).

! Shneidman, E. S. (1998). The Suicidal Mind. New York: Oxford University Press. ! Suicide Prevention Resource Center. Counseling on Access to Lethal Means

[Online Training Module]. https://training.sprc.org/enrol/index.php?id=20

https://training.sprc.org/enrol/index.php?id=20

https://training.sprc.org/enrol/index.php?id=20

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