Transcript Child Victims of Trafficking - Ohio Suicide Prevention

Why People Die By
Suicide
Thomas Joiner, Ph.D.
The Robert O. Lawton Distinguished
Professor of Psychology
Department of Psychology
Florida State University
[email protected]
On February 1,
2003, the
space shuttle
Columbia
disintegrated
as it flew over
the western
United
States…
… finally
showering
down over
East Texas
and Louisiana
in thousands
of pieces,
killing all
seven crew
members.
The cause was a
dense, dry,
brownish-orange
piece of foam
weighing about 1.7
pounds, 19 inches
long and 11 inches
wide. The foam hit
Columbia’s left
wing traveling 545
mph, causing what
investigators now
know was a
significant breach in
the wing.
One of the members of the panel
investigating the accident said “The
excitement that only exists when there
is danger was kind of gone – even
though the danger was not gone.” Key
NASA administrators decided against
getting in-flight satellite images of the
left wing, in part because their sense
of danger about foam strikes has
eroded over the years, due to repeated
experience with them.
Relevance to Suicide
A key point of my theory is that when people
get used to dangerous behavior – when they
lose “the excitement that only exists when
there is danger” in the words of the accident
investigator – the groundwork for
catastrophe is laid down. Just as NASA
administrators became inured to a very real
danger, to the point of no longer even
worrying about foam strikes, so too, I will
argue, do potentially suicidal people lose
the danger signals and alarm bells that
should accompany self-injury.
The Acquired Ability for Suicide
When self-injury and other dangerous
experiences become “unthreatening
and mundane” – when people work up
to the act of death by suicide by getting
used to its threat and danger – that is
when we might lose them. That is
when they have developed the
acquired ability to enact lethal selfinjury.
A Good Theory
Explains the
heretofore
unexplained….

Why….?
 …. do female physicians and
prostitutes have high rates of suicide?
 …. do suicide rates decrease in times
of national crisis and increase when a
city’s sports team dashes expectations?
 …. have societies across history and
across culture sanctioned ritual
suicide?
Tall Order for a Comprehensive
Theory of Suicide

Not only must the
theory illuminate these
and other questions, it
must also be compatible
with these facts:
Facts
 Suicide rates highest in older




people
… and in men (except in China)
… and in Caucasian people in the
U.S.
Suicide is associated with impulsivity,
yet very few die ‘on a whim.’
Suicide is more associated with
anorexia than with bulimia.
More Facts…
 Completed suicide is relatively
rare – 80 per day die in U.S.,
compared to 1,900 per day from
heart disease.
Sketch of the Theory
Those Who
Desire Suicide
Perceived
Burdensomeness
Those Who Are
Capable of Suicide
Thwarted
Belongingness
Serious Attempt or Death by Suicide
The Acquired Capability to Enact
Lethal Self-Injury
 “It seems rather absurd to say that Cato slew
himself through weakness. None but a strong man
can surmount the most powerful instinct of
nature” – Voltaire.
 Accrues with repeated and escalating
experiences involving pain and provocation,
such as
– Past suicidal behavior, but not only that…
– Repeated injuries (e.g., childhood physical abuse).
– Repeated witnessing of pain, violence, or injury (cf.
physicians).
– Any repeated exposure to pain and provocation.
The Acquired Capability to Enact
Lethal Self-Injury: Habituation
Habituation:
Response
decrement
due to
repeated
stimulation.
The Acquired Capability to Enact
Lethal Self-Injury
With repeated exposure, one
habituates – the “taboo” and
prohibited quality of suicidal
behavior diminishes, and so may
the fear and pain associated with
self-harm.
Relatedly, opponent-processes may
be involved.
The Acquired Capability to Enact
Lethal Self-Injury
Briefly, opponent process theory
(Solomon, 1980) predicts that, with
repetition, the effects of a
provocative stimulus diminish….
habituation in other words.
BUT….
The Acquired Capability to Enact
Lethal Self-Injury
Opponent process theory
also predicts that, with
repetition, the opposite
effect, or opponent process,
becomes amplified and
strengthened.
Example of skydiving.
The Acquired Capability to Enact
Lethal Self-Injury
The opponent process for
suicidal people may be that they
become more competent and
fearless, and may even
experience increasing
reinforcement, with repeated
practice at suicidal behavior.
Why I Jumped by Tina Zahn
 In the midst of a recurrent, very severe
(at times near-catatonic) postpartum
depression, Zahn decided to jump off a
bridge near Green Bay, Wisconsin.
 She fled relatives in her car, who called
police. Police clocked her at 120 mph.
 Still, she is ambivalent, some signs of
which show up in the following video.
The Documentary The Bridge
Photographer saves
someone who is pondering
jumping from the Golden
Gate Bridge.
 Here too, behavioral
indicators of ambivalence.

“Don’t kill your own”:
A rule of nature

It’s the 6th
commandment,
but piranha and
rattlesnakes
know it too, as
did Civil War
soldiers at
Vicksburg.
Anecdotal Evidence: Cobain
 Cobain was temperamentally fearful –
afraid of needles, afraid of heights,
and, crucially, afraid of guns. Through
repeated exposure, a person initially
afraid of needles, heights, and guns
later became a daily self-injecting drug
user, someone who climbed and
dangled from 30 foot scaling during
concerts, and someone who enjoyed
shooting guns.
Anecdotal Evidence: Cobain
 Regarding guns, Cobain initially felt that
they were barbaric and wanted nothing to
do with them; later he agreed to go with his
friend to shoot guns but would not get out
of the car; on later excursions, he got out of
the car but would not touch the guns; and on
still later trips, he agreed to let his friend
show him how to aim and fire. He died by
self-inflicted gunshot wound in 1994 at the
age of 27.
Anecdotal Evidence: Fire Victim
 “I wonder why all the ways I’ve tried to kill myself
haven’t worked. I mean, I tried hanging; I used to
have a noose tied to my closet pole. I’d go in there
and slip the thing over my head and let my weight
go, but every time I started to lose consciousness,
I’d just stand up. I tried to take pills; I took 20
Advil one afternoon, but that just made me sleepy.
And all the times I tried to cut my wrist, I could
never cut deep enough. That’s the thing, your body
tries to keep you alive no matter what you do (italics
added).”
Anecdotal Evidence: Meriwether
Lewis (of Lewis & Clark fame)

From Stephen Ambrose’s biography of
Lewis, Undaunted Courage:
– Lewis paced for several hours (agitation), as
others could hear him all night as the floorboards
creaked.
– Two self-inflicted gunshot wounds, neither fatal.
– Servants found him “busily cutting himself from
head to foot.”
– Lewis said to servants, “I am no coward, but I am
strong, it is so hard to die.” He died a few hours
later.
Suicide in Anorexia Nervosa
 Mortality is extremely high in anorexic
women (SMR = ~60).
 It is an under-appreciated fact that,
should an anorexic patient die
prematurely, the cause of death is more
likely to be suicide than complications
arising from compromised nutritional
status.
Suicide in Anorexia Nervosa
 There are at least two possible
accounts of the high association
between AN and suicide. In one view,
anorexic women die by suicide at high
rates because they are unable to
survive relatively low lethality
attempts and/or they may be less likely
to be rescued after an attempt due to
their socially isolated status.
Suicide in Anorexia Nervosa
 In another view, informed by my
theory of suicidal behavior, anorexic
women die by suicide at high rates
because their histories of selfstarvation habituate them to pain and
inure them to fear of death, and they
therefore make high lethality attempts
with high intent-to-die.
Suicide in Anorexia Nervosa
 We pitted these two accounts against
each other, in a study of 239 women
with AN, followed over ~15 years.
 9 died by suicide, the leading cause of
death among the sample.
 Of these 9, were they mostly highly
lethal methods or not?
Suicide in Anorexia Nervosa

The least lethal method: Ingestion
of 12 oz. of Lysol toilet bowl
cleaner, along with an unknown
amount of a powerful sedative and
alcohol (BAC = 0.16%). Cause of
death was gastric hemorrhaging due
to hydrochloric acid in the Lysol.
Those Who
Desire Suicide
Perceived
Burdensomeness
Those Who Are
Capable of Suicide
Thwarted
Belongingness
Serious Attempt or Death by Suicide
Constituents of the Desire for
Death
Perceived Burdensomeness
Thwarted Belongingness
Perceived Burdensomeness
Essential calculation:
“My death is worth more
than my life to my loved
ones/family/society.”
Perceived Burdensomeness:
Anecdotal Evidence
 Among the Yuit Eskimos of St.
Lawrence Island, to become too sick,
infirm, or old may threaten the
group’s survival (i.e., burden the
group); the explicit and socially
sanctioned solution to this problem is
ritual suicide. The ritual is graphic,
often involving the family members’
participation in the shooting or
hanging of the victim
Perceived Burdensomeness:
Anecdotal Evidence
 Burn victim mentioned earlier: "I felt my
mind slip back into the same pattern of
thinking I'd had when I was fourteen
[when he attempted suicide]. I hate
myself. I'm terrible. I'm not good at
anything. There's no point in me hanging
around here ruining other people's lives.
I've got to get out of here. I've got to figure
out a way to get out of my life."
Perceived Burdensomeness: SelfSacrifice Across Species
Fire ants.
Pea aphids.
Lions.
Spiders
…. even a palm tree.
Strengthening Belongingness
 New CDC vision: Promote connectedness
– The degree to which a person or group is
socially close, interrelated, or shares resources
with other persons or groups
• Between individuals
• Between individuals/families and community
organizations
• Among community organizations and social
institutions
Those Who
Desire Suicide
Perceived
Burdensomeness
Those Who Are
Capable of Suicide
Thwarted
Belongingness
Serious Attempt or Death by Suicide
Constituents of the Desire for
Death
Perceived Burdensomeness
Thwarted Belongingness
Thwarted Belongingness:
Empirical Evidence
 Hoyer and Lund (1993) studied nearly
a million women in Norway; over the
course of a 15-year follow-up, over
1,000 died by suicide. They reported
that women with six or more children
had one-fifth the risk of death by
suicide as compared to other women.
Hoyer, G., & Lund, E. (1993). Suicide among women related to number of
children in marriage. Archives of General Psychiatry, 50, 134-137. .
Thwarted Belongingness:
Empirical Evidence
Twins die by suicide at lower rates
than others despite having slightly
higher rates of mental disorders.
Tomassini et al. (2003). Risk of suicide in twins: 51 year follow up.
British Medical Journal, 327, 373-374 .
Thwarted Belongingness:
Empirical Evidence
 The camaraderie and sense of
belongingness from being a fan
of sports teams can be
considerable, especially under
conditions of success…
Thwarted Belongingness:
Empirical Evidence
 … as many who have lived in
university towns can observe for
themselves when the university wins a
national championship, say, in
football, say in 1993 or 1999.
Thwarted Belongingness:
Empirical Evidence
 It is interesting to consider, then,
whether teams’ success affects
suicidality; from the present
perspective, it might, in that
increased belongingness should be
associated with lower suicidality.
Thwarted Belongingness:
Empirical Evidence
 Several studies have documented
this association.
Joiner, T., Van Orden, K., & Hollar, D. (2006). On Buckeyes, Gators,
the Miracle on Ice, and Super Bowl Sunday: Pulling Together Is
Associated With Lower Suicide Rates. Journal of Social & Clinical
Psychology.
Fernquist, R.M. (2000). An aggregate analysis of professional sports,
suicide, and homicide rates: 30 U.S. metropolitan areas, 1971-1990.
Aggression & Violent Behavior, 5, 329-341.
Steels, M.D. (1994). Deliberate self poisoning - Nottingham Forest
Football Club and F. A. Cup defeat. Irish Journal of Psychological
Medicine, 11, 76-78.
Trovato, F. (1998). The Stanley Cup of Hockey and suicide in Quebec,
1951-1992. Social Forces, 77, 105-126.
Thwarted Belongingness:
Poor Red Sox Fans
Thwarted Belongingness:
Poor Red Sox Fans (Well, Until
2004 and 2007)
 Miracle on Ice,
February 22, 1980
Number of Daily Suicides
100
90
80
70
60
1972
1976
Missing
1980
1978
1984
1982
February 22 (1972-1989)
1988
1986
Missing
D
i
s
t
a
l
F
a
c
t
o
r
s
Those Who
Desire Suicide
Perceived
Burdensomeness
Those Who Are
Capable of Suicide
Thwarted
Belongingness
Serious Attempt or Death by
Suicide
Prevention/Treatment
Implications
The model’s logic is that
prevention of “acquired ability”
OR of “burdensomeness” OR of
“thwarted belongingness” will
prevent serious suicidality.
Belongingness may be the most
malleable and most powerful.
Prevention/Treatment
Implications
Example PSA: “Keep your
old friends and make new
ones – it’s powerful
medicine.”
1-800-273-TALK
Suicidepreventionlifeline.org
Prevention/Treatment
Implications
CBT ->
burdensomeness and
low belonging.
Available at places like amazon.com
Thank you for your attention
[email protected]
Theory-Based Assessment &
Treatment of Suicidal
Behavior
Thomas Joiner, Ph.D.
The Bright-Burton Professor
Department of Psychology
Florida State University
[email protected]
Goals
 Epidemiology
 Risk Factors
 Assessment and Diagnosis (including
in some special populations)
 Therapy foundations
 Crisis resolution
 Choosing and Implementing treatments
Prevalence, Incidence, Morbidity,
Mortality
Each year in the U.S., approximately 30,000
people die by suicide (about 1 every 17
minutes; about 82 per day). ~10th leading cause
of death. More common than death by
homicide. For every completion, there are 25
attempts, for a total of around 750,000 U.S.
attempts per year (not individuals but attempts).
Approx. 5 million people living in the U.S.
have attempted suicide at least once.
Age, Gender, and EthnicityRelated Issues
Overall rate in U.S. is around 10 per
100,000; for people ages 15-24, rate is
similar; rate is highest among people
65+, where rate is 17 per 100,000 and
this is mostly accounted for by white
men (among whom rate is around 37
per 100,000).
Age, Gender, and EthnicityRelated Issues (continued)
Regarding gender, chances of death by suicide
are considerably higher in men than in
women (overall U.S. rates are 19/100,000 for
men, and 5/100,000 for women) – partly a
function of tendency toward violent behavior
(2 of 3 male suicide victims in U.S. die by
firearm; 1 of 3 for women – most common
method for female victims is
overdose/poisoning).
Age, Gender, and EthnicityRelated Issues (continued)
However, chances of attempting
suicide are higher in women
(about 3 times higher). Women’s
attempts are more frequent but
less violent; vice-versa for men.
Age, Gender, and EthnicityRelated Issues (continued)
Age, Gender, and EthnicityRelated Issues (continued)
Regarding ethnicity, in the U.S. suicide has
historically been a “white” problem, but
that has changed somewhat recently,
mostly owing to an increase in AfricanAmerican men (rate is now over 10 per
100,000; used to be under 5 per 100,000;
for African-American women, rate is
around 2 per 100,000 and has not changed
much over time).
Suicide Rates
Historically,
the suicide
rate for
African
Americans
has been
much lower
than that of
most
racial/ethnic
groups.
25
20
15
Native
Amer.
White
10
Black
5
Asian
0
Male
Female
Suicidal Behavior in Context of
Axis I and II Psychopathologies
 Disorders that share features of
burdensomeness, low
belongingness, and acquired ability
(fearlessness, resolve re: suicide)
are most likely to involve
suicidality.
Suicidal Behavior in Context of
Axis I and II Psychopathologies
Mood disorders: Regarding major depression,
estimates are ~10% mortality due to suicide
- may be particularly true for those with
“double depression” (dysthymia + major
depression), and for those comorbid for
major depression and anxiety disorders.
Regarding bipolar disorder, mortality
estimates are 10-15% for bipolar I, same for
bipolar II.
Suicidal Behavior in Context of
Axis I and II Psychopathologies
Anxiety disorders: Mortality estimates
are less clear here (fearfulness is an
issue), but there is risk, one source of
which is comorbidity with major
depression (e.g., GAD and major
depression share genetic risk).
Anxiety can be very painful and can
instill hopelessness.
Suicidal Behavior in Context of
Axis I and II Psychopathologies
Schizophrenia: Mortality
estimate is around 10%, in part
due to delusional self-hatred,
or delusional burdensomeness
(Joiner, Gencoz, Gencoz,
Metalsky, & Rudd, 2001).
Suicidal Behavior in Context of
Axis I and II Psychopathologies
Schizophrenia (continued): In his classic
Dementia Praecox, Bleuler (1911) described
the self-concept of schizophrenic patients as
often including delusions of inferiority,
poverty, and sinfulness. He stated: “The
delusions have the same content as
depression, except that schizophrenia often
tinges them with its own peculiar coloring of
contradiction, incompleteness and
senselessness” (p. 122).
Suicidal Behavior in Context of
Axis I and II Psychopathologies
Schizophrenia (continued): Bleuler cites an
example of a schizophrenic patient who
believes that God has withdrawn from
him through his belly; a second
schizophrenic patient, in explaining a
suicide attempt, stated “All the world’s
murderers wait for me; they cannot die
without me.”
Suicidal Behavior in Context of
Axis I and II Psychopathologies
Substance use disorders: Again,
mortality estimate approaches
10%; here, impulsivity is an
issue.
Suicidal Behavior in Context of
Axis I and II Psychopathologies
Borderline personality disorder:
10% mortality estimate. At least
50% with at least one severe attempt
in the past. Some evidence that past
attempt is more predictive of
completed suicide in this group vs.
other diagnostic group. The
unfortunate reputation for
manipulation/gesturing can misguide
clinicians.
Suicidal Behavior in Context of
Axis I and II Psychopathologies
Antisocial personality disorder:
Somewhat elevated risk, but only for a
proportion. My colleagues and I
recently found that those who
impulsively engage in antisocial
behaviors are at risk; those who are
“Cleckley psychopaths” (e.g., callous,
unemotional) are not.
Suicidal Behavior in Context of
Axis I and II Psychopathologies
 These diagnostic issues are key in terms of
treatment planning – for someone who is
repeatedly suicidal, a therapy that primarily
targets suicidality is probably best;
whereas, for someone who becomes
suicidal for the first time in context of a
major depressive episode, a therapy
primarily targeting depression may be best
(more on this when treatment is discussed).
General Risk Factors – a very long list
 genetics (one candidate gene is the serotonin
transporter gene)
 prenatal stress (maternal influenza plays a possible
role)
 childhood/family factors
 sexual orientation (especially among adolescents)
 whole class of negative life events
 loneliness
 hopelessness (Brown/Beck study)
General Risk Factors – a very long list
(continued)
 previous suicidal experience (acquired
ability)
 emotional pain (termed psycheache by
Shneidman), especially about
burdensomeness and loneliness
 impulsivity
 self-hatred (compare to burdensomeness)
 many Axis I and II diagnoses
Barriers to Risk Assessment
Prodromality
Unaware/Latent Risk
Deceit/Demand
Characteristics
Distillation of Risk Factors
Talking about/planning suicide
(safety planning)
Agitation (benzos)
Insomnia (sleep hygiene)
Nightmares (rescripting)
Marked social withdrawal (list of
300).
– Motivational Interviewing
Distillation of Risk Factors
Two others to consider (but
less strongly):
–Humiliation
–Anger (marked increase)
Distillation of Risk Factors
What’s not listed?
–Sluggishness
• Hopelessness
• Depression
VIP mnemonic
V is for voluntary
hospitalization – mention it.
 I is for intensify treatment –
more frequent, additional
treatments, etc.
 P is for phone check-ins.
More on Risk Categories
 If risk category is Mild-Moderate: possible
actions include more frequent sessions, referral
for adjunctive treatments (e.g., antidepressant
medicines), phone monitoring, incorporation of
family members, “coping card” (discussed in a
moment), provision of crisis hotline numbers,
reminder of emergency contact numbers.
Documentation in progress notes of risk
category and attendant actions is necessary.
More on Risk Categories

If risk category is Severe: actions are similar
to those for Mild-Moderate, but “stepped” up
(e.g., do most or all of these), and voluntary
hospitalization is discussed. Again,
documentation in progress notes of risk
category and attendant actions is necessary.
 If risk category is Extreme: Hospitalization
is enacted.
 Documentation: Just do it every time.
No Suicide Contracts
 What about no suicide contracts?
Agreement to follow “coping card” may
be better, because it tells people what to do
instead of what not to do.
 In one study, 41% of clinicians using
contracts had patients die by suicide or
severely attempt while on contract (Kroll,
2000, Am. J. Psychiat.).
Setting the foundation for
treatment
- Informed consent: confidentiality as
balanced by safety; commitment to
treatment – revisit as needed using
motivational interviewing techniques.
Informed Consent
“If you’re presenting with some form of
suicidality (i.e. suicidal thinking or a suicide
attempt), it’s important to recognize the risks
inherent in treatment, as well as a decision not
to seek treatment. Randomized controlled
trials for the treatment of suicidality have
found re-attempt rates during treatment as
high as 47%, with a number of experimental
treatments significantly reducing the rate of
subsequent attempts by as much as half. The
risk of a suicide attempt during treatment is
greatest for those who have made multiple
suicide attempts (i.e. two or more)…”
Fascinating and Provocative
Approach
“I tell my patients certain actions
are evil - and if you do this - if
you kill yourself or someone else
- I'm going to come after you and
drag you out of hell.”
- quoted (anonymously) from an eminent
psychiatrist.
Fascinating and Provocative
Approach
“My patients - to a man and woman - are both
astonished that a psychiatrist would make a
judgment about good and evil in the present
day and are comforted that someone cares
enough about them and their life to try to do
everything possible to protect and sustain it.
The point is usually being made in the midst
of therapeutic planning and I back it up with
my availability to them during the crisis and
its resolution that has prompted their sense of
despair. Try it, you'll like it.” - quoted
(anonymously) from an eminent psychiatrist.
Risk Factors - Summary
 The list of risk factors is so long
that it can be overwhelming. No
real solution to this problem, but
best approach is to rely on
efficient, objective assessment
framework, to be presented later.
Very Brief Self-Report Measure
A brief self-report measure (Joiner,
Pfaff, & Acres, Behaviour
Research & Therapy, 2002).
Likely similar to other good scales
(e.g., the Beck Suicide Scale), but
many of these are costly; this one
is free.
Very Brief Self-Report Measure
 0 I do not have thoughts of killing myself.
 1 Sometimes I have thoughts of killing myself.
 2 Most of the time I have thoughts of killing
myself.
 3 I always have thoughts of killing myself.
Very Brief Self-Report Measure
 0 I am not having thoughts about suicide.
 1 I am having thoughts about suicide but have
not formulated any plans.
 2 I am having thoughts about suicide and am
considering possible ways of doing it.
 3 I am having thoughts about suicide and have
formulated a definite plan.
Very Brief Self-Report Measure
A cut-off of 3 or above (for the
4 items summed) seemed a
sensible cut-off.
Clinical Anecdote: Near-Lethal Suicide
Attempt
Survivor of Suicide Attempt
 “After she broke up with me, I started thinking
about suicide. That night, I drank 3 or 4 beers
and then got together all my medication, and
just counted out all the pills. I wrote a note to
her and my parents. I took all the pills and just
lay down on the couch. I got scared and
called my mom. I don’t remember anything
after that and the next morning I woke up in
the ER.”
Clinical Anecdote: Completed
Suicide
Suicide Victim’s Journal Entries
 First Entry: I bought a gun the other day. Didn’t buy
ammo, but not too far off. Been obsessing about
my gun.
 Second Entry: I fired my gun today; five rounds. It’s
really loud. Been thinking and dreaming about it
(suicide).
 Third Entry: I really flipped out today; threw my
ammo at someone in public; I know I have to do it
now; there’s no hope for me.
 [person died by self-inflicted gunshot wound 4 days
after this last entry].
Toward a Risk Assessment
Framework
 A General Framework for Suicide Risk
Assessment (Joiner, Walker, Rudd, & Jobes,
1999) will be presented
 Its Goal is to efficiently and objectively
categorize with regard to suicide risk.
 Specific names of categories are less
important than their consistency and their
tie to clinical decision-making.
 I like these 4 categories: None, mildmoderate, severe, and extreme.
Toward a Risk Assessment
Framework
 Two Most Important Areas: History of Previous
Attempt/Fearlessness and Nature of Current Suicidal
Symptoms
 Regarding History of Previous Attempts, our
research shows that people who have a history of 0
or 1 previous attempt are just in a different risk
category than people who have 2 or more attempts.
Regardless of all the other things going on, this one
variable tells you a lot about risk. The multiple
attempters are virtually always in a higher risk
category than their counterparts with 0 or even 1
previous attempt.
Toward a Risk Assessment
Framework
 Two Most Important Areas: History of
Previous Attempt/Fearlessness and
Nature of Current Suicidal Symptoms
 Regarding nature of current suicidal
symptoms, two concepts are important. The
first is what we’ve termed Resolved Plans &
Preparation (Developed Plan for Suicide,
Sense of Courage & Competence to Commit
Suicide, Opportunity, Intensity/Duration of
Ideation).
Resolved Plans & Preparations
 This symptom cluster includes
– Vivid, detailed, long-lasting ideas about suicide
– A sense of competence about suicide
– A sense of fearlessness about suicide.
– Well-developed plans
Dangerous set of symptoms
Toward a Risk Assessment
Framework
 The other concept is what we’ve termed
Suicidal Desire (Desire for Death,
Frequency of Ideas and so on).
 Both of these concepts represent serious
things, but relatively speaking, the
Resolved Plans & Preparation symptoms
are more dangerous than the Suicidal
Desire & Ideation factor.
Desire for Death
 This symptom cluster includes
– Vague and fleeting ideas about suicide
– Statements like “would be better off dead.”
– No well-developed plans
Still worrisome set of
symptoms, but RELATIVELY
less dangerous.
Toward a Risk Assessment
Framework
The idea of the Risk Assessment Framework is
that Other Risk Factors (e.g., Substance
Abuse, Marked Impulsivity, Personality
Disorder, others discussed above) Are
Interpreted In Light of Two Main Areas
Assessment (again, two main areas are
History of Previous Attempt/Fearlessness and
Nature of Current Suicidal Symptoms). This
relieves somewhat the “laundry list”
problem.
The Framework
NOTE: “Other significant finding” means the list of
suicide risk factors, things like severe recent negative
life events, marked hopelessness, deteriorating health,
loneliness, and so on.
“Moderate Risk” refers to risk categories,
such as None, Mild-Moderate, Severe, and Extreme. A
multiple attempter with one other significant finding
would be in the mild-moderate category; a multiple
attempter with two other significant findings would be
in the severe category; a multiple attempter with three
or more other significant findings would be in the
extreme category.
The Framework
Multiple Attempter/Fearless?
Yes
No
Any Other
Significant
Finding = AT
LEAST
Moderate Risk
Elevated on Resolved Plans &
Preparation?
Yes No
Elevated on
Suicidal
Desire & Ideation
Yes
No
Two or More Other Significant
Any Other Significant
Finding = AT LEAST
Moderate Risk
Findings = AT LEAST
Moderate Risk
Low Risk
The Framework

Miscellaneous considerations can be
used for people who are on the “edges”
of categories (social support;
religiosity).
 Framework has to be used together
with common sense.

The framework appears to be
general across populations, with minor
amendments as needed.
More on Risk Categories
 The whole point of risk categories is to
facilitate clinical decision-making.
 If risk category is None: no action necessary,
except determination to monitor risk in case
it does increase (regular progress note to this
effect is good practice).
More on Risk Categories
 The coping card simply involves the
development of a straightforward crisis plan
that can be written down on the back of a
business card, a 3 x 5 index card, or a sheet
of paper. An example would be “When I’m
upset and thinking of suicide, I’ll take the
following steps:
More on Risk Categories
 The coping card (cont).: 1) use what I’ve learned in
therapy to try to identify what is upsetting me; 2)
write down and review some reasonable, nonsuicidal responses to what is bothering me; 3) try to
do things that, in the past, have made me feel better
(e.g., talking to , music, exercise, etc.); 4) if the
suicidal thoughts continue and get specific, or I find
myself preparing for suicide, I’ll call the emergency
call person at (phone number; xxx-xxxx) or 1-800273-TALK; 5) if I feel that I cannot control my
suicidal behavior, I’ll go to the emergency room or
call 911.”
More on Risk Categories

If risk category is Severe: actions are similar
to those for Mild-Moderate, but “stepped” up
(e.g., do most or all of these), and voluntary
hospitalization is discussed. Again,
documentation in progress notes of risk
category and attendant actions is necessary.
 If risk category is Extreme: Hospitalization
is enacted.
 Documentation: Just do it every time.
No Suicide Contracts
 What about no suicide contracts?
Agreement to follow “coping card” may
be better, because it tells people what to do
instead of what not to do.
 In one study, 41% of clinicians using
contracts had patients die by suicide or
severely attempt while on contract (Kroll,
2000, Am. J. Psychiat.).
Previous Treatment Research
The controlled studies on
psychotherapy converge on the
finding that techniques involving
CBT and problem-solving are safe,
effective, and indicated.
Setting the foundation for
treatment
- Informed consent: confidentiality as
balanced by safety; commitment to
treatment – revisit as needed using
motivational interviewing techniques.
Some Points about Therapeutic
Relationship

a) explain that therapy relationship is a
real relationship, and that suicidality is
often interpersonally triggered in real
relationships (e.g., perceived rejection)
– discussing this openly will be
important; b) expect to be provoked; c)
consider tendency for “help negation”
(Rudd, Joiner, & Rajab, 1995).
An empirically validated
treatment for resolving suicidal
behavior (cont.)
“Assume a virtue if you have it not,
for use can almost change the stamp
of nature.”
- From Shakespeare’s Hamlet
An empirically validated treatment
for resolving suicidal behavior
(book by Rudd, Joiner, & Rajab,
2000)
 Module/Session “1”: Main goals are to
establish risk category (using techniques
described earlier), to diagnose on Axis I and II
(recall material on this described earlier),
provide diagnostic feedback, and to diffuse
crisis and lessen most troubling symptom or
two.
An empirically validated
treatment for resolving suicidal
behavior (cont.)
 Session 1 (continued): How to give standardized diagnostic







feedback
Basic Steps:
1) Introduce your agenda of providing diagnostic feedback
2) Verbally reflect the main symptoms they have reported
3) Tell them the name for the disorder they are experiencing,
and provide information about that disorder
4) Assure them that we know a lot about treatment for the
disorder
5) Advise them to guard against misinformation regarding the
diagnosis
6) Answer any diagnostic questions that they have
An empirically validated
treatment for resolving suicidal
behavior (cont)
 "(step 1) Now that I have a sense of what has brought
you here for treatment, I want to discuss your diagnosis.
(step 2) You told me that recently you've been
experiencing these symptoms, ____ and ____, and that
you've been feeling ____ and ____. These symptoms
and feelings cluster together into a syndrome. (step 3)
There's a name for the syndrome that you've described,
and it's called _____. This syndrome typically consists
of symptoms like ___ and ____. People with this
disorder typically feel like _____ [use the DSM for
support during step 3. You may include additional
information about course of the disorder if you desire].
An empirically validated
treatment for resolving suicidal
behavior (cont.)
 We know a lot about this syndrome, both scientifically
and clinically. (step 4) We also know a lot about how to
treat this disorder effectively. (step 5) There is a lot of
information available about this disorder. However, I'd
like to caution you that much of the information you
will find about this disorder (online, from a friend, or in
a bookstore) may be incorrect. However, at this clinic,
we know a lot about your syndrome, and I will be
happy to give you as much information as you desire
and help you to find good sources of information about
the disorder. (step 6) Do you have any questions about
your diagnosis?"
An empirically validated
treatment for resolving suicidal
behavior (cont.)
 Session 1 (continued): Crisis resolution
can be accomplished by plugging the
crisis into the coping card, described
earlier. Coping card also gives plan for
what to do if suicidality escalates.
An empirically validated
treatment for resolving suicidal
behavior (cont.)
 Session 1 (continued): Symptoms can
be targeted by having patients list the
several feelings, thoughts, experiences,
etc., that are most troubling to them,
and rating each on a scale of 1 to 10
(with 10 most severe).
An empirically validated
treatment for resolving suicidal
behavior (cont.)
 Session 1 (continued): For the top two or so
symptoms (e.g., sadness, loneliness, sleep
problems, anxiety), recommend simple,
straightforward things that “won’t
necessarily solve the whole problem, but
will take the edge off; this will make you
more comfortable so that later, we’ll be able
to get to the root problem.”
An empirically validated
treatment for resolving suicidal
behavior (cont.)
 Session 1 (continued): Commonly
recommended things are behavioral
activation/pleasant activities (listening
to music, seeing movies, taking a walk,
calling a friend), sleep hygiene,
exercise, and elicitation of social
support (Linehan lists > 200).
An empirically validated
treatment for resolving suicidal
behavior (cont.)
Sessions 2 & 3: Assess risk;
review treatment log; review use
of coping card. Main additional
tasks are introduction of the
Suicidal Thought Record and a
description of the suicidal cycle.
An empirically validated
treatment for resolving suicidal
behavior (cont.)
 Sessions 2 & 3 (continued): The Suicidal
Thought Record is a way for patients to learn
on their own about the suicidal cycle; i.e.,
about the interconnections between situations,
what they’re thinking and feeling, and their
suicidal behavior. Filling one or more out in
session, and discussing then and there, is a
quick way to impart the basics.
An empirically validated
treatment for resolving suicidal
behavior (cont.)
 Sessions 4 and beyond: The rest of the work
involves in-session and between-week
– problem-solving;
– cognitive restructuring;
– and emotion regulation work
• all on the material from the Suicidal
Thought Record.
An empirically validated
treatment for resolving suicidal
behavior (cont.)
So, week in and week out,
problem-solving, cognitive, and
emotion regulation techniques are
taught, applied to real life
situations, applied to the
therapeutic relationship, written
about in the treatment log, and so
forth.
An empirically validated
treatment for resolving suicidal
behavior (cont.)
“Assume a virtue if you have it not,
for use can almost change the stamp
of nature.”
- From Shakespeare’s Hamlet
An empirically validated
treatment for resolving suicidal
behavior (cont.)
Sessions 4 and beyond
(continued): The problem-solving
technique essentially amounts to the
coping card, referred to already.
An empirically validated
treatment for resolving suicidal
behavior (cont.)
 Sessions 4 and beyond (cont.): For emotion
regulation, problem-solving and cognitive
approaches are emotion regulation techniques. Also,
mood graphs are useful ways to teach people about
how “bad feelings do not last forever.” Just by
waiting, bad feelings tend to lessen (and they lessen
even more quickly when they are addressed with
problem-solving and cognitive techniques). “Bad
feelings do not last and are changeable” becomes a
mantra of therapy.
An empirically validated
treatment for resolving suicidal
behavior (cont.)
 Sessions 4 and beyond (continued): Cognitive
restructuring, The ICARE approach:

I for Identify – identify the negative thought.

C for Connect – connect the negative thought to
the type of distortion it represents.

A for Assess – assess the thought, asking “what
objective evidence supports this thought?” “What
evidence refutes it?”
An empirically validated
treatment for resolving suicidal
behavior (cont.)
 Sessions 4 and beyond (continued): Cognitive
restructuring, The ICARE approach:

R for Restating – restate the thought in more
reasonable terms; often this involves removing the
cognitive distortion from “C for Connect.”

E for Execute – act as if the restated belief
were true.
An empirically validated
treatment for resolving suicidal
behavior (cont.)
“Assume a virtue if you have it not,
for use can almost change the stamp
of nature.”
- From Shakespeare’s Hamlet
Pulling It All Together
- Toward
an algorithm for
choosing and timing
treatments
Pulling It All Together
- If suicidality is primary, essentially regardless
of what’s going on on Axes I/II, then a
treatment focused on suicidality is indicated,
for the simple reasons of decreasing
dangerousness, and the fact that progress
with regard to suicidality (e.g., using
problem-solving, emotion regulation,
cognitive restructuring) is very likely to
benefit whatever else is going on
diagnostically (e.g., mood or anxiety
disorder; personality disorder).
Pulling It All Together
- If
suicidality is primary (cont.):
Once suicidality has receded, reevaluate and then target remaining
symptoms, using the logic
described next.
Pulling It All Together
If suicidality is secondary to Axis I or II
disorder, then a treatment focused on
suicidality is probably not indicated (but
remains a defensible choice, because of
dangerousness, and the fact that progress with
problem-solving, emotion regulation,
cognitive restructuring, etc. will benefit Axis I
and II disorders). Might be better to regularly
monitor to suicidality, and to institute
diagnosis-based treatments, and once targeted
disorders have receded, re-evaluate and then
target any remaining suicidal symptoms,
using treatments focused on suicidality.
Thank You!
[email protected]