Transcript Dr. Firestone`s Presentation

Suicide: The Silent Epidemic
A Clinical Focus on Students
Lisa Firestone, PhD
The Glendon Association
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Suicide Rates by Age for Youths Aged 10-19 Years
in the United States, 2000-2006 [8]
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Epidemiology of Youth Suicide and Suicidal Behavior ,Scottye J. Cash, Ph.D. and Jeffrey A. Bridge, Ph.D.
Curr Opin Pediatr. 2009 October ; 21(5): 613–619
Number of Youth Suicides, by Gender: 2009
California
Number
Female
83
Male
304
Total
387
Definition: Number of suicides by youth ages 15 - 24, by gender.
Data Source: California Department of Public Health, Center for Health Statistics, Vital Statistics Section, CD-Rom Public Use
Death Files.
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Youth Suicide Rate: 1995-1997 - 2007-2009
Definition: Number of suicides per 100,000 youth age 15 - 24.
Data Source: California Department of Public Health, Center for Health Statistics, Vital Statistics Section, CD-Rom Public Use Death
Files. State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, 1990-1999, 2000-2050, accessed
online at http://www.dof.ca.gov (August 2011).
Footnote: Figures are presented as rates over three-year periods. LNE (Low Number Event) refers to data that have been
suppressed because there were fewer than 20 suicides.
8
Self-Inflicted Injury Hospitalization Rate: 2009
Definition: Number of non-fatal self-inflicted injury hospitalizations per 100,000 for children/youth ages 5 - 20.
Data Source: State of California Department of Public Health, Epidemiology and Prevention for Injury Control Branch, California
Office of Statewide Health Planning and Development, Patient Discharge Data. Accessed online
athttp://epicenter.cdph.ca.gov/; State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail,
1990-1999, 2000-2050. Accessed online at http://www.dof.ca.gov (May 2011).
Footnote: Injury hospitalizations are measured by the number of discharges from acute care hospital facilities for injuries among
children and youth. The most common types of self-inflicted injuries are related to poisoning, and cutting or piercing. LNE (Low
Number Event) refers to data that have been suppressed because there were fewer than 20 cases in the numerator.
9
Number of Youth Suicides, by
Race/Ethnicity: 2009
California
Number
African American/Black
25
Asian/Pacific Islander
36
Caucasian/White
173
Hispanic/Latino
134
Native American/Alaska Native
7
Multiracial
11
Total
387
Data Source: State of California Department of Public Health, Epidemiology and Prevention for Injury Control Branch,
California Office of Statewide Health Planning and Development, Patient Discharge Data. Accessed online
athttp://epicenter.cdph.ca.gov/; State of California, Department of Finance, Race/Ethnic Population with Age and Sex
Detail, 1990-1999, 2000-2050. Accessed online at http://www.dof.ca.gov (May 2011).
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Suicide Figures from the Centers for Disease Control for the year 2009.
All rates are per 100,000 population.
11
Suicide Figures from the Centers for Disease Control for the year 2009.
All rates are per 100,000 population.
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Why is this topic important?
• Suicide is the third leading cause of death for youth ages 10-24
nationwide.
• In 2009, 6.3% of U.S. 9th-12th-graders reported having attempted
suicide one or more times in the past year.
• Approximately 149,000 young people ages 10-24 are treated for selfinflicted injuries at U.S. emergency departments every year.
• According to data collected by the National Center for Injury
Prevention and Control, poisoning is the most common reason for
intentional, self-inflicted, non-fatal injury hospitalizations for 10- to 24year-olds.
• Self-injurious behavior, in general, often is stigmatized and hidden
from family and friends.
Data Source: State of California Department of Public Health, Epidemiology and Prevention for Injury Control Branch,
California Office of Statewide Health Planning and Development, Patient Discharge Data. Accessed online
athttp://epicenter.cdph.ca.gov/; State of California, Department of Finance, Race/Ethnic Population with Age and Sex
Detail, 1990-1999, 2000-2050. Accessed online at http://www.dof.ca.gov (May 2011).
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ED Treatment of
Mental Disorders
One in ten suicides are by people
seen in the ED within two months of
dying.
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Suicide in Adolescents
• A previous suicide attempt increases suicide risk by 38-40
times.
• Forwood et al. (2007) reported that a suicide attempt is
likely to be highest among youth presenting with a
combination of depression and externalizing behavior
and those with a romantic breakup, being assaulted, or
being arrested.
• More than 90% of adult suicide attempters and 80% of
adolescent attempters and completers communicate
suicidal ideation prior to the attempt.
• Adolescents with prior attempts are 18x more likely to
make future attempts.
• Half of the youth who attempt suicide do not receive
treatment beyond psychotropic medication.
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Suicide in College Students
• Self-reports of suicidal ideation in college students have
ranged from 32% to 70%.
• It is estimated that there are 1100 suicides on college
campuses in the US each year
• Suicide is the second leading cause of death in collegeage students.
• One in 12 college students have seriously contemplated
suicide.
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Implications of Epidemiological
Data
• There is a need to intervene early
in the development trajectory of
the depression and suicidal
behavior.
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The Melissa Institute for Violence Prevention
Misconceptions About Suicide
•
Most suicides are caused by one particular trigger
event.
•
Most suicides occur with little or no warning.
•
It is best to avoid the topic of suicide.
•
People who talk about suicide don't do it.
•
Nonfatal self-destructive acts (suicide attempts) are
only attention-getting behaviors.
•
A suicidal person clearly wants to die.
•
If a person who has been depressed is suddenly
feeling better, the danger of suicide is gone.
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Our Approach to Suicide
Each person is divided:
•One part wants to live and is goal directed and life affirming.
• And one part is self-critical, self-hating and at its ultimate end, selfdestructive. The nature and degree of this division varies for each individual.
Real Self - Positive
Anti-Self - Critical
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Our Approach to Suicide
Negative thoughts exist on a continuum, from mild self-critical
thoughts to extreme self-hatred to thoughts about suicide
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Our Approach to Suicide
Self-destructive behaviors exist on a continuum from self-denial to
substance abuse to actual suicide.
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Our Approach to Suicide
There is a relationship between these two continuums. How a person
is thinking is predictive of how he or she is likely to behave.
Thoughts
Event
Feelings
Behavior
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Definition of the Voice
The critical inner voice refers to a well-integrated pattern of destructive
thoughts toward our selves and others. The “voices” that make up this
internalized dialogue are at the root of much of our maladaptive behavior.
This internal enemy fosters inwardness, distrust, self-criticism, self-denial,
addictions and a retreat from goal-directed activities. The critical inner
voice effects every aspect of our lives: our self-esteem and confidence,
our personal and intimate relationships, and our performance and
accomplishments at school and work.
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Where Do Critical Inner Voices Come From?
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How Voices Pass From
Generation to Generation
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Attachment Theory
Sir John Bowlby, Ph.D.
Harry Harlow, Ph.D.
Rene Spitz, M.D
Mary Ainsworth, Ph.D.
Mary Main, Ph.D.
Erik Hesse, Ph.D.
Adult Attachment Interview:
predicts the baby’s attachment to
the parent with 80% accuracy before
the baby is even born
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Where do voices come from?
Patterns of Attachment in Children
Category of Attachment
Parental Interactive Pattern
 Secure
 Emotionally available, perceptive,
responsive
 Insecure – avoidant
 Insecure- anxious/ambivalent
 Insecure - disorganized
 Emotionally unavailable, imperceptive,
unresponsive and rejecting
 Inconsistently available, perceptive and
responsive and intrusive
 Frightening, frightened, disorienting,
alarming
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Attachment Figures
• Low Risk Non-Clinical Populations
 Secure
55-65%
 Ambivalent
5-15%
 Avoidant
20-30%
 Disorganized
20-40%
• (Given a Best Fit Alternative)
• High Risk, Parentally maltreated
 Disorganized
80%
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What causes insecure attachment?
 Unresolved trauma/loss in the life of the parents
statistically predict attachment style far more than:
 Maternal Sensitivity
 Child Temperament
 Social Status
 Culture
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Implicit Versus Explicit Memory
 Implicit Memory
 Explicit Memory
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How does disorganized attachment
pass from generation to generation?
 Implicit memory of terrifying experiences may
create:
 Impulsive behaviors
 Distorted perceptions
 Rigid thoughts and impaired decision making
patterns
 Difficulty tolerating a range of emotions
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The Brain in the Palm of Your Hand
Daniel Siegel, M.D. – Interpersonal Neurobiology
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9 Important Functions of the
Pre-Frontal Cortex
1.
2.
3.
4.
5.
6.
7.
8.
9.
Body Regulation
Attunement
Emotional Balance
Response Flexibility
Empathy
Self-Knowing Awareness
(Insight)
Fear Modulation
Intuition
Morality
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“Type D” Attachment
Disorganized/Disoriented
Predicts later chronic disturbances of:
– affect regulation
– stress management
– hostile-aggressive behavior
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Infant’s Response to Trauma
Two sequential response patterns:
– hyperarousal
– dissociation
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Poly-Vagal Theory
-Stephen Porges, 2007
Environment
Inside the Body
Outside the Body
Neuroception
(Vagus Nerve)
Nervous System
Safety
Danger
Life Threat
Reactivity
Receptivity
Spontaneously
engages others
Eye contact,
Facial expression
Defensive Strategies
Fight/ Flight
behaviors
Defensive Strategies
Death feigning
Shut down
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(Immobilization)
Division of the Mind
Parental Ambivalence
Parents both love and hate themselves
and extend both reactions to their
productions, i.e., their children.
Parental Nurturance
Parental Rejection, Neglect Hostility
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Prenatal Influences
Disease Trauma
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Substance Abuse/ Domestic Violence
Birth
Trauma
Baby
Genetic
Structure
Temperament
Physicality
Sex
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Self-System
Parental Nurturance
Unique make-up of the individual
(genetic predisposition and
temperament); harmonious identification
and incorporation of parent’s positive
attitudes and traits and parents positive
behaviors: attunement, affection,
control, nurturance; and the effect of
other nurturing experience and
education on the maturing self-system
resulting in a sense of self and a greater
degree of differentiation from parents
and early caretakers.
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Personal Attitudes/
Goals/Conscience
Realistic, Positive Attitudes Toward Self
Behavior
Realistic evaluation of talents, abilities,
etc…with generally positive/
compassionate attitude towards self
and others.
Ethical behavior
towards self and others
Goals
Needs, wants, search for
meaning in life
Moral Principles
Goal Directed
Behavior
Acting with
Integrity
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Anti-Self System
Unique vulnerability: genetic predisposition and temperament
Destructive parental behavior: misattunement, lack of affection, rejection,
neglect, hostility, over permissiveness
Other Factors: accidents, illnesses, traumatic separation, death anxiety
The Fantasy Bond (core defense) is a
self-parenting process made up of
two elements: the helpless, needy
child, and the self-punishing, selfnurturing parent. Either aspect may
be extended to relationships. The
degree of defense is proportional to
the amount of damage sustained
while growing up.
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Anti-Self System
Self-Punishing Voice Process
Voice Process
Behaviors
1. Critical thoughts toward self Verbal self-attacks – a
generally negative attitude
toward self and others
predisposing alienation.
Source
Critical parental attitudes,
projections, and
unreasonable
expectations.
2. Micro-suicidal injunctions
Addictive patterns. Self-punitive
thoughts after indulging.
Identification with parents
defenses
3. Suicidal injunctions –
suicidal ideation
Actions that jeopardize, such as
carelessness with one’s body,
physical attacks on the self,
and actual suicide
Parents’ covert and overt
aggression (identification
with the aggressor).
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Anti–Self System
Self- Soothing Voice Process
Behaviors
Source
1. Self-soothing
attitudes
Self-limiting or selfprotective lifestyles,
Inwardness
Parental over protection,
imitation of parents’
defenses
2. Aggrandizing
thoughts toward self
Verbal build up toward
self
Parental build up
3. Suspicious paranoid
thoughts toward
others.
Alienation from others,
destructive behavior
towards others.
Parental attitudes, child
abuse, experienced
victimization.
4. Micro-suicidal
injunctions
Addictive patterns.
Thoughts luring the
person into indulging.
Imitation of parents’
defenses.
5. Overtly violent
thoughts
Aggressive actions,
actual violence.
Voice Process
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Parental neglect,
parents’ overt aggression
(identification with the aggressor).
How does a Suicide Occur?
Underlying Vulnerability
e.g. Mood disorder/Substance abuse/
Aggression/ Anxiety/Family history/Sexual
orientation/Abnormal serotonin metabolism
Stress Event
(often caused by underlying condition)
e.g. In trouble with law or school/Loss
Acute Mood Change
Anxiety/Dread/Hopelessness/Anger
Inhibition
e.g. Strong taboo/Available
support/Slowed down mental
state/Presence of others/Religiosity
Survival
Facilitation
e.g. Weak taboo/ Method weapon available/
Recent example/State of excitation agitation/
Being alone
Suicide
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Continuum of Negative
Thought Patterns
Thoughts that lead to low-self-esteem or inwardness (self-defeating thoughts):
Levels of Increasing Suicidal Intention
Content of Voice Statements
1. Self-depreciating thoughts of
everyday life
You’re incompetent, stupid. You’re not very
attractive. You’re going to make a fool of
yourself.
2. Thoughts rationalizing self-denial;
thoughts discouraging the person
from engaging in pleasurable
activities
You’re too young (old) and inexperienced
to apply for this job. You’re too shy to make
any new friends. Why go on this trip? It’ll be
such hassle. You’ll save money by staying
home.
3 Cynical attitudes towards others,
leading to alienation and distancing
Why go out with her/him? She’s cold,
unreliable; she’ll reject you. She wouldn’t go
out with you anyway. You can’t trust
men/women.
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Continuum of Negative
Thought Patterns
Thoughts that lead to low-self-esteem or inwardness (self-defeating thoughts):
Levels of Increasing Suicidal Intention
Content of Voice Statements
4. Thoughts influencing isolation;
rationalizations for time alone, but
using time to become more
negative toward oneself
Just be by yourself. You’re
miserable company anyway;
who’d want to be with you? Just
stay in the background, out of
view.
5. Self-contempt; vicious self-abusive
thoughts and accusations
(accompanied by intense angry
affect)
You idiot! You bitch! You creep!
You stupid shit! You don’t
deserve anything; you’re
worthless.
47
Continuum of Negative
Thought Patterns
Thoughts that support the cycle of addiction (addictions):
Levels of Increasing Suicidal
Intention
6. Thoughts urging use of
substances or food followed
by self-criticisms (weakens
inhibitions against selfdestructive actions, while
increasing guilt and selfrecrimination following acting
out).
Content of Voice Statements
It’s okay to do drugs, you’ll be
more relaxed. Go ahead and
have a drink, you deserve it.
(Later) You weak-willed jerk!
You’re nothing but a druggedout drunken freak.
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Continuum of Negative
Thought Patterns
Thoughts that lead to suicide (self-annihilating thoughts):
Levels of Increasing Suicidal Intention
Content of Voice Statements
7. Thoughts contributing to a sense of
hopelessness urging withdrawal or
removal of oneself completely from
the lives of people closest.
See how bad you make your family
(friends) feel. They’d be better off
without you. It’s the only decent
thing to do; just stay away and stop
bothering them.
8. Thoughts influencing a person to give
up priorities and favored activities
(points of identity).
What’s the use? Your work doesn’t
matter any more. Why bother even
trying? Nothing matters anyway.
9. Injunctions to inflict self-harm at an
action level; intense rage against
self.
Why don’t you just drive across the
center divider? Just shove your hand
under that power saw!
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Continuum of Negative
Thought Patterns
Thoughts that lead to suicide (self-annihilating thoughts):
Levels of Increasing Suicidal
Intention
Content of Voice Statements
10. Thoughts planning details of
suicide (calm, rational, often
obsessive, indicating
complete loss of feeling for the
self).
You have to get hold of some
pills, then go to a hotel, etc.
11. Injunctions to carry out
suicide plans; thoughts baiting
the person to commit suicide
(extreme thought constriction).
You’ve thought about this
long enough. Just get it over
with. It’s the only way out.
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Why Use Objective Measures?
What Interferes with Clinical Judgment
• Anxiety
• Counter Transference
• Psych Ache
• Research Minimizing
• Diverse Menu of Risk Factors
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The Suicidal Child
by Cynthia R. Pfeffer, MD
The Guilford University Press
Spectrum of Suicidal Behavior
1. Nonsuicidal- No evidence of any self-destructive or suicidal thoughts or actions.
2. Suicidal Ideation- Thoughts or verbalization of suicidal intention.
Examples: a. “I want to kill myself”
b. Auditory hallucination to commit suicide
3. Suicidal Threat- Verbalization of impending suicidal action and/ or a precursor
action which. If fully carried out, could have led to harm.
Examples: a. “I am going to run in front of a car”
b. Child puts a knife under his or her pillow
c. Child stands near an open window and threatens to jump
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Thoughts about my life
Name___________________________ Date________
Sex_____ Race_________________ Age_________
Education________________________________________
Occupation______________________________________
Directions
Listed below are thoughts that people sometimes have. Read each sentence carefully and decide which of
these thoughts you had in the past month. Circle the letter beneath the answer that best describes your own thoughts.
If you make a mistake or change your mind, make an “X” through the incorrect response and then circle the correct
response. DO NOT ERASE. There are no right or wrong answers so answer each sentence as openly and honestly as
possible. Be sure to answer each sentence. DO NOT leave any sentence blank.
This thought was in my mind
Almost
Everyday
Couple
times
a week
About
once
a week
Couple
times
a
month
About
once
a
month
Had this
thought
before but
not in the
last month
I never had
this thought
1.
I thought it would be better if I was not alive............................................
A
B
C
D
E
F
G
2.
I thought about killing myself…………………………………………………..
A
B
C
D
E
F
G
3.
I thought about how I would kill myself………………………………………
A
B
C
D
E
F
G
4.
I thought about when I would kill myself…………………………………….
A
B
C
D
E
F
G
5.
I thought about what to write in a suicide note……………………………
A
B
C
D
E
F
G
6.
I thought about telling people I plan to kill myself…………………………
A
B
C
D
E
F
G
7.
I thought that people would be happier if I was not around……………
A
B
C
D
E
F
G
8.
I thought about how people would feel if I killed myself…………………
A
B
C
D
E
F
G
9.
I wished I were dead……………………………………………………………..
A
B
C
D
E
F
G
10.
I thought about how easy it would be to end it all…………………………
A
B
C
D
E
F
G53
Columbia Suicide Severity Scale
( C-SSS)
• Suicidal Behavior
• Suicidal Ideation
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Columbia-Suicide Severity Rating Scale
(C-SSRS)
Suicidal Ideation
Ask questions 1 and 2. If both are negative, proceed to “Suicidal
Behavior” section. If the answer to question 2 is “yes”, ask questions 3,
4, and 5. If the answer to question 1 and/or 2 is “yes”, complete
“Intensity of Ideation” section below.
1. Wish to be Dead
2. Non-specific Active Suicidal Thoughts
3. Active Suicidal Ideation with any Methods (not plan) without Intent to
Act
4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan
5. Active Suicidal Ideation with Specific Plan and Intent
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Columbia-Suicide Severity Rating Scale
(C-SSRS)
• Intensity of Ideation
• Frequency
• Duration
• Controllability
• Deterrents
• Reason for Ideation
56
Columbia-Suicide Severity Rating Scale
(C-SSRS)
Suicidal Behavior
(Check all that apply, so long as these are separate events; must ask about all
types)
Actual Attempt
Have you made a suicide attempt?
Have you done anything to harm yourself?
Have you done anything dangerous where you could have died?
What did you do?
Did you ________ as a way to end your life?
Did you want to die (even a little) when you _________?
Were you trying to end your life when you __________?
Or did you think it was possible you could have died from __________?
Or did you do it purely for other reasons/without ANY intention of killing yourself
(like to relieve stress, feel better, get sympathy, or get something else to
happen)? (Self-injurious behavior without suicidal intent)
If yes, describe:
Has subject engaged in Non-Suicidal Self-Injurious Behavior?
Past X years
or Lifetime
YES
NO
Total # of
attempts
______
57
YES
NO
Columbia-Suicide Severity Rating Scale
(C-SSRS) cont’d
Interrupted Attempt:
Has there been a time when you started to do something to end your
life but someone or something stopped you before you actually did
anything?
If yes, describe:
Aborted Attempt:
Has there been a time when you started to do something to try and
end your life but you stopped yourself before you actually did
anything?
If yes, describe:
Preparatory Acts or Behavior:
Suicidal Behavior:
Suicidal Behavior was present during the assessment period?
Past X years
or Lifetime
YES
NO
Total # of
interrupted
______
YES
NO
Total # of
aborted
_______
YES
NO
YES NO
58
BHS Sample Questionnaire
1. I look forward to the future with hope and enthusiasm.
T
F
2. I might as well give up because there is nothing I can do
about making things better for myself.
T
F
3. When things are going badly, I am helped by knowing that
they cannot stay that way forever.
T
F
4. I can’t imagine what my life would be like in ten years.
T
F
59
Our Measures
Based on Separation Theory developed by Robert W.
Firestone, PhD. and represents a broadly based
coherent system of concepts and hypothesis that
integrates psychoanalytic and existential systems of
thought. The theoretical approach focuses on internal
negative thought processes. These thoughts (i.e.
“voices”) actually direct behavior and, thus, are likely to
predict how an individual will behave.
60
Firestone Assessment of SelfDestructive Thoughts
Never
Rarely
Once In
A
While
Frequently
Most Of
The Time
1.
Just stay in the background.
0
1
2
3
4
2.
Get them to leave you alone. You
don’t need them.
0
1
2
3
4
3.
You’ll save money by staying home.
Why do you need to go out anyway?
0
1
2
3
4
4.
You better take something so you can
relax with those people tonight.
0
1
2
3
4
5.
Don’t buy that new outfit. Look at all
the money you are saving.
0
1
2
3
4
61
Figure 3. Approximate ROC Curves
for the FVSSDB, SPS, and BHS
62
63
64
65
66
Uses for Our Measures
• Risk Assessment
• Treatment Planning
• Targeting Intervention
• Outcome Evaluation
67
Firestone Assessment of Suicide
Intent Record Form
Name: ____________________________________
Sex: Male Female
Age: ______ Date:
/
/
Examiner: ______________________________________
Instructions
This form contains a number of statements. I want you to read each statement carefully and indicate how often you
have each thought by filling in the appropriate box to the right. For example, consider the thought, “You are going to
make a fool of yourself.” Do you experience this thought never, rarely, once in a while, frequently, or most of the time?
Please indicate the frequency with which you experience the following thoughts toward yourself. If you wish to
change your answer, put an X through it and fill in your new choice. If you have questions, be sure to let me know.
Never Rarely Once in Awhile Frequently Most of the Time
1. Life would be so much easier if you just killed yourself.
2. Life would be simple; there would be no life and you wouldn’t
have to torture yourself any longer.
3. You coward, just do it already. Kill yourself.
4. It’s too bad you have to kill yourself to show people how
much you’re hurting.
5. Why don’t you end it all? Go ahead! It’ll be over in a minute.
6. It’s such a struggle to simply get through a day.
You can always choose death as a last resort.
7. Look at all the trouble you’re causing. If you were dead,
there would be no more trouble.
8. Smash yourself! You don’t deserve to be alive!
□ □
□
□
□
68
Suicide Warning Signs
•
•
•
•
•
•
•
Disturbed sleep patterns
Anxiety, agitation
Pulling away from friends and family
Past attempts
Extremely self-hating thoughts
Feeling like they don’t belong
Hopelessness, Feelings of hopelessness and
worthlessness that often accompany
depression
• Rage, Impulsive aggression (the tendency
to react to frustration or provocation with
hostility or aggression)
69
Suicide Warning Signs
•
•
•
•
•
•
•
•
Feeling trapped
Increased use of alcohol or drugs
Feeling that they are a burden to others
Loss of interest in favorite activities -“nothing
matters”
Giving up on themselves
Risk-taking behavior
Suicidal thoughts, plans, actions
Sudden mood changes for the better
70
Suicide Warning Signs, cont’d
•
•
•
•
•
•
•
•
•
•
A psychiatric disorder, especially major depressive disorder, bipolar disorder,
conduct disorder, and substance (alcohol and drug) use disorders
Psychiatric comorbidity, especially the combination of mood, disruptive, and
substance abuse disorders
Personality disorders (especially cluster B disorders: antisocial, borderline, histrionic,
narcissistic)
Availability of lethal means
A family history of depression or suicide
Loss of a parent to death or divorce
Family discord
Physical and/or sexual abuse
Lack of a support network, poor relationships with parents or peers and feelings of
social isolation
Dealing with homosexuality in an unsupportive family or community or hostile
school environment
Data Source: State of California Department of Public Health, Epidemiology and
Prevention for Injury Control Branch, California Office of Statewide Health Planning
and Development, Patient Discharge Data. Accessed online
athttp://epicenter.cdph.ca.gov/; State of California, Department of Finance,
Race/Ethnic Population with Age and Sex Detail, 1990-1999, 2000-2050. Accessed
online at http://www.dof.ca.gov (May 2011).
71
Protective Factors
• Family and community connections/
support
• Clinical Care (availability and
accessibility)
• Resilience
• Coping Skills
• Frustration tolerance and emotion
regulation
• Cultural and religious beliefs; spirituality
72
Those Who Desire Suicide
Those who desire
Suicide:
Perceived
Burdensomeness
+
Thwarted
Belongingness
Those Who Are
Capable of Suicide
Serious Attempt or Death by Suicide
Joiner, Thomas. Why People Die By Suicide. “The Three Components of
Completed Suicide.” Harvard University Press, 2005.
73
Joiner (2005, p. 227) assesses these
attributes by asking such questions as:
a. Acquired Ability to Enact Lethal Self-Injury
Things that scare most people do not scare me.
I can tolerate a lot more pain than most people.
I avoid certain situations (e.g., certain sports) because of the possibility of
injury (Reversed scored)
b. Burdensomeness
The people I care about would be better off if I were gone. I have failed the
people in my life.
c. Belongingness
These days I am connected to other people.
These days I feel like an outsider in social situations (Reversed scored)
These days I often interact with people who care about me
74
75
76
Multiple Attempters as a Special High-Risk
Group (in comparison to single
attempters/ideators)
• Distinctive in every way
– Greater likelihood to have diagnosis, co-morbidity,
personality disorder
– Younger at time of first attempt (greater chronicity)
• Lower lethality first attempt (raises question about intent,
function of behavior)
• More impulsive
• More likely to be associated with substance abuse
– Greater symptom severity
• Anxiety, depression, hopelessness, anger, suicidal
ideation (frequency, intensity, specificity, duration,
intent)
– More frequent histories of trauma, abuse
– Distinctive characteristics of crises
77
78
Safety Plan, Stanley and Brown, 2008
Figure 6.3. Example of a safety plan developed during the early phase of treatment.
ED=emergency department
1. Warning signs (when I am to use the safety plan):
 wanting to go to sleep and not wake up
 wanting to hurt myself
 thinking “I can’t take it anymore”
2. Coping strategies (things I can try to do on my own):
 listening to rock music
 rocking in a chair
 going for a walk
 controlled breathing
 taking a hot or cold shower
 exercising
3. Contacting other people:
 Calling a friend to distract myself: ______________________ Phone:__________________
If distraction does not work, I will tell any of the following people that I am in crisis and ask for help:
 Calling a family member:_______________________Phone:_______________________
 Calling or talking to someone else:_______________________Phone:___________________
4. Contacting a health care professional during business hours:
Calling my therapist:_____________________Phone:__________________________
Calling my psychiatrist:_______________________Phone:______________________
Calling my case manager:______________________Phone:____________________
The following agencies or services may be called 24 hours a day/7 days a week:
Calling the psychiatrist ED:_________________________Phone:____________________
Calling National Suicide Prevention Lifeline
Phone: 1-800-273-TALK
Patients signature:_______________________________Date:___________
Clinician signature:______________________________Date:___________
79
Safety Plan, Stanley and Brown,
2008 - Adolescent
STEP ONE: WARNING SIGNS AND TRIGGERS:
Ask: “How will you know when the safety plane should be used?”
Ask: “What do you experience when you start to think about suicide or feel extremely depressed?”
List warning signs (thoughts, images, thinking processes, mood, an/or behaviors) using adolescent’s
own words
Ask: “What sets off the ‘bad’ thoughts?” (consider, thoughts, events, emotional states etc.)
List triggers
STEP TWO: INTERNAL COPING SKILLS
Ask: “What can you do on your own, if you become suicidal again, to help yourself not to act on your
thoughts or urges?”
Ask: “How likely are you to do this during a time of crisis?”
Ask: “What might stand in the way of you using these strategies?”
List coping strategies and barriers
STEP THREE: SOCIAL CONTACTS WHO MAY DISTRACT FROM THE CRISIS
Ask: “Who or what social settings can help take your mind off your problems at least for a little while?”
Ask: “Who helps you feel better?”
Ask about potential obstacles
Ask about a “Safe Place” they could go (i.e.. Coffee Shop)
80
List people (with phone numbers) and places
Safety Plan, Stanley and Brown,
2008 - Adolescent
STEP FOUR: FAMILY AND FRIENDS WHO MAY OFFER HELP
Ask: “Among your friends and family, who do you think you could contact during a crisis? Who is
supportive of you?”
Role play and rehearsal can be very useful in this step
List names and numbers of people who could come over and keep an eye on your teenager
STEP FIVE: PROFESSIONALS AND AGENCIES TO CONTACT FOR HELP
Ask: “Who are the mental health professionals that you should identify to be on your safety plan?” and
“Are there other health care providers?”
If your teen’s thoughts of suicide persist please contact your local mental health provider immediately
to have your child assessed for his or her level of risk!!
List names and numbers of mental health professionals, caseworkers, juvenile offers etc. that can help
your teenager with their suicidal thoughts.
STEP SIX: MAKING THE ENVIRONMENT SAFE
Ask: “Do you or your family own a gun? Knives?” or “Where are all the pills in your house?”
Ask: “What other means of hurting yourself do you have access too?”
Ask: “How can we go about limiting access to these items?”
Lock up all guns, knives, and pills and begin to monitor all other potential weapons
All of this information should be written down and should be easily accessed by your teenager as well
as other family members who may be assisting in maintaining your teen’s safety. I suggest
keeping a copy on the frig, placing one in your teenager’s room, and keeping one in your wallet or
81
purse.
Ways to Increase Social Supports
•
•
•
•
•
•
•
Make a list of possible social supports
Utilize family resources
Proactively develop healthy new social supports (e.g., join social club)
Teach the patient how to access and use social supports
Involve family members (significant others) in treatment with the patient’s
permission. For example, educate the patient’s parents about the nature of
depression and comorbid disorders and on ways they can provide support.
Help significant others understand that it is not dangerous to ask the patient how
he/she is feeling.
Encourage the patient to let people know when he/she is suicidal.
Patient can be asked:
“Who are three people you will call if you are feeling like hurting yourself? Which
adult or helper (counselor, therapist) do you feel comfortable calling? What is
there name?”
1.
2.
3.
This activity is designed to challenge the patient’s belief that “No one cares” and to
ensure that the patient contacts “safe” supportive people (non-suicidal).
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Crisis Response Plan
When I’m acting on my suicidal thoughts by trying to find a gun (or another
method to kill myself), I agree to take the following steps:
• Step 1. I will try to identify specifically what’s upsetting me.
• Step 2. Write out and review more reasonable responses to my suicidal
thoughts, including thoughts about myself, others, and the future.
• Step 3. Review all the conclusions I’ve come to about these thoughts in
the past in my treatment log. For example, that the sexual abuse wasn’t
my fault and I don’t have anything to feel ashamed of.
• Step 4. Try and do the things that help me feel better for at least 30
minutes (listening to music, going to work, calling my best friend)
• Step 5. Repeat all of the above at least one more time.
• Step 6. If the thoughts continue, get specific, and I find myself preparing to
do something, I’ll call the emergency call person at (phone number:
XXXXXXX).
• Step 7. If I still feel suicidal and don’t feel like I can control my behavior, I’ll
go to the emergency room located at XXXXXXX, phone number XXXXXXX.
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10 Most Common Errors in
Suicide Prevention
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Superficial Reassurance
Avoidance of Strong Feelings
Professionalism
Inadequate Assessment of suicidal intent
Failure to identify the precipitating event
Passivity
Insufficient Directiveness
Advice Giving
Stereotypic Responses
Defensiveness
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Practice Recommendations
1. When imminent risk does not dictate
hospitalization, the intensity of
outpatient treatment (i.e., more
frequent appointments, telephone
contacts, concurrent individual and
group treatment) should vary in
accordance with risk indicators for
those identified as high risk.
85
Practice Recommendations
2. If the target goal is a reduction in suicide
attempts and related behaviors,
treatment should be conceptualized as
long-term and target identified skills
deficits (e.g., emotion regulation, distress
tolerance, impulsivity, problem-solving,
interpersonal assertiveness, anger
management), in addition to other
salent treatment issues.
86
Practice Recommendations
3. If therapy is brief and the target variable
are suicidal ideation, or related
sumptomatology such as depression,
hopelessness, or loneliness, a problemsolving component should be used in
some form or fashion as a core intervation.
87
Practice Recommendations
4. Regardless of therapeutic orientation,
an explanatory model should be
detailed identifying treatment
targets, both direct (i.e., suicidal
ideation, attempts, related selfdestructive and self-multistory
behaviors) and indirect (depression,
hopelessness, anxiety, and anger;
interpersonal relationship dysfunction;
low self-esteem and poor self-image;
day-to-day functioning at work and
home).
88
Practice Recommendations
5. Use of standardized follow-up and
referral procedure (e.g., letters or
phone calls) is recommended for
those dropping out of treatment
prematurely in an effort to enhance
compliance and reduce risk for
subsequent attempts.
89
Practice Recommendations
6. Informed consent
90
Commitment to Treatment
Statement in Practice
• I understand and acknowledge that, to a large degree, a
successful treatment outcome depends on the amount energy
and effort I make. If I feel like treatment is not working. I agree
to discuss it with my therapist and attempt to come to a
common understanding as to what the problems are and
identify potential solutions. In short, I agree to make a
commitment to living. This agreement will apply for the next
three months, at which time it will be reviewed and modified.
Signed: _____________________
Date: _______________________
Witness: _____________________
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Commitment to Treatment
Statement in Practice
1.
2.
3.
4.
5.
6.
7.
8.
Attending sessions (or letting my therapist know when I
can’t make it),
Setting goals,
Voicing my opinions, thoughts, and feelings honestly and
openly with my therapist (whether they are negative or
positive, but most importantly my negative feelings),
Being actively involved during sessions,
Completing homework assignments,
Taking my medications as prescribed,
Experimenting with new ways of doing things,
And implementing my crisis response plan when needed
(see attached crisis response plan card for details).
92
93
Mood
94
Suicide Status Form-III (SSF III) Initial Session
Rank
Patient__________________________ Clinician______________________ Date___________ Time_____
Section A-Patient
Rate and fill out each item according to how you feel right now. Then rank items in order of importance 1 to 5 (1=most
important, 5=least important)
1.
N/A
Rate psychological pain (hurt, anguish, or misery in your mind; not stress; not physical pain):
Low Pain: 1 2 3 4 5 :High Pain
What I find most painful is:__________________________________________________________________
2. Rate stress(your general feeling of being pressured or overwhelmed):
Low Stress: 1 2 3 4 5 :High Stress
What I find most stressful is:__________________________________________________________________
3. Rate agitation(emotional urgency; feeling that you need to take action; not irritation; not
annoyance):
Low Agitation: 1 2 3 4 5 :High Agitation
I most need to take action when:____________________________________________________________
4. Rate Hopelessness (your expectation that things will not get better no matter what you do)
Low Hopelessness: 1 2 3 4 5 :High Hopelessness
I am most hopeless about:___________________________________________________________________
5. Rate Self-Hate (your general feeling or disliking of yourself; having no self-esteem; having no selfrespect)
Low Self-Hate: 1 2 3 4 5 :High Self-Hate
What I hate most about myself is:_____________________________________________________________
6. Rate overall Risk of Suicide:
Extremely Low Risk (will not kill self: 1 2 3 4 5 :Extremely High Risk (will kill self)
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1.How much is being suicidal related to thoughts and feelings about yourself? Not at all:1 2 3 4 5 :Completely
2. How much is being suicidal related to thoughts and feelings about others? Not at all:1 2 3 4 5 :Completely
Rank
Reason for living
Rank
Reason for dying
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
96
CAMS patients reached resolution of
suicidality about 4-6 weeks more quickly
than treatment as usual patients.
( Jobes et al., 2003, Wong, 2003)
97
Effective Therapy Approaches for
Treating the Suicidal Person
•Cognitive Therapy for suicidal people was developed by Aaron Beck and Gregory Brown. Unlike other
CBT treatments, this approach is not time limited. The third and last stage is “Relapse Prevention with a
Twist.” Clients do not graduate from treatment until they demonstrate that they are ready to do this on
their own.
•Dialectical Behavior Therapy, developed by Marsha M. Linehan, is designed to treat emotion regulation
difficulties and suicidal behavior. One element, the skill-building component of DBT, addresses the issues
of distress tolerance and the development of healthy affect regulation strategies, both of which are
essential for suicidal clients.
•Mentalizing Treatment, developed by Jon Allen and Peter Fonagy, emphasizes emotional regulation
and expressiveness. The techniques implemented assist clients in forming good affect regulation and
tolerance through the process of developing the mentalizing capability to observe and understand their
mind and the minds of others, accurately seeing the mind behind the behavior.
•Transference Focused Therapy, developed by Kernberg, Clarkin, and Yeomans, concentrates on the
intermediate interaction between the client and therapist in session by focusing on the therapeutic
relationship.
• Voice Therapy, which was developed by Robert Firestone, is a cognitive-affective-behavioral
therapeutic methodology that brings introjected hostile thoughts, with the accompanying negative
affect, to consciousness, rendering them accessible for treatment. This technique facilitates the
identification of the negative cognitions driving the suicidal actions, which in turn helps clients to gain a
measure of control over all aspects of their self-destructive or suicidal behavior. This process helps clients
expand their personal boundaries, develop a sense of meaning in life, and reduce the risk of self98
destructive behavior, including suicide.
Construction of a Hope Kit*
Another activity that is undertaken in the middle phase of therapy is the
construction of a hope kit. A hope kit consists of a container that holds
mementos (photographs, letters, souvenirs) that serve as reminders of reasons
to live. Patients are instructed to be as creative as possible when creating their
hope kit, so that the end result is a powerful and personal reminder of their
connection to live that can be used when feeling suicidal. We have found that
patients report making their hope kits to be a highly rewarding experience that
often leads them to discover reasons to live they had previously overlooked.
Suzanne was rather artistic and reported that she enjoyed this task. She found
an old shoe box and decorated it using some of her favorite pictures. Inside
she included pictures of her mother, her friends, and her cart. She also
included the lyrics of her favorite song, a potpourri bag filled with her favorite
scent, and a piece of her childhood blanket. Suzanne kept the hope box on her
dresser, and it frequently reminded her of all the good things in her life.
**Excerpted from “Cognitive Therapy, Cognition, and Suicidal Behavior” by GK Brown, E Jeglic, GR Henriques, and
AT Beck In T.E. Ellis (Ed.), Cognition and Suicide (APA Books, 2006).
99
Establish therapeutic alliance with the
suicidal patient, Brown and Beck
(2008, p. 162)
“Be attentive, remain calm and provide the patient with a private,
non-threatening and supportive environment to discuss experienced
difficulties. Do not express anger, exasperation, or hostile passivity. Be
forthright and confident in manner and speech to provide the
patient with a stable source of support at a time of crisis. Stress a
team approach to the problem(s) presented; for instance, freely use
the collaborative pronoun “we” when discussing suicidal behavior.
Model hopefulness, but make sure to acknowledge the patient’s
distress and perspective on the problem. Do not avoid using the
word “suicide” because this gives the impression that you stigmatize
the concept. Most importantly, do not immediately suggest
hospitalization. In our experience, patients are most agreeable if the
therapist carefully explores various safety options, then plans for the
most appropriate clinical response to an acute suicidal episode.”
100
Establish therapeutic alliance
with the suicidal patient,
Brown and Beck (2008, p. 162)
1.
2.
3.
4.
5.
Have the patient tell his/her “story at his/her own pace. Conduct a behavioral
chain analysis of events of the proximal factors that triggered the suicide
attempt.
Help the patient define the suicidal crisis. Remember that the patient is
communicating how badly he or she feels.
Use phrases such as “murdering yourself” or “self-annihilation” when referring to
suicide.
Help the patient view suicide as an attempt to solve a problem. Convey that
you do not want the patient to employ a “permanent solution to what might
be a temporary problem.”
Use motivational Interviewing procedures. Zerler (2008) has discussed how to
apply the principles of motivational interviewing of suicidal patients (EE,DD, RR,
and SS). The four principles of Motivational Interviewing are: Expressing
Empathy; Developing Discrepancy between the patient’s present behaviors
and values; Rolling with Resistance as the therapist strives to understand and
respect both sides of the ambivalence for the patients perspective. The
therapist can empathize with the needs that give rise to the suicidal ideation,
without approving suicidal behaviors. Finally, the therapist can Support the
patient’s Self-efficacy by acting as a guide or consultant suggesting possible
ways to proceed.
101
Establish therapeutic alliance
with the suicidal patient,
Brown and Beck (2008, p. 162)
• Address any barriers that may contribute to antitherapeutic behaviors
• Use collaborative setting
• Periodically summarize throughout the session and at the end of the
session. As psychotherapy progresses, ask the patient to summarize what
was covered in the session and what he/she plans to do between
sessions and, most importantly, the reasons why he/she should conduct
these activities (homework assignments). Build in reminders that the
patient and significant others can take home.
• Therapists should model hopefulness and “dogged determination” and
convey a “team” approach.
• CBT helps to prevent depression in psychotherapists.
• “One story”- They have to feel heard.
• Solicit feedback regularly from the patient and significant others. Ask:
I want to check in with you about how you found our meeting today.
Were there any things I said or did, or did not say or do, that you found
particularly helpful, or particularly unhelpful, or that bothered you? What
102
can we do differently the next time we meet?
Voice Therapy
Cognitive Affective Behavioral Approach
103
The Therapeutic Process
in Voice Therapy
Step I
Identify the content of the person’s
negative thought process. The person is
taught to articulate his or her self-attacks in
the second person. The person is
encouraged to say the attack as he or she
hears it or experiences it. If the person is
holding back feelings, he or she is
encouraged to express them.
Step II
The person discusses insights and reactions
to verbalizing the voice. The person
attempts to understand the relationship
between voice attacks and early life
experience.
104
The Therapeutic Process
in Voice Therapy
Step III
The person answers back to the voice attacks,
which is often a cathartic experience.
Afterwards, it is important for the person to make
a rational statement about how he or she really
is, how other people really are, what is true about
his or her social world.
Step IV
The person develops insight about how the voice
attacks are influencing his or her present-day
behaviors.
Step V
The person then collaborates with the therapist to
plan changes in these behaviors. The person is
encouraged to not engage in self-destructive
behavior dictated by his or her negative thoughts
and to also increase the positive behaviors these
negative thoughts discourage.
105
Self
Anti-Self
106
Address patient’s impulsivity
• Teach the patient how to “procrastinate” suicide and
how to “stretch out time”
• Ride out suicidal urges
• Delay acting on impulse to self-harm
• Compile and practice delaying strategies such as talking
to someone, telephone a therapist, engage in
distracting tasks, sleeping
• Safeguard one’s environment so it is unfriendly to suicide
107
Interpersonal Neurobiology
C urious
O pen
A ccepting
L oving
108
Most Helpful Aspects from
Client Perspective
Validating Relationships
Participants describe the existence of an affirming
and validating relationship as a catalyst for
reconnection with others and with oneself. A
difficult part of the recovery process was breaking
through, cognitive, emotional, and behavioral
barriers that participants had generated for survival.
109
Counseling for Suicide: Client Perspective. Paulson & Worth, 2002
Most Helpful Aspects from
Client Perspective
Working with Emotions
Dealing with the intense emotions underlying suicidal
behavior was perceived as crucial to participant’s
healing. The resolution of despair and helplessness
was a pivotal and highly potent experience for all
participants in the study. Almost paradoxically, if a
client did not receive acknowledgement of these
powerful and overwhelming feelings, they reported
being unable to move beyond them.
Counseling for Suicide: Client Perspective. Paulson & Worth, 2002
110
Most Helpful Aspects from
Client Perspective
Developing Autonomy and Identity
Participants identified understanding suicidal
behaviors, developing self-awareness, and
constructing personal identity as key components of
the therapeutic process. Participants
conceptualized the therapeutic experience as
confronting and discarding negative patterns while
establishing new, more positive ones.
Counseling for Suicide: Client Perspective. Paulson & Worth, 2002
111
Common Emotions
Experienced in Grief:
•
•
•
•
•
•
•
•
•
•
Shock
Guilt
Despair
Stress
Rejection
Confusion
Helplessness
Denial
Anger
Disbelief
•Sadness
•Loneliness
•Self-Blame
•Depression
•Pain
•Shame
•Hopelessness
•Numbness
•Abandonment
•Anxiety
These feelings are normal reactions, and the expression of them is a natural
part of grieving. Grief is different for everyone. There is no fixed schedule or
one way to cope.
112
Self-Care & Help Seeking Behaviors
•
•
•
•
•
•
•
Ask for help
Talk to others
Get plenty of rest
Drink plenty of water, avoid caffeine
Do not use alcohol and other drugs
Exercise
Use relaxation skills
American Association of Suicidology’s Survivors’ Support Group Directory
http://www.suicidology.org/web/guest/support-group-directory
IASP Suicide Survivor Organizations (listed by country) http://www.iasp.info/resources/Postvention/National_Suicide_Survivor_Organizations/
Faces of Suicide – A Film for Survivors of Suicide Loss 113
http://www.glendon.org/store/catalog/product_info.php?cPath=0_23&products_id=43
Suicide Prevention:
Making a Difference
Be Aware of the Do’s…
–
–
–
–
–
–
Be aware. Learn the warning signs.
Get involved. Become available. Show interest and support.
Ask if she or he is thinking about suicide.
Be direct. Talk openly and freely about suicide.
Be willing to listen. Allow expressions of feelings. Accept the feelings.
Be non-judgmental. Don’t debate whether suicide is right or wrong, or feelings are
good or bad. Don’t lecture on the value of life.
– Offer hope that alternatives are available and Take Action.
114
Suicide Prevention:
Making a Difference
…and the Don’ts…
–
–
–
–
–
Don’t dare him or her to do it.
Don’t ask why. This encourages defensiveness.
Offer empathy, not sympathy.
Don’t act shocked. This will put distance between you.
Don’t be sworn to secrecy. Seek support.
115
Resources: Books
For Public and Professionals
For Professionals
Visit www.psychalive.org for resource links
116
Resources: Films
For the Public
For Professionals
Visit www.psychalive.org for resource links
For Survivors
117
Upcoming Webinars
The Fantasy Bond, March 20
CE Webinar, $25
Presenter: Dr. Lisa Firestone
4pm – 5:30pm PDT
Real Love or a Fantasy Bond, April 3
Free Webinar for the public
Presenter: Dr. Lisa Firestone
11pm – 12pm PDT
Creating Meaning: On the Role of Death in Life, May 22
CE Webinar, $25
Presenters: Dr. Sheldon Solomon and Dr. Lisa Firestone
4pm – 5:30pm PDT
Self Esteem: the Belief that One is a Valuable Contributor to
a Meaningful Universe
Free Webinar
Presenters: Dr. Sheldon Solomon and Dr. Lisa Firestone
11am- 12pm PDT
118
Learn more or register at: www.psychalive.org
Archived CE Webinars
•
•
•
•
•
•
•
•
•
•
Treatment of Individuals with PTSD, Complex PTSD,
and Comorbid Disorders: A Life-Span Approach
Dr. Donald Meichenbaum – (2.5 CEs, $35)
Relationships and the Roots of Resilience
Dr. Daniel Siegel (1.5 CEs– $35)
Love in the Time of Twitter
Dr. Pat Love (1.5 CEs – $35)
Innovative Approach to Treating Depression
Dr. Lisa Firestone (1.5 CEs– $25)
Conquer Your Critical Inner Voice:
An Adjunct to Clinical Practice
Dr Lisa Firestone (2 CEs $25)
Helping Parents to Raise Emotionally Healthy Children
Dr. Lisa Firestone(2 CEs $25)
Overcoming the Fear of Intimacy
Dr. Lisa Firestone(2 CEs $25)
Suicide: What Every Therapist Needs to Know
Dr. Lisa Firestone(1.5 CEs, $25)
Understanding and Assessing Violence
Dr. Lisa Firestone (1.5 CEs – $25)
Helping Parents to Raise Emotionally Healthy Children
Dr. Lisa Firestone (2 CEs– $25)
119
All Webinars can be found at http://www.psychalive.org/2011/09/psychalive-ce-webinar-series/
Contact:
[email protected]
Toll Free - 800-663-5281
(For Professionals)
www.glendon.org
(For the Public)
www.psychalive.org
120
Contact Information
• Dr. Lisa Firestone
• Phone (805) 681-0415
• Email: [email protected]
• Website: www.glendon.org
• Facebook: Glendon Association
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