Introduction to conceptualizing suicide risk in those with TBI Part 2 Beeta Y. Homaifar, PhD Melodi Billera, LCSW Where we discuss: Conceptualization of suicide risk

Disclosure This presentation is based on work supported, in part, by the Department of Veterans Affairs, but does not necessarily represent the views of the Department of Veterans Affairs or the United States Government.

Disclaimer Information during this presentation is for educational purposes only – it is not a substitute for informed medical advice or training. You should not use this information to diagnose or treat a mental health problem without consulting a qualified professional/provider

Objective 3 Conceptualization of suicide risk

Many people wish suicide risk was a math equation, but it’s not that easy… Risk factors – protective factors ≠ suicide risk

The Process of Conceptualization Assessment: We gather data Conceptualization: We then use this data to generate a “story” to explain how and why they have developed their presenting problems Intervention: This process, and our resulting understanding of the patient’s situation, helps us to develop a treatment plan that is most likely to help this particular patient during this particular time University of Tennessee, Memphis

CONCEPTUALIZATION INTERVENTION ASSESSMENT

Strengths Bias to challenges What about strengths (i.e., protective factors)? – As part of the conceptualization process it is important to identify strengths in: General functioning Overcoming adversity Therapeutic alliance

With all of the time in the world… Psychosocial/family history Interpersonal relationships Cultural identity Personality Coping style (i.e., distress tolerance, emotion regulation, etc.) Cognitive functioning (i.e., impulsivity, cognitive flexibility, problem solving, etc.) Psychiatric history (diagnoses, history of losses, insight into psychological functioning, etc.) Medical history (diagnoses, perception of health status, sleep, chronic pain, TBI, etc.) Hopelessness and other salient risk factors

With all of the time in the world… Current Stressors/Losses Warning Signs Suicidal Ideation/Intent/Plans – Why does the patient want to die? – What is the function of their ideation? Is it a means of control? Is it soothing? Is it an escape? Etc. Suicidal Behaviors (including preparatory) – Were they injured? What was their reaction to surviving?

Assessment is a Process, not an Event It will take time to get the various pieces of information – From the patient directly – From a chart review – From other providers/collateral contacts You don’t need (and often won’t have) all of the information to begin forming a conceptualization – But it helps…

CONCEPTUALIZATION INTERVENTION ASSESSMENT

Stories More than just facts/information – I’ve lost even more cognitive functioning than I had previously NOT A STORY – I’ve lost even more cognitive functioning than I had previously, and as a result I feel broken Now we’re getting somewhere… Susan Baur, Confiding (1994); Arthur Frank, The Wounded Storyteller (1995)

Stories Malleable: the meaning of events can change over time as we change and grow Susan Baur, Confiding (1994); Arthur Frank, The Wounded Storyteller (1995)

Stories Can reveal turning points – The patient’s negative experience can become a transforming experience… Susan Baur, Confiding (1994); Arthur Frank, The Wounded Storyteller (1995)

Listen for Turning Points What is a turning point? – A disruption in a trajectory, a deflection in a path – Must include awareness of the significance of the change – More than a temporary detour – Some turning points can have more momentum and be sustained for longer McAdams, Josselson, & Lieblich (2001)

A conceptualization is NOT Merely a short version of the clinical facts A restatement of the patient’s history

A conceptualization IS An interpreted evaluation incorporating our ideas about – WHY things happened as they did – HOW this particular person is affected – WHAT needs to happen next in the clinical situation

As you get to know your patient better Your conceptualization will likely change It will deepen You have a responsibility to be flexible in your conceptualization University of Tennessee, Memphis

Keep in mind Are we immune from making faulty assumptions or inferences about a client? – Be mindful when you find yourself seeking to confirm your existing hypotheses about a client It can help to have someone help you generate competing hypotheses to counteract any bias you may have

Do I keep my conceptualization to myself? NO When we demonstrate an understanding of their “story” and share our conceptualization, this can enhance the therapeutic alliance

How do we, as clinicians, take information and use it to conceptualize suicide risk? How do we put the pieces of a person’s story together?

Conceptualization: Step 1 What does the client think is driving his/her suicidal thinking/behavior?

Conceptualization: Step 2 – How is it that he/she came to have these particular problems? – How have they coped thus far? – What theory or set of theories can help explain this information? This theory could be one that already exists in the literature, or one that you come up with based on an interpretation of the patient’s life story (often these are the best ones!!!)

Conceptualization: Step 3 Based on your conceptualization, what interventions make the most sense to help address suicide risk?

Let’s take a moment to talk specifically about coping…

During a suicidal crisis Coping will require an ability to flexibly employ various strategies, potentially adapting them to the circumstance, until one works

Unfortunately Some have difficulty coping with a crisis, often because of executive dysfunction – Participants with histories of TBI and suicidal thoughts/behaviors discussed “deficits negatively impacting their ability to track suicide warning signs, employ coping strategies, or see alternatives to intentional self-harm behavior. As a result, suicide was frequently seen as ‘the only way’” (Brenner et al, 2010)

Do executive functioning difficulties apply only to people with brain injuries?

This doesn’t just apply to people with brain injuries Those who are acutely suicidal often become fixated on suicide and develop a kind of "tunnel vision," whereby their ability to see coping alternatives is significantly restricted (Shneidman, 1957)

Understanding factors that may influence one's ability to successfully cope with a suicidal crisis is crucial to suicide prevention

This concludes Part 2 of Conceptualizing Suicide Risk in those with TBI Continue on to Part 3