1 Presented by Judith Springer, Psy. D. Highlighting concepts from Lifelines: Interventions Hazelden, 2011

The Assessment Interview 2

3 WHERE SUICIDE PREVENTION BEGINS: SELF-AWARENESS

1. What are the words people use to talk about suicide? 2. Is suicide morally wrong? 3. Is it a sin? 4. Do people have a right to choose suicide as an option? 4

On a 1 to 10 scale, rank how comfortable you are talking about suicide Very UncomfortableVery Comfortable 5

6 A PROBLEM WELL DEFINED IS A PROBLEM HALF- SOLVED

7 SUICIDAL BEHAVIOR SUICIDAL BEHAVIOR Attempt to solve a problem of intense pain with impaired skills

1. Alternative 2. Crisis Thinking 3. Ambivalence 4. Irrational 5. Communication 8 ◦ ( Shneideman, 1985)

Intolerable problem 2. One in a series of problems 3. Seem un-resolvable except by suicide 4. Suicide is consistent with view of self 5. Other alternatives disregarded 6. Death seems only answer

10 Triggering Event Tunnel Vision of Suicide Thinking

11DEMOGRAPHY/BIOLOGY FAMILY History Clinical diagnosis Previous ATTEMPT ACCESS TO MEANS

12  Age ◦ Before 10 ◦ ◦  Sex  Geography

13  Family history of suicide  Psychiatric disorders  Family discord  Abuse: ◦ Physical ◦ Sexual

14  Loss ◦ Actual ◦ Symbolic ◦ Imagined  Change  Trouble ◦ At home ◦ In school ◦ With police

15 Intervention: “TELL ME MORE”

16  ASSESSMENT  EVALUATION  PARENTAL CONTACT  REFERRAL

17  Teacher referral  Parent referral  Peer referral  Emerges in another context

18  Have you noticed any major changes in your student’s schoolwork recently?  Have you noticed any behavioral, emotional, or attitudinal changes?  Has the student experienced any trouble in school? What kind of trouble?  Does the student appear depressed and/or hostile and angry? If so, what clues does the student give?  Has the student either verbally, behaviorally, or symbolically (in an essay or story) threatened suicide or expressed statements associated with self-destruction or death?

19  Setting the Stage  Establishing Rapport  Asking the Questions  Making the Referral

20  Personal values & attitudes  Professional experiences & skills  Interviewing strengths & limitations  Student biases & prejudices  Previous contact w/student or never having met the student before

 Positives ◦ Relationship brings familiarity ◦ Rapport exists/easier to establish ◦ Previous knowledge puts current information in context ◦ Problem-solving may be quicker, more targeted to student’s personal situation  Challenges  Relationship brings familiarity  Rapport may not exist: student may refuse to cooperate  Objectivity may be difficult  Previous history may predetermine outcome 21

22  Personal objectivity may be easier  Establishing rapport may take work  Must rely on 2 nd hand information  Problem solving will not be confounded by historical antecedents

HOW STUDENTS FEEL ABOUT ASKING ADULTS FOR HELP  Concerned that adults don’t understand their feelings  Don’t think adults listen to them  Worried they be seen as crazy or weak.  Misunderstand mental health or the counseling process  Scared about parental reactions or being hospitalized  Relieved 23

24  Remember developmental issues  Be clear: speak English!  Be directive  Be specific  Use collateral resources if necessary  Be supportive

25  Remember developmental issues ◦ Peer group allegiance ◦ Distrust of adults ◦ Separation/individuation ◦ Limit-testing ◦ Affective insecurity

26 ◦ Avoid abstractions & ask specific questions ◦ Do your homework: Offer specific examples of worrisome behaviors ◦ Don’t be intimidated or intimidating ◦ Clarify “adolescent” jargon; clarify “psychological” jargon

27 Get collateral information:  Observations of teachers  Attendance & tardiness records  School nurse contacts  Prescribed medications ASSESSMENT: THE FIRST STEPS

28  …assume the student is just trying to get attention  …promise you won’t tell anyone  …say you know exactly the student feels  …try to argue the student out of being suicidal  …say that suicide is ‘dumb’ or the student should just snap out of it

29  Calmly gather information  Be direct and unambiguous in asking questions  Assess lethality of method and identify a course of action  Use effective listening skills by reflecting feelings, remaining non-judgmental, and not minimizing the problem  Communicate caring, support, and trust while providing encouragement for coping strategies  Be hopeful; emphasize student’s worth  Recognize student probably doesn’t have a thorough understanding of the finality of death

30  Gather information about youth’s and family’s history, with emphasis on suicide and substance abuse  Don’t make any “deals” to keep suicidal thoughts or actions a secret  Do not leave high-risk youth alone  Get supportive collaboration from colleagues  Be familiar with community resources  Outline the steps that will be taken to help the student  Keep detailed notes of procedures

31  Why is the youth thinking about suicide now?  How long has the youth been having these thoughts?  Has the youth made any specific plans to carry out the suicide?  Does he/she have access to the means?  What is the youth’s support system (e.g. parents, caregivers, other adults, friends, etc.)  What does the youth perceive as deterrents to suicide?

32 1.Be prepared with a sequence of opening questions: a. Establish empathy: “What I’ve heard you say concerns me” b. Explore peer support: “Have you talked with anyone else about these feelings?” c. Ask permission to get more information: “Can I ask you a bit more about what’s been going on?”

33 2. Explore specificity of risk logically: a. Clarify what concerns you: “What I hear you saying is that you’ve been thinking that life isn’t worth it anymore” b. Check it out: “Am I getting that right?” c. Be direct: “Are you thinking about killing yourself?” d. Ask about the particulars: ”Do you have a plan?”; “Have you rehearsed it?”

34 3. Take ideation as seriously as behavior a. Ask about thoughts- frequency, duration: “When did you start thinking about this? How often do you have these thoughts?” b. Try to clarify ‘triggers’ : “When did you start to think about suicide? What was happening in your life?”

35 4. Even if student has ‘reasons for living’, remember impulsivity of suicide! 5. Always get consultation from designated school personnel 6. Document your observations

36 7. Even if you determine student does not need mental health referral, assessment MUST include a crisis plan:  Identification of triggers to suicidal ideation  Plan to deal with these triggers  Names and contact information of specific support people  Crisis services information

37  Assess severity of suicidal risk  Remove access to methods  Notify parents/caregivers and others as needed  Supervise student at all times  “Suicide-proof” the environment  Seek support and collaboration from colleagues  Mobilize a support team for student  Document all actions

: Involving the Parents or Guardians 38

39  Provides opportunity to validate student’s feelings  Involves student in referral process and strategy- people are more invested in what they own  Models joint problem solving

40  Prepare specific information with examples  Indicate changes in student’s behavior  Be prepared for resistance  Validate parental concerns  Convey your collaboration with them  Refer to appropriate resources

41  Has any serious change occurred in your child’s or family’s life recently?  (If yes) How did your child respond?  Has your child had any accidents or illnesses without a recognizable physical basis?  Has your child experienced a loss lately?  Has your child experienced difficulty in any areas of his/her life?  Has your child been very self-critical, or does he/she seem to think that you or teachers have been very critical lately?

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