1. Crisis Response Planning for Suicidal Patients
Craig J. Bryan, PsyD, ABPP
National Center for Veterans Studies
The University of Utah

3. What a Crisis Response Plan Is
a memory aid to facilitate early identification of emotional crises
a checklist of personalized strategies to follow during emotional crises
a problem solving tool
a collaboratively-developed strategy for managing acute periods of risk

4. What a Crisis Response Plan Is Not
a no-suicide contract
a no-harm contract
a contract for safety

5. Essential Ingredients of Effective Interventions
Based on a simple, empirically-supported model
High fidelity by the clinician
Adherence by the patient
Emphasis on skills training
Prioritization of self-management
Easy access to crisis services
Rudd et al. (2009)

6. Crisis Response Planning: Effectiveness

7. CRP As Stand-Alone Intervention
Study
Design Tx
Comparison
Condition
Setting
Sample
Follow-Up
Attempt
Rates
Bryan et al. (2017)
N=97
RCT
Standard CRP &
Enhanced CRP
TAU
ED,
Outpt MH
Military,
78% male,
26 y
6 months
5% CRP vs.
19% TAU
(76% rel. reduction)
Miller et al. (2017)
N=1376
Quasi
Self-guided
Safety Plan +
f/u phone calls ED
ED patients,
55% male,
56 y
12 months
18% SP vs.
23% TAU
(20% rel. reduction)

8. Treatments With Embedded CRP
Study
Design Tx
# of
Sessions
Comparison
Condition
Setting
Sample
Follow-Up
Findings
Brown et al. (2005)
N=120
RCT
CT-SP 10
TAU
Outpt MH
Attempters,
40% male,
35 y
18 months
24% CT-SP vs.
42% TAU
(50% rel. reduction)
Rudd et al. (2015)
N=152
Brief CBT 12
Military,
87% male,
27 y
24 months
14% BCBT vs.
40% TAU
(60% rel. reduction)
Gysin-Maillart et al. (2016)
ASSIP 3
45% male,
38 y
5% ASSIP vs.
27% TAU
(80% rel. reduction)

9. Understanding Suicidal Behaviors

10. Functional Model of Suicide
Reinforcement
Positive
Negative
Automatic
(Internal)
Adding something desirable
(“To feel something”)
Reducing tension or negative affect
(“To stop bad feelings”)
Social
(External)
Gaining something from others
(“To get attention or let others know how I feel”)
Escape interpersonal task demands
(“To avoid punishment or doing something undesirable”)
Bryan, Rudd, & Wertenberger (2012, 2016); Nock & Prinstein (2004)
(Bryan, Rudd, & Wertenberger, 2012; Nock & Prinstein, 2004)

11. Negative Reinforcement
“I could just kill myself”
Suicide attempt
Emotional distress
Preparing
Failed attempts to suppress / control thoughts

12. Stable and Dynamic Aspects of Suicide Risk
(Bryan & Rudd, in press)
Bryan & Rudd (2016)
(Bryan & Rudd, 2016)

13. Cognitive flexibility
The Suicidal Mode
Predispositions
Acute .
Cognitive
Self-regard
Cognitive flexibility
Problem solving
Cognitive
“This is hopeless”
“I’m trapped”
“I’m a burden”
Behavioral
Prior attempts
Emotion regulation
Interpersonal skills
Emotional
Psychiatric disorder
Emotional lability
HPA axis
Behavioral
Substance use
Social withdrawal
Preparations
Emotional
Depression
Guilt
Anger
Trigger
Relationship problem
Financial stress
Perceived loss
Physical sensation
Negative memories
Physical
Genetics
Medical conditions
Demographics
Physical
Agitation
Insomnia
Pain

14. Multiple Levels of Suicide Risk
Symptoms Depression Hopelessness Anxiety Suicidal thoughts Shame Anger Substance abuse
Skills deficits Problem solving Emotion regulation Distress tolerance Interpersonal skills Anger management
Underlying Vulnerabilities
Cognitive Inflexibility
Emotion Regulation
(Rudd, Joiner, & Rajab, 2001)

15. Common Reactions to Suicidal Individuals
Helplessness
Hopelessness
Over-protectiveness
Under-protectiveness
Lack of compassion
Criticism
Fear
Anxiety
Anger

16. Clinician vs. Suicidal Individual Goals
prevent death
don’t get sued
Suicidal Individual alleviate suffering solve the problem

17. Narrative Assessment: Mechanics

18. Narrative Assessment vs. Traditional Interview
Higher empathy ratings
Higher affective synchrony
Emotional co-regulation
Lower speech complexity
Lower empathy ratings
Lower affective synchrony
Emotional co-dysregulation
Greater speech complexity

19. Moment-to-Moment Synchrony & Empathy
We currently only have a sample of 13 individuals for whom we have processed complete data, so these results are very preliminary. But really interesting trends seem to be emerging.
First, descriptives show that both patient and therapist tend to express more emotion in their voice during the intervention itself, compared with during the assessment.
The bottom table shows results from the regression model. We included patient and therapist f0 at both assessment and intervention in the model to predict bond. Note that we excluded age, gender, and type of treatment from this model simply because we don’t have the sample size to include that many predictors. Again these are very preliminary results. However, the first thing to notice is that therapist f0 at assessment still does not seem to predict bond, and patient f0 at assessment still seems to be an important predictor of bond, and a strong one, even when f0 at intervention is included in the model. Again, higher patient vocally encoded emotional arousal at assessment is associated with lower ratings of bond.
During the intervention itself, suddenly therapist f0 matters, and seems to matter a lot. The more the therapist expresses emotion in her voice, the strong bond tends to be.
But the most interesting trend that seems to be emerging from these data is that the relationship between patient f0 and bond is flipped during intervention. Suddenly, higher vocal expression of emotion predicts higher bond, as we originally hypothesized. So for the patient, higher vocally encoded emotional arousal at assessment is bad for bond, but during intervention it is good.
Lowess smoothed plots of two example cases demonstrating variability and synchrony in patient and clinician mean f0 over time during the intervention phase of emergency behavioral health encounters rated as high (left panel) and low (right panel) in emotional bond. (Note: bandwidth = .1).
Bryan et al. (under review)

20. Narrative Assessment
Ask patient to describe the chronology of events for the suicidal episode that led up to the crisis
“Let’s talk about your suicide attempt/what’s been going on lately.”
“Can you tell me the story of what happened?”
Assess events, thoughts, emotions, physical sensations, and behaviors
“What happened next?”
“And then what happened?”
“What were you saying to yourself at that point?”
“Did you notice any sensations in your body at that point?”

21. Narrative Assessment: Practice

22. Narrative Assessment
Ask patient to describe the chronology of events for the suicidal episode that led up to the crisis
“Let’s talk about your suicide attempt/what’s been going on lately.”
“Can you tell me the story of what happened?”
Assess events, thoughts, emotions, physical sensations, and behaviors
“What happened next?”
“And then what happened?”
“What were you saying to yourself at that point?”
“Did you notice any sensations in your body at that point?”

23. Crisis Response Planning: Mechanics

24. Crisis Response Plan Explain rationale for CRP
Provide card for patient to record CRP
Identify personal warning signs
Identify self-management strategies
Identify reasons for living
Identify social supports
Provide crisis / emergency steps
Verbally review and rate likelihood of use

25. Introducing the Crisis Response Plan
It sounds like things haven’t been going really well for you lately. Of all those issues and problems you described, which ones would you say you want to change the most?
I can see how you got to that point. If you could change one thing about what’s happening to you right now, what would that be?
What would you like to be different about what’s going on right now?

26. Warning Signs
What are some of the things you notice inside of yourself during these situations?
What are some of your indicators that things aren’t going so well and are getting out of control?
If we wanted to prevent this from happening in the future, how might we know when you’re heading down this road?
CRP Tips
Ask clarifying questions to obtain specific warning signs.
Ensure the warning signs occur far enough in advance to be helpful.

27. Self-Management
When feeling upset or stressed, what are some things that help you to calm down or feel less stressed?
What are some things you used to find helpful when stressed, even if you don’t do them anymore?
CRP Tips
If unable to identify self-management strategies, ask about strategies that have worked in the past.
If a strategy works in only one setting, ask about other strategies that can work in other settings.

28. Reasons for Living What are your reasons for living?
What gives you a sense of purpose and meaning in life?
What stands in the way of you killing yourself?
CRP Tips
Ask the individual to describe their reasons for living in detail to increase their emotional vividness.
If an individual says they have no reasons for living, reword by asking about what gets in the way of a suicide attempt.

29. Social Support
When feeling stressed or upset, who helps to take your mind off of things or cheer you up?
Who do you know who provides you with support during tough times?
People often have a family member, friend, or coworker who supports them in times of need. Who would that person be in your life?
CRP Tips
If an individual cannot identify a social support, provide some general suggestions.
If an individual still cannot identify a social support, normalize the situation and move to the next step.

30. Emergency Support Services
National Suicide Prevention Hotline: TALK
If you don’t answer your phone, make sure the patient knows that in advance
Include “go to the hospital or call 911” as the final step.
CRP Tips
If an individual is reluctant to include a particular emergency service, invite them to explain why.
Ask individuals if they would include emergency services even if unmotivated to use them.

31. Sample Crisis Response Plans

32. Other Tips for Effective Crisis Response Planning
Laminate the card
Take a picture of the card to keep in their smart phone
Complement with the “Virtual Hope Box” app

33. Crisis Response Planning: Practice

34. Crisis Response Plan Explain rationale for CRP
Provide card for patient to record CRP
Identify personal warning signs
Identify self-management strategies
Identify reasons for living
Identify social supports
Provide crisis / emergency steps
Verbally review and rate likelihood of use

35. Questions?