2. Introduction to conceptualizing suicide risk in those with TBI Part 3 Beeta Y. Homaifar, PhD Melodi Billera, LCSW Where we discuss: Role of executive functioning in conceptualizing and intervening with suicide risk

3. 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.

4. 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

5. Objective 4 Role of executive functioning in conceptualizing and intervening with suicide risk

6. A Number of Experts Encourage Assessment of Executive Functioning Rudd (2006) discusses "impaired self- control" in delineating levels of acute suicide risk among those with severe and extreme risk for suicide – In this context, impaired self-control may be related to problems with impulsivity and has implications for suicide risk

7. A Number of Experts Encourage Assessment of Executive Functioning Joiner et al (2007) state that in some individuals "cognitive constriction" underlies the feeling of being "trapped," which they believe may, in part, underlie the desire for suicide In this context, cognitive constriction may be related to a concrete thinking process during which an individual feels that there is no other choice but suicide

8. A Number of Experts Encourage Assessment of Executive Functioning Finally, the American Association of Suicidology (AAS) refers to various warning signs for suicidal behavior such as "acting reckless" and "feeling trapped" – Acting recklessly and feeling trapped may represent impulsivity and a concrete thinking process which lead to an increased risk for suicide

9. However… Limited clinical guidance regarding how to assess and incorporate this knowledge into one's understanding of an individual's suicide risk

10. Historically Formal assessment of executive functioning has been seen as the domain of those who assess and treat patients with neurologic disease But…it’s everyone’s domain

11. You want me to do more assessment???

12. Here’s the good news… Since formal assessments of executive functioning require more time, training, and resources than most clinicians are able to offer, we encourage providers to use their own ways of assessing executive functioning

13. Here’s the good news… Clinicians often assess some components of executive functioning during mental status exams or clinical interviews (e.g., impulsivity, insight, problem solving)

14. Here’s the good news… In other words, you likely already have some of this information!

15. CONCEPTUALIZATION INTERVENTION ASSESSMENT

16. Impulsivity Research/Clinical Relevance Compared to those who have not attempted suicide, those with a history of suicidal behavior show deficits in impulse control (Dougherty et al., 2004) For some, suicidal behavior may occur within ten minutes of having had suicidal ideation (Deisenhammer et al, 2009) ***When impaired inhibition is present, individuals may be less likely to make use of Safety Plans, consequently perhaps making them more likely to act on suicidal ideation*** An individual's inability to inhibit a particular behavior

17. Impulsivity Evaluation Informal: Infer from past behaviors (e.g., reckless driving, etc.) Formal: The following questions were taken from Rudd (2006): 1.Do you consider yourself an impulsive person? 2.Why or why not? 3.When have you felt out of control in the past? 4.What did you do that you thought was out of control? 5.What did you do to help yourself feel more in control? 6.When you're feeling out of control, how long does it usually take for you to recover?

18. Impulsivity Intervention Removing access to lethal means Devising barriers to lethal means Making items on Safety Plans simpler Ensuring that coping strategies have a component of immediate gratification that has positive emotional valence ***If your patient is impulsive and you believe s/he may have less than 2-3 minutes from ideation to behavior, what things might you not put on a Safety Plan?***

19. Insight Research/Clinical Relevance Believe they are not valued by others, despite evidence to the contrary Having insight into suicidal ideation/behavior, mental illness: May offer reassurance about the episodic nature of illness and the ebb and flow of symptoms Such insight in turn may reduce feelings of hopelessness, which are often associated with suicide (Beck, Steer, Kovacs, & Garrison, 1985) An appreciation of one's own behavior as well as the impact one makes on others

20. Insight Evaluation Informal: Is the individual aware of the interaction between their problems and their behavior and do they believe they need treatment? Formal: Joiner et al (2009) encourage clinicians to assess: – “The degree to which clients feel connected to – and cared about – by others, as well as the degree to which clients believe that others would be better off if they were gone" – Clinicians interested in specific assessment of these can use the Interpersonal Needs Questionnaire (Van Orden, Witte, Gordon, Bender, & Joiner, 2008)

21. Insight Intervention Involving family and loved ones in treatment – May help bolster an individual's sense of feeling connected to others – Give them an opportunity to see firsthand how their suicide would affect those around them Providing patients with psychoeducation about psychiatric illness – May help increase insight – Promote expectations of recovery ***Example: If insight is an issue, can clinicians assume that the patient will be aware of when they may need to use their Safety Plan?***

22. Problem Solving Clinical Relevance Individuals with concrete, inflexible thinking may have a bevy of maladaptive coping strategies that they continue using to no avail during a crisis When acutely suicidal, they may lack the cognitive flexibility needed to identify new solutions or strategies to cope with the issues driving their suicidal thoughts The ability to be flexible in how one thinks, shifting behavior when necessary

23. Problem Solving Evaluation Informal: Paying attention to the individual's manner of answering questions throughout the clinical interview (e.g., note when client thinks of only the most obvious solutions to various problems) Formal: Zuckerman (2000) suggests noting a tendency to: 1.Not grasp the nature of abstract questions such that it is difficult to find metaphors simple enough to help them understand 2.Note only surface features of life experiences 3.Offer only very specific examples to general questions 4.Have an overly broad or narrow degree of generalization

24. Problem Solving Intervention Providing patients with a variety of coping strategies, including barriers to their use ***Example: Once items are listed on a Safety Plan (e.g., taking a walk), how can clinicians trouble-shoot with patients regarding scenarios in which the patient may not be able to engage in the coping strategies listed?***

25. Thank you! This concludes Part 3 Please continue onto Part 4 beeta.homaifar@va.gov melodi.billera@va.gov