2. Introduction to conceptualizing suicide risk in those with TBI Part 4 Beeta Y. Homaifar, PhD Melodi Billera, LCSW Where we discuss: Cost of not conceptualizing Barriers to conceptualization

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 5 Cost of not conceptualizing

6. Why bother conceptualizing?

7. Conceptualization: Why Bother? Developing a case conceptualization is time consuming – why not just go directly to a treatment plan?

8. Conceptualization: Why Bother? A Sample Case Illustrating a Common Problem for Many Clinicians

9. Conceptualization: Why Bother? A Sample Case Veona, a White female in her mid-30s, comes to see you because her teenage son has just been arrested and she doesn’t know what to do. She expresses a lot of fears for his safety in jail. She reveals occasional suicidal ideation with no intent and a past history of moderate-severe TBI. Since she presents with this crisis, you go into crisis management mode and provide her with emotional support, a safety plan, and advice about how to get legal representation. You intend to do a careful intake at the next session. Case Conceptualization and Treatment Planning - Sage Publications

10. Conceptualization: Why Bother? A Sample Case Week 2 arrives, however, and before you can try to do this, she presents with a new crisis (a romantic relationship is ending). You try to initiate a conversation about her previous crisis (her son), but she quickly diverts back to the current relationship crisis. She continues to express suicidal ideation with no intent. She admits to not having used her Safety Plan. You go into crisis management mode and encourage her again to use her safety plan, give her emotional support to calm her down and try to initiate a constructive conversation about her relationship issues. You’re determined to conduct your intake in the next session. Case Conceptualization and Treatment Planning - Sage Publications

11. Conceptualization: Why Bother? A Sample Case However, at the 3 rd session, Veona comes in drunk. She denies suicidal ideation at this appointment. You make several attempts to find out what happened with her teenage son and her significant other but she is unable to provide any information. You again encourage the use of her Safety Plan and send her home to sober up. Case Conceptualization and Treatment Planning - Sage Publications

12. Conceptualization: Why Bother? A Sample Case Your plan is to be very firm when she comes in for her fourth session; thus, before she has a chance to tell you anything, you indicate the need to conduct a thorough intake. Veona interrupts you and indicates she is about to become homeless if she can’t find the money to pay her rent by tomorrow. She used her rent money to pay the attorney you had recommended she get to represent her son. She reveals ideation at this session with no intent. Frustrated, you go into crisis intervention mode and again encourage the use of her Safety Plan, try to connect the client with community resources so that she won’t become homeless. Case Conceptualization and Treatment Planning - Sage Publications

13. Conceptualization: Why Bother? A Sample Case Treatment is in a state of chaos because you don’t know whether Veona’s son is out of jail or not, you don’t know if Veona is still with her significant other, and you don’t know if she has a long-standing problem with alcohol or if her drunkenness was just a reaction to extreme stress. You are also worried that the next crisis will push her over the edge and that she may act on her suicidal ideation. Case Conceptualization and Treatment Planning - Sage Publications

14. Conceptualization: Why Bother? A Sample Case You may be exhausted from all these crises

15. Conceptualization: Why Bother? A Sample Case And you may feel like you have a lot of “pieces” of information but don’t know what to do with all of it…

16. Conceptualization: Why Bother? A Sample Case Rewind and assume that while acknowledging the seriousness of her son’s difficulties and her suicidal ideation, when she brings them up, you still carry out an intake during the first session. After you obtain information about her history, you decide to form a conceptualization. Case Conceptualization and Treatment Planning - Sage Publications

17. Step 1 What does Veona think is driving her suicidal thinking? – “The crises in my life”

18. Step 2 How is it that she came to have these particular problems? – “Veona is a 35-year-old Caucasian woman who was raised by parents who either ignored how she was behaving or used abusive punishment. Veona survived this history by developing a people-pleasing style so that she wouldn’t get hurt.”

19. Step 2, continued How has she coped thus far? – “During times when she is overwhelmed, her problem solving ability goes out the window”

20. Step 2, continued What theory or set of theories can help explain this information? – “She never learned to set limits on other people’s behavior, including her son. As a result of being a people pleaser, she tends to find herself in romantic relationships with men who take advantage of her financially. Her life appears to be one crisis after another.” – “Her past history of moderate-severe TBI may also be contributing to her poor problem solving skills.”

21. Step 3 What interventions could be implemented to help address her crises and suicidal ideation? – Improving her communication and problem-solving skills

22. Conceptualization: Why Bother? A Sample Case When Veona comes in for Session 2, if she wants to talk about her break-up, you will: Share your conceptualization with her Get her feedback Begin addressing her difficulty with problem solving Case Conceptualization and Treatment Planning - Sage Publications

23. Conceptualization: Why Bother? A Sample Case You are not ignoring the crisis Veona wants to discuss. However, you are helping her build the skills she needs no matter what “issue” or “crisis” she wants to talk about. Case Conceptualization and Treatment Planning - Sage Publications

24. Conceptualization: Why Bother? A Sample Case Thus, while the process of developing a case conceptualization and treatment plan is time consuming at first, over time it will increase the likelihood you will provide effective and time-efficient treatment that could help reduce current suicidal ideation/behavior and potentially avert future instances of this... Case Conceptualization and Treatment Planning - Sage Publications

25. Objective 6 Barriers to conceptualization

26. What are the barriers to using conceptualization? It doesn’t fit with the way things are done at my facility There are liability issues – I have to respond to crises Lack of time

27. Conceptualization in Real Life OIF Veteran with TBI, PTSD, and Suicidal Ideation "Imagine the embarrassment. I used to be the protector, and now I can't even ****ing read? Somebody has to read to me, like I'm a child?" Cutler said. Wrote a book about his experiences "They started asking me my story, and other war fighters started telling me their story. 'It's like you're speaking for me,'" Cutler recalled. "I now had a real mission in life, and that's what saved my life, and continues to save my life every day." http://www.huffingtonpost.com/2013/09/28/iraq-veteran-suicide_n_3817583.html

28. Conceptualization: Reporters vs. Clinicians If you put a Veteran in a room with a reporter and a clinician, who is more likely to develop a story? What if we can be the clinician AND the reporter? Credit, Tammy Hopman, VISN 19 SPC

29. Objective 7 Summary

30. Conceptualizing your client’s experience of suicidal ideation/behavior is at the core of all treatment efforts

31. It enables us to have empathy for them

32. It reduces our anxiety about what to do for them

33. CONCEPTUALIZATION INTERVENTION ASSESSMENT INCREASES BUY-IN FOR TREATMENT

34. Thank you! beeta.homaifar@va.gov melodi.billera@va.gov