1. Addressing Suicide in Your Practice Gary McConahay PhD ColumbiaCare Services, Inc. gmcconahay@columbiacare.org

2. Expanding opportunities for doing therapy with people with suicide thoughts -National Strategy for SP -Affordable Care Act -OHP Expansion -Screening for Depression in Primary Care -Follow up after psychiatric hospitalization

3. What is your experience?

4. What are your worst fears?

5. Stone…1971 Many therapists unwittingly contribute to the probability of Suicide attempts in ‘suicide- prone’ patients by: – “Externalizing the superego” by mirroring the patient’s self-revilings – “Interrupting autistic defenses” by removing wish- fulfilling fantasies leading to confrontation of unbearable reality – Developing a “symbiotic transference”of an extremely primitive nature that is then broken off

6. Chemtob et al…1989 Survey says that 22% of psychologists and 51% of psychiatrists had experienced a patient suicide. “Both groups reported significant disruptions in their personal and professional lives after the patient’s suicide”. “We argue that patient suicide is an occupational hazard for psychologists and psychiatrists”

7. Hendin et al…2000 In depth testing and interview with 26 therapists who had lost a patient to suicide Shock, grief, guilt, fear of blame, self-doubt, shame, anger, and betrayal were major reactions 21 out of 26 said they would change tx decision: change medication, hospitalize, consult with previous therapist 19 said they met with family afterwards: almost all were not critical of the therapist

8. Hendin et al…2004 Questioned 34 therapists whose patients died by suicide 13 of 34 “severely distressed” by the suicide Sources of distress: – Failure to hospitalize – Tx decision therapist felt contributed to the suicide – Negative reactions from the therapist’s institution – Fear of a lawsuit by patient’s family

9. Yaseen et al…2013 Compared 82 therapists who had a patient die by suicide, had a high or low lethality attempt, or die by natural causes regarding how they felt about the patient last visit before they did their act. Therapists treating imminently suicidal patients had less positive feelings toward their patient but more hopeful for treatment than those treating non-suicidal patients Felt more overwhelmed, distressed by, and avoidant of suicidal patients

10. 1.Maintain appropriate clinician-patient relationships 2.Evaluate risk: intake and ongoing (e.g. management transitions) 3.Take adequate history, including records of past treatment 4.Examine mental status 5.Diagnose 6.Plan Treatment Outpatient standards of care Bongar 1992 10

11. 7.Specify hospitalization criteria 8.Obtain consultation & supervision 9.Properly evaluate need for pharmacological intervention 10.Properly evaluate suitability of pharmacotherapy provided 11.Safeguard the environment 12.Document, Document, Document Outpatient standards of care (cont) 11

12. How close to suicide is my patient? *Get some perspective; not all suicide thoughts mean the same thing *Makes a difference in approach

13. Let’s break it down… Prevent Death Address External Factors that contribute to suicide thoughts Change Internal Factors that foster suicide thoughts Change Internal Dynamics that predispose the person to suicide thoughts

14. Let’s break it down… INTERVENTION: Prevent Death MANAGEMENT: – Address External Factors that contribute to suicide thoughts – Change Internal Factors that foster suicide thoughts TREATMENT: Change Internal Dynamics that predispose the person to suicide thoughts

15. Intervention Unless the person has a suicide in progress you have time to talk As long as the person is talking to you they are safe Ask directly about suicide As the conversation progresses, the person feels relieved As the person feels relieved of pain and they feel hope When the person feels hope they are less likely to suicide Ambivalence

16. Intervention 2 Develop a plan to keep the person safe That may involve you and it will likely involve others…working together Go for plans that last hours or days, not weeks

17. Risks and Benefits of Hospitalization +May keep person safe for now +Relieves the therapist’s feeling of responsibility -Stigma, Cost -Hospital stay itself usually changes nothing -Post-hospital discharge period very vulnerable time -May damage therapeutic relationship -Where does the person go for help afterwards?

18. Intervention 3 Take: Applied Suicide Intervention Skills Training (ASIST) www.columbiacare.org/ASIST

19. Management Reasons for dying

20. Management Reasons for Dying can be external or internal Every reason for dying has embedded within it a reason for living It is not the event itself but the meaning behind the event The key meaning is LOSS

21. Management When a person is talking about their reasons for dying they are talking their losses. When a person is talking about their losses, they are talking about what they care about (if they did not care about it, it would not be a loss). When a person is talking to us about what they care about, they are telling us their reasons for living. Therefore, the more reasons for dying we can identify within a person at risk of suicide the more we learn about their reasons for living.

22. Management Bryan Tanney MD, SuicideCare, 2012 22

23. Assumption: Structural and developmental deficits may underlie the suicidal condition. Treatment 23

24. Meanings of suicidal acts Bryan Tanney MD, SuicideCare, 2012 24

25. Strategies  Repair or support a deficit state, whether structural or developmental  Resolve a focal conflict through enhanced insight  Integrate unhealthy attachment patterns by attending to the treatment relationship  Develop skills to support deficit states and overcome maladaptive coping styles Treatment 25

26. Additional resources Oregon Youth Suicide Prevention listservyspnetwork- bounces@listsmart.osl.state.or.usyspnetwork- bounces@listsmart.osl.state.or.us Oregon Suicide Prevention Coordinator-Donna Noonan Donna.noonan@state.or.us Clinician Survivor’s listserv aascliniciansurvivortaskforce@googlegroups.com

27. Additional Training ASIST (for intervention) Suicide to Hope (management and treatment) Gary McConahay PhD gmcconahay@columbiacare.org