Suicide: The Silent Epidemic A Clinical Focus on Students

Suicide: The Silent Epidemic A Clinical Focus on Students
Lisa Firestone, PhD The Glendon Association

Suicide Rates by Age for Youths Aged 10-19 Years in the United States, 2000-2006 [8]
Epidemiology of Youth Suicide and Suicidal Behavior ,Scottye J. Cash, Ph.D. and Jeffrey A. Bridge, Ph.D. Curr Opin Pediatr October ; 21(5): 613–619

Number of Youth Suicides, by Gender: 2009
California Number Female 83 Male 304 Total 387 Definition: Number of suicides by youth ages , by gender. Data Source: California Department of Public Health, Center for Health Statistics, Vital Statistics Section, CD-Rom Public Use Death Files.

Youth Suicide Rate: 1995-1997 - 2007-2009
Definition: Number of suicides per 100,000 youth age Data Source: California Department of Public Health, Center for Health Statistics, Vital Statistics Section, CD-Rom Public Use Death Files. State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, , , accessed online at 2011). Footnote: Figures are presented as rates over three-year periods. LNE (Low Number Event) refers to data that have been suppressed because there were fewer than 20 suicides.

Self-Inflicted Injury Hospitalization Rate: 2009
Definition: Number of non-fatal self-inflicted injury hospitalizations per 100,000 for children/youth ages Data Source: State of California Department of Public Health, Epidemiology and Prevention for Injury Control Branch, California Office of Statewide Health Planning and Development, Patient Discharge Data. Accessed online athttp://epicenter.cdph.ca.gov/; State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, , Accessed online at 2011). Footnote: Injury hospitalizations are measured by the number of discharges from acute care hospital facilities for injuries among children and youth. The most common types of self-inflicted injuries are related to poisoning, and cutting or piercing. LNE (Low Number Event) refers to data that have been suppressed because there were fewer than 20 cases in the numerator.

Number of Youth Suicides, by Race/Ethnicity: 2009
California Number African American/Black 25 Asian/Pacific Islander 36 Caucasian/White 173 Hispanic/Latino 134 Native American/Alaska Native 7 Multiracial 11 Total 387 Data Source: State of California Department of Public Health, Epidemiology and Prevention for Injury Control Branch, California Office of Statewide Health Planning and Development, Patient Discharge Data. Accessed online athttp://epicenter.cdph.ca.gov/; State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, , Accessed online at 2011).

Suicide Figures from the Centers for Disease Control for the year 2009
Suicide Figures from the Centers for Disease Control for the year All rates are per 100,000 population.

Why is this topic important?
Suicide is the third leading cause of death for youth ages nationwide. In 2009, 6.3% of U.S. 9th-12th-graders reported having attempted suicide one or more times in the past year. Approximately 149,000 young people ages are treated for self-inflicted injuries at U.S. emergency departments every year. According to data collected by the National Center for Injury Prevention and Control, poisoning is the most common reason for intentional, self-inflicted, non-fatal injury hospitalizations for 10- to 24-year-olds. Self-injurious behavior, in general, often is stigmatized and hidden from family and friends. Data Source: State of California Department of Public Health, Epidemiology and Prevention for Injury Control Branch, California Office of Statewide Health Planning and Development, Patient Discharge Data. Accessed online athttp://epicenter.cdph.ca.gov/; State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, , Accessed online at 2011).

ED Treatment of Mental Disorders
One in ten suicides are by people seen in the ED within two months of dying.

Suicide in Adolescents
A previous suicide attempt increases suicide risk by times. Forwood et al. (2007) reported that a suicide attempt is likely to be highest among youth presenting with a combination of depression and externalizing behavior and those with a romantic breakup, being assaulted, or being arrested. More than 90% of adult suicide attempters and 80% of adolescent attempters and completers communicate suicidal ideation prior to the attempt. Adolescents with prior attempts are 18x more likely to make future attempts. Half of the youth who attempt suicide do not receive treatment beyond psychotropic medication.

Suicide in College Students
Self-reports of suicidal ideation in college students have ranged from 32% to 70%. It is estimated that there are 1100 suicides on college campuses in the US each year Suicide is the second leading cause of death in college-age students. One in 12 college students have seriously contemplated suicide.

Implications of Epidemiological Data
There is a need to intervene early in the development trajectory of the depression and suicidal behavior. The Melissa Institute for Violence Prevention

Misconceptions About Suicide
Most suicides are caused by one particular trigger event. Most suicides occur with little or no warning. It is best to avoid the topic of suicide. People who talk about suicide don't do it. Nonfatal self-destructive acts (suicide attempts) are only attention-getting behaviors. A suicidal person clearly wants to die. If a person who has been depressed is suddenly feeling better, the danger of suicide is gone.

Our Approach to Suicide
Each person is divided: One part wants to live and is goal directed and life affirming. And one part is self-critical, self-hating and at its ultimate end, self-destructive. The nature and degree of this division varies for each individual. Real Self - Positive Anti-Self - Critical

Negative thoughts exist on a continuum, from mild self-critical thoughts to extreme self-hatred to thoughts about suicide You need to have a drink, so you can relax You don’t deserve anything You should be by yourself You should just kill yourself You’re a creep

Self-destructive behaviors exist on a continuum from self-denial to substance abuse to actual suicide. Hating Yourself Substance Abuse Self-Denial Isolation Risk Taking Suicide

There is a relationship between these two continuums. How a person is thinking is predictive of how he or she is likely to behave. Thoughts Feelings Behavior Event

Definition of the Voice
The critical inner voice refers to a well-integrated pattern of destructive thoughts toward our selves and others. The “voices” that make up this internalized dialogue are at the root of much of our maladaptive behavior. This internal enemy fosters inwardness, distrust, self-criticism, self-denial, addictions and a retreat from goal-directed activities. The critical inner voice effects every aspect of our lives: our self-esteem and confidence, our personal and intimate relationships, and our performance and accomplishments at school and work.

Where Do Critical Inner Voices Come From?

How Voices Pass From Generation to Generation

Attachment Theory Sir John Bowlby, Ph.D.
Harry Harlow, Ph.D. Rene Spitz, M.D Mary Ainsworth, Ph.D. Mary Main, Ph.D. Erik Hesse, Ph.D. Adult Attachment Interview: predicts the baby’s attachment to the parent with 80% accuracy before the baby is even born

Where do voices come from?
Patterns of Attachment in Children Category of Attachment Secure Insecure – avoidant Insecure- anxious/ambivalent Insecure - disorganized Parental Interactive Pattern Emotionally available, perceptive, responsive Emotionally unavailable, imperceptive, unresponsive and rejecting Inconsistently available, perceptive and responsive and intrusive Frightening, frightened, disorienting, alarming

Attachment Figures Low Risk Non-Clinical Populations Secure 55-65%
Ambivalent 5-15% Avoidant % Disorganized % (Given a Best Fit Alternative) High Risk, Parentally maltreated Disorganized 80% 28

What causes insecure attachment?
Unresolved trauma/loss in the life of the parents statistically predict attachment style far more than: Maternal Sensitivity Child Temperament Social Status Culture

Implicit Versus Explicit Memory
Implicit Memory Explicit Memory

How does disorganized attachment pass from generation to generation?
Implicit memory of terrifying experiences may create: Impulsive behaviors Distorted perceptions Rigid thoughts and impaired decision making patterns Difficulty tolerating a range of emotions

Daniel Siegel, M.D. – Interpersonal Neurobiology
The Brain in the Palm of Your Hand Daniel Siegel, M.D. – Interpersonal Neurobiology

9 Important Functions of the Pre-Frontal Cortex
Body Regulation Attunement Emotional Balance Response Flexibility Empathy Self-Knowing Awareness (Insight) Fear Modulation Intuition Morality 33

“Type D” Attachment Disorganized/Disoriented
Predicts later chronic disturbances of: affect regulation stress management hostile-aggressive behavior

Infant’s Response to Trauma
Two sequential response patterns: hyperarousal dissociation

Poly-Vagal Theory -Stephen Porges, 2007
Neuroception (Vagus Nerve) Receptivity

Division of the Mind Parental Ambivalence Parents both love and hate themselves and extend both reactions to their productions, i.e., their children. Parental Nurturance Parental Rejection, Neglect Hostility 37

Prenatal Influences Disease Trauma Substance Abuse/ Domestic Violence
38

Birth Trauma Baby Genetic Structure Temperament Physicality Sex 39

Self-System Parental Nurturance Unique make-up of the individual
(genetic predisposition and temperament); harmonious identification and incorporation of parent’s positive attitudes and traits and parents positive behaviors: attunement, affection, control, nurturance; and the effect of other nurturing experience and education on the maturing self-system resulting in a sense of self and a greater degree of differentiation from parents and early caretakers. Self-System Parental Nurturance 40

Personal Attitudes/ Goals/Conscience
Realistic, Positive Attitudes Toward Self Realistic evaluation of talents, abilities, etc…with generally positive/ compassionate attitude towards self and others. Behavior Ethical behavior towards self and others Goal Directed Behavior Goals Needs, wants, search for meaning in life Moral Principles Acting with Integrity

Unique vulnerability: genetic predisposition and temperament
Anti-Self System Unique vulnerability: genetic predisposition and temperament Destructive parental behavior: misattunement, lack of affection, rejection, neglect, hostility, over permissiveness Other Factors: accidents, illnesses, traumatic separation, death anxiety The Fantasy Bond (core defense) is a self-parenting process made up of two elements: the helpless, needy child, and the self-punishing, self-nurturing parent. Either aspect may be extended to relationships. The degree of defense is proportional to the amount of damage sustained while growing up. 42

Anti-Self System Self-Punishing Voice Process
1. Critical thoughts toward self 2. Micro-suicidal injunctions 3. Suicidal injunctions – suicidal ideation Behaviors Verbal self-attacks – a generally negative attitude toward self and others predisposing alienation. Addictive patterns. Self-punitive thoughts after indulging. Actions that jeopardize, such as carelessness with one’s body, physical attacks on the self, and actual suicide Source Critical parental attitudes, projections, and unreasonable expectations. Identification with parents defenses Parents’ covert and overt aggression (identification with the aggressor). 43

Anti–Self System Self- Soothing Voice Process
Behaviors Self-limiting or self-protective lifestyles, Inwardness Verbal build up toward self Alienation from others, destructive behavior towards others. Addictive patterns. Thoughts luring the person into indulging. Aggressive actions, actual violence. Voice Process 1. Self-soothing attitudes 2. Aggrandizing thoughts toward self 3. Suspicious paranoid thoughts toward others. 4. Micro-suicidal injunctions 5. Overtly violent thoughts Source Parental over protection, imitation of parents’ defenses Parental build up Parental attitudes, child abuse, experienced victimization. Imitation of parents’ defenses. Parental neglect, parents’ overt aggression (identification with the aggressor). 44

How does a Suicide Occur?
Underlying Vulnerability e.g. Mood disorder/Substance abuse/ Aggression/ Anxiety/Family history/Sexual orientation/Abnormal serotonin metabolism Stress Event (often caused by underlying condition) e.g. In trouble with law or school/Loss Acute Mood Change Anxiety/Dread/Hopelessness/Anger Inhibition Facilitation e.g. Strong taboo/Available support/Slowed down mental state/Presence of others/Religiosity e.g. Weak taboo/ Method weapon available/ Recent example/State of excitation agitation/ Being alone Survival Suicide

Continuum of Negative Thought Patterns
Thoughts that lead to low-self-esteem or inwardness (self-defeating thoughts): Levels of Increasing Suicidal Intention Self-depreciating thoughts of everyday life 2. Thoughts rationalizing self-denial; thoughts discouraging the person from engaging in pleasurable activities 3 Cynical attitudes towards others, leading to alienation and distancing Content of Voice Statements You’re incompetent, stupid. You’re not very attractive. You’re going to make a fool of yourself. You’re too young (old) and inexperienced to apply for this job. You’re too shy to make any new friends. Why go on this trip? It’ll be such hassle. You’ll save money by staying home. Why go out with her/him? She’s cold, unreliable; she’ll reject you. She wouldn’t go out with you anyway. You can’t trust men/women.

Thoughts that lead to low-self-esteem or inwardness (self-defeating thoughts): Levels of Increasing Suicidal Intention 4. Thoughts influencing isolation; rationalizations for time alone, but using time to become more negative toward oneself 5. Self-contempt; vicious self-abusive thoughts and accusations (accompanied by intense angry affect) Content of Voice Statements Just be by yourself. You’re miserable company anyway; who’d want to be with you? Just stay in the background, out of view. You idiot! You bitch! You creep! You stupid shit! You don’t deserve anything; you’re worthless.

Thoughts that support the cycle of addiction (addictions): Levels of Increasing Suicidal Intention 6. Thoughts urging use of substances or food followed by self-criticisms (weakens inhibitions against self-destructive actions, while increasing guilt and self-recrimination following acting out). Content of Voice Statements It’s okay to do drugs, you’ll be more relaxed. Go ahead and have a drink, you deserve it. (Later) You weak-willed jerk! You’re nothing but a drugged-out drunken freak.

Thoughts that lead to suicide (self-annihilating thoughts): Levels of Increasing Suicidal Intention Thoughts contributing to a sense of hopelessness urging withdrawal or removal of oneself completely from the lives of people closest. 8. Thoughts influencing a person to give up priorities and favored activities (points of identity). 9. Injunctions to inflict self-harm at an action level; intense rage against self. Content of Voice Statements See how bad you make your family (friends) feel. They’d be better off without you. It’s the only decent thing to do; just stay away and stop bothering them. What’s the use? Your work doesn’t matter any more. Why bother even trying? Nothing matters anyway. Why don’t you just drive across the center divider? Just shove your hand under that power saw!

Thoughts that lead to suicide (self-annihilating thoughts): Levels of Increasing Suicidal Intention 10. Thoughts planning details of suicide (calm, rational, often obsessive, indicating complete loss of feeling for the self). 11. Injunctions to carry out suicide plans; thoughts baiting the person to commit suicide (extreme thought constriction). Content of Voice Statements You have to get hold of some pills, then go to a hotel, etc. You’ve thought about this long enough. Just get it over with. It’s the only way out.

Why Use Objective Measures? What Interferes with Clinical Judgment
Anxiety Counter Transference Psych Ache Research Minimizing Diverse Menu of Risk Factors

The Suicidal Child Spectrum of Suicidal Behavior
by Cynthia R. Pfeffer, MD The Guilford University Press Spectrum of Suicidal Behavior 1. Nonsuicidal- No evidence of any self-destructive or suicidal thoughts or actions. 2. Suicidal Ideation- Thoughts or verbalization of suicidal intention. Examples: a. “I want to kill myself” b. Auditory hallucination to commit suicide 3. Suicidal Threat- Verbalization of impending suicidal action and/ or a precursor action which. If fully carried out, could have led to harm. Examples: a. “I am going to run in front of a car” b. Child puts a knife under his or her pillow c. Child stands near an open window and threatens to jump

Thoughts about my life Name___________________________ Date________
Sex_____ Race_________________ Age_________ Education________________________________________ Occupation______________________________________ Directions Listed below are thoughts that people sometimes have. Read each sentence carefully and decide which of these thoughts you had in the past month. Circle the letter beneath the answer that best describes your own thoughts. If you make a mistake or change your mind, make an “X” through the incorrect response and then circle the correct response. DO NOT ERASE. There are no right or wrong answers so answer each sentence as openly and honestly as possible. Be sure to answer each sentence. DO NOT leave any sentence blank. Had this thought before but not in the last month F F F F F F F F F F Couple times a month D D D D D D D D D D About once a month E E E E E E E E E E I never had this thought G G G G G G G G G G Couple times a week B B B B B B B B B B About once a week C C C C C C C C C C Almost Everyday A A A A A A A A A A This thought was in my mind I thought it would be better if I was not alive I thought about killing myself………………………………………………….. I thought about how I would kill myself……………………………………… I thought about when I would kill myself……………………………………. I thought about what to write in a suicide note…………………………… I thought about telling people I plan to kill myself………………………… I thought that people would be happier if I was not around…………… I thought about how people would feel if I killed myself………………… I wished I were dead…………………………………………………………….. I thought about how easy it would be to end it all…………………………

Columbia Suicide Severity Scale ( C-SSS)
Suicidal Behavior Suicidal Ideation

Columbia-Suicide Severity Rating Scale (C-SSRS)
Suicidal Ideation Ask questions 1 and 2. If both are negative, proceed to “Suicidal Behavior” section. If the answer to question 2 is “yes”, ask questions 3, 4, and 5. If the answer to question 1 and/or 2 is “yes”, complete “Intensity of Ideation” section below. Wish to be Dead 2. Non-specific Active Suicidal Thoughts 3. Active Suicidal Ideation with any Methods (not plan) without Intent to Act 4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan 5. Active Suicidal Ideation with Specific Plan and Intent

Intensity of Ideation Frequency Duration Controllability Deterrents Reason for Ideation

Suicidal Behavior (Check all that apply, so long as these are separate events; must ask about all types) Actual Attempt Have you made a suicide attempt? Have you done anything to harm yourself? Have you done anything dangerous where you could have died? What did you do? Did you ________ as a way to end your life? Did you want to die (even a little) when you _________? Were you trying to end your life when you __________? Or did you think it was possible you could have died from __________? Or did you do it purely for other reasons/without ANY intention of killing yourself (like to relieve stress, feel better, get sympathy, or get something else to happen)? (Self-injurious behavior without suicidal intent) If yes, describe: Has subject engaged in Non-Suicidal Self-Injurious Behavior? Past X years or Lifetime YES NO Total # of attempts ______ YES NO

Columbia-Suicide Severity Rating Scale (C-SSRS) cont’d
Past X years or Lifetime YES NO Total # of interrupted ______ YES NO Total # of aborted _______ YES NO Interrupted Attempt: Has there been a time when you started to do something to end your life but someone or something stopped you before you actually did anything? If yes, describe: Aborted Attempt: Has there been a time when you started to do something to try and end your life but you stopped yourself before you actually did anything? Preparatory Acts or Behavior: Suicidal Behavior: Suicidal Behavior was present during the assessment period?

BHS Sample Questionnaire
1. I look forward to the future with hope and enthusiasm. T F 2. I might as well give up because there is nothing I can do about making things better for myself. T F 3. When things are going badly, I am helped by knowing that they cannot stay that way forever. 4. I can’t imagine what my life would be like in ten years. T F

Our Measures Based on Separation Theory developed by Robert W. Firestone, PhD. and represents a broadly based coherent system of concepts and hypothesis that integrates psychoanalytic and existential systems of thought. The theoretical approach focuses on internal negative thought processes. These thoughts (i.e. “voices”) actually direct behavior and, thus, are likely to predict how an individual will behave.

Firestone Assessment of Self-Destructive Thoughts
Never Rarely Once In A While Frequently Most Of The Time 1. Just stay in the background. 1 2 3 4 2. Get them to leave you alone. You don’t need them. 3. You’ll save money by staying home. Why do you need to go out anyway? 4. You better take something so you can relax with those people tonight. 5. Don’t buy that new outfit. Look at all the money you are saving.

Figure 3. Approximate ROC Curves for the FVSSDB, SPS, and BHS

Uses for Our Measures Risk Assessment Treatment Planning
Targeting Intervention Outcome Evaluation

Firestone Assessment of Suicide Intent Record Form
Name: ____________________________________ Sex: Male Female Age: ______ Date: / / Examiner: ______________________________________ Instructions This form contains a number of statements. I want you to read each statement carefully and indicate how often you have each thought by filling in the appropriate box to the right. For example, consider the thought, “You are going to make a fool of yourself.” Do you experience this thought never, rarely, once in a while, frequently, or most of the time? Please indicate the frequency with which you experience the following thoughts toward yourself. If you wish to change your answer, put an X through it and fill in your new choice. If you have questions, be sure to let me know. Never Rarely Once in Awhile Frequently Most of the Time 1. Life would be so much easier if you just killed yourself. □ □ □ □ □ 2. Life would be simple; there would be no life and you wouldn’t have to torture yourself any longer. 3. You coward, just do it already. Kill yourself. 4. It’s too bad you have to kill yourself to show people how much you’re hurting. 5. Why don’t you end it all? Go ahead! It’ll be over in a minute. 6. It’s such a struggle to simply get through a day. You can always choose death as a last resort. 7. Look at all the trouble you’re causing. If you were dead, there would be no more trouble. 8. Smash yourself! You don’t deserve to be alive!

Suicide Warning Signs Disturbed sleep patterns Anxiety, agitation
Pulling away from friends and family Past attempts Extremely self-hating thoughts Feeling like they don’t belong Hopelessness, Feelings of hopelessness and worthlessness that often accompany depression Rage, Impulsive aggression (the tendency to react to frustration or provocation with hostility or aggression)

Suicide Warning Signs Feeling trapped
Increased use of alcohol or drugs Feeling that they are a burden to others Loss of interest in favorite activities -“nothing matters” Giving up on themselves Risk-taking behavior Suicidal thoughts, plans, actions Sudden mood changes for the better

Suicide Warning Signs, cont’d
Major Risk Factors for Suicide Among Adolescents Suicide Warning Signs, cont’d A psychiatric disorder, especially major depressive disorder, bipolar disorder, conduct disorder, and substance (alcohol and drug) use disorders Psychiatric comorbidity, especially the combination of mood, disruptive, and substance abuse disorders Personality disorders (especially cluster B disorders: antisocial, borderline, histrionic, narcissistic) Availability of lethal means A family history of depression or suicide Loss of a parent to death or divorce Family discord Physical and/or sexual abuse Lack of a support network, poor relationships with parents or peers and feelings of social isolation Dealing with homosexuality in an unsupportive family or community or hostile school environment Data Source: State of California Department of Public Health, Epidemiology and Prevention for Injury Control Branch, California Office of Statewide Health Planning and Development, Patient Discharge Data. Accessed online athttp://epicenter.cdph.ca.gov/; State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, , Accessed online at 2011).

Protective Factors Family and community connections/ support
Clinical Care (availability and accessibility) Resilience Coping Skills Frustration tolerance and emotion regulation Cultural and religious beliefs; spirituality

Those Who Desire Suicide
Those Who Are Capable of Suicide Perceived Burdensomeness + Thwarted Belongingness Serious Attempt or Death by Suicide Joiner, Thomas. Why People Die By Suicide. “The Three Components of Completed Suicide.” Harvard University Press, 2005.

Joiner (2005, p. 227) assesses these attributes by asking such questions as:
Acquired Ability to Enact Lethal Self-Injury Things that scare most people do not scare me. I can tolerate a lot more pain than most people. I avoid certain situations (e.g., certain sports) because of the possibility of injury (Reversed scored) b. Burdensomeness The people I care about would be better off if I were gone. I have failed the people in my life. c. Belongingness These days I am connected to other people. These days I feel like an outsider in social situations (Reversed scored) These days I often interact with people who care about me

Multiple Attempters as a Special High-Risk Group (in comparison to single attempters/ideators)
Distinctive in every way Greater likelihood to have diagnosis, co-morbidity, personality disorder Younger at time of first attempt (greater chronicity) Lower lethality first attempt (raises question about intent, function of behavior) More impulsive More likely to be associated with substance abuse Greater symptom severity Anxiety, depression, hopelessness, anger, suicidal ideation (frequency, intensity, specificity, duration, intent) More frequent histories of trauma, abuse Distinctive characteristics of crises

Safety Plan, Stanley and Brown, 2008 Figure 6. 3
Safety Plan, Stanley and Brown, 2008 Figure 6.3. Example of a safety plan developed during the early phase of treatment. ED=emergency department Warning signs (when I am to use the safety plan): wanting to go to sleep and not wake up wanting to hurt myself thinking “I can’t take it anymore” Coping strategies (things I can try to do on my own): listening to rock music rocking in a chair going for a walk controlled breathing taking a hot or cold shower exercising 3. Contacting other people: Calling a friend to distract myself: ______________________ Phone:__________________ If distraction does not work, I will tell any of the following people that I am in crisis and ask for help: Calling a family member:_______________________Phone:_______________________ Calling or talking to someone else:_______________________Phone:___________________ 4. Contacting a health care professional during business hours: Calling my therapist:_____________________Phone:__________________________ Calling my psychiatrist:_______________________Phone:______________________ Calling my case manager:______________________Phone:____________________ The following agencies or services may be called 24 hours a day/7 days a week: Calling the psychiatrist ED:_________________________Phone:____________________ Calling National Suicide Prevention Lifeline Phone: TALK Patients signature:_______________________________Date:___________ Clinician signature:______________________________Date:___________

Safety Plan, Stanley and Brown, 2008 - Adolescent
STEP ONE: WARNING SIGNS AND TRIGGERS: Ask: “How will you know when the safety plane should be used?” Ask: “What do you experience when you start to think about suicide or feel extremely depressed?” List warning signs (thoughts, images, thinking processes, mood, an/or behaviors) using adolescent’s own words Ask: “What sets off the ‘bad’ thoughts?” (consider, thoughts, events, emotional states etc.) List triggers STEP TWO: INTERNAL COPING SKILLS Ask: “What can you do on your own, if you become suicidal again, to help yourself not to act on your thoughts or urges?” Ask: “How likely are you to do this during a time of crisis?” Ask: “What might stand in the way of you using these strategies?” List coping strategies and barriers STEP THREE: SOCIAL CONTACTS WHO MAY DISTRACT FROM THE CRISIS Ask: “Who or what social settings can help take your mind off your problems at least for a little while?” Ask: “Who helps you feel better?” Ask about potential obstacles Ask about a “Safe Place” they could go (i.e.. Coffee Shop) List people (with phone numbers) and places

Safety Plan, Stanley and Brown, 2008 - Adolescent
STEP FOUR: FAMILY AND FRIENDS WHO MAY OFFER HELP Ask: “Among your friends and family, who do you think you could contact during a crisis? Who is supportive of you?” Role play and rehearsal can be very useful in this step List names and numbers of people who could come over and keep an eye on your teenager STEP FIVE: PROFESSIONALS AND AGENCIES TO CONTACT FOR HELP Ask: “Who are the mental health professionals that you should identify to be on your safety plan?” and “Are there other health care providers?” If your teen’s thoughts of suicide persist please contact your local mental health provider immediately to have your child assessed for his or her level of risk!! List names and numbers of mental health professionals, caseworkers, juvenile offers etc. that can help your teenager with their suicidal thoughts. STEP SIX: MAKING THE ENVIRONMENT SAFE Ask: “Do you or your family own a gun? Knives?” or “Where are all the pills in your house?” Ask: “What other means of hurting yourself do you have access too?” Ask: “How can we go about limiting access to these items?” Lock up all guns, knives, and pills and begin to monitor all other potential weapons All of this information should be written down and should be easily accessed by your teenager as well as other family members who may be assisting in maintaining your teen’s safety. I suggest keeping a copy on the frig, placing one in your teenager’s room, and keeping one in your wallet or purse.

Ways to Increase Social Supports
Make a list of possible social supports Utilize family resources Proactively develop healthy new social supports (e.g., join social club) Teach the patient how to access and use social supports Involve family members (significant others) in treatment with the patient’s permission. For example, educate the patient’s parents about the nature of depression and comorbid disorders and on ways they can provide support. Help significant others understand that it is not dangerous to ask the patient how he/she is feeling. Encourage the patient to let people know when he/she is suicidal. Patient can be asked: “Who are three people you will call if you are feeling like hurting yourself? Which adult or helper (counselor, therapist) do you feel comfortable calling? What is there name?” 1. 2. 3. This activity is designed to challenge the patient’s belief that “No one cares” and to ensure that the patient contacts “safe” supportive people (non-suicidal).

Crisis Response Plan When I’m acting on my suicidal thoughts by trying to find a gun (or another method to kill myself), I agree to take the following steps: Step 1. I will try to identify specifically what’s upsetting me. Step 2. Write out and review more reasonable responses to my suicidal thoughts, including thoughts about myself, others, and the future. Step 3. Review all the conclusions I’ve come to about these thoughts in the past in my treatment log. For example, that the sexual abuse wasn’t my fault and I don’t have anything to feel ashamed of. Step 4. Try and do the things that help me feel better for at least 30 minutes (listening to music, going to work, calling my best friend) Step 5. Repeat all of the above at least one more time. Step 6. If the thoughts continue, get specific, and I find myself preparing to do something, I’ll call the emergency call person at (phone number: XXXXXXX). Step 7. If I still feel suicidal and don’t feel like I can control my behavior, I’ll go to the emergency room located at XXXXXXX, phone number XXXXXXX.

10 Most Common Errors in Suicide Prevention
Superficial Reassurance Avoidance of Strong Feelings Professionalism Inadequate Assessment of suicidal intent Failure to identify the precipitating event Passivity Insufficient Directiveness Advice Giving Stereotypic Responses Defensiveness

Practice Recommendations
When imminent risk does not dictate hospitalization, the intensity of outpatient treatment (i.e., more frequent appointments, telephone contacts, concurrent individual and group treatment) should vary in accordance with risk indicators for those identified as high risk.

If the target goal is a reduction in suicide attempts and related behaviors, treatment should be conceptualized as long-term and target identified skills deficits (e.g., emotion regulation, distress tolerance, impulsivity, problem-solving, interpersonal assertiveness, anger management), in addition to other salent treatment issues.

If therapy is brief and the target variable are suicidal ideation, or related sumptomatology such as depression, hopelessness, or loneliness, a problem-solving component should be used in some form or fashion as a core intervation.

Regardless of therapeutic orientation, an explanatory model should be detailed identifying treatment targets, both direct (i.e., suicidal ideation, attempts, related self-destructive and self-multistory behaviors) and indirect (depression, hopelessness, anxiety, and anger; interpersonal relationship dysfunction; low self-esteem and poor self-image; day-to-day functioning at work and home).

Use of standardized follow-up and referral procedure (e.g., letters or phone calls) is recommended for those dropping out of treatment prematurely in an effort to enhance compliance and reduce risk for subsequent attempts.

Informed consent

Commitment to Treatment Statement in Practice
I understand and acknowledge that, to a large degree, a successful treatment outcome depends on the amount energy and effort I make. If I feel like treatment is not working. I agree to discuss it with my therapist and attempt to come to a common understanding as to what the problems are and identify potential solutions. In short, I agree to make a commitment to living. This agreement will apply for the next three months, at which time it will be reviewed and modified. Signed: _____________________ Date: _______________________ Witness: _____________________

Commitment to Treatment Statement in Practice
Attending sessions (or letting my therapist know when I can’t make it), Setting goals, Voicing my opinions, thoughts, and feelings honestly and openly with my therapist (whether they are negative or positive, but most importantly my negative feelings), Being actively involved during sessions, Completing homework assignments, Taking my medications as prescribed, Experimenting with new ways of doing things, And implementing my crisis response plan when needed (see attached crisis response plan card for details).

Suicide Status Form-III (SSF III) Initial Session
Rank Patient__________________________ Clinician______________________ Date___________ Time_____ Section A-Patient Rate and fill out each item according to how you feel right now. Then rank items in order of importance 1 to 5 (1=most important, 5=least important) Rate psychological pain (hurt, anguish, or misery in your mind; not stress; not physical pain): Low Pain: :High Pain What I find most painful is:__________________________________________________________________ 2. Rate stress(your general feeling of being pressured or overwhelmed): Low Stress: :High Stress What I find most stressful is:__________________________________________________________________ 3. Rate agitation(emotional urgency; feeling that you need to take action; not irritation; not annoyance): Low Agitation: :High Agitation I most need to take action when:____________________________________________________________ Rate Hopelessness (your expectation that things will not get better no matter what you do) Low Hopelessness: :High Hopelessness I am most hopeless about:___________________________________________________________________ 5. Rate Self-Hate (your general feeling or disliking of yourself; having no self-esteem; having no self-respect) Low Self-Hate: :High Self-Hate What I hate most about myself is:_____________________________________________________________ 6. Rate overall Risk of Suicide: Extremely Low Risk (will not kill self: :Extremely High Risk (will kill self) N/A

1.How much is being suicidal related to thoughts and feelings about yourself? Not at all: :Completely 2. How much is being suicidal related to thoughts and feelings about others? Not at all: :Completely Rank Rank Reason for living Reason for dying

CAMS patients reached resolution of suicidality about 4-6 weeks more quickly than treatment as usual patients. ( Jobes et al., 2003, Wong, 2003)

Effective Therapy Approaches for Treating the Suicidal Person
Cognitive Therapy for suicidal people was developed by Aaron Beck and Gregory Brown. Unlike other CBT treatments, this approach is not time limited. The third and last stage is “Relapse Prevention with a Twist.” Clients do not graduate from treatment until they demonstrate that they are ready to do this on their own. Dialectical Behavior Therapy, developed by Marsha M. Linehan, is designed to treat emotion regulation difficulties and suicidal behavior. One element, the skill-building component of DBT, addresses the issues of distress tolerance and the development of healthy affect regulation strategies, both of which are essential for suicidal clients. Mentalizing Treatment, developed by Jon Allen and Peter Fonagy, emphasizes emotional regulation and expressiveness. The techniques implemented assist clients in forming good affect regulation and tolerance through the process of developing the mentalizing capability to observe and understand their mind and the minds of others, accurately seeing the mind behind the behavior. Transference Focused Therapy, developed by Kernberg, Clarkin, and Yeomans, concentrates on the intermediate interaction between the client and therapist in session by focusing on the therapeutic relationship. Voice Therapy, which was developed by Robert Firestone, is a cognitive-affective-behavioral therapeutic methodology that brings introjected hostile thoughts, with the accompanying negative affect, to consciousness, rendering them accessible for treatment. This technique facilitates the identification of the negative cognitions driving the suicidal actions, which in turn helps clients to gain a measure of control over all aspects of their self-destructive or suicidal behavior. This process helps clients expand their personal boundaries, develop a sense of meaning in life, and reduce the risk of self-destructive behavior, including suicide.

Construction of a Hope Kit*
Another activity that is undertaken in the middle phase of therapy is the construction of a hope kit. A hope kit consists of a container that holds mementos (photographs, letters, souvenirs) that serve as reminders of reasons to live. Patients are instructed to be as creative as possible when creating their hope kit, so that the end result is a powerful and personal reminder of their connection to live that can be used when feeling suicidal. We have found that patients report making their hope kits to be a highly rewarding experience that often leads them to discover reasons to live they had previously overlooked. Suzanne was rather artistic and reported that she enjoyed this task. She found an old shoe box and decorated it using some of her favorite pictures. Inside she included pictures of her mother, her friends, and her cart. She also included the lyrics of her favorite song, a potpourri bag filled with her favorite scent, and a piece of her childhood blanket. Suzanne kept the hope box on her dresser, and it frequently reminded her of all the good things in her life. **Excerpted from “Cognitive Therapy, Cognition, and Suicidal Behavior” by GK Brown, E Jeglic, GR Henriques, and AT Beck In T.E. Ellis (Ed.), Cognition and Suicide (APA Books, 2006).

Establish therapeutic alliance with the suicidal patient, Brown and Beck (2008, p. 162)
“Be attentive, remain calm and provide the patient with a private, non-threatening and supportive environment to discuss experienced difficulties. Do not express anger, exasperation, or hostile passivity. Be forthright and confident in manner and speech to provide the patient with a stable source of support at a time of crisis. Stress a team approach to the problem(s) presented; for instance, freely use the collaborative pronoun “we” when discussing suicidal behavior. Model hopefulness, but make sure to acknowledge the patient’s distress and perspective on the problem. Do not avoid using the word “suicide” because this gives the impression that you stigmatize the concept. Most importantly, do not immediately suggest hospitalization. In our experience, patients are most agreeable if the therapist carefully explores various safety options, then plans for the most appropriate clinical response to an acute suicidal episode.”

Have the patient tell his/her “story at his/her own pace. Conduct a behavioral chain analysis of events of the proximal factors that triggered the suicide attempt. Help the patient define the suicidal crisis. Remember that the patient is communicating how badly he or she feels. Use phrases such as “murdering yourself” or “self-annihilation” when referring to suicide. Help the patient view suicide as an attempt to solve a problem. Convey that you do not want the patient to employ a “permanent solution to what might be a temporary problem.” Use motivational Interviewing procedures. Zerler (2008) has discussed how to apply the principles of motivational interviewing of suicidal patients (EE,DD, RR, and SS). The four principles of Motivational Interviewing are: Expressing Empathy; Developing Discrepancy between the patient’s present behaviors and values; Rolling with Resistance as the therapist strives to understand and respect both sides of the ambivalence for the patients perspective. The therapist can empathize with the needs that give rise to the suicidal ideation, without approving suicidal behaviors. Finally, the therapist can Support the patient’s Self-efficacy by acting as a guide or consultant suggesting possible ways to proceed.

Address any barriers that may contribute to antitherapeutic behaviors Use collaborative setting Periodically summarize throughout the session and at the end of the session. As psychotherapy progresses, ask the patient to summarize what was covered in the session and what he/she plans to do between sessions and, most importantly, the reasons why he/she should conduct these activities (homework assignments). Build in reminders that the patient and significant others can take home. Therapists should model hopefulness and “dogged determination” and convey a “team” approach. CBT helps to prevent depression in psychotherapists. “One story”- They have to feel heard. Solicit feedback regularly from the patient and significant others. Ask: I want to check in with you about how you found our meeting today. Were there any things I said or did, or did not say or do, that you found particularly helpful, or particularly unhelpful, or that bothered you? What can we do differently the next time we meet?

Cognitive Affective Behavioral Approach
Voice Therapy Cognitive Affective Behavioral Approach

The Therapeutic Process in Voice Therapy
Step I Identify the content of the person’s negative thought process. The person is taught to articulate his or her self-attacks in the second person. The person is encouraged to say the attack as he or she hears it or experiences it. If the person is holding back feelings, he or she is encouraged to express them. Step II The person discusses insights and reactions to verbalizing the voice. The person attempts to understand the relationship between voice attacks and early life experience.

The Therapeutic Process in Voice Therapy
Step III The person answers back to the voice attacks, which is often a cathartic experience. Afterwards, it is important for the person to make a rational statement about how he or she really is, how other people really are, what is true about his or her social world. Step IV The person develops insight about how the voice attacks are influencing his or her present-day behaviors. Step V The person then collaborates with the therapist to plan changes in these behaviors. The person is encouraged to not engage in self-destructive behavior dictated by his or her negative thoughts and to also increase the positive behaviors these negative thoughts discourage.

Self Anti-Self 106

Address patient’s impulsivity
Teach the patient how to “procrastinate” suicide and how to “stretch out time” Ride out suicidal urges Delay acting on impulse to self-harm Compile and practice delaying strategies such as talking to someone, telephone a therapist, engage in distracting tasks, sleeping Safeguard one’s environment so it is unfriendly to suicide

Interpersonal Neurobiology
C urious O pen A ccepting L oving

Most Helpful Aspects from Client Perspective Validating Relationships
Participants describe the existence of an affirming and validating relationship as a catalyst for reconnection with others and with oneself. A difficult part of the recovery process was breaking through, cognitive, emotional, and behavioral barriers that participants had generated for survival. Counseling for Suicide: Client Perspective. Paulson & Worth, 2002

Most Helpful Aspects from Client Perspective Working with Emotions
Dealing with the intense emotions underlying suicidal behavior was perceived as crucial to participant’s healing. The resolution of despair and helplessness was a pivotal and highly potent experience for all participants in the study. Almost paradoxically, if a client did not receive acknowledgement of these powerful and overwhelming feelings, they reported being unable to move beyond them. Counseling for Suicide: Client Perspective. Paulson & Worth, 2002

Most Helpful Aspects from Client Perspective Developing Autonomy and Identity
Participants identified understanding suicidal behaviors, developing self-awareness, and constructing personal identity as key components of the therapeutic process. Participants conceptualized the therapeutic experience as confronting and discarding negative patterns while establishing new, more positive ones. Counseling for Suicide: Client Perspective. Paulson & Worth, 2002

Common Emotions Experienced in Grief:
Shock Guilt Despair Stress Rejection Confusion Helplessness Denial Anger Disbelief Sadness Loneliness Self-Blame Depression Pain Shame Hopelessness Numbness Abandonment Anxiety These feelings are normal reactions, and the expression of them is a natural part of grieving. Grief is different for everyone. There is no fixed schedule or one way to cope.

Self-Care & Help Seeking Behaviors
Ask for help Talk to others Get plenty of rest Drink plenty of water, avoid caffeine Do not use alcohol and other drugs Exercise Use relaxation skills American Association of Suicidology’s Survivors’ Support Group Directory IASP Suicide Survivor Organizations (listed by country) - Faces of Suicide – A Film for Survivors of Suicide Loss -

Suicide Prevention: Making a Difference
Be Aware of the Do’s… Be aware. Learn the warning signs. Get involved. Become available. Show interest and support. Ask if she or he is thinking about suicide. Be direct. Talk openly and freely about suicide. Be willing to listen. Allow expressions of feelings. Accept the feelings. Be non-judgmental. Don’t debate whether suicide is right or wrong, or feelings are good or bad. Don’t lecture on the value of life. Offer hope that alternatives are available and Take Action.

Suicide Prevention: Making a Difference
…and the Don’ts… Don’t dare him or her to do it. Don’t ask why. This encourages defensiveness. Offer empathy, not sympathy. Don’t act shocked. This will put distance between you. Don’t be sworn to secrecy. Seek support.

Resources: Books Visit www.psychalive.org for resource links
For Public and Professionals For Professionals Visit for resource links

Resources: Films For the Public For Professionals For Survivors
Visit for resource links

Upcoming Webinars Learn more or register at: www.psychalive.org
The Fantasy Bond, March 20 CE Webinar, $25 Presenter: Dr. Lisa Firestone 4pm – 5:30pm PDT Real Love or a Fantasy Bond, April 3 Free Webinar for the public Presenter: Dr. Lisa Firestone 11pm – 12pm PDT Creating Meaning: On the Role of Death in Life, May 22 CE Webinar, $25 Presenters: Dr. Sheldon Solomon and Dr. Lisa Firestone 4pm – 5:30pm PDT Self Esteem: the Belief that One is a Valuable Contributor to a Meaningful Universe Free Webinar Presenters: Dr. Sheldon Solomon and Dr. Lisa Firestone 11am- 12pm PDT Learn more or register at:

Archived CE Webinars Treatment of Individuals with PTSD, Complex PTSD, and Comorbid Disorders: A Life-Span Approach Dr. Donald Meichenbaum – (2.5 CEs, $35) Relationships and the Roots of Resilience Dr. Daniel Siegel (1.5 CEs– $35) Love in the Time of Twitter Dr. Pat Love (1.5 CEs – $35) Innovative Approach to Treating Depression Dr. Lisa Firestone (1.5 CEs– $25) Conquer Your Critical Inner Voice: An Adjunct to Clinical Practice Dr Lisa Firestone (2 CEs $25) Helping Parents to Raise Emotionally Healthy Children Dr. Lisa Firestone(2 CEs $25) Overcoming the Fear of Intimacy Suicide: What Every Therapist Needs to Know Dr. Lisa Firestone(1.5 CEs, $25) Understanding and Assessing Violence Dr. Lisa Firestone (1.5 CEs – $25) Dr. Lisa Firestone (2 CEs– $25) All Webinars can be found at

Contact: Glendon@glendon.org Toll Free - 800-663-5281
(For Professionals) (For the Public)

Contact Information Dr. Lisa Firestone Phone (805) Website: Facebook: Glendon Association

Suicide: The Silent Epidemic A Clinical Focus on Students

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