Feelings about Suicide Suicide is an emotional subject, to patient, - PDF document

10/29/2015 Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. Agenda Mindfulness, Acceptance, and • Discuss the emotional impact of suicide risk on patients, providers, and loved ones. Compassion in Service of Suicide • Describe the psychological process of “reactance,” which sometimes undermines efforts to help. Prevention • Review diagnostic risk factors for suicide and recent developments in understanding and helping suicidal people. Thomas E. Ellis, PsyD, ABPP The Menninger Clinic/ Baylor College of Medicine • Outline the place of acceptance in addressing suicide risk. Houston, Texas • Discuss practical implications of these understandings for helpers and loved ones. Brazoria County Suicide Prevention Symposium November 6, 2015 1 3 Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. Feelings about Suicide Suicide is an emotional subject, to patient, provider, and Strong emotions reflexively lead one toward strong responses, family alike. Some commonly heard comments… such as: Avoidance Anxiety/ avoidance “Let’s talk about something else.” Judgment Hopelessness ”If a person’s really intent on killing Efforts to persuade himself, there’s nothing you can to do stop him.” Demands Disdain “It wasn’t serious – just a manipulative Efforts to control gesture.” Coercion Contempt ”If I were him, I’d kill myself, too !” Invalidating statements, such as… Hostility ”Maybe he’ll get it right the next time.” 5 7 1

10/29/2015 Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. What Does Invalidation Sound Like? Some Examples Although well-intentioned, results often are the • But you have so much to be thankful for! opposite of what we want. • You know, suicide is a permanent solution to a temporary problem. • You’re blowing things out of proportion! Why might this be? • Isn’t that against your religion? • But think about what it would do to your family! Enter: Reactance • If we’re going to work together, you must take suicide off the table. • Try using some of your skills. • Just try thinking more positively! 8 9 Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. Reactance Theory Reactance Theory • Generally speaking, people fiercely defend their freedom and autonomy. • Reactance can cause one to actually adopt or strengthen an • Psychological reactance occurs when a person feels that opposing position, and also increases resistance to persuasion. someone or something is taking away his or her choices. • Reactance is increased when language is dogmatic or controlling • Reactance is an aversive emotional reaction against efforts to (“must” “can’t” “you’d better or else”). control behavior and impinge on freedom and autonomy. • During the reactance experience one tends to have angry or • This emotional state often leads to efforts to restore autonomy. hostile feelings, often aimed more at the source of the message • Examples than at the message itself • Prohibition • Some people are more subject to reactance than others, including • Romeo and Juliet those who are highly independent and who struggle with • Teen smoking mistrust. • Gun control • Defusing reactance is a cornerstone of Motivational Interviewing. • Unhealthy behaviors (e.g., Heart Attack Café) • The emphasis of CAMS on collaboration rather than coercion is intended to create an atmosphere in which the patient can flexibly explore alternatives to suicidal behaviors. 12 13 2

10/29/2015 Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. Suicide: A Multi-factorial Event No apparent psychopathology Psychiatric Illness Neurobiology Substance Co-morbidity Use/Abuse W hy Suicide?? Impulsiveness Severe Medical Illness Suicidal SUICIDE Behavior Personality Disorder/Traits Life Stressors Family History Access To Weapons Hopelessness Douglas Jacobs, MD 14 15 Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. Psychiatric disorder is not the complete story How is suicide risk affected by of suicide. Take depression, for example.. psychiatric illness? Percentage of mental health clients dying by suicide, 18-yr follow-up Depression No psych dx Unipolar dep Bipolar dis. Schizophrenia Substance dis Any psych dx Male .72 6.67 7.77 6.55 4.71 4.33 4-7% of people with 40-50% of people who die Female .26 3.77 4.78 6.55 3.34 2.10 depression eventually by suicide suffer from die by suicide depression or bipolar 40-50% of people who die by disorder suicide suffer from depression Suicide Nordentoft M, Mortensen PB, Pedersen CB. 2011 Absolute risk of suicide after first or bipolar disorder hospital contact in mental disorder. Arch Gen Psychiatry , 68, 1058-64. 16 17 3

10/29/2015 Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. Trans-diagnostic Contributors to Suicide Empirically Supported Interventions for Suicidal Patients • Cognitive rigidity/ inflexibility • Problem-solving deficits Problem-solving Training • Hopelessness • Failed belongingness/ burdensomeness Dialectical Behavior Therapy (DBT) • Acquired capability Rudd and Joiner’s CBT • Dysfunctional attitudes/ irrational beliefs Beck’s Cognitive Therapy for Suicidality • Reasons for living/ dying • Self-hatred Mentalization-based Therapy • Anxiety, insomnia, nightmares Collaborative Assessment and Management • Perfectionism • Rumination of Suicidality (CAMS) • Overgeneral autobiographical memory 18 19 Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. Collaborative Assessm ent and CONVENTIONAL MODEL: Managem ent of Suicidality ( CAMS) Suicide as Symptom Priority focus is to address suicidality and underlying factors. DEPRESSION ?? This involves: LACK OF SLEEP • In-depth risk assessment (Suicide Status Form) POOR APPETITE • Concrete steps to ensure safety in the near- ANHEDONIA ... term (e.g., a written crisis response plan) • Psychotherapeutic intervention to address long- ? SUICIDALITY ? term vulnerability factors (“drivers”) THERAPIST • All of the above is predicated on the PATIENT establishment of an empathic, collaborative therapeutic alliance . Traditional treatment = main focus on the psychiatric disorder (suicidality as symptom). Use of devices such as the no-suicide contract. 20 21 4

10/29/2015 Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. CAMS Key Components COLLABORATIVELY ASSESSING RISK: Targeting Suicide as the Focus of Treatment • Assessment via Suicide Status Form (collaborative) a. Risk level Mood b. Identification of “drivers” c. Safety planning d. Problem identification SUICIDALITY e. Treatment planning • Reducing suicidal ideation and behavior PAIN STRESS AGITATION a. Problem-solving b. Development of alternative coping responses HOPELESSNESS SELF-HATE • Psychotherapy to address underlying vulnerabilities REASONS FOR LIVING a. Self-hate VS. REASONS FOR DYING b. Relationship issues THERAPIST & PATIENT c. Etc. CAMS Treatment = Intensive intervention that is suicide-specific, emphasizing the development of new means of coping and problem-solving, thereby eliminating the need for suicidal coping. Jobes, D.A. (2006). Assessing and Managing Suicidality. New York: Guilford. 22 23 Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. Treatm ent Conditions CAMS Condition Usual Menninger Care CAMS Research at • Medication • Medication The Menninger Clinic • Group therapy • Group therapy • Psychosocial groups • Psychosocial groups • Nursing care • Nursing care • Milieu therapy • Milieu therapy • Family counseling • Family counseling • Vocational counseling • Vocational counseling • I ndividual therapy • I ndividual therapy w/ CAMS-M 24 5

10/29/2015 Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. Change in depression by treatment group Change in suicidal ideation by treatment group (PHQ-9) (Beck Scale for Suicidal I deation) 19.52 15 15.06 19 18.88 13.75 13 17 11 15 13.73 9.35 CAMS 9 CAMS 13 TAU TAU 7 11 5 4.82 9 8.83 3 7 1 5 Admission Discharge Admission Discharge 26 27 Advancing treatment. Transforming lives. Advancing treatment. Transforming lives. Change in hopelessness by treatment group Change in suicidal cognitions by treatment group (Beck Hopelessness Scale) (Suicide Cognitions Scale) 60 15 14.42 59.98 15.15 55 53.61 12.62 13 50.79 50 11 CAMS 9 CAMS 45 TAU TAU 7 6.25 40 5 35 33.27 3 30 1 Admission Discharge Admission Discharge 28 29 6