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Handout 1: Four Core Assessment Strategies Foundations: To conduct efficient and valid suicide assessments, clinicians need an attitude of acceptance (not judgment) and to use state-of-the-art assessment strategies. If clinicians believe suicide ideation is a sign of deviance, students or clients will sense this and be less open. Asking directly is essential, but experienced clinicians use more nuanced strategies.Normalizing statementsI’ve read that up to 50% of teens have thought about suicide. Is that true for you?When people are depressed or feeling down, it’s not unusual to have thoughts of suicide pass through their mind. Have you had any thoughts of suicide?Gentle assumption (Shea, 2002, 2004, 2015)When was the last time you had thoughts about suicide?A solution-focused mood evaluation with a suicide floor“Is it okay if I ask some questions about your mood?” (This is an invitation for collaboration)“Please rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. Zero would mean you’re totally depressed and you’re just going to kill yourself. A 10 is your best possible mood. A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or doing whatever you do when you’re filled with life. Using that zero to 10 scale, what rating would you give your mood right now?” “What’s happening now that makes you give your mood that rating?” (This links the mood rating to the external situation.)“What’s the worst or lowest rating you’ve ever had?” (This informs you of the lowest lows.) “What was happening back then to make you feel so down?” (This links the lowest rating to the external situation and may lead to discussing previous attempts.)“For you, what would be a normal mood rating on a normal day?” (Clients define their normal.) “Now, what’s your best mood rating ever?” (The process ends with a positive mood rating.)“What was happening then?” (The positive rating is linked to an external situation.) Strength-oriented positive questioningDon’t just ask about depression and risk. Focusing on the negative side of life’s ledger can activate depressive thoughts and mood. Be sure to ask about protective factors and strengths. Even if clients or students reject your positive questions, you’re planting a seed and gathering assessment data. Sample strength-oriented questions:When is your sadness gone? [Whenever clients are focusing on pain, distress, negative cognitions, etc., you can shift to exploring for exceptions. But be sure to respond empathically before shifting to exceptions.] What has helped before?If you had a good afternoon today, what would that look like? How about small hopes for tomorrow?What helps you concentrate? What helps you sleep?What recreational (fun) activities do you enjoy now or enjoyed before?What brings a little light into the darkness?What transforms your blackness to blueness?What advice would you give to a good friend going through the very same experience as you? [To set this question up well, it’s important to have clients identify a close friend and build up a concrete and personal scenario.]For more information, contact John Sommers-Flanagan: john.sf@mso.umt.edu. Handout 2: Treatment Plan with Problems Name: ____________________Problems in Emotional DimensionGoals and StrengthsInterventions/PlanExcruciating Emotional DistressAffect DysregulationShame, Guilt, or SadnessProblems in Cognitive DimensionGoals and StrengthsInterventions/PlanProblem-Solving HopelessnessNegative Core BeliefsProblems in Interpersonal DimensionGoals and StrengthsInterventions/PlanUnwanted Social DisconnectionSocial Skill DeficitsSocial BurdenProblems in Physical DimensionGoals and StrengthsInterventions/PlanArousal-AgitationTrauma, insomnia, nightmaresPhysical symptoms of depressionProblems in Spiritual DimensionGoals and StrengthsInterventions/PlanCultural/Spiritual DisconnectionMeaninglessnessShame (Emotional)Problems in Behavioral DimensionGoals and StrengthsInterventions/PlanSuicide DesensitizationLethal MeansSuicide Intent and PlanningProblems in Contextual DimensionGoals and StrengthsInterventions/PlanPovertyDiscrimination and OppressionNotes:Handout 3: Treatment Plan Name: ________________________Problems in Emotional DimensionGoals and StrengthsInterventions/PlanProblems in Cognitive DimensionGoals and StrengthsInterventions/PlanProblems in Interpersonal DimensionGoals and StrengthsInterventions/PlanProblems in Physical DimensionGoals and StrengthsInterventions/PlanProblems in Spiritual DimensionGoals and StrengthsInterventions/PlanProblems in Behavioral DimensionGoals and StrengthsInterventions/Plan? Handout 4: Dimensions + Suicide Treatment Targets + Possible InterventionsDimensionTreatment Target – ProblemsPossible InterventionsEmotionalExcruciating Emotional DistressAffect DysregulationShame, Guilt, or SadnessSeparate pain from the self or neodissociationMindfulness and distress toleranceThree-step emotional changeCognitiveProblem-Solving ImpairmentHopelessnessNegative Core BeliefsProblem-solving or alternatives to suicideHopelessness continuumCognitive or schema therapyInterpersonal Unwanted Social Disconnection Social Skill DeficitsSocial BurdenSocial universe (mapping) activitySocial skills training (group)Third-person perspectivesPhysicalArousal/Agitation/Irritability Trauma, insomnia, nightmaresPhysical symptoms of depressionIrritability protocolTrauma, insomnia, nightmare protocolsPhysical exercise (including relaxation)Antidepressant medicationsSpiritualCultural/Spiritual DisconnectionMeaninglessnessShame (Emotional)Spiritual or cultural acceptance and connectionExistential questions: Six months, purpose?Shame meaning and explorationBehavioralSuicide DesensitizationLethal MeansSuicide Intent and PlanningReasons for living explorationLethal means management Safety planning interventionContextualPovertyDiscrimination/OppressionAdvocacyValidation and coping strategiesHandout 5: Safety Planning Intervention (Stanley & Brown, 2012)How Can I Make My Environment Safe? These are things that can be done immediately and up-front to make the person’s environment safer. [e.g., guns out of the house; meds to brother]________________________________________________________________________________________________________________________________________________________________________Identify the Individual’s Unique Warning Signs. These are often cognitive, emotional, behavioral, physical, physical sensations, and environmental triggers [Be sure to ask: How will you know when to implement this safety plan? List below in the person’s own words.]____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Internal Coping Strategies. These are things the individual can do on his or her own. Ask something like: “Just in case you start feeling suicidal, what can you do to help yourself cope in a healthy way?” (e.g., Television, walking, music, meditation) [Try a solution-focused mind-set here: “Imagine yourself coping well. What do you see yourself doing? What helps you remember to do these healthy things?”]____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________People and Social Settings that Provide Support and Distraction. The purpose of this step is not to share suicidal feelings, but to get into an environment that’s pleasantly distracting. [e.g, bookstore, shopping, church, sister’s house]____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Who Can I Ask for Help? This step involves non-professionals.Name: ___________________ Number: ________________________________Name: ___________________ Number: ________________________________Name: ___________________ Number: ________________________________Professionals or Agencies I Can Contact for SupportName: ___________________ Number: ________________________________Name: ___________________ Number: ________________________________Name: ___________________ Number: ________________________________How I Can Make My Environment Even Safer?________________________________________________________________________________________________________________________________________________________________________Handout 6: Traditional Risk Assessment Principles and ProcessAssess for Risk Factors and Warning Signs: Generally, more risk factors and warning signs equals more risk. Factors that are particularly salient include:2+ previous attemptsCommand hallucinations (e.g., “You must die”)TraumaSevere depression, plus agitation and hopelessnessPreparation, planning, rehearsal behaviors (e.g., stockpile, giving away items)Feeling trapped in immense shame, self-hatred, and excruciating distressImpulsive + alcohol/drugs + lethal means availableConsider Protective Factors: Relationships, hope, engagement in meaningful activities, responsiveness to therapy/treatmentConsultation: Isolation can be contagious; don’t isolate yourselfDocumentation: Include relevant assessment data, consultation results, and rationale for decision-making on level of care.Decision-MakingUsing a traditional assessment approach, you should estimate your client’s suicide risk as fitting into one of three categories: Mild: Minimal risk. The situation may be managed with weekly monitoring and an emergency plan. Make sure firearms and lethal means are safely stored.Moderate. The situation should be managed with an active safety plan. Depending on student or client preference, engaging family or friends as support may be advisable. Make sure firearms and lethal means are safely stored.High: Treatment is likely to include hospitalization and/or an intensive safety plan implemented with family/friends. Make sure firearms and lethal means are safely stored.From: Sommers-Flanagan, J. (2019). Advances in Suicide Assessment and Treatment Planning. Workshop presented on behalf of the Big Sky Youth Empowerment Program. Bozeman, MT. Note: This is a summary. Detailed information is available from many sources, including: Rudd, M. D. (2014). Core competencies, warning signs, and a framework for suicide risk assessment in clinical practice. In M. Nock (Ed.), Oxford Handbook of Suicide and Self-Injury (pp. 323-336). London: Oxford University Press. Also, see: and University Press. Also, see: and Bonus Handout: Sample Treatment Plan for KennedyProblems in Emotional DimensionGoals and StrengthsInterventions/Plan1. Kennedy reports significant emotional distress linked to hearing her parents argue and fight. [Note: Excruciating distress can involve one or many trauma, loss, or emotionally disturbing experiences. Some of these experiences will require additional time, trust, and assessment to uncover.] 1. Develop effective distress tolerance strategies.2. Parents stop or reduce their fighting in Kennedy’s presence.Strengths: Notice, reflect, and nurture Kennedy’s ability to articulate her distress and the life situations contributing to her distress.1. Engage in collaborative brainstorming with Kennedy to identify, select, and practice individualized distress tolerance and immediate coping strategies.2. Solicit Kennedy’s permission to meet with her parents to discuss alternatives to fighting in Kennedy’s presence.3. Refer Kennedy’s parents for couple counseling. Problems in Cognitive DimensionGoals and StrengthsInterventions/Plan1. Kennedy lacks positive coping skills for when she’s in distress and experiencing suicidal thoughts. [Note: Including a skills-training component is a core part of working with clients who are suicidal (Linehan, 1993). Kennedy needs in-session practice and out-of-session homework.]1. Kennedy will enact preferred coping skills in session.2. Kennedy’s parents will report that Kennedy is able to apply her coping skills at home.Strength: Kennedy is able to engage in constructive problem-solving in session.1. Actively engage Kennedy in practicing distraction and coping techniques for 20 minutes during each counseling session. 2. Give Kennedy homework: Implement distraction and coping (aka distress tolerance) strategies outside the counseling office. Problems in Interpersonal DimensionGoals and StrengthsInterventions/Plan1. Kennedy is socially isolated and has very few close friends. 2. Kennedy has poor social skills.3. Kennedy is being bullied at school. 1. Kennedy will develop friendships and be able to identify three friends in whom she can confide.2. Kennedy will learn and practice skills for initiating conversations and active listening. 3. Kennedy will identify places and people who will help keep her safe from bullying. Strengths: Kennedy is interested in interpersonal relationships, and appears ready to contribute to reciprocal intimacy.1. Conduct social universe activity and identify potential friends. 2. Practice conversational and listening skills in session (consult with school counselor on potential groups).3. Engage in role play social skills practice in anticipation of entering new social groups.4. Learn and practice relaxation skills that Kennedy can use in new social situations.5. Consult with school counselor on possible school-wide bully prevention activities.Bonus Handout (cont.): KennedyProblems in Physical DimensionGoals and StrengthsInterventions/Plan1. Kennedy is intermittently agitated. 2. Kennedy has insomnia and nightmares, both of which contribute to her emotional distress. 1. Kennedy is able to use relaxation or meditation to calm her body and mind.2. Kennedy experiences a reduction in nightmare frequency and greater perceived control over her insomnia and nightmares.Strengths: Kennedy is physically fit, and interested in using volleyball and other physical activities to improve her health and well-being. 1. Introduce Kennedy to progressive muscle relaxation and mindfulness meditation of tools for arousal reduction. 2. Kennedy will implement PMR or MM in-session and as daily homework to manage physiological arousal.3. Initiate imagery rehearsal therapy with Kennedy and begin homework assignments related to nightmare reduction.4. Use activity scheduling to increase Kennedy’s daily exercise.Problems in Spiritual DimensionGoals and StrengthsInterventions/Plan1. Kennedy believes that it’s a sin to talk about her suicidal thoughts and feelings. 2. Kennedy has quit going to church because of feeling judged about her sexuality. 1. Kennedy will be able to talk openly about her suicidal thoughts and feelings to select safe people who will not judge her.2. Kennedy will be able to identify church-related activities that feel safe and affirming.Strengths: In the past Kennedy has found church, religion, and the church youth group to be fun and safe. 1. Explore Kennedy’s spiritual beliefs and help her view talking about her thoughts and feelings as spiritually acceptable (possibly obtain a religious/spiritual consult). 2. Identify and discuss religious or spiritual groups that are open and affirming of sexual diversity.3. Explore acceptable religious alternatives with Kennedy’s parents. Problems in Spiritual DimensionGoals and StrengthsInterventions/Plan1. Kennedy abuses alcohol in ways that might cause desensitization to suicide. 2. Kennedy has a plan to use a gun and access to her father’s firearms. 1. Kennedy will agree to not drink alone.2. Firearms will be locked up or given to someone to keep safe. Strengths: Kennedy is open to talking about her alcohol use and willing to have a family meeting where we can talk about guns in the home. 1. Discuss Linehan’s RFL questionnaire and have Kennedy improve it for her and teenagers. 2. Have family meeting and discuss access to firearms and alternative methods for firearm safety. ................
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