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

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Mindfulness, Acceptance, and Compassion in Service of Suicide Prevention

Thomas E. Ellis, PsyD, ABPP The Menninger Clinic/ Baylor College of Medicine Houston, Texas Brazoria County Suicide Prevention Symposium November 6, 2015

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Agenda

• Discuss the emotional impact of suicide risk on patients,

providers, and loved ones.

• Describe the psychological process of “reactance,” which

sometimes undermines efforts to help.

• Review diagnostic risk factors for suicide and recent

developments in understanding and helping suicidal people.

• Outline the place of acceptance in addressing suicide risk.
• Discuss practical implications of these understandings for

helpers and loved ones.

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Feelings about Suicide

Suicide is an emotional subject, to patient, provider, and family alike. Some commonly heard comments… Anxiety/ avoidance “Let’s talk about something else.” Hopelessness ”If a person’s really intent on killing himself, there’s nothing you can to do stop him.” Disdain “It wasn’t serious – just a manipulative gesture.” Contempt ”If I were him, I’d kill myself, too!” Hostility ”Maybe he’ll get it right the next time.”

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Strong emotions reflexively lead one toward strong responses, such as: Avoidance Judgment Efforts to persuade Demands Efforts to control Coercion Invalidating statements, such as…

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What Does Invalidation Sound Like? Some Examples

• But you have so much to be thankful for!
• You know, suicide is a permanent solution to a temporary

problem.

• You’re blowing things out of proportion!
• Isn’t that against your religion?
• But think about what it would do to your family!
• 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!

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Although well-intentioned, results often are the

• pposite of what we want.

Why might this be? Enter: Reactance

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• Generally speaking, people fiercely defend their freedom and

autonomy.

• Psychological reactance occurs when a person feels that

someone or something is taking away his or her choices.

• Reactance is an aversive emotional reaction against efforts to

control behavior and impinge on freedom and autonomy.

• This emotional state often leads to efforts to restore autonomy.
• Examples
• Prohibition
• Romeo and Juliet
• Teen smoking
• Gun control
• Unhealthy behaviors (e.g., Heart Attack Café)

Reactance Theory

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• Reactance can cause one to actually adopt or strengthen an
• pposing position, and also increases resistance to persuasion.
• Reactance is increased when language is dogmatic or controlling

(“must” “can’t” “you’d better or else”).

• During the reactance experience one tends to have angry or

hostile feelings, often aimed more at the source of the message than at the message itself

• Some people are more subject to reactance than others, including

those who are highly independent and who struggle with mistrust.

• Defusing reactance is a cornerstone of Motivational Interviewing.
• 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.

Reactance Theory

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W hy Suicide??

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SUICIDE

Neurobiology Severe Medical Illness Impulsiveness Access To Weapons Hopelessness Life Stressors Family History Suicidal Behavior Personality Disorder/Traits No apparent psychopathology Substance Use/Abuse Psychiatric Illness

Co-morbidity

Suicide: A Multi-factorial Event

Douglas Jacobs, MD Advancing treatment. Transforming lives.

How is suicide risk affected by psychiatric illness?

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 Female .26 3.77 4.78 6.55 3.34 2.10 Percentage of mental health clients dying by suicide, 18-yr follow-up

Nordentoft M, Mortensen PB, Pedersen CB. 2011 Absolute risk of suicide after first hospital contact in mental disorder. Arch Gen Psychiatry, 68,1058-64. 16 Advancing treatment. Transforming lives.

Psychiatric disorder is not the complete story

• f suicide. Take depression, for example..

40-50% of people who die by suicide suffer from depression

• r bipolar disorder

4-7% of people with depression eventually die by suicide

Depression

Suicide

40-50% of people who die by suicide suffer from depression or bipolar disorder

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Trans-diagnostic Contributors to Suicide

• Cognitive rigidity/ inflexibility
• Problem-solving deficits
• Hopelessness
• Failed belongingness/ burdensomeness
• Acquired capability
• Dysfunctional attitudes/ irrational beliefs
• Reasons for living/ dying
• Self-hatred
• Anxiety, insomnia, nightmares
• Perfectionism
• Rumination
• Overgeneral autobiographical memory

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Empirically Supported Interventions for Suicidal Patients

Problem-solving Training Dialectical Behavior Therapy (DBT) Rudd and Joiner’s CBT Beck’s Cognitive Therapy for Suicidality Mentalization-based Therapy Collaborative Assessment and Management

• f Suicidality (CAMS)

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Priority focus is to address suicidality and underlying factors. This involves:

• In-depth risk assessment (Suicide Status Form)
• Concrete steps to ensure safety in the near-

term (e.g., a written crisis response plan)

• Psychotherapeutic intervention to address long-

term vulnerability factors (“drivers”)

• All of the above is predicated on the

establishment of an empathic, collaborative therapeutic alliance.

Collaborative Assessm ent and Managem ent of Suicidality ( CAMS)

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??

THERAPIST PATIENT

CONVENTIONAL MODEL: Suicide as Symptom

DEPRESSION

LACK OF SLEEP POOR APPETITE ANHEDONIA ... ? SUICIDALITY ?

Traditional treatment = main focus on the psychiatric disorder (suicidality as symptom). Use of devices such as the no-suicide contract.

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COLLABORATIVELY ASSESSING RISK: Targeting Suicide as the Focus of Treatment THERAPIST & PATIENT

SUICIDALITY

PAIN STRESS AGITATION HOPELESSNESS SELF-HATE REASONS FOR LIVING

• VS. REASONS FOR DYING

Mood

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.

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• Assessment via Suicide Status Form (collaborative)
• a. Risk level
• b. Identification of “drivers”
• c. Safety planning
• d. Problem identification
• e. Treatment planning
• Reducing suicidal ideation and behavior
• a. Problem-solving
• b. Development of alternative coping responses
• Psychotherapy to address underlying vulnerabilities
• a. Self-hate
• b. Relationship issues
• c. Etc.

CAMS Key Components

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Jobes, D.A. (2006). Assessing and Managing Suicidality. New York: Guilford.

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CAMS Research at The Menninger Clinic

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Usual Menninger Care

• Medication
• Group therapy
• Psychosocial groups
• Nursing care
• Milieu therapy
• Family counseling
• Vocational counseling
• I ndividual therapy

CAMS Condition

• Medication
• Group therapy
• Psychosocial groups
• Nursing care
• Milieu therapy
• Family counseling
• Vocational counseling
• I ndividual therapy

w/ CAMS-M

Treatm ent Conditions

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Change in depression by treatment group (PHQ-9)

18.88 8.83 19.52 13.73 5 7 9 11 13 15 17 19 Admission Discharge CAMS TAU

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Change in suicidal ideation by treatment group (Beck Scale for Suicidal I deation)

13.75 4.82 15.06 9.35 1 3 5 7 9 11 13 15 Admission Discharge CAMS TAU

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Change in hopelessness by treatment group (Beck Hopelessness Scale)

12.62 6.25 15.15 14.42 1 3 5 7 9 11 13 15 Admission Discharge CAMS TAU

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Change in suicidal cognitions by treatment group (Suicide Cognitions Scale)

53.61 33.27 59.98 50.79 30 35 40 45 50 55 60 Admission Discharge CAMS TAU

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Change in experiential avoidance by treatment (Acceptance & Action Questionnaire)

34.79 24.48 36.65 33.77 20 22 24 26 28 30 32 34 36 38 40 Admission Discharge CAMS TAU

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1.67 1.03 1.18 1.11 1.1 1.01 0.59 0.58 0.2 0.33

0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 PHQ 9 BSS SCS BHS AAQ CAMS TAU

Effect Sizes: TAU vs. CAMS

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For more information about CAMS… www.cams-care.com

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So, how does all of this relate to acceptance? Let’s start with a little context…

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The Evolution of “Third-wave” Therapies

1st wave: Behavior therapy (e.g., systematic desensitization) 2nd wave: Cognitive-behavior therapy (cognitive restructuring) 3rd wave: Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), Mindfulness-Based Cognitive Therapy (MBCT), etc.

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The “Third Wave”

The change vs. acceptance issue Things that tend not to change One’s past Temperament Loss The paradox of effort to control inner experience Pink elephants Tip-of-tongue phenomenon Sleep Acceptance as an alternative Panic disorder Couples therapy AAQ data (experiential avoidance) Menninger Suicide Resilience group CAMS

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Acceptance

What it is

• Acknowledging reality
• Meeting a person where

he/ she is

• Not judging/ condemning
• A starting point for

change

• Leaving doors open

What it is not:

• Approval
• Agreement
• Resignation
• Closing doors

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• Attending to the present moment
• Awareness of sensations, thoughts, and emotions
• Practicing nonjudgmental acceptance (yes, even of

suicidal thoughts)

• Distinguishing between inner experience

(thoughts, feelings) and actions

• To learn more: Luoma & Villatte (2012). Mindfulness in the

treatment of suicidal individuals. Cognitive and Behavioral Practice, 19(2), 265-276.

Cultivating Acceptance: Mindfulness as Method

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To be in a position to help a suicidal individual, it is important to cultivate understanding of and empathy for the suicidal wish… How might we cultivate such empathy?

Empathy is helpful as well…

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Who said this?

I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on the earth. Whether I shall ever be better I cannot tell; I awfully forebode I shall not. To remain as I am is impossible; I must die or be better, it appears to me.

• A. Lincoln, 1841

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Recommended Reading

An Unquiet Mind, by Kay Jamison Darkness Visible, by William Styron The Savage God, by A. Alvarez Holiday of Darkness, by Norman Endler Waking Up, by Terry Wise Struck by Living, by Julie Hersh Cry of Pain, by Mark Williams

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Cultivating empathy…

Try this thought experiment: Think of a highly personal fact about yourself,

• ne that you have never disclosed to anyone

else. Now imagine being asked to disclose this to someone whom you have only recently met. Further imagine that this person is in a position

• f considerable power and that you are not at

all convinced that he/ she is on your side. How would you behave? What would you most need?

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Aspects of Intervention with Suicidal Patients

Crisis stabilization: Surviving the suicidal episode “Containment” Means restriction Stabilization of mood and sleep Support Treatment: Addressing vulnerabilities to suicide Hopelessness Coping deficits Self-hatred Relationship issues The importance of “staying therapeutic” Managing emotions Providing validating (rather than invalidating) responses

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Validating Responses: Some Examples

• You must be really hurting if suicide has started to come to

mind.

• Suicide is a scary topic; OK if we talk about it anyway?
• Given all you’re dealing with, it’s no wonder suicidal

thoughts have shown up.

• Sounds like it’s hard for you to imagine things ever getting

better.

• It’s normal to want relief from suffering. Can we talk about

some ways other than suicide?

• I understand it’s hard to “take suicide off the table.” Maybe

we can put some other things “on the table.”

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• Using relationship to keep the conversation going, buying time
• Focusing on needs (relief from suffering)
• Accepting that you can’t do it all alone
• Stance of acceptance
• Acknowledging it’s here (suicide risk)
• Acknowledging (and accepting) your own feelings (e.g., “It

scares me to hear this”)

• Refraining from “common-sense” advice (e.g., “You must

promise you won’t kill yourself.”)

• Acceptance of the person (validation)
• Noting that thoughts are ok; they don’t have to lead to action
• Reactance: So should I say, “Go ahead, kill yourself?”
• Um, no.
• Reminder re: present awareness (vs. past (rumination) or future

(catastrophizing))

• Cultivating empathy and compassion

Employing Acceptance in Helping a Suicidal Person

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Thanks!

Tom Ellis

tellis@menninger.edu

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