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- This continuing education class.

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This is "Assessing the Risk.

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"Interviewing, understanding and managing

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"suicidal and self injurious clients."

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I'm Kirk Woodring.

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I'm going to be your guide, facilitator.

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Okay, great.

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Let me talk a little bit about the day.

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Set this up.

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We're going to start out looking at

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suicide prevalence and risk factors.

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I'll talk a little bit about statistics.

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The communities, individuals,

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who are most at risk,

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and a little bit about
why they're at risk.

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We'll take a break at
10:30 or so for 15 minutes.

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We'll come back.

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We'll start to look at
assessment skills and tools

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that you can use for doing assessments.

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We'll have lunch.

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Depending on how much time
we've been able to spend

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on the assessment tools we may come back

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and finish up on that after lunch.

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If we've done well with that,

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we'll go into doing sort
of a psychological autopsy

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of a case, and look at
the process of suicide

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and what we might have done as clinicians

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if we had been involved.

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Specifically the individual
we'll be talking about

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is Kurt Cobain, who was the
lead singer for Nirvana.

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We'll take another break at 2:30 or so.

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We'll come back.

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We'll actually look at suicide notes

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and do an analysis in groups

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on those suicide notes.

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Again, what would you do?

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What tools would you use

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if you were to have a client

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who had made an attempt

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or who had written this note

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and you were aware of that?

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Then we'll end with questions
that you might have.

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These are the objectives.

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Hopefully by the end of this day

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you'll have a better understanding

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of how to interview,
how to assess for risk.

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I'll give you some tools.

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How to ask questions,

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to do a rapid risk assessment.

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We'll be using some material
from a book that I wrote

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with Sharon Chaput, who's a nurse.

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We wrote a book called
"Assessing the Risk.

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"Suicidal Behavior in the
Hospital Environment of Care."

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It's really geared towards
emergency departments

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and towards folks who are working

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in medical facilities,
but the intervening skills

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and techniques are really
transferable to any location.

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We'll also be using some
of Shawn Shea's work.

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Shawn Shea is a psychiatrist
in New Hampshire.

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He's written extensively
on suicidal behavior

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and assessing for suicide risk,

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so we'll involve some of his material.

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You'll have a better understanding

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of high-risk behavior and how to look at

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the statistical risk factors,

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both in what creates suicidal behavior

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and what factors help
prevent suicidal behavior.

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What are some of the strengths

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that folks bring to, and resiliency,

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that people can bring to
managing their suicide risk?

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Legal and treatment issues,

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we'll talk a little bit about.

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We'll talk about documentation

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and the importance of documentation

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and how to document well

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when you're doing a risk assessment.

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That's becoming more and
more critically important,

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I'm sure all of you are aware,

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if you're involved in
any kind of practice.

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The importance of documenting,

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and documenting for risk particularly.

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Then we'll give you some resources,

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I'll give you some resources,

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for managing suicidality and some tools.

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Give you an evaluation that you can use.

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Kind of an assessment
tool that you can use.

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That's how we'll do the
process for the day.

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I really want this to be interactive.

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One of the things I really can't stand

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is when I'm just standing up here talking,

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so please at any point in time,

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if you have a question,
if you have a comment,

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if you have a thought, bring it forward.

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I'm really interested in hearing about

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personal experiences
that you might have had

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with clients or others who are suicidal

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or who attempted suicide
or who committed suicide.

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It's really important for us to make that

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live in the room, because
it really is so critical

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that people hear the
stories about suicide.

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I'm curious about how many people here

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have been affected in some way by suicide.

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That's the majority of the class.

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It's so prevalent, and for so many years

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was really dismissed and not talked about,

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and I want to be able to talk about it

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and make it real in here,

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so feel free to jump in.

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What can you expect?

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This is going to be a difficult day,

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or it can be a difficult day.

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This is a difficult topic.

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There's a tremendous amount of stigma

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attached to suicide.

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If you've been involved in a suicide

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in any way, shape or form,

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you've been touched by that.

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When we talk about suicidal behavior,

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when we talk about the effect of suicide,

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when we talk about depression,

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when we start to take on
some of those feelings,

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the depression, the anhedonia,

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I really want to try to
avoid that if we can.

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At any point in time, if
you need to take a break,

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even if it's not breaktime,
feel free to do that.

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Get up, stretch, walk around, go outside.

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One of the things that's
important to do is,

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drink water, not only
because it's hot out there,

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but because as you become
more and more activated

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by what we might be
discussing, drink some water.

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It helps flush your system out.

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Ask questions.

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You might feel like you don't understand

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what we're discussing or you might

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feel like you're really lost.

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Don't be afraid to ask questions, at all.

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There are no wrong questions.

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The more we discuss this,

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the more we talk with each other,

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I think the better we'll
understand the topic.

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All right?

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One of the things that I will be doing is,

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in the process of the course today

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I'll be going over and queuing
up some YouTube videos.

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I've taken a lot of material from YouTube

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that helps inform this process.

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There are times, I've found,

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especially more recently,

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that YouTube videos love to had
ads at the beginning of them

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and you usually have to
wait three or four seconds

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at least before you can shut the ad down,

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so please don't pay attention to the ad.

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We'll click off on it when we can,

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and move forward.

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I did a Google search yesterday.

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I just typed in "How to commit suicide."

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There were 23,100,000 results.

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Interestingly, one of the first ones is

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veteranscrisisline.net,
"Thinking of suicide?"

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It's an ad.

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I was heartened by that fact.

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That was a good thing.

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Then as you go down,

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you get all sorts of,

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"How to commit suicide,"

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"How to commit suicide painlessly,"

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cocktails to use for suicide.

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If someone is thinking
about suicide right now,

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they have resources available
to them beyond belief

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in terms of information that
didn't exist even 10 years ago.

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I did the same search, I think in 2006,

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and there were somewhere
around a million results.

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We've gone 23 times that
number in just a few years.

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People have access to information

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when they're feeling suicidal,

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about how to commit suicide,

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and not quite so much about
how to prevent suicide.

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That's where we come in.

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How do we help folks prevent suicide?

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How do we assess when
someone is feeling suicidal

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and maybe they don't
want to talk about it?

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Maybe they don't want to let you know,

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or maybe they're afraid
of letting you know,

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that they're feeling suicidal.

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Today we're really going
to try to figure out ways

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to get into developing that relationship

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with the client quickly to assess for risk

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and looking at some validity techniques

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to get the best answers, the
best information, from them.

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In some ways we have to
be detectives to do that.

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In the past five years,
60% of all suicides

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were committed with firearms.

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It's not really surprising.

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We'll talk about this in different forms

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throughout the day today,

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but firearms are obviously

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the most lethal means,
method, for suicide.

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If somebody is going to make an attempt

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with a firearm they're more
likely to be successful.

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In the US, one person completed suicide

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every 18 minutes.

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Most individuals didn't want to die.

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They just wanted to get rid of the pain

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that they were experiencing.

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Folks who commit suicide, as you may know,

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as you may experience, are
often in tremendous pain.

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It may be physical pain.

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It may be psychological or emotional pain.

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In most cases, they don't want to die,

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but they want to end the pain,

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and the pain is so unremitting

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and so difficult

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that the only way out in their minds

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is to end it with suicide.

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Oftentimes, and we'll talk more about this

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later on as well, there's an element,

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especially with folks who
are chronically suicidal,

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who have attempted many
times, of self-loathing.

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It's not just depression.

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It's his intense self-loathing

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that creates that kind of pain.

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Suicidal crises typically
tend to be brief.

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If you can intervene
in the suicidal crisis,

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you can save that person's life.

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The idea is to be able to
put an intervention in place,

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jump in at a time when
the crisis is happening

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so that you can get that person help

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and get them safe.

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Hospitalizing somebody on an
in-patient psychiatric unit

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keeps them safe.

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It doesn't necessarily
decrease their suicidality,

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but for the period of time

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that they're in there, they're safe,

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and during that time, the hope is

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that they're going to get the assistance

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and the support and the
attention that they need

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to help them decrease their suicidality.

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Intervening in the crisis,

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getting them help, intensive help.

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Maybe it's a partial
hospitalization program.

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Maybe it's something
that's going to hold them.

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Even family support to
get them over the crisis

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can be really helpful.

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What are some of the
specific suicide risks

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in certain conditions?

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One wouldn't be surprised
that a high number

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of individuals who attempt suicide

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have had previous attempts.

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In fact, it's one of the primary factors

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in determining risk, is that
previous attempt at suicide.

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38.4% of suicides are completed by folks

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who have had previous attempts.

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You can see, going down the line here,

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you have a mix

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of other Axis I and Axis II concerns.

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Drug abuse, alcohol abuse,

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all are involved in
creating a risk picture.

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When you're doing an assessment,

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one of the things that you want to do

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is elicit those risk factors.

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What are the risk factors

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that the individual is coming up with?

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You may know that because
you've got a history with them.

264
00:13:19,019 --> 00:13:20,797
You've been working
with them for some time,

265
00:13:20,797 --> 00:13:23,949
in therapy or in the school.

266
00:13:23,949 --> 00:13:25,996
If you're a crisis clinician

267
00:13:25,996 --> 00:13:27,764
you may not have that experience.

268
00:13:27,764 --> 00:13:29,679
If you're a nurse or a doctor

269
00:13:29,679 --> 00:13:31,596
or a social worker in a hospital

270
00:13:31,596 --> 00:13:34,717
you may not have that relationship.

271
00:13:35,778 --> 00:13:37,958
What we'll work on today
is really figuring out

272
00:13:37,958 --> 00:13:41,150
those ways to tease out that information.

273
00:13:41,150 --> 00:13:44,774
How do you get good information
about the risk factors

274
00:13:44,774 --> 00:13:49,774
when the individual might be
challenged to tell you that?

275
00:13:49,959 --> 00:13:51,079
For a variety of reasons.

276
00:13:51,079 --> 00:13:56,008
It may be because of their
mental status, intoxication.

277
00:13:57,560 --> 00:14:02,399
It may be just their
resistance to informing you.

278
00:14:02,399 --> 00:14:06,230
It may be their willingness
to really engage

279
00:14:06,230 --> 00:14:08,984
in an active suicidal plan.

280
00:14:10,372 --> 00:14:10,970
It's interesting.

281
00:14:10,970 --> 00:14:13,290
Alcohol abuse actually,

282
00:14:13,290 --> 00:14:17,621
as a risk rate, is only 5.86%.

283
00:14:18,732 --> 00:14:23,050
Alcohol abuse alone is not
necessarily a risk factor.

284
00:14:23,050 --> 00:14:25,099
Alcohol abuse in combination

285
00:14:25,099 --> 00:14:30,099
with any of these others
is an exacerbating factor.

286
00:14:30,322 --> 00:14:35,322
Someone who is depressed
and using alcohol,

287
00:14:36,585 --> 00:14:38,493
their risk rates go up significantly,

288
00:14:38,493 --> 00:14:41,004
and we'll talk about that in a little bit.

289
00:14:41,004 --> 00:14:45,461
Someone who's depressed
and using other drugs,

290
00:14:45,461 --> 00:14:48,788
any combination of risk factors

291
00:14:48,788 --> 00:14:51,450
exacerbate that risk.

292
00:14:52,261 --> 00:14:54,486
Alcohol use as a primary factor

293
00:14:54,486 --> 00:14:58,605
is not as great a risk rate.

294
00:14:58,605 --> 00:15:00,767
Yeah, there's another slide
in a few minutes about that.

295
00:15:01,767 --> 00:15:04,577
What happens is that somebody comes to you

296
00:15:04,577 --> 00:15:06,579
with a number of risk factors,

297
00:15:06,579 --> 00:15:08,656
and if they're using alcohol

298
00:15:08,656 --> 00:15:10,656
or if they're using substances

299
00:15:10,656 --> 00:15:15,656
that impair their judgment

300
00:15:15,923 --> 00:15:19,118
then the likelihood of
their being successful,

301
00:15:19,118 --> 00:15:21,966
or actually attempting
suicide, goes way up.

302
00:15:21,966 --> 00:15:23,615
Somebody who's feeling depressed

303
00:15:23,615 --> 00:15:26,805
and is drinking alcohol,

304
00:15:26,805 --> 00:15:31,389
their impulse control
lessens, is weakened,

305
00:15:31,389 --> 00:15:34,082
their judgment is impaired,

306
00:15:34,082 --> 00:15:39,082
and it becomes much easier to
actually make that attempt.

307
00:15:40,115 --> 00:15:41,957
It happens with other clients as well.

308
00:15:41,957 --> 00:15:43,137
Substance abusing clients,

309
00:15:43,137 --> 00:15:46,662
alcohol-dependent clients.

310
00:15:46,662 --> 00:15:49,734
How much autonomy do they have

311
00:15:49,734 --> 00:15:53,095
in making poor decisions for themselves?

312
00:15:54,833 --> 00:15:56,454
The case of an anorexic client,

313
00:15:56,454 --> 00:15:57,461
an eating disordered client,

314
00:15:57,461 --> 00:15:58,789
a severe eating disordered client,

315
00:15:58,789 --> 00:16:02,006
or a severe alcohol-dependent client,

316
00:16:02,006 --> 00:16:04,356
you could make the case
they're committing suicide.

317
00:16:04,356 --> 00:16:09,356
They're slowly failing-to-eat
themselves to death.

318
00:16:10,107 --> 00:16:12,197
They're slowly drinking
themselves to death.

319
00:16:12,197 --> 00:16:14,189
They have a capacity to do that,

320
00:16:14,189 --> 00:16:16,111
the capability to do that,

321
00:16:16,111 --> 00:16:19,285
so in some ways they're
even more difficult

322
00:16:19,285 --> 00:16:22,868
to intervene with because
it's a slow process.

323
00:16:22,868 --> 00:16:25,065
I think the suicidal client

324
00:16:25,065 --> 00:16:28,840
that comes in with a plan,

325
00:16:28,840 --> 00:16:30,477
they can give us a little
bit more information

326
00:16:30,477 --> 00:16:34,848
and activate us to get
them help more quickly.

327
00:16:34,848 --> 00:16:36,392
Are we intervening and taking away

328
00:16:36,392 --> 00:16:37,703
their right to commit suicide?

329
00:16:37,703 --> 00:16:38,389
I don't know.

330
00:16:38,389 --> 00:16:41,731
Does somebody have a
right to commit suicide?

331
00:16:41,731 --> 00:16:44,439
Legally it's murder, right?

332
00:16:45,655 --> 00:16:48,064
It is an ethical dilemma,

333
00:16:48,064 --> 00:16:51,004
and I always tend to err on the side of

334
00:16:51,004 --> 00:16:54,253
getting somebody the kind of support

335
00:16:54,253 --> 00:16:56,756
and help that will get
them through that crisis

336
00:16:56,756 --> 00:16:59,480
with the hope that getting
them through that crisis

337
00:16:59,480 --> 00:17:04,480
will then allow them to
develop some resiliency

338
00:17:05,687 --> 00:17:07,371
so that they don't continue to

339
00:17:07,371 --> 00:17:12,304
experience these suicidal thoughts.

340
00:17:13,473 --> 00:17:16,093
Clearly, and I didn't say
this at the beginning.

341
00:17:16,093 --> 00:17:18,484
I really should have.

342
00:17:18,484 --> 00:17:21,812
I think of suicide and suicidal behavior

343
00:17:21,812 --> 00:17:25,740
as being in some cases a chronic illness.

344
00:17:27,113 --> 00:17:30,086
There are times that no matter
what our intervention is,

345
00:17:30,086 --> 00:17:32,579
we can't save the patient.

346
00:17:32,579 --> 00:17:35,063
It's like cancer.

347
00:17:35,063 --> 00:17:39,893
It's like any other chronic illness

348
00:17:39,893 --> 00:17:42,678
that could end-up being fatal.

349
00:17:42,678 --> 00:17:45,351
There are things, as
much as we put in place,

350
00:17:45,351 --> 00:17:48,118
as much as we want to save that patient,

351
00:17:48,118 --> 00:17:49,895
we can't do it.

352
00:17:51,818 --> 00:17:56,818
Someone who is absolutely

353
00:17:57,170 --> 00:17:59,698
determined and convinced

354
00:17:59,698 --> 00:18:02,025
that they are going to commit suicide

355
00:18:02,025 --> 00:18:05,209
will not let you help them.

356
00:18:05,209 --> 00:18:07,217
I think that's one of the
most challenging things

357
00:18:07,217 --> 00:18:09,785
as a clinician to face,

358
00:18:09,785 --> 00:18:12,309
to be reaching out, reaching out.

359
00:18:12,309 --> 00:18:14,467
It's like a doctor who's an oncologist,

360
00:18:14,467 --> 00:18:17,395
who has that medicine and knows

361
00:18:17,395 --> 00:18:18,763
what the treatment protocol is

362
00:18:18,763 --> 00:18:21,682
and knows how to save that patient,

363
00:18:21,682 --> 00:18:23,116
and the patient dies.

364
00:18:23,116 --> 00:18:25,195
It does happen.

365
00:18:26,299 --> 00:18:29,354
I will frame this often as,

366
00:18:29,354 --> 00:18:30,931
"I can only do what I can do."

367
00:18:30,931 --> 00:18:32,427
I can only do as much as I can do

368
00:18:32,427 --> 00:18:34,427
and the person who I'm working with,

369
00:18:34,427 --> 00:18:35,758
that client, has to be willing

370
00:18:35,758 --> 00:18:38,679
to engage in that process with me.

371
00:18:38,679 --> 00:18:40,310
If they're not, it's not likely

372
00:18:40,310 --> 00:18:42,990
that they're going to be able to be saved.

373
00:18:42,990 --> 00:18:46,486
That's the parallel to
other medical illnesses.

374
00:18:46,486 --> 00:18:49,957
Cancer is a great one.

375
00:18:51,387 --> 00:18:53,350
Five years from now,

376
00:18:53,350 --> 00:18:55,161
will there be better treatment

377
00:18:55,161 --> 00:18:58,257
for managing suicidal behavior?

378
00:18:58,257 --> 00:18:59,342
We don't know.

379
00:18:59,342 --> 00:19:00,940
There are treatments now.

380
00:19:00,940 --> 00:19:04,298
Medication is not necessarily ...

381
00:19:04,298 --> 00:19:05,619
Does not necessarily work well

382
00:19:05,619 --> 00:19:08,212
in specifically decreasing
suicidal ideation,

383
00:19:08,212 --> 00:19:11,498
except lithium is one that does.

384
00:19:12,451 --> 00:19:15,947
But you're right, what's next?

385
00:19:15,947 --> 00:19:17,809
What would happen if
we could save somebody,

386
00:19:17,809 --> 00:19:19,383
until they get to that point?

387
00:19:19,383 --> 00:19:20,591
That's a good question.

388
00:19:20,591 --> 00:19:22,231
It's one of those gray areas,

389
00:19:22,231 --> 00:19:26,486
and it gets to the point
of, how much of this

390
00:19:26,486 --> 00:19:28,598
is privileged information from your client

391
00:19:28,598 --> 00:19:33,223
and how much is your determination

392
00:19:33,223 --> 00:19:34,697
that they are at such high risk

393
00:19:34,697 --> 00:19:37,111
that they need intervention immediately?

394
00:19:37,111 --> 00:19:41,619
In Massachusetts we have the ability

395
00:19:41,619 --> 00:19:46,619
to involuntarily commit
somebody to an evaluation.

396
00:19:48,337 --> 00:19:49,950
I think that's used a lot.

397
00:19:51,273 --> 00:19:52,464
I know when I ran a crisis team,

398
00:19:52,464 --> 00:19:54,699
it was used a lot.

399
00:19:54,699 --> 00:19:56,805
We would go, the police
would pick somebody up,

400
00:19:56,805 --> 00:19:58,341
who we were very concerned about,

401
00:19:58,341 --> 00:20:00,496
just given the information
that we received.

402
00:20:00,496 --> 00:20:03,171
Clearly we get into ethical
dilemmas around this.

403
00:20:03,171 --> 00:20:05,969
I remember when I was a new clinician

404
00:20:05,969 --> 00:20:09,700
and working with an agency,

405
00:20:09,715 --> 00:20:12,819
I wasn't actually working
with this particular client,

406
00:20:12,819 --> 00:20:15,411
but consulted on this case.

407
00:20:15,411 --> 00:20:18,541
It was an older gentleman who had AIDS.

408
00:20:18,541 --> 00:20:22,942
He was at the end stage of his illness.

409
00:20:23,888 --> 00:20:27,853
He was facing possible prison time

410
00:20:27,853 --> 00:20:29,724
for a crime he committed.

411
00:20:29,724 --> 00:20:31,797
He was going to trial.

412
00:20:32,797 --> 00:20:35,593
He let it be known to his case worker

413
00:20:35,593 --> 00:20:37,664
that he planned on committing suicide.

414
00:20:41,110 --> 00:20:44,678
He had a plan, he had means.

415
00:20:44,678 --> 00:20:47,784
There was a lot of question about,

416
00:20:47,784 --> 00:20:49,366
we know that.

417
00:20:49,366 --> 00:20:51,614
Do we allow that to happen?

418
00:20:51,614 --> 00:20:54,295
There was a lot of discussion.

419
00:20:54,295 --> 00:20:56,828
Ultimately, we did call the police.

420
00:20:56,828 --> 00:20:58,398
Ultimately they did intervene,

421
00:20:58,398 --> 00:21:02,868
but he did end up committing
suicide at another time.

422
00:21:02,868 --> 00:21:05,628
I do think that somebody
who is reaching out

423
00:21:05,628 --> 00:21:07,491
to talk about their suicidal behavior

424
00:21:07,491 --> 00:21:10,101
or their suicidality, their thoughts,

425
00:21:10,101 --> 00:21:14,318
that's the entree into
getting them some assistance.

426
00:21:14,318 --> 00:21:17,549
It's the folks that don't
talk about it at all

427
00:21:17,549 --> 00:21:21,617
that really create a world

428
00:21:21,617 --> 00:21:24,526
that insulates them and isolates them

429
00:21:24,526 --> 00:21:27,197
from others around their suicidality

430
00:21:27,197 --> 00:21:30,486
that we get particularly concerned about.

431
00:21:30,486 --> 00:21:31,621
If somebody's talking about it

432
00:21:31,621 --> 00:21:33,122
that's the first step.

433
00:21:33,122 --> 00:21:34,937
That's a good thing.

434
00:21:34,937 --> 00:21:38,466
They want to get some help, in most cases.

435
00:21:39,692 --> 00:21:41,836
Were there other questions?

436
00:21:43,871 --> 00:21:46,783
Just in terms of suicides rates

437
00:21:46,783 --> 00:21:48,971
among persons 10 years and older,

438
00:21:48,971 --> 00:21:52,840
and somebody said, "I work
in an elementary school.

439
00:21:52,840 --> 00:21:55,510
"You don't really see suicide."

440
00:21:55,510 --> 00:21:59,164
Probably not as much, but it does happen.

441
00:22:00,795 --> 00:22:05,637
The CDC starts tracking
suicides at the age of 10.

442
00:22:06,852 --> 00:22:10,965
What you can see, non-Hispanic whites,

443
00:22:10,965 --> 00:22:14,970
per 100,000,

444
00:22:14,970 --> 00:22:17,799
somewhere around 26.

445
00:22:17,799 --> 00:22:21,341
Non-Hispanic blacks, around 12.

446
00:22:21,341 --> 00:22:23,048
Hispanics, a little higher.

447
00:22:23,048 --> 00:22:27,774
Native Americans, the highest risk rate

448
00:22:27,774 --> 00:22:31,253
in the country for suicide.

449
00:22:33,099 --> 00:22:38,099
Asian and Pacific individuals around 10%.

450
00:22:40,978 --> 00:22:43,715
This is the map of suicide
rates around the country.

451
00:22:43,715 --> 00:22:45,804
Actually, the CDC ...

452
00:22:45,804 --> 00:22:47,843
The first map I used,

453
00:22:47,843 --> 00:22:50,803
the CDC had it as red and blue,

454
00:22:50,803 --> 00:22:51,708
as a color scheme.

455
00:22:51,708 --> 00:22:52,837
(groups laughs)

456
00:22:52,837 --> 00:22:56,047
Prior to the elections, this was back

457
00:22:56,047 --> 00:22:57,752
in the late 1990s,

458
00:22:57,752 --> 00:23:01,168
and they changed it, because interestingly

459
00:23:01,168 --> 00:23:05,321
the red states had the
higher suicide rates.

460
00:23:05,321 --> 00:23:07,258
The blue states had the
lower suicide rates.

461
00:23:07,258 --> 00:23:09,191
Take a look at this map,

462
00:23:09,191 --> 00:23:12,535
and tell me what's
interesting about it to you.

463
00:23:12,535 --> 00:23:14,262
What do you notice?

464
00:23:14,262 --> 00:23:15,524
Poverty in isolation.

465
00:23:16,740 --> 00:23:18,277
Isolation.

466
00:23:18,277 --> 00:23:19,945
You think about ...

467
00:23:22,813 --> 00:23:25,069
The middle of the country.

468
00:23:25,069 --> 00:23:29,501
Vast areas without necessarily resources.

469
00:23:29,501 --> 00:23:30,924
Gun availability, huge.

470
00:23:30,924 --> 00:23:32,027
Absolutely.

471
00:23:32,027 --> 00:23:34,069
Firearm access and the laws

472
00:23:34,069 --> 00:23:36,692
restricting or not restricting firearms

473
00:23:36,692 --> 00:23:41,405
is one of the most
important considerations

474
00:23:41,405 --> 00:23:45,182
in suicide risks, so if you think about

475
00:23:45,182 --> 00:23:50,182
The Rockies, Alaska,

476
00:23:51,117 --> 00:23:54,131
Florida,

477
00:23:54,131 --> 00:23:56,426
The Appalachian States.

478
00:23:56,426 --> 00:23:58,128
Higher suicide rates.

479
00:23:59,543 --> 00:24:02,403
Less restrictive gun laws, right?

480
00:24:02,403 --> 00:24:05,528
Again, someone who attempts suicide

481
00:24:05,528 --> 00:24:08,349
with a firearm is much more likely

482
00:24:08,349 --> 00:24:10,816
to be successful than someone who attempts

483
00:24:10,816 --> 00:24:13,797
with strangulation or with poisoning.

484
00:24:14,571 --> 00:24:15,898
American Indian population,

485
00:24:15,898 --> 00:24:17,084
Native American population,

486
00:24:17,084 --> 00:24:21,881
is, again, in the middle of the country,

487
00:24:21,881 --> 00:24:23,793
the Middle-Western part of the country.

488
00:24:23,793 --> 00:24:26,861
We have higher rates of suicide.

489
00:24:27,641 --> 00:24:30,801
We don't know what's
happening in this area

490
00:24:30,801 --> 00:24:34,134
or over here in terms of reporting.

491
00:24:34,134 --> 00:24:36,073
Remember, this is CDC information,

492
00:24:36,073 --> 00:24:40,314
so are these counties that
don't report to the CDC?

493
00:24:40,314 --> 00:24:43,393
And, why don't they report to the CDC?

494
00:24:46,254 --> 00:24:47,937
What's the reason for that?

495
00:24:47,937 --> 00:24:48,667
Anything else?

496
00:24:48,667 --> 00:24:49,887
There's one other factor here

497
00:24:49,887 --> 00:24:52,138
that I think is sort of interesting.

498
00:24:54,070 --> 00:24:56,019
Alaska has the highest rate of suicide.

499
00:24:56,019 --> 00:24:59,039
Well, Alaska and Nevada, interestingly.

500
00:24:59,039 --> 00:25:00,745
Alaska has the highest rate of suicide.

501
00:25:01,482 --> 00:25:04,222
In the North-East, especially Maine,

502
00:25:04,222 --> 00:25:06,007
Vermont, New Hampshire,

503
00:25:06,007 --> 00:25:07,516
high rates of suicide.

504
00:25:08,453 --> 00:25:09,997
What's it like in the winter?

505
00:25:09,997 --> 00:25:11,751
(group murmurs)
Right.

506
00:25:11,751 --> 00:25:14,239
This part of the country up here,

507
00:25:14,239 --> 00:25:19,239
it's dark for much of the day.

508
00:25:19,701 --> 00:25:21,597
People are more isolated.

509
00:25:21,597 --> 00:25:24,301
There's snow, so people stay inside.

510
00:25:24,301 --> 00:25:27,162
They can't get out.

511
00:25:28,232 --> 00:25:32,558
The rates of alcohol and
other substance abuse

512
00:25:32,558 --> 00:25:35,445
is much higher in these Northern states

513
00:25:35,445 --> 00:25:39,405
and in Alaska and in
Nevada, actually, too,

514
00:25:39,405 --> 00:25:41,159
it's really through the roof.

515
00:25:41,159 --> 00:25:44,733
The combination, again, of factors,

516
00:25:44,733 --> 00:25:48,093
leads to an increased suicide risk.

517
00:25:48,093 --> 00:25:52,133
If you're living in Oklahoma,
you're paying attention

518
00:25:52,133 --> 00:25:54,708
to some of those factors

519
00:25:54,708 --> 00:25:59,708
that are just basic factors

520
00:26:01,002 --> 00:26:03,008
that exist in the culture
and in the community

521
00:26:03,008 --> 00:26:04,754
that increase risk.

522
00:26:04,754 --> 00:26:07,197
If you're living in Florida,
you're thinking about,

523
00:26:07,197 --> 00:26:09,181
what are the factors that increase risk?

524
00:26:09,181 --> 00:26:11,409
Access to guns.

525
00:26:13,382 --> 00:26:16,830
Age of Floridians is greater

526
00:26:16,830 --> 00:26:18,671
than the general population.

527
00:26:18,671 --> 00:26:21,309
Older adults have a much, much higher,

528
00:26:21,309 --> 00:26:25,069
especially older man, much
higher rate of suicide.

529
00:26:25,069 --> 00:26:27,869
In fact, men over the age of 65 have,

530
00:26:27,869 --> 00:26:29,940
I think, the highest rate of suicides

531
00:26:29,940 --> 00:26:31,465
of any group.

532
00:26:32,270 --> 00:26:34,405
Men over the age of 65.

533
00:26:34,405 --> 00:26:37,892
All men, white men included.

534
00:26:37,892 --> 00:26:39,704
Very high rates.

535
00:26:40,652 --> 00:26:45,652
Interestingly, the rate of
death among those individuals,

536
00:26:47,948 --> 00:26:51,951
suicide doesn't show up as
being even in the top 10,

537
00:26:51,951 --> 00:26:53,547
because they're dying of other things.

538
00:26:53,547 --> 00:26:56,377
When you look at the CDC statistics,

539
00:26:56,377 --> 00:27:00,174
you see older adults, and the suicide rate

540
00:27:00,174 --> 00:27:04,168
compared to other causes
of death is way down,

541
00:27:04,168 --> 00:27:09,168
but when you compare
suicide rates to others,

542
00:27:09,559 --> 00:27:11,163
the rates are very, very high.

543
00:27:11,163 --> 00:27:12,796
Much higher.

544
00:27:14,732 --> 00:27:18,768
These kinds of factors are
really important to consider.

545
00:27:18,768 --> 00:27:21,001
Demographic factors are
important to consider.

546
00:27:21,001 --> 00:27:22,482
Where you're practicing.

547
00:27:22,482 --> 00:27:23,742
Access to resources.

548
00:27:23,742 --> 00:27:26,080
If you're practicing in Boston,

549
00:27:26,080 --> 00:27:28,184
you have hospitals all around you

550
00:27:28,184 --> 00:27:31,047
that can be, hopefully, helpful.

551
00:27:31,047 --> 00:27:33,929
You have emergency services
that can be helpful.

552
00:27:33,929 --> 00:27:38,407
If you're practicing in North Dakota,

553
00:27:38,407 --> 00:27:41,428
probably not so much.

554
00:27:42,489 --> 00:27:45,949
Overall leading causes of death, 2009.

555
00:27:45,949 --> 00:27:47,768
Suicide, what?

556
00:27:47,768 --> 00:27:50,608
Number 10 I think, right here.

557
00:27:50,608 --> 00:27:53,738
Higher than HIV, higher than homicides.

558
00:27:53,738 --> 00:27:55,579
A lot higher than homicides.

559
00:27:55,579 --> 00:27:59,394
Higher than liver disease, hypertension.

560
00:28:01,191 --> 00:28:05,699
This is just overall in the United States.

561
00:28:08,197 --> 00:28:11,237
Trends in suicide rates among people

562
00:28:11,237 --> 00:28:16,071
ages 25 to 64, by both sexes, age group,

563
00:28:16,071 --> 00:28:18,280
from 1991 to 2009.

564
00:28:18,280 --> 00:28:21,023
You can see that

565
00:28:21,023 --> 00:28:23,860
it started to drop a little bit here,

566
00:28:23,860 --> 00:28:26,135
between 1991 and 1999.

567
00:28:26,135 --> 00:28:29,983
Suicide rates began to
level off and drop even,

568
00:28:29,983 --> 00:28:33,623
and then around 1999,
2000, we started to see

569
00:28:33,623 --> 00:28:37,234
an increase in suicide rates.

570
00:28:38,431 --> 00:28:41,941
Particularly in the 45 to 54 year olds,

571
00:28:41,941 --> 00:28:46,748
you can see from 2002 to 2009,

572
00:28:46,748 --> 00:28:48,419
they really started to go up,

573
00:28:48,419 --> 00:28:52,352
and I can tell you that
the more recent data

574
00:28:52,352 --> 00:28:54,535
that the CDC has put out,

575
00:28:54,535 --> 00:28:57,492
this is continuing to climb,

576
00:28:57,492 --> 00:29:00,577
because, what happened in 2008?

577
00:29:00,577 --> 00:29:02,483
Anybody remember?
- [Male] The economy.

578
00:29:02,483 --> 00:29:04,063
- The economy crashed.

579
00:29:04,063 --> 00:29:06,944
Suicide rates, especially among

580
00:29:06,944 --> 00:29:11,944
that 35 to 54 year old
group began to go up.

581
00:29:13,127 --> 00:29:15,273
People started losing their houses.

582
00:29:15,273 --> 00:29:17,391
They started losing their jobs.

583
00:29:17,391 --> 00:29:20,984
Their identity was tied in

584
00:29:20,984 --> 00:29:22,095
to the work they did,

585
00:29:22,095 --> 00:29:23,873
or who they believed they were.

586
00:29:23,873 --> 00:29:25,623
As a result of that, and so,

587
00:29:25,623 --> 00:29:28,746
you began to see suicide rates go up.

588
00:29:32,929 --> 00:29:35,972
Mechanism of suicides.

589
00:29:36,953 --> 00:29:39,816
Interesting, males and females.

590
00:29:39,816 --> 00:29:44,816
Men by and large, over 55% of suicides

591
00:29:46,831 --> 00:29:48,631
are by firearm.

592
00:29:49,640 --> 00:29:52,882
Men are more successful at suicides,

593
00:29:52,882 --> 00:29:55,386
but attempt less often.

594
00:29:55,386 --> 00:29:58,858
Women less successful,
but attempt more often.

595
00:29:58,858 --> 00:30:03,177
Primarily because they
use a less lethal method.

596
00:30:03,177 --> 00:30:07,273
Women, in 30% of the cases used a firearm.

597
00:30:07,273 --> 00:30:09,374
Men, 55%.

598
00:30:09,374 --> 00:30:12,150
Women are more likely to use poisoning

599
00:30:12,150 --> 00:30:15,860
as a means of suicide,

600
00:30:15,860 --> 00:30:19,049
poisoning being overdosing,
typically, on medication.

601
00:30:20,742 --> 00:30:23,717
Stockpiling medication to use.

602
00:30:23,717 --> 00:30:27,151
It's an interesting thing
about stockpiling medication.

603
00:30:28,474 --> 00:30:30,506
People didn't really
think about it so much

604
00:30:30,506 --> 00:30:34,224
as being a means for suicide

605
00:30:34,224 --> 00:30:36,272
or even a question to ask about suicide

606
00:30:36,272 --> 00:30:38,281
but what has happened over time,

607
00:30:38,281 --> 00:30:42,400
especially, I think, with
how we manage and monitor

608
00:30:42,400 --> 00:30:46,082
our pharmaceuticals, insurance companies,

609
00:30:46,082 --> 00:30:48,873
managing and monitoring pharmaceuticals,

610
00:30:48,873 --> 00:30:51,528
is that people will just naturally

611
00:30:51,528 --> 00:30:53,337
begin to hold out some medication

612
00:30:53,337 --> 00:30:56,019
when they are almost at
the end of their meds.

613
00:30:56,019 --> 00:30:57,121
I don't know if this happens to you,

614
00:30:57,121 --> 00:31:02,121
but somebody will have

615
00:31:02,483 --> 00:31:05,138
a 90-day supply of medication,

616
00:31:05,138 --> 00:31:07,647
and when they get down to
those last couple of weeks,

617
00:31:07,647 --> 00:31:10,253
they're ordering a new supply,

618
00:31:10,253 --> 00:31:12,820
and they're going to
save that medication out,

619
00:31:12,820 --> 00:31:16,285
primarily because if
they lose their insurance

620
00:31:16,285 --> 00:31:18,102
they want to make sure
that they have medication.

621
00:31:18,102 --> 00:31:20,437
They stockpile it as a way of making sure

622
00:31:20,437 --> 00:31:23,502
that they have that resource

623
00:31:23,502 --> 00:31:26,956
for managing their medical concern

624
00:31:26,956 --> 00:31:29,452
at home, easily accessible.

625
00:31:29,452 --> 00:31:31,464
If they become suicidal,

626
00:31:31,464 --> 00:31:33,340
or as they become more suicidal,

627
00:31:33,340 --> 00:31:37,115
that becomes a ready-made opportunity

628
00:31:37,115 --> 00:31:41,610
for them to use that stockpile
of medication for suicide.

629
00:31:41,610 --> 00:31:43,393
That's something that's changed

630
00:31:43,393 --> 00:31:45,952
in the last five or six years.

631
00:31:45,952 --> 00:31:48,720
People are much more likely
to be stockpiling medication.

632
00:31:48,720 --> 00:31:50,176
Not because they're suicidal,

633
00:31:50,176 --> 00:31:51,552
but because they want to make sure

634
00:31:51,552 --> 00:31:53,787
that they have that
medication available to them

635
00:31:53,787 --> 00:31:57,442
and it's then available
as a means for suicide.

636
00:31:57,442 --> 00:31:58,821
As a method for suicide.

637
00:31:58,821 --> 00:32:00,230
If you're not aware,

638
00:32:00,230 --> 00:32:04,337
Tylenol is the most lethal means, really,

639
00:32:04,337 --> 00:32:07,603
of non-prescription
medications for suicide.

640
00:32:07,603 --> 00:32:10,979
It's easily-accessible, and you're right,

641
00:32:10,979 --> 00:32:14,286
you can get a bottle of 500, right?

642
00:32:14,286 --> 00:32:14,949
Two.

643
00:32:14,949 --> 00:32:17,872
You can buy as many as you want, right?

644
00:32:20,887 --> 00:32:23,700
What Tylenol does, in high amounts,

645
00:32:23,700 --> 00:32:26,515
over a fairly rapid period of time,

646
00:32:26,515 --> 00:32:30,861
after ingestion, is that it
begins to cause liver failure.

647
00:32:32,568 --> 00:32:36,610
That's why you almost see
these black box warnings

648
00:32:36,610 --> 00:32:38,420
that Tylenol puts out, about,

649
00:32:38,420 --> 00:32:43,420
"Only use the dose that's
recommended on the bottle,"

650
00:32:43,647 --> 00:32:45,549
because if you take more than that,

651
00:32:45,549 --> 00:32:46,721
if you take a lot more than that,

652
00:32:46,721 --> 00:32:49,280
it can become very lethal very quickly.

653
00:32:49,280 --> 00:32:53,285
I had a really tragic situation

654
00:32:53,285 --> 00:32:55,887
that I was involved with as
a crisis clinician one time.

655
00:32:55,887 --> 00:32:57,805
We had a 16 year old girl

656
00:32:57,805 --> 00:33:00,480
who was brought into the
emergency department,

657
00:33:00,480 --> 00:33:02,552
who had broken up with her boyfriend.

658
00:33:02,552 --> 00:33:04,079
She's a good student.

659
00:33:05,372 --> 00:33:08,536
Had a solid family.

660
00:33:08,536 --> 00:33:12,520
But she was devastated by this breakup.

661
00:33:12,520 --> 00:33:16,493
She took an entire bottle of Tylenol.

662
00:33:16,493 --> 00:33:20,251
Ingested an entire bottle of
Tylenol before she went to bed.

663
00:33:20,251 --> 00:33:21,747
She didn't get sick.

664
00:33:23,024 --> 00:33:25,006
Slept through the night,
woke up the next morning.

665
00:33:25,006 --> 00:33:26,234
Felt sick.

666
00:33:26,234 --> 00:33:27,104
Told her parents.

667
00:33:27,104 --> 00:33:29,589
Parents got her to the
emergency department.

668
00:33:30,723 --> 00:33:35,723
She was then moved to
another medical facility,

669
00:33:36,582 --> 00:33:39,476
and ultimately died over
the course of three days.

670
00:33:39,476 --> 00:33:41,209
She didn't want to die.

671
00:33:41,209 --> 00:33:45,020
She wanted to do something
to get rid of the pain.

672
00:33:45,020 --> 00:33:49,801
She wanted to make a statement, right?

673
00:33:49,801 --> 00:33:53,181
But she waited too long to get help.

674
00:33:54,590 --> 00:33:56,926
That's something that really is important

675
00:33:56,926 --> 00:33:57,892
when you're asking questions,

676
00:33:57,892 --> 00:34:00,149
is, "When you take a headache,

677
00:34:00,149 --> 00:34:02,459
"what kind of medication
do you typically use?"

678
00:34:02,459 --> 00:34:03,997
"When you're in pain,
what kind of medication

679
00:34:03,997 --> 00:34:05,428
"do you typically use?"

680
00:34:06,335 --> 00:34:08,694
Be thinking about

681
00:34:08,694 --> 00:34:11,172
someone's access to Tylenol.

682
00:34:11,172 --> 00:34:12,700
I'm not sure everybody
that attempts suicide

683
00:34:12,700 --> 00:34:13,759
goes on the internet to look at

684
00:34:13,759 --> 00:34:15,043
what's going to be most successful.

685
00:34:15,043 --> 00:34:17,920
I think people that are really
doing a lot of planning do,

686
00:34:17,920 --> 00:34:20,367
but someone who's in
crisis is going to go for

687
00:34:20,367 --> 00:34:22,414
the first thing that they can find,

688
00:34:22,414 --> 00:34:27,414
or even if they're in a protracted crisis

689
00:34:27,510 --> 00:34:29,378
over a period of days

690
00:34:29,378 --> 00:34:34,378
they're going to be building
up ideas on their own.

691
00:34:34,382 --> 00:34:35,990
They're not necessarily
going to be looking

692
00:34:35,990 --> 00:34:37,772
for ideas from other folks.

693
00:34:38,680 --> 00:34:40,585
Clearly that's some evidence

694
00:34:40,585 --> 00:34:44,444
that restricting access

695
00:34:44,444 --> 00:34:47,915
has a powerful effect.

696
00:34:47,915 --> 00:34:51,596
Restricting access to firearms
has a powerful effect.

697
00:34:54,211 --> 00:34:56,284
Politically I'm not
making a statement there,

698
00:34:56,284 --> 00:34:58,427
but I'm saying, clinically,
it has an effect

699
00:34:58,427 --> 00:35:03,427
when you restrict access
to a method of suicide.

700
00:35:03,931 --> 00:35:07,629
The likelihood is people are
not going to commit suicide.

701
00:35:07,629 --> 00:35:11,482
There's the big discussion
in San Francisco,

702
00:35:11,482 --> 00:35:16,099
about putting up barriers or fencing

703
00:35:16,099 --> 00:35:18,772
over the Golden Gate Bridge.

704
00:35:18,772 --> 00:35:23,772
The Golden Gate Bridge is the most

705
00:35:25,046 --> 00:35:29,139
jumped off-of bridge in the country.

706
00:35:29,139 --> 00:35:31,212
There's actually a really
interesting movie about it,

707
00:35:31,212 --> 00:35:34,307
called "The Bridge," about suicides off of

708
00:35:34,307 --> 00:35:37,208
the San Francisco Golden Gate Bridge.

709
00:35:37,208 --> 00:35:41,596
There's a lot of tension, politically,

710
00:35:41,596 --> 00:35:42,881
around doing that,

711
00:35:42,881 --> 00:35:45,663
but when it's been done
in other locations,

712
00:35:45,663 --> 00:35:49,267
suicide rates have dropped almost to zero.

713
00:35:49,267 --> 00:35:51,597
If you prevent the suicide,

714
00:35:51,597 --> 00:35:55,831
the ability, the means, for the suicide,

715
00:35:55,831 --> 00:35:59,322
then suicide rates drop.

716
00:35:59,322 --> 00:36:03,086
Often people don't go
to some other method.

717
00:36:03,086 --> 00:36:04,923
Somebody who's committed to jumping off

718
00:36:04,923 --> 00:36:06,279
the Golden Gate Bridge,

719
00:36:06,279 --> 00:36:10,542
they have an image of their
suicide in a certain way.

720
00:36:10,542 --> 00:36:14,678
They're less likely to probably
take an overdose of Tylenol.

721
00:36:14,678 --> 00:36:18,885
It also allows some time
for that intervention

722
00:36:18,885 --> 00:36:22,097
to take place and to get them help.

723
00:36:23,373 --> 00:36:24,733
Racial and ethnic disparities.

724
00:36:24,733 --> 00:36:25,767
We talked a little bit about this

725
00:36:25,767 --> 00:36:30,569
with Native Americans, American
Indians, Alaskan Natives.

726
00:36:30,569 --> 00:36:33,841
Ages 15 to 34, suicide
is the second leading

727
00:36:33,841 --> 00:36:37,106
cause of death for that group.

728
00:36:37,106 --> 00:36:40,071
Suicide rates among American Indian,

729
00:36:40,071 --> 00:36:42,972
Alaskan Native adolescents
and young adults

730
00:36:42,972 --> 00:36:46,757
is 2.2 times higher than
the national average

731
00:36:46,757 --> 00:36:48,836
for that age group.

732
00:36:48,836 --> 00:36:50,602
Hispanic female high school students

733
00:36:50,602 --> 00:36:53,325
in grades 9 to 12 reported
a higher percentage

734
00:36:53,325 --> 00:36:56,082
of suicide attempts, 14%,

735
00:36:56,082 --> 00:36:58,087
than their white non-Hispanic

736
00:36:58,087 --> 00:37:00,854
or black non-Hispanic counterparts.

737
00:37:00,854 --> 00:37:05,044
14% of Latina high school students

738
00:37:05,044 --> 00:37:08,315
reported suicide attempts.

739
00:37:08,315 --> 00:37:09,599
That's pretty high.

740
00:37:09,599 --> 00:37:12,486
You think, 14 out of a 100 are reporting

741
00:37:12,486 --> 00:37:15,030
that they've had a suicide attempt.

742
00:37:15,030 --> 00:37:19,074
We'll just take a quick
look at this video here.

743
00:37:30,137 --> 00:37:32,387
Among young adults, 15 to 24,

744
00:37:32,387 --> 00:37:36,653
there's one suicide for
every 100 to 200 attempts.

745
00:37:36,653 --> 00:37:39,152
Among adult ages 65 years and older

746
00:37:39,152 --> 00:37:41,697
there's one suicide for
every four suicide attempts.

747
00:37:41,697 --> 00:37:44,255
Any thoughts about why
that might be the case?

748
00:37:45,090 --> 00:37:46,741
Why are there ...

749
00:37:47,895 --> 00:37:50,764
Why is someone who's 15 to 24

750
00:37:50,764 --> 00:37:55,374
successful only one in 100 to 200 times

751
00:37:55,374 --> 00:38:00,374
and why is someone who's older

752
00:38:01,197 --> 00:38:04,201
successful one out of every four times?

753
00:38:04,201 --> 00:38:04,921
Interesting.

754
00:38:04,921 --> 00:38:06,667
I hadn't thought about
that, but you're right.

755
00:38:06,667 --> 00:38:08,091
They're less likely to reach out

756
00:38:08,091 --> 00:38:10,750
and have support around them.

757
00:38:13,457 --> 00:38:15,453
What happens when people are younger

758
00:38:15,453 --> 00:38:17,241
is they practice, right?

759
00:38:17,241 --> 00:38:18,972
Practice at everything.

760
00:38:18,972 --> 00:38:21,585
You learn to get better.

761
00:38:22,358 --> 00:38:26,313
Your commitment to
suicide as you get older,

762
00:38:26,313 --> 00:38:29,759
as you practice more,

763
00:38:29,759 --> 00:38:31,320
you're better at it.

764
00:38:31,320 --> 00:38:34,148
You also learn what does and doesn't work.

765
00:38:35,132 --> 00:38:38,302
As people age, they're more likely

766
00:38:38,302 --> 00:38:40,311
to use lethal methods,

767
00:38:40,311 --> 00:38:43,793
and they're more likely to
be committed to the act.

768
00:38:43,793 --> 00:38:45,916
It's less an impulsive act.

769
00:38:45,916 --> 00:38:49,287
It's less about getting attention

770
00:38:49,287 --> 00:38:54,287
and more about actually
committing the act itself.

771
00:38:54,831 --> 00:38:56,447
We'll talk about adolescents
a little bit more.

772
00:38:56,447 --> 00:38:58,726
I don't want to let this go.

773
00:38:58,726 --> 00:39:03,726
Social media and the
intensity of social media.

774
00:39:03,994 --> 00:39:07,329
I have a 14 year old and
a 17 year old daughter.

775
00:39:07,329 --> 00:39:12,135
I'm amazed at their
connection to other people

776
00:39:12,135 --> 00:39:14,558
while they're sitting on the couch.

777
00:39:14,558 --> 00:39:17,288
They have Facebook, they have Instagram,

778
00:39:17,288 --> 00:39:19,048
they have Twitter.

779
00:39:19,048 --> 00:39:22,414
Facebook isn't even cool
anymore, apparently.

780
00:39:22,414 --> 00:39:24,243
Unless you're my age, right?

781
00:39:24,243 --> 00:39:26,959
It's all Twitter, all Instagram.

782
00:39:28,666 --> 00:39:33,147
That social media has
its pluses and minuses.

783
00:39:34,685 --> 00:39:36,026
Facebook actually has a policy

784
00:39:36,026 --> 00:39:40,299
that they screen for anything

785
00:39:40,299 --> 00:39:44,753
that they perceive to
be a suicide message.

786
00:39:46,106 --> 00:39:49,019
They have technology to do that,

787
00:39:49,019 --> 00:39:51,805
but it sends a message to that person

788
00:39:51,805 --> 00:39:54,843
with information about getting help.

789
00:39:56,919 --> 00:39:59,848
Which may or may not be helpful.

790
00:40:00,734 --> 00:40:04,742
What I have seen, even just
recently in the last year,

791
00:40:04,742 --> 00:40:08,811
is such an increase in
the number of young people

792
00:40:08,811 --> 00:40:13,626
posting suicide notes
on Facebook or online,

793
00:40:13,626 --> 00:40:16,533
on Twitter,

794
00:40:16,533 --> 00:40:21,533
or talking in detail
about their suicide plans

795
00:40:23,557 --> 00:40:25,839
in those areas.

796
00:40:26,811 --> 00:40:31,313
Sometimes without being able to get help.

797
00:40:32,574 --> 00:40:35,030
There were two situations recently.

798
00:40:35,030 --> 00:40:36,035
One in my town,

799
00:40:36,035 --> 00:40:38,811
another in a town north of where I live,

800
00:40:38,811 --> 00:40:42,884
where high school students
posted on Facebook

801
00:40:42,884 --> 00:40:47,359
that they just couldn't manage any longer.

802
00:40:49,113 --> 00:40:52,792
In both cases,

803
00:40:52,792 --> 00:40:55,543
people saw those notes within 15 minutes,

804
00:40:55,543 --> 00:40:58,671
and tried to reach out,
but it was too late.

805
00:40:58,671 --> 00:41:03,671
Both of the girls were
successful at committing suicide.

806
00:41:05,109 --> 00:41:09,822
The devastation for
the community of people

807
00:41:09,822 --> 00:41:12,688
who read those notes and would have wanted

808
00:41:12,688 --> 00:41:17,688
to do something or wanted
to reach out was amazing.

809
00:41:19,039 --> 00:41:20,702
It's important to really
be paying attention

810
00:41:20,702 --> 00:41:22,671
to how people use social media.

811
00:41:22,671 --> 00:41:26,256
How do they get information
and access information?

812
00:41:27,189 --> 00:41:31,018
One of the things that
social media promotes,

813
00:41:31,018 --> 00:41:35,100
not manifestly, but just as social media,

814
00:41:35,100 --> 00:41:40,100
is the opportunity for
the copycat incidents.

815
00:41:41,531 --> 00:41:45,259
What you see is that
group contagion effect.

816
00:41:45,259 --> 00:41:48,017
That's especially true in high schools,

817
00:41:48,017 --> 00:41:51,594
but it's absolutely true
in colleges as well.

818
00:41:51,594 --> 00:41:54,758
There's a dynamic that occurs

819
00:41:54,758 --> 00:41:57,330
and a successful suicide

820
00:41:57,330 --> 00:41:59,065
then decreases the stigma

821
00:41:59,065 --> 00:42:02,401
and the resistance to future suicides.

822
00:42:02,401 --> 00:42:05,425
If someone has been thinking about suicide

823
00:42:05,425 --> 00:42:07,595
and they see that somebody
else is successful,

824
00:42:07,595 --> 00:42:11,621
and they see all of the
drama that plays out

825
00:42:11,621 --> 00:42:13,128
as a result of that,

826
00:42:13,128 --> 00:42:18,128
it's encouraging them to
move on their thoughts.

827
00:42:19,056 --> 00:42:20,480
For celebrities that's true,

828
00:42:20,480 --> 00:42:25,480
but it's also true for
just our young children.

829
00:42:25,745 --> 00:42:29,545
15, 16, 17 year olds in schools.

830
00:42:29,545 --> 00:42:34,545
When someone commits suicide

831
00:42:34,590 --> 00:42:36,822
that may not even be well-known

832
00:42:36,822 --> 00:42:39,736
to anybody outside their peer group,

833
00:42:39,736 --> 00:42:42,357
then becomes idealized, and, like you say,

834
00:42:42,357 --> 00:42:46,504
canonized, and again, it's, that drama

835
00:42:46,504 --> 00:42:50,552
can really feed into, for some folks,

836
00:42:50,552 --> 00:42:53,905
that wish to make the attempt themselves.

837
00:42:53,905 --> 00:42:55,409
If you think about the community response,

838
00:42:55,409 --> 00:42:57,024
what would the community response be

839
00:42:57,024 --> 00:43:00,227
if those were three
homicides in the school?

840
00:43:00,227 --> 00:43:03,328
In the course of a month or two months.

841
00:43:03,328 --> 00:43:07,287
It would be a different,
probably, response.

842
00:43:07,287 --> 00:43:09,538
I think as a clinician
you have to recognize

843
00:43:09,538 --> 00:43:14,281
that you can only do
everything that you can do.

844
00:43:15,866 --> 00:43:19,993
Once you've discharged

845
00:43:19,993 --> 00:43:22,999
as much of that responsibility as you can

846
00:43:22,999 --> 00:43:25,838
and tried to reach out,

847
00:43:25,838 --> 00:43:29,107
then that's all you can do.

848
00:43:31,756 --> 00:43:35,438
It is really good
learning for that client.

849
00:43:35,438 --> 00:43:37,942
It's a really good opportunity

850
00:43:37,942 --> 00:43:40,468
to use that as a lesson for that client,

851
00:43:40,468 --> 00:43:44,486
about, you're engaging
in listening to that

852
00:43:44,486 --> 00:43:46,244
and being responsive to that.

853
00:43:46,244 --> 00:43:50,364
It's amazing, especially in
middle school and high school,

854
00:43:50,364 --> 00:43:52,291
but middle school in particular,

855
00:43:52,291 --> 00:43:54,258
is what I've noticed.

856
00:43:54,258 --> 00:43:55,850
The talking about.

857
00:43:55,850 --> 00:43:57,712
The talking about suicide.

858
00:43:57,712 --> 00:44:01,146
The talking about death, wanting to die.

859
00:44:01,146 --> 00:44:06,146
There's a developmental component to that,

860
00:44:06,866 --> 00:44:08,920
but there's a lot of
sharing of information

861
00:44:08,920 --> 00:44:11,787
around thoughts of suicide.

862
00:44:14,479 --> 00:44:16,305
As a clinician, I don't
think asking questions

863
00:44:16,305 --> 00:44:19,095
about suicide will cause the person

864
00:44:19,095 --> 00:44:20,629
to become suicidal, right?

865
00:44:20,629 --> 00:44:23,631
We need to ask those
questions about suicide.

866
00:44:23,631 --> 00:44:28,631
I do think that young
teens talking about suicide

867
00:44:32,174 --> 00:44:34,750
starts to stir up thoughts of suicide

868
00:44:34,750 --> 00:44:36,110
and the more it gets talked about,

869
00:44:36,110 --> 00:44:38,055
the more it gets discussed,

870
00:44:38,055 --> 00:44:42,378
the more the risk increases, or attempts.

871
00:44:42,378 --> 00:44:45,446
Not necessarily successes,
but for attempts.

872
00:44:47,230 --> 00:44:50,695
You create this, again,
group contagion effect.

873
00:44:50,695 --> 00:44:51,945
We talk about it, we attempt,

874
00:44:51,945 --> 00:44:54,499
somebody else attempts,
more people attempt.

875
00:44:54,499 --> 00:44:56,237
It becomes almost a lot like,

876
00:44:56,237 --> 00:44:58,261
and we'll talk about it,

877
00:44:58,261 --> 00:45:02,113
non-suicidal self injurious
behavior like cutting.

878
00:45:02,113 --> 00:45:05,008
Cutting, there's a real contagion effect,

879
00:45:05,008 --> 00:45:06,275
with cutting in schools.

880
00:45:06,275 --> 00:45:08,790
Once it gets talked about

881
00:45:08,790 --> 00:45:10,068
and people start to do it,

882
00:45:10,068 --> 00:45:12,400
you see it becoming almost an epidemic,

883
00:45:12,400 --> 00:45:14,383
especially in middle schools,

884
00:45:14,383 --> 00:45:18,130
and actually I've seen it in
elementary schools as well.

885
00:45:19,730 --> 00:45:22,284
We'll talk about that.

886
00:45:23,971 --> 00:45:24,864
Gender disparities.

887
00:45:24,864 --> 00:45:27,033
We've talked a little
bit about this already.

888
00:45:27,033 --> 00:45:28,499
Men take their lives nearly four times

889
00:45:28,499 --> 00:45:30,141
the rate of females.

890
00:45:30,141 --> 00:45:31,345
They represent almost 80%

891
00:45:31,345 --> 00:45:34,326
of all suicides in the United States.

892
00:45:34,326 --> 00:45:37,228
Among males, adult, ages 75 and older,

893
00:45:37,228 --> 00:45:39,583
they have the highest rate of suicide.

894
00:45:39,583 --> 00:45:43,605
37.97, almost 40, per 100,000.

895
00:45:43,605 --> 00:45:48,605
You could think about
seven per 100,000 of teens.

896
00:45:49,899 --> 00:45:50,964
You can see that it's

897
00:45:50,964 --> 00:45:55,127
a significantly greater rate of suicide.

898
00:45:55,127 --> 00:45:56,428
Females, those in the 40s and 50s

899
00:45:56,428 --> 00:45:59,011
have the highest rates of suicide.

900
00:46:00,118 --> 00:46:02,209
We talked about firearms and poisoning.

901
00:46:03,014 --> 00:46:08,014
I've got a 47 year old
recently-divorced woman,

902
00:46:08,070 --> 00:46:10,183
that I'm working with.

903
00:46:10,183 --> 00:46:11,920
I want to be asking some questions

904
00:46:11,920 --> 00:46:15,646
about what's happening in her life.

905
00:46:17,239 --> 00:46:18,683
Maybe she's not suicidal.

906
00:46:18,683 --> 00:46:19,789
Probably isn't,

907
00:46:19,789 --> 00:46:22,157
but I want to begin to dig a little bit

908
00:46:22,157 --> 00:46:23,495
to find out what might be happening

909
00:46:23,495 --> 00:46:25,818
that would lead her to be suicidal.

910
00:46:25,818 --> 00:46:27,463
What are the other risk factors that exist

911
00:46:27,463 --> 00:46:31,893
besides the age and
maybe the recent divorce?

912
00:46:36,859 --> 00:46:38,776
Almost 375,000 people were treated

913
00:46:38,776 --> 00:46:43,026
in emergency departments
for self-inflicted injuries.

914
00:46:44,164 --> 00:46:46,274
165,000 people were hospitalized

915
00:46:46,274 --> 00:46:48,266
due to self-inflicted injuries,

916
00:46:48,266 --> 00:46:51,336
and there's one suicide for
every 25 attempted suicides.

917
00:46:51,336 --> 00:46:53,317
If you think about this,

918
00:46:53,317 --> 00:46:55,850
the almost 375,000 people in 2005

919
00:46:55,850 --> 00:46:57,351
coming into emergency departments

920
00:46:57,351 --> 00:47:00,449
for self-inflicted injuries,

921
00:47:00,449 --> 00:47:03,584
those weren't necessarily
all suicide attempts,

922
00:47:03,584 --> 00:47:06,230
but many of them, most
of them, probably were.

923
00:47:06,230 --> 00:47:09,010
If you're getting emergency
department treatment

924
00:47:09,010 --> 00:47:12,160
it's probably, for a
self-inflicted injury,

925
00:47:12,160 --> 00:47:16,741
it's probably because there
was some suicidality involved.

926
00:47:16,741 --> 00:47:20,690
People who are non-suicidal
and self-injurious

927
00:47:20,690 --> 00:47:22,380
typically don't get to the point

928
00:47:22,380 --> 00:47:24,795
where they actually reach
the emergency department.

929
00:47:24,795 --> 00:47:26,318
They don't cut that deep.

930
00:47:26,318 --> 00:47:28,844
They don't burn that much.

931
00:47:30,505 --> 00:47:35,505
You can imagine that that cohort,

932
00:47:36,038 --> 00:47:37,085
that's probably a group of people

933
00:47:37,085 --> 00:47:39,294
who were attempting suicide.

934
00:47:39,294 --> 00:47:44,294
When you look at death-rates by suicide,

935
00:47:44,569 --> 00:47:46,427
I think it's important to take that

936
00:47:46,427 --> 00:47:48,023
with a little bit of a caveat

937
00:47:48,023 --> 00:47:51,495
in that there are

938
00:47:51,495 --> 00:47:53,431
areas, places, in the country

939
00:47:53,431 --> 00:47:56,232
that the medical examiner or the coroner

940
00:47:56,232 --> 00:47:59,697
won't necessarily
identify it as a suicide.

941
00:47:59,697 --> 00:48:01,307
For what reasons?

942
00:48:02,342 --> 00:48:03,361
Cultural.

943
00:48:03,361 --> 00:48:04,784
Religious.

944
00:48:05,999 --> 00:48:06,686
Insurance.

945
00:48:06,686 --> 00:48:08,217
Small community.

946
00:48:08,217 --> 00:48:11,230
If there's an opportunity
for that individual

947
00:48:11,230 --> 00:48:15,766
to call it an accidental death, right?

948
00:48:15,766 --> 00:48:18,566
They may be more likely to do that.

949
00:48:18,566 --> 00:48:19,889
Larger cities, it's less likely

950
00:48:19,889 --> 00:48:21,107
that that's going to happen,

951
00:48:21,107 --> 00:48:22,785
but in small communities,

952
00:48:22,785 --> 00:48:25,274
which account for a large percentage

953
00:48:25,274 --> 00:48:28,057
of the United States,

954
00:48:28,057 --> 00:48:29,845
those medical examiners and coroners

955
00:48:29,845 --> 00:48:31,116
are part of the community

956
00:48:31,116 --> 00:48:34,918
and maybe less likely to,

957
00:48:34,918 --> 00:48:37,403
if there's a way to identify that suicide

958
00:48:37,403 --> 00:48:39,650
as something other than a suicide

959
00:48:39,650 --> 00:48:41,810
they may be more likely to do that.

960
00:48:41,810 --> 00:48:45,986
The stigma of suicide

961
00:48:45,986 --> 00:48:47,882
really does still determine

962
00:48:47,882 --> 00:48:50,723
in many cases how suicide is identified

963
00:48:50,723 --> 00:48:53,753
on death certificates.

964
00:48:53,753 --> 00:48:57,609
Something important to remember.

965
00:48:57,609 --> 00:49:01,403
This is something that I
think about all the time

966
00:49:01,403 --> 00:49:04,417
when I'm thinking about suicidality.

967
00:49:04,417 --> 00:49:07,458
I actually heard this when I was working

968
00:49:07,458 --> 00:49:09,695
with some folks at Hospice.

969
00:49:09,695 --> 00:49:14,494
This was how they defined

970
00:49:14,494 --> 00:49:17,048
what causes somebody to become suicidal.

971
00:49:17,048 --> 00:49:19,490
When an individual's intolerance

972
00:49:19,490 --> 00:49:22,152
for the intensity of the stress and pain

973
00:49:22,152 --> 00:49:27,036
they're experiencing
exceeds their capacity

974
00:49:27,036 --> 00:49:31,104
and resources to overcome the problem.

975
00:49:31,104 --> 00:49:33,885
Someone is in so much pain,

976
00:49:33,885 --> 00:49:35,879
or the stress that they're experiencing

977
00:49:35,879 --> 00:49:38,134
psychologically is so great

978
00:49:38,134 --> 00:49:39,895
that it exceeds the resources

979
00:49:39,895 --> 00:49:42,509
that exist for them to
overcome their problem.

980
00:49:43,531 --> 00:49:47,350
That captures a lot.

981
00:49:47,350 --> 00:49:49,967
You think about medical issues.

982
00:49:49,967 --> 00:49:54,352
You think about psychological stress.

983
00:49:54,352 --> 00:49:57,443
Loss, grief.

984
00:49:59,408 --> 00:50:04,316
The stress that's related to losses.

985
00:50:05,694 --> 00:50:08,090
Economic losses.

986
00:50:09,262 --> 00:50:12,030
When the housing market crashed

987
00:50:12,030 --> 00:50:17,012
and their houses were being foreclosed on,

988
00:50:17,012 --> 00:50:18,308
suicide rates in those communities

989
00:50:18,308 --> 00:50:20,539
went up significantly.

990
00:50:20,539 --> 00:50:23,446
The stress and the intensity of the stress

991
00:50:23,446 --> 00:50:25,427
or the intensity of the pain

992
00:50:25,427 --> 00:50:29,713
exceeds the resources
to overcome that pain.

993
00:50:29,713 --> 00:50:31,733
When you're meeting with somebody,

994
00:50:31,733 --> 00:50:34,720
you're hearing the pain that they're in,

995
00:50:34,720 --> 00:50:35,885
it's important to look at,

996
00:50:35,885 --> 00:50:37,846
okay, what a resources that you have

997
00:50:37,846 --> 00:50:40,830
or exist to manage that pain?

998
00:50:40,830 --> 00:50:42,653
Are you using resources to help you

999
00:50:42,653 --> 00:50:45,124
manage that stress or that pain?

1000
00:50:45,124 --> 00:50:46,627
If you're not, let's find

1001
00:50:46,627 --> 00:50:49,706
what the resources are that can help you.

1002
00:50:49,706 --> 00:50:54,550
We want to have resources
that exceed the stress.

1003
00:50:54,550 --> 00:50:58,030
We want to have resources
that exceed the pain.

1004
00:51:00,214 --> 00:51:04,168
I used an example in my book,

1005
00:51:04,168 --> 00:51:06,802
of a patient I was working with

1006
00:51:06,802 --> 00:51:10,092
who was in chronic pain.

1007
00:51:11,794 --> 00:51:15,021
She always was looking for,

1008
00:51:15,021 --> 00:51:17,341
and actually thinking she could find

1009
00:51:17,341 --> 00:51:21,865
the next best thing to get
her out of that chronic pain.

1010
00:51:21,865 --> 00:51:26,865
She went through every
medical practitioner

1011
00:51:27,783 --> 00:51:29,375
that she could find,

1012
00:51:29,375 --> 00:51:33,958
and non-traditional practitioners,

1013
00:51:33,958 --> 00:51:36,736
and there was one individual

1014
00:51:36,736 --> 00:51:40,011
who really, there was a
trial that they were doing,

1015
00:51:40,011 --> 00:51:41,413
a doctor that was doing a trial,

1016
00:51:41,413 --> 00:51:43,099
and they thought that they
could get her into it,

1017
00:51:43,099 --> 00:51:44,718
and she would be a perfect candidate.

1018
00:51:44,718 --> 00:51:46,896
She was very excited about that,

1019
00:51:46,896 --> 00:51:50,157
because she had been in
chronic pain for years.

1020
00:51:50,157 --> 00:51:53,483
She goes to the doctor
and meets with the doctor

1021
00:51:53,483 --> 00:51:57,148
and finds out that she's not
a candidate for the trial.

1022
00:51:58,989 --> 00:52:01,958
She at that point felt that the resources

1023
00:52:01,958 --> 00:52:05,928
were non-existent to
manage her chronic pain

1024
00:52:05,928 --> 00:52:09,011
and became very suicidal.

1025
00:52:10,703 --> 00:52:14,375
Folks who have that sense

1026
00:52:14,375 --> 00:52:16,670
that they're never going to get better.

1027
00:52:16,670 --> 00:52:19,004
That the pain, it's unremitting.

1028
00:52:19,004 --> 00:52:23,524
They will be the ones
that are most at risk.

1029
00:52:23,524 --> 00:52:26,229
It's interesting because PTSD,

1030
00:52:26,229 --> 00:52:28,060
I'll tell you what I think, anyway.

1031
00:52:28,060 --> 00:52:31,319
I think PTSD is so all-encompassing,

1032
00:52:31,319 --> 00:52:35,301
and it's in some ways,

1033
00:52:35,301 --> 00:52:37,843
the way that it's coded

1034
00:52:37,843 --> 00:52:39,731
would be around some of the behaviors

1035
00:52:39,731 --> 00:52:42,075
that are consistent with PTSD,

1036
00:52:42,075 --> 00:52:47,075
so maybe even psychotic episodes

1037
00:52:48,292 --> 00:52:50,763
could be consistent with someone

1038
00:52:50,763 --> 00:52:54,621
who's experiencing post-traumatic stress.

1039
00:52:54,621 --> 00:52:56,325
I'm not sure that it's well-diagnosed,

1040
00:52:56,325 --> 00:52:57,894
and I think when this came out,

1041
00:52:57,894 --> 00:52:58,932
that information came out,

1042
00:52:58,932 --> 00:53:02,275
it wouldn't necessarily
have been identified

1043
00:53:02,275 --> 00:53:05,071
as a primary risk factor for ...

1044
00:53:05,071 --> 00:53:07,038
- [Female] Not even
specifically with veterans?

1045
00:53:07,038 --> 00:53:08,427
- Now with veterans
it's a different thing.

1046
00:53:08,427 --> 00:53:09,832
We're going to talk about
veterans in a minute,

1047
00:53:09,832 --> 00:53:14,189
but that particular cohort

1048
00:53:14,189 --> 00:53:16,167
clearly has become one of

1049
00:53:16,167 --> 00:53:17,602
the primary risk populations,

1050
00:53:17,602 --> 00:53:19,581
and PTSD has been talked about

1051
00:53:19,581 --> 00:53:22,056
more particularly with that group.

1052
00:53:22,056 --> 00:53:27,056
PTSD, if you look at the new DSM,

1053
00:53:27,494 --> 00:53:29,379
stress-related disorders have

1054
00:53:29,379 --> 00:53:34,379
a whole new all-encompassing realm

1055
00:53:34,660 --> 00:53:38,198
within the DSM.

1056
00:53:38,198 --> 00:53:43,198
PTSD in the general population
is less likely to be seen

1057
00:53:43,460 --> 00:53:45,581
as being a primary risk factor,

1058
00:53:45,581 --> 00:53:49,086
but what people experience as a result

1059
00:53:49,086 --> 00:53:51,626
of the PTSD,

1060
00:53:51,626 --> 00:53:54,112
that becomes risky.

1061
00:53:55,379 --> 00:53:56,731
We will talk about PTSD,

1062
00:53:56,731 --> 00:53:58,619
and particularly with
veterans, in a second.

1063
00:53:58,619 --> 00:53:59,472
It's really interesting.

1064
00:53:59,472 --> 00:54:02,306
I've heard that before, but not often.

1065
00:54:03,414 --> 00:54:06,350
You think of, in bipolar illness,

1066
00:54:06,350 --> 00:54:09,462
that it's coming out of that manic episode

1067
00:54:09,462 --> 00:54:12,900
into depression where the
suicide rate is the highest,

1068
00:54:12,900 --> 00:54:15,196
and probably, statistically, that is true,

1069
00:54:15,196 --> 00:54:20,196
but there is that
interesting euphoria, right?

1070
00:54:21,700 --> 00:54:23,200
People talk about, there are people

1071
00:54:23,200 --> 00:54:26,016
who experience that euphoric revelry

1072
00:54:26,016 --> 00:54:28,590
around suicidality, right?

1073
00:54:28,590 --> 00:54:32,983
When they attempt suicide
they experience that euphoria.

1074
00:54:32,983 --> 00:54:34,391
That's interesting.

1075
00:54:34,391 --> 00:54:36,194
I haven't read any research about that.

1076
00:54:36,194 --> 00:54:39,179
We have to remember, as clinicians,

1077
00:54:39,179 --> 00:54:42,014
that they are under the
influence of their illness,

1078
00:54:42,014 --> 00:54:43,311
at that time.

1079
00:54:44,758 --> 00:54:48,147
What seems to be clarity and peace to them

1080
00:54:48,147 --> 00:54:50,468
and what feels peace to them

1081
00:54:50,468 --> 00:54:53,432
is also part of their illness

1082
00:54:53,432 --> 00:54:58,432
and what's next for them in that process.

1083
00:54:58,797 --> 00:55:01,435
I think it's very difficult

1084
00:55:01,435 --> 00:55:06,331
to get a depressed person
out of their depression,

1085
00:55:06,331 --> 00:55:07,818
out of their anhedonia,

1086
00:55:07,818 --> 00:55:09,107
to get to the point where they see

1087
00:55:09,107 --> 00:55:12,667
that they shouldn't be committing suicide.

1088
00:55:12,667 --> 00:55:14,058
They shouldn't commit suicide.

1089
00:55:14,058 --> 00:55:16,613
It's even more difficult to get somebody

1090
00:55:16,613 --> 00:55:19,441
who's out of that euphoric state,

1091
00:55:19,441 --> 00:55:20,478
where they feel at peace

1092
00:55:20,478 --> 00:55:21,979
and they feel like they have clarity

1093
00:55:21,979 --> 00:55:26,979
out of the place where they
feel committed to suicide.

1094
00:55:27,249 --> 00:55:30,165
Couple more things about suicidality

1095
00:55:30,165 --> 00:55:32,545
and folks who are suicidal.

1096
00:55:32,545 --> 00:55:34,612
90% of suicides are by individuals

1097
00:55:34,612 --> 00:55:36,176
who have a significant mental illness

1098
00:55:36,176 --> 00:55:38,693
at the time of death.

1099
00:55:38,693 --> 00:55:41,362
It's not just alcoholism.

1100
00:55:41,362 --> 00:55:43,951
It's bipolar disorder.

1101
00:55:43,951 --> 00:55:45,748
It's schizophrenia.

1102
00:55:45,748 --> 00:55:48,088
It's depression.

1103
00:55:48,088 --> 00:55:51,909
It's any number of other diagnoses.

1104
00:55:53,570 --> 00:55:56,301
Borderline personality disorder.

1105
00:55:58,162 --> 00:56:01,173
90% of folks who commit suicide

1106
00:56:01,173 --> 00:56:02,978
have a significant illness
at the time of death.

1107
00:56:02,978 --> 00:56:04,938
Whether or not they're being treated well

1108
00:56:04,938 --> 00:56:09,020
is another question, right?

1109
00:56:09,020 --> 00:56:11,523
When there's a co-occurring
substance abuse,

1110
00:56:11,523 --> 00:56:15,611
that significantly increases the risk.

1111
00:56:15,611 --> 00:56:20,131
Again, the combination of
a primary mental illness

1112
00:56:20,131 --> 00:56:23,199
and a co-occurring substance abuse

1113
00:56:23,199 --> 00:56:27,211
or alcohol dependence or abuse

1114
00:56:27,211 --> 00:56:30,698
significantly increases the risk factors.

1115
00:56:31,845 --> 00:56:34,071
Research, especially more recently,

1116
00:56:34,071 --> 00:56:39,071
has shown that when there is
open psychomotor aggression

1117
00:56:39,507 --> 00:56:44,321
in patients that have
been previously depressed

1118
00:56:44,321 --> 00:56:49,321
and overt change in their clinical status,

1119
00:56:50,042 --> 00:56:55,042
that is an indicator that
there's a high likelihood

1120
00:56:55,635 --> 00:57:00,544
that they'll be more
likely to be suicidal.

1121
00:57:00,544 --> 00:57:03,079
Any thoughts on why
that might be the case?

1122
00:57:03,079 --> 00:57:05,078
There's a couple of reasons for that.

1123
00:57:05,078 --> 00:57:06,942
They're more activated.

1124
00:57:08,742 --> 00:57:12,924
Use the warnings on Prozac,

1125
00:57:12,924 --> 00:57:14,939
especially in adolescence.

1126
00:57:14,939 --> 00:57:19,506
The negative symptoms
of the depression ...

1127
00:57:21,136 --> 00:57:24,724
What happens is that you get the ability

1128
00:57:24,724 --> 00:57:27,368
to be less anergic.

1129
00:57:27,368 --> 00:57:29,410
The anergia goes away,

1130
00:57:29,410 --> 00:57:31,797
but the anhedonia doesn't.

1131
00:57:33,966 --> 00:57:38,966
You have the ability and the
energy to act on the thoughts.

1132
00:57:38,977 --> 00:57:40,819
With SSRIs particularly,

1133
00:57:40,819 --> 00:57:45,819
the energy comes back before
the anhedonia disappears.

1134
00:57:46,123 --> 00:57:47,967
The other thing is that for some folks

1135
00:57:47,967 --> 00:57:52,967
who are depressed or
who may appear depressed

1136
00:57:53,925 --> 00:57:56,272
and have been contemplating suicide,

1137
00:57:56,272 --> 00:58:00,312
when they make the
decision to commit suicide,

1138
00:58:00,312 --> 00:58:02,568
they get that sort of euphoria,

1139
00:58:02,568 --> 00:58:04,663
the peace, that comes with that.

1140
00:58:04,663 --> 00:58:09,308
When they've really made the commitment

1141
00:58:09,308 --> 00:58:11,936
to follow through, there's
this period of time

1142
00:58:11,936 --> 00:58:14,855
before they act on that,

1143
00:58:14,855 --> 00:58:17,907
that their depression seems to lift.

1144
00:58:17,907 --> 00:58:20,654
That they appear to be less depressed.

1145
00:58:20,654 --> 00:58:22,475
They have more energy.

1146
00:58:22,475 --> 00:58:26,824
They may be more motivated
to put things in place

1147
00:58:26,824 --> 00:58:31,512
and to resolve problems
for those around them,

1148
00:58:31,512 --> 00:58:34,136
so that when they die they know that

1149
00:58:34,136 --> 00:58:37,120
they're not going to be leaving people

1150
00:58:37,120 --> 00:58:39,736
with bills, unpaid bills,

1151
00:58:39,736 --> 00:58:41,629
or things that they might have

1152
00:58:41,629 --> 00:58:45,168
not followed through on previously.

1153
00:58:48,661 --> 00:58:50,447
About 50% of people who kill themselves

1154
00:58:50,447 --> 00:58:54,261
have seen their PCP in
the past two months.

1155
00:58:54,261 --> 00:58:56,698
The primary care clinician, their doctor,

1156
00:58:56,698 --> 00:58:58,839
nurse practitioner, PA,

1157
00:58:58,839 --> 00:59:01,058
they've seen them in the past two months.

1158
00:59:01,058 --> 00:59:05,349
Up until recently, the medical field,

1159
00:59:05,349 --> 00:59:07,110
the non-psychiatric medical field,

1160
00:59:07,110 --> 00:59:10,106
hasn't done a great
job of asking questions

1161
00:59:10,106 --> 00:59:13,362
about depression or about suicide.

1162
00:59:13,362 --> 00:59:18,362
In a regular appointment.

1163
00:59:18,753 --> 00:59:22,121
A physical or a check-up, a med check.

1164
00:59:23,275 --> 00:59:26,269
In the last few years, I
don't know if you've noticed,

1165
00:59:26,269 --> 00:59:28,304
but when you go to your doctor,

1166
00:59:28,304 --> 00:59:30,280
you're probably going to get a question,

1167
00:59:30,280 --> 00:59:32,555
at least some question, about depression

1168
00:59:32,555 --> 00:59:35,756
or about thoughts of suicide

1169
00:59:35,756 --> 00:59:40,704
or just about whether you're
feeling hopeless or not.

1170
00:59:40,704 --> 00:59:42,889
More and more, the medical field

1171
00:59:42,889 --> 00:59:44,472
is paying attention to the fact

1172
00:59:44,472 --> 00:59:47,732
that people coming in to see their doctors

1173
00:59:47,732 --> 00:59:49,785
actually may be experiencing depression

1174
00:59:49,785 --> 00:59:53,147
or other mental illness
and having symptoms

1175
00:59:53,147 --> 00:59:56,712
of thoughts of suicide.

1176
00:59:56,712 --> 00:59:59,446
I know that particularly
with pediatricians

1177
00:59:59,446 --> 01:00:01,730
in the State of Massachusetts,

1178
01:00:01,730 --> 01:00:05,474
there's a screening process
that they go through,

1179
01:00:05,474 --> 01:00:09,195
and asking adolescents and children

1180
01:00:09,195 --> 01:00:12,883
questions around depression.

1181
01:00:12,883 --> 01:00:14,450
The Department of Mental
Health in the state

1182
01:00:14,450 --> 01:00:18,146
pays for consultation
with a child psychiatrist

1183
01:00:18,146 --> 01:00:19,800
if they have concerns, so they can call

1184
01:00:19,800 --> 01:00:21,455
a child psychiatrist who's on call,

1185
01:00:21,455 --> 01:00:24,721
and get some assistance

1186
01:00:24,721 --> 01:00:27,537
with either medication or referrals.

1187
01:00:27,537 --> 01:00:30,207
That's a step in the right direction.

1188
01:00:30,207 --> 01:00:34,361
This is a study that's been
around for a long time.

1189
01:00:36,226 --> 01:00:39,087
One study, 58% had seen their psychiatrist

1190
01:00:39,087 --> 01:00:41,912
the previous week.

1191
01:00:41,912 --> 01:00:44,293
Well over half had seen
their psychiatrist.

1192
01:00:44,293 --> 01:00:45,947
That's sort of interesting, right?

1193
01:00:45,947 --> 01:00:48,201
You think about, what is psychiatry now?

1194
01:00:48,201 --> 01:00:49,538
- [Female] Med management.

1195
01:00:49,538 --> 01:00:51,073
- Med manager, right?

1196
01:00:51,073 --> 01:00:54,278
"Every fifteen minutes,
four times an hour."

1197
01:00:54,278 --> 01:00:56,257
In and out.

1198
01:00:57,888 --> 01:01:00,007
Being a psychiatrist is
a challenge right now

1199
01:01:00,007 --> 01:01:01,061
for folks who were trained.

1200
01:01:01,061 --> 01:01:03,741
Especially folks who
were trained years ago

1201
01:01:03,741 --> 01:01:07,892
as sort of psychoanalytic psychiatrists.

1202
01:01:07,892 --> 01:01:10,493
It's difficult to do that work.

1203
01:01:10,493 --> 01:01:13,169
The expectation is, you're
going to see the patient,

1204
01:01:13,169 --> 01:01:14,961
you're going to check their medication,

1205
01:01:14,961 --> 01:01:16,379
you're going to get them
on the right medication,

1206
01:01:16,379 --> 01:01:17,833
and then they're going to leave.

1207
01:01:17,833 --> 01:01:18,863
You really don't have a lot of time

1208
01:01:18,863 --> 01:01:22,173
to be engaged in the
relationship with them

1209
01:01:22,173 --> 01:01:27,173
to help really tease out
what might be happening.

1210
01:01:27,564 --> 01:01:32,268
Economic factors certainly come into play.

1211
01:01:33,953 --> 01:01:35,232
If you're a client and you know

1212
01:01:35,232 --> 01:01:37,990
you've only got 15 minutes with your doc,

1213
01:01:37,990 --> 01:01:40,343
you're probably going to be careful

1214
01:01:40,343 --> 01:01:43,164
about how much you open up to him or her.

1215
01:01:44,651 --> 01:01:47,161
All right, how successful
is the treatment?

1216
01:01:47,161 --> 01:01:48,049
People are engaged in treatment

1217
01:01:48,049 --> 01:01:50,276
and continue to be engaged in treatment

1218
01:01:50,276 --> 01:01:52,219
that may not be really very successful,

1219
01:01:52,219 --> 01:01:54,021
but what else is there?

1220
01:01:54,021 --> 01:01:57,641
In some instances, people stay engaged

1221
01:01:57,641 --> 01:01:59,788
in treatment because they don't know.

1222
01:01:59,788 --> 01:02:01,174
Is there anything else
that's going to help them?

1223
01:02:01,174 --> 01:02:03,235
Is this the best that it gets?

1224
01:02:03,235 --> 01:02:08,235
Again, at some point,
if they feel hopeless,

1225
01:02:10,015 --> 01:02:11,803
that the treatment is helping them,

1226
01:02:11,803 --> 01:02:13,651
or is going anywhere,

1227
01:02:13,651 --> 01:02:16,205
then there's a likelihood
that that hopelessness

1228
01:02:16,205 --> 01:02:19,468
will lead towards suicidality.

1229
01:02:19,468 --> 01:02:21,473
Again, psychiatry is no different

1230
01:02:21,473 --> 01:02:24,441
than any other medical treatment.

1231
01:02:25,671 --> 01:02:28,606
People with chronic back pain
stay engaged in treatment

1232
01:02:28,606 --> 01:02:31,476
even though the treatment
might not be working

1233
01:02:31,476 --> 01:02:34,095
or it even might be making them worse.

1234
01:02:34,095 --> 01:02:37,650
They might get temporary remission

1235
01:02:37,650 --> 01:02:40,493
from their pain, but the
long-term consequences

1236
01:02:40,493 --> 01:02:43,556
of the medication that they're using

1237
01:02:43,556 --> 01:02:45,388
opens up all sorts of other issues.

1238
01:02:46,249 --> 01:02:49,642
I think it's an interesting
statement to make.

1239
01:02:49,642 --> 01:02:50,614
If they're engaged in treatment,

1240
01:02:50,614 --> 01:02:54,260
then that alone is a sign of hope.

1241
01:02:54,260 --> 01:02:55,579
It is, to some extent,

1242
01:02:55,579 --> 01:02:57,889
but you do have to gauge

1243
01:02:57,889 --> 01:03:00,869
how effective the treatment is.

1244
01:03:02,169 --> 01:03:04,776
I want to talk a little bit
about veterans for a minute.

1245
01:03:04,776 --> 01:03:06,878
I want to show a couple of news clips.

1246
01:03:06,878 --> 01:03:09,408
These news clips are
a couple of years old.

1247
01:03:09,408 --> 01:03:12,869
I think they're still relevant though.

1248
01:03:20,875 --> 01:03:23,277
Let me just set this up real quick.

1249
01:03:23,277 --> 01:03:27,463
This is a story about

1250
01:03:27,463 --> 01:03:30,519
a veteran, a soldier,

1251
01:03:30,519 --> 01:03:33,046
from this area, from this region,

1252
01:03:33,046 --> 01:03:34,358
who committed suicide
a couple of years ago.

1253
01:03:34,358 --> 01:03:36,484
A few years ago.

1254
01:03:36,484 --> 01:03:38,662
Really rocked the community,

1255
01:03:38,662 --> 01:03:39,719
because both of his parents

1256
01:03:39,719 --> 01:03:43,565
were involved in mental health services

1257
01:03:43,565 --> 01:03:45,411
and substance abuse services,

1258
01:03:45,411 --> 01:03:50,411
so they were aware of the
kinds of problems that exist,

1259
01:03:50,739 --> 01:03:53,468
and it really highlights, I think,

1260
01:03:53,468 --> 01:03:57,678
issues around access and
around doing good assessment.

1261
01:04:02,803 --> 01:04:07,626
I know that we don't have,
obviously, all the story there.

1262
01:04:07,626 --> 01:04:11,446
Given what you heard,

1263
01:04:11,446 --> 01:04:15,759
here's this marine back from Iraq,

1264
01:04:15,759 --> 01:04:19,514
drinking heavily, experiencing symptoms,

1265
01:04:19,514 --> 01:04:22,893
of PTSD, probably.

1266
01:04:23,877 --> 01:04:28,786
Gets committed to a VA hospital.

1267
01:04:30,524 --> 01:04:33,142
There's no documentation
that he sees a psychiatrist

1268
01:04:33,142 --> 01:04:35,760
in the three days that he's there.

1269
01:04:35,760 --> 01:04:38,657
What do you think's missing in that?

1270
01:04:42,632 --> 01:04:46,507
I'm not pointing out the
problems at the VA necessarily,

1271
01:04:46,507 --> 01:04:47,778
because I think it's true

1272
01:04:47,778 --> 01:04:52,569
in every hospitalization situation now.

1273
01:04:52,569 --> 01:04:55,326
In these brief hospitalizations,

1274
01:04:55,326 --> 01:04:57,195
often people don't get the attention,

1275
01:04:57,195 --> 01:05:00,011
even in a locked psychiatric unit,

1276
01:05:00,011 --> 01:05:03,927
that they need to help them get stable,

1277
01:05:03,927 --> 01:05:07,505
which is one the reasons I
said at the very beginning,

1278
01:05:07,505 --> 01:05:09,287
being hospitalized does not necessarily

1279
01:05:09,287 --> 01:05:13,196
in and of itself decrease
your likelihood of suicide.

1280
01:05:13,196 --> 01:05:17,643
There's plenty of
research that shows that.

1281
01:05:19,243 --> 01:05:22,282
From many different perspectives,

1282
01:05:22,282 --> 01:05:25,813
from a legal perspective,
an ethical perspective,

1283
01:05:25,813 --> 01:05:27,858
a clinical perspective,

1284
01:05:27,858 --> 01:05:31,980
it's really important that we learn

1285
01:05:31,980 --> 01:05:34,179
how to do really good risk assessments

1286
01:05:34,179 --> 01:05:37,041
and then document those assessments.

1287
01:05:37,041 --> 01:05:41,081
In this case the VA opens itself up

1288
01:05:41,081 --> 01:05:44,569
to huge liability, legally,

1289
01:05:44,569 --> 01:05:48,993
for not documenting whether or not

1290
01:05:48,993 --> 01:05:52,890
an assessment was done.

1291
01:05:52,890 --> 01:05:54,639
I'll talk about that,
and that's one the things

1292
01:05:54,639 --> 01:05:56,917
I'm going to really
point out consistently,

1293
01:05:56,917 --> 01:05:59,737
is the importance of
documenting your assessment,

1294
01:05:59,737 --> 01:06:01,481
because if you do an
assessment, that's great,

1295
01:06:01,481 --> 01:06:02,823
but unless you make sure that it's written

1296
01:06:02,823 --> 01:06:07,649
in a record someplace you open
yourself up for liability.

1297
01:06:07,649 --> 01:06:09,246
Who becomes suicidal?

1298
01:06:09,246 --> 01:06:10,404
Most people have suicidal thoughts

1299
01:06:10,404 --> 01:06:11,631
some time during their lives.

1300
01:06:11,631 --> 01:06:13,942
Often during teenaged years.

1301
01:06:14,818 --> 01:06:15,741
I did.

1302
01:06:15,741 --> 01:06:18,678
I think probably all of my friends did.

1303
01:06:18,678 --> 01:06:21,337
I can't think of anybody
that doesn't really.

1304
01:06:21,337 --> 01:06:26,337
Most people do have some thoughts
about dying as teenagers.

1305
01:06:26,447 --> 01:06:28,678
Interestingly, we'll talk
about teenagers in a minute,

1306
01:06:28,678 --> 01:06:29,891
in terms of their risk factors,

1307
01:06:29,891 --> 01:06:32,079
and their being a high risk population,

1308
01:06:32,079 --> 01:06:34,764
but one of the things
that's certainly true

1309
01:06:34,764 --> 01:06:37,024
about adolescents is that their brains

1310
01:06:37,024 --> 01:06:38,902
are not fully-developed, right?

1311
01:06:38,902 --> 01:06:42,403
They have that teenaged brain.

1312
01:06:42,403 --> 01:06:44,054
I said, I have two teenaged daughters.

1313
01:06:44,054 --> 01:06:47,731
I understand teenaged brain
pretty well right now.

1314
01:06:47,731 --> 01:06:50,041
Especially with my 14 year old.

1315
01:06:51,148 --> 01:06:56,129
Their way of thinking
is very narcissistic.

1316
01:06:56,129 --> 01:06:59,937
They're self-centered and ego-centric

1317
01:06:59,937 --> 01:07:01,738
in their perspectives.

1318
01:07:01,738 --> 01:07:05,067
There's this developmental rapprochement

1319
01:07:05,067 --> 01:07:08,365
going, sometimes I think,
back to four years old,

1320
01:07:08,365 --> 01:07:11,378
in terms of the concrete
nature of how they think.

1321
01:07:12,502 --> 01:07:13,904
That concreteness,

1322
01:07:13,904 --> 01:07:17,103
the concretization of thought,

1323
01:07:17,103 --> 01:07:21,812
is one of the reasons
that makes them high risk.

1324
01:07:21,812 --> 01:07:23,757
It's the "If, then."

1325
01:07:23,757 --> 01:07:26,782
Or, "When this happens,
then this will happen."

1326
01:07:26,782 --> 01:07:28,406
It's that black and white thinking

1327
01:07:28,406 --> 01:07:31,015
that exists often.

1328
01:07:31,015 --> 01:07:34,211
When I was in high school, I had a friend

1329
01:07:34,211 --> 01:07:38,724
who got himself into
trouble playing cards.

1330
01:07:38,724 --> 01:07:42,565
He owed somebody $100.

1331
01:07:42,565 --> 01:07:45,741
He could not imagine how he

1332
01:07:45,741 --> 01:07:47,460
was going to pay that money back.

1333
01:07:47,460 --> 01:07:49,093
Didn't have it.

1334
01:07:49,093 --> 01:07:51,148
If he told his father,

1335
01:07:51,148 --> 01:07:53,091
his father would be very upset,

1336
01:07:53,091 --> 01:07:54,574
and ground him,

1337
01:07:54,574 --> 01:07:57,291
so his response to that

1338
01:07:57,291 --> 01:07:59,335
was to commit suicide.

1339
01:07:59,335 --> 01:08:02,458
This is a guy who was 15 years old.

1340
01:08:02,458 --> 01:08:05,696
Who owed $100 on a gambling debt.

1341
01:08:05,696 --> 01:08:08,963
And ended his life as a result.

1342
01:08:08,963 --> 01:08:12,395
That's not really clearly thinking through

1343
01:08:12,395 --> 01:08:14,645
the consequences of the action, right?

1344
01:08:14,645 --> 01:08:17,111
It's based on what's
right in front of him.

1345
01:08:17,111 --> 01:08:20,184
In the next day or two.

1346
01:08:20,184 --> 01:08:23,046
This was not somebody who was depressed.

1347
01:08:23,046 --> 01:08:25,751
His family was a challenging family,

1348
01:08:25,751 --> 01:08:30,346
but he didn't recognize or wasn't aware

1349
01:08:30,346 --> 01:08:33,421
of resources that might have
been available to help him,

1350
01:08:33,421 --> 01:08:38,421
and did not have, because of
that self-centered behavior,

1351
01:08:38,825 --> 01:08:41,740
the ability to go out and ask for help.

1352
01:08:43,628 --> 01:08:45,784
Adolescence is a tough time.

1353
01:08:45,784 --> 01:08:48,242
Most of suicidal ideation is fleeting.

1354
01:08:48,242 --> 01:08:51,551
When you get help, it passes.

1355
01:08:51,551 --> 01:08:53,482
That's where the crisis ...

1356
01:08:54,476 --> 01:08:58,306
If you intervene at the
crisis, you can get help.

1357
01:08:59,537 --> 01:09:04,537
2007, 14.5% of students grade 9 through 12

1358
01:09:04,548 --> 01:09:08,375
considered suicide in
the previous 12 months.

1359
01:09:08,375 --> 01:09:11,917
18.7% of females did.

1360
01:09:11,917 --> 01:09:13,970
6.9% of students reported making

1361
01:09:13,970 --> 01:09:17,904
at least one suicide attempt
in the previous 12 months.

1362
01:09:18,559 --> 01:09:20,100
2% of students reported making

1363
01:09:20,100 --> 01:09:21,202
at least one suicide attempt

1364
01:09:21,202 --> 01:09:22,279
in the previous 12 months

1365
01:09:22,279 --> 01:09:24,039
that required medical attention.

1366
01:09:24,039 --> 01:09:25,133
You think about that.

1367
01:09:25,133 --> 01:09:27,763
7% of students reported making

1368
01:09:27,763 --> 01:09:30,979
at least one suicide attempt
in the previous 12 months.

1369
01:09:30,979 --> 01:09:35,544
One in every seven high school students.

1370
01:09:35,544 --> 01:09:39,145
Made at least one suicide attempt.

1371
01:09:43,222 --> 01:09:48,222
Seven in every 100 and two in every 100

1372
01:09:48,959 --> 01:09:52,191
admitted that they made attempts

1373
01:09:52,191 --> 01:09:53,835
that required medical attention,

1374
01:09:53,835 --> 01:09:56,528
so two out of 100, that seems high to me.

1375
01:09:56,528 --> 01:09:58,127
That's a lot of kids.

1376
01:09:58,127 --> 01:10:01,928
In a high school of 1,000 kids,

1377
01:10:01,928 --> 01:10:03,023
that's a lot of kids who've had

1378
01:10:03,023 --> 01:10:05,863
a suicide attempt in the previous year

1379
01:10:05,863 --> 01:10:08,739
and required medical attention.

1380
01:10:10,136 --> 01:10:11,751
A couple of things that happened,

1381
01:10:11,751 --> 01:10:13,045
couple of reasons or one reason

1382
01:10:13,045 --> 01:10:18,045
that students end-up feeling suicidal

1383
01:10:18,267 --> 01:10:21,136
is something we talk a lot about,

1384
01:10:21,136 --> 01:10:24,538
or hear a lot about probably, is bullying.

1385
01:10:29,266 --> 01:10:31,299
Some folks are actually
from South Hadley here,

1386
01:10:31,299 --> 01:10:36,299
and I'm sure many people
are aware of that case.

1387
01:10:38,111 --> 01:10:40,773
It's not unique to South Hadley

1388
01:10:40,773 --> 01:10:42,118
or to this part of Massachusetts,

1389
01:10:42,118 --> 01:10:45,072
or really anywhere.

1390
01:10:49,521 --> 01:10:54,521
You hear about these incidents
arising all the time.

1391
01:10:54,884 --> 01:10:57,751
The bullying, if you think about it

1392
01:10:57,751 --> 01:10:59,905
in terms of risk,

1393
01:10:59,905 --> 01:11:03,778
the intensity of the
pain that is experienced

1394
01:11:03,778 --> 01:11:07,131
from the bullying and from the harassment

1395
01:11:07,131 --> 01:11:10,392
that comes from that exceeds the resources

1396
01:11:10,392 --> 01:11:12,883
that are available, at least
the perceived resources,

1397
01:11:12,883 --> 01:11:15,624
that are available to help manage that,

1398
01:11:15,624 --> 01:11:20,004
and for adolescents, that's an
important factor to consider.

1399
01:11:21,404 --> 01:11:24,885
How do they feel like they can reach out

1400
01:11:24,885 --> 01:11:26,353
when they're being bullied?

1401
01:11:26,353 --> 01:11:28,747
As a clinician, if you're
working with adolescents,

1402
01:11:28,747 --> 01:11:31,011
how do you engage them in asking questions

1403
01:11:31,011 --> 01:11:33,468
around that particular risk factor?

1404
01:11:33,468 --> 01:11:35,815
Sometimes, oftentimes, they
don't want to talk about it.

1405
01:11:35,815 --> 01:11:37,212
They're embarrassed by it.

1406
01:11:37,212 --> 01:11:39,011
They're ashamed by it.

1407
01:11:39,011 --> 01:11:42,945
They're afraid of what would
happen if they talk about it,

1408
01:11:42,945 --> 01:11:44,704
because what are the consequences?

1409
01:11:44,704 --> 01:11:45,851
Are they going to get beat up?

1410
01:11:45,851 --> 01:11:47,243
Are they going to get ...

1411
01:11:47,243 --> 01:11:49,301
What's next for them?

1412
01:11:49,301 --> 01:11:51,303
It becomes closeted.

1413
01:11:51,303 --> 01:11:52,677
Like a lot of things in adolescence,

1414
01:11:52,677 --> 01:11:55,332
it becomes closeted.

1415
01:11:56,963 --> 01:12:00,113
It is a significant risk factor

1416
01:12:00,113 --> 01:12:02,633
in adolescents particularly.

1417
01:12:02,633 --> 01:12:07,633
There's even a push-back
amongst adolescent peers,

1418
01:12:08,822 --> 01:12:10,353
to talk about bullying,

1419
01:12:10,353 --> 01:12:14,364
because it seems to be
so much in the news now

1420
01:12:14,364 --> 01:12:17,165
that there's this reluctance
to even acknowledge

1421
01:12:17,165 --> 01:12:18,688
that bullying is occurring.

1422
01:12:18,688 --> 01:12:19,947
"Oh, everybody talks about bullying.

1423
01:12:19,947 --> 01:12:20,995
"That's not bullying.

1424
01:12:20,995 --> 01:12:22,546
"That's something else," right?

1425
01:12:22,546 --> 01:12:24,418
It is bullying.

1426
01:12:24,418 --> 01:12:25,969
It's important, if
you're working with kids,

1427
01:12:25,969 --> 01:12:29,280
to really be clear about
what it means to be bullied,

1428
01:12:29,280 --> 01:12:30,823
and what that actually is.

1429
01:12:30,823 --> 01:12:33,399
Yes, you can call it harassment,

1430
01:12:33,399 --> 01:12:34,786
but it is bullying,

1431
01:12:34,786 --> 01:12:37,294
and if you're being picked on,

1432
01:12:37,294 --> 01:12:41,055
it feels like it's not in your control.

1433
01:12:42,270 --> 01:12:44,250
It becomes a leadership
issue within the school

1434
01:12:44,250 --> 01:12:46,603
to promote that culture.

1435
01:12:46,603 --> 01:12:49,039
Exactly, yeah.

1436
01:12:52,229 --> 01:12:53,728
Another group that I
really want to highlight

1437
01:12:53,728 --> 01:12:56,312
is LGBT youth.

1438
01:12:58,261 --> 01:13:00,773
I just found this study.

1439
01:13:00,773 --> 01:13:03,368
It was just published last week.

1440
01:13:03,368 --> 01:13:07,789
These are data from 2011.

1441
01:13:07,789 --> 01:13:10,741
This is in San Francisco.

1442
01:13:10,741 --> 01:13:13,599
The San Francisco School District

1443
01:13:13,599 --> 01:13:18,599
did a study and they interviewed,

1444
01:13:18,925 --> 01:13:23,430
there were about 2,500 non-LGB students.

1445
01:13:23,430 --> 01:13:27,343
106 LGB and 33 individuals

1446
01:13:27,343 --> 01:13:30,390
who identified as transgendered.

1447
01:13:30,390 --> 01:13:34,427
You can see, around some of the violence,

1448
01:13:34,427 --> 01:13:39,427
the bullying, that might
promote suicidal risk.

1449
01:13:39,971 --> 01:13:44,971
Or exacerbation of stress
and mental illness.

1450
01:13:46,452 --> 01:13:51,452
33% of non-LGBT students had reported

1451
01:13:51,801 --> 01:13:54,056
property damage at school.

1452
01:13:54,056 --> 01:13:56,775
70% of transgendered students.

1453
01:13:57,514 --> 01:13:59,400
Been bullied at school, 20%,

1454
01:13:59,400 --> 01:14:01,263
versus 66%.

1455
01:14:01,263 --> 01:14:02,845
Been in a fight, 17.

1456
01:14:02,845 --> 01:14:04,439
70%.

1457
01:14:04,439 --> 01:14:07,808
Been threatened or injured
with a weapon at school.

1458
01:14:07,808 --> 01:14:08,824
58%.

1459
01:14:08,824 --> 01:14:12,528
Then you go to

1460
01:14:12,528 --> 01:14:15,550
students that have had
suicidal indicators.

1461
01:14:15,550 --> 01:14:18,479
Sad, depressed, seriously
considered suicide,

1462
01:14:18,479 --> 01:14:20,989
made a plan, attempted suicide,

1463
01:14:20,989 --> 01:14:23,498
and suicide attempt with injury.

1464
01:14:23,498 --> 01:14:25,413
You can see again,

1465
01:14:25,413 --> 01:14:30,413
in the LGBT students,

1466
01:14:31,105 --> 01:14:33,368
pretty significant increase

1467
01:14:33,368 --> 01:14:38,317
over the non-LGBT students.

1468
01:14:39,709 --> 01:14:42,148
Suicide indicators,
seriously considered suicide,

1469
01:14:42,148 --> 01:14:45,639
made a suicide plan, attempted suicide.

1470
01:14:47,230 --> 01:14:49,738
You're right, and for the transgenders,

1471
01:14:49,738 --> 01:14:52,037
whose is particularly small,

1472
01:14:52,037 --> 01:14:57,037
but it's clearly an area of ...

1473
01:14:59,204 --> 01:15:03,278
Of attention, when you're
working with adolescents.

1474
01:15:03,278 --> 01:15:05,323
This is really suicide.

1475
01:15:05,323 --> 01:15:07,012
We're not even talking about

1476
01:15:07,012 --> 01:15:10,195
non-suicidal self injurious behavior.

1477
01:15:12,214 --> 01:15:15,731
I guess the point is that, again,

1478
01:15:15,731 --> 01:15:18,411
resources available to adolescents

1479
01:15:18,411 --> 01:15:20,900
who identify as LGBT.

1480
01:15:20,900 --> 01:15:24,489
Very important to ask questions

1481
01:15:24,489 --> 01:15:27,699
around what resources are in place

1482
01:15:27,699 --> 01:15:30,662
or exist for them to help with

1483
01:15:30,662 --> 01:15:31,504
the feelings that they have,

1484
01:15:31,504 --> 01:15:33,300
that they're struggling with.

1485
01:15:35,070 --> 01:15:36,587
Let's talk about non-suicidal

1486
01:15:36,587 --> 01:15:39,274
self injurious behaviors for a minute.

1487
01:15:42,802 --> 01:15:46,469
If you can just pass these
around that would be great.

1488
01:15:49,838 --> 01:15:52,509
Between 33 and 50% of adolescents

1489
01:15:52,509 --> 01:15:56,546
in the United States have done some form

1490
01:15:56,546 --> 01:15:59,286
of non-suicidal self injurious behavior.

1491
01:15:59,286 --> 01:16:00,425
What's the most common?

1492
01:16:01,395 --> 01:16:02,315
- [Female] Cutting.

1493
01:16:02,315 --> 01:16:04,040
- [Kirk] Cutting.

1494
01:16:04,715 --> 01:16:08,063
Burning is,

1495
01:16:08,063 --> 01:16:11,087
actually, interestingly,

1496
01:16:11,087 --> 01:16:12,432
sort of on the rise,

1497
01:16:12,432 --> 01:16:15,732
in terms of self injurious behavior.

1498
01:16:17,044 --> 01:16:21,339
Doing self-tattooing.

1499
01:16:21,339 --> 01:16:22,936
I don't know if people have seen that,

1500
01:16:22,936 --> 01:16:24,134
but that's certainly been something

1501
01:16:24,134 --> 01:16:26,177
that's been on the rise.

1502
01:16:29,058 --> 01:16:32,127
Self injurious behavior
is often impulsive.

1503
01:16:32,127 --> 01:16:34,735
It usually happens with
less than an hour planning.

1504
01:16:35,817 --> 01:16:39,357
More impulsive than
even suicidal behavior.

1505
01:16:39,357 --> 01:16:40,736
Suicidal behavior typically takes

1506
01:16:40,736 --> 01:16:43,236
some more planning than non-suicidal

1507
01:16:43,236 --> 01:16:45,460
self injurious behavior.

1508
01:16:46,706 --> 01:16:48,389
Adolescents who injure themselves

1509
01:16:48,389 --> 01:16:52,526
report that they feel little or no pain.

1510
01:16:52,526 --> 01:16:56,074
Partly because one of the factors involved

1511
01:16:56,074 --> 01:17:01,074
in self injurious
behavior is to get rid of

1512
01:17:01,868 --> 01:17:04,649
the emotional pain that they're feeling.

1513
01:17:04,649 --> 01:17:06,149
What they'll say is,

1514
01:17:06,149 --> 01:17:09,118
"I cut myself and I didn't feel any pain.

1515
01:17:09,118 --> 01:17:11,470
"I just felt relief.

1516
01:17:11,470 --> 01:17:15,759
"That relief, when I saw myself bleeding,

1517
01:17:15,759 --> 01:17:17,620
"I knew I was real.

1518
01:17:17,620 --> 01:17:19,770
"I felt grounded."

1519
01:17:21,677 --> 01:17:24,566
It's often not, and in most cases,

1520
01:17:24,566 --> 01:17:26,037
it's not an attempt

1521
01:17:26,037 --> 01:17:31,037
to commit suicide or to
even injure one's self

1522
01:17:34,022 --> 01:17:37,882
seriously-enough to
end up in the hospital.

1523
01:17:37,882 --> 01:17:42,388
It's really to either ground one's self

1524
01:17:42,388 --> 01:17:45,223
or to regulate affect.

1525
01:17:45,223 --> 01:17:48,005
In some cases it's
about getting attention.

1526
01:17:49,167 --> 01:17:51,901
Self harm in peers is a risk factor,

1527
01:17:51,901 --> 01:17:54,309
because of the contagion effect.

1528
01:17:54,309 --> 01:17:56,907
We talked about that earlier.

1529
01:17:56,907 --> 01:17:59,665
I don't know if you've
seen this in schools,

1530
01:17:59,665 --> 01:18:03,461
but certainly in middle schools

1531
01:18:03,461 --> 01:18:05,519
all over I've seen it

1532
01:18:05,519 --> 01:18:08,401
where students will
begin to talk about it,

1533
01:18:08,401 --> 01:18:09,801
they'll begin to act on,

1534
01:18:09,801 --> 01:18:12,346
or they'll begin to self injure,

1535
01:18:12,346 --> 01:18:15,191
and then other students join in.

1536
01:18:15,191 --> 01:18:17,217
It's almost like a pact.

1537
01:18:17,217 --> 01:18:20,187
This cult contagion effect that occurs.

1538
01:18:20,187 --> 01:18:23,009
It's around, in some cases,

1539
01:18:23,009 --> 01:18:25,462
belonging to a peer group.

1540
01:18:25,462 --> 01:18:27,625
It's around identity.

1541
01:18:27,625 --> 01:18:30,937
Often, that happens,

1542
01:18:30,937 --> 01:18:33,508
although it's typically fleeting.

1543
01:18:33,508 --> 01:18:36,282
It goes,

1544
01:18:36,282 --> 01:18:38,902
and kind of waxes and wanes.

1545
01:18:38,902 --> 01:18:40,987
Often you can see it happening

1546
01:18:40,987 --> 01:18:42,871
with the level of stress

1547
01:18:42,871 --> 01:18:43,971
that occurs at different times

1548
01:18:43,971 --> 01:18:45,899
during the school year.

1549
01:18:45,899 --> 01:18:47,660
Things become more stressful,

1550
01:18:47,660 --> 01:18:48,873
we're on the holidays,

1551
01:18:48,873 --> 01:18:51,761
you're more likely to see
more self-injurious behavior

1552
01:18:51,761 --> 01:18:55,841
and then that wanes as the year goes on,

1553
01:18:55,841 --> 01:18:56,813
and then may increase again

1554
01:18:56,813 --> 01:18:58,893
towards the end of the school year.

1555
01:19:00,707 --> 01:19:05,213
Interestingly, there's a 2007 study

1556
01:19:05,213 --> 01:19:07,832
that really reports there's
no gender difference

1557
01:19:07,832 --> 01:19:09,613
in self injurious behavior.

1558
01:19:09,613 --> 01:19:12,138
Although we often think
of self injurious behavior

1559
01:19:12,138 --> 01:19:14,754
as being more likely to occur with women,

1560
01:19:14,754 --> 01:19:16,800
statistically that's not true.

1561
01:19:16,800 --> 01:19:19,160
One of the things that is true

1562
01:19:19,160 --> 01:19:20,609
is that men are less likely

1563
01:19:20,609 --> 01:19:23,027
to report self injurious behavior.

1564
01:19:23,027 --> 01:19:23,802
They're less likely

1565
01:19:23,802 --> 01:19:28,620
to do it as part of a contagion,

1566
01:19:28,620 --> 01:19:31,049
identity kind of process,

1567
01:19:31,049 --> 01:19:34,711
but they are just as likely

1568
01:19:34,711 --> 01:19:36,650
to self injure as women are.

1569
01:19:36,650 --> 01:19:39,275
That particular study, they did.

1570
01:19:39,275 --> 01:19:42,135
I don't remember how it played out.

1571
01:19:42,135 --> 01:19:42,964
I'm trying to remember,

1572
01:19:42,964 --> 01:19:45,188
because this was from
a couple of years ago

1573
01:19:45,188 --> 01:19:46,090
when I did the research,

1574
01:19:46,090 --> 01:19:49,069
but I think men were more likely

1575
01:19:49,069 --> 01:19:52,594
to self harm in ways other than cutting.

1576
01:19:52,594 --> 01:19:54,901
Burning, head banging, other things.

1577
01:19:54,901 --> 01:19:56,431
- [Female] Punching walls.
- Punching walls.

1578
01:19:56,431 --> 01:19:58,806
That would be more likely

1579
01:19:58,806 --> 01:20:01,072
to not be happening with women.

1580
01:20:01,072 --> 01:20:02,636
Women were much more likely to cut.

1581
01:20:02,636 --> 01:20:04,813
Yeah, and you could even say

1582
01:20:04,813 --> 01:20:08,132
that some of the self injurious behavior

1583
01:20:08,132 --> 01:20:13,132
is things like

1584
01:20:13,347 --> 01:20:16,841
the "fight clubs" that form.

1585
01:20:16,841 --> 01:20:18,642
Boys fighting each other

1586
01:20:18,642 --> 01:20:21,649
to the point where
they're seriously injured

1587
01:20:21,649 --> 01:20:24,178
is really self injurious.

1588
01:20:24,178 --> 01:20:25,901
You're putting yourself in that position.

1589
01:20:25,901 --> 01:20:27,708
While you're being
injured by somebody else

1590
01:20:27,708 --> 01:20:31,141
it's still self injury by proxy, almost.

1591
01:20:31,141 --> 01:20:33,116
My recollection of the
studies that I looked at,

1592
01:20:33,116 --> 01:20:37,402
there was not a socioeconomic difference.

1593
01:20:39,909 --> 01:20:41,275
I don't know more than that,

1594
01:20:41,275 --> 01:20:43,460
but I do remember that I was surprised,

1595
01:20:43,460 --> 01:20:47,007
because you do think of
self injurious behavior

1596
01:20:47,007 --> 01:20:52,007
being reported more, at
least in a private school,

1597
01:20:53,231 --> 01:20:57,213
upper echelon kind of,
upper middle class folks,

1598
01:20:57,213 --> 01:21:00,053
but again I'm not sure that
that's necessarily true.

1599
01:21:00,053 --> 01:21:01,881
It may be reported more,

1600
01:21:01,881 --> 01:21:03,039
but the incidents I think

1601
01:21:03,039 --> 01:21:04,222
are across the board the same.

1602
01:21:04,222 --> 01:21:05,152
- [Female] And race?

1603
01:21:05,152 --> 01:21:06,909
- Race I don't know about.

1604
01:21:06,909 --> 01:21:08,139
It's a good question.

1605
01:21:09,031 --> 01:21:13,478
Favazza said that non-self
injurious behavior

1606
01:21:13,478 --> 01:21:16,263
is a morbid form of self-help.

1607
01:21:16,263 --> 01:21:20,941
Which is different than suicidal behavior.

1608
01:21:20,941 --> 01:21:22,555
Truly suicidal behavior

1609
01:21:22,555 --> 01:21:24,107
isn't really a form of self-help.

1610
01:21:24,107 --> 01:21:27,646
It's a form of ending one's self.

1611
01:21:27,646 --> 01:21:30,168
Non-suicidal self injurious behavior

1612
01:21:30,168 --> 01:21:32,969
really is in some ways

1613
01:21:32,969 --> 01:21:34,394
trying to either help one's self

1614
01:21:34,394 --> 01:21:37,032
or get help, get attention.

1615
01:21:38,262 --> 01:21:40,746
Why do people self injure?

1616
01:21:40,746 --> 01:21:44,230
One reason is for affect regulation.

1617
01:21:45,476 --> 01:21:48,605
Being able to manage anxiety.

1618
01:21:48,605 --> 01:21:50,148
Managing anger.

1619
01:21:50,148 --> 01:21:53,545
Frustration, depression.

1620
01:21:54,483 --> 01:21:57,540
When one has intolerable affect,

1621
01:21:57,540 --> 01:22:00,655
or intolerable emotions,

1622
01:22:00,655 --> 01:22:04,148
self injuring is a way to manage that.

1623
01:22:04,148 --> 01:22:06,237
You think of boys,

1624
01:22:06,237 --> 01:22:07,774
a good example of what boys do.

1625
01:22:07,789 --> 01:22:08,441
What do they do?

1626
01:22:08,441 --> 01:22:09,126
They punch the door.

1627
01:22:09,126 --> 01:22:12,852
They punch the wall when they're angry.

1628
01:22:12,852 --> 01:22:16,932
That helps them manage that anger.

1629
01:22:16,932 --> 01:22:18,763
They are actually able to take that out,

1630
01:22:18,763 --> 01:22:23,437
or their feelings are actually
physically manifested.

1631
01:22:24,453 --> 01:22:26,422
Controlling feelings and cognitions.

1632
01:22:26,422 --> 01:22:28,394
Distracting from problems.

1633
01:22:29,191 --> 01:22:30,792
Stopping suicidal thoughts.

1634
01:22:30,792 --> 01:22:32,590
Dissociation.

1635
01:22:32,590 --> 01:22:35,483
Or stopping dissociation.

1636
01:22:35,483 --> 01:22:40,469
Those are other reasons why
someone would self injure.

1637
01:22:40,469 --> 01:22:42,529
Then self punishment.

1638
01:22:43,789 --> 01:22:47,637
The feeling shame

1639
01:22:47,637 --> 01:22:51,689
and hurting one's self
because they feel ashamed.

1640
01:22:53,822 --> 01:22:55,757
For girls, I've seen that particularly,

1641
01:22:55,757 --> 01:22:58,512
but I think boys are the same.

1642
01:22:59,696 --> 01:23:01,774
Then there's also the interpersonal piece.

1643
01:23:01,774 --> 01:23:06,364
Wanting to be involved
with the peer group.

1644
01:23:06,364 --> 01:23:11,364
Getting care and attention from folks,

1645
01:23:11,978 --> 01:23:14,125
from parents or others,

1646
01:23:14,125 --> 01:23:19,125
so if one self injures then
they get attention for that.

1647
01:23:19,196 --> 01:23:22,863
Certainly there's a part
of the contagion effect

1648
01:23:22,863 --> 01:23:25,236
that's around being part of a peer group

1649
01:23:25,236 --> 01:23:29,956
and feeling that they're
accepted into a peer group.

1650
01:23:29,956 --> 01:23:32,651
In this case, it's to control
the feelings of shame.

1651
01:23:32,651 --> 01:23:35,620
Someone feels incredibly ashamed

1652
01:23:35,620 --> 01:23:37,626
for something that they've done

1653
01:23:37,626 --> 01:23:41,066
and when they self injure, that helps.

1654
01:23:42,512 --> 01:23:44,747
It changes the focus of the shame,

1655
01:23:44,747 --> 01:23:46,676
so the attention for that individual

1656
01:23:46,676 --> 01:23:50,558
that's self harming
goes to the self injury

1657
01:23:50,558 --> 01:23:54,611
versus whatever the event was

1658
01:23:54,611 --> 01:23:56,417
that precipitated the shame.

1659
01:23:56,417 --> 01:23:57,639
That's not to say, then,

1660
01:23:57,639 --> 01:24:00,778
that after they cut, they
don't feel ashamed of that,

1661
01:24:00,778 --> 01:24:04,413
because often they do, so it becomes

1662
01:24:04,413 --> 01:24:08,680
a cycle of self-defeating behavior.

1663
01:24:09,792 --> 01:24:12,267
The reason for the self injurious behavior

1664
01:24:12,267 --> 01:24:17,267
is to help lessen the feeling of shame,

1665
01:24:17,491 --> 01:24:19,666
of something they've participated in.

1666
01:24:19,666 --> 01:24:21,843
There's clearly reasons
why this works, right?

1667
01:24:23,396 --> 01:24:26,302
There's documentation of self injury

1668
01:24:26,302 --> 01:24:31,302
going back to the times of the Egyptians.

1669
01:24:31,407 --> 01:24:35,609
There was an Egyptian
king that self injured

1670
01:24:35,609 --> 01:24:36,723
and there's a lot that's been written

1671
01:24:36,723 --> 01:24:40,066
about his self injurious behavior.

1672
01:24:41,589 --> 01:24:44,619
Probably even further back in history

1673
01:24:44,619 --> 01:24:45,438
people have self injury.

1674
01:24:45,438 --> 01:24:47,190
There's a reason for that, right?

1675
01:24:47,190 --> 01:24:51,480
People do actually feel
relief when they self injure.

1676
01:24:51,480 --> 01:24:56,428
There is that chemical release

1677
01:24:56,428 --> 01:25:00,227
of endorphins that helps
people feel grounded

1678
01:25:00,227 --> 01:25:02,847
and helps them feel real.

1679
01:25:03,816 --> 01:25:05,983
It's important to acknowledge that,

1680
01:25:05,983 --> 01:25:10,329
but it also is very
important to recognize that,

1681
01:25:10,329 --> 01:25:13,904
you're right, as the self
injurious behavior continues

1682
01:25:13,904 --> 01:25:17,666
you have to increase it to
get the same high from it.

1683
01:25:17,666 --> 01:25:20,070
It's like a cocaine addiction.

1684
01:25:20,070 --> 01:25:22,282
You can start out using
a little bit of cocaine

1685
01:25:22,282 --> 01:25:25,182
and feel really good, but down the road

1686
01:25:25,182 --> 01:25:26,643
it's much more serious

1687
01:25:26,643 --> 01:25:28,654
and that's all about the dopamine

1688
01:25:28,654 --> 01:25:32,247
and the endorphins release.

1689
01:25:32,247 --> 01:25:34,123
You know, that is true.

1690
01:25:34,123 --> 01:25:35,657
I also think that,

1691
01:25:35,657 --> 01:25:38,600
and there's something
that goes along with that,

1692
01:25:38,600 --> 01:25:40,734
rites or pacts, rituals,

1693
01:25:40,734 --> 01:25:43,759
so part of the cutting

1694
01:25:43,759 --> 01:25:45,279
and part of the self injurious behavior

1695
01:25:45,279 --> 01:25:47,011
is ritualistic, right?

1696
01:25:47,011 --> 01:25:50,376
Again, just like doing drugs,

1697
01:25:50,376 --> 01:25:54,140
the ritual of preparing for the cutting,

1698
01:25:54,140 --> 01:25:58,193
the ritual involved around
the self injurious behavior,

1699
01:25:58,193 --> 01:26:01,780
actually triggers a lot
of the same feelings

1700
01:26:01,780 --> 01:26:05,707
that one has when they start
to prepare their heroin.

1701
01:26:05,707 --> 01:26:08,809
They get that kind of rush, that high.

1702
01:26:08,809 --> 01:26:11,271
From the expectation of it.

1703
01:26:11,271 --> 01:26:13,688
Part of what we have to look at is,

1704
01:26:13,688 --> 01:26:16,818
how do you replace those rituals?

1705
01:26:16,818 --> 01:26:18,904
What can be provided

1706
01:26:18,904 --> 01:26:22,737
that works for them

1707
01:26:22,737 --> 01:26:27,737
in a way that is not so
potentially devastating to them?

1708
01:26:28,293 --> 01:26:30,314
All right, moving on.

1709
01:26:32,314 --> 01:26:34,872
This is not amazing news.

1710
01:26:34,872 --> 01:26:35,786
What do you do?

1711
01:26:35,786 --> 01:26:39,348
How do you assess for non-suicidal
self injurious behavior?

1712
01:26:39,348 --> 01:26:40,940
It's really important to think about

1713
01:26:40,940 --> 01:26:41,808
the nature and the quality

1714
01:26:41,808 --> 01:26:45,973
of important relationships
for that person.

1715
01:26:45,973 --> 01:26:50,028
Are the relationships
that they're involved in

1716
01:26:50,028 --> 01:26:52,755
supportive or are they punitive?

1717
01:26:52,755 --> 01:26:54,835
Does the person, the
patient, need to influence

1718
01:26:54,835 --> 01:26:58,008
or manipulate others in order to feel like

1719
01:26:58,008 --> 01:27:01,708
they're getting the attention and support

1720
01:27:01,708 --> 01:27:04,714
and compassion in the relationship?

1721
01:27:04,714 --> 01:27:09,714
Is the nature of the
self injurious behavior

1722
01:27:11,589 --> 01:27:15,176
related to that wanting to be

1723
01:27:15,176 --> 01:27:16,391
or needing to be connected,

1724
01:27:16,391 --> 01:27:18,159
or getting attention?

1725
01:27:18,159 --> 01:27:19,200
Does the person have a history

1726
01:27:19,200 --> 01:27:21,672
of being abandoned in relationships?

1727
01:27:21,672 --> 01:27:25,952
Is he or she predisposed with
concerns about abandonment?

1728
01:27:25,952 --> 01:27:28,876
That's a factor in the assessment

1729
01:27:28,876 --> 01:27:33,805
of self injurious behavior

1730
01:27:33,805 --> 01:27:37,401
because there are qualities about,

1731
01:27:37,401 --> 01:27:42,401
folks who self injure often
have that sense of abandonment.

1732
01:27:44,561 --> 01:27:45,592
Other things to think about.

1733
01:27:45,592 --> 01:27:48,387
Are there recent events
that the patient has had

1734
01:27:48,387 --> 01:27:50,474
that may be considered traumatic?

1735
01:27:51,674 --> 01:27:53,856
In this case, with the tattooing,

1736
01:27:53,856 --> 01:27:55,823
that's certainly a culturally-acceptable

1737
01:27:55,823 --> 01:27:58,011
way of self injuring, more so now

1738
01:27:58,011 --> 01:27:59,820
than probably it ever has been.

1739
01:27:59,820 --> 01:28:02,784
Or at least in recent
history in this culture.

1740
01:28:07,230 --> 01:28:11,169
How is self injurious behavior

1741
01:28:11,169 --> 01:28:13,218
being used to manage the feelings

1742
01:28:13,218 --> 01:28:16,222
related to trauma?

1743
01:28:22,653 --> 01:28:25,247
Is there shame that's unremitting?

1744
01:28:26,247 --> 01:28:27,987
That's something to consider

1745
01:28:27,987 --> 01:28:32,052
when you're assessing for
self injurious behavior.

1746
01:28:32,052 --> 01:28:34,145
Something that the person's
been able to discuss

1747
01:28:34,145 --> 01:28:36,711
with another individual.

1748
01:28:36,711 --> 01:28:40,041
If you have somebody
that you're talking with,

1749
01:28:40,041 --> 01:28:44,217
then you're likely to be

1750
01:28:44,217 --> 01:28:46,564
expressing the feelings

1751
01:28:46,564 --> 01:28:49,988
to another versus taking
it out on yourself.

1752
01:28:50,629 --> 01:28:51,563
Then, what's the nature

1753
01:28:51,563 --> 01:28:53,571
and the quality of the coping skills?

1754
01:28:53,571 --> 01:28:57,971
Do they have culturally ego-syntonic,

1755
01:28:57,971 --> 01:29:00,402
appropriate coping skills

1756
01:29:00,402 --> 01:29:04,458
to be able to manage the
feelings that they have?

1757
01:29:08,222 --> 01:29:10,631
I gave you a list of acronyms

1758
01:29:10,631 --> 01:29:14,390
for what to think about
when you're assessing

1759
01:29:14,390 --> 01:29:17,045
in terms of self injurious behavior.

1760
01:29:17,045 --> 01:29:20,981
You want to think about
grounding in reality.

1761
01:29:22,248 --> 01:29:23,747
Is the person grounded in reality

1762
01:29:23,747 --> 01:29:26,302
or can you help them
be grounded in reality?

1763
01:29:26,302 --> 01:29:27,734
Are they escaping from feelings

1764
01:29:27,734 --> 01:29:30,039
from depression, shame or guilt?

1765
01:29:30,039 --> 01:29:33,379
Are they using the self injurious behavior

1766
01:29:33,379 --> 01:29:35,980
to ease tension that they're experiencing

1767
01:29:35,980 --> 01:29:37,927
or the stresses that they're experiencing?

1768
01:29:37,927 --> 01:29:40,893
Are they using it to stop bad feelings?

1769
01:29:40,893 --> 01:29:43,511
Are they doing it for
an emotional release?

1770
01:29:43,511 --> 01:29:45,733
If they're doing it for
any of those reasons,

1771
01:29:45,733 --> 01:29:50,339
then probably they're using
the self injurious behavior

1772
01:29:50,339 --> 01:29:52,731
for affect regulation.

1773
01:29:54,561 --> 01:29:57,274
If they're doing the
self injurious behavior

1774
01:29:57,274 --> 01:30:01,659
as a reaction to or from others,

1775
01:30:01,659 --> 01:30:04,506
if they're using it for attention seeking,

1776
01:30:04,506 --> 01:30:08,236
if they're using it to
gain power or status,

1777
01:30:08,236 --> 01:30:12,221
in their peer group,

1778
01:30:12,221 --> 01:30:14,776
they're using it to
exert a sense of control

1779
01:30:14,776 --> 01:30:17,362
over their own body, or they use it

1780
01:30:17,362 --> 01:30:19,446
to divert attention from other issues,

1781
01:30:19,446 --> 01:30:23,634
then the reason for the
self injurious behavior

1782
01:30:23,634 --> 01:30:27,575
is likely to be around issues of control.

1783
01:30:28,572 --> 01:30:31,910
Then if they're using it

1784
01:30:31,910 --> 01:30:33,874
for coping with alienation,

1785
01:30:33,874 --> 01:30:36,170
alerting others of their need for support,

1786
01:30:36,170 --> 01:30:37,579
validation of feelings,

1787
01:30:37,579 --> 01:30:40,669
or expressing emotional pain,

1788
01:30:40,669 --> 01:30:42,416
then the self injurious behavior

1789
01:30:42,416 --> 01:30:44,842
is really about what they're communicating

1790
01:30:44,842 --> 01:30:46,329
or wanting to communicate something

1791
01:30:46,329 --> 01:30:47,890
that they're unable to communicate

1792
01:30:47,890 --> 01:30:51,994
in other ways, so the affect regulation,

1793
01:30:51,994 --> 01:30:53,835
the control,

1794
01:30:53,835 --> 01:30:55,764
communication.

1795
01:30:57,025 --> 01:30:58,043
For those three reasons,

1796
01:30:58,043 --> 01:31:00,801
the affect regulation, the
control and the communication.

1797
01:31:00,801 --> 01:31:02,340
Those are the areas that
you're really wanting

1798
01:31:02,340 --> 01:31:05,931
to assess, "What's the
reason for the behavior?"

1799
01:31:07,485 --> 01:31:12,485
What is it that is bringing up

1800
01:31:12,660 --> 01:31:14,813
the need for the self injurious behavior

1801
01:31:14,813 --> 01:31:16,210
that the person's engaging in?

1802
01:31:16,210 --> 01:31:18,624
Are they trying to control others

1803
01:31:18,624 --> 01:31:20,649
or control something about themselves?

1804
01:31:20,649 --> 01:31:23,335
Are they trying to regulate affect?

1805
01:31:23,335 --> 01:31:26,055
Are they communicating something

1806
01:31:26,055 --> 01:31:28,817
that they're unable to
communicate in another way?