- This continuing education class.
This is "Assessing the Risk.
"Interviewing, understanding and managing
"suicidal and self injurious clients."
I'm Kirk Woodring.
I'm going to be your guide, facilitator.
Okay, great.
Let me talk a little bit about the day.
Set this up.
We're going to start out looking at
suicide prevalence and risk factors.
I'll talk a little bit about statistics.
The communities, individuals,
who are most at risk,
and a little bit about why they're at risk.
We'll take a break at 10:30 or so for 15 minutes.
We'll come back.
We'll start to look at assessment skills and tools
that you can use for doing assessments.
We'll have lunch.
Depending on how much time we've been able to spend
on the assessment tools we may come back
and finish up on that after lunch.
If we've done well with that,
we'll go into doing sort of a psychological autopsy
of a case, and look at the process of suicide
and what we might have done as clinicians
if we had been involved.
Specifically the individual we'll be talking about
is Kurt Cobain, who was the lead singer for Nirvana.
We'll take another break at 2:30 or so.
We'll come back.
We'll actually look at suicide notes
and do an analysis in groups
on those suicide notes.
Again, what would you do?
What tools would you use
if you were to have a client
who had made an attempt
or who had written this note
and you were aware of that?
Then we'll end with questions that you might have.
These are the objectives.
Hopefully by the end of this day
you'll have a better understanding
of how to interview, how to assess for risk.
I'll give you some tools.
How to ask questions,
to do a rapid risk assessment.
We'll be using some material from a book that I wrote
with Sharon Chaput, who's a nurse.
We wrote a book called "Assessing the Risk.
"Suicidal Behavior in the Hospital Environment of Care."
It's really geared towards emergency departments
and towards folks who are working
in medical facilities, but the intervening skills
and techniques are really transferable to any location.
We'll also be using some of Shawn Shea's work.
Shawn Shea is a psychiatrist in New Hampshire.
He's written extensively on suicidal behavior
and assessing for suicide risk,
so we'll involve some of his material.
You'll have a better understanding
of high-risk behavior and how to look at
the statistical risk factors,
both in what creates suicidal behavior
and what factors help prevent suicidal behavior.
What are some of the strengths
that folks bring to, and resiliency,
that people can bring to managing their suicide risk?
Legal and treatment issues,
we'll talk a little bit about.
We'll talk about documentation
and the importance of documentation
and how to document well
when you're doing a risk assessment.
That's becoming more and more critically important,
I'm sure all of you are aware,
if you're involved in any kind of practice.
The importance of documenting,
and documenting for risk particularly.
Then we'll give you some resources,
I'll give you some resources,
for managing suicidality and some tools.
Give you an evaluation that you can use.
Kind of an assessment tool that you can use.
That's how we'll do the process for the day.
I really want this to be interactive.
One of the things I really can't stand
is when I'm just standing up here talking,
so please at any point in time,
if you have a question, if you have a comment,
if you have a thought, bring it forward.
I'm really interested in hearing about
personal experiences that you might have had
with clients or others who are suicidal
or who attempted suicide or who committed suicide.
It's really important for us to make that
live in the room, because it really is so critical
that people hear the stories about suicide.
I'm curious about how many people here
have been affected in some way by suicide.
That's the majority of the class.
It's so prevalent, and for so many years
was really dismissed and not talked about,
and I want to be able to talk about it
and make it real in here,
so feel free to jump in.
What can you expect?
This is going to be a difficult day,
or it can be a difficult day.
This is a difficult topic.
There's a tremendous amount of stigma
attached to suicide.
If you've been involved in a suicide
in any way, shape or form,
you've been touched by that.
When we talk about suicidal behavior,
when we talk about the effect of suicide,
when we talk about depression,
when we start to take on some of those feelings,
the depression, the anhedonia,
I really want to try to avoid that if we can.
At any point in time, if you need to take a break,
even if it's not breaktime, feel free to do that.
Get up, stretch, walk around, go outside.
One of the things that's important to do is,
drink water, not only because it's hot out there,
but because as you become more and more activated
by what we might be discussing, drink some water.
It helps flush your system out.
Ask questions.
You might feel like you don't understand
what we're discussing or you might
feel like you're really lost.
Don't be afraid to ask questions, at all.
There are no wrong questions.
The more we discuss this,
the more we talk with each other,
I think the better we'll understand the topic.
All right?
One of the things that I will be doing is,
in the process of the course today
I'll be going over and queuing up some YouTube videos.
I've taken a lot of material from YouTube
that helps inform this process.
There are times, I've found,
especially more recently,
that YouTube videos love to had ads at the beginning of them
and you usually have to wait three or four seconds
at least before you can shut the ad down,
so please don't pay attention to the ad.
We'll click off on it when we can,
and move forward.
I did a Google search yesterday.
I just typed in "How to commit suicide."
There were 23,100,000 results.
Interestingly, one of the first ones is
veteranscrisisline.net, "Thinking of suicide?"
It's an ad.
I was heartened by that fact.
That was a good thing.
Then as you go down,
you get all sorts of,
"How to commit suicide,"
"How to commit suicide painlessly,"
cocktails to use for suicide.
If someone is thinking about suicide right now,
they have resources available to them beyond belief
in terms of information that didn't exist even 10 years ago.
I did the same search, I think in 2006,
and there were somewhere around a million results.
We've gone 23 times that number in just a few years.
People have access to information
when they're feeling suicidal,
about how to commit suicide,
and not quite so much about how to prevent suicide.
That's where we come in.
How do we help folks prevent suicide?
How do we assess when someone is feeling suicidal
and maybe they don't want to talk about it?
Maybe they don't want to let you know,
or maybe they're afraid of letting you know,
that they're feeling suicidal.
Today we're really going to try to figure out ways
to get into developing that relationship
with the client quickly to assess for risk
and looking at some validity techniques
to get the best answers, the best information, from them.
In some ways we have to be detectives to do that.
In the past five years, 60% of all suicides
were committed with firearms.
It's not really surprising.
We'll talk about this in different forms
throughout the day today,
but firearms are obviously
the most lethal means, method, for suicide.
If somebody is going to make an attempt
with a firearm they're more likely to be successful.
In the US, one person completed suicide
every 18 minutes.
Most individuals didn't want to die.
They just wanted to get rid of the pain
that they were experiencing.
Folks who commit suicide, as you may know,
as you may experience, are often in tremendous pain.
It may be physical pain.
It may be psychological or emotional pain.
In most cases, they don't want to die,
but they want to end the pain,
and the pain is so unremitting
and so difficult
that the only way out in their minds
is to end it with suicide.
Oftentimes, and we'll talk more about this
later on as well, there's an element,
especially with folks who are chronically suicidal,
who have attempted many times, of self-loathing.
It's not just depression.
It's his intense self-loathing
that creates that kind of pain.
Suicidal crises typically tend to be brief.
If you can intervene in the suicidal crisis,
you can save that person's life.
The idea is to be able to put an intervention in place,
jump in at a time when the crisis is happening
so that you can get that person help
and get them safe.
Hospitalizing somebody on an in-patient psychiatric unit
keeps them safe.
It doesn't necessarily decrease their suicidality,
but for the period of time
that they're in there, they're safe,
and during that time, the hope is
that they're going to get the assistance
and the support and the attention that they need
to help them decrease their suicidality.
Intervening in the crisis,
getting them help, intensive help.
Maybe it's a partial hospitalization program.
Maybe it's something that's going to hold them.
Even family support to get them over the crisis
can be really helpful.
What are some of the specific suicide risks
in certain conditions?
One wouldn't be surprised that a high number
of individuals who attempt suicide
have had previous attempts.
In fact, it's one of the primary factors
in determining risk, is that previous attempt at suicide.
38.4% of suicides are completed by folks
who have had previous attempts.
You can see, going down the line here,
you have a mix
of other Axis I and Axis II concerns.
Drug abuse, alcohol abuse,
all are involved in creating a risk picture.
When you're doing an assessment,
one of the things that you want to do
is elicit those risk factors.
What are the risk factors
that the individual is coming up with?
You may know that because you've got a history with them.
You've been working with them for some time,
in therapy or in the school.
If you're a crisis clinician
you may not have that experience.
If you're a nurse or a doctor
or a social worker in a hospital
you may not have that relationship.
What we'll work on today is really figuring out
those ways to tease out that information.
How do you get good information about the risk factors
when the individual might be challenged to tell you that?
For a variety of reasons.
It may be because of their mental status, intoxication.
It may be just their resistance to informing you.
It may be their willingness to really engage
in an active suicidal plan.
It's interesting.
Alcohol abuse actually,
as a risk rate, is only 5.86%.
Alcohol abuse alone is not necessarily a risk factor.
Alcohol abuse in combination
with any of these others is an exacerbating factor.
Someone who is depressed and using alcohol,
their risk rates go up significantly,
and we'll talk about that in a little bit.
Someone who's depressed and using other drugs,
any combination of risk factors
exacerbate that risk.
Alcohol use as a primary factor
is not as great a risk rate.
Yeah, there's another slide in a few minutes about that.
What happens is that somebody comes to you
with a number of risk factors,
and if they're using alcohol
or if they're using substances
that impair their judgment
then the likelihood of their being successful,
or actually attempting suicide, goes way up.
Somebody who's feeling depressed
and is drinking alcohol,
their impulse control lessens, is weakened,
their judgment is impaired,
and it becomes much easier to actually make that attempt.
It happens with other clients as well.
Substance abusing clients,
alcohol-dependent clients.
How much autonomy do they have
in making poor decisions for themselves?
The case of an anorexic client,
an eating disordered client,
a severe eating disordered client,
or a severe alcohol-dependent client,
you could make the case they're committing suicide.
They're slowly failing-to-eat themselves to death.
They're slowly drinking themselves to death.
They have a capacity to do that,
the capability to do that,
so in some ways they're even more difficult
to intervene with because it's a slow process.
I think the suicidal client
that comes in with a plan,
they can give us a little bit more information
and activate us to get them help more quickly.
Are we intervening and taking away
their right to commit suicide?
I don't know.
Does somebody have a right to commit suicide?
Legally it's murder, right?
It is an ethical dilemma,
and I always tend to err on the side of
getting somebody the kind of support
and help that will get them through that crisis
with the hope that getting them through that crisis
will then allow them to develop some resiliency
so that they don't continue to
experience these suicidal thoughts.
Clearly, and I didn't say this at the beginning.
I really should have.
I think of suicide and suicidal behavior
as being in some cases a chronic illness.
There are times that no matter what our intervention is,
we can't save the patient.
It's like cancer.
It's like any other chronic illness
that could end-up being fatal.
There are things, as much as we put in place,
as much as we want to save that patient,
we can't do it.
Someone who is absolutely
determined and convinced
that they are going to commit suicide
will not let you help them.
I think that's one of the most challenging things
as a clinician to face,
to be reaching out, reaching out.
It's like a doctor who's an oncologist,
who has that medicine and knows
what the treatment protocol is
and knows how to save that patient,
and the patient dies.
It does happen.
I will frame this often as,
"I can only do what I can do."
I can only do as much as I can do
and the person who I'm working with,
that client, has to be willing
to engage in that process with me.
If they're not, it's not likely
that they're going to be able to be saved.
That's the parallel to other medical illnesses.
Cancer is a great one.
Five years from now,
will there be better treatment
for managing suicidal behavior?
We don't know.
There are treatments now.
Medication is not necessarily ...
Does not necessarily work well
in specifically decreasing suicidal ideation,
except lithium is one that does.
But you're right, what's next?
What would happen if we could save somebody,
until they get to that point?
That's a good question.
It's one of those gray areas,
and it gets to the point of, how much of this
is privileged information from your client
and how much is your determination
that they are at such high risk
that they need intervention immediately?
In Massachusetts we have the ability
to involuntarily commit somebody to an evaluation.
I think that's used a lot.
I know when I ran a crisis team,
it was used a lot.
We would go, the police would pick somebody up,
who we were very concerned about,
just given the information that we received.
Clearly we get into ethical dilemmas around this.
I remember when I was a new clinician
and working with an agency,
I wasn't actually working with this particular client,
but consulted on this case.
It was an older gentleman who had AIDS.
He was at the end stage of his illness.
He was facing possible prison time
for a crime he committed.
He was going to trial.
He let it be known to his case worker
that he planned on committing suicide.
He had a plan, he had means.
There was a lot of question about,
we know that.
Do we allow that to happen?
There was a lot of discussion.
Ultimately, we did call the police.
Ultimately they did intervene,
but he did end up committing suicide at another time.
I do think that somebody who is reaching out
to talk about their suicidal behavior
or their suicidality, their thoughts,
that's the entree into getting them some assistance.
It's the folks that don't talk about it at all
that really create a world
that insulates them and isolates them
from others around their suicidality
that we get particularly concerned about.
If somebody's talking about it
that's the first step.
That's a good thing.
They want to get some help, in most cases.
Were there other questions?
Just in terms of suicides rates
among persons 10 years and older,
and somebody said, "I work in an elementary school.
"You don't really see suicide."
Probably not as much, but it does happen.
The CDC starts tracking suicides at the age of 10.
What you can see, non-Hispanic whites,
per 100,000,
somewhere around 26.
Non-Hispanic blacks, around 12.
Hispanics, a little higher.
Native Americans, the highest risk rate
in the country for suicide.
Asian and Pacific individuals around 10%.
This is the map of suicide rates around the country.
Actually, the CDC ...
The first map I used,
the CDC had it as red and blue,
as a color scheme.
(groups laughs)
Prior to the elections, this was back
in the late 1990s,
and they changed it, because interestingly
the red states had the higher suicide rates.
The blue states had the lower suicide rates.
Take a look at this map,
and tell me what's interesting about it to you.
What do you notice?
Poverty in isolation.
Isolation.
You think about ...
The middle of the country.
Vast areas without necessarily resources.
Gun availability, huge.
Absolutely.
Firearm access and the laws
restricting or not restricting firearms
is one of the most important considerations
in suicide risks, so if you think about
The Rockies, Alaska,
Florida,
The Appalachian States.
Higher suicide rates.
Less restrictive gun laws, right?
Again, someone who attempts suicide
with a firearm is much more likely
to be successful than someone who attempts
with strangulation or with poisoning.
American Indian population,
Native American population,
is, again, in the middle of the country,
the Middle-Western part of the country.
We have higher rates of suicide.
We don't know what's happening in this area
or over here in terms of reporting.
Remember, this is CDC information,
so are these counties that don't report to the CDC?
And, why don't they report to the CDC?
What's the reason for that?
Anything else?
There's one other factor here
that I think is sort of interesting.
Alaska has the highest rate of suicide.
Well, Alaska and Nevada, interestingly.
Alaska has the highest rate of suicide.
In the North-East, especially Maine,
Vermont, New Hampshire,
high rates of suicide.
What's it like in the winter?
(group murmurs) Right.
This part of the country up here,
it's dark for much of the day.
People are more isolated.
There's snow, so people stay inside.
They can't get out.
The rates of alcohol and other substance abuse
is much higher in these Northern states
and in Alaska and in Nevada, actually, too,
it's really through the roof.
The combination, again, of factors,
leads to an increased suicide risk.
If you're living in Oklahoma, you're paying attention
to some of those factors
that are just basic factors
that exist in the culture and in the community
that increase risk.
If you're living in Florida, you're thinking about,
what are the factors that increase risk?
Access to guns.
Age of Floridians is greater
than the general population.
Older adults have a much, much higher,
especially older man, much higher rate of suicide.
In fact, men over the age of 65 have,
I think, the highest rate of suicides
of any group.
Men over the age of 65.
All men, white men included.
Very high rates.
Interestingly, the rate of death among those individuals,
suicide doesn't show up as being even in the top 10,
because they're dying of other things.
When you look at the CDC statistics,
you see older adults, and the suicide rate
compared to other causes of death is way down,
but when you compare suicide rates to others,
the rates are very, very high.
Much higher.
These kinds of factors are really important to consider.
Demographic factors are important to consider.
Where you're practicing.
Access to resources.
If you're practicing in Boston,
you have hospitals all around you
that can be, hopefully, helpful.
You have emergency services that can be helpful.
If you're practicing in North Dakota,
probably not so much.
Overall leading causes of death, 2009.
Suicide, what?
Number 10 I think, right here.
Higher than HIV, higher than homicides.
A lot higher than homicides.
Higher than liver disease, hypertension.
This is just overall in the United States.
Trends in suicide rates among people
ages 25 to 64, by both sexes, age group,
from 1991 to 2009.
You can see that
it started to drop a little bit here,
between 1991 and 1999.
Suicide rates began to level off and drop even,
and then around 1999, 2000, we started to see
an increase in suicide rates.
Particularly in the 45 to 54 year olds,
you can see from 2002 to 2009,
they really started to go up,
and I can tell you that the more recent data
that the CDC has put out,
this is continuing to climb,
because, what happened in 2008?
Anybody remember? - [Male] The economy.
- The economy crashed.
Suicide rates, especially among
that 35 to 54 year old group began to go up.
People started losing their houses.
They started losing their jobs.
Their identity was tied in
to the work they did,
or who they believed they were.
As a result of that, and so,
you began to see suicide rates go up.
Mechanism of suicides.
Interesting, males and females.
Men by and large, over 55% of suicides
are by firearm.
Men are more successful at suicides,
but attempt less often.
Women less successful, but attempt more often.
Primarily because they use a less lethal method.
Women, in 30% of the cases used a firearm.
Men, 55%.
Women are more likely to use poisoning
as a means of suicide,
poisoning being overdosing, typically, on medication.
Stockpiling medication to use.
It's an interesting thing about stockpiling medication.
People didn't really think about it so much
as being a means for suicide
or even a question to ask about suicide
but what has happened over time,
especially, I think, with how we manage and monitor
our pharmaceuticals, insurance companies,
managing and monitoring pharmaceuticals,
is that people will just naturally
begin to hold out some medication
when they are almost at the end of their meds.
I don't know if this happens to you,
but somebody will have
a 90-day supply of medication,
and when they get down to those last couple of weeks,
they're ordering a new supply,
and they're going to save that medication out,
primarily because if they lose their insurance
they want to make sure that they have medication.
They stockpile it as a way of making sure
that they have that resource
for managing their medical concern
at home, easily accessible.
If they become suicidal,
or as they become more suicidal,
that becomes a ready-made opportunity
for them to use that stockpile of medication for suicide.
That's something that's changed
in the last five or six years.
People are much more likely to be stockpiling medication.
Not because they're suicidal,
but because they want to make sure
that they have that medication available to them
and it's then available as a means for suicide.
As a method for suicide.
If you're not aware,
Tylenol is the most lethal means, really,
of non-prescription medications for suicide.
It's easily-accessible, and you're right,
you can get a bottle of 500, right?
Two.
You can buy as many as you want, right?
What Tylenol does, in high amounts,
over a fairly rapid period of time,
after ingestion, is that it begins to cause liver failure.
That's why you almost see these black box warnings
that Tylenol puts out, about,
"Only use the dose that's recommended on the bottle,"
because if you take more than that,
if you take a lot more than that,
it can become very lethal very quickly.
I had a really tragic situation
that I was involved with as a crisis clinician one time.
We had a 16 year old girl
who was brought into the emergency department,
who had broken up with her boyfriend.
She's a good student.
Had a solid family.
But she was devastated by this breakup.
She took an entire bottle of Tylenol.
Ingested an entire bottle of Tylenol before she went to bed.
She didn't get sick.
Slept through the night, woke up the next morning.
Felt sick.
Told her parents.
Parents got her to the emergency department.
She was then moved to another medical facility,
and ultimately died over the course of three days.
She didn't want to die.
She wanted to do something to get rid of the pain.
She wanted to make a statement, right?
But she waited too long to get help.
That's something that really is important
when you're asking questions,
is, "When you take a headache,
"what kind of medication do you typically use?"
"When you're in pain, what kind of medication
"do you typically use?"
Be thinking about
someone's access to Tylenol.
I'm not sure everybody that attempts suicide
goes on the internet to look at
what's going to be most successful.
I think people that are really doing a lot of planning do,
but someone who's in crisis is going to go for
the first thing that they can find,
or even if they're in a protracted crisis
over a period of days
they're going to be building up ideas on their own.
They're not necessarily going to be looking
for ideas from other folks.
Clearly that's some evidence
that restricting access
has a powerful effect.
Restricting access to firearms has a powerful effect.
Politically I'm not making a statement there,
but I'm saying, clinically, it has an effect
when you restrict access to a method of suicide.
The likelihood is people are not going to commit suicide.
There's the big discussion in San Francisco,
about putting up barriers or fencing
over the Golden Gate Bridge.
The Golden Gate Bridge is the most
jumped off-of bridge in the country.
There's actually a really interesting movie about it,
called "The Bridge," about suicides off of
the San Francisco Golden Gate Bridge.
There's a lot of tension, politically,
around doing that,
but when it's been done in other locations,
suicide rates have dropped almost to zero.
If you prevent the suicide,
the ability, the means, for the suicide,
then suicide rates drop.
Often people don't go to some other method.
Somebody who's committed to jumping off
the Golden Gate Bridge,
they have an image of their suicide in a certain way.
They're less likely to probably take an overdose of Tylenol.
It also allows some time for that intervention
to take place and to get them help.
Racial and ethnic disparities.
We talked a little bit about this
with Native Americans, American Indians, Alaskan Natives.
Ages 15 to 34, suicide is the second leading
cause of death for that group.
Suicide rates among American Indian,
Alaskan Native adolescents and young adults
is 2.2 times higher than the national average
for that age group.
Hispanic female high school students
in grades 9 to 12 reported a higher percentage
of suicide attempts, 14%,
than their white non-Hispanic
or black non-Hispanic counterparts.
14% of Latina high school students
reported suicide attempts.
That's pretty high.
You think, 14 out of a 100 are reporting
that they've had a suicide attempt.
We'll just take a quick look at this video here.
Among young adults, 15 to 24,
there's one suicide for every 100 to 200 attempts.
Among adult ages 65 years and older
there's one suicide for every four suicide attempts.
Any thoughts about why that might be the case?
Why are there ...
Why is someone who's 15 to 24
successful only one in 100 to 200 times
and why is someone who's older
successful one out of every four times?
Interesting.
I hadn't thought about that, but you're right.
They're less likely to reach out
and have support around them.
What happens when people are younger
is they practice, right?
Practice at everything.
You learn to get better.
Your commitment to suicide as you get older,
as you practice more,
you're better at it.
You also learn what does and doesn't work.
As people age, they're more likely
to use lethal methods,
and they're more likely to be committed to the act.
It's less an impulsive act.
It's less about getting attention
and more about actually committing the act itself.
We'll talk about adolescents a little bit more.
I don't want to let this go.
Social media and the intensity of social media.
I have a 14 year old and a 17 year old daughter.
I'm amazed at their connection to other people
while they're sitting on the couch.
They have Facebook, they have Instagram,
they have Twitter.
Facebook isn't even cool anymore, apparently.
Unless you're my age, right?
It's all Twitter, all Instagram.
That social media has its pluses and minuses.
Facebook actually has a policy
that they screen for anything
that they perceive to be a suicide message.
They have technology to do that,
but it sends a message to that person
with information about getting help.
Which may or may not be helpful.
What I have seen, even just recently in the last year,
is such an increase in the number of young people
posting suicide notes on Facebook or online,
on Twitter,
or talking in detail about their suicide plans
in those areas.
Sometimes without being able to get help.
There were two situations recently.
One in my town,
another in a town north of where I live,
where high school students posted on Facebook
that they just couldn't manage any longer.
In both cases,
people saw those notes within 15 minutes,
and tried to reach out, but it was too late.
Both of the girls were successful at committing suicide.
The devastation for the community of people
who read those notes and would have wanted
to do something or wanted to reach out was amazing.
It's important to really be paying attention
to how people use social media.
How do they get information and access information?
One of the things that social media promotes,
not manifestly, but just as social media,
is the opportunity for the copycat incidents.
What you see is that group contagion effect.
That's especially true in high schools,
but it's absolutely true in colleges as well.
There's a dynamic that occurs
and a successful suicide
then decreases the stigma
and the resistance to future suicides.
If someone has been thinking about suicide
and they see that somebody else is successful,
and they see all of the drama that plays out
as a result of that,
it's encouraging them to move on their thoughts.
For celebrities that's true,
but it's also true for just our young children.
15, 16, 17 year olds in schools.
When someone commits suicide
that may not even be well-known
to anybody outside their peer group,
then becomes idealized, and, like you say,
canonized, and again, it's, that drama
can really feed into, for some folks,
that wish to make the attempt themselves.
If you think about the community response,
what would the community response be
if those were three homicides in the school?
In the course of a month or two months.
It would be a different, probably, response.
I think as a clinician you have to recognize
that you can only do everything that you can do.
Once you've discharged
as much of that responsibility as you can
and tried to reach out,
then that's all you can do.
It is really good learning for that client.
It's a really good opportunity
to use that as a lesson for that client,
about, you're engaging in listening to that
and being responsive to that.
It's amazing, especially in middle school and high school,
but middle school in particular,
is what I've noticed.
The talking about.
The talking about suicide.
The talking about death, wanting to die.
There's a developmental component to that,
but there's a lot of sharing of information
around thoughts of suicide.
As a clinician, I don't think asking questions
about suicide will cause the person
to become suicidal, right?
We need to ask those questions about suicide.
I do think that young teens talking about suicide
starts to stir up thoughts of suicide
and the more it gets talked about,
the more it gets discussed,
the more the risk increases, or attempts.
Not necessarily successes, but for attempts.
You create this, again, group contagion effect.
We talk about it, we attempt,
somebody else attempts, more people attempt.
It becomes almost a lot like,
and we'll talk about it,
non-suicidal self injurious behavior like cutting.
Cutting, there's a real contagion effect,
with cutting in schools.
Once it gets talked about
and people start to do it,
you see it becoming almost an epidemic,
especially in middle schools,
and actually I've seen it in elementary schools as well.
We'll talk about that.
Gender disparities.
We've talked a little bit about this already.
Men take their lives nearly four times
the rate of females.
They represent almost 80%
of all suicides in the United States.
Among males, adult, ages 75 and older,
they have the highest rate of suicide.
37.97, almost 40, per 100,000.
You could think about seven per 100,000 of teens.
You can see that it's
a significantly greater rate of suicide.
Females, those in the 40s and 50s
have the highest rates of suicide.
We talked about firearms and poisoning.
I've got a 47 year old recently-divorced woman,
that I'm working with.
I want to be asking some questions
about what's happening in her life.
Maybe she's not suicidal.
Probably isn't,
but I want to begin to dig a little bit
to find out what might be happening
that would lead her to be suicidal.
What are the other risk factors that exist
besides the age and maybe the recent divorce?
Almost 375,000 people were treated
in emergency departments for self-inflicted injuries.
165,000 people were hospitalized
due to self-inflicted injuries,
and there's one suicide for every 25 attempted suicides.
If you think about this,
the almost 375,000 people in 2005
coming into emergency departments
for self-inflicted injuries,
those weren't necessarily all suicide attempts,
but many of them, most of them, probably were.
If you're getting emergency department treatment
it's probably, for a self-inflicted injury,
it's probably because there was some suicidality involved.
People who are non-suicidal and self-injurious
typically don't get to the point
where they actually reach the emergency department.
They don't cut that deep.
They don't burn that much.
You can imagine that that cohort,
that's probably a group of people
who were attempting suicide.
When you look at death-rates by suicide,
I think it's important to take that
with a little bit of a caveat
in that there are
areas, places, in the country
that the medical examiner or the coroner
won't necessarily identify it as a suicide.
For what reasons?
Cultural.
Religious.
Insurance.
Small community.
If there's an opportunity for that individual
to call it an accidental death, right?
They may be more likely to do that.
Larger cities, it's less likely
that that's going to happen,
but in small communities,
which account for a large percentage
of the United States,
those medical examiners and coroners
are part of the community
and maybe less likely to,
if there's a way to identify that suicide
as something other than a suicide
they may be more likely to do that.
The stigma of suicide
really does still determine
in many cases how suicide is identified
on death certificates.
Something important to remember.
This is something that I think about all the time
when I'm thinking about suicidality.
I actually heard this when I was working
with some folks at Hospice.
This was how they defined
what causes somebody to become suicidal.
When an individual's intolerance
for the intensity of the stress and pain
they're experiencing exceeds their capacity
and resources to overcome the problem.
Someone is in so much pain,
or the stress that they're experiencing
psychologically is so great
that it exceeds the resources
that exist for them to overcome their problem.
That captures a lot.
You think about medical issues.
You think about psychological stress.
Loss, grief.
The stress that's related to losses.
Economic losses.
When the housing market crashed
and their houses were being foreclosed on,
suicide rates in those communities
went up significantly.
The stress and the intensity of the stress
or the intensity of the pain
exceeds the resources to overcome that pain.
When you're meeting with somebody,
you're hearing the pain that they're in,
it's important to look at,
okay, what a resources that you have
or exist to manage that pain?
Are you using resources to help you
manage that stress or that pain?
If you're not, let's find
what the resources are that can help you.
We want to have resources that exceed the stress.
We want to have resources that exceed the pain.
I used an example in my book,
of a patient I was working with
who was in chronic pain.
She always was looking for,
and actually thinking she could find
the next best thing to get her out of that chronic pain.
She went through every medical practitioner
that she could find,
and non-traditional practitioners,
and there was one individual
who really, there was a trial that they were doing,
a doctor that was doing a trial,
and they thought that they could get her into it,
and she would be a perfect candidate.
She was very excited about that,
because she had been in chronic pain for years.
She goes to the doctor and meets with the doctor
and finds out that she's not a candidate for the trial.
She at that point felt that the resources
were non-existent to manage her chronic pain
and became very suicidal.
Folks who have that sense
that they're never going to get better.
That the pain, it's unremitting.
They will be the ones that are most at risk.
It's interesting because PTSD,
I'll tell you what I think, anyway.
I think PTSD is so all-encompassing,
and it's in some ways,
the way that it's coded
would be around some of the behaviors
that are consistent with PTSD,
so maybe even psychotic episodes
could be consistent with someone
who's experiencing post-traumatic stress.
I'm not sure that it's well-diagnosed,
and I think when this came out,
that information came out,
it wouldn't necessarily have been identified
as a primary risk factor for ...
- [Female] Not even specifically with veterans?
- Now with veterans it's a different thing.
We're going to talk about veterans in a minute,
but that particular cohort
clearly has become one of
the primary risk populations,
and PTSD has been talked about
more particularly with that group.
PTSD, if you look at the new DSM,
stress-related disorders have
a whole new all-encompassing realm
within the DSM.
PTSD in the general population is less likely to be seen
as being a primary risk factor,
but what people experience as a result
of the PTSD,
that becomes risky.
We will talk about PTSD,
and particularly with veterans, in a second.
It's really interesting.
I've heard that before, but not often.
You think of, in bipolar illness,
that it's coming out of that manic episode
into depression where the suicide rate is the highest,
and probably, statistically, that is true,
but there is that interesting euphoria, right?
People talk about, there are people
who experience that euphoric revelry
around suicidality, right?
When they attempt suicide they experience that euphoria.
That's interesting.
I haven't read any research about that.
We have to remember, as clinicians,
that they are under the influence of their illness,
at that time.
What seems to be clarity and peace to them
and what feels peace to them
is also part of their illness
and what's next for them in that process.
I think it's very difficult
to get a depressed person out of their depression,
out of their anhedonia,
to get to the point where they see
that they shouldn't be committing suicide.
They shouldn't commit suicide.
It's even more difficult to get somebody
who's out of that euphoric state,
where they feel at peace
and they feel like they have clarity
out of the place where they feel committed to suicide.
Couple more things about suicidality
and folks who are suicidal.
90% of suicides are by individuals
who have a significant mental illness
at the time of death.
It's not just alcoholism.
It's bipolar disorder.
It's schizophrenia.
It's depression.
It's any number of other diagnoses.
Borderline personality disorder.
90% of folks who commit suicide
have a significant illness at the time of death.
Whether or not they're being treated well
is another question, right?
When there's a co-occurring substance abuse,
that significantly increases the risk.
Again, the combination of a primary mental illness
and a co-occurring substance abuse
or alcohol dependence or abuse
significantly increases the risk factors.
Research, especially more recently,
has shown that when there is open psychomotor aggression
in patients that have been previously depressed
and overt change in their clinical status,
that is an indicator that there's a high likelihood
that they'll be more likely to be suicidal.
Any thoughts on why that might be the case?
There's a couple of reasons for that.
They're more activated.
Use the warnings on Prozac,
especially in adolescence.
The negative symptoms of the depression ...
What happens is that you get the ability
to be less anergic.
The anergia goes away,
but the anhedonia doesn't.
You have the ability and the energy to act on the thoughts.
With SSRIs particularly,
the energy comes back before the anhedonia disappears.
The other thing is that for some folks
who are depressed or who may appear depressed
and have been contemplating suicide,
when they make the decision to commit suicide,
they get that sort of euphoria,
the peace, that comes with that.
When they've really made the commitment
to follow through, there's this period of time
before they act on that,
that their depression seems to lift.
That they appear to be less depressed.
They have more energy.
They may be more motivated to put things in place
and to resolve problems for those around them,
so that when they die they know that
they're not going to be leaving people
with bills, unpaid bills,
or things that they might have
not followed through on previously.
About 50% of people who kill themselves
have seen their PCP in the past two months.
The primary care clinician, their doctor,
nurse practitioner, PA,
they've seen them in the past two months.
Up until recently, the medical field,
the non-psychiatric medical field,
hasn't done a great job of asking questions
about depression or about suicide.
In a regular appointment.
A physical or a check-up, a med check.
In the last few years, I don't know if you've noticed,
but when you go to your doctor,
you're probably going to get a question,
at least some question, about depression
or about thoughts of suicide
or just about whether you're feeling hopeless or not.
More and more, the medical field
is paying attention to the fact
that people coming in to see their doctors
actually may be experiencing depression
or other mental illness and having symptoms
of thoughts of suicide.
I know that particularly with pediatricians
in the State of Massachusetts,
there's a screening process that they go through,
and asking adolescents and children
questions around depression.
The Department of Mental Health in the state
pays for consultation with a child psychiatrist
if they have concerns, so they can call
a child psychiatrist who's on call,
and get some assistance
with either medication or referrals.
That's a step in the right direction.
This is a study that's been around for a long time.
One study, 58% had seen their psychiatrist
the previous week.
Well over half had seen their psychiatrist.
That's sort of interesting, right?
You think about, what is psychiatry now?
- [Female] Med management.
- Med manager, right?
"Every fifteen minutes, four times an hour."
In and out.
Being a psychiatrist is a challenge right now
for folks who were trained.
Especially folks who were trained years ago
as sort of psychoanalytic psychiatrists.
It's difficult to do that work.
The expectation is, you're going to see the patient,
you're going to check their medication,
you're going to get them on the right medication,
and then they're going to leave.
You really don't have a lot of time
to be engaged in the relationship with them
to help really tease out what might be happening.
Economic factors certainly come into play.
If you're a client and you know
you've only got 15 minutes with your doc,
you're probably going to be careful
about how much you open up to him or her.
All right, how successful is the treatment?
People are engaged in treatment
and continue to be engaged in treatment
that may not be really very successful,
but what else is there?
In some instances, people stay engaged
in treatment because they don't know.
Is there anything else that's going to help them?
Is this the best that it gets?
Again, at some point, if they feel hopeless,
that the treatment is helping them,
or is going anywhere,
then there's a likelihood that that hopelessness
will lead towards suicidality.
Again, psychiatry is no different
than any other medical treatment.
People with chronic back pain stay engaged in treatment
even though the treatment might not be working
or it even might be making them worse.
They might get temporary remission
from their pain, but the long-term consequences
of the medication that they're using
opens up all sorts of other issues.
I think it's an interesting statement to make.
If they're engaged in treatment,
then that alone is a sign of hope.
It is, to some extent,
but you do have to gauge
how effective the treatment is.
I want to talk a little bit about veterans for a minute.
I want to show a couple of news clips.
These news clips are a couple of years old.
I think they're still relevant though.
Let me just set this up real quick.
This is a story about
a veteran, a soldier,
from this area, from this region,
who committed suicide a couple of years ago.
A few years ago.
Really rocked the community,
because both of his parents
were involved in mental health services
and substance abuse services,
so they were aware of the kinds of problems that exist,
and it really highlights, I think,
issues around access and around doing good assessment.
I know that we don't have, obviously, all the story there.
Given what you heard,
here's this marine back from Iraq,
drinking heavily, experiencing symptoms,
of PTSD, probably.
Gets committed to a VA hospital.
There's no documentation that he sees a psychiatrist
in the three days that he's there.
What do you think's missing in that?
I'm not pointing out the problems at the VA necessarily,
because I think it's true
in every hospitalization situation now.
In these brief hospitalizations,
often people don't get the attention,
even in a locked psychiatric unit,
that they need to help them get stable,
which is one the reasons I said at the very beginning,
being hospitalized does not necessarily
in and of itself decrease your likelihood of suicide.
There's plenty of research that shows that.
From many different perspectives,
from a legal perspective, an ethical perspective,
a clinical perspective,
it's really important that we learn
how to do really good risk assessments
and then document those assessments.
In this case the VA opens itself up
to huge liability, legally,
for not documenting whether or not
an assessment was done.
I'll talk about that, and that's one the things
I'm going to really point out consistently,
is the importance of documenting your assessment,
because if you do an assessment, that's great,
but unless you make sure that it's written
in a record someplace you open yourself up for liability.
Who becomes suicidal?
Most people have suicidal thoughts
some time during their lives.
Often during teenaged years.
I did.
I think probably all of my friends did.
I can't think of anybody that doesn't really.
Most people do have some thoughts about dying as teenagers.
Interestingly, we'll talk about teenagers in a minute,
in terms of their risk factors,
and their being a high risk population,
but one of the things that's certainly true
about adolescents is that their brains
are not fully-developed, right?
They have that teenaged brain.
I said, I have two teenaged daughters.
I understand teenaged brain pretty well right now.
Especially with my 14 year old.
Their way of thinking is very narcissistic.
They're self-centered and ego-centric
in their perspectives.
There's this developmental rapprochement
going, sometimes I think, back to four years old,
in terms of the concrete nature of how they think.
That concreteness,
the concretization of thought,
is one of the reasons that makes them high risk.
It's the "If, then."
Or, "When this happens, then this will happen."
It's that black and white thinking
that exists often.
When I was in high school, I had a friend
who got himself into trouble playing cards.
He owed somebody $100.
He could not imagine how he
was going to pay that money back.
Didn't have it.
If he told his father,
his father would be very upset,
and ground him,
so his response to that
was to commit suicide.
This is a guy who was 15 years old.
Who owed $100 on a gambling debt.
And ended his life as a result.
That's not really clearly thinking through
the consequences of the action, right?
It's based on what's right in front of him.
In the next day or two.
This was not somebody who was depressed.
His family was a challenging family,
but he didn't recognize or wasn't aware
of resources that might have been available to help him,
and did not have, because of that self-centered behavior,
the ability to go out and ask for help.
Adolescence is a tough time.
Most of suicidal ideation is fleeting.
When you get help, it passes.
That's where the crisis ...
If you intervene at the crisis, you can get help.
2007, 14.5% of students grade 9 through 12
considered suicide in the previous 12 months.
18.7% of females did.
6.9% of students reported making
at least one suicide attempt in the previous 12 months.
2% of students reported making
at least one suicide attempt
in the previous 12 months
that required medical attention.
You think about that.
7% of students reported making
at least one suicide attempt in the previous 12 months.
One in every seven high school students.
Made at least one suicide attempt.
Seven in every 100 and two in every 100
admitted that they made attempts
that required medical attention,
so two out of 100, that seems high to me.
That's a lot of kids.
In a high school of 1,000 kids,
that's a lot of kids who've had
a suicide attempt in the previous year
and required medical attention.
A couple of things that happened,
couple of reasons or one reason
that students end-up feeling suicidal
is something we talk a lot about,
or hear a lot about probably, is bullying.
Some folks are actually from South Hadley here,
and I'm sure many people are aware of that case.
It's not unique to South Hadley
or to this part of Massachusetts,
or really anywhere.
You hear about these incidents arising all the time.
The bullying, if you think about it
in terms of risk,
the intensity of the pain that is experienced
from the bullying and from the harassment
that comes from that exceeds the resources
that are available, at least the perceived resources,
that are available to help manage that,
and for adolescents, that's an important factor to consider.
How do they feel like they can reach out
when they're being bullied?
As a clinician, if you're working with adolescents,
how do you engage them in asking questions
around that particular risk factor?
Sometimes, oftentimes, they don't want to talk about it.
They're embarrassed by it.
They're ashamed by it.
They're afraid of what would happen if they talk about it,
because what are the consequences?
Are they going to get beat up?
Are they going to get ...
What's next for them?
It becomes closeted.
Like a lot of things in adolescence,
it becomes closeted.
It is a significant risk factor
in adolescents particularly.
There's even a push-back amongst adolescent peers,
to talk about bullying,
because it seems to be so much in the news now
that there's this reluctance to even acknowledge
that bullying is occurring.
"Oh, everybody talks about bullying.
"That's not bullying.
"That's something else," right?
It is bullying.
It's important, if you're working with kids,
to really be clear about what it means to be bullied,
and what that actually is.
Yes, you can call it harassment,
but it is bullying,
and if you're being picked on,
it feels like it's not in your control.
It becomes a leadership issue within the school
to promote that culture.
Exactly, yeah.
Another group that I really want to highlight
is LGBT youth.
I just found this study.
It was just published last week.
These are data from 2011.
This is in San Francisco.
The San Francisco School District
did a study and they interviewed,
there were about 2,500 non-LGB students.
106 LGB and 33 individuals
who identified as transgendered.
You can see, around some of the violence,
the bullying, that might promote suicidal risk.
Or exacerbation of stress and mental illness.
33% of non-LGBT students had reported
property damage at school.
70% of transgendered students.
Been bullied at school, 20%,
versus 66%.
Been in a fight, 17.
70%.
Been threatened or injured with a weapon at school.
58%.
Then you go to
students that have had suicidal indicators.
Sad, depressed, seriously considered suicide,
made a plan, attempted suicide,
and suicide attempt with injury.
You can see again,
in the LGBT students,
pretty significant increase
over the non-LGBT students.
Suicide indicators, seriously considered suicide,
made a suicide plan, attempted suicide.
You're right, and for the transgenders,
whose is particularly small,
but it's clearly an area of ...
Of attention, when you're working with adolescents.
This is really suicide.
We're not even talking about
non-suicidal self injurious behavior.
I guess the point is that, again,
resources available to adolescents
who identify as LGBT.
Very important to ask questions
around what resources are in place
or exist for them to help with
the feelings that they have,
that they're struggling with.
Let's talk about non-suicidal
self injurious behaviors for a minute.
If you can just pass these around that would be great.
Between 33 and 50% of adolescents
in the United States have done some form
of non-suicidal self injurious behavior.
What's the most common?
- [Female] Cutting.
- [Kirk] Cutting.
Burning is,
actually, interestingly,
sort of on the rise,
in terms of self injurious behavior.
Doing self-tattooing.
I don't know if people have seen that,
but that's certainly been something
that's been on the rise.
Self injurious behavior is often impulsive.
It usually happens with less than an hour planning.
More impulsive than even suicidal behavior.
Suicidal behavior typically takes
some more planning than non-suicidal
self injurious behavior.
Adolescents who injure themselves
report that they feel little or no pain.
Partly because one of the factors involved
in self injurious behavior is to get rid of
the emotional pain that they're feeling.
What they'll say is,
"I cut myself and I didn't feel any pain.
"I just felt relief.
"That relief, when I saw myself bleeding,
"I knew I was real.
"I felt grounded."
It's often not, and in most cases,
it's not an attempt
to commit suicide or to even injure one's self
seriously-enough to end up in the hospital.
It's really to either ground one's self
or to regulate affect.
In some cases it's about getting attention.
Self harm in peers is a risk factor,
because of the contagion effect.
We talked about that earlier.
I don't know if you've seen this in schools,
but certainly in middle schools
all over I've seen it
where students will begin to talk about it,
they'll begin to act on,
or they'll begin to self injure,
and then other students join in.
It's almost like a pact.
This cult contagion effect that occurs.
It's around, in some cases,
belonging to a peer group.
It's around identity.
Often, that happens,
although it's typically fleeting.
It goes,
and kind of waxes and wanes.
Often you can see it happening
with the level of stress
that occurs at different times
during the school year.
Things become more stressful,
we're on the holidays,
you're more likely to see more self-injurious behavior
and then that wanes as the year goes on,
and then may increase again
towards the end of the school year.
Interestingly, there's a 2007 study
that really reports there's no gender difference
in self injurious behavior.
Although we often think of self injurious behavior
as being more likely to occur with women,
statistically that's not true.
One of the things that is true
is that men are less likely
to report self injurious behavior.
They're less likely
to do it as part of a contagion,
identity kind of process,
but they are just as likely
to self injure as women are.
That particular study, they did.
I don't remember how it played out.
I'm trying to remember,
because this was from a couple of years ago
when I did the research,
but I think men were more likely
to self harm in ways other than cutting.
Burning, head banging, other things.
- [Female] Punching walls. - Punching walls.
That would be more likely
to not be happening with women.
Women were much more likely to cut.
Yeah, and you could even say
that some of the self injurious behavior
is things like
the "fight clubs" that form.
Boys fighting each other
to the point where they're seriously injured
is really self injurious.
You're putting yourself in that position.
While you're being injured by somebody else
it's still self injury by proxy, almost.
My recollection of the studies that I looked at,
there was not a socioeconomic difference.
I don't know more than that,
but I do remember that I was surprised,
because you do think of self injurious behavior
being reported more, at least in a private school,
upper echelon kind of, upper middle class folks,
but again I'm not sure that that's necessarily true.
It may be reported more,
but the incidents I think
are across the board the same.
- [Female] And race?
- Race I don't know about.
It's a good question.
Favazza said that non-self injurious behavior
is a morbid form of self-help.
Which is different than suicidal behavior.
Truly suicidal behavior
isn't really a form of self-help.
It's a form of ending one's self.
Non-suicidal self injurious behavior
really is in some ways
trying to either help one's self
or get help, get attention.
Why do people self injure?
One reason is for affect regulation.
Being able to manage anxiety.
Managing anger.
Frustration, depression.
When one has intolerable affect,
or intolerable emotions,
self injuring is a way to manage that.
You think of boys,
a good example of what boys do.
What do they do?
They punch the door.
They punch the wall when they're angry.
That helps them manage that anger.
They are actually able to take that out,
or their feelings are actually physically manifested.
Controlling feelings and cognitions.
Distracting from problems.
Stopping suicidal thoughts.
Dissociation.
Or stopping dissociation.
Those are other reasons why someone would self injure.
Then self punishment.
The feeling shame
and hurting one's self because they feel ashamed.
For girls, I've seen that particularly,
but I think boys are the same.
Then there's also the interpersonal piece.
Wanting to be involved with the peer group.
Getting care and attention from folks,
from parents or others,
so if one self injures then they get attention for that.
Certainly there's a part of the contagion effect
that's around being part of a peer group
and feeling that they're accepted into a peer group.
In this case, it's to control the feelings of shame.
Someone feels incredibly ashamed
for something that they've done
and when they self injure, that helps.
It changes the focus of the shame,
so the attention for that individual
that's self harming goes to the self injury
versus whatever the event was
that precipitated the shame.
That's not to say, then,
that after they cut, they don't feel ashamed of that,
because often they do, so it becomes
a cycle of self-defeating behavior.
The reason for the self injurious behavior
is to help lessen the feeling of shame,
of something they've participated in.
There's clearly reasons why this works, right?
There's documentation of self injury
going back to the times of the Egyptians.
There was an Egyptian king that self injured
and there's a lot that's been written
about his self injurious behavior.
Probably even further back in history
people have self injury.
There's a reason for that, right?
People do actually feel relief when they self injure.
There is that chemical release
of endorphins that helps people feel grounded
and helps them feel real.
It's important to acknowledge that,
but it also is very important to recognize that,
you're right, as the self injurious behavior continues
you have to increase it to get the same high from it.
It's like a cocaine addiction.
You can start out using a little bit of cocaine
and feel really good, but down the road
it's much more serious
and that's all about the dopamine
and the endorphins release.
You know, that is true.
I also think that,
and there's something that goes along with that,
rites or pacts, rituals,
so part of the cutting
and part of the self injurious behavior
is ritualistic, right?
Again, just like doing drugs,
the ritual of preparing for the cutting,
the ritual involved around the self injurious behavior,
actually triggers a lot of the same feelings
that one has when they start to prepare their heroin.
They get that kind of rush, that high.
From the expectation of it.
Part of what we have to look at is,
how do you replace those rituals?
What can be provided
that works for them
in a way that is not so potentially devastating to them?
All right, moving on.
This is not amazing news.
What do you do?
How do you assess for non-suicidal self injurious behavior?
It's really important to think about
the nature and the quality
of important relationships for that person.
Are the relationships that they're involved in
supportive or are they punitive?
Does the person, the patient, need to influence
or manipulate others in order to feel like
they're getting the attention and support
and compassion in the relationship?
Is the nature of the self injurious behavior
related to that wanting to be
or needing to be connected,
or getting attention?
Does the person have a history
of being abandoned in relationships?
Is he or she predisposed with concerns about abandonment?
That's a factor in the assessment
of self injurious behavior
because there are qualities about,
folks who self injure often have that sense of abandonment.
Other things to think about.
Are there recent events that the patient has had
that may be considered traumatic?
In this case, with the tattooing,
that's certainly a culturally-acceptable
way of self injuring, more so now
than probably it ever has been.
Or at least in recent history in this culture.
How is self injurious behavior
being used to manage the feelings
related to trauma?
Is there shame that's unremitting?
That's something to consider
when you're assessing for self injurious behavior.
Something that the person's been able to discuss
with another individual.
If you have somebody that you're talking with,
then you're likely to be
expressing the feelings
to another versus taking it out on yourself.
Then, what's the nature
and the quality of the coping skills?
Do they have culturally ego-syntonic,
appropriate coping skills
to be able to manage the feelings that they have?
I gave you a list of acronyms
for what to think about when you're assessing
in terms of self injurious behavior.
You want to think about grounding in reality.
Is the person grounded in reality
or can you help them be grounded in reality?
Are they escaping from feelings
from depression, shame or guilt?
Are they using the self injurious behavior
to ease tension that they're experiencing
or the stresses that they're experiencing?
Are they using it to stop bad feelings?
Are they doing it for an emotional release?
If they're doing it for any of those reasons,
then probably they're using the self injurious behavior
for affect regulation.
If they're doing the self injurious behavior
as a reaction to or from others,
if they're using it for attention seeking,
if they're using it to gain power or status,
in their peer group,
they're using it to exert a sense of control
over their own body, or they use it
to divert attention from other issues,
then the reason for the self injurious behavior
is likely to be around issues of control.
Then if they're using it
for coping with alienation,
alerting others of their need for support,
validation of feelings,
or expressing emotional pain,
then the self injurious behavior
is really about what they're communicating
or wanting to communicate something
that they're unable to communicate
in other ways, so the affect regulation,
the control,
communication.
For those three reasons,
the affect regulation, the control and the communication.
Those are the areas that you're really wanting
to assess, "What's the reason for the behavior?"
What is it that is bringing up
the need for the self injurious behavior
that the person's engaging in?
Are they trying to control others
or control something about themselves?
Are they trying to regulate affect?
Are they communicating something
that they're unable to communicate in another way?