Suicide Assessment and Treatment Planning

Suicide Assessment and Treatment Planning
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John Sommers-Flanagan. Suicide Assessment and Treatment Planning

Table of Contents

List of Tables

List of Illustrations

Guide

Pages

Suicide Assessment and Treatment Planning. A Strengths-Based Approach

DEDICATION

Preface

Do the Self-Care Thing

What Is a Strengths-Based Approach?

The Book’s Organizing Themes

Language Use

Incorporating Positive Psychology

Case Material

About the Authors

Acknowledgments

Chapter 1. Emotional Preparation

Getting Ready

Practical Realities

Emotional Responses to the Topic of Suicide

Professional Self-Care

Stop Reading

Recognize the Hazards

Intentionally Focus on Positive and Rewarding Life Experiences

Use a Variety of Self-Care Strategies

Wellness Practice 1.1 Three Good Things (or Three Blessings)

Manage Your Environment

Accept Your Distress and Engage in Self-Soothing Behaviors

Practice What You Preach

Examining and Bracketing Attitudes and Beliefs

What Is Ethical Bracketing?

Staying Focused When Strong Emotions Rise Up

Seven Dimensions of Being Human: Where Does It Hurt, and How Can I Help You?

Suicide Treatment Models

The Seven Dimensions

Using the Seven-Dimension Model for Initial Treatment Planning

Emotional Dimension

Cognitive Dimension

Interpersonal Dimension

Physical Dimension

Cultural-Spiritual Dimension

Behavioral Dimension

Contextual Dimension

Concluding Comments

Practitioner Guidance and Key Points to Remember

Chapter 2. Competence and Ethics

Understanding Suicide Competence

Ten Suicide Assessment and Treatment Planning Competencies

Competency 1: Be Aware of and Manage Your Attitude and Reactions to Suicide

Competency 2: Develop and Maintain a Collaborative, Empathic Stance With Clients

Competency 3: Know and Elicit Evidence-Based Risk and Protective Factors

Competency 4: Focus on Current Plan and Intent of Suicidal Ideation

Competency 5: Determine the Level of Risk

Competency 6: Develop and Enact a Collaborative Evidence-Based Treatment Plan

Competency 7: Notify and Involve Other Persons

Competency 8: Document Risk Assessment, the Treatment Plan, and the Rationale for Clinical Decisions

Competency 9: Know the Law Concerning Suicide

Competency 10: Engage in Debriefing and Self-Care

Suicide-Related Ethical Issues

Is Serena Suicidal?

Informed Consent

Confidentiality and Its Limits

Social Media and After-Hours Contact

Emergency Procedures

Ethical Issues Pertaining to Suicide in Online and Other Distance Counseling Formats

Boundary Setting and Tending

Case Vignette 2.1 Beyond the Boundaries

Case Vignette 2.2 Indirect Giving to Preserve Boundaries

When Suicide Happens

Consultation Groups

Wellness Practice 2.1 Happy Songs in Your Life

Postvention

Concluding Comments

Practitioner Guidance and Key Points to Remember

Chapter 3. Suicide Assessment

Suicide Assessment as Therapeutic Assessment

Suicide Assessment: Process and Protocols

Know About Suicide Risk Factors, Protective Factors, and Warning Signs

A Brief Overview of Suicide Risk Factors

A Brief Overview of Suicide Protective Factors

General protective factors (see Rudd, 2014)

Specific protective factors

A Brief Overview of Warning Signs

Suicide Assessment Instruments or Questionnaires

Columbia-Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011)

Reasons for Living Inventory (Linehan et al., 1983)

Beck Hopelessness Scale (A. T. Beck & Steer, 1988)

Suicide Status Form (SSF; Jobes et al., 1997)

Patient Health Questionnaire–9

Ask About and Collaboratively Explore Suicidal Ideation

Use a Normalizing Frame

Use Gentle Assumption

Use Mood Ratings With a Suicide Floor

Responding to Suicidal Ideation

Gathering Useful Details About Suicidal Ideation

Be Prepared for Irritability, Hostility, and Hopelessness

A Strategy for Responding to Irritability or Hostility

Case Vignette 3.1 Intense Irritability

Hopelessness

Ask About Wellness, Strengths, and Positive Experiences

Ask About and Explore Suicide Plans

Specificity

Lethality

Availability

Proximity

Ask About and Explore Previous Attempts, Client Self-Control, and Agitation

Exploring Previous Attempts

Evaluating Self-Control and Impulsivity

Case Vignette 3.2 A Previous Attempt and Posttraumatic Growth

Observing for Arousal/Agitation

Ask About and Explore Reasons for Living, Reasons for Dying, the “One Thing” Question, Suicidal Intent, and (Maybe) Trauma

What’s Helping Now?

The “One Thing” Question

Reasons for Living and Reasons for Dying

Suicidal Intent

Wellness Practice 3.1 Your Happy Places

Asking About Trauma

Engage in Collaborative Problem-Solving and Safety Planning for Assessment, Treatment, and Decision-Making Purposes

Risk Categorization

Final Clinical Decision-Making

Contact Collateral Informants

Engage in Consultation and Documentation

Case Vignette 3.3 Calling in Mom

Concluding Comments

Practitioner Guidance and Key Points to Remember

Chapter 4. The Emotional Dimension

Working in the Emotional Dimension

Key Emotional Issues to Address

Excruciating Distress

Acute or Chronic Shame and Guilt

Anger

Sadness

Emotional Dysregulation

Interventions in the Emotional Dimension

Empathic Responding to Client Distress

Wellness Practice 4.1 Savoring the (Positive) Moment

Focus First on Exploring Emotional Distress

Shifting From Distress to Positive Problem-Solving

Using Motivational Interviewing (MI)

Case Vignette 4.1 Motivational Interviewing (MI) With an Emergency Room Referral

Separating the Pain From the Self and Other Emotional Reframing Strategies

How to Separate the Pain From the Self

Framing Pain and Suicidality as Evidence of a Normal Self-Care Impulse

Framing Pain as Meaningful

When Reframes Fail

Mindfulness, Distress Tolerance, and Emotional Regulation

Mindfulness

Distress Tolerance

Emotional Regulation

The Three-Step Emotional Change Trick

Step 1: Feel the Feeling

Step 2: Think a New Thought or Do Something Different

Step 3: Spread the Good Mood

Step 4: Teach Someone the Three Steps

Additional Interventions in the Emotional Dimension

Concluding Comments

Practitioner Guidance and Key Points to Remember

Chapter 5. The Cognitive Dimension

Working in the Cognitive Dimension

Key Cognitive Issues to Address

Hopelessness

Problem-Solving Impairments

Maladaptive Thinking

Negative Core Beliefs and Self-Hatred

Interventions in the Cognitive Dimension

Showing Empathy for Cognitive Impairments

Case Vignette 5.1 The Pit of Despair

Wellness Practice 5.1 Witness Something Inspiring

Collaborative Problem-Solving

Pivoting to the Positive

Using Motivational Interviewing (MI) During the Problem-Solving Process

Alternatives to Suicide, Part I

Psychoeducation on Behavioral Activation

Alternatives to Suicide, Part II

Decision-Making Dilemmas

Working With Hopelessness as It Emerges During Sessions

Resonating With Hopelessness

Integrating Solutions

Matching Client Language and Using Validation

Working From the Bottom Up to Build a Continuum of Hope

Using CBT for Questioning, Countering, Modifying, and Accepting Maladaptive Thinking

Cognitive Reappraisal and Socratic Questioning

Questioning and Modifying Core Beliefs

Concluding Comments

Practitioner Guidance and Key Points to Remember

Chapter 6. The Interpersonal Dimension

Working in the Interpersonal Dimension

Key Interpersonal Issues to Address

Social Disconnection

Wellness Practice 6.1 Intentional Acts of Kindness

Interpersonal Loss and Grief

Social Skill Deficits

Repeating Dysfunctional Relationship Patterns

Interventions in the Interpersonal Dimension

Assessing and Improving the Client’s Social Universe

Identifying and Modifying Toxic Relationships

Working With Clients Following Romantic Relationship Breakups

Social Skills Training and Related Interventions

Externalizing the Cyberbullying Problem

Working From a Collectivist Interpersonal Perspective

Embracing Normal Cultural Variation

Listening for and Summarizing Important Cultural Values

Collectivist Goal Setting

Identifying and Creating Functional Relationship Patterns

Concluding Comments

Practitioner Guidance and Key Points to Remember

Chapter 7. The Physical Dimension

Working in the Physical Dimension

Key Physical Issues to Address

Biogenetics and Medical Treatments

Physical Movement or Exercise

Agitation, Arousal, and Anxiety

Trauma, Nightmares, and Insomnia

Interventions in the Physical Dimension

Physical Exercise for Depression, Anxiety, and Suicidality

Simon Says . . . Exercise

Wellness Practice 7.1 Creating New Habits 101

Medication Consultation With a Younger Client

Self-Regulation and Anxiety Management

Physical Self-Regulation

Strategies for Dealing With Insomnia and Nightmares

Case Vignette 7.1 Using Mindfulness With a Veteran With a Mild Traumatic Brain Injury

Focusing on Insomnia

Exploring Nightmares

Asking About Trauma

Evidence-Based Trauma Treatments

Concluding Comments

Practitioner Guidance and Key Points to Remember

Chapter 8. The Cultural-Spiritual Dimension

Working in the Cultural-Spiritual Dimension

Key Cultural-Spiritual Issues to Address

Religious or Spiritual Disconnection and Connection

Meaninglessness and Meaning Fulfillment

Cultural Disconnection, Dislocation, and Acculturative Stress

Interventions in the Cultural-Spiritual Dimension

Opening the Door to Spiritual and Religious Discussions

Exploring Intersectionality

Dealing With Moral Injury: A Case Example

Incorporating Indigenous and Alternative Treatments

Addressing Religious Excommunication or Exile

Working With Loss, Religion, and Passive Suicidal Ideation: A Case Example

Case Vignette 8.1 Gay, Gray, and a New Identity

Exploring Religion and Suicidality

Using an Existential 6-Months-to-Live Question

Exploring, Framing, and Enhancing Meaning

Asking and Learning About Cultural Perspectives on Suicide: A Case Example

Case Vignette 8.2 Loss and Possible Replacement

Reconnection, Reconciliation, or Reconstruction

Forgiveness

Reconstructing Spiritual Community Connections

Helping Clients Seek Higher Causes

Taking Baby Steps Toward Meaning

Wellness Practice 8.1 Your Best Possible Self

Concluding Comments

Practitioner Guidance and Key Points to Remember

Chapter 9. The Behavioral Dimension

Working in the Behavioral Dimension

Key Behavioral Issues to Address

Suicide Planning or Intent

Suicide Desensitization or Acquired Capability

Impulsivity

Access to Lethal Means

Interventions in the Behavioral Dimension

Reasons for Living

Developing a Personalized Version of the RFL

Behavioral Activation

Countering Suicide Desensitization

Addictions Treatment

Lethal Means Restriction (Safety)

Case Vignette 9.1 Outdoor Addiction Treatment

The Safety Planning Intervention (SPI)

The Opening and Unique Suicide Warning Signs

Personal Coping Strategies

Social Contacts and Settings That Are Distracting

Family/Friends and Other People Whom I Can Ask Help

Mental Health Professionals or Agencies I Can Contact for Help

How Can I Make My Environment Safe?

Becoming Directive and Responsible

Concluding Comments

Wellness Practice 9.1 Expressing Gratitude

Practitioner Guidance and Key Points to Remember

Chapter 10. The Contextual Dimension

Context—The Seventh Dimension

Context and Suicide: A Glimpse at the Scientific Literature

Uncontrollable Aversive Events and Toxic Stress

Externalizing the External

Strategies for Coping With Toxic or Malignant Stressors

Empathic Commiseration

Discernment and Goal Setting

Opportunity Ameliorates

The Role of Activism

Concluding Comments: In the End

Wellness Practice 10.1 Forest Bathing

Practitioner Guidance and Key Points to Remember

References

Index

A

B

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D

E

F

G

H

I

J

K

L

M

N

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P

Q

R

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T

U

V

W

Y

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John Sommers-Flanagan

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Ethical bracketing is defined as “the intentional separating” or “setting aside” of personal values to “provide ethical . . . counseling to all clients” (Kocet & Herlihy, 2014, p. 182). Ethical bracketing requires that counseling practitioners honor their commitment to working in the best interests of their clients—even when doing so conflicts with their religious values or beliefs.

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