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
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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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