 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. Welcome everybody to today's presentation. We're going to be talking about 10 risk factors, 10 warning signs about, there's a few more, and points to remember about suicidality. We're going to talk about some general practice points. Most of you have been in practice for a while, so you've done some suicide assessments. You had some training on it. So for most of you, hopefully this is just a refresher training. So we're going to talk about some things that we just kind of need to keep fresh in our mind. Explore and review risk and protective factors and talk about ways we can help enhance protective factors and mitigate risk factors in our clients. And we want to do this before clients are suicidal, ideally. So when they come in, you know, if they're presenting with even moderate depression or whatever, when they come in for whatever reason brings them to counseling, they are in some state of flux slash crisis. So let's see what things we can mitigate and what things we can enhance early on in treatment so we can give the client the best shot at not spiraling into a significant crisis. We're going to talk about the suicide warning sign using the acronym. The path is is path warmed. And I added the ED on the end of warm because there are two of them to characteristics that I think are really important to take a look at. And then we'll learn the splash acronym for suicide screening. So in general, clients should be screened for suicidal thoughts and behaviors routinely at intake and at specific points in the course of treatment. When I was working in a clinic, I had my clinicians and when I see clients, I do a mini mental status exam every single visit. Are they willing to talk about future plans? Are they willing to talk about goals for next week? Are they seeming seeming to have a significant change in attitude? Are there any warning signs that I'm seeing that may indicate suicidal or homicidal ideation? So those are the things that I look at and I document in every single progress note. And that's just a good general way of making sure that we're remembering that this could happen at any time. We want to screen for clients with high risk factors regularly throughout treatment, again, especially preferably at each episode. Most clients when they're in counseling may be considered high risk. I mean, there's high risk that we're going to talk about. And then there's people who are not, you know, your average Joe walking around on the street who is not at this moment in time in a personal crisis. So again, I typically just for safety and, you know, I'd rather err on the side of caution. I encourage my staff as well as myself to do some sort of mini mental status and mini suicide assessment at every meeting. If you're doing group counseling, for example, you know, you're talking to people when they're doing the check-in. If they're talking about what they're going to do next week, if they're talking about what they're going to do tomorrow, that's a good sign. And you can also listen for some of the risk factors that we're talking about or warning signs that we're talking about for suicidality when they're participating in group. You know, sometimes you only see clients in group sessions or and maybe you see them for 30 minutes once a week individually. If you're seeing them in group sessions, it doesn't mean that you can't do that assessment. So figure out ways that you might be able to maybe step up your suicide assessment. Counselors should be prepared to develop and implement a treatment plan to address suicidality and coordinate the plan with other providers. I always have, and I was taught this way, we had sort of a standard treatment plan that we had ready that could be modified, obviously, to meet the individual's strengths, needs and abilities, ready to go for suicidality. We had the crisis stabilization unit was part of our agency. So we obviously could make referrals there. We had the crisis center. We had a lot of other resources that we could hand the person that was already written out. So we didn't have to try to remember all this stuff from jump. We had a handout we could give them we had some basic steps that we took whenever somebody indicated that they might be suicidal. If a referral is made, we need to check that the referral appointments are kept and continue to monitor clients after the crisis has passed, just, you know, okay, I'm going to hand you off, you go to crisis stabilization and whenever you're ready, come on back and we'll start again. No, we need to make sure that the client actually goes that the handoff is successful and then we need to follow up. We once they come back, you know, that doesn't mean that the crisis is completely passed. So we want to continue to talk to them there in a vulnerable state at that point. And so we want to help them kind of get their mojo back and get their energy back get back into the swing of things. We want to ensure ongoing coordination with mental health providers that they may have seen at the crisis center, for example, and other practitioners, family members and community resources as appropriate. And this really feeds in to those risk and protective factors we're going to talk about we want to make sure that that network that hopefully we created and identified when they came into treatment, we want to make sure that we bolster that as much as possible. Counselors should acquire basic knowledge about the role of warning signs risk factors and protective factors as they relate to suicide risk. We're going over that in this presentation for the most part. I mean, there's always going to be something else that may correlate, but we're going to talk about the biggies today. Counselors should be empathetic and non-judgmental with people who experience suicidal thoughts and behaviors. And this tends to be more problematic when you're working with clients who have borderline type traits. And as you know, I think that some of the suicidal ideation and impulsivity can be present in people with addictive behaviors who are undergoing withdrawal. They can be present in people with borderline personality disorder. They can be present in a lot of places, which is why I say borderline type behaviors where there may be a higher risk of self injury. So we want to be careful not to say, well, that person is just acting out or that person is just this. We don't want to minimize suicidal ideation. We need to be empathic. And yeah, if the person is repeatedly suicidal, it can get frustrating and it can get exhausting for us. But think about what it's like in their head. That's just think about living in that kind of environment that feels that chaotic. We need to understand the impact of our own attitudes and experiences with suicidality and counseling our clients. And I've seen several, unfortunately, clients talking or not clients. I'm sorry, clinicians talking in different professional groups that I'm in about experiences with a client committing suicide over the past few months. And once a client has committed suicide, you tend people tend to react differently, a little bit differently when another client becomes suicidal. But there's also a lot of us who, you know, when you first come out of school, you've had all this training and there's a certain air of trepidation about if somebody becomes suicidal. Oh my gosh, what am I going to do? How am I going to handle it? So wherever you are in your career path, whether you've never experienced it, whether you've dealt with it and you're a little nervous that it might happen again, or whether you've had a couple of experiences and it's unfortunate, but you've kind of got it covered. You need to know where you're at because that'll project onto the client when they're in their crisis state. If you start freaking out that, oh my gosh, they're going to become suicidal. They may not understand what your anxiety is about, but your anxiety is going to be palpable, most likely. So be aware of how you feel. If you are nervous about what do I do if I have a client that becomes suicidal, get with your supervisor. If, you know, most likely you're probably not in private practice yet. If you are in private practice, get with somebody else who is a colleague and develop a plan for how you're going to handle it. Talk to your attorney to dot any eyes and cross any T's. But once you have that standard operating procedure, you know, that's the first hurdle. If you have a client who's committed suicide or attempted suicide before, it's important to recognize how you feel. Did you feel like you were effective with that client or did you feel like you failed that client? Did you feel like you were competent and equipped or did you feel like you were floundering? And have you addressed those issues? Are you at peace with it? Have you come to a place of acceptance with it? If not, you need to figure out when this happens again. Because when we're working with clients who are in crisis, the chances of it happening are there. We want to say when this happens again, how am I going to feel? How am I going to approach it? We need to understand the ethical and legal principles and potential areas of conflict that exist in working with clients who have suicidal thoughts and behaviors. And depending on your state, and I come from Florida, we have pretty liberal laws in terms of involuntary commitment. Now that doesn't mean that somebody is going to be involuntarily committed indefinitely. But the 72-hour hold is pretty liberal for both detoxification as well as crisis stabilization. So there's the ethical and legal issues of taking away someone's power and involuntarily committing them. Where do you draw the line? Where is it important for you to stand in and say, I need to do this, I need to involuntarily commit somebody? And that's going to be on a case-by-case basis. And you've got to be able to figure out where that line is, where a reasonable professional would make that call. Now the nice thing is when somebody goes to crisis stabilization that they have to be evaluated by a psychiatrist or whomever within 72 hours. So you've got kind of backup. Hopefully you've got documentation leading up to it. Your documentation should indicate why is it that you felt at this point this person had to be involuntarily committed. Or on the other hand, if you decide not to, make sure you document all of the reasons you thought this person was safe to not be committed. Suicide risk may increase at transition points in care, especially when a plan transition breaks down. So it's important that we anticipate transition points, we anticipate any risks when we're talking to clients. If they're going from residential to outpatient therapy, or if they're getting ready to step down from treatment to after care or just be discharged. This is a transition point and it can trigger a lot of anxiety in clients which can cause an upsurge in symptomatology. So being aware of that, making sure that the client has a plan and the client feels empowered and excited to discharge, not anxious and fearful. Suicide risk may increase when a client is terminated administratively, such as poor attendance, chronic substance abuse. You know, if for some reason you need to discharge the client, whether it's to refer them to a higher level of care, or you just need to discharge them because they keep no showing. And you know, they're not compliant with treatment. It is critical that we recognize that this can trigger a suicide episode in some clients. So we want to make sure that we plan for that. We've got a backup plan for that. And sometimes clients are refused care for some reason. You know, maybe you don't have an opening right now. Or maybe they've been there six times and the decision is made by the powers that be whoever those powers are to refer them to a different facility. You know, there's a lot of reasons. But when a client hears no, when a client hears, I can't help you anymore. They're here and talk to the hand. And then they may start to get very angry and very scared because, you know, they're seeing you kind of as a lifeline. You're supposed to help me. So we want to make sure that we prepare for that. It is unethical to discharge a client and or refuse care to someone who is suicidal without making appropriate alternate arrangements for treatment to address suicide risk. So it doesn't mean you have to say, okay, okay, okay, I'll treat you. It means that we have to make sure that the person is referred and transferred to a safe place. So if they need to be committed at that point, if they become that suicidal, if they need an appointment with someone else, we need to facilitate that transition and make sure it happens. If the client is suicidal, obviously we're probably going to be looking for something that's more imminent like today, getting to the emergency room. Suicide risk may increase in clients with a history of suicidal thoughts or attempts who relapse. And if they relapse on alcohol or substances, or if they have, you know, recurrent major depressive disorder or generalized anxiety disorder, if their problem starts to come back again. And they've had suicidal ideation in the past because it has just been intolerable. They're just like, I can't live like this anymore. And all of a sudden they start feeling that way again. You can see how the suicidal ideation may come back. They're like, I swore I was never going to feel this way again. So we need to make sure that all of our clients have really strong relapse prevention plans. But if they have suicidal ideation, we need to sort of make doubly sure that we've got extra things in there to identify early warning signs of relapse and early warning signs for ideation. Suicide risk may increase in clients with a history of suicidal thoughts or attempts who imply that the worst might happen if they relapse. And that's kind of what we were just talking about. If they say, I just can't go through this again. Or if I have another episode, that's it. I'm done. We want to hear what the underlying meaning is in that. What do you mean you're done? Tell me a little bit more about that. And if they make a direct threat, such as saying, this is my last chance. I'm going to kill myself if I have another episode. Obviously that's a much higher level of concern. But we don't want to not concern ourselves with the vague ideation. And I try not to use the word threats because threats implies something you don't intend to follow through with. And if somebody says, I can't go through this again. That's not a threat. That's them being very genuine and honest at this point in time. If I see this happening in the future, I'm not sure that I've got it. Got the energy to go through this again. Suicide risk may increase when clients are experiencing acute stressful life events. So when we're talking to them, pay attention. Are they getting married? Are they having a baby? Did they have their house foreclosed on? You know, and it can be, you know, if you've gotten married, if you've had a big wedding or something, it may be supposed to be the best, happiest day of your life. But it's also one of the most stressful when you've got all your new in-laws and everybody coming in and DJs and this and that to coordinate. And you're just like, I'm going to lose my mind. So we don't want to assume that just because something's happy, it's not going to be extraordinarily stressful. And it couldn't trigger suicidal ideation because the client may start feeling anxious, out of control, helpless. If something goes bad, three days before my wedding, the DJ canceled. I'm like, what? But you know, thankfully, all things work out or worked out in that particular situation. But if something like that should happen, a client could spiral and start going, okay, that was the omen. I'm calling off the wedding and spiral downwards from there. So being aware of those things. If they're going through a really stressful life event, treatment should be adjusted by adding more intensive treatment, closer observation, or additional services to manage the life crises. Maybe they want to start talking to their pastor. Maybe they need to start going to support groups or, you know, they come to see you once a week, but you want to make sure they're going out with their friends or contacting their friends two or three times a week. You know, there are a lot of things you can do to increase their social support and increase their network and, you know, fortify their resources. We want to make sure we do this. And ideally, use Socratic questioning. So instead of telling somebody, this is what you need to do, asking them. So what steps can you take in order to mitigate your stress at this point in order to help you start feeling a little bit better and try to get them to come up with those ideas because then they're going to be more likely to follow through and they're going to be more likely to remember to do those things the next time. So risk factors. We keep talking about them. Let's address them. Mental health conditions and, you know, you can throw the whole DSM up here, but it's important to recognize that if somebody is presenting with a mental health condition, they may be at higher risk for suicidal ideation. So we want to make sure that we're paying attention. They're depressed. Substance abuse problems, bipolar disorder, schizophrenia, emotional dysregulation, and that's not a DSM diagnosis. But if somebody tends to go from zero to 200 in 1.2 seconds, it's important to understand that that person may be more impulsive. Conduct disorder and anxiety disorders. So with any of these things, we want to make sure that the person who we're working with, you know, has some hope, has some future plans, can visualize a rich and meaningful life. You know, where do you want to be? What does happiness look like to you? We want to talk about what their resources are, where their social supports are. We want to mitigate as much as possible. So for depression, for example, we want to start asking about their nutrition, their sleep, their exercise, their, you know, what's going on in their life that's stressful. So we can help them figure out ways to maybe ease the load a little bit. If that's all you do in your first session, that may be huge for that person. Substance use problems obviously are going to exacerbate, regardless of whether it's stimulants or depressants, and bipolar disorder. Remembering that when people have bipolar disorder, the time that they're at greatest risk, not the only time they're at risk, but the greatest risk is after a depressive episode when they start getting their energy back. So they've been down. They've been at bottom, and it's been awful. And they're coming back up. Down there, they didn't have the energy to think about putting together a plan and committing suicide. Now that they're getting their energy back, they have more energy and they're looking back there and going, I can't go back there again. That was, that was horrific. Being aware of that. So even though clients look like they're starting to feel better, that's when they're in the most, the most danger. We don't want to take the wind out of their sails and go, okay, well, you got to be careful here. But we do want to be extremely cognizant of what we hear them saying. Emotional dysregulation, we can help people by referring, referring them to dialectical behavior therapy groups, teaching them dbt skills to control and get out of their emotional mind and into their wise mind. So there are a lot of things we can do to help mitigate some of these risk factors, even in that first session. And I know you get tired of hearing me say that, but it's so important for clients to get engaged and start getting momentum in that first session. Serious or chronic health conditions or pain are risk factors. If they see that their life is going to deteriorate over the next 10 years, that can be really traumatic and that can increase their suicide risk. Or if they see their life is not getting any better because they had an accident and they broke their back or they're in some sort of chronic pain for whatever reason, that also may be something that the pain is just untenable. And they don't see themselves being able to go on like this. Traumatic brain injury is also a risk factor. And being aware that depending on the area of the brain that's implicated, there can be mood problems, there can be cognitive problems, and there can also be problems with impulse control. So knowing a little bit about what happened in the person's brain, how it's affecting them, their mood, their impulse control, and their ability to reality test are going to be really important. But also remembering that TBI can occur when somebody is deployed, but it can also occur in football. It can occur during a car crash. It can occur during a domestic violence incident if somebody is hit hard enough in the head or pushed up against a wall or whatever the case may be. And they get their bell wrong hard enough. So we don't want to negate these things. We want to be aware that the brain is sensitive. And so if somebody has had a TBI, be cognizant of that and also be cognizant of whether the person needs to be referred for a neuro evaluation. Precipitance triggering events leading to humiliation, shame, or despair, such as the loss of a relationship, loss of their health, deteriorating financial status, all of those things can trigger suicidal ideation. And it doesn't have to be actual. And it can be anticipated. I worked with an attorney or I worked with an attorney who represented an attorney who committed suicide because the attorney who committed suicide believed that he was getting ready to lose his license and he couldn't bear that. So, you know, it hadn't happened yet, but the thought of the process and the humiliation was more than he could bear. So being aware of what's going on in your client's life and how much does it impact them. Prolonged stress such as harassment, bullying, relationship problems, or unemployment can also be precipitants. It may not be something that, you know, it's this one thing we can put our finger on. It may be 20 different things that just wouldn't let up. And finally the person just threw up their hands and they said, enough. I just can't do it anymore. And other stressful life events that can include death, divorce, or job loss. Another risk factor is exposure to another person's suicide or to graphic or sensationalized accounts of suicide including through the media. And there was a movie and I believe, I'm sure one of you has seen it or heard of it. I think it was called 13 Reasons or 13 Ways. It was talking about this person's, this adolescence decision to commit suicide. And there was a lot of hubbub about whether that was appropriate to put out there or not for adolescence to see. Some parents said it opened the door so we could talk and 13 reasons why. Thank you. And other parents said no, it planted ideas. So being aware of the media that's out there, especially popular media and whether it's sort of glorifying these things or making it, putting it right out there for people to see if it's, you know, on a movie. It can increase people's risk for committing suicide. It kind of lowers that threshold because it doesn't look as scary sometimes. Family violence or physical or sexual abuse and previous suicide attempts. Those are also risk factors. And in response to your question, age does make a difference in terms of risk factors. Partly because it will determine which risk factors the person has access to or whatever. Adolescents tend to be somewhat more impulsive. They found that 14 year olds tend to be the angriest. But when you're looking at adolescents, they don't have the same cognitive development as maybe somebody who's 50 or 60. But somebody who's 50 or 60 may have a whole lot more risk factors going into it. So age, there's a period in there where people tend to be a little bit safer in your 20s and 30s. But adolescents and then 45 to 45 plus can be more problematic. But as far as handling any one stressor, no, they haven't done a regression analysis that I know of to identify whether age plays a factor in any one particular risk factor. So y'all are saying that 13 reasons why several female clients have indicated that they actually felt very validated by that movie. So see, it was a good thing for them. I was glad to a certain extent to hear people talking and at least broaching the subject and not being afraid to mention the S word. I'll be honest. I haven't seen it. But it is one of those that sparked a lot of controversy. There can be copycat suicides. And that does happen on college campuses and in high schools. More particularly, it doesn't seem to happen as much with adults. If there's a family history of suicide, there's a higher risk that your client may try. Barriers to accessing health care, especially mental health and substance abuse treatment increase risk. Well, go figure. But we want to make sure that we don't just say, okay, you've got mental health counseling. You're good. No, you know, if they've got underlying biological issues that may be contributing to their depression or anxiety or chronic pain or whatever it is, we need to make sure that they're getting their bio psychosocial needs met. Certain cultural and religious beliefs can also be risk factors, but sometimes they can be protective factors as well. So we don't want to just say that certain cultures are more at risk. We want to look at what might be the reason. In certain cultures, it may be a noble resolution for a person to commit suicide to prevent their family from experiencing shame. In other cultures, the suicide itself may bring more shame. So we just be cognizant. Is path warmed? So warning signs we want to look for. Ideation. If the person's having suicidal thoughts, even talking vaguely about it, such as, you know, at some, some warnings, I just wish I wouldn't wake up. Okay, I want to talk about that a little bit. Substance abuse because especially alcohol tends to be a disinhibitor. Opiates. It's really easy to overdose and some people sort of romanticize, you know, just going to sleep and never waking up. So substance abuse is there. We want to be cognizant. If they have purposelessness or they don't feel like they've got a reason to live. They just say, I don't know why I even get up in the morning. I don't know why I'm here. If they have anxiety, if they feel trapped, if they feel hopeless and helpless, like they're being a burden, you know, I can't do anything right. I can't succeed. Nothing goes my way. I'm constantly calling my parents for help. If they feel withdrawal or if they start withdrawing or isolating from people, you know, not going out as much and it can be subtle. You know, they may stop calling their friends as much or stop calling their parents as much, not doing as much. If you see anger, aggression or agitation, some people get really irritable before they become suicidal. Wrecklessness can be there. They're like, well, if I die, I die. I don't really care. So I'm just going to do whatever I please. Mood changes. Sudden unexpected switch from being very sad to very calm or even appearing to be happy. Sometimes people feel a great sense of relief once they've made the decision that they want to commit suicide. So being aware of that and not going, oh, good. I'm glad you came out of it. Let's talk about that a little bit. The two I added, the ED, are for extreme pain. If somebody does have that chronic pain, it's a risk factor and it's also kind of a warning sign. And if they're showing signs of depression, which most people who are suicidal will, that's another one of those things to be aware of. You're probably going to have depression before suicidal ideation, but just getting that whole picture there. Additional warning signs, significant sleep changes, direct and indirect verbal warnings such as, I don't want to live anymore. There's nothing to live for or people will be better off without me. Risk taking behavior, lack of self care or outright neglect of self. So if they quit eating or they come to your office and they're just disheveled, you can tell they haven't taken a bath in days. Changes in eating and sleeping patterns, all of these, well, most of these are pretty characteristic of major depressive disorder. So we don't want to just say, well, that's major depressive disorder, nothing to worry about. It's something to worry about. If they start giving away prize possessions or their cherished pets, making a will, tidying up personal affairs, writing notes and making notes on belongings about who's supposed to get it. That's, you know, really glaring. You need to stand up and take a look because they're putting everything in order because they don't intend to be there to do it tomorrow. If they're reconnecting with old friends and extended family as if to say goodbye. So we talked about withdrawal on the last side. That's true. But then if suddenly they start calling everybody up going, hey, it's been years since we talked and I just wanted to let you know how much you meant to me. Okay. You know, we want to kind of listen to that. We're not going to hear that when they're not going to say, yeah, I called my Aunt Joe. I haven't talked to her in 15 years and I just wanted to say goodbye. Most likely that's not going to come up in counseling. So this is one of the reasons we want to make sure that we educate the community. We educate the family that these are warning signs to be aware of not saying that your loved one is going to become suicidal. But, you know, these are warning signs of the depression getting worse. These are warning signs that, you know, you really need to step up. Obviously, we have to have a release of information to talk with the family. But if we have that, then we want them ideally to be able to call and give us the heads up that their loved one is starting to reconnect with old friends and it doesn't look like it's a good thing. And an unwillingness to discuss future plans. Sometimes they can't see to the end of the week. That's just too far. But you might be able to get them to see till tomorrow or the next day. And when I worked at the crisis center, that was what we would work with. It was a crisis hotline and people would call at, you know, two in the morning and, you know, they wouldn't be willing. It was anonymous and they wouldn't be willing to go to the hospital. So we would talk for a while and the whole goal was to get them until the opening of business the next day. If they weren't willing to go to the emergency room before that, you know, are you willing? Can you call me back? And will you call me back in four hours? Will you call me back in two hours and start getting a little bit of future movement for them until we could get them to a safe place? Protective factors. Now these are the things we can start emphasizing as soon as somebody comes into counseling. Life satisfaction and being clean and sober. If they're clean and sober, that's a great thing right there. But life satisfaction. Yes, this one area of your life is kind of challenging right now. Or maybe it just really sucks. I hear you and we are going to work on that. So let me let's talk about all the areas of your life because remember the concept of hardening hardiness is commitment control and challenge and commitment is being committed to those other things in your life that are going pretty well and recognizing that this one piece. Well, it's not going well right now is not all your entire life right here. You know, your, your relationship, your job, whatever it is that's a miss. That's one part and it's a significant part. Don't get me wrong. But you know, just let me learn about other things. I'm not going to say, well, look at all those other things that are going great, but I am going to start exploring with the person who's important in their life. What goals are important in their life and those sorts of things. I'm going to have them tell me about it. So then they may start hearing themselves talk about their awesome kids or their new puppy. They got or whatever it is social support and belongingness. Who are your friends? What is your social support system? This I do in relapse prevention planning in that first session for all my clients regardless of their presenting diagnosis. You know, who is it that you can lean on when it's, you know, two in the morning. Who is it that you can lean on when you're not in counseling, when you're having a bad day? Because, you know, you come to me as a resource, but you've got those other six and seven eighths of a day to contend with. What's their reality testing ability? Now, a lot of times we can't bolster this, but we can encourage them to use the challenging questions worksheet. And when something happens, when they start having a thought that's catastrophic, encourage them to look at the evidence for and against it, identify, you know, looking at facts there, figuring out if they're using fact reasoning or emotion reasoning, and looking at their words to see if they're using extreme verbiage such as it will never get better or I always do this. Generally, those three steps really helps people get a little bit more perspective. And the fourth step is to step back and take a look at it and go, okay, you're looking at this kind of like you're looking through a binoculars right now and you're only seeing what you're focused in on. But there's this whole other world in your periphery that was going on during this situation. So what else that you're not focusing on, what else may have contributed to this situation? So encouraging them to get a broader perspective. Or, you know, if your mother told me about what happened, you know, tell me the story like your mother would tell it. Because moms always have a way of sugarcoating things, I think. But pick anybody. But that gives a little bit more of an alternate perspective. There religious faith and spirituality. This can be a protective factor, as I said. Some people's religion believe it to be a unacceptable sin to commit suicide. Other people will turn to their higher power for comfort, for guidance, for strength. So let's explore and figure out what your spirituality means. And if they don't have a particular religious faith, so to speak, talk about spirituality and interconnectedness and how many people you've touched. What's that? It's a wonderful life. That's one of those movies that kind of highlights spirituality and interconnectedness and chaos theory and a whole bunch of other stuff. I love using that around the holidays for group work. Do they have reasons for living that they can articulate? Their family. Is there a presence of a child in the home and or child rearing responsibilities? This is actually a protective factor. Is the marriage intact? And doing reasonably well. I mean, obviously you don't want a chaotic, violent, intact marriage. But if they have a relatively okay marriage at this point, it may not be beautiful, but if it's okay, that's a strength. And do they have beloved pets? Maybe people don't have a child in their home. Maybe they're not married yet. Their four-legged child means the world to them and they wouldn't ever do anything to harm that animal. So let's start talking about those. Who in your family relies on you? And maybe they rely on you too much. We can talk about that. Trait optimism or their tendency to look at the positive side of life. So if they typically are optimistic, we might want to start saying, okay, you know, you seem to be looking at the negatives right now. And I'm wondering you tell me you're generally an optimistic person. What changed? So we can start looking at that and helping them bolster that optimism, helping them return to look at finding the silver lining. This is one I personally don't push early on because it feels it can feel very invalidating in my opinion. If you're always telling them, well, let's look at the bright side of it or let's look at the silver lining or, you know, no, no, right now I'm miserable and I need you to help me understand how to mean not miserable is kind of the idea I get from clients. And I don't want to tell them that, you know, it could be worse even if it could be because right now they're hurting. So trait optimism is one of those things they're probably going to have. But if they're to the point of being suicidal, then all of their coping skills have been overwhelmed. If they come into our clinic and they're seeking help for generalized anxiety disorder or major depression or whatever, and they still have some optimism, we're going to build on that. You know, it's amazing how optimistic you are considering all you're going through right now. It might be something that you could highlight to help them see that they're focusing on the positive and talk about how that helps them. Adaptive coping skills and effective problem solving skills are always helpful, providing them the improve the moment, the improve acronym and the accept acronym from DBT. And I have videos on our YouTube video channel that go over those acronyms for DBT if you're not familiar with them. But those are good things to go over early in treatment, if not the first session, maybe the second to help people develop some distress tolerance skills. And then you can move on to more active coping and problem solving. And do they have a sense of competence? You know, if they feel like, okay, the world is not going to completely get me down. I can do this. If they feel a sense of self-efficacy and competence in running their own lives, you're going to be a lot better off. So some clients with really low self-esteem, this may be a good place to start. Let's tell me about some things that you're good at. Tell me about some things that you do really well. So we can start establishing that self-confidence in them. In the community, there's also protective factors that we can help with or at least allude to. If they have positive relationships with colleagues, that's a protective factor. So if they come in and they're reporting they're having problems at work, maybe we can role-play some of the things that they need to do differently or they not need to. Some of the things they could do differently when interacting with their colleagues, work on some communication skills, assertiveness, creating a win-win, you know, go back to that whole seven habits of highly effective people mantra. Professional development opportunities tend to be protective factors because if somebody is doing professional development, then they see that there's a future. They see growth. They see opportunity. They see past today. And access to employee assistance programs. Believe it or not, the majority of employers out there, even today, don't have EAPs available. So people are left going, well, let's see. I've still got $5,000 left on my deductible and it's going to cost me $100 an hour to see a therapist. So I'm going to pay for everything out of pocket. You know what? No. I don't have it. So if there's not employee assistance programs, what things are available in the community as far as pastoral counseling or free crisis counseling, make sure you know some resources for people. In the community, if the people have opportunities to participate in the community, when you go out and participate, even if it's cleaning up trash on a road or volunteering at a festival or something, you make connections with other people. And I'm not saying like political connections. I'm saying you connect with somebody on a human sort of basis. And that can feel very validating to people. They find somebody who has a similar interest, who has similar ideals. If they have a trusting relationship with a counselor, physician or other service provider, including clergy or, you know, fill in the blank, wherever that person has a trusted service provider, that's great. You know, I would like to know that you have three or more people that you could really trust, but let's make sure that you've got an outlet somewhere. And affordable, accessible, supportive services. What's out there in the community? Do clinicians volunteer certain hours? Call the local United Way information and referral. You might find that certain counselors maintain a scholarship slot. So, you know, maybe their case load is 30, but they have one scholarship slot out of that 30 that people can come in and pay $5 an hour to meet the needs of people who are not able to afford full rate counseling. So, assessment. I use the acronym SPLASH. Suicidal thoughts is the S. Are they present? When did they begin? How persistent are they? Can the person control them? You know, if it's this fleeting thought is one thing. If it's persistent and it's constantly going and the person can't push it out of their mind, obviously that's more problematic. What has stopped the person from acting on their thoughts so far? Have they made any plans? How specific are the plans? Is there a specific method and place? And how often does the person think about the plan? Now, in reality, everybody has knives in their drawer in their kitchen. Everybody, most people have medication, enough medication in their medicine cabinet that they could probably overdose if they really wanted to. So, thinking that somebody, if somebody doesn't have a, you know, a gun in the house or hasn't purchased all of the whatever medication it is that they plan to use, thinking that they're totally safe, it's important to recognize that should things get bad enough, they have the opportunity. So, we don't want to just assume that, alright, we went through this, they don't have a specific plan, we're good. No, but it means to this point, they haven't gotten there. They could get there in an hour. So, you know, we want to be aware of the fact that suicidality can come on really quickly. The P stands for protective factors. What protective factors does the person have? We just went through a bunch of those. L stands for lethality. What is the lethality of the means that they're choosing? Hanging and shooting oneself and slitting one's wrists are obviously more lethal than potentially trying to overdose on certain types of medications. But again, everybody has a lethal method in their home at any time. So, you don't want to just hang your hat on that. Access or availability of proposed method. Seclusion. How long would it take for resources to get there? If somebody's out in a cabin or maybe they drove their car out into the middle of the woods somewhere and they're calling to say goodbye. And, you know, they have GPS turned off on their phone and yada, yada, yada, it'll take forever for anybody to find them. That's a whole lot more worrisome than somebody who has, you know, three family members in the other room. Now, it doesn't mean that the person with three family members in the other room is safe by any means. But it means there's a greater chance that intervention can be done. And H stands for history of suicidal behavior. Has the person felt like this before? Have they harmed themselves before? What were the details and circumstances of previous attempts? And are there similarities in the current circumstances? And I would also ask, add to that, what, if the person ended up deciding not to commit suicide, they were suicidal and they didn't attempt what prevented them. Or if they were suicidal and the attempt was not lethal, they actually didn't intend to die. And they can articulate, you know, I just, I needed somebody to finally pay attention or whatever the case may be. Then you want to say, okay, so what prevented you from completing the suicide at that point? Let's talk about what helped you survive. 10 points to remember, almost all of your clients who are suicidal are ambivalent. If they're still sitting before you, if they're talking about it, there's a 99.99% chance that they're ambivalent about it. So we have some hope. It may be a little tiny sliver or it may be a good old chunk, but you've got something to work with. Suicidal crises can be overcome. Although it can't be predicted with certainty, suicide risk assessment is a valuable clinical tool. But, and we're going to jump down to five real quick, suicide contracts are not recommended and are never sufficient. So we want to do these assessments. We want to regularly check in with our clients. We want to regularly do these. But we want to recognize that it's not perfect. And, you know, even some of the best therapists in the world, you know, are going to occasionally have a client become suicidal and attempt suicide. Suicide prevention actions should extend beyond the immediate crisis. So once you get them stabilized, that's great. Then you need to figure out what precipitated it, how you can prevent that from happening again, and what you need to do to keep the person moving forward to get them, you know, back in the groove. Suicide contracts, those things that say, I promise I won't kill myself, are from what I understand, from the research and talking to suicide specialists, not worth the paper they're written on. Because if the client is in enough pain, they will commit suicide anyway. So you don't want to say, well, he signed the contract. Yeah, doesn't necessarily mean anything. Some clients will be at risk of suicide, even recovering from their presenting issues. So as they're getting better, you know, they can look back and go, I really don't want to go back there. Or they may start feeling a little icky about what's going on. And may start to feel suicidal at that point because they're like, oh, you know, I can't go back down there. They may start to feel those warning signs. And in terms of suicide contracts, definitely document everything you do to assess. Definitely document the warning signs, the steps you took. The contract is there to identify that you discussed it with the client. But a lot of times in court, the contract will not hold up very well. So the recommendation has been, at least from the suicide experts that I've worked with, it can be done, but it's really more of a smoke and mirror sort of thing. And that's what they testify to in court. So you really want to document what you did. You want to document what the plan is and obviously have the client sign it. But having them sign a separate document that says, I promise I won't commit suicide. That's not really going to help at all. All suicide attempts and ideation must be taken seriously. Suicidal individuals generally show warning signs. So pay attention. And it may not be in session. It may be at home. So if we can have the family involved, all the better. It's best to ask clients about suicide and ask directly. You're not going to plant the idea in there. If a client has been thinking about suicide, they've already thought about it. They're not going to go, oh, hey, you know, that'd be a good idea. No. If they've been thinking about it or if they're going to think about it, asking about it just lets them feel a little bit more free to talk. The outcome does not tell the whole story. A good outcome, that is, if the client survives, does not by itself equate to proper treatment of suicidal thoughts and behaviors. You might have just gotten lucky. So it's important, even if a client attempts suicide or has some suicidal ideation and pulls out of it, you want to go back ideally and do a retrospective on what you did leading up to it. Did you identify it early enough? What could you have done differently in order to prevent it in the future and to make sure that when you work with other clients in the future, you know, your skills are as honed as possible. Personal attitudes, asking yourself, what is my personal family history with suicidal thoughts and behaviors? So we were talking earlier about if you're a clinician and you've never had a client commit suicide or if you're a clinician and you have, you know, those are two different camps. But there are a lot of other things that impact your attitude about working with a client who has suicidal thoughts. So what's your personal and family history? What personal experiences do you have with suicide or suicide attempts and how do they affect your work with suicidal clients? If you went to a high school and a friend of yours committed suicide or somebody you knew committed suicide, how did it impact you? What is my emotional reaction to clients who are suicidal? Some people want to rescue. Some people get terrified. Some people get angry. Some people get annoyed. What is your gut reaction? It's not wrong. It is. And then you need to figure out what's underneath those feelings. What did I learn about suicide in my formative years? How does what I learned then in my formative years affect how I relate to people who are suicidal and how do I feel about clients who are suicidal today? And what beliefs and attitudes do I hold today that might limit me in working with people who are suicidal? So for example, if you hold a strongly held religious belief that suicide is a mortal sin, you know, how does that impact how you work with suicidal clients? Or if you believe that it's the right thing to do to prevent shame from coming on your family, you know, again, how does that impact how you work with suicidal clients? One point that y'all bring up is a great one. Safety plans. Do them in the beginning or if you do them in the beginning of treatment, asking clients what can trigger them. And when they are triggered, what helps to deescalate them? What's the most effective doing any of your advanced directives at that point? And, you know, just kind of planning ahead, maybe not if they're suicidal, but what triggers them? And if they become angry, what are the best ways to handle them? And what are the worst? We used to have clients fill that out. So we would have an idea about what would work for safety plans. We also, you know, provide them a sheet that they sign off on that gives them the list of other resources, you know, 9-1-1 the emergency room, the crisis center, yada-yada in addition to our crisis availability. So those are all good things to have at the beginning of and give clients at the beginning of treatment. All expressions of suicidality indicate significant distress and heightened vulnerability that require further questioning and action. So if somebody says something, that concerns me. You know, let's talk about that for a second. You know, we can get back to the story in a few minutes, but let's stop and talk about this because I heard something that concerns me. And most clients will be very appreciative. Warning signs for suicide can be indirect. So we need to develop a heightened sensitivity to expressions of hopelessness, feeling trapped, having no purpose, and observable signs such as withdrawal from others, mood changes, and reckless behavior. Talking with a client about their past suicidal behavior can also provide information about triggers for future suicidal behavior so we can develop a relapse prevention plan and give clients who are at risk of suicide the telephone number of a suicide hotline. It doesn't do any harm and could actually save a life. So at that assessment, when you're doing your initial meeting, give them these numbers. So even if they never come back, maybe you didn't develop great rapport or whatever, or they just changed their mind for whatever reason. They have that number now. They have another lifeline that they can tap into. Suicidal ideation represents an opportunity. Somebody is struggling and something needs to change. So we can help them embrace this opportunity. Clinicians need to prepare ahead of time for the event of a suicidal client. So you're not kind of scrambling going, what do I do? What do I do? What do I do? Suicide assessment should be part of every assessment and a mini assessment completed at each visit ideally. Be aware of and educate clients and their families about suicide risk factors and warning signs and steps to take in the event of a crisis. And always document assessments and interventions when you do them. I love checklists. That's just the way I'm wired. So when we have a suicidal client, there are certain policies and procedures we go through. But we want to check off, did you do this? Did you do this? Did you give them this document? Did you do this? To make sure that during this time of high stress and crisis for both the client and potentially the staff person, we're making sure that the client is getting all the assistance and resources that they need. Resources you can look at to give to your clients about suicide. The National Institute of Mental Health has publications in English and Spanish. SAMHSA has addressing suicidal thoughts and behaviors in substance abuse treatment manual. And there are suicide publications for clients by SAMHSA that talk about what suicide is, what suicidal ideation is, what happens if you start feeling suicidal, what you need to do. So those are all things that your tax dollars have already paid for. You can order from SAMHSA or NIMH and have them available for your clients. When talking about past suicidal behavior, you know, being very open and, you know, tell me about what happened there, you know, how did you feel when you woke up in the hospital or, you know, really talking about what happened and validating that the person felt like they had no other options. That'll give you a better understanding of what got them to that point. And, you know, since then they've obviously, you know, wanted to live, you know, what changed. So we're going to start identifying some mitigating factors. But generally, if we tiptoe around the topic of a prior suicide, it often communicates to the client that there's some element of shame about it or that people are afraid to ask about it. Clients really are not as breakable as we might think. So saying, let's talk about that and put it out there on the table so the client knows that this is okay, something that's okay to discuss. Any other questions? The challenging questions worksheet. I can find a link for you. I do, I have it in several classes. I didn't put it in this one. But yes, I will put it together and I will put it if you remember on the front page of all CEUs. There's a tab that says resources. And I will put it here under the, your toolbox resources for you as soon as I find it. Alrighty, everybody have a fabulous day and I will talk to you tomorrow, same time, same station. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipe's by subscribing at allCEUs.com slash counselor toolbox. This episode has been brought to you in part by allCEUs.com providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists and nurses since 2006. Use coupon code counselor toolbox to get a 20% discount off your order this month.