 I'd like to thank you and welcome you to coming. Today is March 9th 2012 3 9 12 it's a year since the Japan's earthquake that was devastating in and of itself. Subsequently there was a tsunami warning and last year's conference was canceled and it happened right around this very same time a year ago so that was the 13th annual conference which was canceled and so if you're superstitious there's where 13 comes in. I'm extremely excited to spend an entire day dedicated to the discussion around suicide. I would I would have to say right up front that I think that's part of the problem is there isn't enough discussion around suicide. Typically it's we're sad to hear and let's not talk about it anymore. So the more we talk about it the more we look at the causes the more likely we are to interrupt that devastating event in people's lives. My name is George Jarron I'm the director of behavioral health services Dominican Hospital also the conference chairperson. Today's event in part is being videotaped for future cable cast on community television of Santa Cruz County and each year we've had community television for the last six or seven years tape these events which is a really great thing. I say this every year I want to say it each time that the community at large gets the benefit of the information that we're all going to receive here today. At this time now I'd like to introduce to you Joshua Nathen-Hernie Calciano. Good morning everyone I'm glad there's no barricades this year last year was maybe these first three tables and then was big empty room so there were maybe ten people that were able to to get through and that was about it so it's definitely nice to speak to a full house. I want to welcome all of you to our 14th annual symposium and I wish to welcome all the new attendees as well as our students and our tablers our exhibitors and during the break I really encourage you that I think this is our fourth year doing the tabling and I really do encourage you to network with these people that's that's the goal of bringing the man is to network so that we all have the resources that we need. My brother John was 23 years old when he passed away and over the years I have often wondered what his life would have been like today. What he would have done with his life what he would have been happy and although these questions will remain forever answered in our mind my mind. One thing I know is for certain is that his life as well as his death did have a purpose. Although this symposium bears his name I believe it has come to represent the countless families that are inflicted with violence and drugs and suicide. Our family is incredibly great and gratified to have seen this symposium in memory of my brother and son John to develop over the years into the widely attended event of today. We continue to be we continue to be impressed by the literally hundreds of practitioners clinicians educators parents and public safety officials that have attended this symposium year after year. Your post symposium comments and the number of attendees that return indicate that we really are making a difference in our community. Our deepest appreciation goes out to the advisory committee who meets every month to select topics and speakers as well as our countless volunteers members of the Guild and the Dominican Hospital Foundation who with their help we've been doing establish the Johnny Natterney Endowment Fund that will allow us to live these these symposiums to continue in perpetuity. And of course all of you for your devotion and your quest for knowledge is what allows us to continue our work. So in summary I want to thank all of you for being a part of this symposium today and hope you find that this information useful in your clinical work. And now in the words that of my mother that have inspired me over the years these symposiums are a wonderful legacy and give a real sense of purpose to John's life. Thank you. That speech never gets easier. Before I introduce our next speaker I want to just take a second. A lot of you I know you've gone onto our website and registered and whatnot and I it's I want you to know that it's not just a place to register it's a place to gather community resources. And we took quite a bit of time developing it into areas for past symposiums where if for example if you were not here in 2006 we had a methamphetamine conference you're actually able to download those PowerPoints directly from our slide our website. Also this past year with the help of Diane Bridgman we've established on our on our website if you go to our community resource page this is a about a 10 page document that has all of the community resources as much as we have from crisis emergencies to food homeless services. So really I do encourage you today or tomorrow to go on our website and spend some time looking through it and it's there for you as community resource. So now it's my distinct pleasure to introduce Bonnie Sultan who's the assistant program director for suicide prevention services for the Central Coast. Good morning everyone. Hi I'm Bonnie Sultan I'm the assistant program director for suicide prevention for the Central Coast. We serve Santa Cruz County Monterey County and San Benito County. On behalf of suicide prevention family service agency we first want to thank you for all being here taking your time to learn more about suicide and suicide prevention and we appreciate your effort and interest in this work. Suicide is the second leading cause of death among 25 to 35 age group. It's the third leading cause of death among ages 15 to 24. Suicide is a national issue and it's a personal issue. Everyone has been impacted by suicide either personally or through their community. According to the Center for Disease Control suicide was the 11th leading cause of death for all ages in 2007. In 2008 more than 36,000 Americans died from suicide and another 666,000 went to the hospital emergency for an attempted suicide. Daily there are at least 1500 suicide attempts. Among adults ages 65 and older there are approximately 4 suicide attempts for every suicide and among ages 15 to 24 there are approximately 100 to 200 attempts for every suicide. Among counties in California Santa Cruz has ranked 29th out of 58 for suicide. These numbers are very large and they're almost impossible to understand and comprehend. We at suicide prevention understand the numbers and understand that these numbers are each individual people. These are people that are connected to others they're connected to you and we're here to serve you and our community. The impact of suicide is a ripple effect and we also feel that healing is a ripple effect that we can help to promote at suicide prevention. We've been serving the community for over 47 years. We have a volunteer base of over 70 individuals on our crisis line 24 hours a day, seven days a week. We offer emergency suicide service to anyone and everyone and we offer these services in 150 languages and dialects. So within one minute we can connect you to someone who can speak your language and who can talk you through a crisis. We believe in normalizing suicide and we believe that suicide is a thought that everyone has had and we want to make sure that through normalizing suicide we can help to destigmatize this issue and it's events such as this and people such as yourself that by talking about it and coming together people can come to get the assistance that they really do need. We believe that stigma can also be reduced in education and communication. We offer outreach services and education in schools. We offer this to professionals. We offer this to emergency responders, police and we also offer it to people in the emergency 911. We're here to help you to deescalate and we're also here to talk about these issues. Reducing the stigma of suicide is saving the lives of those that we love. We believe that suicide can be prevented by creating a safe space and at suicide prevention we offer the space for individuals to talk about their feelings, to talk about their loss and to talk about their sense of being overwhelmed. We understand that suicide many times is not about death. It's about feeling that you have a lack of options. It's feeling that you have no control and it's feeling that you don't have any other way to end whatever is happening in your life. We believe that in this safe space we can talk about options, we can talk about regaining control and we can talk about feeling normal that you're feeling overwhelmed. We've taken a look at some studies and of those that have survived their suicide attempt while in the hospital 24 to 48 hours after they have attempted to take their own life, researchers go in and they say, are you happy that you survived or do you wish that your suicide was successful? 93% quoted saying they're glad they didn't die and they just wanted something to change. If we understand that suicide is not always about death, we can create a safe space for people to talk about these options. We can create a space for people to talk about loss and the need for connection. It's when isolation occurs that people feel that suicide is their only option. We at suicide prevention provide that to you on the line in trainings and we're also here in person. So our crisis line has 70 volunteers, everyone is trained in de-escalation, they're trained in reflective listening and they're trained in being a responsive individual. We're there to make a connection with people who feel isolated. This is a key point in suicide. Things that you'll be hearing about today talk about people feeling not connected and feeling isolated from their community. We also have a resource table here. So if you're interested in learning more about suicide prevention, if you're learning about how you can become a first responder on our crisis line, we welcome you to do this and we welcome you to talk to us after about how we can create more of a community with you and your agency. It's my great honor to now introduce Lisa Firestone. She's a clinical psychologist and the director of research and education at the Glendon Association in Santa Barbara, California. She's been involved in clinical training and applied research in the suicide, violence, and interpersonal relationships. She's the co-author of the Firestone Assessment of Self-Destructive Thoughts, known as FAST, Scale and Manual on the Firestone Assessment of Suicide Intent, known as FASI. It's a scale manual instruments that measure the risk of self-destructive and suicidal behavior. She's also the senior editor at psychalive.org and we certainly recommend that you take care of that. Thank you again for your time and your assistance and we look forward to speaking with you after. Take care. First of all, I want to thank John's family for inviting me here today. And I think it's important to acknowledge that most of the advances that have happened in terms of suicide prevention have been mainly driven by family members who've lost loved ones to suicide. That activism and that wanting to make a significant contribution based on the loss of their loved one has led to a lot of the advances that we've had over the years in suicide prevention in this country. So I think it's really important and I really want to commend John's family for what they're doing. So I'm going to be talking to you today about use suicide. Let's see how this works. So we had some facts and figures and I'm just going to go over this real briefly because of that my suicide, my statistic slides. But so as you see again, this is the third leading cause of death for young people in our country. And if we look at the top three things that are killing young people in our country, it's substance, it's accidents, homicides and suicides, all related to lifestyle issues. So while we're doing a good job of fighting disease, we're struggling with some of these issues of lifestyle that are killing our young people. Also when we look at attempts, the majority of suicide attempts are made by young people. For every young person that dies by suicide, there's an estimated 100 attempts, whereas in older individuals, it's more like a four to one ratio. And if we look at research from the youth risk behavior survey, what we see is in the typical high school classroom, one male and two females have probably attempted suicide within the last year. Now when you say this to high school teachers, they get horrified. But that's the students that they're looking out on. And when I talked to ninth grade health classes in our community in Santa Barbara, just down the road from here, almost all of the young people know a friend who's been suicidal at one point or another. And my big take home message to kids is you can't afford to keep your friends secret. You need to tell somebody you need to reach out to somebody who can help. Again, there are completed suicides kind of the tip of the iceberg of the problem that we're talking about today. We have many more attempts, many more people who end up in the hospital needing services. And what we see is that suicide rates go up throughout adolescence. They're very low in younger children, but they do go up and then they kind of level off looking like older adults. If we look at data from California, these were the suicides for 2009 by gender in California of young people. And this is different counties within California. The green line is California as a whole. The yellow line is Sacramento County and the purple line Fresno County. So this is just looking at the suicide rates and the red line is Los Angeles County in California. This is looking at it again by county and we see that there's a real range of differences that there's some areas where we're having many more use suicides than others within California. And there's also the break down ethnically. You know, overall our rate of suicide in California has actually declined some that has happened in conjunction with our state becoming more Hispanic. And that's partly because there's lower suicide rates in that population in general. That doesn't mean that we don't lose young people from this population . So we in Santa Barbara had a suicide cluster a couple years ago of young Hispanic males. This is an unusual group, but it was a cluster that we have that we were able to put a stop to as well by forming something we call the Santa Barbara Response Network where we go in and respond after there's been an act of suicide or violence in our community to help calm things down. What we see is that the suicide rates over a 16 year period and the most recent data we have is for 2009 because our death reporting system in the United States is underfunded and rather broken. And so we have data that is somewhat behind. We're just starting to get figures now for 2009. But what it looks like is that since the economic crisis, suicide rates are going up and they're going up particularly among working age people. And if we look at the data that we have from Europe where their death reporting system is not as broken or as underfunded in the countries with the greater the financial crisis in a country, the higher the suicide rate is gone, and particularly when there's a lack of a safety net. So this topic is important because suicide is the third leading cause of death for youth 10 to 24 years old. In 2009, 6.3% of ninth to 12th graders reported having attempted suicide one or more times in the past year. Approximately 149,000 young people 10 to 24 are treated for self-inflicted injuries in U.S. emergency departments every year. And according to data collected by the National Center for Injury Prevention and Control, poisoning is the most common reason for intentional self-inflicted non-fatal injury hospitalizations for the 10 to 24 year old age group. And self-injurious behavior in general is often stigmatized and hidden from family and friends. So we don't even know all of the suicide attempts that occur among this population. I think we have a very large underestimate. For instance, we have a young man in our community, 20 years old, who became suicidal after the breakup of a relationship, not an uncommon trigger. And when he went to be evaluated in the emergency room, it turns out he had two prior attempts. When he was nine, he attempted to hang himself. When he was 16, he cut his wrist. On the phone with his father, his father had no idea, didn't know about either previous suicide attempt. His parents were divorced when he was a young child, but he's closest to his father of all people in the world. And his father didn't know about those prior attempts. What we see is that one in 10 people who die by suicide have been in the emergency department within two months of their losing their life. If we did better screening in emergency rooms, we could do a lot to prevent suicide. These people are not only showing up for suicidal ideation or for suicidal behavior, but they're injuring themselves more because they're doing more risk taking behaviors. In terms of suicide and adolescence, a previous suicide increases the suicide risk by 38 to 40 times. So this young man, his father, I was talking to having two or more attempts astronomically increases risk, much more over one attempt. And I'll talk a little later about multiple attempters and how they're different. Also, it was found that a suicide attempt is likely to be highest among youth presenting with a combination of depression and externalizing behavior. And kids that are externalizing like the young men that we lost in our community were involved in gang activity. And those with a romantic breakup is often a precipitator again for young men. And being assaulted or having been arrested and a number of the young men we lost were thought that they were on the verge of getting arrested. It turned out they were not. More than 90% of adult suicide attempters and 80% of adolescent attempters and completers communicate suicidal ideation prior to the attempt. They tell somebody. We have a young man who was very prominent in our community because he was a athlete and a star of the basketball team and had been in the newspapers a lot who took his life on the Cold Springs Arch Bridge, which has become a hotspot in Santa Barbara for suicide until just the other day last week we got the barriers finally erected on our bridge. An effort that was a combination of our organization, the Glennon Association, Caltrans and our local sheriffs because they had two sheriffs who almost lost their lives on the bridge trying to save somebody. And the sheriff who was on the bridge the day that this young man took his life who tried to engage him and couldn't was traumatized by the experience himself. And adolescents with prior attempts are 18 times more likely to make future attempts. This behavior gets easier and easier to do. And half of youth who attempt suicide do not receive treatment beyond psychotropic medication. In the case of this young man that I was just talking about in our community he didn't get any treatment for either of his attempts. In terms of college students, self-reported suicidal ideation in college students ranges from 32 to 70 percent of college students' report having had suicidal ideation. Again, this is not an unusual thing. It's a taboo topic that we don't talk about yet. It's really common that people think about it. It's estimated that there are 1,100 suicides on college campuses in the U.S. every year. And suicide is the second leading cause of death in college age students. And it's often the straight-A student who's getting their first B who's more at risk than the person who's flunking out. And it's something we need to think about. We also need to think about the fact that we have a lot of returning soldiers now going to college who are going to be a high-risk population. And you'll hear more about the military issue from Dr. Jan Kemp. One in 12 college students have seriously contemplated suicide. What's the implications of all this data? The implication is there's a need to intervene early in the developmental trajectory of depression and suicidal behavior. The earlier we intervene, the more we can do to prevent suicide. So here's some common misconceptions suicides, misconceptions about suicide that keep us from intervening. One is that most suicides are caused by one particular triggering event. So there's no time for us to intervene. It was the breakup of a relationship. Well, it doesn't work like that. There has, there's often a triggering event that is the catalyst. It's like the straw that breaks the camel's back. But this is a person who's been struggling for a long time. If we look at the last young man that we lost in our community who was 16 at the time of his death, when he was eight years old, his elementary school counselor identified him as being suicidal. This had been going on a long time. And in males we find that it starts as young as age eight. And with young women it more starts at puberty. Another idea is most suicides occur with little or no warning. So how are we supposed to do anything? This is simply not true. Mostly there has been this buildup. There have been people who've known that this person was at risk. And often they've talked about it directly. The young man who we lost off the bridge told his friends he would say things like maybe I should just kill myself. And his friends would say really are you going to do that? And he would say what are you telling me I should? And guess what they backed off right? Suicidal people put it out there and take it back in a way that makes it hard to respond. The night before his suicide when his friends asked him what are you doing tomorrow night? He said I'm jumping off a bridge. And they said really are we going to see you? And he said well if the bridge thing doesn't work out. Well unfortunately the bridge thing did happen. And you know they didn't know whether to take it seriously or not. Another idea is that if we don't talk about it it won't happen. This doesn't work right? We've been trying this for a long time. It's time to break the silence and to get talking about it. And I really commend all of you for being here today and being part of that. Another idea is people who talk about it especially young people don't really do it. They're just trying to manipulate us. They're just trying to get our attention. Another thing that happened in my conversation with the father of this young man who got hospitalized the other day. His father was like well you know he was just trying to get his girlfriend's attention. Now she's paying attention. She went with him to the hospital. It wasn't just that. True there's an element of that. We used to think there's people who are really manipulative around suicide and people who are really serious and that there were two different populations. Turns out that now we know that some of the most manipulative people around suicide are also the most lethal. It doesn't work like that. They're not too nice distinct populations. Another idea is people who make suicide attempts especially minor league are not very lethal attempts are just trying to get our attention. But if we ignore people's attempt to get our attention by risking their own lives what are we telling them. You have to do more to get my attention. I think that's a big mistake. We have a young woman in our community who when she was 12 she took some aspirin as a suicide attempt told her mom right away. Not a very lethal attempt. Second time she took a little bit more medication but again she told her mom. She got to the hospital. Third time she jumped off a cliff. Broke almost every bone in her body. Has mild brain damage from the attempt. Doesn't remember it. We need to take these attempts seriously. Another idea is a suicidal person clearly wants to die so why should we try to stop them. This is just not true. People who die by suicide are ambivalent. Part of them wants to die but part of them wants to live. And just to stress this I'll give you the example of the Golden Gate Bridge. There have been something like 29 people who survived that jump. Which is almost 100% lethal jump. It's a very lethal jump. All of them say the minute they jump they wish they hadn't. And you'll hear Kevin Hine say this on tape that I'll share with you in a minute. Another idea is a person who suddenly has been depressed and they're suddenly feeling better. We don't have to worry about their suicide risk anymore right. They're feeling better. This is not true. When people are in a lot of psychological pain and distress and they come up with a solution which is to end their own lives. They feel relieved. Often they look much happier than they have in a long time. And you'll hear Kevin talk about this as well. That feeling is when we need to reassess for risk. So here's just a brief clip we're going to see three individuals who appear throughout the films that we've made on suicide prevention. One for the public and one for professionals. Talking about the thoughts they were experiencing just prior to their attempts. Okay. I think somebody's going to have to do it from down there. You have to click on it. Thanks Sarah. You're alone. You'll die alone. You'll always be alone. The only thing you can do is go and kill yourself. I start to think things like if you don't matter what does matter. Nothing matters. What are you waking up for? You know you hate waking up every morning. Why bother? It's so agonizing to wake up in the morning. Why bother doing it? End it. Just end it. I got out of the Gwongae Bridge. Still begging myself not to jump but hearing the voice of saying you must die and now saying jump now, jump now. It was so clear. It was crystal clear and it wouldn't go away. The words you are hearing illustrate the thoughts going on in the minds of these three people in the time leading up to their highly lethal suicide attempts. You've already blown it with this class. Now you've got to kill yourself. You know you can't fail this. I remember saying that to myself that once you buy the gun, you can't go back. So finally I went back through the whole thing and the safety on, the safety off, the safety on, the safety off, my head, my mouth, my chest, my gut and as I had it to my gut and was pressing on the trigger, it went off. You should do this. This is something you should do. Sometimes I remember it's being rational like that. This is really something you should do. You thought about it long enough. You decide you're going to do it. Now do it. Now quit fooling around and just get it over with. Go ahead. Quit fooling around already. Now you've got these pills. Go ahead and start taking them. At this point it was abundantly clear. You must die. You must die. I walked back and forth across the span. Finally I found a spot. Hey, this is it. This is the place I'm going in my life. Nobody cares. It's time to go. I turned, walked back toward the railing next to the roadway on the bridge, next to the traffic. I ran and I shoved myself only using my arms over the bridge. So you can see how each of these individuals was thinking at the time they attempted to take their own life and these were all very lethal suicide attempts including Kevin's jump from the bridge. I think it's also striking to think about as Trish the blonde woman was talking how she was pulling on the trigger but it went off. There's this disconnection, our disassociation that is a big part of the suicidal state and I'll talk a bit more about that as we go along. So basically I'd like to introduce you to our approach to suicide and when I say our approach I mean that of myself and my father Dr. Robert Firestone and there's a couple of premises behind our approach. One is that each person is divided. That part of us is goal directed and life affirming our real or positive self and a part of us is self-critical self-hating its ultimate end potentially self-destructive. Now the nature and degree of this division is going to vary and it's going to vary a great deal depending on our early life experiences but this division exists within all of us. Also negative thoughts that people have toward themselves exist on a continuum from mild self-critical thoughts that we all have at one time or another like you get up to give a presentation like this and you think who's going to want to hear what you have to say? Not an uncommon thought. I think the number one fear in America is public speaking. I think death ranks about number three and I used to feel that way so I can identify with that feeling. All the way up to extremely self-hating thoughts and actual thoughts about suicide. So thoughts like you don't deserve anything. You shouldn't be you should just be by yourself. You're a creep. You need to have a drink so you can relax. You should just kill yourself. There's a whole continuum of self-destructive thoughts that people experience. There's also a whole continuum of self-destructive behaviors that people can engage in. Everything from just limiting our life and being self-denying to engaging in behaviors like substance abuse that truncate or shorten our lives potentially and all the way up to suicide. So everything from self-denial to isolation to extreme self-hatred to substance abuse, risk-taking and actual suicide. And lastly our last premises that there's a relationship between those two continuums. That how a person is thinking about themselves does a lot to let us know how they're likely to behave. It can help us to predict. It can target where we need to intervene and it can also measure how effective we've been in intervening with somebody who's been at risk. So there's events that happened to all of us but then there's our thoughts about those events which also influence our feelings and our behaviors and the feelings and thoughts influence each other. But if we can get a hold of those thoughts we can do a lot to prevent suicide. And again the person who's suicidal it's not, these are not realistic thoughts. These are seeing things through a negative filter. So I just wanted to find this thought process or these negative voices that drive suicidal behavior. The critical inner voice that we're talking about here refers to a well integrated pattern of destructive thoughts toward ourselves and toward others. The quotes voices that make up this internalized dialogue are at the root of much of our maladaptive behavior. This internal enemy fosters inwardness, distrust, self criticism, self denial, addictions and a retreat from goal directed activities in life. The critical inner voice affects every aspect of our lives, our self esteem and confidence, our personal and intimate relationships and our performance and accomplishments at school and at work. So where do these critical inner voices come from? And how do they get passed from one generation to the next? Because in our 30 year longitudinal study what we have found is that children very much have similar negative thoughts toward themselves that their parents do. And this is in spite of the fact that the group we've been working with the parents have had the older generations in our sample have had much more trauma in their childhoods than their children have had. And yet their children have much the same negative thoughts about themselves as their parents do. I'm going to show you this brief clip of mother talking about her critical inner voices and then her daughter talking about them. Now I apologize in advance for the language in this clip because these critical inner voices when they are verbalized in an emotional way often are not said in nice language. So hopefully we have no children in the room. But we do have some negative language and this is a mother who had a huge amount of trauma in her early childhood. Her mother deserted the family when she was only two years old. She lived with a father who was intermittently very explosive. One funny story in the family is where she got milk on her upper lip. This is now a commercial right. But she was in the high chair and she got milk on her upper lip and he came across the table at her and she was so afraid of him that she went on her dad. This was a funny story. Her father went through two more failed relationships. So all these transitions and the children were often neglected and left to fend for themselves. And when she was 10 she was finally put on a train back to her mom. A mom she mother she didn't even remember a mother who made fun of her because she would stutter in front of her mother would give her medications to get her to go to sleep and leave her alone. Really traumatic childhood I think in anybody's estimation. Her daughter Jenny who you're going to hear speak after her has had nowhere near this level of trauma. She was a wanted child who has been in a stable situation and it's not the same level of trauma at all but she has very similar negative thoughts to her mother. And the film of Jenny was done five years prior to the filming with her mother. It's not that she heard her mom saying these things either. And her mother is quite emotional in the film that I'm going to show you because her older brother has just lost his life to suicide. Catherine verbalizes voices she experienced following her brother's suicide. I was going to ask you a question of what voices do you think you had after you found out that your brother had died? What did you tell yourself? Say it as a voice if you can. It's like he was the perfect one. Like how can you be alive? You're the fucked up one. You're the one who never did anything right. Never did anything responsible. Never did anything. You never did anything. And he did everything right. And he's dead. He's the one who's dead. You should be dead. You're the one who should be dead. Not him. He did everything right. He was, he was smart. He did everything right. He had a family. He had a wife. He had everything. You're the one who's supposed to be dead. You're the fucked up one. You're the stupid one. You're the ugly one. You're the one who was never supposed to be born. I was never supposed to be born. I mean I just kind of sneaked out. It's what I feel like. I feel like in my whole life. I just kind of sneaked in. I was never supposed to be born. And I was never supposed to have a life. It was a life like I have. Just not entitled to it. I wasn't even supposed to be born. It's like nobody was happy that I was born. So in a way I don't even believe, I don't even believe people. I feel like I'm very skeptical. I don't believe people. I don't believe something on some basic level that I could be somebody that somebody would like to care for. How do they go? They're like, Bobby, sort of. How do they go? They're like, you're not worth it. You should be on this world to say you've been born in the first place. Where'd you get an idea like that? I mean, those ideas. Where do you think they come from? That Mr. Cameron, I think the amazing of me like that. I mean, I thought they'd be nicer. So you read it from their behavior. Not even things they necessarily said. You know what I mean? And these are not a realistic perception of herself. This is a little girl who is so generous that everybody wanted to do things for her. But that's the filter she's seeing the world through. And it's so similar to how her mother feels about herself. So I'm going to take us back to attachment theory a little bit. How many of you are familiar with attachment theory? Okay, so we're just going to touch on this. But I think that this is important in terms of understanding this. You know, Sir John Bolby, the founder of attachment theory. Also occurring at the same time as Harry Harlow's studies with his Reese's monkeys that you might remember with the Wiremothers and Renee Spitz doing work on infants in orphanages who were getting all their physical needs met, but they were failing to thrive. So starting to understand how important early childhood experiences were. And Mary Ainsworth who then carried on the research on attachment, looking at infant's reaction in this quote, strange situation where you bring a mother and child into the lab in the playroom with toys and the child goes down and plays with the toys and the mother leaves and she comes back and she leaves and she comes back. And what you really measure in terms of attachment behavior is on the second reunion. How does the mother and child interact? We'll talk a little bit more about that. And then I'm also going to refer to the work of Mary Mayne and Eric Hesse up at the University of California at Berkeley in terms of two things that they added to the attachment research. One is the disorganized attachment category which was a third type of insecure attachment and the most concerning type. And also when they discovered this category by the way and Mary Ainsworth went back and looked at all her failure to classify cases in the strange situation they all fit into this disorganized attachment category. And also Mary Mayne and colleagues developed the adult attachment interview which is a one-hour structured interview that you do with a parent that predicts what type of attachment their child will have with them. And each parent is different obviously and that interview can be done before the child is born and it will predict what kind of attachment the child is going to have to the parent. So the patterns of attachment the different categories we have secure attachment which is optimal. This is a parent who's emotionally available perceptive and responsive to the child. What it looks like in the strange situation is a baby who can go to the parent for comfort and gets comforted they're upset when the parent leaves but they get comforted and they can go back down and explore the environment. What it looks like on the adult attachment interview is somebody who can tell a coherent narrative about their early childhood and remain in good communication with the investigator. It's not a matter of how negative their childhood has been but whether they've been able to feel the full pain of their childhood and make sense of it that predicts an adult attachment interview. In terms of insecure avoidant attachment what that looks like in terms of a parent is a parent who's emotionally unavailable in perceptive unresponsive and rejecting and the child adapts to this by learning that the best way to get your needs met in the situation is to act like you don't have any. So what it looks like in the strange situation is a child who acts like they don't care when mom leaves. They don't care when she comes back. They keep playing with the toys but if you put a heart rate monitor on these kids they're anxious the whole time she's gone and they feel better when she's in the room. What it looks like an adult attachment interview is somebody when you ask them about their childhood they say don't remember much before I was 15 it was fine. Next question. They are not able to access or talk about their history. Insecure anxious ambivalent attachment. What does that look like in terms of a parent? A parent is inconsistently available. Sometimes they're perceptive and responsive. Other times they're intrusive or acting out of their unmet needs. What the child learns that is if they cling they get their needs met. So what it looks like in the strange situation is a child is quite clingy has trouble going down and exploring the toys. When mom comes back in they go to mom for comfort but they don't get comforted. They cling because they found that eventually you get your needs met if you cling. What it looks like on the adult attachment review is when you ask this person about their childhood. They start to tell you about their childhood and then they launch into it like it's still going on. So you know not only when I was a kid did my mom prefer my brother but you know just last week she came to town and she visited my brother and took his kids to Disneyland that didn't come see me and that's not what you asked about. You're asking about their childhood. Most concerning in terms of attachment patterns is disorganized attachment. And this is where the parent is either frightening directly or acts frightened when the child comes to them for comfort which is terrifying to a child. And they do things that are disorienting and alarming unpredictable so that there's no organized strategy for getting your needs met by this parent. What it looks like in terms of the strange situation is a child who does things that don't make sense. They start to go toward the parent but then they get close and they run away or they try to run out of the room past the parent. Or maybe they run up and hit the parent. They don't have an organized strategy for getting their needs met by this parent. What it looks like on the adult attachment interview is when somebody is trying to talk about their childhood it's an incoherent narrative. They say things that don't make sense but they don't say well you know I know it doesn't really make sense but they don't notice that they're not making sense. And they often will say things like you know it was really loving well or except for that time they beat me. Well you know it was really a loving you know and there'll be these pauses where they kind of freeze. And in doing the adult attachment interview and scoring it you look at these pauses they're significant. How long it takes people to answer how the communication flow goes during the interview. If we look at in low non-clinical low-risk non-clinical populations in America about 55 to 65 percent of kids and parents their relationship is scored is secure. About five to 15 percent have that ambivalent kind of clingy attachment. Avoiding attachment is 20 to 30 percent of the general population. These are not people who often show up in our psychotherapy offices except when they're dragged by marital partners who are very frustrated with them for being emotionally unavailable. And disorganized attachment is something like 20 to 40 percent of non-clinical populations. And the reason that disorganized why that doesn't add up to 100 percent is because when somebody's given disorganized they're also given the next best fit alternative. So it can be disorganized secure disorganized ambivalent or disorganized avoidant. But in high risk parentally maltreated samples what we see is disorganized attachment is more like 80 percent much higher. So what causes disorganized attachment? What the research has found is unresolved trauma and loss and the life of a parent statistically predicts disorganized attachment in general far more than maternal sensitivity ratings done in the home many times within the first year of life child temperament social status of the family or the culture of the family. So what's going on at these moments of stress for parents who have unresolved trauma and loss? And I think it helps us to look at the difference between implicit and explicit memory. Implicit memory is online from the last trimester of pregnancy throughout our lives so we do on some level have a memory merged with another person as we were before we were born and the best way to think of implicit memory is if I got out of a bicycle here and asked you to ride it you would get on the bike and start to ride you wouldn't think about how do I ride? You just motor memory is implicit you would just know how to ride the bike. But explicit memory is like if I asked you to tell me the story of how you learned to ride a bike if you told me that story you would feel like you were remembering and you would tell me the story of who it was who taught you to ride the bike. So how does disorganized attachment get passed from one generation to the next? What happens at moments of stress between parent and child is that implicit memories of terrifying experiences that the parent had that are unresolved may create impulsive behaviors on the part of parents distorted perceptions rigid thoughts and impaired decision-making patterns and difficulty tolerating a range of emotion from their child. A brief word about suicidality I'm not going into this whole things but often this is what's going on in moments of stress between parent and child. So we're going to do the brain in the palm of your hand. This comes from Dr. Dan Siegel who spoke at this conference a number of years ago and I've been studying with him and his work in interpersonal neuro biology for about the last six years. So I'll share with you his handy hand model of the brain. So if you put your hand up this is our model of the brain that we always have with us right and if you think of your risk coming up into your palm as your as your spinal cord and the base of your your palm is the base of your brain your brain stem area is part of our brain that's millions of years old that we share with all reptiles and other animals and that part of our brain is what does all the automatic functions our heart rate our breathing our blood pressure things we don't think about and then if you fold your thumb over your palm and think of this as the limb big areas of your brain something we have in common with all mammals yes your dog has feelings or your cat or your rat it turns out if you tickle rats they laugh they laugh at a frequency that we can't hear without a transducer but if you don't believe me go on YouTube and Google rats laughing and you'll get yawk pink snap a brain scientist tickling a rat and they follow your hand around when you do it they love it they actually really like getting tickled and then if you take your fingers and you put it over that limbic area this is your cerebral cortex something we have in common with all of the great apes and most developed in human beings is this area behind your middle two finger nails behind your eyes that's what we call the middle prefrontal cortex and this is a very important part of your brain because it's very integrative it integrates integrates information from your cerebral cortex from the limbic areas and directly gets messages from the body too okay and what happens at moments of stress is we quotes flip our lid and our emotional centers of our brain get firing out of control without the oversight of our cerebral cortex and we lose the nine important functions of our middle prefrontal cortex which I'll go over now so what are those nine functions one is it allows us to regulate our bodies how many of you remember Phineas Gage from early psychology classes he was the original experiment in a damaged middle prefrontal cortex this was a railway worker during the time they were building out the railway across our country who was hammering in a spike hit dynamite and it went back up through his skull he survived but his personality was completely changed from a mild-mannered easy-going guy to a very explosive unable to regulate person we lose a tune communication with others that's our middle prefrontal cortex allows us to have a tune communication emotional balance to have a break and accelerator that are in run smoothly to have response flexibility to be able to pause before we act to have empathy to be able to understand another person's experience to have self-knowing awareness or insight there's our book Conquer your critical inner voice which can help with this fear modulation that when we get afraid that we can calm it down this is the sticky switch that we see in people with OCD intuition and morality people who have damage to this part of their brain don't become immoral they become amoral they lose immoral compass so these are nine very important functions right that we'd like to have our brain online they are also all now been found to be through research outcomes of secure attachment and there is earned secure attachment that can come about by psychotherapy or by getting into a relationship with somebody with healthier attachment than you have and staying in it for a long time but we can develop this part of our brain we also know they're all outcomes now of mindfulness practices and people who do mindfulness practices actually grow their middle prefrontal cortex the original research we had on this from FMRI studies was that people who had long term mindfulness practices had bigger thicker middle prefrontal cortex we now know that if you engage in mindfulness practices you can actually grow your mental prefrontal cortex so when people have disorganized attachment it predicts later chronic disturbances of affect regulation stress management hostile aggressive behavior toward ourselves and toward others and it's interesting because I think it's important to think about the fact that while suicidal people are different they are a diverse group one thing they have in common is low tolerance for strong unpleasant emotions and not good healthy coping strategies for bringing those emotions down those are the two things that suicidal people have in common so what's the infant's response to trauma? there's two responses that occur one is hyper arousal first there's a very hyper arousal state and then dissociation and there's a lot of research linking dissociation to violent behavior towards others but there's now research coming online that shows that dissociation plays a big role in suicide too that people are in a disconnected state and this is the work of Steve Porgas on the Polly Bagel theory he's looking at the vagus nerve which is at the base of our brainstem and the vagus nerve is job is to perceive whether our environment is safe dangerous or actually life-threatening when we think that the environment is safe we use our facial facial cues and verbal ability to verbalize to communicate with other people but when we think the environment is dangerous we go into fight or flight mode and all of our blood flow goes to our big muscles and we get ready to either flee or fight and if we actually think the environment is life-threatening we go into a shutdown state where there's actually a decrease in our heart rate and in our breathing and that level of shutdown or immobilization I think is what we have to be concerned about in terms of suicide it's that disconnected state so I'm going to go into this division that exists within within each of us with a little bit more depth we believe that this division within each of us originally stems from parental ambivalence now I'm not trying to blame parents here I'm a parent and I would guess that many of you are as well got a lot of parents out there yeah okay but parents are real people and we have mixed emotions toward ourselves there's ways that we like ourselves or care about ourselves and there's ways that we're critical and self-hating and we tend to extend both of those reactions to our products to our children this is not an intentional process parents do not have parents have children with the best of intentions but the degree to which we have unresolved trauma or loss we're going to have difficulty particularly at moments of stress with our children because nothing triggers unresolved issues from your childhood like children particularly your children that look a lot like you and have behaviors that are somewhat similar the positive side of this leads to the part we like to think about parental nurturance but the negative side can lead to parental rejection neglect and actual hostility at those moments of stress there's also prenatal influences that are obviously going to have an impact things like disease or trauma we know that second trimester insults during pregnancy are risk factors for suicide whether that be having the flu or some kind of traumatic experience there's things that are more active on the part of parents like substance abuse or domestic violence that also impact the developing fetus there's also birth trauma which impacts suicide risk and factors about the baby themselves the genetic structure that the baby is born with their temperament there's the physicality of the baby the sex of the baby the positive side of this leads is made up of the unique individual characteristics that we all have the unique biology that we all are along with an incorporation of positive attitudes from our early caretakers the nurturing experiences we get from parents and from others and when we look at resilient kids who do well in very bad situations there was at least one caring adult can make a huge difference and the good take-home message from this is we can all be that one caring adult in a child's life this positive side of self is made up of a realistic positive attitude toward ourselves not an inflated one but a realistic positive attitude and compassionate attitudes towards others that lead to ethical behavior toward ourselves and toward other people our goals the real things that we need and want and give our life meaning that lead to goal-directed behavior and our own moral principles our own moral compass which lead us to act with integrity where our words and our behaviors actually match in terms of the anti-self or this negative side of the self is also made up of the unique vulnerability of the individual our predisposition predisposition temperament genetic structure along with any destructive elements of our early life experiences rejection neglect hostility over permissiveness of parents which feels like neglect to children and is experienced by is not caring along with other factors that can happen in the early life of a child accidents illnesses traumatic separations from parents if you think about in terms of military suicide which we'll be talking about next parents that are deployed is one of those traumatic separations for kids and we now have some families with dual deployed both parents deployed I saw a young girl recently who had that situation and then death anxiety somewhere between ages of three and seven children start to understand death and when they do that also makes them want to be more defended so we believe that the court defense is something we call the fantasy bond or an illusion of connection where the child starts to feel merged with the parent by parenting themselves so at times of stress they start to parent themselves both punishing themselves and nurturing themselves much as they were treated early in their life in terms of the self-punishing part what we found is three levels or stages of self-attack just critical thoughts toward ourselves which lead to a verbal attack against ourselves that make us feel alienated from others as well this can come from critical critical parental attitudes or labels people receive in the community at school peers can be quite cruel as well an unreasonable agent-appropriate expectations parents can have of children in terms of microsusital injunctions of the types of negative thoughts that support the cycle of addictions the self-punitive part of that is when people engage in addictive behavior they beat themselves up for it they've been bad they deserve to be punished but what happens as they beat themselves up as they feel more and more psychologically distressed and they're more likely to drink the rest of the bottle to try to get rid of that feeling it's part of the cycle we don't get over addictive behaviors by beating ourselves up if it worked we wouldn't have the problem with addictions we have in our country and these are lessons that we often learn by identifying with ways our parents defended themselves these are not lessons taught with words these are behaviors that we observe and then most serious in terms of the self-punishing part of suicidal injunctions suicidal ideation actual suicidal behavior resulting in actions that actually jeopardize the ongoing life of the person extreme risk-taking carelessness when the body attacking oneself directly and often this comes from these particular moments of stress when the person not the parent as they were on the average but at extreme signs of stress when they've lost it with the child the child eternalizes that and later acts out that same kind of aggression toward themselves in terms of the self-soothing part of this this is just self-soothing attitudes that we have toward ourselves that lead us to limit ourselves and be overly cautious with ourselves not take risk or go after the things we really want in life again if we had parents that were particularly overprotective of us or who were overprotective of themselves we may adopt these patterns self-engrandizing thoughts this is the you know we think about self-esteem and there's a big difference between self-esteem and desperately wanting to think well of yourself which is more of this inflated self-esteem issue a verbal build-up of ourselves of how we're perfect or we have to be perfect and if we're not perfect we're nothing and this can come from parents who build up a child or a parent who needs the child to be a great artist because I need to be the mother of a great artist so you will be a great artist and you will get straight A's suspicious paranoid thoughts towards others which feel self-protective but can lead to a lot of destructive behavior toward other people and these are a lot of the thoughts that precipitate violent behavior toward others and we can learn these from parents attitudes towards people who are different or other or if we've had a lot of abuse experiences we're going to have paranoid suspicious ideas towards other people or if we've grown up in a dangerous situation a dangerous environment in terms of the addictive behaviors the self-soothing part of this are the thoughts that seduce the person into the behavior to begin with have a drink you really need to relax with those people tonight have an extra piece of cake you've been good on your diet all week it won't matter and those seductive thoughts that we need to get a hold of if we're going to really deal with the cycle of addictions and again people in our early life and then overtly violent thoughts and while some people may use self-harm as a way of regulating their emotions some people use outwardly directed aggression to regulate their emotions as well and they use exploding at others and if all the violent individuals we interviewed for the work we've done extensively on developing scales to assess violence potential and making films about it all of the violent individuals we interviewed were also suicidal there was never we didn't find one who had not been including gang members they told us yeah when you're running into you know a barrage of bullets you're suicidal I'm not going to show this developmental clip right now because we don't have time if I have time at the end I'll come back to it so what happens in suicide there's an underlying vulnerability that is then triggered by a stressful event which can actually be caused by the underlying vulnerability that leads to the stressful event so you're engaging in substance abuse because of the underlying vulnerability and that creates stressful events because then your life's not working out so well and things fall apart like a relationship that leads to acute mood changes and then there's either inhibition against suicide because of strong taboo in your family in your culture there's available support there's access to mental health services like the ones we heard about at the beginning of the day today that are so valuable here in this community and then there's things like religious beliefs or spirituality that might be protective as well but when there's these acute mood changes there can also be things that facilitate the person like a weak taboo against suicide for instance in our family there have been a number of suicides could be could weaken the taboo if somebody's had that history or somebody in our community recently died by suicide or somebody else at my high school died by suicide there's easy access to lethal means that's why bridge barriers are so important or restricting means in general as an important strategy for preventing suicide there's a recent example will help facilitate it there's a state of emotional agitation and agitation and that agitated level of anxiety and desperation are the main feelings that drive suicidal behavior and being alone the more isolated the person is the higher the risk and this can mean the difference between survival and suicide I'm not going to show this either because it's long oops I'm going backwards instead of forwards I'm going why do I have this film again okay so what about this continuum of negative thought processes I'm just going to put these up our first five levels all make up a factor that we call low self-esteem or inwardness they're everything from just living your life in a way that's self-denying to engaging in isolation and isolation here at level four is a key factor of risk for suicide these are the thoughts that just be by yourself you're miserable company anyways and when people get alone when they're in a self-destructive state things get much worse it's much better to be around people care about you level five are vicious self-abusive thoughts that lead to a lot of the agitation and distress and desperation that drives suicidal behavior and again this is not a realistic evaluation self-destructive self-critical self-hating thoughts level six are the cycle of addiction thoughts you know both the the seductive thoughts and the self-punishing thoughts and then the last five levels all make up a factor we actually call self-annihilation and they're everything on level seven and eight turning suicide around and feeling like you're doing your family a favor because you're such a burden and perceived burdensomeness is a necessary factor for suicide to occur so these are thoughts are like see how bad you make your friends and family feel they'd be better off without you now I've talked to a lot of people who've lost loved ones to suicide families never feel better off without the person that is it's always this negative filter through which the person is seeing it though and we want to assess suicide risk we need to get into their mindset it's not that their family doesn't care or they're not there for them it's that they're not they're thinking they're going to do spare their family this burden of themselves there's thoughts influencing the person to give up priorities favorite activities they're disconnecting from their self the things they used to love to do don't matter anymore so a person has cared very much about their appearance who's now coming to work disheveled or a person has cared very much about a young person has cared very much about being on a team and now they're not showing up for practice when the person gives up doing the things they used to love to do we need to get worried level 9 are thoughts that lead to self mutilation behavior and self mutilation is a coping strategy for some individuals it helps them regulate their emotions and the last thing you want to do and treating them is to rip that away from them you want to replace it with more healthy coping strategies but you don't want to just get them to stop this leads to suicide because when it's working for them they're not very likely to kill themselves it's when they when it's not working for them they're having to do more self-harm to get the same effect and increasing their risk taking that we have to get worried level 10 are thoughts planning the details of suicide the where when and some suicides are more impulsive and some are more planned but they all have elements of both and the plan of where when and how are you going to do it and the more easy the access to lethal means the more likely the person is going to die having access to bridges or guns methods that are almost a hundred percent lethal is very different than taking an overdose where you have a long time to change your mind and we have a long time to intervene potentially by somebody else finding you so only about 25% of people take an overdose stop end up dying big difference when you jump off the bridge you don't get a time to change your mind and again that ambivalence at the moment they make the attempt they often reconnect with themselves and all of a sudden they want to live as you'll hear Kevin talking about level 11 are the actual injunctions to inflict self-injury these are the thoughts that drive suicidal behavior you better do it can't even do this can you the only thing you can do there's a lot of these very destructive thoughts happening right at the end and there's a number of works that support this there's the work by Richard Heckler in his book Waking Up Alive where he interviewed 50 people who survived very lethal suicide attempts and they all talked about this thought process that he came to call the suicidal trance cognitive therapists tend to call it the suicidal mode or the suicidal cycle it's a way of thinking that is taken over where the person doesn't see all their options it's a very narrow window there's also research in Switzerland that was done by people with people two days after their attempt while they were still in the hospital by Conrad Miquel and others a Swiss psychiatrist that showed this thought process very much at the end of people's lives I think I am going to show you this brief clip this is teenagers talk about suicide these are two young people talking about the thoughts that go into their thinking about suicide kind of thought to action clip I always feel like a disappointment almost and it's makes it hard for me to ask for anything because I I'm not perfect and the person that I try and perform like I can never be almost and unless I'm that person I think that if I'm that person then I can ask for things and if I'm not that person then I don't deserve anything and I barely deserve friends money life anything and there's times there for a while I was having a hard time in school and right around grading time I would just get so afraid that I wouldn't be perfect and I I somehow I never was and it would just snowball down to where I just think life would be so much easier if I'd just kill myself and it was very logical life would be simple there would be no life and I wouldn't have to worry about grades or anything and I'm always comparing myself to this perfect person that I want to be like taking the pressure off you could kill yourself when you're taking the pressure off like I'm off the pressure yeah I can feel like a voice or like I can feel like it feels like it comes directly from my mother like want anything how could you want anything you should be happy to be here like you know you're here and and you're lucky you're here you know look at all the trouble I had to go through just for you to be here so you know you can't want anything you know just be happy to be here don't want it's wrong to want but it's like I mean it's like I do I feel that same way that there's somebody there's a perfect person that I can't be that I can't live up they'll never live up to and I think I even like try to like I I idealize my friends and things they're that perfect person but I'm not and I'll never be you know and I put myself down you know but I do feel also that if things are going really hard and I can't even think of what things are but you know school is going bad or I feel like my friends hate me that I feel that same way it's like you know why go through all this trouble you know if you just if you just weren't here you know you wouldn't have to go through these feelings you know and I don't feel like that sir as that Syria I mean I feel like I'm not going to kill myself but I there's a voice or I think it's like a feeling inside like you know look at all this trouble you have to go through look at all the trouble you're causing you know if you just ended it if there was just no trouble like if you were dead there would be nothing there would be no you wouldn't be bad because you wouldn't be okay so that kind of negative thoughts we that what do they see as risk factors for suicide and their friends and they very quickly ended up talking about their own thoughts and feelings so what about assessing suicide risk we're going to switch gears here from sort of what goes into what developmental routes are to how do we assess suicide risk and then we're going to leave a little time for treatment as well so I'm going to make a pitch to you to use objective measures when you're assessing suicide risk along with your clinical judgments and here's some reasons why nothing causes us anxiety like dealing with the suicidal crisis here we're dealing with a life and death situation and most of us go into the business of being a mental health professional because we want to help people we feel a lot of anxiety when we're dealing with this kind of situation suicidal people often tend to evoke in therapists too and others in their life a feeling of they try to get us to feel like getting rid of them much like they feel like getting rid of themselves and often suicidal clients get passed from therapist to therapist and don't get the help that they need necessarily and we need to look at those feelings within ourselves as actually a sign that this person might be at risk because you don't go into this business because you don't like people so if you have a client walking that you feel like getting out of your office there's a reason it's often because of what it's triggering inside of you also the level of psychological pain what Edwin Steinman the father of suicidology like to call psych ache his he like to make up terms according suicidology is a term he made up psych ache is another one and it's for that deep psychological pain the anguish and despair that people are feeling who are suicidal if you have never fully felt that it's hard to fully empathize with somebody who's suicidal it's hard to know what their experiences like if you've never felt that level of pain and despair or if you have felt it you do not want to go there you start to empathize and you pull back because it feels too painful so when they do research looking at therapist rating their clients level of suicidality and the patient rating their level of suicidality we consistently underestimated so it's a good idea to clarify our clinical judgments with some kind of objective instrument there's also such a diverse menu of risk factors that were handed in terms of suicide risk although there's a lot of work now to try to identify which are the ones that are more immediate as opposed to lifetime risk factors that we should be looking at but that in itself is overwhelming this diverse menu you know and checking off all these boxes what we really need to be doing is communicating with our client directly so if we're talking about assessing risk in children there's a structured interview that was developed by Cynthia Pfeffer it's in the book the suicidal child and it looks at all of these different things that are risk factors for suicide in children now it's a good measure because it not only helps you get a better idea of the young person's suicidality but it also makes the primary care taker who you're interviewing more aware that their child is at risk and sometimes it's hard for parents to really accept or understand that their child's at risk because nobody wants to think that our child would do this right but it happens in all kinds of families into all kinds of parents and we need to be willing to recognize that when this happens this is a conversation questionnaire this was developed by Ed Reynolds all of these copyrighted instruments are available from par psychological assessment resources and we have some materials from them that are in the back of the room but this is a questionnaire it's kind of an odd because on the outside it says about my life and when the young person opens it it's all about suicide and death so it's odd in that way it's a longer version for older adolescents this is I'm going to just briefly show you some slides that talk about Columbia teen screen suicide severity scale the two things that they're mainly looking at is any suicidal behavior that the young person's had and suicidal ideation they go very deeply into ideation and ask very specific questions but then you ask them about different methods on the third method may say yes and you're kind of like didn't you hear the first question but for whatever reason it's much harder to deny the specific so be willing to ask questions and lots of questions and detailed questions about it they look at the intensity of the ideation frequency duration controllability deterrence and reasons for the ideation they also look at suicidal behavior in quite a lot of depth do you ever affirm yourself have you ever done anything dangerous where you put your life at risk what did you do specifically getting them to describe it if there was any aborted attempts what did those look like if there was attempts that were interrupted this is some sample questions from the Beck's hopelessness scale Aaron Beck the cognitive therapist has developed a number of measures of hopelessness when the person is giving up on themselves that's what we have it's not that they're worried about the global warming or the financial crisis it's their personalized hopelessness these are our measures the firestone assessment of suicide intent is our brief suicide screener and the firestone assessment of suicide of self-destructive thoughts fast is our screener for suicide our self-destructive behavior along the whole continuum what we ask people to do is just endorse how frequently they're experiencing various negative thoughts toward themselves we have found that people are much more honest about their thoughts than they are about their behavior and when you ask about their thoughts you really get into their minds and then you can directly intervene with those thoughts in session these are some of the things you thought let's address those you can also see a reduction on the what's card an ROC operating curve it's looking at the ability of a scale to predict something that would otherwise be predicted at chance and we were able to demonstrate that our scale was better able to predict suicide than the best hopelessness scale and you cannot see these I'm sure well hopefully on the composite than people with major depression who were not suicidal and didn't have prior attempts the same was true for our bipolar sample the same was true for our substance abuse sample all of whom scored high on our substance abuse level but there's a real difference between those who are suicidal and not in terms of how they scored on the suicidal items and those who are not you can use our measures for risk assessment for treatment planning for targeting your interventions directly at the thoughts and also for outcome evaluation has there been significant clinical change or reduction in the person's risk this is what the record form looks like for the short suicide screener again asking about the person's thought process experiencing these thoughts from never to most of the time for looking at the intensity of the ideation I'm going to show you this clip which is David Jobes a noted suicideologist interviewing an adolescent who has been brought to his parents brought in by his parents because his friend told the parents that he had said some things about thinking about suicide this is an actor and a patient because the American Psychological Association who made this taped in want to have the situation of actually dealing with a suicidal adolescent but as you can see this young man very much portrays a suicidal adolescent incredibly accurately and you can see David's skill in engaging him in looking at the risk and getting him talking about suicide by persisting in asking him to do some motivational interviewing to get him to consider treatment as an alternative Pete, have you had thoughts of suicide? Is that something that crossed your mind ever? It's always something to think about and it's not incredibly practical it's just it's there it's an option it's an out it's easier I guess So you've had some thoughts and when you think about it does it comfort you or does it freak you out? Very important question less to deal with less to deal with Yeah in a big way But when you think about suicide does it comfort does it feel like something that you could do or that would and you know the feelings or the things that you're going through feeling pressured overburdened involved in too many things fighting with friends There's so many ways to do it it's got to be easy I mean it can be comforting it's I guess I don't think I'm going to do it I mean Why not? Why wouldn't you? Life is fun I guess it's just you know play some basketball I mean friends sometimes when they're not fighting with me or telling me that I do things wrong and misunderstanding and So when you think about suicide do you think specifically how? Do you think about a method? How not? So you think stories and and you said there's there's there's hundreds of ways to kill yourself She's one in particular come to mind My dad hunts Guns around the house? Yeah They're not safe that wouldn't be too hard and he takes them out everyone's going to clean them Yes Pete, do you find yourself fantasizing about that or being preoccupied with that? Every once in a while I don't sleep much I don't know why but I think about it Let me ask you have you ever made an attempt before? Why not? Haven't quite worked out the guts Feels like something you'd have to have courage to do Have you gone about making preparations for your death? Have you gone around you know maybe writing a suicide note or giving away something special to somebody saying goodbye? I write things down a lot I could journal I don't like talking to people much it's not like they ever help but I guess I could give that to someone needed to Have you actually gotten a hold of a gun put to your head or sort of rehearsed it in any way? held the gun once What was that like? Full Powerful because something like that could just has the power to change everything and sort of clears the deck doesn't it? One little pull Not much work big result Yeah So why didn't you pull the trigger when you did that? You go to basketball practice You regret it You wanted to play basketball right there so Okay But when you look back on that moment that you felt so powerful Do you regret not having pulled that trigger? No Now for some people Pete they think about this or they get close they feel powerful they feel like it's a way that they can end their suffering sometimes they also feel like it's the big flip-off you know to people that make them mad or betray them or over tax them like certain parents that you may know Is that wrapped up in this at all for you? I'm gonna be sad I just You don't want them to be sad No All I ever do to my friends is make them feel bad and worry and I was getting fights and I never see other friendships like that Do you think Pete they'd be better off without you? I guess less of a hassle less of a burden Do you think your folks would be better off without you? Cause you're such a pain in the neck I know they love me and all that but I don't know how much they like me You know it's the worst at night Because you're troll sleeping Yeah with the darkness and it's kinda so better there's nothing else to do It's never fun Yeah, it sounds really hard Probably in your experience you don't have a lot of people A. who are interested B. who get you the one person who was interested was killed tragically in a car accident and yet if you work with me then that's the problem your parents write and I think that would be a really tough thing to accept Or the alternative model is that we could find a way to work together with the understanding that you always kill yourself later I'm not much of a difference between now and later but Oh there's a gigantic difference between now and later See the fact is that I can't prevent you from killing yourself and as you say you know this is something you think about it gives you comfort and it's something that feels like really powerful so on one level I don't want to take that away from you because you don't have any power you have very few things that comfort you on the other hand I'd love to give you something that gives you power or comfort or meets the same needs without costing you your life that's what I'd like but I think that's a lot to ask of you I really do I think it's a lot to ask of you to not kill yourself when it's so powerful and so seductive where you could wipe the slate clean and it would just all be over so what I would propose to you and I'm going to say a version of this to your folks when they come back in is I think you should put it off for now and I think that you should try to give me a chance to be helpful to you but I think that's a lot to ask of you Okay so there's a couple important things that David did in that clip and one is that he connected with this young man he asked the question of whether it comforted him or freaked him out that's an important question you want to know how they feel and it's a much scarier prognosis when it comforts them like it did this young man he also is trying to get him to procrastinate suicide and he's part of the Ashley working group that was started in Switzerland by Conrad McKell David is and I am and a number of people in this field where we understand that you do in a way have to understand the suicidal wish and have tolerance for that as a therapist while at the same time trying to help the person find a better alternative and that's part of what he's doing when he's talking about how much this makes this how much comfort it gives this young man to think about this at the same time why not put it off and why not try working with me and what he proposes to them is you know let's take the next six weeks you could always do this later and the more that we can get our clients to procrastinate suicide the more likely they are to stay alive again anything that puts time between the person and their plan including restriction of means saves lives but also are you willing to work with me for some period of time okay so in terms of warning signs the issue of not sleeping is huge research now shows that most people who died by suicide have had serious sleep problems anxiety and agitation is one of those right now risk factors pulling away from friends and family often people think they're just rejecting me but they're rejecting everybody turns out past attempts again even if those attempts were not very lethal they increase risk two or more attempts and lifetime risk is incredibly higher extremely self-hating thoughts feeling like they don't belong like they don't fit in anywhere again only through a negative filter their friends may feel like they very much belong hopelessness particularly personalized hopelessness rage impulsive aggression the tendency to react to frustration or provocation with hostility or aggression it's part of why they drive other people away feeling trapped like there's no other alternative like this young man feels another factor by the way that was precipitating factor for this young man in the interview is his sister the one person who quotes got him was killed in a car accident and the question I would have wanted to ask that David doesn't ask is do you ever wish it was you or do you ever think your parents wish it had been you or do you want to join her yeah do you want to reunite with her exactly I'd want to know more about that whole issue increased use of alcohol or drugs and by far the most dangerous drug when it comes to suicide is alcohol the way it interacts with our brain chemistry it is the most likely precipitant and 50% of suicides occur under the influence and alcohol long-term alcohol problems are the second highest psychological disorder associated with suicide risk number one are mood disorders both major depression and bipolar disorder number two is alcohol dependence number three is schizophrenia and again upwards of 90% of people who died by suicide have a diagnosable mental health disorder doesn't mean that they were diagnosed or necessarily receiving treatment at the time of their death although a lot of them do come across our paths sometimes during their lifetime feeling that they are burdened to others this perceived burdensomeness is huge and again it's through that negative filter loss and interest in favorite activities the things they used to love to do they're not doing they're not taking up on themselves risk taking behavior suicidal thoughts, plans or actions the more detailed the plans the more they've taken action toward the plan the higher the risk the fact that he had gotten out the gun and played with it and considered it makes it a higher risk and the method he's deciding on is so lethal sudden mood changes for the better having a major psychiatric disorder again particularly depressive disorder bipolar disorder, substance disorder and underlined personality disorders play a huge role when there's more than one psychiatric condition dual diagnosis, comorbidity, higher risk again personality disorders particularly cluster B personality disorders like borderline, antisocial, histrionic, narcissistic availability of lethal means the easier the access to lethal means the higher the risk one thing we have to let the parents or caretakers of adolescents know is you need to get the means out of the house whether it's a gun or whether it's the Tylenol which is the big risk factor in terms of over the counter medication you don't want to have the super sized bottle of Tylenol in England they've actually made it so you can only buy little bottles of Tylenol and the suicide rate went down and so did the need for liver transplants when they did that it's that impulsivity family history of depression or suicide or substance abuse is going to put somebody at greater risk loss of a parent during childhood put somebody at greater risk and it could be a death of a parent or divorce family discord physical or sexual abuse and sexual abuse actually has a higher correlation with suicide than physical abuse lack of support network, poor peer relationships or lack of connection with parents or others or feeling like you have that lack of connection even if they don't feel it and dealing with sexual orientation issues in adolescents is going to put people at higher risk particularly identifying with the sexual orientation that you don't feel like it's approved by your parents your community and when you have parent support you can make a huge difference which we'll hear about from Dr. Caitlin Ryan this afternoon in her project so some protective factors family and community connections and support clinical care being available and accessible to the person resilience, having more resilience skills some people are just more resilient than others and having more coping skills and having frustration tolerance and emotional regulation some people can sit with feeling bad a long time and other people don't have that having a narrow window of tolerance is going to put you at greater risk and in therapy we're kind of pulling at the windows at that window of tolerance so people can recognize when they're getting into crisis sooner and they have more tolerance and more strategies for dealing with it when they're getting into crisis cultural and religious beliefs and spirituality can be protective for people this is Thomas Joiner's model and this is the model that our national lifeline runs on three things have to be present for people to die by suicide feeling like you're a burden feeling like you don't belong and having acquired capability and acquired capability is partly this ability to disconnect from yourself people who have had multiple painful experiences many operations when they were young have been in a lot of physically painful situations it's part of the problem why we're having the problem we do with our military people who have been in a lot of traumatic situations are going to have higher risk or vicarious traumatization that's why people in our profession have higher risk which they do so look out for your colleagues as well so they look at assessing the acquired ability if a person is more fearless than other people they're going to have more acquired ability or they don't avoid painful things so they don't feel much physical pain these are people who have desensitization of physical pain but heightened awareness of psychological pain and distress and ego threats burdensomeness people will be better off when I'm gone things like that and belongingness lack of connection to others I'm not going to walk you through this assessment but if you'd like to see it in more detail please send us an email I'm El Firestone at glendon.org and it should be on your last slide too I'd be glad to send you this in a full page so you can actually see it and look at it and it just walks us through the things that we need to do in terms of deciding risk can the person be maintained as an outpatient or do they need to be inpatient to be safe if they're going to be outpatient how do we make their home environment safe how do we make them to resources how do we help bring their friends and family and the people they're in daily contact with on board as a support what are they going to do when they get into crisis how can they access you how can they access other crisis resources and when somebody is in crisis we want to connect with the part of them that wants to live and we don't want to do anything to support or to weigh in on the part that wants to die and that is the main thing in crisis multiple attempt are particularly high risk because they have a greater likelihood of having abuse or comorbidity of diagnosis in their early childhood younger at the time of first attempt even though the first attempts are low lethality more impulsive, more likely to have substance abuse issues greater symptom severity in terms of anxiety, depression hopelessness more frequent histories of trauma distinct characteristics of a crisis when this happens I get into crisis I think about a young work woman I worked with who would get into crisis every time there would be a break up of a relationship she did a lot of things to contribute to these break ups but she still would get in crisis when they would occur so people attempt at lower and lower levels of distress it gets easier to do safety planning this comes from the work of Greg Brown who also worked with Aaron Beck on developing the cognitive behavioral therapy for suicidal people and this is something that we now can do in emergency rooms and in first contacts that is much better than an anti-suicide contract this is a safety plan that we keep a copy of and we make sure the person walks out with because sometimes our only contact with a suicidal person is our first contact with them we want them to have this when they leave us so what are the warning signs what are their personalized warning signs that they are getting into trouble is it when they are feeling like they want to go to sleep and not wake up is it when they are thinking that they want to hurt themselves is it when they are feeling like they are a failure when they start having those thoughts that is when they are getting into trouble so how can they recognize a crisis at earlier stages what are some coping strategies the things that they can do that help them calm down that have worked for them in the past things like listening to music we want them to listen to music from a hopeful period in their life when they were feeling good music is incredibly mood inducing it can make you very depressed to listen to music from those really low periods in your life but the music from those really better periods in your life will make you in a better mood maybe it is rocking in a rocking chair or going on a walk or going for a run or taking a hot bath or cold shower whatever works for them baking brownies doesn't matter what are the things that they can do and easily access that make them feel better help get that cerebral cortex back online are there people that can contact that just distract them not that they have to talk to about being suicidal but can they call their brother their parent, their friend somebody they can just talk to that when they talk to that person it distracts them from suicide go to Starbucks, go down the block come out here on the boardwalk be around a lot of people that will distract you who can they contact that they can actually talk to about this who are they willing to reach out to in their social network again a family member or friend and does that person know what to do when they get that call I think of a young woman I worked with who the only person in the world she would call was her brother okay but her brother needed to know what to do when he got those calls how can they get a hold of you how can they get a hold of the national local lifeline local lifelines are better in the sense that they know more about the community's resources and how to access them but the national lifeline is also available 24-7 that's the 1-800-273 top number that's our national lifeline there's also online what they call the national lifeline gallery where people can go on and hear stories from people who have been there and have gotten through it and what they see is an actually animated character that you make of yourself that tells your story and Dr. Phil is on there with his animated character also telling them not to do it so the ideas you sign it and they sign it but they have this concrete document that helps provide structure in times of crisis to them so with adolescents you can do this as well how will you know when you should use your safety plan when do you know you're getting an elevated risk what are some of the coping skills you can implement what are some of the social contacts that distract you from a crisis who in your family can offer you help who professionally can offer you help and how can we make your environment safer how can we get things out of the house that when you're in that impulsive mood are going to be potentially lethal you want to increase their social supports by making lists with them looking at family resources looking at friends how can they join social clubs anything that gets people more connected can be lifesaving how can we improve or involve their relationships with their family how can we let help significant others understand them so who are the three people you could call and that's starting to generate that okay the crisis response plan which I won't go into in depth either but again it looks at the same issues what's upsetting me how am I going to calm myself down if I do all these things and I still don't feel better the idea is to take 30 minutes and do them all again because again the more you can procrastinate the less likely you are to do it and then how could I specifically get help if doing all these things still isn't calming me down is there a walk in place in my community to access those services one of the great resources we have in Santa Barbara and this is from our film for the public the helper task of how you can help somebody who's at risk to help train everybody in the general public on what to do when they're worried about a friend, a family member a loved one we also have these helper tasks available on our website Psychalive so I'm not going to show them right now but you can access them and look at them the idea is these are five things that were developed for the California Helpers Handbook and we're ready to write Canadian psychiatrist interestingly enough it's a very good document but then they didn't fund distributing it so it's add in a warehouse we've turned it into our brochure our save a life brochure which you can download from our website our Glen and Association website things that we tend to fail to do write when it comes to suicide prevention we often over we can offer superficial reassurance avoid the strong feelings the more the client can express their strong feelings to you the less likely they are to do it we don't want to make distance between ourselves by standing behind our doctor role we want to connect with the person as another caring human being in their presence we want to ask directly about suicide even therapists are afraid to talk about it we need to talk about it and ask we need to look at the precipitating event the why now because if we can deal with the pain about the why now we can reduce the risk we don't want to be passive we need to provide structure for people when they're fragmenting we need to be very direct we don't need to be giving advice we need to be drawing out what works for you when you're just in distress we don't want to just give this is what I say to all my suicidal clients that's not helpful you don't want to get defensive because often these clients will attack you as well because they feel like even you can't help them you don't understand they're worried that we can't help them so when imminent risk does not dictate hospitalization the intensity of treatment should vary with the intensity of crisis we need to increase our contact with patients during times of risk whether that's multiple sessions during the week or check in phone calls that are scheduled phone calls not the one we get at 2 o'clock in the morning easier to deal with also if the target goal and suicide attempts and related behaviors we should conceptualize treatment as long term and target identified skilled deficits emotional regulation deficits distress tolerance deficits impulsivity problem solving deficits in interpersonal relationships and anger management if therapy is going to be brief because of circumstances we need to build in a problem solving component because this person needs to learn skills with the longer term problems that we're not going to be able to solve in the short term and regardless of our therapeutic orientation we should have an idea of what it is we're doing and why we're doing it the more we believe in our treatment model and it can explain it to the client in a way that makes sense to them the more likely it is going to be effective so your belief in the model you're using is going to influence the outcome and it's important to follow up the postcard study that just sending a postcard after somebody's dropped out of treatment saying I'm still here, hope you're doing well if you need me call me can save lives even for treatment resistant patients who never call the group who get the postcard stay alive that comes from a study done up in the Bay Area by Jerry Motto so we also want to have informed consent we want family members to know this is the risk given your family, your loved ones risk factors this is what I'm going to try to do this is how we're going to work together to try to help save your loved one so we also want to get people to commit to treatment and I'm not going to go through this in detail either but we want a commitment to treatment and to being actively involved in their treatment so whatever the outline of our treatment looks like we want them to commit to that whether it's making their appointments being actively involved during session doing homework if that's part of our treatment taking their medications as prescribed being willing to experiment with new ways of doing things that might help them and implementing their crisis response plan when they're in crisis this is David Jove's comes from his CAMS collaborative assessment and management of suicide risk treatment model he says usually this is the way we approach it as the therapist sitting above the patient talking down to them what we really need to do is collaborate with them they are the expert on their suicidality and we need to draw that out of them he has something he calls the suicide status form again I'm happy to send you a full copy of this but it asks them to rate the things that drive suicidal behavior like psychological pain like self-hatred like stress like agitation and hopelessness and also to rank which one of those is most driving suicide for them it also to give reasons for living versus reasons for dying it turns out people who give you less material of both are the highest risk from his research and he's done this with military groups with hospitalized patients at the Mayo Clinic and also with college students and counseling centers he also asks what degree do you want to die and what degree do you want to live and when this method is employed the CAMS method the suicidal crisis resolves more quickly so what are some effective therapy approaches when treating suicidal people there is now an effective cognitive behavioral therapy for depression again developed by Aaron Beck and Greg Brown the most significant feature of this compared to other cognitive behavioral therapies is it is not time limited because the third step is what they call relapse prevention with a twist and what that means is that before you graduate from this therapy you use a suicidal crisis in session and you have to be able to use the coping skills on your own to get out of that state if they can't get out of it you help them as the therapist and walk them through the process of getting out of that state but they don't graduate from therapy until they can do it on their own a lot of therapists are afraid of the idea of inducing a suicidal state in session but what we know about suicidal people is that when they're in that state all of the coping skills we teach them go out the window we need to make sure they can use them while they're in crisis dialectic behavioral therapy which was originally developed to deal with borderline women who had acting out in suicidal behaviors has also been found to be effective and one of the things I think that it stresses that all suicidal clients need is strategies for tolerating emotion and regulating emotion effectively and in healthy ways and DBT offers that, the DBT skills building model and also Matt McKay has written a book on skills building from a DBT perspective for New Harbinger as well as the one Marcia has written mentalizing treatment all John Allen and Peter Fonigge has also been found to be helpful for people who are suicidal there's now some good research data and transference focused therapy developed by Kernberg, Clarkin and Yemen's and our approach is called voice therapy developed by my father, Dr. Robert Firestone and it's a method of giving voice to these critical inner thoughts it's a cognitive affective behavioral approach cognitive because we're interested in the thoughts affective because we're interested in the feeling behind these thoughts this is never simply a cognitive process and it's behavioral because we're really focused on changing behavior this is something I think from all perspectives can be helpful but it came out of the cognitive model which is constructing a hope kit this is a box where a person puts things in it that are going to help them when they're in crisis and then they put that box somewhere prominently in their living space where they can easily access it things like a card when they give it to their partner that means it's time you have to sit down and really talk to me and be there for me pictures of loved ones music that makes them feel better a DVD of a movie that always makes them laugh whatever it might be that helps them when they're in crisis it's really important it's really important to establish a therapeutic alliance and maintain that alliance and repair any ruptures that happen in that alliance because when we look at people who die by suicide when they're in treatment there's always been a breakdown of the relationship and keeping our relationship strong with a client can be life-saving even if we're working from a cognitive behavioral therapy standpoint so it's really important even stressed by Greg Brown and Aaron Beck clearly coming from a cognitive perspective that the relationship is essential when you're treating suicidal people and they talk about how to maintain that alliance by making the patient the expert on their condition and really trying to reach out and connect with them about how they see their suicidal story and also they talk about addressing any barriers what are they going to be the therapy interfering behaviors that the patient's likely to engage in and that you yourself might engage in and make sure that you're on the same page with the client checking in with them regularly that you're understanding what's helping you want to have one story a shared story between you and the client about what's going on in therapy I'm not going to go into our approach but there's my father and his book about this I'm not going to go through the steps so one thing I want to share with you before we stop and go to questions but basically what you're wanting to do is not grow the anti-self of the person but rather have them stand up to that monster that lives inside of them like when Max says goodbye to the things in where the wild things are I'm not going to show you that treatment clip either so we need to address the patient's impulsivity because if we're going to save a life I'm not going to go through these things either I'm going to go these are from interpersonal neurobiology this is what I wanted to get to suicidal find most helpful in treatment what worked for them validating relationships were number one where they felt that the person connected with them the person being willing to work with the strong negative emotions associated with suicide was number two on what saved their life and if the therapist doesn't have tolerance for strong emotions your client won't go there and you need to let them go there lastly developing an identity that was life sustaining so at the end of the day while we've done a lot of studying about suicide if we're going to save people's lives we need to help make their life worth living to them help them develop meaning in their life so these are some of the common emotions experienced in grief and when we lose a client to suicide we go through all the same grieving that family members and loved ones do so it's important to take care of ourselves and to deal with these emotions we need to ask for help and consultation when we need it this also helps us guarantee that we're practicing up to the standard of care talk to others get plenty of rest drink plenty of water but not drink plenty of alcohol because that doesn't help us in coping either exercise and relaxation skills we need to keep centered if we're going to do this work so this is a reminder to take care of yourself and these are some websites that can have a lot of helpful resources for you the American Association of Suicidology, the International Association for Suicide Prevention so what do the do's and don'ts just quickly be aware learn the warning signs get involved become available show interest and support ask about suicide be direct talk openly about it be willing to listen and allow the strong expression of feelings the more the person can express the feelings the less likely they're going to feel that they have to act on them don't get into a debate about whether it's right or wrong don't be judgmental but draw the person out because if you lecture about why they should stay alive they'll just stop listening offer hope that alternatives are available and take action don't don't dare the person to do it often people get baited into this by people who are suicidal doing that putting it out there and taking it back thing don't ask why why questions make us defensive in general we don't know why we do almost anything and it shuts the person up offer empathy for the feeling but not sympathy with the solution don't act shocked because that'll just put distance between you and the person and don't be sworn to secrecy seek support here's our books and resources when our conquer your critical inner voices in the inner voice for professionals these are the three films we have about suicide which you saw some brief excerpts from understanding and preventing for professionals voices of suicide understanding and preventing for the general public voices of suicide for professionals and lastly faces of suicide which is a survivor film where you see survivors talking about the loss of their loved one and going on and being able to develop meaning after the loss of somebody significant to them to suicide these are some of our upcoming webinars and we have ones that are archived about suicide and we have ones with experts like Dan Siegel and Donald Meikinbaum and Pat Love and this is our contact information so if you want any more of these resources that I wasn't able to share with you I'm very happy to send those to you if you contact us at either Glendon Association our website for the professionals thank you again all for being here today so I guess we have time for questions we have a mic over here if you would come up to the mic to ask your questions I'd be more than happy to answer them I'll also be around during the lunch break if you want to ask questions one on one quick announcement a lot of folks have been asking about the PowerPoint we'll also put the PowerPoint up on our website for people to download and color full pages so that you can see some of the detail that you couldn't see with your permission it works best if you come up to the mic if you have a question www.calcianousymposium.org and we'll put it up on the the Glendon website as well no questions here we get one thank you I'm just a parent but I was wondering if you thought social media Facebook and stuff has increased the suicide attempts and suicide ideation I think it's done both I think that for young people who are vulnerable through social media and through websites there's actually websites that tell you how to do it effectively in terms of suicide that are really a problem and there are people who will connect with young people and actually encourage them to do this or support it Facebook has also been a way to reach out and help get connected that has been preventive as well so it's very much a mixed bag it can be a way for kids that don't feel very connected to feel connected and there are a lot of good resources out on the internet as well that can help people and can be helpful to people Facebook itself has a policy of now reaching out and trying to connect with anybody who shows signs of being worried if friends are worried about a friend they can contact Facebook and they will help to try to get them resources so Facebook itself is taking a proactive approach about this but certainly social media can work both ways it helps keep us connected on one level but it isn't quite the same as connecting face to face and we have a lot of young people that feel more comfortable on social media I mean the main way of communicating has become texting right if we have a young person that's giving away any of their social media devices any i-device we should be worried about their suicide risk because we actually map these as part of our body at this point so I don't think we're going to get away from social media I think it's a matter of what is the young person accessing and there's both good and bad out there thank you I'm Kaylee from SoCal High School I'm a student I've got a question regarding somebody who is suicidal and you're trying to help them but you need to separate your feelings from their feelings to be able to help them do you have any suggestions on how to do that methods you can do to not take on what they're feeling so you can help them yeah and the first thing is we need to calm ourselves down and get ourselves centered when we're dealing with this because we're going to feel upset if a friend of ours or somebody we care about is talking like this I think we need to take it seriously and my biggest message to young people is you need to tell somebody you need to get help with this young people are often loathe to do this because they want to keep their friend secret and my message is you can't afford to keep your friend secret you can't afford to let your friend die you need to reach out and get them help and take it seriously and you can call the local hotline they'll talk to you as well so with the national lifeline you can reach out and get support from your parents their parents, somebody at school you know it's really worth getting them to the help that they need you can't take this on and solve all of it yourself but being a good friend and sticking in there does make a difference but like this young man who you saw on the videotape with David he had told his friend and she got really you know really upset about it and worried about it so she told his parents and he was really angry at her but you know even if your friend gets angry at you at least they'll still be alive so that later on they might be able to be friends with you it's worth dealing with their anger they'll usually get over it they may be angry at first but eventually they'll really thank you for caring and so I think it's really important to take these things seriously when we hear them from a friend even though it's hard because you see all your friends good traits but if they're talking like this or giving us indications we're better off overreacting than underreacting that's what I would say welcome okay so the local person who talked first is going to be at which high school oh at her high school okay your high school yeah come talk to them they can help you through this with a friend okay two presentations in April great John John Merkling house I just want to double check if we download the slideshow that would include the video clips if you do it from us we can give you a full file with the video clips I don't know if they're going to be able to do that on the website for the conference or not but if they want to they are more than happy to and we will make it so you could access them do it from you yes if you come to contact us either at Glendon or through Psychalive and we'll make them available thank you thank you Carol Berman therapist something about self soothing you had up here as a negative quality maybe I misunderstood yeah I think that we're talking about self soothing in such a way as to cut off emotions and when we try to suppress our emotions it's not really helpful so we're talking about a self soothing voices that seem self protective and like it's not there but it's not it's part of that anti self I do think we need to have healthy self soothing strategies but that's not what the self soothing part that is part of this anti self is doing it's suggesting we engage in things like substance abuse to self soothe which is not really helpful it's just going to make things worse what we do want our clients to have is ways of calming themselves down or helping getting that cerebral cortex back online that are healthy talking about his jump from the Golden Gate Bridge one of the things he's learned to do is to put on his running shoes and go for a run now he's got himself a big dog that needs to get walked and that will help him to calm down and be able to get back centered in himself so those kind of self soothing strategies can be really helpful I guess it would be more clear if it was positive self soothing versus negative self soothing thank you so there's ways that we can self soothe and deaden ourselves in a way that is not helpful but self soothing that makes us feel calmer and then be able to approach our emotions more directly is helpful and one thing that helps get that cerebral cortex back online is doing something rhythmical like going on a run like roller skating if you're in your living room and you can't it's night and you don't want to go out doing some jumping jacks will help some breathing and paying attention to your breath will help as well setting behaviors often thought of is something different from suicidal behavior and I've seen a number of people who have gone through that and don't seem to go to suicide but I thought from something you were saying in a way it almost seems obvious that that also is a risk factor is that true yeah it is a risk factor when it isn't working for the person for some people and that doesn't something that doesn't work well how can we tell when it's not working when they're escalating they're having to cut more frequently they're having to cut more extremely or engage in more self mutilation behavior it's going to be worse the other time they get suicidal though is when we ripped that away from them we have a young man in our community who died on his 16th birthday and he had been cutting about a year before and his mother being a good responsible parent and the therapist got him to stop but she didn't replace it with healthier self soothing strategies and he spent the 6 months between when he stopped therapy which he stopped prematurely and dying by suicide every day he had an hour after school where he got home before his parents and he systematically searched the boxes in the attic until he found the bullets and the day he found the bullets is the day he died so I guess something like shaming the person on that yes shaming them or just trying to get them to stop is not a good idea we want to replace it with healthier strategies and that would be really good we'd rather they went on a run for instance or exercise which is only going to increase their physical health than do something that actually harms them but for people who engage in self harm it really is soothing for them and we have to at least respect that as a strategy until we get some other ones in place yeah it's really on a continuum it is on the continuum of self destructive behavior certainly eating disorders by the way can work that way too they can be very self soothing for people that are feeling that control of their life by not letting themselves eat but again when that strategy is not working or they're feeling out of control with it it's when their suicide risk will actually increase if there are no other questions I'd like to thank Dr. Lisa Firestone for a wonderful presentation