I'm Donna Sudeck, and I'm a professor of psychiatry at Drexel University, and I'm the training director at Tower Health in Phoenixville. And this is Jess Wright from the University of Louisville. He's a professor of psychiatry there as well. And we're delighted to have you here today to hear a little bit about how one would work with CBT in patients who have suicide risk. This is our, we don't have too many, there's so many we can't count them all, presentation times we've presented this. We've done this a number of times, and we found that this is a topic that people have a tremendous interest in, mainly I think because all of us want to do better with these patients and want tools that we can use. And we will be spending our time both letting you know some facts about this, as well as watching a video with some demonstrations, and potentially hearing difficult problems that you've had and doing role play, if that's something that would be helpful. So by way of disclosures, I write books, and I'm on an editorial board for which I receive an honoraria, and I'm not going to reference any of those in this program. And these are Dr. Wright's disclosures, and I don't think they have anything to do with this particular program as well. So the first thing I'd like to do is to review for a few minutes the scope of this problem. Suicide has been the 10th, 11th, or 12th leading cause of death as long as I've been talking about it, which is now much longer than I'd care to remember, but it's been a long time. And it would be the 10th leading cause of death were it not for COVID. So we have made very little headway in changing this. About 46,000 people in 2020. Suicide rates are measured epidemiologically per 100,000 people. It's easier to quantitate year to year in that way. And also, we're about two years behind, generally speaking. So just know that we know now that it's the 11th leading cause of death in 21. What's different about the rates now is that we had this period of time where it dipped in the rates that were over 75 years of age in white men, and the highest rate was between folks who were between 45 and 65 for just pre-pandemic. But now we're back to the oldest, oldest being the folks at highest risk, along with American Indian, Alaska Native males. People die in the U.S. by suicide because they use lethal means. Most of the time people die by gunshot or by hanging. There is a survey called the Small Arms Survey, and it counts the number of guns per people. And in the United States, we are the number one country with guns per people, 121 guns per 100 people. Our second closest group is Yemen at 53 guns per 100 people, and then Serbia at 39 guns per 100 people, with most of Europe less than 10 guns per 100 people. So we have lots of means available to our patients, so much so that I have taken now to asking my patients where they keep their gun on evaluation rather than whether they have one, because asking whether you have one sounds a little judgmental, and if I say where do you keep it, I'm getting the answer, and then we can start a conversation. The majority of folks who die by suicide, we believe, have a psychiatric illness. Many of them are untreated. And the top 1% of people at risk are probably people who have a confluence of risk factors. That is, if we look at folks who have drug abuse and depression and multiple inpatient stays, that's probably the top 1% at risk. But we know that a gun in the home increases your risk by about 10%, and much higher if you're an adolescent. So we had a peak in 2019, and then there was some decline in 2020, but rates are now back and increasing. Women's rates are up 55% in the last 20 years, we're catching up. And rates in 10 to 14-year-old girls are up by 250%. So adolescence rates are skyrocketing. So that's something to keep an eye on, and my last week on call bore that out dramatically. So this is euphemistically what I call the Sudak Pyramid of Death, and what it illustrates is the problem for all of us. So in the U.S., we have about 46,000 suicides, and we are tasked with the idea, when we evaluate to evaluate who's at highest risk, how are we going to prevent this, right? That's like going into a neurologist when you have hypertension and say, I want you to predict whether I'm going to have a stroke. You might have a risk factor, but it's very hard to predict who with hypertension is going to have a stroke. And this is a similar level of question for us when we think about people with depression. There are 21 million people with depression, and how do we predict which of those 46,000 in that 21 million are going to be the person that dies by suicide? If we look at suicide attempts, which is one of the highest risk groups for future suicide, there's 1.2 million suicide attempts. So hopefully, we will start to think about, number one, about prevention, not prediction, that maybe we need to do more to mitigate the risks that people have by providing better mental health treatment, by doing things around controlling access to weapons. Or perhaps we might think about using machine learning to aggregate risks. Almost all of the studies about risk factors consider one risk at a time, rather than maybe there's a confluence of things we should be looking at. And hopefully, we'll get better at this. One thing that's really important to remember is that rates are extremely high after discharge from the inpatient psychiatric hospital. So remember I said that the rates are about 14 or change per 100,000. Rates after your discharge from the hospital in the first week are 1,100 per 100,000. This is for any diagnosis. And less than half of people get an appointment in the first week after discharge. So what we really have to think about in clinical practice, what I think about is, if I've had somebody who's been in the hospital, I'm going to stay really near. And that rate remains high, really over 500 per 100,000 in the first year after discharge. And it's 274 per 100,000 over someone's lifetime after hospitalization. So those people are at particularly high risk to consider. And I've already mentioned this. So people sometimes scratch their head and they say, what does folks with CBT have to do with this particular problem? And the fact is that Tim Beck was a giant in suicide research. He was the person who disarticulated how people thought who made the decision to try and end their life. And really looked at that curiously and looked at the data. And what he found really influenced all of our questions. He's the person who found out that separating suicide attempts and the intention to die and ideation, that they were all separate risk factors for death by suicide. He actually was the person who made studies about perceived lethality. That if someone took a handful of something that wasn't lethal and they thought it was going to kill them, that they were much higher at risk than the person who took a bottle of something that could kill them but was thinking that maybe they'd wake up. And he made many of the scales that we used for years to try and determine whether somebody could be in a research protocol who was in terms of suicidality. He also discovered that hopelessness is a key variable. If you have a strong history of hopelessness, that is a bigger risk factor for eventually dying by suicide than depression is. So that he looked at that as a key intervening factor. And finally, he developed a protocol for working with CBT for suicide itself. And if there's anything to take home from this today, one of the key points is that you have to work with suicide independently of the diagnosis itself. When I trained initially, the idea was get rid of the depression and you're fine. And we know that that's not true. We know that suicide needs to be dealt with independently, just in the same way that you would insomnia. But you have to treat both things. And that protocol really influenced how we think about this. So one of the things about the evidence for CBT in this particular problem is that there's less of it than there is for a lot of other things. Now, CBT for depression is probably one of the most researched things in all of medicine. And so we've got a lot of evidence there. But for years, people didn't study patients who had suicide as a part of the problem. Because we thought about it as unethical. Marsha Linehan actually talks about this as the most discriminated against group in research, right? That we're not going to look at those people because they might die. And so therefore, we don't know as much about it. Although these days, we have far more in the way of data about this. So this is the study that I referenced before that was done in Philadelphia. Greg Brown, a number of colleagues of his at Penn and Dr. Beck actually did a study where they had 10 sessions of CBT for suicide as an add-on that was actually prescribed for patients who had been hospitalized after a suicide attempt. Now, this was done at Presbyterian Hospital in Philly, which is an inner city hospital. People who were admitted had lots of different problems, multiply diagnosed, had all kinds of different other therapy. And this, after hospitalization, was a treatment that was applied as 10 additional sessions plus whatever kind of treatment you had. And what they found 18 months later was that the folks who had the 10-session add-on had about half the rate of suicide attempts, which is a very large effect and quite important. And what has held up has been one feature about this as clearly something that has changed practice really, and that is safety planning. Safety planning was a big part of what was done in that study, and we're going to actually describe how to do that in this particular session. And what a cohort study that was done later found that just the safety planning intervention in an emergency setting meant that the odds of suicidal behavior decreased by 50 percent and the odds of increasing engagement in outpatient treatment increased twofold. And this was a study 24 months after the original safety plan. There is a website, www.suicidesafetyplan.com, that Barbara Stanley and Greg Brown put together. You can get a free safety planning manual and worksheets to do safety plans with patients on that website. And Barbara and Greg did incredible work in suicide together, and unfortunately, she recently just died, and so we've lost a giant in this particular field. There are a number of meta-analytic studies that show that CBT interventions about suicide have an impact. We know that that's true with CBT. We know that that's also true in DBT and that it works in teenagers. And so we have a remarkable number of tools. And when I think about myself as doing this sort of work, I can think that a number of the different things that we can do as CBT therapists could remedy risk factors for suicide. We think about suicide as often someone's decided solution to a problem. And so working to solve problems differently is one area that I think we do well with. Another is to help people to develop some wiggle room around hopelessness, to see that there are other kinds of perspectives that they might have. Looking at symptoms that we treat well in terms of anxiety, insomnia, or symptoms of psychosis that we can help them with. Helping people to develop better social networks and problem-solve about that. And then other issues that CBT works and has tools to tackle. So most of the time when we work in CBT, part of what we do is to develop a specific conceptualization of the kind of problem that exists. And the conceptualization is derived from the cognitive model for a particular problem and the person's personal history. So when we think about depression, we think about the cognitive triad that Beck had. You know, the negative thoughts about yourself, about the world, and about the future. And the idea that when bad things have happened in your life, it's been because of you and that was totally because of you and it's never going to change or be any different. And then what we do is we think about the person's personal history and how that fits within that model. How did they develop this way of looking at the world? What's their current interpersonal field and the thoughts and beliefs that they have that have led them to this place of being depressed? Well how we think about this in terms of suicide is to think about folks as having, really I think about a triangle of things. One is suicide generating beliefs that they have. Like I can't stand pain anymore. This is too much for me. I deserve to die. There's no hope for the future. Those kind of belief systems that would lead you to think that there was just no other alternative. So that's one point in the triangle. Another is lack of coping skills. I just don't have the skill to solve my problems. I'm not capable of regulating my emotions. I can't stand pain or distress. And last but not least, unstable affect. Mood that just is variable or does not seem to be predictable for the person. And the more risk factors in this particular personal triangle, the more likely that suicidal thinking may get activated during moments of distress. And the kind of thinking that people do when they have suicidal behavior are generally thoughts of being hopeless, completely helpless to do anything about your problems. Or that love is just not going to be for you. That you are just totally unlovable. Frequently there are beliefs about not being able to stand pain. This is too much for me. I can't stand it. I won't be able to tolerate it for another instant. And finally, and very importantly, suicide gets to be seen as a solution to a problem or to this pain. And often what we find is that when people have the thought and they're in intolerable pain, I'm just going to kill myself, they feel better. They have something that they feel is a way out. And when that happens, guess what? What do primates do when something makes us feel better? It means the next time we're in distress, the chances are good that I'm going to think this again. And so it becomes something that is frequently in the mind of the person and they become preoccupied with suicide as the way to a solution to this. Often, I don't know about you, but I've often had patients who have said, I did it because I just couldn't stop thinking about it. It was just in my mind all the time. I couldn't get my mind off of it. And I think that it's important to recognize how that might come about. Another thing that we have here is what is sometimes called the tunnel vision of depression, where the thoughts that people have are so rigid and so dichotomous, so all or nothing about I'm all bad, this is all awful, it will never be good again, that they just can't get out of. And often people who have suicidal thinking have the trait of perfectionism, so that that becomes something that they're constantly disappointing themselves. So it looks like a desirable solution. And last but not least, they cannot remember positive things. They have a deficient autobiographical memory. And what that means to me is that if a terrible thing befell me, generally speaking, I would go back and I'd say, oh Donna, you know, you've gotten through some tough stuff before, you've been able to do this, you've been able to do that, your life has been better at other times, you can, you got this, you can work on this, you'll get through it. But the person who develops this problem, when they look back in time, they cannot see that. They cannot see times where they've coped well, they cannot remember better times in their life. And so they're left with this relentless barrage of hopelessness, of suicide as a solution, and not be able to see that there was a time where things were better. Our job becomes shining a light so that they can see that. The other piece is helping people to solve problems better, because deficient problem-solving is at a high level in folks with depression, in generalized anxiety disorder, and in borderline personality disorder. And so we have to teach people how to solve their problems. Also, often the things they do to solve problems have very deleterious effects. Avoiding confrontation, avoiding negative emotion, doing things that make your life worse, or churning over all the bad things that have happened in your life. Now one of the things we want to do is to manage risk factors and increase hope. We want to help the person to look at reasons they have for living, and Jess is going to talk about that in a few minutes, evaluate their negative thinking, develop a sense of self-compassion, and help them solve their problems better. And in hopelessness, what we really need to do is to try to develop some wiggle room, to create some reasonable doubt in this absolutistic thinking. A common misconception about CBT is that we're telling people to buck up and look on the bright side, right? And we're really not doing that. We're just shining a light on maybe some of the darker places and saying, could you be neglecting something here? Is this really as bleak as it seems? Just creating a reasonable doubt in this absolutistic thinking. Because indeed, to be on the other side of that 180 degrees wouldn't be very believable to the person, right? We would be like everybody else in their life who is saying, it's not really that bad, right? And that isn't very believable, but a question about, oh gosh, you know, can we look at the evidence for that? What do we know about you as a person that could help us to be more hopeful? First of all, the person's in our office, right? They're still getting dressed. They're coming into treatment. There is something about this that is giving them hope. And frequently, I think particularly when you're early in your career, the idea of building hope is a daunting thing. And particularly because at least early in your career, my career, and in my trainee's career, often the patients they're seeing have the weight of psychosocial problems that seems unliftable on their back, right? And so we have to think about what is it that we can do that will help create hope? One is it's the relationship. It's I believe that things will get better. I don't want you to die. I think that we can do things to help you with these problems. And here's how we're going to work together to solve these problems. Every week when you come in, you're going to bring in something that we're going to work on together, and we'll figure out steps that you can take to make your life more meaningful. And I think that we can do that. We're going to tackle what gets in the way. It's being able to have that mindset and directly say that to the patient. It's teaching people about the reasons for an optimistic outcome, right? We have a lot of data that this this treatment works. And also finding out why they're hopeless about therapy if they're hopeless. Because frequently people who come in and say therapy doesn't work for me, and I'll ask them, well what did you do in therapy? Well I came every three months. I'll say well that's that's not going to do it here when we don't have something we can work on in every three months. And that's not really what we would think of as therapy. Or they'll say well I've had CBT and it doesn't work for me. And I'll say well what did you do? Well I had to say I said to say good things to myself. So I so I can tell people that you know there's good reason to suspect that this form of treatment will help you. And I have a plan B. If this doesn't work, here's what we're going to do. You know we're going to work to get you interpersonal therapy because that can help. Or we're going to get you acceptance and commitment therapy. Or we're going to get you a consultation about X. But I have a plan B if this doesn't work for you. So that I am giving someone information that I think that I can help them solve this problem and cope with their emotions. Right so I'm structuring treatment and setting goals makes a difference. Being able to set small goals that you actually attain. And then ask the patient what does it say about you that you were able to do this? So that you're shining light on their capacity. I'll talk about a hope box in a few minutes. But we want to be able in the moment to modify hopeless cognitions. For those of you who know about how to do that, generally when we do thought records with patients, it's teaching them a process of learning how to do this. With someone in this predicament, we're not going to do that. We're going to work with them and evaluate their cognitions on the spot. I'm going to say well let's look at the evidence for and against being hopeless. With this evidence in mind, what would that say? Rather than let me teach you how to do a thought record. Because generally that takes too much time for folks. One thing that we want to do is to really help the person envision the life that they want. You know if you had a crystal ball in an ideal world and you had the life that you wanted, what time would you wake up in the morning? What would you do first? What would you do next? What would you do next? So that we're not just doing this in global terms. We want to get really granular about the things that would be important to this person. We want to really increase their engagement with positive activities and strengthen a sense of connection to other people. We want to have an emphasis on the fact that you can learn to do things differently. You can learn to manage your thinking differently. You can learn to manage your emotions differently and have a better life. When you know that the person has had other good times in their life, something that's really vital to do is to get back to that time. Help the person to recall more positive memories. When was the best time in their life? What was important to them then? What kinds of things were they doing then? And potentially that's going to help inform things that might be goals for the patient in therapy. We want to help them to remember when they coped well in the past and what conclusions could they draw about that. What does it mean that they were able to solve some really difficult problem when they were in college? And with each step the person takes toward recovery, say, what does it say about you that you were able to do this? Because that gives the person a sense of their own capacity. Now one thing that I do differently with patients who have this problem that I don't do as often, although I probably could, we do a mood check at the beginning of most sessions. We ask people on a scale of 1 to 10, how's their depression been this week? And are there any problems that they want to work on in therapy? One thing that I do with these patients is I'll also ask them, can you let me know one or two things that went well this week? Because I know that they are not highlighting for themselves things that are working. And if all I'm asking about are the things that aren't working, that's what's going to be on their mind. And I want the other side to have a little light on it. And so you might want to do that a little differently. Here are some good questions that you can use to prioritize the person's values. What were they doing during the best part of their life? What did they do when they had problems? Who was in their life? You can sometimes ask the miracle question. Everybody know what the miracle question is? I think you have to, the miracle question, for those of you who don't know it, is asking someone if there was some miracle that happened tonight when you went to sleep. And you woke up in the morning and this problem that you're having was gone. What would be happening in your life? And then you get an, it's another way of saying, what would your vision be of your life? You have to be careful about this depending on the situation for the patient. You know, if I have someone who's had a spouse who just died, you know, it's going to be sort of obvious. And it's not going to help me as much. So you have to decide whether you're going to ask that question. But sometimes that can help people jump start looking at different realistic goals and future kinds of things. We want to really get a sense of what this person values because we want to build a case for living. And in order to do that, we have to look at a wider swath of things. You know, what's important to this person? What about, what are they attending to? How are they caring for certain parts of their life? Because we want to look at things they might be neglecting that would be important to them. And maybe jumpstart some adaptive thinking toward doing that. And that leads to goals, right? What's one step you could take that would get you closer to having the kind of environment you want at home? Or who can you get closer to this week? What can we do to improve your well-being? So we're thinking about connection, well-being, and goals when we're thinking about building hope. The other thing that we do is to build a hope box. Now hope boxes came from safety planning. And Jess is going to talk about that a tiny bit. But since I'm doing hopelessness, they seem like a good thing to include here. And a hope box is an actual physical or virtual container that has things in it that reminds the person of their reason for living, right? Because there's a much more emotional connection if you can see things. So if somebody said to me, what reason did you have for living? You know, the top of the list is going to be my husband and my daughter. And you could amplify this, and I'm sure Jess is going to do this, and by asking me about the qualities of those relationships and what was important to me about them and what would be important to them if I died, what would that be like for them essentially? What would they miss? And all of that amplifies the connection I feel. But if I were to see a picture of my daughter in her wedding dress, which she's wearing in February by the way, hands down I would be like, oh my gosh, like this, right? And so what we want in the hope box is to put things that really amplify the connection the person feels with the reasons to stay alive. And sometimes it's things about the future. Like for teenagers, it might be, you know, the prom date or the, you know, picture of Bruno Mars and you're going to go see him in concert. Do it, because it's great. And or of, I want to go to Paris someday, or I want to go to nursing school. And so you would have reminders of things that the person hopes for in the future. The other thing we can put in is inspirational letters, things from your grandmother, poems, coping cards, something that you learned in therapy that's going to be important for you to hang on to. And so we give the person the assignment to start putting things into this and to look at it several times a day, or whenever they feel the need to, based on having some thoughts that maybe they don't want to be around anymore. Parenthetically, I use this in patients who have terminal illnesses as well, and I call it a bad days box. It is not studied in any way, but what I have them do is to put in things that are comforting for them and things they know that will reliably make them feel even just a little bit better. Movies, music, things like that. And so when they're worried about a test result, or what's going to happen when they go see their oncologist, they have something that they can just quickly fall back on. And they have found that it's been really helpful. There is also a virtual hope box. It's a free app, so you can have it in your phone. And since most people live and die by their phone, there you go. But it's a putting together emotionally significant things that kindle your attachment to life. So with that preamble and a little introduction to the epidemiology, I'm going to turn it over to Jess. It's always daunting to stand up here after Donna speaks because she has so much to say and says it in such a beautiful way. It's good to see all of you here. I started my work in CBT back in 1980 when there weren't so many people that knew about this treatment. There wasn't so much research done on it. And I was very fortunate for Aaron Beck to take me under his wing and mentor me. And it was a singular experience in life, and it's informed much of what I've done. I wish that I would have had his training and knowledge very early in my career when I had some tragic outcomes with patients. I'm looking around and seeing a number of clinicians, and I bet some of you have had this occur in your practices, too. And it's highly traumatic and something we obviously want to try to avoid if we at all can. I've been asked to talk about safety planning, which is, I guess, the piece out of the Greg Brown, Aaron Beck, and others protocol that has sort of stood by itself in a way and has shown such power. I wonder how many in the room are actually doing this in their own practices and doing this the formal cognitive behavioral therapy method for safety planning with patients. How many are doing that? Okay, a few. Well, it's good to see. I hope if we came back and did this in another year or two, there'd be a lot more. I know that the Joint Commission in the United States is very interested in doing safety planning as a quality measure and for very good reason. And I know that the Veterans Administration and the military is very interested in this procedure for very good reason. Our own hospital at the University of Louisville has tried to endorse this, and I've done lots of training, and I'm hopeful that our residents and faculty and other staff members are doing it on a routine basis because it can save lives. So we're going to walk through it today, and then we're going to have the great pleasure of actually seeing Greg Brown, who was the person that figured this out, do a safety plan. So I think that should be very interesting for you. Okay, let's see if I can figure out how to move these slides. Is it this is a funny keyboard? Is it this one? Thank you. Great. So this was the protocol. I think you saw a slide earlier, one of the slides that looked like there was a 50% drop in subsequent suicide attempts, and I studied that in Pennsylvania. So that came out of the work of Greg Brown and Barbara Stanley, and they did focus on suicidal behavior as a primary problem. As in all forms of CBT, there's a big attempt to be collaborative, to really engage the patient, work with the patient as a team, if you will. So a safety plan is not something to be done to somebody, it's something to be done with somebody. And I do see mistakes being made when I hear about safety planning on say inpatient units when the patient's been in three days and it's time for them to be discharged and someone says we should do a safety plan and so a nurse or someone else comes in and tells the patient it's time to do your safety plan and they do it in 15 minutes or so and just knock it out so it's in the chart so now you've done everything you should do for medical legal purposes when this is really supposed to be done over a period of time when you build a relationship with a person, you get to know them, they get to know you. In an inpatient setting, I think it's really good to do this with a whole team so that people can have input to it. So we do have this very active engagement of subjects. Donna talked about the hope box and if I had a video I could show you, I actually have the virtual hope box on my phone so sometimes when I'm showing patients this technique or describing it to them, I can pull it out and show them what's in my virtual hope box which by the way, as far as helping people use apps, I think it's a good idea to use them yourself or know what they're like and to be able to actually demonstrate them or show you have them. So I have things like Headspace and Calm and those kinds of apps that are really good and the ones from the Department of Defense that are very well vetted and nicely done and they're able to show patients about them. The last key point was a relapse prevention task and this is one that I really wish I would have known about a long time ago and I'll take just a moment to tell you, it was a tragic story of one of my very first encounters with a patient that suicided. This was a woman that came to our inpatient unit at the University of Louisville when I was I think a first year faculty member, it was before I was trained in CBT and she had attempted suicide by overdose and was quite depressed. We put her on, it was a tricyclic antidepressant back then, I'll show my age, it was before Prozac. I can see a couple of people head shaking, they're people that were in the same boat and we did some, I guess it was supportive therapy or whatever it was and she wasn't getting better and so she got electroshock therapy and indeed she seemed to improve greatly after the electroshock therapy and back in those days we kept people in the hospital longer than now so it was I think three weeks or something like that and it was getting time to perhaps discharge her and the social work team always interviewed family members and tried to assess the family situation and the patient had brought up that one of the reasons that she'd gotten depressed was that she was worried that her husband might be having an affair and so the husband came in and talked to the social worker, not to me, I should have also interviewed him but the social worker talked to the husband who completely denied this and said it was just her negativism and that there was nothing to it at all and so she was discharged and two days later we got the word that she shot herself and killed herself and we did I guess a post-mortem, psychological post-mortem, we found out that when she went home her husband told her, well I didn't want to tell you when you were in the hospital because you were so stressed out but it's true, you know, I really haven't loved you for years and I have another woman and our marriage is over and that was it. So today if we had a situation like that we should have, thinking with a CBT lens on this situation of asking her for the worst case scenario. Okay, so we hope that things are gonna be fine when you go home with your marriage but let's just imagine for a moment that it isn't, that there is trouble and that you do end up finding out that your husband's having an affair, what happened then, how would you feel, what would you think? And of course she would probably say, well I'd be devastated, you know, I couldn't go on without him or something like that and now you have something to work with, right? So now you begin to figure out, okay, how could we begin to manage that or cope with that? And if you've done CBT, I think there's a lot of people shaking their head, you know that this thinking ahead doing cognitive behavioral rehearsal can be very helpful to patients to identify triggers that could send them spiraling right back down where they were. So this is a big part of the Brown protocol. So, a safety plan. So we wanna collaborate and we actually have a paper form which I'm gonna show you in a minute. These are widely available. Donna gave the website where you can get a whole packet. If any of you have one of the books that I've written called Learning Cognitive Behavior Therapy, Greg Brown wrote the chapter in there on CBT for suicide risk reduction and you can go to www.appi.org slash write. That's www.appi.org slash write and you can get all these forms including the safety plan for free. Now we wanna instruct the patient to actually follow the steps of the plan and then if it doesn't work, then they have another plan. That's to seek out direct help or even perhaps go to the emergency room of the hospital. So here are the key points and the rationale for them. The idea here is that people aren't suicidal all the time. They have crises that come up and these urges fluctuate. So if you have a plan in place that you've worked out when things aren't quite so bad and then you can rely upon that when times get tough, it can save your life. So here are some of those common steps. You identify activities or people that can distract and by the way, this sounds almost superficial, something to distract you. You know, if you're thinking of suicide, how could distraction help? But it actually does. The research shows that people that identify some distractions to get their mind off the desperate kinds of despairing thoughts that they're having, it can get them through the crisis. We wanna be real practical about this, find specific ways that you can get mental health support. We talked about reasons for living before, we'll go into that in more detail and of course we wanna restrict access to lethal means. These things are all common sense. I'm sure most of you are doing this with patients. It's a way of organizing it and doing it in a way that's extremely helpful to them. So when we look at each step, we first ask the patient for ideas. What can they come up with? Now sometimes they can't come up with them, so then what do you do? We'll talk about that in a little bit. The goal here is not to be undepressed right now or to feel great, but it's just to get through this crisis. You wanna elicit the likelihood of them doing it. You know, what are the percent chances you're gonna carry this plan around and be able to use it if you're in trouble? If the patient says, well, I don't know, a third, 33%. Well, that's not so good, is it? Because then you know you might need to go back to the drawing board. If they say, well, I don't know, 90% probably, that sounds pretty good, I'm glad to hear that. So if you get a low percentage, you need to look at the obstacles and figure out some solutions that you're gonna talk about in a little bit. And then provide a written reminder. I bet most of you now are seeing a lot of patients by telemedicine, aren't you? I know I have been. And this is a little harder to do with telemedicine, but I can tell them where to get the form and how to fill it out, and ask them if they can carry it around with them. If they're in the office, which I'm seeing more and more patients in the office, I can pull these written form in the old-fashioned way right out of my desk drawer, and we write it out, and we get a copy for the chart and a copy for them, and we make sure we follow up on it for homework when we see them again. So we say that we're gonna pay attention to this. Okay, Donna talked about the number of guns. That's amazing, isn't it, in the United States? So that's the main thing to look for. How about managing lethal restrictions that are things like ropes and so forth? Do you know how to do that, Donna? How do you handle something like that? It's a lot harder. I just had somebody ask me this question. People have taken down closet bars and shower curtain bars. It's not so much, there's so many things you can use in a house. It's really getting places where people can hang themselves from that's much easier to do, but that is a much more complicated problem. There's no question. I just had a patient that identified his whole closet full of neckties, which he didn't wear anymore, by the way, but he still had up there as a risk factor, so he agreed to give all of them to Goodwill because he wasn't gonna wear a necktie ever again, he said. So I wondered if he maybe kept a really special one or something, but he didn't, I don't think. So finding reasons to live. This is, in my opinion, one of the most important things of the safety plan. A better question, actually, I think, than, well, what are your reasons for feeling so much despair and thinking of taking your own life because it takes them to that point of beginning to examine what it is that could prevent them from doing it, and a very therapeutic question to ask, and also a really good question for assessment. So what if you have a, let's think of an example, a patient who has postpartum depression. She has a young baby that's about six weeks old, and is thinking of suicide, and you ask her about this reasons to live, and she says, well, not really. My baby would be much better off with someone else beside me, because I know I'm gonna destroy this baby's life. And you go on from there, and you're finding this really absolute view of the value of her dying as opposed to living, and can't really identify anything, even though you're hopefully very creative in asking questions and stick with her on it. So that helps you with the assessment of, gee, that patient probably needs to be in a hospital, because she's really at high risk. On the other hand, you ask somebody about reasons to live, and they say, well, you know, my mother. I mean, how could I ever do that to her? And then, as Donna suggested, you ask for more depth. You put some flesh on the bone, if you will, and you say, well, I can see that your mother means a whole lot to you, right? Tell me about, what's your relationship with your mother been like? What are the important things? And then that adds to it, so it builds the case, if you will, and it's cutting through that really constricted, very negativistic view of depression, where the patient hasn't really been able to see that, and has sort of gotten himself to the point where he thinks that, well, maybe it would be better off, others would be better off with me dead, which is a fallacy, but that's where the patient's been. So your goal is to get them to some other place. So asking really great Socratic questions is the heart of all this, and not giving up and showing you're really interested, and then giving you a full explanation of the reasons to live. So the more this can be connected emotionally, the better. One of the myths about CBT that I hear a lot is it's sort of this mechanistic, cookbook-y kind of thing, and I just see the opposite. I remember Aaron Beck once saying that emotion was the royal road to cognition. Just like, I think Freud said, what dreams are the royal road to the unconscious? Wasn't that it? So having something that's really emotionally relevant is so important in learning, and so we want to try to make these connections in our questions about reasons to live. And if you're not getting it, then you need to step back and say, well, why am I not getting any of these important, am I almost bringing tears to people's eyes, or deep feelings, and that's really good if you can do that. So here's a safety plan, if you haven't seen one. I think they should be on every inpatient unit and every therapist's office, and readily available, and they're pretty straightforward, and you start just step by step, and we're gonna see Greg Brown do one of these in just a few moments. First thing is to ask are the warning signs, what would tell you that you're beginning to have more despair or you're at risk, that you're going downhill, you're moving toward this position where you think that you'd be better off dead than alive. So if you can identify those warning signs, then that's an indication that you should use this plan. So what are some of the internal coping strategies, the things I can do to take my mind off my problems without contacting another person? So you've all been out there listening nicely and paying attention, but maybe we could begin to make this a little more interactive. So I wonder if anyone would maybe think of some things that you might say or one of your patients might say if you asked, well, what things could you do just by yourself that would help you distract you or help you manage this level of despair? Anyone like to make a suggestion? If you can, talk into the microphone or speak really loudly, because I think this is being web-streamed. YouTube puppy videos or animal videos? Oh, there we go, YouTube animal videos, right. Yeah, sure, I bet you've seen some of those, haven't you? They can be really heartwarming. I just tried to put one yesterday on Instagram because I was out at the Japanese tea garden and I saw this beautiful blue heron in the pond there and a big goldfish came up right behind it and it scared the blue heron and it began to move away from the goldfish. I don't think it's had many hits yet. Hasn't gone viral, but that's the kind of thing that, yeah, it does sort of take your mind off your troubles and you laugh a little bit and it warms your heart some. Yeah, great idea. So that's just an example how you never know what you're gonna get if you ask a patient. It's best not to have a closed mind yourself about the things they should do in order to be able to take a little of the stress off. How about people in social settings that provide distraction? We're gonna give you some examples of these in a few moments. You wanna have people that you can actually reach out to and ask for help and sometimes folks will have trouble identifying somebody that could actually ask for it. They'd feel embarrassed or they wouldn't wanna reveal the degree of distress they're having and so then you have to work through that obstacle and find someone that, there's more than one hopefully, that they can ask for help. Professionals, by the way, you can see this plan's a little dated because it has the old Suicide Prevention Lifeline phone so we put 988 on this now and scratch this off and put 988 and then making the environment safe. This is a really key part of asking for things that could be used and figuring out solutions for this. Sometimes you have to be really creative in doing this. It's tough in Kentucky where I live because there are a lot of guns, a lot of hunters, and like Donna does, I assume that they have guns and I have to think about what can be done to make the environment safe. Here's a place where sometimes having a family member involved in a safety plan can be very useful, particularly if you're not quite sure if the patient's gonna do this or not, to have a partner that you call up on the phone and work together as a team on what's gonna be done to manage this lethal means. And then finally, we have this reasons for living, the things that are most important to me and worth living for. So I think we have an example now. Here's Luke and Luke had his warning signs of staying up past midnight and brooding, thinking that I'm bound to lose everything and feeling disconnected from my family. So these would be all signs of deepening pessimism, negativism, depression, and suicide risk. And he had some internal coping strategies. Again, I wouldn't have thought about this when he said go fishing, even if it's cold outside, even in the middle of the winter, just to go out fishing for him was very important. He was a fellow that liked to work around the house and do craft projects, had a workshop and so forth, and he would watch this TV program called This Old House, work on his house projects. He identified some people in social settings, his brother, he put the phone number down, his friend, Sid, attend church. For him, that was very useful. And then go to a store that his friend owned. People who could ask for help, he put the same two down, Andy and Sid, and then his pastor would be another one. And then we had the professionals and agencies. He was gonna get his brother, Andy, to lock his guns in his cabinet. And here were his reasons to live. There were a lot of them. Often, they're relationships. His faith. He wanted to be alive to see his grandchildren. And he wanted to travel to Ireland to see places where my ancestors lived. And then he wanted to build a new house someday. So these all sounded really great to me as I was hearing them. This is an actual case that I treated. So how about if you're having trouble with these anti-suicide plans or these safety plans? Here are some problems. So difficulty generating reasons to live. Ask more questions, Socratic questions. And sometimes you have to suggest a bit and see if you get anything. Like, well, what about your family? How'd they react? How about spiritual beliefs? Things you still wanna do? How would you have answered this question before you were depressed? Or as we always do in CBT, try to get a different perspective. What would a good friend say? Someone who really cared about you? A coach or whatever? And see what comes up with those kinds of questions. How about difficulties finding behaviors that would reduce emotional pain? Sometimes with depression, you have to be more active than with other cases, particularly if they're deeply depressed and the therapist may need to make some ideas or come up with some suggestions. Ambivalence. Get the family or friends involved. You might need to admit. And we talked about high stress expected and doing a relapse prevention task. And so now we're ready to take a look at one of these actually in action. I think Donna, you're going to pull this up, aren't you? By the way, these videos are all simulations. This is not an actual patient, but I think that they do capture a lot of what actually happens in sessions. This is a video from the book Learning Cognitive Behavior Therapy, an illustrated guide. So thank you, David, for telling me your story. As you notice, that crisis got more intense and then it came back down. And one of the things I like to do is identify some of the warning signs or triggers of that crisis. And so I want to record this on your safety plan so that you know when to use the safety plan. So what were some of the warning signs that you had? I guess, like I said, when I heard about the test score and not being able to make the grade, I just felt like a complete failure, you know? And it was just so overwhelming because I put out my best. And the fact that I didn't get the results I was looking for, it's like, what good am I, you know? And the first thing I thought was my parents are going to be so disappointed. Like, I can't tell them. So I was feeling overwhelmed and just anxious about that. And I was just so ashamed that this was the way things turned out. Yeah, that's a good summary. So let's list down specifically what they were. Sure. What do I put on the first line here? I guess when I start to feel overwhelmed or anxious. So overwhelmed, anxious. Or ashamed. Ashamed. Yeah. Great. So you had those feelings. What else? Not being able to tell my parents. I'm usually, like, very open and can talk to them about anything. But I feel like whenever I feel like I can't, when I need to shut down and I feel like I can't share those things with them, I think. So I can't tell my parents? Yeah. And what else? I'm just overall feeling like a failure. Feeling like a failure. Okay. So whenever you have any of these warning signs, you'll know to look at your safety plan. It's a cue to you to use it. So the first thing I want to talk about is when you go to that dark place, you're feeling overwhelmed, anxious, ashamed, having these other thoughts, and maybe feeling like giving up. That's when you use some strategies to help you get through the crisis or keep it from escalating. So what I'd like you to do is think about some things, see if we can brainstorm some ways that you can identify some strategies that's going to take your mind off your problems, kind of get away from that crisis for even a little while. What have you done in the past that's helped you deal with a crisis like this? Well, I guess in high school whenever I was feeling kind of down and dealing with this kind of stuff, I used to sing in a choir. Okay. So I'd like to just go off and sing by myself. What do you like to sing? Top 40 stuff, classic rock. Okay. So you're going to say singing top 40? Sure. Sounds good. So what other strategies could you use to take your mind off your problems? Something that I think I've started since coming to college, I've started cooking more by myself. And I like making some of the foods that remind me of home. A lot of stir fry is rice stuff. So cooking stir fry? Yeah. Okay. Sounds like a good strategy. And you have a kitchen that you can cook in? Yeah. Okay. So what other strategies could you use to distract yourself from the crisis, do you think? This is sort of new. I discovered it freshman year in a class. But there's a pottery studio just down the street from my apartment that I can go down and sort of throw pots for hours. It feels good making something. And is that something that you could do at any point or is available? That sounds very good. So let's put down pottery. Now you have singing, cooking, and pottery. If none of those strategies are helpful for you getting outside yourself and feeling better, then go to the next step, which is to socialize with people or go to places where there are people who are actually very good distractors. So is there somebody in your life that you can go to who's available that you like to hang out with? Sure. Yeah. Charlie, my roommate, he's a good guy. Okay. Let's put down Charlie. And I guess he lives with you so you know how to get in touch with him. And you have his phone number. So the next step on your safety plan is learning to make the environment safe. And I have to ask you this question, and I ask this of everybody I do safety plans with. Do you have access to a firearm? No. No? Okay. That's good to hear. I know you've taken medicine in the past and had an overdose several years ago. And I don't want anything like that to happen again. So I want to make sure the medication you're taking is secure or that it's safe for you. What do you think we can do about that? I guess I would just maybe be helpful if there was somebody that kind of knew how much I was taking and made sure I was taking exactly what was prescribed. Okay. That sounds good. Somebody to dispense the medication. Yeah. Who do you think could do that? I guess I could ask my roommate, Charlie. Okay. He's a good guy. Does he know you're taking medication? Yeah. Yeah? So I'll write down, give the medication to Charlie. So the next step on the safety plan is coming up with reasons for living. This is important so that it gives you a sense of hope and meaning in your life and something to go to when you're feeling in crisis. So can we come up with six reasons for living? My family, I think. Okay. Anybody in particular? I've got a little sister. I don't know. I think I'm like the world to her. Okay. don't want to lose that okay so your sister anybody or anything else that gives you meaning in your life um i have a best friend back home okay you know we're kind of miles apart right now but um you know anytime we college so we pick up like we you know just where we left off um yeah her name's vanessa vanessa okay and how you will you remember both your sister and vanessa how would you uh how would you remember them in terms of reminding you of the reason for living um i just i would you know think back to all of the times that you know um even before like school and all this mess that like you know i'm not like the perfect person but they don't care you know we hang out and enjoy each other's company so just recall a memory maybe okay so david what other reasons do you have for living there's a lot of things i haven't gotten to do yet um there i have some family in china that i haven't seen and met before and i'm really looking forward to um to going out there at some point taking a trip out there so taking a trip to china yeah that sounds like fun yeah other reasons for living i find i find a lot of meaning and joy out of just singing in general okay and yeah i wouldn't want to give that up i'll put singing and then i'll put joy There we go, perfect, we're back. So just to wrap up, we have a couple of other strategies that might be useful, behavioral and cognitive ones. One of the things that can be helpful when a person has this kind of thinking, if they've begun to access some positive side of things, is to have them journal, particularly looking at things that were positive or meaningful that happened during the day, ending with something that they're thankful about. Getting people involved in activity, this is a very important time to use behavioral activation, particularly as it relates to small assignments, to getting connected to other people. And the kinds of things that help people to soothe themselves and regulate their emotion. If you don't know the DBT skills training book, they have fabulous ways of teaching people how to do this. And I would also say that frequently people think this isn't something that normal people need to do, even though normal people do it all the time. And so we have to watch out for those self-punitive cognitions. One thing in the early going is that it's very helpful to play for time. Actually talk about the advantages and the disadvantages of living and dying. Get this to be really real and not abstract. And how about the advantages and the disadvantages now versus a year from now versus five years from now versus ten years from now. Did you ever think that your life could get better and you could be dead for no reason? The idea of looking at the long view. And for other people in the person's life. Adolescence, I find it's fabulous to do a timeline of all the things they might miss. You know, prom, graduation, going to college, whatever it is. You know, all the way out. And people will often say when you do these, well, you know, you don't know that those things are going to happen for me. And I'll often say, well, I know one way they won't. And in addition, if you don't want to be so glib and smart-alecky, you can say, if you know this, did something ever happen to you that you didn't expect that was good? How do you know that that wouldn't happen again? You can always kill yourself. That's another thing that I think is important. The idea is, would it be possible to give us six months? Because as long as this is all we can talk about, this is all we can talk about. You know, I don't work very well with dead people. And so it's a really good thing to figure out, can we take this off the table and work on the problems in your life? And being able to navigate that delay can be very useful. There are particular beliefs, I think, that you have to watch out for. Folks who think death is a solution, you know, most people in the United States believe that when you're dead, you're going to feel better. Even though we might not know that for sure. And there may be other ways to solve this problem. Those folks who say, they're going to be better off without me, again, just alluded to that as something to watch out about. I also think it's important to watch out about it in the other direction. Men who die by suicide often take their families with them. I don't ever ask about suicide without asking about homicide, particularly in men. Because it's frequently the case that not only would they be better off without me, maybe we'll all die because the life is so terrible. A person who believes they deserve to die, I think it's handleable in two ways. I have a really close friend, Jess knows him as well. His name is Eris Maldalavira. He's Brazilian. And he has a particular form of CBT that he uses a courtroom setting and puts your beliefs on trial. And so I've taken that here. And when someone says I deserve to die, I'll say, did whatever you do, was it so bad that if you went to court, a jury could give you the death penalty? There has been an occasion or two where people have said yes. And in that circumstance, I reach back into my past and say penance is a really good idea. So how does the world get better if you kill yourself? You're not making up for this thing that you did. If you really want to do something about this bad thing that you did, we have to think of a way for you to make the world a better place. What can we do to make that happen? A person who says I could decrease my pain by dying, I have to figure out what is it that hurts so much and how can we help you with that. The last two are either teenagers or people with personality issues. I'll get back at them by killing myself or I'll know that they'll be able to let me know they love me if I die. The way I talk about it there is usually can we find some way to get you what you want that's less expensive. Dying is really expensive. We in CBT use coping cards, written reminders of the things we learn in therapy, in the phone these days. Sometimes it used to be on 3x5 cards. I have the world's largest collection of 3x5 cards now because people put it on their phone. Anyway, what we do is put what happened in therapy on a card. If there's a particularly risky belief the person has, we might put the belief on the card and then the things we found out in therapy that they need to remember. This happened to be a person that I worked with who had a lot of shame based ideas about suicide. When the boss humiliated her, she felt like she should kill herself. These are the things we came up with in therapy and what she could do. This is a coping card about pain and the kinds of things that you could have to remember if you had so much pain. What would you tell yourself that you learned in therapy? This isn't a script that I wrote out. This is something that we came up with together that the person could remind themselves later. It jump starts adaptive thinking. The reason it has to be written down is that people do not remember what happens in your office. You've got to have something that they can use in an emergency until it becomes more a habit of their mind. We've left about 20 minutes or so for discussion, for questions, for patient examples that you would want the wisdom of this group. Please let us know what's on your mind. We have microphones in the center for people who have questions or thoughts that they'd like to talk about. I'm an adolescent psychiatrist. This is a quick, funny story. There's a young man in the emergency room. He expressed suicidal ideation. He had not even been depressed. I asked him why he wanted to die. He said, because my girlfriend's parents won't let me see her anymore. What's there left to live for? I said, did you think you were going to marry her? Of course. She was my girlfriend. You can meet someone new. He said, I could? Nobody told me that. He says, I don't want to kill myself. I said, I'm going to go meet someone new. I do what you do. One thing that comes up very often is kids cannot imagine that their parents could understand. They don't want to get their parents worried because if they know that I feel this way, it'll make their life even worse. I can see what they're going through. I do something where we pretend I'm your mother and tell me how you're feeling and bring your mother in and tell her. The one problem is, there are some parents who are really hostile, who really do say, oh, you're just trying to get attention here. I just have no idea what to do once we're there. That's a really good question and a really wonderful story. I will say it's not just kids. 60% of people who die by suicide have told a family member they were going to do it. 50% have told another family member. It's a very common phenomenon where people don't want to believe it. They don't want to think about it. They think the person is just being dramatic. He's always saying that, those sort of things. I'm wondering how often you have the chance to speak with the family in private? I think that the child, I want to respect the child and not tell the parent something the child won't be a part of. I think all of those things. One thing that occurs to me, and I'm going to ask Jess for his wisdom on this and other people around as well, is that I might speak to the anxiety that the parents must be feeling when somebody says something like that. On one level, I think this is dismissing this kid out of hand. On another level, it must be really difficult to hear this and we've got to come up with a plan that keeps your child safe and kind of being matter of fact about it in that particular way. But, yes, I think that it's a pretty tough situation with adolescents that way. Do you have some thoughts about it? Well, again, a tough one. No, I don't work with adolescents myself, but I have seen at least one suicide, probably two in my practice where family members, I think, played a role and I wouldn't say enabled it, but certainly played into it. It makes me, if I can, try to bring the whole family together, if that's possible, I think it's going to be very useful. Sometimes the patient doesn't want to do that, but if that patient will agree to it, then it's probably a good thing to do. And if somebody in the audience has an idea about that? Could you please come to the microphone? This is being web streamed, so we have to capture all this. Thank you. And then everybody could hear, too. I was just going to add, it could be helpful to tell parents that they could like, if they're kind of invalidating the suicide, that the kids will turn up the volume and the actions and things like that might end up being more extreme. And so if they take it seriously, validate it now, they might be able to prevent it, but kids will kind of go through more emotional reactions or gestures if they're not being heard. So sometimes that works. Okay. Thanks so much. I'm a child adolescent psychiatrist, and I first want to make a comment about the previous question is that, well, I don't think parents are immune from their own issues, including aggression, anger, and the shame and everything that they're facing towards a child. I think in those cases, I would really think about at times exploring those in the dynamic of family, and if it needs, parents may need actually individual therapy or family therapy by themselves. Rarely ever I have come across that the child has to be removed from the family because the parent's wish is death of a child. And if that's the case, really that kid needs to be removed, including, for example, I work a lot with transgender patients. If the parent's wish is the death of a child, and if it can be explored, maybe it's better for that kid to be removed from family. It happens very rarely. Like parents often love their kids and they can get over that. Thanks. Actually, Mike, I have a question as well. My question is, well, safety planning is amazing, and the CBT today really helped to review the whole thing that we're all doing. Thank you very much for putting it together and presenting it. The complex situations that I sometimes face is when it creates a dichotomy between us and the patient, and then we become the one who is defending life, and the patient becomes the person who is defending the death. So sort of like in many of these toolboxes, especially I've seen in my staff when they're doing it, when they engage in sort of in a way that they become the defender of, okay, where is the hope? Where is everything? And this dichotomy keeps getting bigger. And I found it sort of like sometimes I'm a dynamic person, intervention from that angle, and I'm also like, you know, that's basically the main one, that how to break that one and help the patient to exit it from the CBT point of view. My very favorite way of doing that is the person who says, well, what's the use of living? And I'll say, that's a great question. Can you let me know? Do you switch? You switch the seats. Exactly. Thank you. Well, thank you for your observation. I would say this goes back to the heart of CBT, of hoping and trying your very best to be very collaborative from the get-go. And when you spot something like that beginning to brew, you're stepping back and thinking about what can I do to interrupt this spin toward me trying to argue with the patient about a problem that I want them to solve and they don't want to solve, at least in the way I want them to solve it. Same thing could be true. We're doing a lot of work now with CBT with psychosis, and you certainly don't want to get in the position of arguing that this is the illusion, you need to see this, that you try to get in and help have the patient believe that they're understood and that you're with them and you're collaborating with them. And sometimes that's tough to do, as you pointed out. It's always our goal. And the empathy, I guess, is very important. Yeah, very much so. For sure. Yes. Thank you. Hi. Kurt West. I'm an adult psychiatrist. I want to hear your thoughts as you were talking about making the environment safer and talking about means restriction, because I think, especially when it comes to firearms, we tend to think of that in a binary sense of guns present, guns absent. I'd just like to hear your thoughts about pushing patients towards safer storage options, all sorts of things that put time and space between that impulsive thought and the impulsive act. Yeah, great. Glad you brought that up. And I'm sure that you've thought about that. And maybe you could give us some suggestions of things that you do in that arena. So I actually have a podcast on that. But no, actually, what I did want to say is that, yeah, it's one thing that many psychiatrists, we don't tend to know about what safe storage of firearms is and even how to counsel our patients on that. So there are wonderful websites that help you with that. There's a website, I believe it's New Jersey has its bullet points, which talks about how to talk patients about making safer choices. But the other part is to really, I've always advocated for using motivational interviewing principles, starting out by getting the standpoint of the patient, why have they made this choice that we perceive as unsafe? And helping them, you know, again, nudge them towards those safer options, if not getting those firearms out of the house, because obviously, that is the gold standard, and especially if we're dealing with this specific population that's already identified themselves as high risk. Yeah. Thank you very much. I think that's very well put. I'm one of a psychiatrist that grew up as a hunter with my dad and my grandfather. So we had guns around the house a lot and still do have some antiques, so I know a bit about that. But I think there might be a reaction that, gee, you know, no guns at all, and no way that you can have them in your world and remain safe. So thanks for your comment. Thank you. Thank you for your presentation. In the patients that I've treated who've taken their own lives, I've been impressed by shame and that emotion, being involved in their suicide. What are your thoughts on how you assess for that emotion? In my own practice, it's hard for me to figure out how to do that, and in some of the standard assessments, I don't see that concept of shame really being highlighted. Well, so that's interesting. From the standpoint of the question, I'm trying to think about particular things that I do around that. It is the case that people who are shamed, who are prominent, have about a 25% risk of dying in the first year of that by suicide. So it's a very common problem. So one of the things you obviously would look at would be life trajectory in that story. But generally, the way I would assess it would be looking at the chain of events that goes from the thoughts the person was having and the emotion that they were having that led to the thought, I need to die, right? So I'd be looking there for thoughts like, I can't show my face anymore, no one should know how bad a person I am, or brooding over events that they were regretful and ashamed of. So I'd be looking at that particular chain. Most of the time, what we are working with in treatment has to do with the minute-to-minute thoughts and beliefs and emotions that go on just before the person makes this decision. And so I would be looking for that as a thematic piece of things. And it's certainly very common in borderline patients. That's an emotion to which many people are less tolerant, and we have to work with getting them to increase their tolerance for that. I think the CBT method does work with people that are suffering from shame. I'm thinking about a case, I've sort of obscured some of the details, but a person who embezzled from a family business and was caught and thought that the solution was suicide and needed to work through that. And part of it was understanding from the therapist and empathy and trying to show that we would work together on trying to figure out a solution other than this one that would make the problem worse for all that had been hurt already. And then problem-solving, really, about what he could begin to do that could take steps that would move it in a more positive direction. And indeed, he was able to do that, so it was a good outcome. That's just one case. I know perhaps you have some thoughts on it, because I know you brought up the question. Could you share some things with the group? I posed this question to a colleague who made the following distinction, which was very helpful to me, the distinction between guilt and shame. And a colleague said, guilt is an emotion when you've done something wrong, but there's the possibility of repair, and the emotion of shame is you've done something and you see that there's no possibility. So you have to hide what you've done, because there's no possibility of repair. Well, yeah, good point. I'm not sure I completely agree with that, but... Well, it was a useful construct in terms of trying to connect with the patient around feeling guilty. Yeah, yeah. The idea that you couldn't repair it or you couldn't do anything with it would be... Would sort of go against the grain if you're a cognitive behavior therapist. You're always thinking of, you know, there's got to be a way to manage this, no matter how desperate the situation. Thank you. We'll take the front person first. We've been alternating. I'm a psychiatry resident in the Netherlands, and I work in a crisis team at the moment, so there are a lot of suicidal patients there. And the toughest group for me is the people with autism, because they have the rigid thoughts towards suicide, and they kind of also isolate themselves. The last case was a 21-year-old male. He was kind of abused by his mother, then went to live with his father. It was also not a good situation for him. No connection to anyone, didn't feel any connection to his family, was struggling at the school he was at. So often his thoughts went to suicidal thoughts directly, and the isolation, the tough way of living with autism, and everything being difficult for him, was quite a difficult case for me to deal with. So I was thinking, do you have any experience with suicidal thoughts with people with autism, and how would you suggest to deal with those cases? I couldn't hear that very well. It's how to deal with a patient with autism. No social interaction, and parents are not in the picture. Can you answer that? What? Can you answer that? Can I answer that? Sorry about that. We're still friends. I was complaining that I couldn't hear it very well, so I was passing the question over to... Not just the question, but anyway. So here's what I would do. I do not have any experience in this area, but what I would do would be to look at the literature for, are there things written about this? Are there experts in this field? In the UK, there's been a lot more done with CBT with autism. I know that, and I might look to see whether or not there would be avenues and people that have worked with this. That's one thing I would do for sure. But the other thing I would think about is, how can I build this person's network? Is there an advocacy group? Is there a place where he could live in a group setting where he would have more people in his corner? When the world looks this narrow, what I'm looking for are teachers, pastors, old friends, neighbors, relatives, maybe a cousin or an aunt who was somebody who really took an interest in this person, to think about how you can expand that person's world. But I don't have as much information as I would like about this. That's a good suggestion. He did come with a teacher who took an interest in him, and they were looking to put him in a different living situation. And then what we want to do is to think about that slice of time until we can get you there. What are the things that are going to get you through? We don't have to think about this forever. We need to think about this for the next week or the next month and really expand that time frame. Thank you. I think we only have time for maybe one. One more. Sorry. I've done a lot of safety planning with different people, and I'll occasionally run into someone who gets to the coping distraction section, and they either have shame about their coping mechanism, or it's something that's potentially harmful. I'm thinking small version, and it's usually the only thing that helps. The only thing that helps is smoking pot. The only thing that helps with this is drinking. The only thing that helps with this is cutting myself. So I'm wondering, in your experience, what do you do with those kind of responses? What would you suggest? Thank you. Well, thanks for bringing that up, because you certainly can get that, that they suggest things that you think are not a very good idea at all. So I think that the therapist does have a responsibility, then, to bring that up, to question it. And it sounds like you do, too. From what I can see, you're shaking your head that you would probably not just let that go and try to see if you come up with some healthier things that might be helpful to the patient. Do you have some suggestions of things that you would do in a case like that? Yeah. I mean, it kind of depends on what it is. So if it's something like smoking pot, does that change your suicidality? Has that in the past? Sometimes I feel like that, maybe it's not where we want to be, but that's where we are right now. What are some other things that may be potentially helpful? If people have nothing, I'll be like, okay, what else have you tried that hasn't been helpful for you in the past? Kind of exploring that, because that can help me see some of the gaps that people might have. Sometimes the pros and cons. If I go, for example, with drinking, how does that tend to go with suicidality? Frequently people will be like, oh, yeah, one of my attempts was when I was drinking. So we'll explore that. Yeah, it's really tempting here to say, well, you can't drink and you can't smoke pot and you can't do all these things. It's not going to work. You're going to get a lot worse. But that's trouble if you start going down that path, if you're trying to be collaborative. So you have to figure out another way. How has it worked? Someone mentioned motivational interviewing over here. That's always a good idea to bring that up, too. Yeah. What are some things we could put before those things? Did you want to try any of these coping things before you get to the cutting? Thanks so much. I think you think we have to wrap up. I think we need to exit the room. Exactly. Thank you all so much for being here.

Cognitive Behavioral Therapy

CBT

suicide risk

mental health

safety planning

gun ownership

lethal means

hope box

suicidal ideation

prevention

coping strategies

empathetic communication

clinical practice