Advancing treatment. Transforming lives. Mindfulness, Acceptance, and Compassion

Advancing treatment. Transforming lives. Mindfulness, Acceptance, and Compassion

Advancing treatment. Transforming lives. Mindfulness, Acceptance, and Compassion in Service of Suicide Prevention Thomas E. Ellis, PsyD, ABPP The Menninger Clinic/Baylor College of Medicine Houston, Texas Brazoria County Suicide Prevention Symposium November 6, 2015 1 Advancing treatment. Transforming lives. Disclosures Senior consultant, CAMS-care, LLC Advancing treatment. Transforming lives.

Agenda Discuss the emotional impact of suicide risk on patients, providers, and loved ones. Describe the psychological process of reactance, which sometimes undermines efforts to help. Review diagnostic risk factors for suicide and recent developments in understanding and helping suicidal people. Outline the place of acceptance in addressing suicide risk. Discuss practical implications of these understandings for helpers and loved ones. 3 Advancing treatment. Transforming lives. Be careful what you ask for 4

Advancing treatment. Transforming lives. Feelings about Suicide Suicide is an emotional subject, to patient, provider, and family alike. Some commonly heard comments Anxiety/avoidance Lets talk about something else. Hopelessness If a persons really intent on killing himself, theres nothing you can to do stop him. Disdain It wasnt serious just a manipulative gesture. Contempt If I were him, Id kill myself, too! Hostility Maybe hell get it right the next time. 5 Advancing treatment. Transforming lives. 6 Advancing treatment. Transforming lives.

Strong emotions reflexively lead one toward strong responses, such as: Avoidance Judgment Efforts to persuade Demands Efforts to control Coercion Invalidating statements, such as 7 Advancing treatment. Transforming lives. What Does Invalidation Sound Like? Some Examples

But you have so much to be thankful for! You know, suicide is a permanent solution to a temporary problem. Youre blowing things out of proportion! Isnt that against your religion? But think about what it would do to your family! If were going to work together, you must take suicide off the table. Try using some of your skills. Just try thinking more positively! 8 Advancing treatment. Transforming lives.

Although well-intentioned, results often are the opposite of what we want. Common reactions include anger, rigidity, uncooperativeness, greater resistance How are we to make sense of this? Enter: Reactance 9 Advancing treatment. Transforming lives. What is reactance and what do butter, bacon, and suicide have in common? 10 Advancing treatment. Transforming lives.

11 Advancing treatment. Transforming lives. Reactance Theory Generally speaking, people fiercely defend their freedom and autonomy. This seems to be human nature. Psychological reactance is a negative emotional response that occurs when a person feels that someone or something is taking away his or her choices. This emotional state often leads to behaviors intended to restore autonomy. Examples Prohibition Romeo and Juliet Cigarette smoking Gun control Unhealthy behaviors (e.g., Heart Attack Caf) 12

Advancing treatment. Transforming lives. Reactance Theory Reactance can cause one to actually adopt or strengthen an opposing position, and also increases resistance to persuasion. Reactance is increased when language is dogmatic or controlling (must cant youd better or else). During the reactance experience one tends to have angry or hostile feelings, often aimed more at the source of the message than at the message itself. Some people are more subject to reactance than others, including those who are highly independent and who struggle with mistrust. Defusing reactance is a cornerstone of Motivational Interviewing. The emphasis of CAMS on collaboration rather than coercion is intended to create an atmosphere in which the patient can flexibly explore alternatives to suicidal behaviors. 13

Advancing treatment. Transforming lives. Why Suicide?? 14 Advancing treatment. Transforming lives. Suicide: A Multi-factorial Event No apparent psychopathology Psychiatric Illness Substance Use/Abuse Co-morbidity Neurobiology Impulsiveness

Severe Medical Illness Suicidal Behavior SUICIDE Personality Disorder/Traits Life Stressors Family History Access To Weapons Douglas Jacobs, MD Hopelessness 15

Advancing treatment. Transforming lives. How is suicide risk affected by psychiatric illness? Percentage of mental health clients dying by suicide, 18-yr follow-up No psych dx Unipolar dep Bipolar dis. Schizophrenia Substance dis Any psych dx Male

.72 6.67 7.77 6.55 4.71 4.33 Female .26 3.77 4.78

6.55 3.34 2.10 Nordentoft M, Mortensen PB, Pedersen CB. 2011 Absolute risk of suicide after first hospital contact in mental disorder. Arch Gen Psychiatry, 68,1058-64. 16 Advancing treatment. Transforming lives. Psychiatric disorder is not the complete story of suicide. Take depression, for example.. Depression 4-7% of people with depression eventually die by suicide

40-50% of people who die by suicide suffer from depression or bipolar 40-50% of people disorderwho die by suicide suffer from depression Suicide or bipolar disorder 17 Advancing treatment. Transforming lives. Trans-diagnostic Contributors to Suicide

Cognitive rigidity/inflexibility Problem-solving deficits Hopelessness Failed belongingness/burdensomeness Acquired capability Dysfunctional attitudes/irrational beliefs Reasons for living/dying Self-hatred Anxiety, insomnia, nightmares Perfectionism Rumination

Overgeneral autobiographical memory 18 Advancing treatment. Transforming lives. Empirically Supported Interventions for Suicidal Patients Problem-solving Training Dialectical Behavior Therapy (DBT) Rudd and Joiners CBT Becks Cognitive Therapy for Suicidality Mentalization-based Therapy Collaborative Assessment and Management of Suicidality (CAMS) 19 Advancing treatment. Transforming lives.

Collaborative Assessment and Management of Suicidality (CAMS) Priority focus is to address suicidality and underlying factors. This involves: In-depth risk assessment (Suicide Status Form) Concrete steps to ensure safety in the near-term (e.g., a written crisis response plan) Psychotherapeutic intervention to address longterm vulnerability factors (drivers) All of the above is predicated on the establishment of an empathic, collaborative therapeutic alliance. 20 Advancing treatment. Transforming lives. CONVENTIONAL MODEL: Suicide as Symptom DEPRESSION

?? LACK OF SLEEP POOR APPETITE ANHEDONIA ... ? SUICIDALITY ? THERAPIST PATIENT Traditional treatment = main focus on the psychiatric disorder (suicidality as symptom). Use of devices such as the no-suicide contract. 21 Advancing treatment. Transforming lives. COLLABORATIVELY ASSESSING RISK: Targeting Suicide as the Focus of Treatment

Mood SUICIDALITY PAIN STRESS HOPELESSNESS THERAPIST & PATIENT AGITATION SELF-HATE REASONS FOR LIVING VS. REASONS FOR DYING CAMS Treatment = Intensive intervention that is suicide-specific, emphasizing the development of new means of coping and problem-solving, thereby eliminating the need for suicidal coping. 22

Advancing treatment. Transforming lives. CAMS Key Components Assessment via Suicide Status Form (collaborative) a. b. c. d. e. Risk level Identification of drivers Safety planning Problem identification Treatment planning

Reducing suicidal ideation and behavior a. Problem-solving b. Development of alternative coping responses Psychotherapy to address underlying vulnerabilities a. Self-hate b. Relationship issues c. Etc. Jobes, D.A. (2006). Assessing and Managing Suicidality. New York: Guilford. 23 Advancing treatment. Transforming lives. CAMS Research at The Menninger Clinic

24 Advancing treatment. Transforming lives. Treatment Conditions Usual Menninger Care Medication Group therapy Psychosocial groups Nursing care Milieu therapy Family counseling Vocational counseling Individual therapy CAMS Condition

Medication Group therapy Psychosocial groups Nursing care Milieu therapy Family counseling Vocational counseling Individual therapy w/CAMS-M Advancing treatment. Transforming lives. Change in depression by treatment group (PHQ-9)

19.52 19 18.88 17 15 13.73 13 CAMS TAU 11 9 8.83 7 5 Admission

Discharge 26 Advancing treatment. Transforming lives. Change in suicidal ideation by treatment group (Beck Scale for Suicidal Ideation) 15 13 15.06 13.75 11 9 9.35 CAMS

TAU 7 5 4.82 3 1 Admission Discharge 27 Advancing treatment. Transforming lives. Change in hopelessness by treatment group (Beck Hopelessness Scale) 15.15

15 14.42 12.62 13 11 9 7 6.25 CAMS TAU 5 3 1 Admission

Discharge 28 Advancing treatment. Transforming lives. Change in suicidal cognitions by treatment group (Suicide Cognitions Scale) 59.98 60 53.61 55 50.79 50 45 CAMS TAU

40 35 30 Admission 33.27 Discharge 29 Advancing treatment. Transforming lives. Change in experiential avoidance by treatment (Acceptance & Action Questionnaire) 40 38

36.65 36 34.79 34 33.77 32 CAMS TAU 30 28 26 24 24.48 22 20

Admission Discharge 30 Advancing treatment. Transforming lives. Effect Sizes: TAU vs. CAMS 1.8 1.67 1.6 1.4 1.18 1.2 1 1.01 1.03

1.11 1.1 CAMS TAU 0.8 0.59 0.6 0.58 0.4 0.33 0.2

0.2 0 PHQ 9 BSS SCS BHS AAQ 31 Advancing treatment. Transforming lives. For more information about CAMS

32 Advancing treatment. Transforming lives. So, how does all of this relate to acceptance? Lets start with a little context 33 Advancing treatment. Transforming lives. The Evolution of Third-wave Therapies 1st wave: Behavior therapy (e.g., systematic desensitization) 2nd wave: Cognitive-behavior therapy (cognitive restructuring) 3rd wave: Dialectical Behavior Therapy (DBT), Integrative Couple Therapy (ICT), Acceptance and Commitment Therapy (ACT), Mindfulness-Based Cognitive Therapy (MBCT), etc. 34

Advancing treatment. Transforming lives. The Third Wave The change vs. acceptance issue Things that tend not to change Ones past Temperament Loss Chronic pain The paradox of effort to control inner experience Pink elephants Tip-of-tongue phenomenon Sleep Acceptance as an alternative Panic disorder Couples therapy AAQ data (experiential avoidance) Menninger Suicide Resilience group

CAMS 35 Advancing treatment. Transforming lives. Acceptance What it is not: What it is Approval Agreement

Resignation Closing doors Acknowledging reality Meeting a person where he/she is Not judging/condemning A starting point for change Leaving doors open 36 Advancing treatment. Transforming lives. Cultivating Acceptance:

Mindfulness as Method Attending to the present moment Awareness of sensations, thoughts, and emotions Practicing nonjudgmental acceptance (yes, even of suicidal thoughts) Distinguishing between inner experience (thoughts, feelings) and actions To learn more: Luoma & Villatte (2012). Mindfulness in the treatment of suicidal individuals. Cognitive and Behavioral Practice, 19(2), 265-276. 37 Advancing treatment. Transforming lives. Empathy is helpful as well To be in a position to help a suicidal individual, it is important to cultivate understanding of and empathy for the suicidal wish How might we cultivate such empathy?

38 Advancing treatment. Transforming lives. Who said this? I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on the earth. Whether I shall ever be better I cannot tell; I awfully forebode I shall not. To remain as I am is impossible; I must die or be better, it appears to me. -A. Lincoln, 1841 39 Advancing treatment. Transforming lives. Recommended Reading An Unquiet Mind, by Kay Jamison Darkness Visible, by William Styron

The Savage God, by A. Alvarez Holiday of Darkness, by Norman Endler Waking Up, by Terry Wise Struck by Living, by Julie Hersh Cry of Pain, by Mark Williams 40 Advancing treatment. Transforming lives. Cultivating empathy Try this thought experiment: Think of a highly personal fact about yourself, one that you have never disclosed to anyone else. Now imagine being asked to disclose this to someone whom you have only recently met. Further imagine that this person is in a position of considerable power and that you are not at all convinced that he/she is on your side. How would you behave?

What would you most need? 41 Advancing treatment. Transforming lives. Aspects of Intervention with Suicidal Patients Crisis stabilization: Surviving the suicidal episode Containment Means restriction Stabilization of mood and sleep Support Treatment: Addressing vulnerabilities to suicide Hopelessness Coping deficits Self-hatred Relationship issues The importance of staying therapeutic Managing emotions

Providing validating (rather than invalidating) responses 42 Advancing treatment. Transforming lives. Validating Responses: Some Examples You must be really hurting if suicide has started to come to mind. Suicide is a scary topic; OK if we talk about it anyway? Given all youre dealing with, no wonder suicidal thoughts have shown up.

Sounds like its hard for you to imagine things ever getting better. Its normal to want relief from suffering. Can we talk about some ways other than suicide? I understand its hard to take suicide off the table. Maybe we can put some other things on the table. 43 Advancing treatment. Transforming lives. Employing Acceptance in Helping a Suicidal Person

Using relationship to keep the conversation going, buying time Focusing on needs (relief from suffering) Accepting that you cant do it all alone Stance of acceptance Acknowledging its here (suicide risk) Acknowledging (and accepting) your own feelings (e.g., It scares me to hear this) Refraining from common-sense advice (e.g., You must promise you wont kill yourself.) Refraining from the no-suicide contract Noting that thoughts are ok; they dont have to lead to action Concerning reactance: So should I say, Go ahead, kill yourself? Um, no. Mindfulness reminder re: staying in the present (vs. past (rumination) or future (catastrophizing)) Cultivating empathy and compassion concerning suffering

44 Advancing treatment. Transforming lives. 45 Advancing treatment. Transforming lives. Kevin Berthia, eight years later, at the American Foundation for Suicide Preventions annual dinner in New York, where he presented Officer Kevin Briggs with an award for public service. 46 Advancing treatment. Transforming lives. Thanks! Tom Ellis [email protected] 47

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