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Suicide: The Silent Epidemic A Clinical Focus on Students


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Title: Suicide: The Silent Epidemic A Clinical Focus on Students

Suicide The Silent EpidemicA Clinical Focus on
  • Lisa Firestone, PhD
  • The Glendon Association

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Suicide Rates by Age for Youths Aged 10-19 Years
in the United States, 2000-2006 8
Epidemiology of Youth Suicide and Suicidal
Behavior ,Scottye J. Cash, Ph.D. and Jeffrey A.
Bridge, Ph.D. Curr Opin Pediatr. 2009 October
21(5) 613619
Number of Youth Suicides, by Gender 2009
California Number

Female 83
Male 304
Total 387
Definition Number of suicides by youth ages 15 -
24, by gender. Data Source California Department
of Public Health, Center for Health Statistics,
Vital Statistics Section, CD-Rom Public Use Death
Youth Suicide Rate 1995-1997 - 2007-2009 
Definition Number of suicides per 100,000 youth
age 15 - 24. Data Source California Department
of Public Health, Center for Health Statistics,
Vital Statistics Section, CD-Rom Public Use Death
Files. State of California, Department of
Finance, Race/Ethnic Population with Age and Sex
Detail, 1990-1999, 2000-2050, accessed online
at http// (August
2011). Footnote Figures are presented as rates
over three-year periods. LNE (Low Number Event)
refers to data that have been suppressed because
there were fewer than 20 suicides.
Self-Inflicted Injury Hospitalization Rate 2009
Definition Number of non-fatal self-inflicted
injury hospitalizations per 100,000 for
children/youth ages 5 - 20. Data Source State of
California Department of Public Health,
Epidemiology and Prevention for Injury Control
Branch, California Office of Statewide Health
Planning and Development, Patient Discharge Data.
Accessed online athttp//
State of California, Department of Finance,
Race/Ethnic Population with Age and Sex Detail,
1990-1999, 2000-2050. Accessed online
at http// (May 2011). Footnote Inj
ury hospitalizations are measured by the number
of discharges from acute care hospital facilities
for injuries among children and youth. The most
common types of self-inflicted injuries are
related to poisoning, and cutting or piercing.
LNE (Low Number Event) refers to data that have
been suppressed because there were fewer than 20
cases in the numerator.
Number of Youth Suicides, by Race/Ethnicity 2009
California Number

African American/Black 25
Asian/Pacific Islander 36
Caucasian/White 173
Hispanic/Latino 134
Native American/Alaska Native 7
Multiracial 11
Total 387
Data Source State of California Department of
Public Health, Epidemiology and Prevention for
Injury Control Branch, California Office of
Statewide Health Planning and Development,
Patient Discharge Data. Accessed online
athttp// State of
California, Department of Finance, Race/Ethnic
Population with Age and Sex Detail, 1990-1999,
2000-2050. Accessed online at http//
v (May 2011).
Suicide Figures from the Centers for Disease
Control for the year 2009.All rates are per
100,000 population.
Suicide Figures from the Centers for Disease
Control for the year 2009.All rates are per
100,000 population.
Why is this topic important?
  • Suicide is the third leading cause of death for
    youth ages 10-24 nationwide. 
  • In 2009, 6.3 of U.S. 9th-12th-graders reported
    having attempted suicide one or more times in the
    past year.
  • Approximately 149,000 young people ages 10-24 are
    treated for self-inflicted injuries at U.S.
    emergency departments every year.
  • According to data collected by the National
    Center for Injury Prevention and Control,
    poisoning is the most common reason for
    intentional, self-inflicted, non-fatal injury
    hospitalizations for 10- to 24-year-olds.
  • Self-injurious behavior, in general, often is
    stigmatized and hidden from family and friends.

Data Source State of California Department of
Public Health, Epidemiology and Prevention for
Injury Control Branch, California Office of
Statewide Health Planning and Development,
Patient Discharge Data. Accessed online
athttp// State of
California, Department of Finance, Race/Ethnic
Population with Age and Sex Detail, 1990-1999,
2000-2050. Accessed online at http//
v (May 2011).
ED Treatment of Mental Disorders
  • One in ten suicides are by people seen in the
    ED within two months of dying.

Suicide in Adolescents
  • A previous suicide attempt increases suicide risk
    by 38-40 times.
  • Forwood et al. (2007) reported that a suicide
    attempt is likely to be highest among youth
    presenting with a combination of depression and
    externalizing behavior and those with a romantic
    breakup, being assaulted, or being arrested.
  • More than 90 of adult suicide attempters and 80
    of adolescent attempters and completers
    communicate suicidal ideation prior to the
  • Adolescents with prior attempts are 18x more
    likely to make future attempts.
  • Half of the youth who attempt suicide do not
    receive treatment beyond psychotropic medication.

Suicide in College Students
  • Self-reports of suicidal ideation in college
    students have ranged from 32 to 70.
  • It is estimated that there are 1100 suicides on
    college campuses in the US each year
  • Suicide is the second leading cause of death in
    college-age students.
  • One in 12 college students have seriously
    contemplated suicide.

Implications of Epidemiological Data
  • There is a need to intervene early in the
    development trajectory of the depression and
    suicidal behavior.

The Melissa Institute for Violence Prevention
Misconceptions About Suicide
  • Most suicides are caused by one particular
    trigger event.
  • Most suicides occur with little or no warning.
  • It is best to avoid the topic of suicide.
  • People who talk about suicide don't do it.
  • Nonfatal self-destructive acts (suicide attempts)
    are only attention-getting behaviors.
  • A suicidal person clearly wants to die.
  • If a person who has been depressed is suddenly
    feeling better, the danger of suicide is

Our Approach to Suicide
  • Each person is divided
  • One part wants to live and is goal directed and
    life affirming.
  • And one part is self-critical, self-hating and
    at its ultimate end, self-destructive. The nature
    and degree of this division varies for each

Anti-Self - Critical
Real Self - Positive
Our Approach to Suicide
Negative thoughts exist on a continuum, from mild
self-critical thoughts to extreme self-hatred to
thoughts about suicide
You need to have a drink, so you can relax
You dont deserve anything
You should be by yourself
You should just kill yourself
Youre a creep
Our Approach to Suicide
Self-destructive behaviors exist on a continuum
from self-denial to substance abuse to actual
Substance Abuse
Hating Yourself
Risk Taking
Our Approach to Suicide
There is a relationship between these two
continuums. How a person is thinking is
predictive of how he or she is likely to behave.
Definition of the Voice
  • The critical inner voice refers to a
    well-integrated pattern of destructive thoughts
    toward our selves and others. The voices that
    make up this internalized dialogue are at the
    root of much of our maladaptive behavior. This
    internal enemy fosters inwardness, distrust,
    self-criticism, self-denial, addictions and a
    retreat from goal-directed activities.  The
    critical inner voice effects every aspect of our
    lives our self-esteem and confidence, our
    personal and intimate relationships, and our
    performance and accomplishments at school and

Where Do Critical Inner Voices Come From?
How Voices Pass From Generation to Generation
Attachment Theory
  • Sir John Bowlby, Ph.D.
  • Harry Harlow, Ph.D. Rene Spitz, M.D
  • Mary Ainsworth, Ph.D.
  • Mary Main, Ph.D. Erik Hesse, Ph.D.
  • Adult Attachment Interview
  • predicts the babys attachment to
  • the parent with 80 accuracy before
  • the baby is even born

Where do voices come from?
Patterns of Attachment in Children
  • Parental Interactive Pattern
  • Emotionally available, perceptive, responsive
  • Emotionally unavailable, imperceptive,
    unresponsive and rejecting
  • Inconsistently available, perceptive and
    responsive and intrusive
  • Frightening, frightened, disorienting, alarming
  • Category of Attachment
  • Secure
  • Insecure avoidant
  • Insecure- anxious/ambivalent
  • Insecure - disorganized

Attachment Figures
  • Low Risk Non-Clinical Populations
  • Secure 55-65
  • Ambivalent 5-15
  • Avoidant 20-30
  • Disorganized 20-40
  • (Given a Best Fit Alternative)
  • High Risk, Parentally maltreated
  • Disorganized 80

What causes insecure attachment?
  • Unresolved trauma/loss in the life of the
  • statistically predict attachment style far
    more than
  • Maternal Sensitivity
  • Child Temperament
  • Social Status
  • Culture

Implicit Versus Explicit Memory
  • Explicit Memory
  • Implicit Memory

How does disorganized attachment pass from
generation to generation?
  • Implicit memory of terrifying experiences may
  • Impulsive behaviors
  • Distorted perceptions
  • Rigid thoughts and impaired decision making
  • Difficulty tolerating a range of emotions

The Brain in the Palm of Your Hand
Daniel Siegel, M.D. Interpersonal Neurobiology
9 Important Functions of the Pre-Frontal Cortex
  1. Body Regulation
  2. Attunement
  3. Emotional Balance
  4. Response Flexibility
  5. Empathy
  6. Self-Knowing Awareness (Insight)
  7. Fear Modulation
  8. Intuition
  9. Morality

Type D AttachmentDisorganized/Disoriented
  • Predicts later chronic disturbances of
  • affect regulation
  • stress management
  • hostile-aggressive behavior

Infants Response to Trauma
  • Two sequential response patterns
  • hyperarousal
  • dissociation

Poly-Vagal Theory -Stephen Porges, 2007
Neuroception (Vagus Nerve)
Division of the Mind
Parental AmbivalenceParents both love and hate
themselves and extend both reactions to their
productions, i.e., their children.
Parental Nurturance
Parental Rejection, Neglect Hostility
Prenatal Influences
Disease Trauma
Substance Abuse/ Domestic Violence
Baby Genetic Structure Temperament Physicalit
y Sex
Unique make-up of the individual
(genetic predisposition and temperament)
harmonious identification and incorporation of
parents positive attitudes and traits and
parents positive behaviors attunement,
affection, control, nurturance and the effect
of other nurturing experience and education on
the maturing self-system resulting in a sense of
self and a greater degree of differentiation from
parents and early caretakers.
Self-System Parental Nurturance
Personal Attitudes/Goals/Conscience
  • Realistic, Positive Attitudes Toward Self
  • Realistic evaluation of talents, abilities,
    etcwith generally positive/ compassionate
    attitude towards self and others.
  • Behavior
  • Ethical behavior
  • towards self and others

Goal Directed Behavior
Goals Needs, wants, search for meaning in life
Moral Principles
Acting with Integrity

Anti-Self System Unique vulnerability genetic
predisposition and temperament Destructive
parental behavior misattunement, lack of
affection, rejection, neglect, hostility, over
permissiveness Other Factors accidents,
illnesses, traumatic separation, death anxiety
The Fantasy Bond (core defense) is a
self-parenting process made up of two elements
the helpless, needy child, and the
self-punishing, self-nurturing parent. Either
aspect may be extended to relationships. The
degree of defense is proportional to the amount
of damage sustained while growing up.
Anti-Self SystemSelf-Punishing Voice Process
Voice Process 1. Critical thoughts toward
self 2. Micro-suicidal injunctions 3.
Suicidal injunctions suicidal ideation
Behaviors Verbal self-attacks a generally
negative attitude toward self and others
predisposing alienation. Addictive patterns.
Self-punitive thoughts after indulging. Action
s that jeopardize, such as carelessness with
ones body, physical attacks on the self, and
actual suicide
Source Critical parental attitudes, projections,
and unreasonable expectations. Identification
with parents defenses Parents covert and
overt aggression (identification with the
AntiSelf System Self- Soothing Voice Process
Behaviors Self-limiting or self-protective
lifestyles, Inwardness Verbal build up toward
self Alienation from others, destructive
behavior towards others. Addictive patterns.
Thoughts luring the person into indulging.
Aggressive actions, actual violence.
Source Parental over protection, imitation of
parents defenses Parental build up Parental
attitudes, child abuse, experienced
victimization. Imitation of parents
defenses. Parental neglect, parents overt
aggression (identification with the aggressor).
  • Voice Process
  • 1. Self-soothing
  • attitudes
  • 2. Aggrandizing
  • thoughts toward self
  • 3. Suspicious paranoid
  • thoughts toward
  • others.
  • 4. Micro-suicidal
  • injunctions

How does a Suicide Occur?
Underlying Vulnerability e.g. Mood
disorder/Substance abuse/ Aggression/
Anxiety/Family history/Sexual orientation/Abnormal
serotonin metabolism
Stress Event (often caused by underlying
condition) e.g. In trouble with law or school/Loss
Acute Mood Change Anxiety/Dread/Hopelessness/Ange
e.g. Strong taboo/Available support/Slowed down
mental state/Presence of others/Religiosity
e.g. Weak taboo/ Method weapon available/ Recent
example/State of excitation agitation/ Being alone
Continuum of Negative Thought Patterns
Thoughts that lead to low-self-esteem or
inwardness (self-defeating thoughts)
  • Levels of Increasing Suicidal Intention
  • Self-depreciating thoughts of everyday life
  • 2. Thoughts rationalizing self-denial thoughts
    discouraging the person from engaging in
    pleasurable activities
  • 3 Cynical attitudes towards others, leading to
    alienation and distancing

Content of Voice Statements Youre incompetent,
stupid. Youre not very attractive. Youre going
to make a fool of yourself. Youre too young
(old) and inexperienced to apply for this job.
Youre too shy to make any new friends. Why go on
this trip? Itll be such hassle. Youll save
money by staying home. Why go out with her/him?
Shes cold, unreliable shell reject you. She
wouldnt go out with you anyway. You cant trust
Continuum of Negative Thought Patterns
Thoughts that lead to low-self-esteem or
inwardness (self-defeating thoughts)
  • Levels of Increasing Suicidal Intention
  • 4. Thoughts influencing isolation
    rationalizations for time alone, but using time
    to become more negative toward oneself
  • 5. Self-contempt vicious self-abusive thoughts
    and accusations (accompanied by intense angry
  • Content of Voice Statements
  • Just be by yourself. Youre miserable company
    anyway whod want to be with you? Just stay in
    the background, out of view.
  • You idiot! You bitch! You creep! You stupid
    shit! You dont deserve anything youre

Continuum of Negative Thought Patterns
Thoughts that support the cycle of addiction
Levels of Increasing Suicidal Intention 6. Thoug
hts urging use of substances or food followed by
self-criticisms (weakens inhibitions against
self-destructive actions, while increasing guilt
and self-recrimination following acting out).
Content of Voice Statements Its okay to do
drugs, youll be more relaxed. Go ahead and have
a drink, you deserve it. (Later) You weak-willed
jerk! Youre nothing but a drugged-out drunken
Continuum of Negative Thought Patterns
Thoughts that lead to suicide (self-annihilating
Content of Voice Statements See how bad you make
your family (friends) feel. Theyd be better off
without you. Its the only decent thing to do
just stay away and stop bothering them. Whats
the use? Your work doesnt matter any more. Why
bother even trying? Nothing matters anyway. Why
dont you just drive across the center divider?
Just shove your hand under that power saw!
  • Levels of Increasing Suicidal Intention
  • Thoughts contributing to a sense of hopelessness
    urging withdrawal or removal of oneself
    completely from the lives of people closest.
  • 8. Thoughts influencing a person to give up
    priorities and favored activities (points of
  • 9. Injunctions to inflict self-harm at an action
    level intense rage against self.

Continuum of Negative Thought Patterns
Thoughts that lead to suicide (self-annihilating
Levels of Increasing Suicidal Intention 10.
Thoughts planning details of suicide (calm,
rational, often obsessive, indicating complete
loss of feeling for the self). 11. Injunctions
to carry out suicide plans thoughts baiting the
person to commit suicide (extreme thought
Content of Voice Statements You have to get
hold of some pills, then go to a hotel,
etc. Youve thought about this long enough.
Just get it over with. Its the only way out.
Why Use Objective Measures?What Interferes with
Clinical Judgment
  • Anxiety
  • Counter Transference
  • Psych Ache
  • Research Minimizing
  • Diverse Menu of Risk Factors

The Suicidal Child
by Cynthia R. Pfeffer, MDThe Guilford University
  • Spectrum of Suicidal Behavior
  • 1. Nonsuicidal- No evidence of any
    self-destructive or suicidal thoughts or actions.
  • 2. Suicidal Ideation- Thoughts or verbalization
    of suicidal intention.
  • Examples a. I want to kill myself
  • b. Auditory hallucination
    to commit suicide
  • 3. Suicidal Threat- Verbalization of impending
    suicidal action and/ or a precursor action which.
    If fully carried out, could have led to harm.
  • Examples a. I am going to run in front of a
  • b. Child puts a knife under
    his or her pillow
  • c. Child stands near an
    open window and threatens to jump

Thoughts about my life Name______________________
_____ Date________ Sex_____
Race_________________ Age_________ Education___
_____________________________________ Occupation__
Directions Listed below are thoughts that people
sometimes have. Read each sentence carefully and
decide which of these thoughts you had in the
past month. Circle the letter beneath the answer
that best describes your own thoughts. If you
make a mistake or change your mind, make an X
through the incorrect response and then circle
the correct response. DO NOT ERASE. There are no
right or wrong answers so answer each sentence as
openly and honestly as possible. Be sure to
answer each sentence. DO NOT leave any sentence
Had this thought before but not in the last
Couple times a month DDDDDDDDD
About once a month EEEEEEEEEE
I never had this thought GGGGGGG
Couple times a week BBBBBBBBBB
About once a week CCCCCCCCCC
Almost Everyday AAAAAAAAAA
This thought was in my mind
  1. I thought it would be better if I was not
  2. I thought about killing myself.
  3. I thought about how I would kill
  4. I thought about when I would kill
  5. I thought about what to write in a suicide
  6. I thought about telling people I plan to kill
  7. I thought that people would be happier if I was
    not around
  8. I thought about how people would feel if I killed
  9. I wished I were dead..
  10. I thought about how easy it would be to end it

Columbia Suicide Severity Scale ( C-SSS)
  • Suicidal Behavior
  • Suicidal Ideation

Columbia-Suicide Severity Rating Scale (C-SSRS)
  • Suicidal Ideation
  • Ask questions 1 and 2. If both are negative,
    proceed to Suicidal Behavior section. If the
    answer to question 2 is yes, ask questions 3,
    4, and 5. If the answer to question 1 and/or 2 is
    yes, complete Intensity of Ideation section
  • Wish to be Dead
  • 2. Non-specific Active Suicidal Thoughts
  • 3. Active Suicidal Ideation with any Methods (not
    plan) without Intent to Act
  • 4. Active Suicidal Ideation with Some Intent to
    Act, without Specific Plan
  • 5. Active Suicidal Ideation with Specific Plan
    and Intent

Columbia-Suicide Severity Rating Scale (C-SSRS)
  • Intensity of Ideation
  • Frequency
  • Duration
  • Controllability
  • Deterrents
  • Reason for Ideation

Columbia-Suicide Severity Rating Scale (C-SSRS)
  • Suicidal Behavior
  • (Check all that apply, so long as these are
    separate events must ask about all types)
  • Actual Attempt
  • Have you made a suicide attempt?
  • Have you done anything to harm yourself?
  • Have you done anything dangerous where you could
    have died?
  • What did you do?
  • Did you ________ as a way to end your life?
  • Did you want to die (even a little) when you
  • Were you trying to end your life when you
  • Or did you think it was possible you could have
    died from __________?
  • Or did you do it purely for other reasons/without
    ANY intention of killing yourself (like to
    relieve stress, feel better, get sympathy, or get
    something else to happen)? (Self-injurious
    behavior without suicidal intent)
  • If yes, describe
  • Has subject engaged in Non-Suicidal
    Self-Injurious Behavior?

Past X years or Lifetime YES NO
Total of attempts ______ YES
Columbia-Suicide Severity Rating Scale (C-SSRS)
Past X years or Lifetime YES NO Total
of interrupted ______ YES NO Total of
aborted _______ YES NO YES NO
  • Interrupted Attempt
  • Has there been a time when you started to do
    something to end your life but someone or
    something stopped you before you actually did
  • If yes, describe
  • Aborted Attempt
  • Has there been a time when you started to do
    something to try and end your life but you
    stopped yourself before you actually did
  • If yes, describe
  • Preparatory Acts or Behavior
  • Suicidal Behavior
  • Suicidal Behavior was present during the
    assessment period?

BHS Sample Questionnaire
  • 1. I look forward to the future with hope and
    enthusiasm. T F
  • 2. I might as well give up because there is
    nothing I can do
  • about making things better for myself.
  • T F
  • 3. When things are going badly, I am helped by
    knowing that
  • they cannot stay that way forever.
  • T F
  • 4. I cant imagine what my life would be like in
    ten years. T F

Our Measures
  • Based on Separation Theory developed by Robert
    W. Firestone, PhD. and represents a broadly based
    coherent system of concepts and hypothesis that
    integrates psychoanalytic and existential systems
    of thought. The theoretical approach focuses on
    internal negative thought processes. These
    thoughts (i.e. voices) actually direct behavior
    and, thus, are likely to predict how an
    individual will behave.

Firestone Assessment of Self-Destructive Thoughts
Never Rarely Once In A While Frequently Most Of The Time
1. Just stay in the background. 0 1 2 3 4
2. Get them to leave you alone. You dont need them. 0 1 2 3 4
3. Youll save money by staying home. Why do you need to go out anyway? 0 1 2 3 4
4. You better take something so you can relax with those people tonight. 0 1 2 3 4
5. Dont buy that new outfit. Look at all the money you are saving. 0 1 2 3 4
Figure 3. Approximate ROC Curves for the FVSSDB,
SPS, and BHS
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Uses for Our Measures
  • Risk Assessment
  • Treatment Planning
  • Targeting Intervention
  • Outcome Evaluation

Firestone Assessment of Suicide Intent Record Form
  • Name ____________________________________ Sex
    Male Female
  • Age ______ Date / /
    Examiner _____________________________
  • Instructions
  • This form contains a number of statements. I want
    you to read each statement carefully and indicate
    how often you
  • have each thought by filling in the appropriate
    box to the right. For example, consider the
    thought, You are going to
  • make a fool of yourself. Do you experience this
    thought never, rarely, once in a while,
    frequently, or most of the time?
  • Please indicate the frequency with which you
    experience the following thoughts toward
    yourself. If you wish to
  • change your answer, put an X through it and fill
    in your new choice. If you have questions, be
    sure to let me know.
  • Never Rarely Once in Awhile Frequently Most
    of the Time
  • 1. Life would be so much easier if you just
    killed yourself. ? ? ? ?
  • 2. Life would be simple there would be no life
    and you wouldnt
  • have to torture yourself any longer.
  • 3. You coward, just do it already. Kill
  • 4. Its too bad you have to kill yourself to
    show people how
  • much youre hurting.
  • 5. Why dont you end it all? Go ahead! Itll be
    over in a minute.
  • 6. Its such a struggle to simply get through a
  • You can always choose death as a last

Suicide Warning Signs
  • Disturbed sleep patterns
  • Anxiety, agitation
  • Pulling away from friends and family
  • Past attempts
  • Extremely self-hating thoughts
  • Feeling like they dont belong
  • Hopelessness, Feelings of hopelessness and
    worthlessness that often accompany depression
  • Rage, Impulsive aggression (the tendency to react
    to frustration or provocation with hostility or

Suicide Warning Signs
  • Feeling trapped
  • Increased use of alcohol or drugs
  • Feeling that they are a burden to others
  • Loss of interest in favorite activities -nothing
  • Giving up on themselves
  • Risk-taking behavior
  • Suicidal thoughts, plans, actions
  • Sudden mood changes for the better

Suicide Warning Signs, contd
Major Risk Factors for Suicide Among Adolescents
  • A psychiatric disorder, especially major
    depressive disorder, bipolar disorder, conduct
    disorder, and substance (alcohol and drug) use
  • Psychiatric comorbidity, especially the
    combination of mood, disruptive, and substance
    abuse disorders
  • Personality disorders (especially cluster B
    disorders antisocial, borderline, histrionic,
  • Availability of lethal means
  • A family history of depression or suicide
  • Loss of a parent to death or divorce
  • Family discord
  • Physical and/or sexual abuse
  • Lack of a support network, poor relationships
    with parents or peers and feelings of social
  • Dealing with homosexuality in an unsupportive
    family or community or hostile school environment

Data Source State of California Department of
Public Health, Epidemiology and Prevention for
Injury Control Branch, California Office of
Statewide Health Planning and Development,
Patient Discharge Data. Accessed online
athttp// State of
California, Department of Finance, Race/Ethnic
Population with Age and Sex Detail, 1990-1999,
2000-2050. Accessed online at http//
v (May 2011).
Protective Factors
  • Family and community connections/
  • Clinical Care (availability and accessibility)
  • Resilience
  • Coping Skills
  • Frustration tolerance and emotion regulation
  • Cultural and religious beliefs spirituality

Those Who Desire Suicide
Those who desire Suicide
Those Who Are Capable of Suicide
Perceived Burdensomeness
Thwarted Belongingness
Serious Attempt or Death by Suicide
Joiner, Thomas. Why People Die By Suicide. The
Three Components of Completed Suicide. Harvard
University Press, 2005.
Joiner (2005, p. 227) assesses these attributes
by asking such questions as
  • Acquired Ability to Enact Lethal Self-Injury
  • Things that scare most people do not scare me.
  • I can tolerate a lot more pain than most people.
  • I avoid certain situations (e.g., certain
    sports) because of the possibility of injury
    (Reversed scored)
  • b. Burdensomeness
  • The people I care about would be better off if I
    were gone. I have failed the people in my life.
  • c. Belongingness
  • These days I am connected to other people.
  • These days I feel like an outsider in social
    situations (Reversed scored)
  • These days I often interact with people who care
    about me

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Multiple Attempters as a Special High-Risk Group
(in comparison to single attempters/ideators)
  • Distinctive in every way
  • Greater likelihood to have diagnosis,
    co-morbidity, personality disorder
  • Younger at time of first attempt (greater
  • Lower lethality first attempt (raises question
    about intent, function of behavior)
  • More impulsive
  • More likely to be associated with substance abuse
  • Greater symptom severity
  • Anxiety, depression, hopelessness, anger,
    suicidal ideation (frequency, intensity,
    specificity, duration, intent)
  • More frequent histories of trauma, abuse
  • Distinctive characteristics of crises

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Safety Plan, Stanley and Brown, 2008Figure 6.3.
Example of a safety plan developed during the
early phase of treatment. EDemergency department
  • Warning signs (when I am to use the safety plan)
  • wanting to go to sleep and not wake up
  • wanting to hurt myself
  • thinking I cant take it anymore
  • Coping strategies (things I can try to do on my
  • listening to rock music
  • rocking in a chair
  • going for a walk
  • controlled breathing
  • taking a hot or cold shower
  • exercising
  • 3. Contacting other people
  • Calling a friend to distract myself
    ______________________ Phone__________________
  • If distraction does not work, I will tell any of
    the following people that I am in crisis and ask
    for help
  • Calling a family member_______________________Pho
  • Calling or talking to someone else_______________
  • 4. Contacting a health care professional during
    business hours
  • Calling my therapist_____________________Phone__
  • Calling my psychiatrist_______________________Pho

Safety Plan, Stanley and Brown, 2008 - Adolescent
  • Ask How will you know when the safety plane
    should be used?
  • Ask What do you experience when you start to
    think about suicide or feel extremely depressed?
  • List warning signs (thoughts, images, thinking
    processes, mood, an/or behaviors) using
    adolescents own words
  • Ask What sets off the bad thoughts?
    (consider, thoughts, events, emotional states
  • List triggers
  • Ask What can you do on your own, if you become
    suicidal again, to help yourself not to act on
    your thoughts or urges?
  • Ask How likely are you to do this during a time
    of crisis?
  • Ask What might stand in the way of you using
    these strategies?
  • List coping strategies and barriers
  • Ask Who or what social settings can help take
    your mind off your problems at least for a little
  • Ask Who helps you feel better?
  • Ask about potential obstacles
  • Ask about a Safe Place they could go (i.e..
    Coffee Shop)
  • List people (with phone numbers) and places

Safety Plan, Stanley and Brown, 2008 - Adolescent
  • Ask Among your friends and family, who do you
    think you could contact during a crisis? Who is
    supportive of you?
  • Role play and rehearsal can be very useful in
    this step
  • List names and numbers of people who could come
    over and keep an eye on your teenager
  • Ask Who are the mental health professionals
    that you should identify to be on your safety
    plan? and Are there other health care
  • If your teens thoughts of suicide persist please
    contact your local mental health provider
    immediately to have your child assessed for his
    or her level of risk!!
  • List names and numbers of mental health
    professionals, caseworkers, juvenile offers etc.
    that can help your teenager with their suicidal
  • Ask Do you or your family own a gun? Knives?
    or Where are all the pills in your house?
  • Ask What other means of hurting yourself do you
    have access too?
  • Ask How can we go about limiting access to
    these items?
  • Lock up all guns, knives, and pills and begin to
    monitor all other potential weapons
  • All of this information should be written down
    and should be easily accessed by your teenager as
    well as other family members who may be assisting
    in maintaining your teens safety. I suggest
    keeping a copy on the frig, placing one in your
    teenagers room, and keeping one in your wallet
    or purse.

Ways to Increase Social Supports
  • Make a list of possible social supports
  • Utilize family resources
  • Proactively develop healthy new social supports
    (e.g., join social club)
  • Teach the patient how to access and use social
  • Involve family members (significant others) in
    treatment with the patients permission. For
    example, educate the patients parents about the
    nature of depression and comorbid disorders and
    on ways they can provide support.
  • Help significant others understand that it is not
    dangerous to ask the patient how he/she is
  • Encourage the patient to let people know when
    he/she is suicidal.
  • Patient can be asked
  • Who are three people you will call if you are
    feeling like hurting yourself? Which adult or
    helper (counselor, therapist) do you feel
    comfortable calling? What is there name?
  • 1.
  • 2.
  • 3.
  • This activity is designed to challenge the
    patients belief that No one cares and to
    ensure that the patient contacts safe
    supportive people (non-suicidal).

Crisis Response Plan
  • When Im acting on my suicidal thoughts by trying
    to find a gun (or another
  • method to kill myself), I agree to take the
    following steps
  • Step 1. I will try to identify specifically
    whats upsetting me.
  • Step 2. Write out and review more reasonable
    responses to my suicidal thoughts, including
    thoughts about myself, others, and the future.
  • Step 3. Review all the conclusions Ive come to
    about these thoughts in the past in my treatment
    log. For example, that the sexual abuse wasnt
    my fault and I dont have anything to feel
    ashamed of.
  • Step 4. Try and do the things that help me feel
    better for at least 30 minutes (listening to
    music, going to work, calling my best friend)
  • Step 5. Repeat all of the above at least one more
  • Step 6. If the thoughts continue, get specific,
    and I find myself preparing to do something, Ill
    call the emergency call person at (phone number
  • Step 7. If I still feel suicidal and dont feel
    like I can control my behavior, Ill go to the
    emergency room located at XXXXXXX, phone number

10 Most Common Errors in Suicide Prevention
  1. Superficial Reassurance
  2. Avoidance of Strong Feelings
  3. Professionalism
  4. Inadequate Assessment of suicidal intent
  5. Failure to identify the precipitating event
  6. Passivity
  7. Insufficient Directiveness
  8. Advice Giving
  9. Stereotypic Responses
  10. Defensiveness

Practice Recommendations
  1. When imminent risk does not dictate
    hospitalization, the intensity of outpatient
    treatment (i.e., more frequent appointments,
    telephone contacts, concurrent individual and
    group treatment) should vary in accordance with
    risk indicators for those identified as high risk.

Practice Recommendations
  1. If the target goal is a reduction in suicide
    attempts and related behaviors, treatment should
    be conceptualized as long-term and target
    identified skills deficits (e.g., emotion
    regulation, distress tolerance, impulsivity,
    problem-solving, interpersonal assertiveness,
    anger management), in addition to other salent
    treatment issues.

Practice Recommendations
  • If therapy is brief and the target variable are
    suicidal ideation, or related sumptomatology such
    as depression, hopelessness, or loneliness, a
    problem-solving component should be used in some
    form or fashion as a core intervation.

Practice Recommendations
  1. Regardless of therapeutic orientation, an
    explanatory model should be detailed identifying
    treatment targets, both direct (i.e., suicidal
    ideation, attempts, related self-destructive and
    self-multistory behaviors) and indirect
    (depression, hopelessness, anxiety, and anger
    interpersonal relationship dysfunction low
    self-esteem and poor self-image day-to-day
    functioning at work and home).

Practice Recommendations
  1. Use of standardized follow-up and referral
    procedure (e.g., letters or phone calls) is
    recommended for those dropping out of treatment
    prematurely in an effort to enhance compliance
    and reduce risk for subsequent attempts.

Practice Recommendations
  1. Informed consent

Commitment to Treatment Statement in Practice
  • I understand and acknowledge that, to a large
    degree, a successful treatment outcome depends on
    the amount energy and effort I make. If I feel
    like treatment is not working. I agree to
    discuss it with my therapist and attempt to come
    to a common understanding as to what the problems
    are and identify potential solutions. In short, I
    agree to make a commitment to living. This
    agreement will apply for the next three months,
    at which time it will be reviewed and modified.
  • Signed _____________________
  • Date _______________________
  • Witness _____________________

Commitment to Treatment Statement in Practice
  1. Attending sessions (or letting my therapist know
    when I cant make it),
  2. Setting goals,
  3. Voicing my opinions, thoughts, and feelings
    honestly and openly with my therapist (whether
    they are negative or positive, but most
    importantly my negative feelings),
  4. Being actively involved during sessions,
  5. Completing homework assignments,
  6. Taking my medications as prescribed,
  7. Experimenting with new ways of doing things,
  8. And implementing my crisis response plan when
    needed (see attached crisis response plan card
    for details).

(No Transcript)
Suicide Status Form-III (SSF III) Initial Session
  • Patient__________________________
    Clinician______________________ Date___________
  • Section A-Patient
  • Rate and fill out each item according to how you
    feel right now. Then rank items in order of
    importance 1 to 5 (1most important, 5least
  • Rate psychological pain (hurt, anguish, or misery
    in your mind not stress not physical pain)
  • Low Pain 1 2 3 4 5 High Pain
  • What I find most painful is______________________
  • 2. Rate stress(your general feeling of being
    pressured or overwhelmed)
  • Low Stress 1 2 3 4 5 High Stress
  • What I find most stressful is____________________
  • 3. Rate agitation(emotional urgency feeling
    that you need to take action not irritation not
  • Low Agitation 1 2 3 4 5 High
  • I most need to take action when__________________
  • Rate Hopelessness (your expectation that things
    will not get better no matter what you do)
  • Low Hopelessness 1 2 3 4 5 High
  • I am most hopeless about_________________________
  • 5. Rate Self-Hate (your general feeling or
    disliking of yourself having no self-esteem
    having no self-respect)
  • Low Self-Hate 1 2 3 4 5 High
  • What I hate most about myself is_________________
  • 6. Rate overall Risk of Suicide

1.How much is being suicidal related to thoughts
and feelings about yourself? Not at all1 2
3 4 5 Completely2. How much is being
suicidal related to thoughts and feelings about
others? Not at all1 2 3 4 5
  • Reason for living
  • Reason for dying

CAMS patients reached resolution of suicidality
about 4-6 weeks more quickly than treatment as
usual patients.( Jobes et al., 2003, Wong, 2003)
Effective Therapy Approaches for Treating the
Suicidal Person
  • Cognitive Therapy for suicidal people was
    developed by Aaron Beck and Gregory Brown. Unlike
    other CBT treatments, this approach is not time
    limited. The third and last stage is Relapse
    Prevention with a Twist. Clients do not graduate
    from treatment until they demonstrate that they
    are ready to do this on their own.
  • Dialectical Behavior Therapy, developed by Marsha
    M. Linehan, is designed to treat emotion
    regulation difficulties and suicidal behavior.
    One element, the skill-building component of DBT,
    addresses the issues of distress tolerance and
    the development of healthy affect regulation
    strategies, both of which are essential for
    suicidal clients.
  • Mentalizing Treatment, developed by Jon Allen and
    Peter Fonagy, emphasizes emotional regulation and
    expressiveness. The techniques implemented assist
    clients in forming good affect regulation and
    tolerance through the process of developing the
    mentalizing capability to observe and understand
    their mind and the minds of others, accurately
    seeing the mind behind the behavior.
  • Transference Focused Therapy, developed by
    Kernberg, Clarkin, and Yeomans, concentrates on
    the intermediate interaction between the client
    and therapist in session by focusing on the
    therapeutic relationship.
  • Voice Therapy, which was developed by Robert
    Firestone, is a cognitive-affective-behavioral
    therapeutic methodology that brings introjected
    hostile thoughts, with the accompanying negative
    affect, to consciousness, rendering them
    accessible for treatment. This technique
    facilitates the identification of the negative
    cognitions driving the suicidal actions, which in
    turn helps clients to gain a measure of control
    over all aspects of their self-destructive or
    suicidal behavior. This process helps clients
    expand their personal boundaries, develop a sense
    of meaning in life, and reduce the risk of
    self-destructive behavior, including suicide.

Construction of a Hope Kit
  • Another activity that is undertaken in the middle
    phase of therapy is the
  • construction of a hope kit. A hope kit consists
    of a container that holds
  • mementos (photographs, letters, souvenirs) that
    serve as reminders of reasons
  • to live. Patients are instructed to be as
    creative as possible when creating their
  • hope kit, so that the end result is a powerful
    and personal reminder of their
  • connection to live that can be used when feeling
    suicidal. We have found that
  • patients report making their hope kits to be a
    highly rewarding experience that
  • often leads them to discover reasons to live they
    had previously overlooked.
  • Suzanne was rather artistic and reported that she
    enjoyed this task. She found
  • an old shoe box and decorated it using some of
    her favorite pictures. Inside
  • she included pictures of her mother, her friends,
    and her cart. She also
  • included the lyrics of her favorite song, a
    potpourri bag filled with her favorite
  • scent, and a piece of her childhood blanket.
    Suzanne kept the hope box on her
  • dresser, and it frequently reminded her of all
    the good things in her life.
  • Excerpted from Cognitive Therapy, Cognition,
    and Suicidal Behavior by GK Brown, E Jeglic, GR
    Henriques, and AT Beck In T.E. Ellis (Ed.),
    Cognition and Suicide (APA Books, 2006).

Establish therapeutic alliance with the suicidal
patient, Brown and Beck (2008, p. 162)
  • Be attentive, remain calm and provide the
    patient with a private, non-threatening and
    supportive environment to discuss experienced
    difficulties. Do not express anger, exasperation,
    or hostile passivity. Be forthright and confident
    in manner and speech to provide the patient with
    a stable source of support at a time of crisis.
    Stress a team approach to the problem(s)
    presented for instance, freely use the
    collaborative pronoun we when discussing
    suicidal behavior. Model hopefulness, but make
    sure to acknowledge the patients distress and
    perspective on the problem. Do not avoid using
    the word suicide because this gives the
    impression that you stigmatize the concept. Most
    importantly, do not immediately suggest
    hospitalization. In our experience, patients are
    most agreeable if the therapist carefully
    explores various safety options, then plans for
    the most appropriate clinical response to an
    acute suicidal episode.

Establish therapeutic alliance with the suicidal
patient, Brown and Beck (2008, p. 162)
  • Have the patient tell his/her story at his/her
    own pace. Conduct a behavioral chain analysis of
    events of the proximal factors that triggered the
    suicide attempt.
  • Help the patient define the suicidal crisis.
    Remember that the patient is communicating how
    badly he or she feels.
  • Use phrases such as murdering yourself or
    self-annihilation when referring to suicide.
  • Help the patient view suicide as an attempt to
    solve a problem. Convey that you do not want the
    patient to employ a permanent solution to what
    might be a temporary problem.
  • Use motivational Interviewing procedures. Zerler
    (2008) has discussed how to apply the principles
    of motivational interviewing of suicidal patients
    (EE,DD, RR, and SS). The four principles of
    Motivational Interviewing are Expressing
    Empathy Developing Discrepancy between the
    patients present behaviors and values Rolling
    with Resistance as the therapist strives to
    understand and respect both sides of the
    ambivalence for the patients perspective. The
    therapist can empathize with the needs that give
    rise to the suicidal ideation, without approving
    suicidal behaviors. Finally, the therapist can
    Support the patients Self-efficacy by acting as
    a guide or consultant suggesting possible ways to

Establish therapeutic alliance with the suicidal
patient, Brown and Beck (2008, p. 162)
  • Address any barriers that may contribute to
    antitherapeutic behaviors
  • Use collaborative setting
  • Periodically summarize throughout the session and
    at the end of the session. As psychotherapy
    progresses, ask the patient to summarize what was
    covered in the session and what he/she plans to
    do between sessions and, most importantly, the
    reasons why he/she should conduct these
    activities (homework assignments). Build in
    reminders that the patient and significant others
    can take home.
  • Therapists should model hopefulness and dogged
    determination and convey a team approach.
  • CBT helps to prevent depression in
  • One story- They have to feel heard.
  • Solicit feedback regularly from the patient and
    significant others. Ask
  • I want to check in with you about how you found
    our meeting today. Were there any things I said
    or did, or did not say or do, that you found
    particularly helpful, or particularly unhelpful,
    or that bothered you? What can we do differently
    the next time we meet?

Voice Therapy
  • Cognitive Affective Behavioral Approach

The Therapeutic Process in Voice Therapy
  • Step I
  • Identify the content of the persons negative
    thought process. The person is taught to
    articulate his or her self-attacks in the second
    person. The person is encouraged to say the
    attack as he or she hears it or experiences it.
    If the person is holding back feelings, he or she
    is encouraged to express them.
  • Step II
  • The person discusses insights and reactions to
    verbalizing the voice. The person attempts to
    understand the relationship between voice attacks
    and early life experience.

The Therapeutic Process in Voice Therapy
  • Step III
  • The person answers back to the voice attacks,
    which is often a cathartic experience.
    Afterwards, it is important for the person to
    make a rational statement about how he or she
    really is, how other people really are, what is
    true about his or her social world.
  • Step IV
  • The person develops insight about how the voice
    attacks are influencing his or her present-day
  • Step V
  • The person then collaborates with the therapist
    to plan changes in these behaviors. The person is
    encouraged to not engage in self-destructive
    behavior dictated by his or her negative thoughts
    and to also increase the positive behaviors these
    negative thoughts discourage.

Address patients impulsivity
  • Teach the patient how to procrastinate suicide
    and how to stretch out time
  • Ride out suicidal urges
  • Delay acting on impulse to self-harm
  • Compile and practice delaying strategies such as
    talking to someone, telephone a therapist, engage
    in distracting tasks, sleeping
  • Safeguard ones environment so it is unfriendly
    to suicide

Interpersonal Neurobiology
C urious O pen A ccepting L oving
Most Helpful Aspects from Client
PerspectiveValidating Relationships
Participants describe the existence of an
affirming and validating relationship as a
catalyst for reconnection with others and with
oneself. A difficult part of the recovery process
was breaking through, cognitive, emotional, and
behavioral barriers that participants had
generated for survival.
Counseling for Suicide Client Perspective.
Paulson Worth, 2002
Most Helpful Aspects from Client
PerspectiveWorking with Emotions
Dealing with the intense emotions underlying
suicidal behavior was perceived as crucial to
participants healing. The resolution of despair
and helplessness was a pivotal and highly potent
experience for all participants in the study.
Almost paradoxically, if a client did not receive
acknowledgement of these powerful and
overwhelming feelings, they reported being unable
to move beyond them.
Counseling for Suicide Client Perspective.
Paulson Worth, 2002
Most Helpful Aspects from Client
PerspectiveDeveloping Autonomy and Identity
Participants identified understanding suicidal
behaviors, developing self-awareness, and
constructing personal identity as key components
of the therapeutic process. Participants
conceptualized the therapeutic experience as
confronting and discarding negative patterns
while establishing new, more positive ones.
Counseling for Suicide Client Perspective.
Paulson Worth, 2002
Common Emotions Experienced in Grief
  • Shock
  • Guilt
  • Despair
  • Stress
  • Rejection
  • Confusion
  • Helplessness
  • Denial
  • Anger
  • Disbelief
  • Sadness
  • Loneliness
  • Self-Blame
  • Depression
  • Pain
  • Shame
  • Hopelessness
  • Numbness
  • Abandonment
  • Anxiety

These feelings are normal reactions, and the
expression of them is a natural part of grieving.
Grief is different for everyone. There is no
fixed schedule or one way to cope.
Self-Care Help Seeking Behaviors
  • Ask for help
  • Talk to others
  • Get plenty of rest
  • Drink plenty of water, avoid caffeine
  • Do not use alcohol and other drugs
  • Exercise
  • Use relaxation skills

American Association of Suicidologys Survivors
Support Group Directory http//
/web/guest/support-group-directory IASP Suicide
Survivor Organizations (listed by country) -
al_Suicide_Survivor_Organizations/ Faces of
Suicide A Film for Survivors of Suicide Loss -
Suicide Prevention Making a Difference
  • Be Aware of the Dos
  • Be aware. Learn the warning signs.
  • Get involved. Become available. Show interest and
  • Ask if she or he is thinking about suicide.
  • Be direct. Talk openly and freely about suicide.
  • Be willing to listen. Allow expressions of
    feelings. Accept the feelings.
  • Be non-judgmental. Dont debate whether suicide
    is right or wrong, or feelings are good or bad.
    Dont lecture on the value of life.
  • Offer hope that alternatives are available and
    Take Action.

Suicide Prevention Making a Difference
  • and the Donts
  • Dont dare him or her to do it.
  • Dont ask why. This encourages defensiveness.
  • Offer empathy, not sympathy.
  • Dont act shocked. This will put distance between
  • Dont be sworn to secrecy. Seek support.

Resources Books
For Public and Professionals
For Professionals
Visit for resource links
Resources Films
For the Public
For Professionals
For Survivors
Visit for resource links
Upcoming Webinars
The Fantasy Bond, March 20  CE Webinar,
25 Presenter Dr. Lisa Firestone 4pm 530pm PDT
Real Love or a Fantasy Bond, April 3 Free Webinar
for the public Presenter Dr. Lisa Firestone 11pm
12pm PDT
Creating Meaning On the Role of Death in Life,
May 22 CE Webinar, 25 Presenters Dr. Sheldon
Solomon and Dr. Lisa Firestone 4pm 530pm PDT
Self Esteem the Belief that One is a Valuable
Contributor to a Meaningful Universe Free
Webinar Presenters Dr. Sheldon Solomon and Dr.
Lisa Firestone 11am- 12pm PDT
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