Hi, everyone, I'm Dr. David Stifler. I just want to welcome you on behalf of the American Academy of Addiction, Psychiatry and SAMHSA. Welcome you to today's webinar in our series on Advanced Addiction Psychotherapy, which is a monthly series focused on evidence based intensive psychotherapy training for Addiction Psychiatry fellows and faculty. This is hosted in partnership with Oregon Health and Science University and New York University. We're excited you could join us today and to offer you these live trainings that will be held on the second Wednesday of each month from 530 to 7 p.m. Eastern. Today's presentation is on CBT approaches for the suicidal patient. And our next presentation will be in May when Dr. Amanda Spray will talk about CBT for adult ADHD. You can check out the Triple AP website for updates on other upcoming speakers. Thanks, everybody. And we appreciate you guys coming to join us for this. We're very excited to have our first repeat speaker in the series. Dr. Donna Sudak is professor and vice chair in education in the Department of Psychiatry at Drexel University. She is very accomplished in the field and has written multiple books and has multiple publications on the topic of CBT. And you can read the, you know, extensive bio on your own. But I think what I'll just say is that she's one of the true masters in the field as an educator and a teacher, and she's able to communicate her wisdom, you know, to us lucky folks who are listening. And so we're just grateful that she's here. She's dedicated her life to teaching and education. And I think she just recently became the chair of the review committee for psychiatry at ACGME. So I'm grateful that we have such a thoughtful person doing that job. So, Dr. Sudak, thank you so much for joining us again. And take it away. Wonderful. Thank you. Oops, somebody's going to be. Oh, thanks, Chris, for your kindness and having me back. I'm going to get my slides up here. At least I hope so. Somehow they seem to be. Let's see. There we go. Great. So I'm assuming everybody can see those. And for some reason, they're forged ahead here. There we go. So this particular talk is about a topic that I am quite passionate about because it's really a sea change in how we think about working with patients with suicidal behavior, at least for, I think, some length of time. Many of us thought that what we needed to do was to help people to get to the hospital to be safe and then somehow they'd miraculously be well and we could just begin to work with their primary condition. What we know now is that we need people to work directly with suicidal behavior and that doing so really can change things and save lives. So as you know, this is a series that's hosted in partnership with NYU and Oregon Health and Science University. And I have nothing to disclose in terms of my discussion today. I write books and I work on an online educational product. I've also included my email. And if you have questions or need references or other kinds of info about CBT, I'm happy to have you write to me and I'll help with that as I can. So this is what we're going to spend our time on. It's a lot of territory. Some of it will be just a bird's eye view about suicide and CBT. But I want to give you sort of a set of principles by which you can start to think about this and perhaps do further reading and in working with these very challenging patients. Now, as I started to allude to, this is different from CBT for depression. It's actually deploying the therapy, targeting suicidal behavior specifically. And there really is a mounting amount of evidence that indicates that in the several months after a suicide attempt, when someone is most acutely in danger, that these approaches can make a tremendous difference in terms of helping people to stay alive and begin to work on their problems. So sometimes people are kind of scratching their head and thinking about, well, how is it that folks who are interested in CBT are working with this particular problem? And one thing that I think people don't know is that Aaron Beck was a giant in suicide research. He was really insatiably curious about how people with suicidal behavior thought. And as you might expect, he was able to disarticulate the key components of what we take for granted right now in terms of suicide assessment. So, for example, when you ask if somebody's made a will or if they're giving away their possessions or the like, you're looking at intent. And Beck was really the first person that separated intent as an independent risk factor, that suicide attempts were an independent risk factor, that when someone thought that what they did was going to kill them, even if it wasn't, that that would make them highly lethal compared to someone who thought this large overdose was going to be safe. So he really began to, in a research driven way, look at particular things that made someone more at risk. And up until the Columbia came about, the scale for suicide, the scale for suicide ideation and the suicide intent scale were really the scales that people used the most. The other thing that Beck did was to identify that hopelessness was really a key issue. And we're going to discuss that a little bit later. But hopelessness is actually more a factor that contributes to your dying by suicide than depression is. So if you've had that along the way or if you still have it, even though you're not depressed, you are at much higher risk to die by suicide. And finally, the protocol that we're going to really talk about today was a brief CBT intervention for suicide that was developed and tested here in Philadelphia. And it really was one of the first evidence supported treatments that we had that could help mitigate suicide risk. So we're going to do a cursory review of the evidence, not very much of that, but give you some understanding about that. And then I'm going to take a deeper dive into actually what this is all about. So, as I mentioned, CBT now is shown to protect people in the most critical months after the initial therapy contact. And one of the first things that was discovered in that protocol that was tested here in Philadelphia was the value of safety planning. And many of you probably do safety plans without knowing that that's where this came from. Barbara Stanley, who is another wonderful suicide researcher and Greg Brown really promulgated and tested the value of safety planning and found that just doing that in emergency settings can really decrease the risk of suicidal behavior, which lasts over a six-month period. And it actually increases people's ability to get to treatment after an emergency room visit. And if you don't know much about safety planning or you want to know more about safety planning, that website that I've indicated, suicidesafetyplan.com, you sign up, you'll get a manual and worksheets. And it is an incredibly valuable resource. Patients who engage in this think that it's really helpful because it acknowledges that suicidal thinking and behavior is generally not a one-and-done thing. One of the things when I was in training that was always terrifying for me was to have somebody come into my office who had suicidal thinking and they had this raft of problems. And I would think to myself, oh my God, I am going to need to fix all of this right now because if I don't, this person's going to be in danger because obviously, you know, I was a trainee and anxiety was fairly high. And in fact, what you need to acknowledge is that it's not possible to solve everybody's problems in 15 minutes. Most people's problems don't get solved in that amount of time. And usually people who have this problem have lots of problems. And so the key is to manage suicidal thinking while you work to have a better life. And safety planning is one way to do that. Now, the other thing about safety planning is that often we are not seeing people who make suicide attempts. They're seen in emergency departments. Over 500,000 visits to emergency departments occur a year for self-harm. And less than 16% of them include an evaluation by a mental health professional. That's sort of staggering. So teaching people in emergency settings how to do this could be very, very effective at helping people to save lives. There've been a lot of meta-analytic studies about CBT approaches. There are a variety of different types. There's DBT, obviously, which is a very potent approach for individuals who have suicidal behavior and borderline personality disorder. It's also very effective in adolescents with suicidal behavior. But common to all of these approaches is an empathic assessment of the chain of events that leads to suicidal thinking or behavior, a safety plan of some sort, and then an understanding of this behavior in detail, and then conceptualizing particular interventions that will target the things that put the person at risk for becoming, really sort of seeing suicide as the most desirable solution. So that's the chain of events in most people's approaches to this in CBT. So this is the graph that depicts the evidence from the study that went on here in Philadelphia. Let me tell you a little something about the background of that study. So Greg and Dr. Beck got together with some of the folks at Penn and put together this protocol of a 10-session intervention that was added to treatment as usual on inpatients that were admitted for a suicide attempt at Presbyterian Hospital here in Philly. And Presbyterian Hospital is a typical city hospital here. Patients were admitted, had multiple problems, lots of diagnoses, lots of psychosocial issues, and get a variety of different treatments. So people were admitted with a suicide attempt, half of them got regular treatment, whatever it was, half of them got treatment as usual, plus this 10-session intervention that continued after the person was discharged. And what happened is they followed these folks for 18 months thereafter, and it about halved the number of suicide attempts repeated in the next six months. Now, if you know anything about the demographics of suicide attempting, the highest risk for dying by suicide is in the year following the attempt. So this is a very important time to decrease further attempts. And there's a very potent intervention in complex patients with multiple diagnoses that lasted for 18 months out. And they didn't follow them after that, so I don't know if it would have been further than that. So DBT obviously is highly effective as well. So before we segue onto what suicide prevention looks like in CBT or suicide treatment, I wanna talk about some of the basic principles because I never know in the audience what people know about this, so I'm just gonna do a quick review. And CBT is a solution-focused, present-oriented form of treatment that is based on a very collaborative therapeutic alliance and guided by an understanding of the patient's problems via two things. One is the cognitive behavioral model, which essentially says what you think affects the way you feel and what you do. More about that later. And it's also based on learning theory. We see ourselves as educating people. And so a lot of the stuff that people have that's mythology about CBT, like it's really very structured and you have to do homework and all the rest of that, even though it doesn't look always like that, is there because learning something new and learning it efficiently is important. And it uses a variety of different strategies in a formulation-driven way so that it's not one-size-fits-all. Obviously, I would do CBT for suicidal behavior differently in patient A and patient B because they would have very different paths to that behavior. And I would be targeting the specifics about them, not doing it like a cookbook. So the CBT model looks a little like this, right? It's not events that cause us to feel a certain way, it's how we think about them. And that when we are emotionally charged up, depressed, anxious, angry, our thinking is not very accurate. It might be partly accurate, might be totally inaccurate, might be accurate, but often when we're emotionally charged up, our thoughts are pretty extreme. And so one of the things that we know is that if we look at that thinking and apply the scientific method to it, look at evidence, look at logical analysis, frequently what can happen is we can appraise things a little differently. And that often has an impact on the way that we think, the way that we feel, the way that we behave, and also our physiology. Now, this is highly simplistic. We also know that behavior can affect people's emotion. We know that emotion can alter people's cognitive appraisal, but the basic way of thinking about it is this. And I mentioned that we try to look at things individually. And the way that we do this in suicidal behavior is we try to explain the personal triggers that lead a person to thinking about suicide as desirable. We look at particular vulnerabilities that they might have and try to detune some of those. And that helps us to develop a treatment plan. We also want to account for those things that keep a problem going and look for strengths. So really, when I think about the case formulation, what I really want to understand is how did this person learn to think about the world? And why is it that they keep thinking about the world in a particular way when other information might be happening that could alter that way of thinking? So that's what I'm trying to do in an individual case formulation. Now, this is a review of the things we do in CBT. There's really not a lot of modalities that we wouldn't use, but we'd use any modalities in a particular formulation-driven way. It has to make sense. It has to make sense for that particular person's difficulties. Cognitive restructuring, which means applying a scientific method to somebody's thinking and helping them come up with a different way of thinking. Behavioral activation, which is really exposure to activity, generally pleasant or important activities the person's avoiding. Exposure, which is contacting a stimulus that produces a negative emotional response that's not life-threatening, the stimulus, but until that response starts to go down naturally and learning something new about it. Contingency management, which is rewarding the things we want, not rewarding the things we don't want. Stimulus control, for those of you who work in substance use disorders, that's people, places, and things, right? Staying away from those things that are associated with a particular stimulus, at least until you have some other methods of dealing with that. And the other two things are education. All of us need psychological skills to function well. Not all of us get them when we're growing up. We don't all have good conflict resolution skills. If you've watched the people in your house resolve conflict by punching each other out, you're not gonna be very good at it. And so sometimes there are holes in people's development that we help them with. And obviously we want people to know about the disorder that they have and all the tools that we can teach them to help remedy that. We also think that it doesn't do anybody any good to be a good patient, that they have to be able to leave the session and do things outside the session that they learn with us. And that, hence, is what leads to practicing outside the session. You gotta remember 70% of the information that somebody gets in a particular doctor visit, not even a therapy session, is forgotten, not when they're anxious or depressed. And so that means we have to overlearn certain things. Patterns of negative thinking are highly overlearned. You go over that in your head over and over again, right? And so we have to really help to overlearn other things to help the person learn to do things differently, learn to regard things in their world differently based on logic. And we do a lot of writing so that we make sure the person can remember what happened in the session with us. CBT sessions are relatively structured. It's not like lockstep, but we try to do these things in them because it helps people to get more work done. It helps them build their skills and knowledge. And it's also important because it shows them we have a plan. And if you're really hopeless, if your therapist says, I gotcha, we've got a plan, you and I are gonna together every week identify one or two things that are really important to you. And we're gonna work on those together. We're gonna work on finding solutions to these problems. And that's how we're gonna unpack this and help you to build a different kind of life. If I'm a really hopeless person and my therapist says that, I'm feeling a little better. Therapist has a plan. Now action plan on this list is now the new word for homework. I don't like either one of those words. Most people have an adverse feeling about school, especially here in Philadelphia. Action plan sounds way too corporate for me, so I generally call it practicing or finding out or figuring out or taking care of yourself or one step you can do to help your well-being. So I use other terms for it. Sometimes people get it and say, oh you're giving me homework, aren't you doc? But there you go. The other thing about this is that we don't tell people what to think. Another genius thing about Tim figuring out all of these parts of CBT, when he was treating depression initially, he'd see these people who were depressed and they'd say how worthless that they were. And he'd say, well wait a minute, you're not worthless. Look at all the degrees you have and you have a nice family and all of these things. And they looked at him and they said, well you don't know what you're talking about. And if you think about it, the average depressed person may have said this to a family member or a friend and they actually might say, well you don't know what you're talking about. Because you have to have the patient discover it for themselves. They don't discover things for themselves. They're not going to believe you. Hence we do a lot of Socratic question and we really foster the therapeutic alliance that is very, very important to every therapy. But it's very important in CBT for suicide because the alliance is the primary determinant of whether the patient will buy things that you're asking them to do. It's the primary motivator for them to make change efforts. So the conceptualization of suicidal behavior is finding an in-depth understanding of what happens, the chain of events. And then we are looking at those particular things that put the person at risk for suicide. This is a wonderful article by John Mann that put into words the kinds of things we look for. We look for emotional pain. We look for cognitive distortions. And he in this article amplifies the biological roots of all of these things. We see that the decision making of the person leads to suicide attempts as the most desirable way out. They don't seek help because they feel hopeless that there is any or they're ashamed. And when they think I'm just going to kill myself, they often feel relief. And we need to remember that because that's a key feature here. If somebody is beset with horrible emotional pain and they think, I just can't think of anything else to do. I'm just going to kill myself. And they feel relieved. We need to remember the power of that relief. We are primates. If something makes us feel better, what happens, we repeat that. And so essentially what happens is that the person feels better. So the next time they're in pain, they are likely to start thinking about suicide attempts again. And I have had patients, I imagine people on the call may have as well, who have said to me at the very end, I just couldn't think of anything else. That it was just overwhelming how much they were turning to this as a solution. Now, we know that for many people, suicide is a problem solving strategy. And the person thinks they have no other options. Now, the fundamental way that we conceptualize this in CBT is what I euphemistically call the Sudak triangle of death. And that is that in an individualized way, we start looking for belief systems this person has that potentially could generate suicide as a possible answer to these. For example, I can't stand pain. I'm in intolerable pain and I can't stand it anymore. Or there are no solutions for my problems, or it's hopeless to try anything else, or I'm totally unlovable. So there's that in my mindset. On top of this, I have poor coping skills. I may not be a very good problem solver. I may have very bad distress tolerance or emotion regulation skills. And on top of that, I have unstable moods for whatever set of reasons. There may be a number of things impinging on my mood state. For example, if I'm using substances and that's making my mood state unstable. If I have a condition that makes me genetically vulnerable to my mood state being unstable, all of those things will contribute to this triangle. And the more risk factors the person has in each of these bubbles, the more easily this will be activated with stress. And my attention will start to become fixed once I think about suicide, on suicide as a solution. We think about individuals who have this as cognitively far less flexible. They don't reflect. They don't try to think, is there another way to solve this problem? Schneidman once talked about this. He's a famous writer about suicide. It's the tunnel vision of depression. And that's really what we see. So if I was thinking about this in words, this is from Amy Wenzel's book, which is really a description of this particular mode of treatment. These are really the core features of what happens to someone who develops suicidal thinking and behavior. This is a person who cannot solve problems very well and can't take a view from the balcony. Can't see that five years from now, this probably won't matter very much. And problem solving is highly deficient in these patients. We'll discuss that in a couple of moments. They don't have good autobiographical memories. That's very important as well. What does that mean? So if something bad happens to me, I happen to have a very good autobiographical memory. And so I have a bad event occur. I would think to myself, well, first of all, Donna, you have gotten through a lot of bad stuff in your life and you've been able to manage, you've been able to get through it. And furthermore, I would remember here's what you did. So the way I problem solved would come to me as well as hope that I would get through hard times. But people who have suicidal behavior don't have that. And actually there's some conditions, generalized anxiety, depression, and borderline personality disorder are three conditions where people have deficient autobiographical memories. We can talk about why, but probably not tonight. What happens as well is that once people begin to have suicide generating beliefs or unstable affect, their attention becomes biased toward losses, failures, and suicide cues. So for example, when you break up with someone, you generally don't start thinking about all your successful relationships. Our memory is actually tilted toward remembering more negative events. That's somewhat protective. So if you remember that you really got anxious in this situation or this situation was really dangerous, it gets really rooted in your head. And losses are like that too. And so we already have that bias, but individuals who develop this behavior are highly biased toward their failures. They have frequently significantly inaccurate thinking about those. And the ideation and attempts are often perpetuated by this decreased and negative affect and sometimes by the behavior of people as well. So for example, in the world, if you make a suicide attempt and you call your psychiatrist, you're likely to get a lot of attention. But if you call your psychiatrist and say, I'm really having some problems tonight and I'm terribly upset and I want to be able to talk them over, generally speaking, you're not going to get a lot of attention. You'll get a, well, we'll have to do that the next time you see me. And so there are some models of treatment, dialectical behavior therapy being one of those where we flip the script. We reward people calling us before they make an attempt because we want them to potentially do that. That doesn't mean that people get to call you every minute. That's another talk for another day. So I mentioned problem-solving behavior as being a deficiency. And it's truly remarkable how much people avoid solving problems. And this is deficient also in generalized anxiety disorder. It's deficient also in borderline personality disorder. And the styles that people have make their problems worse. And the person who stuffs the bills in the drawer, the person who avoids any negative confrontation with someone else, the person who uses substances or makes decisions that are self-destructive and makes their life worse when they have problems. The person who broods, if you don't know what brooding is, it's worse than worry. Worry is repetitive verbal behavior that doesn't solve anything. Brooding is the person who over and over again thinks about how the world has screwed them. And all of those styles of doing things make things worse. And that compounds this person's psychosocial problems. So eventually we must do something about that. That becomes part of the treatment plan. So the risk assessment that we do is not just the demographic risk assessment. And you probably know most of these. I'm not going to go over them today, except I'm going to go over a little something about the way that people think. And that's risk assessment too. So we want to look for hopelessness. How do you see the future? We want to look for behavior that indicates hopelessness or engagement in future orientation, which can help us to think, well, this person is looking toward the future. People who are impulsive, who take rapid unplanned actions. The average person, after they think, I'm going to kill myself, does so within 10 to 60 minutes. This is a very impulsive action, which is why it's very difficult when we're working with someone. They may feel just fine when they see us and they don't feel so fine when they leave our office and suddenly they're impulsive. That's why safety planning is so important. We want to look for perfectionism. People have a high degree of perfectionistic thinking. Two kinds of perfectionism. One is I'm a total failure because I'm not perfect. That's the easy one. The other one is the world is terrible. It should be a certain way and people are awful. It's a perfectionism for everybody else. And those people are angry perfectionists. They are also at risk. And the risk assessment helps us in terms of thinking about their thinking. Think about what we need to tune into when we start to work with this in treatment. People who have suicidal behavior also have more undiagnosed psychosis. And so we need to be a little more careful about looking at that. But people who have obviously a history of attempts are a much higher risk group. So we really want a chain of this person, the series of events that go on that lead up to and follow the last incident or the most severe incident of suicidal behavior. And that could be attempts or ideation. We want to look at what was going on before and what was the day like, what are vulnerability factors and what led up to the person making the decision that death was preferable and what did they do each step of the way. And we're really looking to do this by examining the person's thinking while this is all going on, their emotion, their behavior. Generally what I say to people is I want to go back like we're in a time machine together. And then I want you to describe this to me like it's a movie, like we're in slow motion. And I'm going to ask some questions because we want to get a really good picture of what happens. Now it's also true that there are some thoughts that people have that make them less vulnerable to suicide. And actually this study was done in Seattle when I was in training actually in Seattle. And what Marsha Linehan and her crew, one of these folks was one of my attendings and who I worked with later and doing some research about this. What they did was they went out to street fairs and they did questionnaires about whether you've ever been or had thoughts about suicide and what your thinking was like. And what they came up with was that people who really were not ever thinking about this had particular ideas. And if someone promulgates these, I feel a little better, not a lot better, but a little better. So if somebody says, I will survive, you know, the Gloria Gaynor's of the world, no matter what happens to me, I'm going to get through it. Or I couldn't do that to my family. Or I couldn't do that to my kids. They need me. Or I'd screw it up and I'm afraid I'd be in a coma or I'd break my neck. Or people would disapprove of me or of my family or I'm morally, I can't do this, it's against my religion. All of those are ideas that make it less like, it's not a hundred percent, but it certainly helps me if I have a person who's got a lot of depression, but who really thinks of themselves in this particular way. It's the reverse of, I can't solve my problems. But the thoughts that get activated prior to attempts, in addition to general hopelessness, look like this. You're looking for unlovability. My problems can't be solved. The pain is unbearable. I'm a burden. Really all or nothing terms. And not being able to ever see the world as different. So if I'm thinking about this conceptualization in a linear way, I'm looking for the cues that might have triggered the attempt. What thoughts are active? Like I can't stand the pain. What feelings are present? Unbearable sadness. And what's my body feel like? My chest is tight. I'm tearful. And I start thinking about the knives in the drawer and I go look at them. And eventually I get preoccupied and that's all I can think about until I actually cut my wrist. And so I'm also looking at other predisposing factors like the kinds of styles of thinking that I just spoke about. And again, if I'm thinking about the cognitive model, if the suicidal behavior produces relief, it's likely to be more activated each time. And particular triggers are often what activate the person's despair and increases their behavioral practice. So that conceptualization individually is what leads me to make a plan for treatment. And a plan for treatment in this circumstance is thinking through what is the problem? What is the skill deficit in this person that is the most life-threatening or dangerous? And what interventions do I know that will address that? And then we're actually going to go through A to Z, those particular things. So generally, these are the things that I'm thinking about when I'm thinking about treatment. I've got to change the mechanism that leads to suicidal behavior and I've got to replace it with skills. And it's important that before any of this starts, the goal of treatment between me and this person must be preventing suicide. And if the goal isn't that, then obviously they need a different level of care. That's beyond the scope of this conversation. But in a general way, I've got to keep this in my mind. I also want to make sure that I'm assessing risk in an ongoing way. And that means that every time I set an agenda, part of what I'm going to do is to make sure that there's a risk assessment that goes on. I'm going to have the person bring in a diary card about the number of times they've thought about it this week or any times they were close to making an attempt, how many times they used their safety plan, et cetera, because that's going to help me. I'm going to really keep in mind that this person might fluctuate in their commitment to this, particularly early on. One thing that I want to be clear about is that the person has to come to treatment. And what this means for me is I remember a study. There was a study by a group of people, Motto and Bostrom. They took a mental health center with lots and lots of patients, hundreds, and they divided two groups of patients up. And these two groups of patients had both stopped coming to the clinic. They might've stopped because they were discharged or they stopped because they were quick treatment for whatever reason. Some of them might've moved away. They didn't know. This was somehow HIPAA compliant. They sent half of these people a postcard that said, we are Handy Dandy Mental Health Center. And we know you came to see us once before. We just hope everything's fine. We wanted you to know we're still out here if you need us. The people that got the postcard had a decreased risk of suicide attempts by a factor of four for a two-year period of time. Now, this is obviously a caring contacts kind of intervention, but what it means to me is if the person hasn't shown up for the first 10 minutes of their appointment, I'm going to be on the phone. I'm going to call them. I'm going to say, it's your appointment time. Where are you? What's the problem with getting here? Because it's important that you come and I'm in this with you and you and I together need to work on this. So you got to get here. What do we need to do to get you here? So it's really important. The other thing about this is that I'm going to be really empathic about the pain the person's going to be in. And I'm going to be talking about what's happening for them rather than shying away from a discussion of suicide. Are you thinking about it now? What's bringing it on? What do we need to do to help solve the problem? In addition, we've got to think about coping ahead. We remember a person doesn't have a good autobiographical memory. They're not thinking out in the future. So if they get into trouble with family conflict, it means if I'm treating them in October, I'm starting to plan for Thanksgiving and thinking about what are they going to do to manage being in the circumstance of being with their family over the holidays. How is that going to work out? Coping ahead. That's also called anticipatory guidance, if you want the fancy term for it. This is the goal of treatment in the very beginning. There's got to be an alternative to killing yourself. That life has to become bearable. Because this is an emergency, the person has to have a fire drill mentality. They have to over-rehearse staying alive when they feel bad. The idea is that you're going to resolve to live even though you have stress, that you're going to develop a belief that your problems can be solved and the two of us together are going to change those mechanisms that result in suicidal behavior and replace them with skills. So the first goal of treatment, we're going to prevent suicide. If the person says yes, then we're going to do a safety plan. And that's a critical step. And a safety plan includes three things. One is the plan. Two is getting rid of lethal means. Three is developing reasons for living. That's the first three things that we do as a part of the safety plan. Frequently, I will tell people that I don't want them to kill themselves. I will tell them that I believe their problems will get better. And I might say, here's why, and give them reasons that I believe that based on their life experience or based on my knowledge about a particular condition or by my knowledge about what kind of treatment they've had. And I think it's a very important thing to let somebody know that. So I'm going to switch out for a few minutes and talk about safety planning. I don't know how many of you do this. It is really considered the standard of care and risk management now. It's really systematically identifying and helping the person plan to use internal and interpersonal resources when they get into this emergency. And it's designed to be a brief clinical intervention after you do a risk assessment and decide that the person is leaving. And so part of what we want to do is to make sure that the person understands when to use the plan, where the plan should go, like where are they going to keep it? In their phone? Are they going to put some on the medicine cabinet? And that they have to follow the plan in order and stop when the urges pass and then go to the hospital if acting is imminent. And the rationale for the plan is that you really can get it from the person. You can ask them, have they ever had a period where they had a sense that they really wanted to harm themselves and then it went away? Because most people have had that happen. And so we know that the urge to do this goes up and down and a plan to manage this urge could save your life, right? Time is your friend. And if you can manage this way of thinking, we can work to make you have a better life. And until that happens, we have to do things to deal with this way of navigating your problems. Oops, sorry. One too many. I'm not going to go through how to do this, but I am going to tell you about the particular ways that people go wrong in doing this. Whoops, sorry. Back to me. So these are the steps in a safety plan. Three things the person can do by themselves. Two, places with people or people that can distract you. So a place with people could be a coffee shop. My favorite example of a place with people is Trader Joe's. I love going to Trader Joe's and it's very distracting for me. I can walk through and kind of look at the new products and it's, but so that would be a place that could distract somebody. Three people who can discuss this crisis with you, a mental health professional, a hospital and 988 and then lethal means and reason for living. So generally what happens is that the mistakes that are made is that people tell people what to do and you don't want coping strategies you would do. You want strategies the patient would do. So you ask them, take a minute and think, what have you done in the past when you've been beset by problems? Or you might just give them some general ideas. Some people find that X, Y, and Z are helpful, but you probably have specifics. And so we want to have those. And with each step, we want to say, person might say, well, I could read because I like to read and I find it really distracting. Okay, great. So reading is your first coping strategy. What would get in the way of your reading? And the person, oh, nothing. Well, let's take a minute and think, what could get in the way? Maybe you happen to be a place where it's three o'clock in the morning and you can't turn the light on easily. Can you think of any other obstacles? And so we want to really problem solve any obstacles that could go on, particularly with activities that involve going outdoors. That could be a deal, right? We want to look at, if the person comes up with an obstacle, what they would do to solve it. And then what we want to say, how likely is it when you're really upset that you will try this out on a scale of zero to 100%? If you get less than 70, it's back to the drawing board. So you've got to give this time and make sure that the person buys in and makes a commitment to doing it. I will say the important thing is that many people will say, I don't have any people I can talk to. And so I'll go through, you know, neighbors, pastors, old friends, people in the family who've been kind to you. If the person says nobody still, then I will say that the first tasks of therapy will include getting you more people because social interactions make a difference. Then we want to collaborate to get rid of lethal means. And it's important that other people be a part of this, particularly if they're guns involved. So we want to get rid of the person's method of choice and any firearms. The longer it takes, the safer it is for you. And we don't have to get rid of the firearm forever, just for right now. If you won't get rid of the gun, will you get rid of the bullets? And often this is a negotiation, just for the period of time while you are in danger. And finally, we want to make a list of reasons to live. And we really don't want to just have people make a list. If somebody says my kid, I'll say, what's your kid's name? What do you like to do with them? What do they like about being with you? What would they miss if you were to be dead? What would you miss seeing in their life? And generally speaking, I want to paint an emotional picture. The person says, I'm not sure. I don't have any reasons. What would you have answered before this last crisis? What would a family member say? And then we're going to ask people to build a hope kit. And a hope kit was one of the key components of the suicide protocol that we're discussing. It's developing an actual container or a phone app that contains vivid reminders of things the person aspires to, things that can kindle hope, pictures of people. If I see a picture of my daughter, it's going to be a lot more potent to me than actually saying I'm my daughter. I've had people, I want to go to Paris so I can have a tiny Eiffel Tower that helps me to remember. That's one thing I hope for in the future. And patients really like doing this and we want them to keep adding to it. So this is a good example of reasons to live that have emotional connections. If you have problems with the person developing a safety plan, we might sometimes need to be more directive. If somebody doesn't have good skills to get their emotion pain down, you might have to suggest some behaviors. But, and if there's ambivalence, that's really where we have to really go back to the drawing board and see, is this a person that needs to have a bit different level of care? Okay, so next we're going to look at, what do we do about the drivers of suicide? And there are four that I think about. One is we have to develop a more hopeful stance toward life. We want to help the person fortify their reasons for living. Another is we want to really evaluate people's negative thinking. We want to help people to develop a better sense of self-compassion, of being kind to themselves, of treating themselves kindly. And last but not least, by any means, is teaching people how to solve problems. So, oops, I forgot I had that slide there. There you go. So we mentioned hopelessness as being an issue. And what we really want to do is create some reasonable doubt. I don't expect 180 degree turn, but I might have the person, if I know about this a little, go back in time and look at the best period of their life and what was in their life then that isn't in their life now, what they might like to recreate in their life that might be important to them. And you have to be careful about this depending on any recent losses the person has had. You may go at this a different way in that circumstance. If the person's hopeless about treatment, you want to be very, very careful about making sure you build a case for treatment. Number one, giving people a short explanation of the nature of the treatment and that many people are helped by it and some little bit of science we know helps the person's therapeutic alliance with you. We want to give them a plan of action. Here's how I think you'll get better. Every week, we're going to figure out what problems to work on and the steps you could take to make those solutions happen. We're going to look at ways to make your life more meaningful and see what's getting in the way. We really want to develop a vision of the life the person wants and strengthen connections to other people, to a sense of purpose, to a sense of safety and control. One thing that's really important, every week in CBT, we check on people's mood. Generally, if somebody's depressed, we want to see how depressed they are. I do this a little bit in reverse when I'm working with somebody in this predicament. I'll say, is there one or two things that you were able to accomplish this week toward one of your goals? Were there one of two things this week that you felt went a little better for you? And if the person says, well, yeah, I was able to call my sister. That's terrific. How did that go? What does it say about you that you were able to do that? And the week before, that wasn't something you were able to do. So I want to be able to check in about their ability to face some challenges or make some changes and highlight those. I'm not going to say, oh, that's great. You called your sister. I'm going to ask them, what does it say about them that they were able to do that, right? And we're going to set goals. There are some particular behavioral techniques that we can use. As people get along the way, we can have them begin to journal. And we ask them if they're journaling to look for positive things or changes that they're making. I will often say to people that they have a very overactive prosecuting attorney in their head who is constantly gathering evidence about what kind of a failure that they are, but they don't have a good defense attorney. And what they need to do is to collect those positive things that are going on so that they can have a more balanced view of themselves. I'm not going to say everything is wonderful, but I am going to say you are going to pick up negative information more carefully than you are those things. Gratitude can be helpful over the long haul. We want to help people treat themselves and take care of themselves better. In the very beginning though, what we want to do is to help people to understand that those things they do in safety planning aren't to feel good. They're to get through the crisis. What we want to teach them besides that are things they can do to care for themselves. It's remarkable how denigrating people are about the need to care for themselves. Normal people don't need to do that. I'm just being a baby if I make myself a nice dinner when I've had a disappointing day, or I'm just having, what is it, a pity party, and when I tell somebody how badly I feel. And so we want to help normalize the need for support in the world. We can use certain kinds of physical sensations. This is beyond the scope of this particular talk, but we know that intense emotion often requires more intense interventions to bring it down. And there are a number of skill sets we can teach people. Intense physical exercise is one of those, but we can use temperature and other kinds of physical sensations to help bring people's physiology down so they can start to think more clearly. And I've mentioned most of these things. When I'm describing therapy to people, if they're hopeless about therapy, I'm generally telling them that we're going to implement CBT and why, but then I'm going to say, if over the next eight weeks, we're not getting much in the way of movement and how things are going, then here's what plan B is going to be. Here's what I'm going to do next. And I always have a plan B. And so the person knows that I'm not going to just allow this to languish. And the number of weeks really depends on the person in terms of how I'm going to implement plan B. I also will delineate things I think were accomplishments for the person in the past and what qualities that has shown me about them and why I think they can make things change. Now, acutely, there are a number of things you can do. If the person says, I just, I don't know that it's worth living. I'll say, well, let's take a look at that together. So what are the advantages of living today? And what would be the advantage of dying? What would be the good things about each of those things? And a year from now, what would be the advantage of living or dying? I might do it a month from now. I might do it six months from now. I might say, well, what's the advantage for your family of your dying versus living? Can we look at that together? And so I'm looking at this in a very dispassionate way so that person begins to look at this. I can also do timelines, which I really love. I love them for adolescents because adolescents are not very good at, young adults too, at looking at what they're going to miss out on. So, okay, so you're 18 right now. And if you die today, what are you going to miss doing? Let's see, you're going to miss the Bruno Mars concert. That would be like really terrible. You're going to miss going to college. You'll miss getting married. You'll miss, and I have the person list the things that you might miss in the future, right? All the way out. And people might say, well, you don't know that those things are going to happen. And I will say, I know one way they won't. And then when I'm done being a smart aleck, I will also say potentially, have there been things that have happened in your life that have been good that you didn't expect? We don't really know what the future holds, but there won't be any future if you die today. I use delay tactics. Wouldn't it be terrible if you died for no reason, if your life could have gotten better in six months? I am not going to be able to help you solve all the problems that you've got in a week or in a month. I'm telling you, it's going to take six. And we might not get through all of them in six, but I'm pretty confident that your life could look better for you. And you can always do this, but it would be, wouldn't it be bad if you had died for no reason? Some rhetorical questions is really great. Like, what's the use of going on? Great question. What is the use of going on? If somebody agrees to a safety plan, another thing that you can do is to ask them, why would you agree to not kill yourself? Because that starts to get at the reasons they have to stay alive, and that's really important. You need to monitor particular thoughts about suicide that are problematic, like they'll be sorry when I'm dead, or I'll find out if somebody really loves me. Those are usually adolescents or people with personality issues. And generally, I'm going to ask people if they could find that out in a less expensive way. Dying is really expensive. And so figuring that out in a different way could be important. So one thing we do in CBT is we make coping cards. And coping cards are things that people discover in therapy that we write down for them and have them keep either in their phone, now mostly in the phone. I have still a collection of multicolored three-by-five cards for when we didn't have phones, which tells you how long I've been doing this. And the idea about these are really to jumpstart adaptive thinking. Remember, thinking is a habit. It's like driving. You get on the track and you go this very well-worn synaptic path. And so one of the things we have to do is to help the person, once that path begins, to remember the adaptive way that they're learning to think until that new set of synapses becomes pretty well-worn. And so we can have lots of different kinds of coping cards depending on the person's stage of treatment. But one of the things that we wanna do eventually is to get to the kind of thinking that usually leads down the path to suicide. And so these are things that I don't just make up and write and say, here, read this. These are the things that we discover over a therapy session. And the eventual goal would be that the person would use these and eventually be able to image their boss humiliating them and come up spontaneously with other ideas to think about this and what they would do. So the eventual goal of treatment is for the person to have different ways to think and behave at times of past vulnerability. And I know that when that happens, that this person has a little bit of an inoculation to help prevent this sort of devastating outcome. I've given you a bunch of resources about this. These are all good websites. Now Matters Now is a website that has a lot of resources around suicide prevention, suicide safety plan, I mentioned already. If you don't know about the American Foundation for Suicide Prevention, it is a fabulous organization. It's devoted to doing research about suicide. It's the only organization in the United States that raises money for that alone, suicide research. It has an amazing webpage with lots of resources, demographics, resources for talking to educators about suicide, resources also about navigating being bereaved by suicide. They have groups for people who are bereaved by suicide. That is a club that no person wants to be a member of. Most people aren't ready to go for about six months, but when they do, it can be quite helpful. There's a virtual hope box. There are lots of virtual hope box apps out there. Some of them are named differently so that adolescents can have them on their phone and not worry about that. Okay, more resources that have lots of different suicide prevention and resources that are available to people. I will stop there and take questions. Well, thank you, Dr. Sudhak. That was completely chock full of pearls that I'm going to continue to try to absorb over time. We'll wait for people to put the questions in the Q&A spot, but I'll start off by asking about something that I've noticed for a while is the sense of relief that people get from knowing that they can kill themselves is profound. I find that acknowledging that really deepens the therapeutic alliance. In some sense, I think that normalizing the fact that suicidality is not always pathologic also can really help the patient understand that we get it. Yeah, I guess I don't think about... Oh, Chris, you're going to have to mute again. Sorry. I don't think about ways of thinking as generally pathologic. I think about them as that this is a solution that has come to you and it relieves your pain. What we need is to figure out other solutions because this one leads to an outcome that is pretty extreme. If there's another way to solve the problem and manage your pain, we might be able to help you build a life that you feel is good and full and meaningful and worth living. I think that it is really important to not just acknowledge the relief, but to remember the relief as an enormous driver of this engine. While we're waiting, go ahead. I also think it's important to ask the question, what is this relieving? Because that's the money question in terms of the solutions that you've got to figure out. What do you have to put in place to make things better for this person? Okay. I was going to fill in a question, but we have some coming in. I'll ask the first one. How would you navigate a situation and or create a safety plan with a patient or client who you do not know well? I ask because I imagine it would be somewhat difficult to help guide them to reasons to live. Most safety plans are done with people that people don't know well because they're done in emergency rooms. That's one thing to think about. It's important to remember that one of those particular pitfalls, I think about the pitfall in that situation as more about the fact that this person doesn't have much of an alliance with me. The alliance helps me to feel a little more comfortable about safety plans being implemented. If I know how this person behaves in treatment, do they keep their treatment agreements? That's a really important piece too. Part of what I'm asking is I'm asking the patient for reasons to live. What are the things in their life that they value? Who are the people in their life that they're close to? What kinds of things have they wanted to do that they haven't gotten to do yet? What kinds of things in the past have been meaningful or worthwhile for them? All of those are things that you might be asking for in terms of that. Getting some prior psychosocial history can be helpful in that regard. Who are the people in this person's life? What impact would suicide have on them even if they don't feel particularly close to those folks now? So many private psychiatrists decline patients with active suicidal ideation due to the high acuity and likely concern about liability as a singular practitioner. I'm curious your thoughts on treating a patient with active suicidal ideation in a private practice setting versus PCP, IOP, or outpatient clinics with more wraparound services. Well, so I must say I had a private practice for most of my career and treated those folks. And one of the things I think it's not just liability, it's also feeling like they don't have tools. And so if you haven't been trained in particular ways of managing this that you feel confident about, it's harder to bear the responsibility. I will also say that if you don't feel comfortable fielding telephone calls when you are not in the office, then that is also something that makes doing this more difficult because occasionally problems will happen and stressful events will occur. And from my point of view, I feel like I'm the best person for that person to call in that circumstance. This doesn't mean that I'm going to solve the problem on the phone. This means that I might approach it from the standpoint of what skill do you need to use right now to help you to get through this moment? And how confident are you that you're going to implement it? And in 10 minutes, I'm going to check back with you and make sure that the emotional pain you're feeling has gone down. And then we'll work on this particular problem outside of that. So I think those are parts of the concern that people have. I don't know that it's just liability. In addition, I can say pretty confidently having worked with folks in this circumstance, that there is an emotional component to working in a high-risk circumstance. And many people don't want that sort of burden. I don't have another good word for it. And when you're dealing with large numbers of these folks, having a team makes a lot of sense. That's why dialectical behavior therapy does things the way it does, which involves a team of therapists who all work together and who all discuss the group of patients they're dealing with together and who all manage crisis calls. And so that it isn't just having one person. I think if you are working with this population, it's really important to have consultants and people that you work with that you can say, am I missing something? Is there any other aspect of this that I might be neglecting? Because you're dealing with a very high-risk group. And when I'm doing this, I'm thinking of myself as an oncologist and not a GP. And not everybody wants to be an oncologist. I'm going to jump in and ask one related to substance use and I guess kind of piggybacking on what somebody was alluding to earlier, where I find myself doing these when I have a new assessment, it's 60 minutes, and I make sure I kind of quickly have an idea where this might be going. And then I'm kind of squeezing in a safety plan at the end, and maybe I need to keep them longer depending on how concerned I am. And we see patients with co-occurring substance use disorders. So many times, whether the patient explicitly identifies it or not, a substance is something that very well could be increasing their risk or at a minimum, it is calming their affect. They view it as a way to problem solve, and it is more soothing than thinking about their problem. So I'm wondering how you kind of navigate that, especially doing the suicide safety plan or kind of any other aspects early on in treatment. So if that is in the chain of events, that becomes something that potentially we look at as, this needs to stop. We have to figure this out. Can you see that every time you do this, it leads you to be more impulsive? What can we do to navigate whatever it is that this does for you in a different way so that we don't lead you to this outcome of making a suicide attempt? One of the things that Beck did discover was the relationship between substances and suicide attempts, that there's a high degree of correlation between, particularly alcohol use. And so that what we want to do is to help the person to see, can you see the connection here and what can we do instead? What would be other behaviors you could try? Would you be willing to try? How would you remind yourself? Those kinds of things. So a peak usually occurs in crises of suicidal ideation and attempts. What do you recommend as an intervention when it is possible to detect that peak? I think that's what you're asking. I'm actually not sure. So when you are at the, there's nothing else to be done, then you've got to figure out other things to do to distract yourself until that goes down. It's an arc, it goes up, it goes down. Next one. What do you do if a patient does not follow the safety plan? I have a patient who disappeared from the shelter he was staying in. Well, that would be a person that you need to remember that some people don't keep treatment agreements. And the decision-making about people, whether they should be in a more restrictive or less restrictive environment, often is around, can they keep treatment agreements? And there are circumstances where that's much harder. We know, for example, that the outcome of therapy in general is less good in people who don't have stable housing. We know that they are a higher risk group and unfortunately are frequently in emergency services and you have to make decisions about that. And often we don't have a lot of collateral information or interpersonal supports that can help in those circumstances. And so the degree of support and other services may be what needs to happen. One thing I think is important is being able to try and get enough good information about how to find people. So for example, in doing remote tele-therapy or tele-psychiatry with folks, we generally speaking, at least in my clinic, one of the things the person has to do is to identify their location when they're doing their therapy session in order so that the person who's in therapy, doing the therapy would know where they were in case of an emergency. Because of those kinds of circumstances, it's really pretty difficult. Do you find that there's any value in a no harm to self or others contract that the patient signs prior to leaving the emergency department? I've drawn them up on my own and several people sign them before leaving. I'm so glad someone asked that question. There is no value unless the person won't sign it. And if they don't sign it, then you know what to do. If they do sign it, it will not protect you in court and it doesn't protect the patient. It's just promising you something. And if they leave and the arc hits again, they don't have anything they can do about it except, oh, I did make that promise. And for most people, that's not going to be enough. The safety plan works much better. People made no suicide contracts, no harm contracts for years and years. And it didn't make a dent in whether they made an attempt, but safety plans do. And one of the reasons about that is that there are many times when people are discussing those folks with me, there are people who are in a very difficult position. They may not have caring contacts. They may not have family around them. They may not have other people they can turn to or as many resources. But many people who have suicidal behavior do have all of those things and can get in touch with people and do have other things that they can do. And that, you know, we're saving those lives too. Next one, what is your approach to patients who romanticize suicide and turn to films or shows like 13 Reasons Why or books like The Awakening as their evidence to pursue it? Yes. Well, 13 Reasons Why did us the favor of raising the suicide attempt rate in adolescence for a while. It did everything that AFSP says not to do. There are 13 Reasons Why handouts that you can get why all the things in 13 Reasons Why is wrong. And I actually will ask, you know, people if they've watched that show and explain what about it is not a fact. I will actually go so far as to say nobody has ever come back to tell me that death is better. I haven't seen anybody haunting anyone from beyond the grave. And the punishment you might inflict on other people or the whatever else, is it worth dying for? Is it worth paying that kind of a price? Is there another way for you to communicate besides that? Unfortunately, the people that romanticize this a lot are people with very limited impulse control and abstract thinking, they're adolescents. And that is problematic. And so there are ways to discuss suicide with adolescents, that it is generally about a psychiatric issue, that a person can get help, that help helps, that keeping a secret about this is not a good idea. And we have to really portray suicide in different ways with adolescents, we have to make it a, you know, we don't want to have a big ceremony in the gym with lots of candles and retiring the person's jersey and all the rest after a suicide, that is a surefire way to have more. That's a, it is a big problem. Because lots of, you know, popular things popularize this in a particular way. Could you suggest any practical books on CBT and suicide? The book that I referred to is quite good. There are, there are sections of several other basic textbooks that do a good job. There's, Jess Wright's books are pretty good. Although I probably shouldn't say that because I wrote one of them with him. But he has a book on severe CBT with severe mental illness that deals with suicide that I did not write with him. So I feel better about recommending that one. I think that Marsha Linehan's books are invaluable for anybody. Both the dialectical behavior, the therapy, it's actually called CBT for borderline personality disorder and the skills training manual. The skills training manual is phenomenal and will give you good ways to teach skills for every patient. Not all patients who need psychological skills have borderline personality disorder. And so it gives you a good spectrum of how to train that, how to help people tolerate distress better, manage their emotion better. I'll just end on this. Somebody's asking, I think, just for further confirmation that suicide safety contracts are not recommended. Safety plans are recommended. And what isn't recommended is no suicide contracts. I promise never to do it or I promise not to harm myself. Those are not recommended, but safety plans where if I notice that this is happening to me, here are the steps I'll take to save my life. I agree to do all of these things. And if I feel like I can't manage it, I'm going to go to the emergency room. Well, maybe we have time for one more. I wonder if fleeting thoughts humans have about not being alive when under too much distress, maybe in the spectrum of normal versus getting to a point of deciding that taking one's life is the best solution, which may be outside the realm of what is considered normal. I think that most people would say that that might be considered normal. If you ask the average person, they might say, well, if I had cancer and if I was in tremendous pain, I would do that. What we often neglect is that the person who makes a suicide attempt is in tremendous pain. That's what it's all about. And we find it understandable when it's about cancer. We don't find it so understandable when it's about depression or the other things that flesh is heir to. Well, thank you so much, Dr. Sudhak. I definitely feel smarter for having been a part of this and we're grateful that you came back and join us next month for, what are we doing, CBT? Yes, CBT for adult ADHD. Yeah. A couple ADHD in a row. So thanks again, Dr. Sudhak. My pleasure. It was great to be with you. Bye, everybody. Bye, everyone. See you in May.

Cognitive Behavioral Therapy

Suicidal Patients

Addiction Psychiatry

Dr. Donna Sudak

Therapeutic Alliance

Safety Planning

Hope Kit

Problem-Solving Strategies

Cognitive Distortions

Hopelessness

Emergency Services

Safety Plans