My Thoughts on Zero Suicide as a Person with Lived Experience

My thoughts about Zero Suicide as a person with Lived Experience

There has been a lot of talk on Twitter about Zero Suicide and it’s mission to reduce the suicide rate to zero, because 1 is just too many. At first, I was appalled that clinicians think that is possible. I for one think that it is outrageous because there is always going to be someone who dies by suicide. Maybe not in their organization but outside their organization. But then I learned that it’s not an individual’s practice but an organization or health system that strives to achieve this goal. They have trainings and meeting with those in the suicidology world.

Something kept bugging me about this. I kept quiet because I didn’t want to anger those that are for it, though I think there are a few blogs that I wrote about it before I understood the mission. While talking to a friend that is a suicide loss survivor, the bells went off. She said that it goes against Shneidman’s questions, where do you hurt and how can I help?

I am a big supporter of Dr. David Jobes work with his framework called CAMS (Collaborating, Assessment, and Management of Suicidality). I don’t know if Dr. Jobes trains these Zero Suicide clinicians. And even if they are trained, I am not sure it will be used. Most clinicians have the attitude that their skills on suicide risk are good enough when it could be faulty. Worse, they go through the training yet don’t use what they are taught. That drives me up the wall. Why bother going to a training (unless it’s a mandatory thing) if you aren’t going to take away from it?

I really think CAMS is a tried and true framework to prevent suicide based on my experience of using it in my former therapy. I also used the Suicide Status Form. Unfortunately, my therapist did not want training in CAMS and we drifted apart, thus ending our relationship. We did, while we worked together, use the initial and tracking forms but unfortunately, we never got to the outcome form. She wasn’t committed enough to see it through and that kind of pissed me off. Every time I had a suicidal episode, she just wanted to know one question on the form, The one thing that would help me no longer feel suicidal. It is an open ended statement where the client fills in their thoughts on the matter. Unfortunately, I could never come up with a satisfactory answer as I really didn’t know the reason for my suicidality. I just wanted to die and that was that. I wrote a blog about CAMS if you would like more information about how it is formed and the use of the Suicide Status Form.

I went on the website for Zero Suicide but could not seem to find the specific training that they went through. From what I gathered on Twitter from their live tweets, some of it is CAMS and some of it is using risk factors for suicide. Unfortunately, risk factors alone are not predictive of a suicide attempt. CBT has been useful in reducing suicide attempts but not all clinicians are trained in this modality. The book by Craig Bryan on CBT for preventing suicide attempts is a good book to learn more about it. I also wrote a review on the book that you can see here.
The other thing that gets me is that no where among Zero Suicide is there talk of a person’s psychological pain. There are measures, if you look for it. Dr. Holden at Queen University in Canada has created a scale to measure what Dr. Shneidman calls psychache. See my review on the research article for more information. I think it is a good psychometric to gauge a person’s level of suicidality and pain, which ultimately leads to thoughts of suicide. This must be included in any talk of preventing or intervention of suicide and also postvention, should a suicide attempt occur.

My final thoughts of Zero Suicide is that it is a novel idea but as Dr. Shneidman says, “How many suicides do you want, and I say I don’t want any, but I want there to be the freedom to do it. I study suicide but I am not pro-suicide. I’m for suicide prevention.” I share his sentiments. I do not like the talk of “suicide is not an option”. To me, that is hindering free will. I do hope the rate of suicides goes down, but the way that health care and mental health are going, I think there will be more before it lowers, especially among the chronic pain patient population.

CBT for Preventing Suicide Attempts: A Review

CBT for Preventing Suicide Attempts: A Review

I have been reading CBT for Preventing Suicide Attempts edited by Craig Bryan, PhD and these are my thoughts about the book by chapter. I also describe what each chapter is about.

Chapter 1: Deals with the problem of suicide and how it’s on the rise. It also describes the difficulty of knowing what works and what doesn’t. The authors goes on to what the book is about and how CBT has been shown to be useful in some clients with suicide ideation.

Chapter 2: Describes the dreaded nomenclature of suicide attempts, ideas, suicidality, etc. The authors describe how the term SDV (self-directed violence) is a more accurate term and also other terms to decide pathways on treatment protocols. They term the entire suicidality as SDVCS-Self-Directed Violence Classification System. It is used by three large federal organizations- the CDC (Center for Disease Control and Prevention), the VA (Veterans Administration), and the DOD (Department of Defense).

This chapter gives good examples of how different researchers, clinicians, and other professionals can use this classification system. I didn’t review the system pathways and yes/no guidelines because terms don’t mean that much to a suicide attempt survivor writing about my lived experience. I’m either suicidal or I’m not. I don’t need to classify and put myself into a category. But if you are a clinician/researcher or other academic interested in suicide prevention, the nomenclature is pretty good and better than what Silverman et. al. proposed in 2007 a and b (see this blog post on my thoughts about their terms).

Chapter 3 deals with what works and what doesn’t in suicide risk. It talks about studies pertaining to talking therapies and psychopharmalogical treatment of suicidal behaviors. I found this to be more of a review of what I know as of right now in terms of evidence based practices (EBP) and what is not. Some studies were really small and others were large. Most centered around Borderline Personality Disorder (BPD) as that is a high risk group. What I found upsetting is that those with bipolar disorder or those that were psychotic were excluded from most of the studies. As I suffer from psychosis and bipolar disorder, my participation would not be included and I find that disappointing, especially since bipolar disorder and other psychotic disorders such as schizophrenia have a higher incidence of suicide than major depression alone.

Chapter 4 was an eye opening chapter that I really liked. It talked about all of the suicidologists that I have been following for the past eleven years. It discusses different theories and models of suicide and risk assessment. It also discusses protective factors of suicide such as reasons for living/dying. I found this chapter to be really good and a lead off to how all of the things talked about lead to the next chapter, which is a case example.

Chapter 5: In this chapter, a case is described step by step of a suicidal older gentleman and the cognitive steps, consent, etc. are used by a play by play dialogue. Things like safety planning, coping cards, and hope kit are discussed in detail and how to implement them in therapy using cognitive therapy.

Chapter 6 talks about a brief cognitive behavior treatment (BCBT) for inpatient units called PACT (Post Admission Cognitive Therapy). It discusses the criteria for engaging patient, pros/cons of treatment and how not everyone may be suitable for this type of treatment, e.g., those with active psychosis/mania.
It would be good if this could be implemented but as the treatment is 5-6 days and on average most admissions are 3 days, I don’t see how this is to be helpful. Discussion of staff resistance and burnout are also discussed.

Chapter 7: This was very interesting as I’ve never really read about military psychotherapy before. The chapter gives specifics on how to approach a veteran or active military personnel in crisis or dealing with suicidal thoughts. It talks in detail about Brief Cognitive Behavioral Therapy (BCBT) and the steps per session. Not all persons will respond within the 12 sessions. It is individualized for each person. The chapter also talks about hot to discuss lethal means safety and means restriction (see chapt 9 for more information; e.g., gun safety in particular). When the sessions are down to the last two and command of previous exercises are demonstrated to be efficient, end of therapy is initiated. Booster sessions are discussed in case of future crises should happen. I found this therapy to be specific not only for military but can be used for any type of suicidal behavior. It’s a collaboration between therapist and client.

Chapter 8: Emergency departments are the top places suicidal people end up, either with an attempt, ideation, or crisis. Sadly, if the right precautions are not set (e.g., inpatient care or some type of follow up care), individuals are more than likely to die by suicide.
This chapter talks about the challenges and brief interventions that can be initiated so that death by suicide does not occur after a visit. The authors describe specific suicide safety planning that is individualized for that person to help them cope with stress that makes suicide appealing. It also gives crisis numbers, either a trusted person they can talk to in time of need and/or the National Suicide Hotline (1-800-273-8255, text 741741 (US only)). Once a little role play is done and the individual can demonstrate they will use this plan, patients are discharged to follow up outpatient care.
Only trouble I have with this approach is that not all EDs are equipped with mental health professionals and don’t have the 30-45 minutes or so it would take to implement the safety plan, even though it is crucial this should happen.

Chapter 9: As more and more evidence is building that suicidal individuals are seeing a primary care provider prior to death by suicide, it’s become imperative that PCPs have the training to ask patients for means restriction. The author suggests several ways to initiate the conversation and lists steps to do this. If patients are resistant, the use of motivational interviewing techniques are employed. The end result is a means restriction receipt where PCP and patient have agreed to restrict their lethal means. If possible, a supportive person is asked to help secure the means.

Chapter 10: This chapter talks about the use of psychotropic medication and the use of CBT or BCBT in suicidal patients. To date, there has not been studies where therapy and medication has been shown to be effective in reducing suicide risk. It is suggested that despite the thoughts and black box warnings of the FDA, suicide ideation is still likely to occur of not treated or dealt with at the beginning of pharmacological treatment. The author also discusses the risk of substance use and dependence disorders that can increase the risk of a suicide attempt. PTSD has also been discussed as hyperarousal states can increase suicide risk.

Concluding thoughts: Overall, I found this book to be extremely helpful, concise, and important in the prevention of suicide attempts. With the right intervention at the right time, Brief CBT can help decrease the suicide risk and possibly the overall suicide rate.

Friday Morning blog

Friday morning blog

I am watching my niece today because it’s Good Friday, a religious Catholic holiday. She has the day off from school, something that I never got when I was in school. Apparently, rules changes concerning religion so any time there is a religious holiday due to whatever domination, the kids have the day off from school.

Next week is April vacation week. I will be watching my niece on Tuesday as well. Today I will be ordering pizza. I don’t know what I will be doing Tuesday. Maybe I will take her to Starbucks with me, if she is willing to go. I was thinking of going today but my ankle is hurting kind of severely. I really don’t want to leave the house.

I woke up to a weird dream. I dreamed that I was in therapy with an older woman. It was our second session and I could barely hear her as she had laryngitis. My former therapist was in the room while we were talking. Then my teddy bear became a male toddler. He had just a diaper on him and was getting cranky because it was wet. I didn’t have another diaper but the therapist did. As I was changing him, he started crapping and it was diarrhea. I cleaned him up and he crapped green shit again. I got it all over myself. There was a shower in the office so I washed him and myself up. I didn’t have another diaper to change him. I felt like a bad father. I had no idea why my teddy bear became a live human. Anyways he walks to a chair and as I am telling him not to sit down, he sits and shit gets all over the chair. I pick him up and then I wake up, shaking my head. Weirdest dream ever.

I just ordered pizza and fries. Should be here in about a half hour or less. I can’t wait. I have been craving pizza all week long. I ordered a large so that my mother can have some, too. I usually order half because no one but me eats cold pizza. I don’t like it reheated. It tastes funny.

I am going to try finishing the CBT book that I started earlier this week after lunch. I should type up what I have written for the blog I am writing. I wrote it in a notebook on Monday. It’s an interesting book and I find it exciting to read because it stimulates my thought process. It’s a short book, only about 8 or 9 chapters and I am in chapter 5 right now. Reading it is not technical, least for me because I have a clinician brain. I am learning as I go as I am more psychodynamically oriented than Cognitive behaviorally. I can’t wait to write up this blog!

For the Love of Espresso

For the Love of Espresso

Yesterday, I made coffee at home and when I poured the half and half, there was shit on top. I asked my mother if it was fine and she said it was “cream”. Coffee tasted okay and I didn’t die as I am living to tell the story. Today, the curdling was worse and I wasted a cup of coffee. I was pissed because the half and half was a new quart that hadn’t been opened yet and had an expiration of Dec 21. I had a Neurontin hangover and I desperately needed coffee. But it was Sunday and there were no direct buses to the Square. I just missed the bus going near the Square, which pissed me off more. I had to wait an hour for the next one. I decided to sojourn in the opposite direction and take the trek to Station Landing, where there was a Starbucks.

I decided just to bring my book with me because I didn’t want to carry anything heavy as that would make the long walk more strenuous. I was feeling pretty good so it wasn’t much difficulty getting to my happy place. I stayed for an hour after having a sandwich and my much desired drink. I read to the point where Lincoln is elected president, South Carolina secedes from the Union and the Lincoln family enters the White House, along with Hay and Nicholay in tow.

It took me fifteen minutes to get back to the train station and to my stop. Not bad for someone who is disabled. Though by the time I was waiting for the bus home, my ankle was starting to throb and increased by the time I got home. I took a pain pill soon as I got into my room. My sister had invited us for dinner and I was just in time. I was kind of hungry from my travels so the timing was perfect. I had half a glass of wine before I realized I had just taken a pain pill. OOPS. I hope it doesn’t cause drowsiness because I don’t want to fall asleep this early. Last night I fought against the drowsiness and couldn’t sleep until nearly 0300. Anxiety from possible pain kept me awake. It was terrible.

I have my first session of CBT tomorrow. I am really nervous as I am more psychodynamic than a cognitive person. To me, this therapy is rigid and I don’t like rigid but, unfortunately, all the current research has lead to say this form of therapy helps those with chronic health conditions so I am giving it a shot against my better judgement. I hope the therapist is willing to work with me and not against me, with the “I know better” attitude. I will be out the door so fast if this is the case. I also hope that the therapist allows my therapist and I to work while doing this as an adjunctive thing. I have mixed feelings about this therapy and the process. I hope it will be a brief therapy, with kind of a relapse therapy sessions available if needed kind of thing. AND it MUST focus more on my pain issues than my depression as the pain is more debilitating me than the depression right now. I also hope the therapist isn’t going to freak out when she finds out about my suicidality. That is another element I am afraid of, being turned down because I am “too sick” for therapy. I don’t know if this therapist is on the up that CBT can actually help suicidal thinking as well. I really hope I don’t have to be the professor either. She is a resident, not a full fledged therapist so we’ll see. If I have to resort to being a suicidologist to her, I will. I have a full library on the subject so I think I know what the hell I am talking about. I just wish I had the time to read Craig Bryan’s book about CBT in suicidality. Damn depression. Maybe I will take it with me and show it to her so to give her background that this isn’t my first therapist and won’t be my last that I have to “train”.

I had to further aggravate my ankle/foot by going downstairs again because I had to use the bathroom. I don’t know who’s brilliant idea it was to have bedrooms upstairs without at least a half bath. Sure it would make the bedrooms smaller but it would be a life saver!