Treating Chronic Suicidality in an Outpatient Setting

Dr. Amanda Fialk: Welcome. We are here today to talk about treating chronic suicidality in outpatient settings. And with us to give this presentation is Michael Riley, who is the director of the Menninger 360 program. Michael has a special interest in emerging and young adulthood as well as co-occurring disorders. He earned a Masters of Social Work and a Bachelor of Science in the Brain Behavior and Cognitive Science from the University of Michigan Ann Arbor, and he completed a postgraduate fellowship with the Menninger Clinic in 2013 before becoming a staff clinician. So without further ado, I’m going to turn this presentation over to Michael.

Mychal Riley: Thank you. So I’m going to start the presentation, so give me one second to share my screen. All right, there we go. And so again, I want to thank Amanda for having me and the Dorm for having me to talk about this topic. So the learning objectives for today will be to talk about the difference between acute and chronic suicidality and generally some background about the data behind suicidality, to discuss evidence-based variables that contribute to chronic suicidality, and then also to think about some of the value of suicide-specific treatment based on collaboration with clients. And I do want to just plug, so I’ve worked with Menninger for about 10 years, and I would say over 60% of our clients struggle with suicidality, either acute or chronic. In that time, I’ve worked with probably over 60 or 70 clients who have chronic suicidality. Of those, I’ve lost a few. And so this topic is really important to me because I think as clinicians, working with suicide can be very scary, and thinking about how we can do so safely when there isn’t really a manual to do it is really important. So I’m hoping that if nothing else, people walk away knowing that this isn’t an easy thing to do, and if we think about it effectively, we can do it well.

So with that, we’ll jump right in. So I always like making sure I’m using the same language where everybody’s on the same page, so I just want to do a quick defining suicide, although most people know this. So we think about suicide as when people harm themselves with the goal of ending their life and they die as a result. The reason why I start here is because we no longer really use the term “committed suicide” just because of the negative connotations that come with that. So that really invokes that there’s a criminal overtone there, that the client did something wrong. But what we know is suicide is something that lots of people struggle with, and it’s not a matter of right or wrong. It’s a matter of figuring out what’s driving it for them. And so throughout the presentation, you’ll hear me using language like suicide or die by suicide or suicide and turning it into a verb versus “committed suicide.”

Suicide attempts are when people have the goal of ending their life but do not die. Passive or indirect suicide, so this isn’t a terminology I use too often, but you will hear it. This is when we’re thinking about people not taking as many active steps to suicide, but maybe their wish to die is very high, and so they’re engaging in other behaviors that could lead to suicide. So things like reckless driving, refusing to eat, refusing to take medications like diabetes medications that are needed for them to survive. I kind of lump all that into behaviors that I’m assessing for a client versus separating them out, but some people do.

The last piece I do want to touch on is non-suicidal self-injury, which is self-injurious behavior without intention of ending one’s life. We, 30, 40 years ago, some of the scholars would lump this in with suicide. We’ve really found over time that the drivers for non-suicidal self-injury can often be different or separate from suicide. There are links and it can be helpful in predicting someone we may need to assess, but we’re also finding there’s a paradoxical relationship in that non-suicidal self-injury is actually for a lot of clients providing relief from some of the pain that drives suicide. And so while we want to watch NSSI and target interventions toward it when we’re working with clients, it is important to recognize that there’s a distinction between the two.

So that’s kind of some of the boring background. We’ll jump into some of the data. So this data was intriguing to me because it shows that from 2000 to 2018, we saw suicide rates go up with a slight decrease from 2018 to 2020. We don’t have all the data yet for the last few years, and I’m really interested in seeing how COVID impacted that. But the bigger trend is still there. So from 2000 to 2020, even with that decrease, we’re seeing an increase in suicide rates. There are some theories about that. So we’ve seen some closures of community mental health clinics, but we still don’t totally know why. But we know this is something we probably really need to focus on and address.

Also, the other thing is the advent of the internet. So people’s access to ideas. We are actually working with a 12-year-old in our program right now who had a pretty significant suicide attempt, and we were all surprised when we learned how she found out about them. So what we know is from the time we’re five to later adulthood, suicide is among the top 10 reasons, top 10 causes for death. And what we also know is that for adolescents and young adults, it is the third and second respectively cause of death. So this is why this is so important for the populations that we’re treating across the board, but especially young adults.

So some important facts. As I was saying before, adolescents and emerging adults from 10 to 24 account for 14% of all suicides. It’s the second highest cause of death, with 6,000 a year, close to 7,000 a year. Some of the groups that are most at risk are non-Hispanic American Indians and Alaska Natives, sexual minorities, and we don’t have the stats for the LGBTQ+ community totally because a lot of those folks can’t report or don’t feel comfortable reporting their identity, and so it’s hard for us to get that. But that’s data we’re trying to get more, but we know they’re one of the higher at-risk groups. Interestingly enough, compared to other groups, young adults and emerging adults don’t have the highest completed rate, but they tend to have the highest attempts and end up with the highest in ER visits. So that’s what that last stat is.

But behind all these numbers and all this data are real people. And so for the rest of the presentation, I’m going to use a case that we’ve worked with. Actually, before I worked at Menninger 360, I worked at a program called Pathfinder through Menninger that’s a lot like the Dorm, where it’s a community integration program where we’re looking at treating clients outside of the hospital, outside of locked walls. And so one of the cases I’m going to use throughout this presentation is case JJ. So JJ was a 20-year-old when we started working with them, who had just finished eight weeks on the inpatient side of the hospital. JJ was a pretty complex case in that they started therapy when they were 10. So they were pretty tearful in class, they were sleeping more, and they were really hard to regulate. And so their parents started therapy. As early as 11, they were starting to have thoughts of suicidality. They ended up at 12 having their first inpatient stay, and for the next four years, they were in and out of residentials and inpatient hospitalizations.

They had a period of time for about four years before they came to us where they were maintaining outpatient. And I say maintaining because they reported to us they did not feel like they were progressing. They felt like they were just maintaining during that time. And what led to that current hospital stay was the loss of a friend, actually from treatment, who either overdosed or died by suicide. It wasn’t totally clear to us. And then the stressors of college and being uncertain about their future made them finally drop out. And so that’s what brought them to us.

I will say, without getting too far into it in this presentation, I’ll get into this later, they had a lot of trauma, some which was clear, about which they could recognize certain things as traumatic but not others, including some of these very abrupt losses in their life. This was a polysubstance user, so a lot of marijuana use and alcohol use. Highly, highly emotionally sensitive. This client could barely tolerate being in a session for more than 25 minutes, and that was if we were lucky. And typically the session ended with them very upset with us. And that’s going to be something that we talk about when we look at some of these variables we want to pay attention to.

Very ambivalent attachment style, which made interpersonal relationships difficult. Lots of sleep difficulties, which adds to the complexity of this case. And then high shame and perfectionism. And then really a lot of relational difficulties. And what was interesting is they had done a lot of family work in their first inpatient stay as an adolescent, and you could see that from the parents. And the parents were quite nurturing, but this was one of the situations where the temperament didn’t necessarily match. They were given a diagnosis of borderline personality disorder early on, which adds this complexity, and I’ll touch on that a little bit later in the presentation. So JJ, we’ll keep referring to, so hold them in mind as we keep moving on.

So acute versus chronic suicidality. JJ fit in this category of chronic suicidality. And how we really think about or distinguish the two: acute suicidality typically will be associated with some combination of reversible factors or stressors happening in someone’s life. So it might be substance use, it might be psychiatric disorders, it could be losses. This can typically be addressed directly, targeted, and what you would see is when those factors reverse, the suicidality should dissipate.

In contrast, chronic suicidality is typically a pattern of recurrent suicidal thoughts, behaviors, gestures, or threats. And we’ve seen chronic suicidality is not amenable to the same rapid change you can see in acute suicidality. So with acute suicidality, you might do a hospitalization and the person is able to keep themselves safe, or direct intervention. With chronic suicidality, you want to directly intervene, but we’ve actually seen that, and especially with some of the complex diagnoses like borderline personality disorder, repeated hospitalizations can be counterproductive. And a part of that that we found is you want to target the suicidality directly, which is going to be a theme in the presentation, but also recognizing that with chronic suicidality, when you start to take suicidality off the table for them, that actually may make people feel less safe if that feels like an option to escape pain. So let’s touch on why that might be.

All right. So that takes us all the way back to suicidology. So Dr. Edwin Shneidman founded the Los Angeles Suicide Prevention Center and started doing a lot of the early research on suicide, particularly complex suicide and what drives that. He was also Chief of the National Institute of Mental Health, which was pretty cool. But what he really looked at is that suicide is typically an effort for us to deal with negative affect or pain. And it’s something that he coined psychache. So psychache, he theorized that suicide is really pushed by pain and our efforts to escape it. And it’s typically an intense pain that’s pushing us into a place of needing to escape.

And so he goes into a lot of more points about this that I’m not going to totally touch on today, but the idea is this is typically one of the biggest drivers. It’s typically the more concrete things clients will say is what’s driving their suicide. So these are going to be things like their shame, their depression, their anxiety that is making it feel very uncomfortable.

And so in his research, he actually created what we call the Shneidman Cubic Model of Suicide, which looked at the psychache or psychological pain and suffering. He also looked at press, which we refer to nowadays as stress. So really the pressures, stressors, or demands on an individual that really take away from their ego resources to be able to support themselves and cope.

The last thing he talked about was this concept of perturbation. Which when we’re talking to clients and even sometimes when I’m training clinicians, we talk about agitation. It’s kind of how to think about it. But this isn’t anger or frustration. This really is that sense of not being able to sit in your skin. So when we talk about JJ, I’ll explain more, but you could see in the room where they would physically turn in on themselves, and it felt uncomfortable. You could see that it felt uncomfortable to be in the room, to be talking about the topics that we were. Dr. Shneidman theorized that this energy is really what would push people past the fears or other barriers of suicide.

In addition to Dr. Shneidman’s variables that we want to keep in mind when working with clients, we also want to look at hopelessness. And this came from Aaron Beck’s research. And this really is expectation that they won’t get out of the negative situation or it won’t get better.

The last variable then is self-hate. And this came from research in the VA with Air Force personnel, where they found that 60% of personnel who participated in the study reported some form of self-hate or that they weren’t acceptable or unlovable or not worthwhile. And so when we’re looking at these variables, these five variables can be very predictive that you need to do a more thorough assessment and that someone may be moving closer to what’s driving them to suicide.

All right, so those variables, though, are separate from drivers. And so when we look at our indirect drivers, which I’ll get to in a few slides, but those are the things that put someone more at risk and warning signs. And then direct drivers, the things that are actually going to move us to suicide being an option. And so as I was saying, when we look at direct drivers, these are going to be very specific thoughts, feelings, behaviors, and patterns. So these are going to be identifiable things. When we’re getting close to a suicide attempt or after a suicide attempt, a person can link back to, this is what was pushing me to that. A lot of times these are going to be internal experiences, and it’s really good to have a thorough understanding of that.

And direct drivers are things that we think about more commonly as risk factors and warning signs. And so I’ll go to that in a minute. I do want to say the driver’s language I’m using really comes from a treatment intervention we’ll talk about a little bit later called CAMS. You don’t have to do CAMS to assess any of these things. These are all research variables that are helpful in thinking about clients. And again, the indirect drivers don’t necessarily trigger a crisis, but they increase someone’s vulnerability.

All right, watching time, we’re doing okay. All right, so risk factors are stressful events or situations that may increase the likelihood, as we said, but they are not predictive. So again, two clients can have the same amount of risk factors, and one may be at higher risk for suicide than the other. One may never think about suicide. One may think about it all the time. Some may have less risk factors but still be someone that you want to monitor really closely.

Warning signs are those kind of early observable signs that in the near term, so hours, days, or weeks, this person is moving closer to suicide. And then protective factors, of course, the things that put barriers between the client and suicide.

And so when we think about common risk factors, these are some of the things that we all know. So, you know, history of prior suicide attempts, psychiatric conditions, substance use, suicide ideation, perceived burdensomeness, limited coping skills, a lot of psychosocial stressors, but also things like age, gender, and race. And so one of the things that I don’t touch on as much in this presentation, just because I ran out of time, is a lot of the biological factors that we want to pay attention to, a lot of how the early trauma can change some of the stress pathways in the brain and how we have data showing that the brain structure can change for some folks who are struggling with suicidality.

One particular risk factor I want to make sure we touched on is sleep, because sleep is one of those things that as clinicians, we can sometimes, especially when we’re working with a client who has chronic suicidality, we may look past because we’re really focused on suicidality. But sleep can be a very big predictor of what’s going on for the client. Not only does it give us less resources that we can use to cope, it also can make some of the underlying disorders or things like that, the symptoms higher. So sleep is something we want to be thoroughly assessing. We have the privilege here of working with a sleep clinic, so whenever we’re worried about it, we can kind of refer out and get more support. But each of us as clinicians can be looking at that and trying to work with clients on how to address it.

Warning signs, those more predictable, you know, hey, we’ve got to really do something different right now. We use the linear IS PATH WARM acronym to help us look at the big things we need to be watching for when working with clients with suicidality. So ideation, is there substance use, what is their sense of purposelessness, where is their anxiety, how trapped are they feeling, how hopeless are they feeling, how withdrawn, anger, recklessness, and mood changes. And so those are kind of things that we want to be looking at every single session, seeing where they are from the last session and kind of building a picture and a mental model in our mind of how the client is doing.

All right, so protective factors. And I’m just going to add all of these in right now. So when we think about protective factors, we want to think about things like how connected is the client to their family or a support system of some kind. Is there a fear of pain or dying? Is there any cultural or religious beliefs that discourage suicide and support self-preservation that we can pull on? Do they have support through ongoing relationships with providers? Do they have problem-solving skills, conflict resolution skills? Do they have access to care? Do they have access to, can we limit their access to means? And then are they future-oriented? Are there things that they could see that they want or could get out of their life? The protective factors can also help as a part of the treatment planning and thinking about what things do I want to help put around this young person when I’m working with them.

So we put all that together and get back to our case study in JJ. So when JJ came to us, thankfully there at that phase, while suicide was still definitely on the table for them, they were willing to set it aside. So their overall suicide risk of suicide right in that moment when they first started working with us was a little bit on the lower side. And what we found is a lot of these variables were really high for them. So psychological pain had been there since they were 12 years old. They had found treatment helpful, but they found that when they left treatment, it got pretty high again pretty quickly. And so that was something that we knew we wanted to kind of watch with them.

I was telling you all about the perturbation. And really, when I say this client could not tolerate it, the sense of shame this client had, and a lot of the shame was tied to the hopelessness that they’d been in this cycle of being in treatment, going to treatment centers, getting better, and then collapsing again. And in their mind, they didn’t think that after really, after eight years at that point, they weren’t hopeful that this was going to change. And they couldn’t see how they could keep doing this cycle the rest of their life. And because of that, there was a lot of shame around, why am I this way and why can’t I just be different?

And so whenever they had to start to interact with that shame, you could see the perturbation in them. You could see them unable to sit in the room. Two of my colleagues who I’ve worked with on this case, we would all kind of call each other whenever. It never failed that someone that week was going to set them off. We just didn’t know who. And we had to kind of really support each other and say, like, this is not necessarily about something we were doing if we couldn’t figure that out. Sometimes we would have to say, like, okay, so is this about how they’re just experiencing being in the room? That nothing feels helpful? And they would tell us, you know, it’s frustrating because I feel frustrated, I snap on you all, then I leave and I feel even more shame. And so then I have to come back in the room and I feel this way all over again. So this discomfort, just really this agitation of wanting it to be different so badly and not knowing how to do it.

Their self-regard, again, attached to the hopelessness, was pretty loud. So already we see we have all four of these variables. So as a team, we started thinking directly pretty quickly. We really need to be monitoring suicide with this client every single session and every single day.

Similarly, when we looked at the indirect drivers, these are some of the history I gave you before. One of the big ones we noticed was they had an ambivalent attachment style. And so the very nature of what we were trying to do with them and doing this work would activate a lot of the things that could push them closer to suicide. And so when we would see it come up in our work with them, when they first started working with us, the direct driver really was when we made them too close to planning their future and it seemed hopeless that they could ever get there. And so it triggers strong, strong senses of shame and strong senses of hopelessness. And so we had to think about how we were going to tackle that.

So let’s hop to that next. So what do we do? Well, the first thing is thinking about, and this is the part where I wish I was going to say something totally groundbreaking, but it is just as simple as how do we build, get a good assessment, how do we build rapport, and how do we collaborate with the client? And so especially working outpatient, a thorough assessment really is kind of thinking about, I’m a social worker by trade, that old school biopsychosocial. What is everything I need to know about this client, you know? And so doing a thorough assessment in the front end, looking at the likelihood of suicide, looking at the history of other attempts, looking at those drivers that we just talked about, but also those variables. So the warning signs, the risk factors, creating a safety plan, and we’ll talk about that. And then assessing the ability and willingness to collaborate, means restrictions. And then I’m also a big fan of using screeners.

So I have some clients that may not be able to say it the first time, but they can write something on a screener. The screener shouldn’t be the end-all-be-all. Nothing surpasses that whole assessment. But screeners can be quite helpful. At the clinic, we use the SBQ-R, but there are tons of suicide screeners out there that are easy. It can be in your intake paperwork to help flag, hey, do I need to do this assessment? And then I’m going to hit on these other points kind of as we go.

So I’m going to skip that part of the slide. And I kind of just covered this slide, which is just saying how do we look at the client as multi-dimensional? And so one of the things about working with clients who are struggling with suicide, who come in with chronic suicide ideation in the outpatient setting, is we both have to balance having suicide at the forefront of treatment while also looking at them as a whole person. And we’re going to touch on that in a second.

So safety planning. Safety planning is one of those things that the biggest thing about safety planning is both coming up with a plan and documenting it. And I’ll talk about documenting it later. But the things I want in every safety plan I talk to my team about every time is, have we tried to reduce means? So what is the person’s plan if they have one? And what are the means we can reduce? Have we identified how they can cope, and do they have the capacity to cope? And how do we make that bigger? These are the ways I’m also assessing, can I work with this person outpatient? Are they safe enough to be outpatient? What is their support system? Who can they reach out to? What are going to be the barriers to the plan? And then what’s their willingness to do the plan?

And that becomes something really important that I want to talk about. Everything I say in this presentation is based off of the ability and willingness of the client to work with you. We don’t have to get clients to commit to never dying by suicide. In fact, what I found with chronic suicidality, as I said in that third or fourth slide, that often is more than a client is willing to commit to. It’s a lot for us to ask. At the end of the day, their brain is finding an escape for them that feels safe.

So we have a lot more conversations around, cool, how long can you keep yourself safe? Can you keep yourself safe for two months, three months? A lot of times, especially with my adolescents, they will say, I’ll give you till my 30th birthday, or I’ll give you until my next birthday because I don’t want to upset my parents. I can work with that, right? I’m still monitoring them a little bit differently than someone who’s saying I want to live, but I can work with someone saying, I’ll give you till this day, because now there’s some collaboration in there.

The other thing you can use to see the collaboration is the willingness to reduce means. And so I want to talk about that for a second. So the most common means we’re finding is firearms. And I live in Texas, y’all, so trying to get people to give up their firearms is not a battle you want to be in, but it’s also when we have to take on when we’re working, especially with young adults and adolescents around us. And so one of the things I talk to clients and their families about is, can we get safes? Can we get fingerprint safes? So we’re working with adolescents into emerging adults. For the parents, and helping them understand, just like your kids found the Christmas gifts when they were six, and just like they found their PlayStation when they were on punishment that you hid, they’re going to find the key to your regular safe.

If it’s someone who is closer to the young adult side, the 24, 25, 26, with their personal guns, it’s even saying, hey, is there a friend we could leave the firearms with while we’re in treatment, while we’re working together? What’s the one thing you’re willing to do, right? It’s seeing where are they willing to give at all, if there’s anything that they can do.

If the clients aren’t willing to give me anything, they’re like, nope, there’s nothing I’m willing to do, again, that’s where I’m starting to wonder, can I work with you outpatient? But what I’ve found is, if clients see I’m trying to work with them, if using the firearm thing, if this is a person who’s a hunter and I say, I’m not asking you to give up your hunting rifles, I’m asking you to have a friend that, so that when you are in that dark place at two in the morning, there’s one barrier in between you and getting that gun. That to me, if I can get that person there, that’s that piece that shows me, okay, they’re willing to be a little bit more collaborative.

So interventions we use. So the first intervention, as I said before that we use, is the Collaborative Assessment and Management of Suicidality, which was created by Dr. David Jobes. It’s actually not a treatment of itself. It’s just an intervention that focuses on thorough assessment, safety planning, and regular monitoring and monitoring, and putting suicide at the front, and both the clinician and client agree, put it at the front.

What that means is we have to have a comfort level with, A, talking about suicide directly and early and often. B, our limitations that we can’t stop someone from dying by suicide if they make that choice. So we can do all of the no-suicide contracts in the world, but that’s probably not going to work as well as a good safety plan. And C, it’s getting the client on board.

What I love about this intervention is it’s supposed to be quick. So it’s 8 to 12 sessions they say. So it’s really good for acute cases. For chronic suicidality, depending on the clinical makeup of the client, you may need to do it with kind of DBT or other interventions. So we have seen particularly with borderline personality disorder, DBT is still a bit more, has a bit more empirical basis than the CAMS. CAMS still works. We’re just finding CAMS by itself needs more.

But the nice thing about CAMS is it’s designed to work with really any theoretical frame. So if you are a behavioral therapist, you can do CAMS. If you are a psychodynamic therapist, you can do CAMS. CAMS should take one session at the beginning and then the first 10 minutes of every session after that. So it’s something that can be nicely tucked in with other assessment models. And one of the things that you do to make sure it’s collaborative is you sit right there with the client. So when you’re doing the CAMS portion of your session, the client and you are looking at this piece of paper and going through the assessment, so they see what you’re writing and they’re telling you if you’re getting it right. It’s both qualitative and quantitative in that it uses a Likert scale for the pain, stress, agitation, hopelessness pieces, but it’s also using sentence completion to help figure out what are really the drivers for the suicide.

The other most evidence-based intervention right now for chronic suicidality is Dialectical Behavior Therapy. Again, what they’re looking at is the way DBT talks about putting suicide at the front is you have to manage anything that is treatment-interfering first, and suicidality is the most treatment-interfering behavior. It’s treatment-interfering because you can’t do treatment with someone who’s not here. And so we talk to clients directly about that. We get their willingness and their commitment to doing this work. It’s about skill building, and it’s about really saying, how do we make your life more livable and the life you want it to be?

And so I’m not selling either of those interventions, but those are the two most evidence-based. And what I want to talk more about is why and what they have in common. So both interventions have a robust research base, but the thing that’s interesting to me about what’s important for both of them is collaboration, is that suicide is the priority and you’re targeting it every session when it comes up. Your problem-solving what’s driving the suicide. So in CAMS, it’s really making that a part of the treatment plan of we’re going to target what is making you want to use suicide as an option. And DBT, it’s things like diary cards and chain analysis and saying, we’re going to break this down. We can’t do anything else today until we figure out what got you here. It’s thorough safety planning. It’s identifying supports and skills and strength. And then for both of them, it’s saying, how do we make your life worth living?

There’s a question asked in CAMS that most DBT therapists I think ask too, which is, if we could do one thing that would make this better, if we could take away one thing, if we could change one thing, what would it be? And that’s what I think these things have in common. And honestly, that’s what community integration, the work the Dorm and Pathfinder and 360 are doing, is working with clients and saying we can try and solve chronic depression all day long, we can try and solve chronic suicide ideation all day long, or we can look at making your life worth living so that it’s easier to manage the depression. It’s easier to not have to go to suicide as an option.

In part, this is because at the end of the day, we’re really bad at predicting when a client is going to die by suicide. It’s very difficult to predict. The data shows we’re not. All of the warning signs, all the variables, and none of it still says when it’s this collection of things, this client’s probably going to do it. We just don’t know. And because we don’t have the right answers, we have to figure out how to protect ourselves. One of those things is by collaboration, seeing that a client is willing to work with us. I think one of the biggest predictors about whether I can work with someone outpatient or not is, are they, one, do they want to be there? And are they willing to work with me around some of the interventions? We don’t have to agree on everything, and I may be a little uncomfortable at times, and they may be a little bit uncomfortable at times, but can we do this together? And then constantly assessing a level of support.

So protecting our clients also means protecting ourselves. And so that’s why I’ll get to the last part of this, and we’ll get back to our case study. And that’s thinking about, you know, liability and documentation and honestly just self-care. And so malpractice for clinicians really boils down to, is there evidence that we had a dereliction of duty that caused harm to our clients?

And so when we’re thinking about working with suicide, what we’re really thinking about is, is this foreseeable? Could we anticipate that the risk of suicide was there and it was imminent? Was there a clear treatment plan? Did we have a clear idea in, and part of that treatment plan is the safety plan, that we were targeting the suicide? Both DBT and CAMS are very specific in, if suicide is there, we have to target it. That needs to be at the forefront. And then did we follow through with that plan? Did we get consultation where we needed to? Did we help connect clients to the resources they need?

All right, and the other place where sometimes clinicians are doing the best work, or because of their stress, they’re not documenting that work. And so what I tell folks, document everything. Everything you’re assessing here, level of risk, stressors, safety plan, all that should be reflected in your documentation. The CAMS form is pretty cool because the form itself you do with the client right there in the room, then you put that in the chart. So it’s both your treatment plan, it’s the intervention, and it’s your documentation all in one.

Same thing with DBT. A lot of times the diary cards and things like that, if you’re keeping that, you’re copying the charts, you have what you came up with, a safety plan. You have what skills were there. And in that way you can back up the rationale for why you kept working with this person outpatient. I will tell you, for the clients I have lost, as painful as it was, the thing that was most helpful to me is that I could go to my colleagues and review the documentation afterwards, and they would say, this made sense. It seems like though that this is just the outcome you got. Like, you could have done this six more times and it would have worked, and this time it didn’t. And knowing that, being able to just for my own peace of mind go back to that documentation and say, like, I know why I made this choice and I can defend why I made this choice, helped me feel better about what was going on.

Last piece of this is self-care. Working with suicidality outpatient is very, very hard. And so, you know, if you have the luxury of working in a team, I highly recommend working in a team. But even if you’re working in a private practice by yourself, if I’m working with a client who’s struggling with suicidality, I’m referring them to a psychiatrist so I have one more person on my team. If the client refuses but I’m still working with them, I’m consulting and I’m finding a group, whether that’s a CAMS group, a DBT group, or just plain old consultation group of saying, here’s how I’m thinking about this client. Am I missing anything?

The other part of that is knowing your own limits. So, you know, a lot of folks who work in DBT programs will do phone coaching and some people won’t. That’s okay. You don’t have to do DBT to work with clients who are suicidal, but you do need to make sure your clients know what their resources are. If they can’t call you, who are they going to call and what? So knowing what your limits and what you can offer the clients and being very transparent with them about that at the beginning.

And then the last piece, as I said, is preparing for negative outcomes. And so that’s where, as I said, I’ve been in the field 10 years and I’ve lost probably about seven patients in that time because I work so directly with suicidality. And it never stops being hard. The best thing I can do is really, again, heavy consultation, my own therapy when these incidents occur, and really rely on my team and the people who care about me.

So let’s wrap back up with JJ. So what we found in working with them is that they were begrudgingly willing to set suicide aside when they first started working with us. They weren’t willing to say they weren’t going to do it, but they said they would at least give us until they finished treatment with us and then see where they were. We’re like, great, we can work with that. But then suicide became something that we had to check on every session and what was driving it and why they saw that as an option. And for them, it really did boil down to their life was not worth living and they didn’t think they’d ever get out of the cycle.

And so we looked at, so how do we make it worth living for them? A lot of this was not only did they not see a future, but every time they went to school or tried to get a job, they felt like they failed. They couldn’t do it. They felt overwhelmed. They didn’t finish. So part of this was saying, okay, so can we get you some vocational, academic support? We have the luxury of working with rehabilitation, psychiatric rehabilitation specialists who specialize in that area. And so that clinician worked with this client not only around making a plan and moving forward, but disappointments and setbacks and failures and still trying and breaking it down into the smallest steps and needing help.

The other thing with JJ that we found out is working outpatient, we were sitting in the room with this client and we’re saying, we feel like we’re missing something. Because they had had the borderline personality disorder diagnosis for so long, we actually think that maybe something else was getting missed on the biological side. And what we started noticing with their agitation and their sleep being off, and this is where sleep is important, the more we looked at the sleep, we actually found a pattern over the years of where they were sleeping maybe two or three hours for four or five day stretches. So now we’re looking at a bipolar disorder and a mood disorder. The client at that point wasn’t on anything but antidepressants. So we were able to get a mood stabilizer on board. We saw some of the agitation release. And once some of the agitation released, we were able to work a little bit more on some of the other areas, including the recovery work.

The recovery work, I want to really acknowledge my colleague Sonya, who did a lot of recovery work with this client who refused to get sober but was willing to be abstinent while on the program with us and then really worked hard on a harm reduction plan with the clinician when they went outpatient. But that period of abstinence is what led us to see that, hey, them not sleeping isn’t just because they use substances. Actually, the substances probably were letting them sleep more. And so that’s where we were able to say, like, okay, now we’ve peeled that away. So we just kind of slowly worked at this.

I actually did the family work with this client. So a lot of the work with them became helping the family understand what the suicidality provided for them. And then also it was helping the family be more comfortable trusting the client could share, which let the client share more with them. The family was so reactive and so scared that it actually increased the client’s shame, which increased their suicidality, because the client was constantly worried about the fact that they had been in the cycle for eight years and was costing their family a lot of money and a lot of time. And so we did a lot of work around how does everybody learn to trust each other more and recognize that we can’t stop this if the client chooses that route. So how do we support them?

So it’s just as we peeled back each of these layers with suicide as, hey, how do we make this less of an option? Hey, what about this? What about this? Their life became more livable. And as their life became more livable, suicide became less of an option. I’m really happy to say, actually, with this client, they worked with us for a year at Pathfinder, actually two years at Pathfinder and one year outpatient. They just terminated with the team here, so there was about four of us still working with them, and they’re moving out of state. They’re going back to college.

Suicide is still something that they struggle with, suicide ideation when they’re feeling overwhelmed, but it’s not their first option anymore. They are looking at all these skills. They’re able to tell us, hey, I think I can keep myself safe, but I’m really thinking about this a lot. And they’re able to tell us when they can’t keep themselves safe without it being a setback. So this is where actually being able to have those direct conversations about suicide was really important.

And then the last thing I will say is for this particular client, I don’t know that I would have felt super comfortable working with them just by myself. I actually really appreciated having the team effort because if nothing else, it helped us keep our mind in the times where we wanted to say, like, do we go to the hospital? What do we do? We were able to kind of rely on each other and say, like, no, we know that you can reach out to us. I’m available this day. You’re available that day. So we were able to kind of hold them there. And I think the important thing that I meant to say earlier is at the end of the day, we have an onus to have clients at the best, the standard of care is having clients at the lowest possible level of treatment needed. And that’s what we were able to do with this client. We were able to walk with them until they didn’t need us anymore, which I think really helped them get out of the cycle.

And then finally, working in a team with this case helped us have breaks because we all need breaks sometimes in that. So this was a happy outcome, but it also was an outcome that made me realize, despite how difficult and complex this case was, we were able to work with this client outpatient. And so that’s just something I truly believe is important that we can keep doing.

So that’s the case with JJ. Like I said, I’m very happy that they are moving on. And I’m really grateful to my team. Acknowledging a few people before we close out the slides, but I do want to thank Amanda and the Dorm, of course, my team at the Menninger Clinic, the 360 team, but also the Pathfinder team who I worked with for five years, Dr. Jobes, and then Adrian, Lira, Angela, and Patty, who all helped me teach suicide to the clinicians at Menninger, and then Dr. Ellis, who taught me a lot about suicidality when I first came here, and Dr. Allen.

I have tons of references, so I’m happy after these slides are shared, I think the Dorm will handle all of that, but I’m also happy to send them to people. And then just again, thank you all for coming, because I think this is how we all generate more comfort in working with suicide. I will stop sharing my screen now.

Dr. Amanda Fialk: Thank you so much, Michael. That was fantastic on so many different levels. And I want to say a special thank you for being so honest. And I think I saw some comments coming in the chat about this as well, about losing patients. I think there’s a lot of stigma and shame and fear around that as clinicians, and it’s important that we have people who are brave to talk about this very real, that this happens in our field, right? And that we can talk about it even in webinars where there’s 200-plus attendees that we don’t know. It’s important to be able to have these conversations. So thank you for that courage and talking about that in your presentation.

Mychal Riley: Thank you. And that’s honestly, I could probably do a whole follow-up presentation that’s just a couple case studies around that, because it’s hard. And I think it’s hard because on top of losing it, there is a fear. People know I lost people. Are they still going to refer to me? Is the family going to come after me? Are people angry? On top of all of our own emotions around, I spent tons of time with this person over the last year or two years, three years, and they still did this. And did I fail? And I think the thing we have to remember is that mental illness, like all disease, can be fatal. We do have fatality rates. And reminding ourselves again of our limitations is really important, that we can do everything right and we cannot take this option off the table for our clients. And so the only thing we can do then, just like families have to grieve, we have to figure out how we…

Dr. Amanda Fialk: Absolutely. Thank you so much for that. There’s a bunch of questions that have come in in the Q&A as well that I want to try to get to as well in the last 10 minutes or so. One question came in around the CAMS training. Can you recommend one?

Mychal Riley: So our clinic actually found that there’s something called Psy Hub that does a whole bunch of trainings, and they have an online training. If you just Google CAMS, David Jobes’ team has a whole website about how they’ll either send trainers to you or you can, sometimes they’ll schedule trainings. And I saw one question in the chat around the cost. I don’t know the exact cost. And the truth is you can even buy the book. So if you just buy the book and start using the intervention even from there, you can’t say you’re CAMS-trained, but your intervention is going to be there because it’s all stuff we know. What CAMS really does, in my opinion, is it takes the things we’re trained in and keeps it forefront of mind when we’re terrified, right? Because when we’re sitting in a room with someone that we don’t know if they’re about to walk out, it’s real easy to forget, did I ask this? Did I assess that? So it’s all right in front of you.

Dr. Amanda Fialk: How do you handle somebody who is averse to formulating safety plans that involve the standard hotlines, et cetera, because they have relatively rational fears about police intervention, also fears of triggering hospitalization when that has not generally worked in the past due to disruption of meds?

Mychal Riley: Yes. If I’m hearing the question right, what do we do when someone doesn’t want to use a hotline or things that might end up with them getting hospitalized or police response? Yeah, so one of the things that I’ve kind of learned from the CAMS training is that’s a part of my conversation with them. The reason I’m making a safety plan is so you don’t get hospitalized. Your goal is to be out of a hospital. My goal is to keep you out of the hospital. So what do we do? That’s where it really depends on what their support system is. So if they have a support, I might ask, who else are you willing to call that if you’re not willing to use a hotline, if you’re not willing to use this? And honestly, sometimes it’s even better because if they have a family member they’re willing to call, then that person might be more responsive than a hotline can because they can be there in real time.

If they don’t have a support system, it would really depend on the rest of that safety plan. I could get away with, depending on how imminent the risk is at that moment, not having a contact. I might say, like, okay, it’s me or it’s this. But what I would really want to know then is, so how are we reducing means if you had? There’s got to be some way then that we can take this off the table so that if I’m not available and I’m the only person you can call, then how are you going to get in between? And so that’s where we really start doing that. Can we compromise somewhere here? But the reality is I can’t make them call those things. And if they’re telling me, like, I’m afraid of this, that’s not going to feel like a safe place for them to go, right?

Dr. Amanda Fialk: So it sounds like as long as there are other people that they are willing to list as people to call as part of their support network, that, you know, 911 or 988 or whatever it may be, whatever hotline number does not need to be part of a safety plan?

Mychal Riley: Correct. Well, what I will say is, I’m always, and this is one of those times where it’s a little bit tricky from the collaborative standpoint, I’m always going to tell them, and if the difference is you being here versus not being here, I know this is scary, I’d rather you do that. And so I’d rather us have it there and just write on the plan, probably not going to use it, but just so that it’s in your mind, right? Because then I’m also kind of covering myself on my end as well, being able to document that I did say this to them. But if it’s something that doesn’t feel safe, it has a significant barrier. Given what we know about DBT and the potential detriment of repeat inpatient admissions for specific client populations, how do we have a conversation with the client or the family that may be pushing towards a higher level of care, obviously in the absence of acute suicidality risks?

Dr. Amanda Fialk: That is a great question that I actually wanted to put a slide about and didn’t have time. There’s a great article. Let’s see if I can find the name of it. So as far as the family side, I can’t find it, but I think it was something like Communicating Suicide Risk to Families of Chronically Suicidal Clients. And it’s, again, it’s pretty straightforward, but they say, like, basically map out all the documentation as far as protecting yourself, but then talk to families really directly around, hey, long term, this can have an adverse effect. It’s not going to meet your treatment goals. And that’s where, again, I really like going back to clients of, what do you want your life to look like? Okay, great. How is going here going to help you get there? Right now we know that feels safe, but we’re moving away from your goal.

At the end of the day, though, this is back to the collaborative part, which is, if I have someone who is chronically suicidal but giving me acute suicide risk at that moment and they’re not willing to tell me they can keep themselves safe, I’ve got to go to the inpatient side. And it’s mostly because now they’re no longer collaborative. They’re telling me what they want. They’re telling me they’re not going to do the other thing. I can’t say I can keep them safe. So the direct answer to that question is we can explain the phenomena the best we can. A lot of times families will get it. A lot of times what I found is when we’re at the point where the family is saying they want to do it, they’re exhausted. And so what I want to do is say, here’s how we’re going to keep your family member safe and how I’m going to take some of that burden off of you. And then they can kind of wrap their mind around it. But again, that’s where things like DBT, that might be the person that one-on-one individual therapy isn’t enough, but there’s still other levels of care like the Dorm or Pathfinder or things like that where maybe we can add something else around them before inpatient.

Dr. Amanda Fialk: Along those same lines, the question, and we’ll wrap up after this question, there was also a request to put the name of the article and author in the chat. But one last question to get to is, what do you advise for unique situations such as petitioning suicidal individuals and enforcing treatment?

Mychal Riley: I’m trying to see if I understand the question. It sounds like the question is basically asking, what do you advise or how do you feel, and if the person who asked the question wants to clarify, feel free to put so in the Q&A, how do you feel about basically, you know, forcing treatment on somebody who doesn’t want to be in treatment?

Dr. Amanda Fialk: Yeah, involuntary hospitalizations or how, okay, sorry, okay, she’s saying exactly, and or how do you work with individuals who have been forced into treatment?

Mychal Riley: So JJ actually was kind of that individual. They were somewhere in between. They knew they didn’t really have other options. And so at the very beginning of treatment, we were doing a lot of work around what would a life worth living look like for you? And it was just a lot of motivational interviewing around that. And again, I had the luxury of being residential advisors. They had some motivation there. For the clients that are totally coerced, again, you’re probably not going to work with them outpatient, right? We’re going back to inpatient or residential where you can safely do this motivational interviewing that we would otherwise try and do outpatient.

And then the last piece of just my personal feelings about it, it’s complex, you know? I’m really a clinician that believes in autonomy, and we have a duty to keep clients alive, even if that’s not what they want. And honestly, and this is one of those things where I think sometimes I find the CAMS training really helpful, even if you’re not going to use the intervention, because what it does is it really talks about, what do we do when we are in these situations of the clients who don’t want to keep themselves safe, don’t want to do things? It’s just about talking directly with them about the dilemma. And I put it to them. I say, okay, so you’re here right now. You don’t want to go in the hospital. You don’t want to be alive. I’m kind of stuck. I want to support you and make you not feel the way you do, but I can’t do that because I have this other imperative over here that I have to follow because of my ethics and my rules and just who I am as a person, that I don’t want you to die. And so I don’t want this to be a power struggle. So what can we find a middle ground? But sometimes we can’t, right? And so that’s where we have to say, like, that’s where we are now, no longer just in the chronic but also the acute phase, where maybe hospitalization is the right intervention.

Dr. Amanda Fialk: I also think, and then we’ll end, I promise, that especially when working with the younger population, that it’s really important to really explore what the word “force” means to them. I’m not talking about somebody who’s been, like, court-mandated or, like, you know, but a lot of our younger population will say, well, I’m just forced to be here. I don’t want to be here. And when you really explore with them, there were other options, and a part of them chose this, which speaks to, like, a strength that’s inside them that they’re not giving enough credit to. So I do think it’s important to explore the real meaning of that word to them.

Mychal Riley: Absolutely, because a lot of times they don’t see that themselves. One of the things that was so, it was funny because JJ could be so caustic in sessions and it was off-putting, but they also, there was something that just pulled. The whole team really liked them. There was something that pulled us. And what we found there is, even though they had doubts about how much connection they had, they were adamant they didn’t want any connection, but you could feel it in the room. They always came back to the room. So you could point that out and say, like, and yet you’re here. Like, you’re over here, but you could leave, but you showed up for the session. And I’ll tell them, I have clients that say, I slept in the room this morning, but you didn’t. So, like you said, that motivational interviewing of, like, there’s something, though, that made you get up. So let’s figure out what that was.

Dr. Amanda Fialk: Yeah, definitely. Michael, thank you so much.

Mychal Riley: Thank you.