0:01 hello everyone this is a new topic here in in DBT intensive and it's the suicide crisis protocol very important topic obviously and at the core of DBT and you consider that Marsha Linehan was first and foremost a suicidologist suicide behavior researcher and that is really what led her to develop DBT was to reduce suicide suicide attempts self-harm behaviors and other related behaviors so this is at the core it's really important so on the other hand isn't all of DBT a suicide protocol you
0:49 might say suicide treatment protocol and I would say yes it is so what's different about this one thing that we're going to talk about now is that it's the suicide crisis protocol if you remember suicide types of behavioral targets if you were listing the person's primary targets for treatment very high on that list are life-threatening behaviors very high among those behaviors are suicide behaviors the highest suicide risk behavior out of a list of five types is the suicide crisis behaviors and those are the kind of behaviors that make you worry as a therapist that you know the person might be dead before they see you again based
1:35 on their suicidal risk factors so this is an acute this is when there's an acute episode of elevated suicide risk compared to your usual suicide ideations for a given client and you have to use people as their own baseline for this so for instance on a diary card if somebody presents with a suicide ideation or suicidal urge of four out of five and they're usually at two that's a crisis if they present at three and they're usually at one that's a crisis and generally Linehan has recommended that if somebody jumps up by two points over their usual baseline
2:22 consider that a crisis it's also a crisis just if you're in the middle of a session and you learn about the current situation and the current clinical status of the client and it's obvious to you that you know there's a there's a higher suicide risk edit and you feel you need to depart from business as usual in order to focus in on that and that's what this protocol is for it's really to depart from usual business which is to try to work towards a life worth living and an lowered suicide risk as a result of that and it's to zero in because things are getting close to where you think it's more dangerous and it isn't like there's anything brand new in the protocol it's a it's a
3:07 combination of a lot of elements of DBT and I want to go over it with you and the main ingredients in the protocol are first of all the suicide risk assessment what are the factors you consider to tell you if you think that there's elevated risk and to confirm that there might be elevated risk as difficult as it is to predict suicide there are still a number of statistically based risk factors that increase that at least correlate with completed suicides and then there'll be the protocol we'll move into what do you do so it's the risk management part I'm going to talk about the suicide risk factor as an assessment
3:54 and then also at least orient you briefly to the Linehan risk assessment and management protocol or the L ramp Linehan risk assessment and management protocol which is a now has been developed and is a seven page step-by-step way to assess suicide risk document it make decisions about what to do about it document that and then have a disposition at the end of that document that and so it's it helps you think clearly helps you stay on track and also helps you have documentation for how you've thought it through which could be useful for all kinds of reasons mm-hmm all right so I'm gonna go through
4:42 slides and then depart from slides now and then to just talk a little more but the slide the first slide is a as a title slide in among the slides that's the DBT suicide risk protocol it says guidelines for suicidal crises suicide risk assessment L ramp and the suicide risk protocol okay so let's start with guidelines either like general guidelines for dealing with suicidal crises they aren't the protocol they're kind of the background to the protocol mm-hm and there were I have three slides about this which adds up to about twelve different guidelines so let me go ahead with that first you have
5:28 emotions there to come contact to touch in the patient and you also have content the patient may be telling you about the situation and you may be tuning into the content tuning in to the effect and the first guideline is just to realize the extreme importance of connecting with the effect tuning to affect validating effect if you had to make a choice which you might not have to you want to prioritize making an effective connection attunement over getting all of the content and going over content you can go over content and if you don't make a connection it probably won't reduce the risk very much but sometimes just making a really
6:15 good connection hearing the patient out about their suicidal thinking their suicidal planning their suicidal effects can be helpful okay second explore the problem now as opposed to long-term in other words somebody might want to start telling you why they need to die that goes back years of hopeless of episodes in their life of factors in their life that generate hopelessness all of which might be worthy of discussion but not during the suicide crisis because actually to go into those probably just heightens the sense of hopelessness and it's hard to counter things that go way back so what you really want to focus on is what's been
7:01 going on since the last session and in the last couple days that has really brought suicidal risk or crisis or ideation or urges to a higher level and so it's a focus on now rather than reviewing history the next guideline is if you have a choice between focusing on emotional tolerance tolerance of distress effective tolerance as opposed to changing affect you know transforming your emotions you want to probably highlight affect tolerance techniques affect tolerance concepts because you might not be able to change the emotion right now but you might be able to help the person ride through the current level of distress until things can go
7:48 down so prioritize affect tolerance next guideline is to while you're interacting you want essentially you want to really prompt and reinforce the patient for taking action toward safety themselves so anything at all even if they're highly suicidal if you can pull for behavior that's that's attempt to remove themselves from the means let's say for suicide or the location that they're more likely or to take action to get away from a person whose presence triggers the increased likelihood of suicide anything they can do to take
8:35 action themselves and not just become the passive recipient of all of your efforts mm-hmm next guideline it isn't like there's any one thing that's the right thing to do here you really have to explore use these guidelines use the protocol but it's a lot of kind of feeling your way trying things prompting things assessing where you're at ten minutes down the road of these kind of interventions and being flexible in what various things you're considering you know whether it's hospitalization all the way out to no major intervention or having them team up with someone else or be with somebody or having them have a check in with you
9:20 later in the same day or the next day or more frequent sessions briefly or something like that whatever you're going to be considering doing make it flexible ranging from the most aggressive I'm going to I'm going to have to take over to staying back and letting the client generate safety promoting behaviors next one be willing to openly discuss and listen to discussion of suicide there's nothing really positive to be said for telling the patient the discussion of suicide is off the table which is what I've heard sometimes people say no if anything that increases the pressure towards suicide
10:08 the person is more alone with the thoughts of suicide so you want to be willing not that you want to spend a ton of time on it at least during a crisis but you want to be willing to hear that they're thinking of killing themselves and and they might say something about you know why that's coming about and then you want to get some assessment of that and the likelihood of that and then and then consider what to do you know to try to reduce the risk until your next contact this is an until your next contact kind of protocol right what else it can be very helpful as a guideline to make comments that indicate that you
10:53 understand suicide is from the patient's point of view suicide would be a solution to problems wouldn't and and even though it's a problem in itself really the more important unders the more validating understanding is that okay so you've arrived at suicide as a solution so let's talk about the problem and what has escalated the problem and what we can do about that and next guideline be steadfast and explicit in arguing or stating that you don't think suicide is a good option that it is an irreversible solution to what can be a reversible set of problems
11:39 and that you're just not ready to go there you couldn't support that right now as a as a plan you won't help support that you won't help figure that out and just keep maintaining that you don't think it's a good option you're patient it may be sounding you out or a reading between the lines saying to themselves oh does my therapist think that suicide is okay that's my therapist actually quietly think it's the best thing to do because the therapist just can't say it out loud so you want to be clear to drown that out any fantasy of that next guideline schedule contacts frequently enough and there's no real guideline right here I wouldn't overdo it but I really don't like I mean if
12:25 it's too much then the person probably should be in another level of care if that's the only thing that you think is gonna work but I would increase the frequency of contact a contact could mean checking in by phone leaving voicemail for you to tell you how things are going maybe scheduling an extra appointment that week or checking in briefly in brief appointments through the week okay another guideline which is different than standard DBT is to more involve significant others so you're getting at a point where suicide is a crisis it could happen the risks are up the door is open so to speak and this is the time
13:12 to consider whether there's certain supportive significant others in the patient's life that you might involve that both will help with making clear the point about trying to address this firmly but also brainstorming solutions with other people who have often more contact than you do with the client next one avoid that putting yourself in the position of being the omnipotent rescuer the one who feels that this is my job I've this has come on my shift and I'm gonna handle this and it can for some people really activate the sense of I am the omnipotent rescuer I'm gonna do this I don't know what other people think going out of your way I'm going out of
13:59 usual protocol be careful about that it can be a temporary state of mind which actually can increase the risk for the patient and increase your own risk as a therapist in a number of ways what we want to be doing is trying to coordinate this in concert with the colleagues where our team members or even a consultant final general guideline is to focus yourself on problem solving you're gonna hear that throughout the protocol though you do validate start by validating in here without suicide you really want to be making suggestions giving advice being more directive than usual suggesting skills framing solutions in terms of skills predicting
14:45 future consequences of behavior at some times confronting the patient's maladaptive ideas okay be back with you in the next video to move on to the protocol
