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Functional Analysis for Suicide Prevention

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Functional Analysis for Suicide Prevention Working with individuals at risk for suicide is one of the most anxiety ‐producing aspects of mental health work. Learning how to better understand and clinically manage suicidal behavior can: . increase effectiveness in suicide prevention . reduce some of the stress related to treating at‐ risk individuals. A step by step in‐depth examination of the triggers, events, thoughts, feelings, body sensations and behaviors that lead to self‐harm urges and behaviors An effective clinical tool for targeting and decreasing suicidal ideation and behaviors in at‐risk clients. For use in ongoing outpatient treatment settings Functional analysis increases awareness of patterns and consequences that reinforce behaviors and provides opportunity for problem solving Not a one time intervention –can be used whenever there is a self‐harm behavior or urge You will learn how to use functional analysis to: understand the function of suicidal behaviors; identify and analyze client risk factors: environmental triggers, thoughts, feelings, body sensations and behaviors, that lead to a suicide act; Collaborate with clients to identify and apply problem‐ solving suicide prevention interventions. Alice is a 29 ‐year old woman with a college degree who works as an administrative assistant. She is in a serious relationship with her boyfriend, whom she has been dating for 1 year. On Thursday of last week, she attended her therapy session and revealed that she had taken an overdose (with intent to die) of about 12 pills of Klonopin two days earlier. She slept it off and did not receive any medical attention at the time. She and her therapist agreed to do a functional analysis in order to better understand why she made the overdose, and to problem solve to avoid doing so in the future. Understanding the function of a suicidal act can help make sense of the behavior. The theory of Operant Conditioning helps us understand the function of a behavior If something positive results from a behavior, that behavior is more likely to occur again If something negative results from a behavior, that behavior is less likely to occur again Often there are (short‐term) “positive” consequences to suicidal behaviors For example, immediately following her overdose, Alice fell asleep and experienced an “escape” from intense feelings of distress. This is an example of negative reinforcement, which is often the case with self‐injurious and suicidal behaviors –they result in an immediate sense of relief from emotional pain, therefore increasing the likelihood of these behaviors, by removing a negative situation or experience. Therefore, the self‐harm act serves the function of reducing distress, at least in the short term. NYASSC2016 NYASSC2016 NYASSC2016 NYASSC2016 A: Antecedents: Events that lead to B: Behaviors: Actions that result in C: Consequences: Either reinforcing or punishing, thus affecting future behaviors. The theory of Classical Conditioning helps us to identify antecedents and cognitive interpretations that lead to suicidal behaviors. Remember Pavlov’s dog? This model helps us understand and identify triggers (antecedents) for emotional reactions that can lead to suicidal acts For example, the aroma of baking bread might be paired with a traumatic childhood event, and therefore might be the antecedent to a flashback, even in the absence of the traumatic event We are focusing on using functional analysis to decrease undesired suicidal behaviors: . Suicide attempts . Non‐suicidal self‐injury . Suicidal urges and ideation . Suicidal communications . Preparatory behaviors . Other impulsive/destructive behaviors related to suicidal behavior, such as drug abuse, promiscuity, violence Positive Reinforcement (increases chance of a behavior re‐occurring) A consequence that is experienced as positive following a behavior. Example: Child receiving praise after doing a chore Negative Reinforcement (also increases chance of behavior re‐occurring) The removal of an uncomfortable feeling or stimulus after engaging in a behavior. Example: Teen cleans room and parent stops nagging Punishment (decreases chance of behavior re‐occurring) A consequence that is experienced as negative following a behavior. Example: Being arrested for drunk driving Extinction The disappearance of a previously learned behavior due to lack of reinforcement of that behavior. Example: Workers stop asking for a raise when it falls on deaf ears Choose a target behavior Identify antecedent/environmental trigger Identify pre‐existing vulnerability Choose a starting point Conduct a chain analysis Identify consequences Highlight points on the chain for problem solving Problem solve by offering alternative skillful responses Maintain a validating stance and attending to affect throughout the process What is the behavior that is being subjected to the functional analysis? When did it occur? Examples of behaviors to target: . Overdose . Self‐cutting . Head banging . Spike in suicidal ideation or urges to act on a plan . Self‐poisoning . Self‐choking . Standing and contemplating jumping from a bridge or other high perch (roof, edge of subway platform, terrace) . Preparatory behaviors . Suicidal communications . Others? What the individual brings to the current moment in which the trigger occurs Within‐self . Sleep deprivation . PMS . Rejection sensitivity Environmental . Deadline . Stress at work Vulnerability interacts with the trigger . Trigger alone does not always lead to behavior Precipitants/triggers are often specific to the individual, based on their past history (classical conditioning for example). Obstacles to identifying trigger ‐ feelings are experienced as coming out of the blue, clients dismiss what could be a trigger because its “too small” or the particular event doesn’t always trigger unskillfulness Common triggers: . Break up of romantic relationships . Other interpersonal disappointments/real or perceived rejection . Unexpected bad news . Triggers of past traumatic events How to decide where to start chain analysis? First awareness that things are headed for trouble From moment of waking up the morning of the day of the target behavior Work backwards from the target behavior Method of inquiry . Ask for first awareness –a thought, feeling, physical sensation, event, behavior? . Cognitions, feelings, events, behaviors –what did you do, think, feel, what happened, next? . As much detail as possible –do not assume you understand how one step leads to another . For example, how exactly does feeling depressed lead to suicidal thoughts or urges? Collaborative effort between client and clinician Attentive to affect Balance with validation Solution Analysis – weaving in skills Correction/overcorrection – making repairs and managing consequences Avoiding vulnerability in the future In self . Positive (reinforcing) – immediate relief . Negative (aversive) ‐ shame (often not as immediate –kicks in later) In the environment . Positive – attention . Negative –fear of losing people Short term –often only positive . Immediate relief (very strong positive reinforcer) Long term –often more negative . Shame . Scars . Loss Identifying consequences normalizes, validates, helps with contingency management and problem solving Problem Behavior – Overdose of 12 pills of Klonopin, with some intent to die Vulnerability factors –hangover headache, 4 drinks, work stressful Trigger/precipitating event –boyfriend cancelled dinner plans CHAIN OF EVENTS PROBLEM SOLVING Clinician: When did your first notice your feelings change? n/a Monday feeling stressed at work (feeling) . But also Looking forward to seeing boyfriend Na/ for dinner (thought) Clinician: And then? Boyfriend called to say he was too tired (event n/ ‐ Antecedent) I started screaming at him, hung up (behavior) How to express self more skillfully? Clinician: What were your thoughts? Thought if he really loved me he wouldn’t be too tired (thought) Check the facts –is that really true? Felt disappointed and angry (feeling) Clinician: What happened after that? Self‐validate –I’m allowed to feel angry and He called back to try to apologize and said he wasn’t feeling well (event) disappointed NYASSC2016 NYASSC2016 NYASSC2016 CHAIN OF EVENTS PROBLEM SOLVING I yelled at him again (Behavior) Clinician: Did you not believe him? Take a time out (Inquiry into thinking) Right, I thought if he really wanted to he would figure out how to make it Check the facts (thought) Anyway, after I yelled he got angry and he hung up (event) Clinician: What were you feeling? Frustration, anger. I started crying, Allow myself to have my feeling guilty, confused (feelings and feelings behavior) Clinician: What did you do then? Called my best friend for help to sort out SKILLFUL! feelings –she wasn’t available (behavior) Clinician: That was skillful, you were enlisting help to calm down. Yeah I guess. Then I left work for home. CHAIN OF EVENTS PROBLEM SOLVING Clinician: And how were you feeling once you hold ice/intense exercise, muscle got home? Felt empty, agitated, needed to calm down relaxation (body sensation) Started eating a lot of cereal that was in my pros and cons of binge eating – awareness cabinet (behavior) of long range consequences Friend called and asked me to come out (event) Clinician: And what happened then? Had four drinks –got drunk (behavior) Awareness of long range consequences of Clinician: And then? drinking Woke up with a hangover (body sensation) Felt miserable –kept having urges to call
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