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 bf (feeling, actions urges) Clinician: What stopped you? Think about what you might want to say Didn’t know what to say, hoped he would call (thoughts) to him Then I felt guilt, shame at my behavior (feelings) Guilt can be justified and can help to form apology and relationship repair CHAIN OF EVENTS PROBLEM SOLVING
Clinician: What was going through your mind? Check the facts Fear that he would leave me (thought/feeling) Clinician: Then what were you thinking? I’ll never be able to keep a boyfriend (thought) Be in the moment –don’t project into Clinician And was there another thought or physical the future ‐ mindfulness feeling connected to that first thought? I hate myself, I’m hopeless. I can’t change (feeling, thought) I would be better off dead Hold ice/intense exercise, muscle (thought) relaxation Head felt as if it would explode (body sensation) Clinician: And then? Again avoid projecting too far into the I don’t want to feel this way forever, can’t stand future feeling this way anymore (thought) I can take pills so I don’t have to feel this anymore Pros and Cons –what are the long (thought/action urge) range consequences CHAIN ANALYSIS:
Agitated, needed Miserable. Monday felt stressed at urges to call work, looking forward to to calm down seeing boyfriend, he boyfriend cancelled Friend called, went drinking Afraid boyfriend Argument will leave me, I will never I yelled at him be able to keep a and hung up phone boyfriend BINGE EATING Hopeless, thinking I would be Thoughts: if he loved me he would not cancel, better off dead, pressure in he won’t love me if I head, don’t want to feel this way behave this way anymore Body sensations: empty Feelings: disappointed, OVERDOSE angry, guilty Physical relief at first, Called but could not then self- hate reach friend, went home Antecedent: Boyfriend cancelled . Classical conditioning: In Alice’s previous relationships, cancelled plans signaled the beginning of the end of the relationship
Behavior: Overdose
And the consequences… Consequences in self: Short‐ term fell asleep – which gave me immediate relief of intense pressure in my head, and validation of how upset I was Long‐ term: shame, self‐hate, feeling like a loser, feeling hopeless about being able to get better
Consequences in environment: Short ‐term boyfriend promised never to cancel plans in the future when he found out that I overdosed Long‐ term having to do this analysis, guilty that boyfriend feels responsible for my overdose “Rejecting” behaviors by boyfriend are triggers (antecedents) for suicidal behavior Especially when she is already stressed (vulnerability) She makes assumptions about the intentions of others and doesn’t always check the facts (cognitive error) Cognitive errors around black/white, all/nothing, always/never thinking Erroneously equates feelings with behaviors – self‐invalidates her feelings when they lead to unskillful behaviors (cognitive errors and emotional self‐ invalidation/dysregulation) Impulsive eating and drinking behaviors to momentarily self‐soothe can contribute to suicidal risk (behaviors) Body sensations accompany emotional dysregulation –can be warning signs There are strong, immediate positive and negative reinforcers for her overdose behaviors and therefore these suicidal behaviors serve an emotion regulation function for Alice. (understanding the function) Emotion regulation skills . self‐validation, opposite actions, mindful of current emotion, check the facts, avoid all/nothing, black/white thinking
Mindfulness . avoid projecting into the future
Distress tolerance . Self‐soothe, pros and cons, time out, reduce intensity of body sensations
Interpersonal effectiveness . Clarify what I want to ask for . Ask for what I want skillfully . Learn how to accept no How to avoid vulnerability . deal with stress at work more effectively Review Caitlyn’s case and discuss among yourselves to identify the following:
Target Behavior
Trigger
Vulnerability
Relevant thought patterns
Relevant behaviors
Relevant feelings
Relevant body sensations
Immediate short term consequences in herself Immediate short term consequences in the environment Longer‐term consequences in self/environment
Problem solving around means restriction, avoiding triggers/reducing vulnerabilities
Any other questions you want to ask/information you would like to know Caitlyn is a 21‐ year old mixed race female, lives with her mother and elder brother, just completed an Associates’ Degree and works at Payless Shoes. Caitlyn was brought into her local ER by her mother after she admitted taking an overdose of allergy medication. After being medically stabilized, Caitlyn met with an ER social worker, who administered a Columbia Suicide Severity Rating Scale. On it, Caitlyn admitted she had overdosed on the allergy medication with intent to die, but became alarmed after she took a few pills and went to her mother for help. The social worker takes a suicide history. Caitlyn reports that her severest episode of suicidal thinking was just before taking the pills. She recalls feeling sadness and anger, noticing tightness in her throat and thoughts that she was ‘useless’ and that her ‘life was hopeless.’ She felt hopeless because she works at Payless Shoes, the only place where she can get a job despite just graduating with an Associates’ Degree. Early on the day she took the pills, she overheard a customer saying, her job was for “dumbass losers”. She had spent the rest of the day feeling angry and sad, repeating the customer’s words over and over in her mind. Once she arrived home, her elder brother began pestering her about how little rent she paid their mother, calling her a “lazy bum”. Overwhelmed, Caitlyn slammed the door to her room, thought ‘I’m a useless waste of space’, found her allergy medication and gulped a mouthful. Caitlyn was admitted to the hospital. While on the unit, she recognized that she had experienced trouble sleeping for weeks, spent hours browsing the Facebook pages of friends with “better” jobs, calling herself a “worthless idiot” in comparison and avoiding them. Several of her friends visited her in the hospital and express sadness over what she had done. Her expresses sadness and alarm. Her brother visits and apologizes for calling her a lazy bum. She speaks to her boss several times from the hospital and though he grudgingly gives her the time off, warns he may not be able to guarantee her shift when she returns. Collaboration between client and clinician to identify the events that lead to suicidal behavior, the functions of suicidal behavior, and problem solving strategies that may stop clients from attempting suicide in the future
Increases awareness of events, thoughts, feelings and body sensations that lead to suicidal behaviors
Increases empathy and non‐judgment regarding suicidal behaviors
Problem solving strategies identified during solution analysis can be derived from DBT skills: mindfulness, distress tolerance, emotional regulation and interpersonal effectiveness
Can be used multiple times and on any behavior a client wishes to alter.
Analysis is comprehensive but easily organized on functional analysis worksheets.
Teaches clients that urges and behaviors have causes and consequences, and can be changed. For more on the coping skills referenced DBT Skills Training Manual, Second Edition, Marsha Linehan
http://il.nami.org/ABCs%20of%20DBT.pdf
To see a demonstration of these skills https://www.youtube.com/watch?v=V1GBvP VvOhA Barbara Stanley, PhD, Director Beth Brodsky, PhD, Associate Director Christa Labouliere, PhD Cory Cunningham, LCSW Yvonne Noriega, MPA