Course Articles

Editor's Note: This text-based course is a transcript of the webinar, Assessing and Treating Non-Suicidal Self-Injury, presented by Patrice Berry, PsyD, LCP.

Learning Outcomes

• After this course, participants will be able to explain non-suicidal self-injury, discuss different types of self-injury, and dispel common myths about self-injury.
• After this course, participants will be able to identify ways to assess for non-suicidal self-injury, safety plan, and common reasons why people engage in this behavior.
• After this course, participants will be able to identify clinical approaches to consider when treating non-suicidal injury.

Introduction

• Why is this important for psychologists?
  • Learning how to address non-suicidal self-injury applies to psychologists in all settings (School/Education, Justice System, Medical/Hospital Settings, Community Programs, Outpatient Clinics, Residential/Group Homes, etc.)

I am excited to be here, as this is a topic for which I am passionate. This topic is essential for psychologists to learn how to address non-suicidal self-injury across all settings, from schools, justice systems, both juvenile and adults, medical and hospital settings, community-based programs, outpatient clinics, and also residential and group homes. I have worked in many settings throughout my career, and I have seen individuals present with self-injury in each one. Knowing what to look for and how to help individuals is essential. We need to see things from their perspective and connect with them.

Limitations

• Some of the treatments listed in this presentation require additional training, and this training is not a comprehensive review of these treatment protocols.
• Mental Health professionals are responsible for reviewing scope of practice, including activities that are beyond the boundaries of practice in accordance with and in compliance with your professional standards.

Here are a few limitations of this presentation. Some of the discussed treatments require additional training. Today's training will not comprehensively review all of those treatment protocols. For example, I will mention dialectical behavior therapy (DBT), but training is needed to be proficient in that treatment.

Mental health professionals are responsible for reviewing the scope of practice, only engaging in behaviors within their scope of practice, recognizing the boundaries, and complying with their area's ethical and professional standards.

Terms Defined

• Suicidal Ideation-Thoughts of wanting to die
• Suicide Attempt-Acting on thoughts of wanting to die
• Thoughts of Self-harm-Thoughts about harming self
• Non-Suicidal Self-Injury (NSSI)-Acting on thoughts of harming self

(Donath, C., Bergmann, M. C., Kliem, S., Hillemacher, T., & Baier, D., 2019)

I want to define some terms. Suicidal ideation is thoughts of wanting to die, and a suicide attempt is acting on those thoughts. Thoughts of self-harm include thoughts of engaging in any self-harm, which could be related to a possible suicide attempt, or might not. Non-suicidal self-injury is acting on those thoughts of self-harm.

We are differentiating between a suicide attempt and non-suicidal self-injury because you will approach these in very different ways. I will have a different approach with an individual who presents with non-suicidal self-injury versus somebody who is presenting to a hospital after a suicide attempt. We will get more into this a little bit later. I will also be using the acronym NSSI for non-suicidal self-injury.

Examples of Types of Self-injury

• Cutting
• Scratching
• Head banging
• Pinching
• Hair pulling (Trichotillomania)
• Biting nails to the point of bleeding
• Punching self or objects
• Carving words or images into skin
• Burning
• Rubbing sharp objects
• Teeth Pulling
• Eating sharp or dangerous things (not pica)
• Putting needles or objects under the skin
• Breaking bones
• Intentionally reopening healed wounds

https://www.healthyplace.com/abuse/self-injury/10-ways-people-self-harm-self-injure

Here are some examples of different types of self-injury that come from healthyplace.com. There is a long list of ways an individual might engage in self-harm. The most common that we hear about is engaging in cutting. Self-harm can also include scratching, head banging, pinching, hair pulling, biting nails to the point of bleeding, punching to feel pain, carving words or images, burning oneself, rubbing self until it hurts, rubbing sharp objects, teeth pulling, eating sharp or dangerous things (not associated with pica), putting needles or objects under the skin, breaking bones, or intentionally reopening healed wounds. When a client presents with injuries, I assess if it is an accident or from self-harm. Being able to differentiate between those is very important for treatment.

Special Note

• NSSI is in the DSM 5 listed as a "condition requiring further study."
• Criteria if the person does not meet criteria for depression, anxiety, eating disorder, substance abuse, or trauma-related disorder
• NSSI common symptom within Borderline Personality Disorder, along with suicidal self-injury, suicidal gestures, and/or suicide attempts
• Cultural Formation Interview

(Hooley, J. M., Fox, K. R., & Boccagno, C., 2020; Lewis-Fernández, R., Aggarwal, N. K., Hinton, L., Hinton, D. E., & Kirmayer, L. J. (Eds.), 2016)

In the DSM 5, they have listed non-suicidal self-injury (NSSI) as a condition for further study, and the references are listed there. You will only use that particular diagnosis if the person does not meet the criteria for depression, anxiety, or eating disorders or if symptoms are not better understood within another diagnosis. Non-suicidal self-injury, along with making suicidal statements, gestures, or attempts, are also very common with a borderline personality disorder. Sometimes, people do this as a way to regulate their emotions. Practitioners with this education and understanding use a non-judgmental approach to connect with the person to help them find other ways to express those intense feelings.

The Cultural Formation Interview within the DSM 5 might be helpful if you are working with somebody from a different culture. You need to know how this behavior is seen within their culture. We do not want to pathologize something if it is part of certain spiritual or religious rituals. The Cultural Formation Interview has some great questions within the DSM 5 about how you can understand things from a client's perspective.

Common Myths About NSSI

• Self-injury is rare
• Self-injury always requires hospitalization
• Self-injury is only for attention
• If they really wanted to die, they would cut deeper
• Self-injury is only cutting
• Tattoos and piercings are a form of self-injury
• Nothing helps/there is no treatment

(Klonsky, E. D., Victor, S. E., & Saffer, B. Y., 2014)

https://health.usnews.com/health-news/health-wellness/articles/2014/12/26/myths-and-facts-about-self-injury

(Solís-Bravo, M. A., Flores-Rodríguez, Y., Tapia-Guillen, L. G., Gatica-Hernández, A., Guzmán-Reséndiz, M., Salinas-Torres, L. A., Vargas-Rizo, T. L., & Albores-Gallo, L. 2019)

There are common myths about non-suicidal self-injury.

Myth #1

Some people feel that it is rare when it is pervasive, especially among adolescents. Different studies say anywhere between 30 to 40% of adolescents have attempted some form of self-harm. They must have the proper treatment and professionals, primarily because by the time the behavior comes to light, the person has often engaged in it for a while. It could be anywhere from a few months to a year or more.

Myth #2

The second myth is that self-injury always requires hospitalization or that you would automatically seek hospitalization with any form of self-injury. Research has shown that maintaining them on an outpatient basis and not sending them to the hospital is a better option. Sometimes hospitalization can worsen their symptoms. You will do your standard safety planning if somebody engages in this behavior, and we will discuss it in depth, including the specific questions to ask. If the person has an injury that requires medical attention, we will refer them to the appropriate doctor or ER for treatment. Still, they do not automatically need to go to the hospital.

Myth #3

Something that I often hear from parents is the myth that self-injury is only for attention or so that other people see it. Self-injury is often a hidden and private act and is always a negative coping skill. It is always a way to cope with pain, what the person is going through, or meeting an unmet need. If a teenager is looking for additional attention, we want to help them find healthy and appropriate ways to get attention or uncover what is under that pain. We see the best success when we address the pain underlying the behavior. Often, I see people overreact to the behavior and not try to understand what the person is going through. We want to help teach them skills to get their needs met.

Myth #4

Number four is that they would have cut deeper if they wanted to die. I have heard people say things like this. This statement is very dismissive and puts the behavior aside instead of taking the self-injury seriously. Even though I say do not immediately hospitalize, we still need to pay attention to the behavior and get some treatment. We should pay attention because there are often other things going on within the individual, and we want to be able to meet those needs.

Myth #5

The next one is that self-injury is only cutting. We discussed this myth previously when we went over that self-injury can include many different things. I have even had some people intentionally antagonize a pet so that the pet would scratch them. The goal was they wanted to cause some form of pain to be able to cope, and that was a form of self-injury for them.

Myth #6

Myth six is that tattoos and piercings are a form of self-injury. Tattoos and piercings can be a form of expression. You need to determine if the client felt like harming themselves when participating in those activities.

Myth #7

It is not an all-or-nothing thing but rather a gray thing, which is why we will talk about dialectical behavior therapy a little bit later in this training. Some people will feel like nothing helps or there is no treatment. I think why this myth exists because it is not a linear behavior. It is not like somebody starts and stops. For some people, it can be a cycle. The person can be in treatment for a while, and then they might engage in the behavior again. We then need to come back and treat it again. There are evidence-based approaches that are extremely helpful, and this is something that can be treated. We will talk about some treatments a little bit later.

Signs of Self-Harm

• Unexplained marks or injuries/bandages or injury does not match explanation
• Long sleeves when it is warm outside
• Marks in private areas (breasts/chest, upper thighs, etc.)
• Covering wrists or forearms
• Injury does not match explanation
• Posting pictures of self-harm on social media

(Pritchard, T. R., Lewis, S. P., & Marcincinova, I., 2021).

Some signs that somebody may be engaging in self-harm include unexplained marks or injuries, bandages, or if the damage does not match the explanation. If you have a good rapport with them, they may tell you. Clients may wear long sleeves when warm outside or long pants and hoodies instead of their typical shorts and t-shirts. You can check with them to see if they have engaged in self-harm. Some people have chronic thoughts of self-harm, while others have thoughts and behavior. It is essential to work on safety planning and help them feel safe enough in sessions so they are honest about the thoughts and feelings that they are having.

They may have marks on private areas, which is not something that I typically ask. However, a client may say that they intentionally did self-harm in a place where a parent or somebody is not going to see it or is covered by clothes. This is where you can see some of the guilt and shame that can come up about engaging in these behaviors. You want to stay grounded and connect with them to have a therapeutic, non-judgmental relationship. My face is very expressive, so I am mindful of my expressions when asking these questions or when clients self-report this behavior. I try to understand what is happening instead of focusing on the behavior. I want to know what happened before the self-harm. How was the person's day, sleep, or what led to this? Often, there is a buildup that has been happening over time.

Somebody may cover their wrists or forearms if that is where the injury has occurred. The injury may also not match the explanation. For example, they may say it was their cat, but there are precise marks. You need to use your clinical judgment to determine how to create a safe relationship.

Recently, I have seen individuals posting pictures of self-harm on social media. I see this mostly with teenagers. It can start as early as childhood, and research has shown it as early as eight or earlier. Typically, eight to 18 are peak times for kids and teens engaging in this behavior and then posting it online. A parent or relative will see this and inform the therapist or the school psychologist.

Assessing for NSSI

• Informal
  • Nonverbal
  • Verbal
• Formal
  • Critical item endorsement of actions ("When things get tough, I normally do something to harm myself)
  • Critical item endorsement of thoughts ("Thoughts of hurting myself)
  • DSM 5 Clinician-Rated Severity of Non-suicidal Self-Injury (Level 0 - Level 4)

Gratz, K. L., Dixon-Gordon, K. L., Chapman, A. L., & Tull, M. T. (2015). Diagnosis and characterization of DSM-5 non-suicidal self-injury disorder using the clinician-administered non-suicidal self-injury disorder index. Assessment, 22(5), 527–539.

You must assess what has been happening and how we best help this individual. My goal is to help first instead of stopping this behavior. If we only focus on stopping the behavior, the person might start to engage in another negative coping skill. Non-suicidal self-injury is closely tied with that lack of ability to manage emotions appropriately and intense feelings of overwhelming within their life.

Here are some tips for assessing for non-suicidal self-injury. There is an informal assessment where you ask during your intake. I am going to go over example questions in a moment. I often send them a document, a nonverbal tool, that asks about self-injury. A parent also may report that their child is engaging in this behavior. Other questions asked are about thoughts of harm to self and others, hallucinations, and other pertinent things. I always want to check in on this, especially for somebody that is presenting for therapy with significant depression, anxiety, bullying at school, and different things like that.

Verbally, I will ask questions related to this topic. You can work with somebody for a while, and they do not disclose this. However, it can come up later on. As I said earlier, there is often guilt and shame, which leads to secrecy. They must have a calming, safe person. I want to make a special note that when you work with kids and teens, you must ensure that they know what you need to disclose to parents. Ethically, it is anything related to safety. You must all partner together, so the client feels safe enough to let you know if they have engaged in the behavior. Let's say the client engaged in the conduct a year ago, and the parents are aware. However, they might not know the specifics of your confidentiality agreement. This agreement should include what you share with parents and what you are not communicating. And if you are working with an adult engaging in self-harm, have another person in that safety planning process.

There are also formal assessments. The DSM 5 has a clinician-rated severity of non-suicidal self-injury, with zero being the lowest level and four being the highest. This is a clinician-rated scale that you can use to track behavior over time, which might be helpful. Personality assessments, like the MMPI, the Personality Assessment Inventory, the PAI, and an assessment within the BASC, have questions about self-harm. An example may be, "I normally do something to harm myself." If somebody acknowledges that, I want to ask additional questions like, "What do you do?" to get an idea of the thoughts behind that. Was it to relieve pain, or was this an attempt? They may take a different approach if it is a past attempt versus non-suicidal self-injury. 

Example Questions to Ask During Assessment and Safety Planning

• Are you having thoughts about harming yourself?
• Are you having thoughts about dying?
• How have you harmed yourself in the past? (Give examples to lower the shame, cutting, punching walls, banging head, etc.)
• If you are feeling unsafe, what are some things that you should have access to?
• Do any of your friends know that you engage in self-injury, and do any of them engage in self-injury?

(Franzen, M., Keller, F., Brown, R. C., & Plener, P. L., 2020).

Here are some example questions to ask during the assessment and safety planning process. I like to ask, "Are you having any thoughts of harming yourself?" If the therapist is uncomfortable asking the question, the client can sense this and might not be as comfortable sharing. This is where I think normalizing it is imperative. And if the therapist is not comfortable working with somebody that does engage in self-harm, refer the client to somebody that is equipped. If you are taking this training, I believe you want to feel more comfortable working with clients with these thoughts.

Other questions to ask are, "Are you having thoughts about dying or not wanting to be here?" and "Have you ever harmed yourself in the past?" We also want to lower the shame associated with self-injury. We may need to ask more specific questions or give examples because they may say no, they do not self-injure but do something like pull out their eyelashes or engage in other behavior.

We need to take some of the shame out of that from a clinician's perspective and ask questions such as, "If you are feeling unsafe, what are some things you shouldn't have access to? "This is part of the safety planning when the client is calm. The person may say something like a razor, knife, et cetera, and those are the things that I want to make sure to safety plan around.

We will discuss this more, but if somebody wants to engage in self-harm, it is hard to protect them from everything. I have had people self-harm with pencils. In the school system, they had an accommodation where they used pens while we worked on getting them to a safer place. But, they could get a pencil from a peer. We need to assess their method and access and make a safety plan.

I also like to ask if any of their friends also engage in self-harm. Peer groups will often talk about it. It can be supportive, where a friend can talk another friend out of doing it, or it can be triggering. Thus, a safety plan can include that if one of their friends talks to them about engaging in self-harm, ways they can then protect themselves. Make sure to include adults in the safety planning process, so that young kids or teenagers are not feeling emotionally responsible for one another. We can assess many behaviors by asking some of these questions.

Reasons Why People Engage in NSSI

• Self-injury ALWAYS serves a purpose for the individual. We need to LOCATE their PAIN.
• Important to understand the function of the behavior before removing the negative coping:
• Distraction (emotions, painful memories/thoughts, environmental issues)
• Manage Emotions (emotional numbing, or to feel when they feel numb)
• Self-punishment
• Control-maintain control or feel control over their minds and bodies

(Hooley, J. M., Fox, K. R., & Boccagno, C. 2020; Laye-Gindhu, A. & Schonert-Reichl, K.A., 2005; van der Kolk, B.A., Perry, J.C., & Herman, J.L., 1991)

Again, it is crucial to understand the why behind NSSI. Sometimes the person might not know. In general, self-injury is always serving a purpose for the individual. There is a reason for this behavior, whether they are using their frontal lobe and are aware of it, or it is a survival response triggered in the amygdala, as a fight, flight, or freeze response.

It might be more of a survival response, but we want to locate their pain because the behavior will not go away, or if the behavior does go away, they may replace it with something else that might be more harmful. For example, they may be at a higher risk of using substances or engaging in risky behaviors. And so being able to help locate that pain is significant.

Before removing this negative form of coping, I want to add something like a distraction. It might distract from negative emotions, painful memories or thoughts, or specific environmental issues. I have had many clients who self-harm if their parents argue. Adults may do so if they have a conflict with people and may use it to help them calm down.

It can be a way of emotionally numbing yourself. When we talk about parent education, I may dig a little bit deeper into the fact that engaging in self-harm can have a numbing effect on people. This can help me to figure out what tools this person might need.

For some people, it is about self-punishment. Non-suicidal self-injury often correlates with low self-esteem, negative thoughts about their body, and body dysmorphia. They may have a distorted perception of their body. Others may use it as a way to control their emotions.  

• Express things that they cannot put into words (emotions, feelings of loneliness/misunderstood/isolation)
• Relieve tension and/or anxiety
• Relieve and/or fully express a negative emotion (e.g., anger, depression, etc.)
• To feel real by feeling the pain or seeing the injury
• Purify self
• Punish self
• Nurture self or receive nurturing
• Boredom
  • Often more of a cycle than linear behavior

(Hooley, J. M., Fox, K. R., & Boccagno, C. 2020; Franzen, M., Keller, F., Brown, R. C., & Plener, P. L., 2020).

For some people, it is a way to see or express things they cannot say. You cannot see depression on someone's body or if somebody has been through a lot. A trauma survivor may not have a physical mark, especially for something emotional. It is a way to see their pain, and that gives them relief.

Self-harm behaviors can also relieve tension or anxiety or fully express a negative emotion like anger or depression. Emotions can get so big, and engaging in this behavior helps them come back down.

Self-harm may help someone feel real. I see this a lot with individuals who also have dissociation, who are kind of disconnected. They can be at a higher risk of self-harm, especially when in a dissociative or disconnected state.

It can be a way to purify or punish some unrelated to a spiritual or religious ceremony. It is a way of acting out self-hatred or that shame within themselves. For some people, it is a way to get nurturing from somebody else. 

One that is most surprising for people is boredom. If somebody already engages in this behavior, thoughts of self-harm might get very strong if they are bored. We may recommend that they are not alone when they are bored. They need to be with family or go somewhere. You can make an activity jar with ideas for when their thoughts get dark. With non-suicidal self-injury, it is often that cycle where the person engages in the behavior, stops for some time, is triggered, and starts again. This cyclical behavior can be very frustrating for parents. We need to educate parents that this is normal behavior.

Comorbid Presenting Issues

• Low self-esteem and feelings of shame/worthlessness
• Trauma and dissociative symptoms/disorders
• Relationship problems and/or bullying
• Less dense social networks
• Mood Disorders/Depression/Anxiety
• Psychosis
• Mood Disorders
• Substance Abuse
• Borderline Personality Disorder

(Hooley, J. M., Fox, K. R., & Boccagno, C. 2020; Franzen, M., Keller, F., Brown, R. C., & Plener, P. L., 2020).

Some comorbid presenting issues are pervasive, like low self-esteem and feelings of shame and worthlessness. An intervention would be helping them build their self-esteem and address their shame and worthlessness. The behavior will continue or worsen if I do not address these issues.

Research has also shown that trauma and dissociative disorders and symptoms are common. Self-harm might have been a way that they coped with a situation they did not have control over. After the trauma has ended, they might still engage in the behavior as a survival technique and response. For some, it can be hard to let go of because they might feel safer when engaging in self-harm. Thus, addressing that sense of safety can be incredibly important.

Relationship problems or bullying are also widespread. People take that stress out on themselves. Parents must be mindful of what is happening on social media or within certain text groups. Cyberbullying can be relentless. Twenty years ago, bullying was mostly at school or in your neighborhood, but now with kids having access to phones, the bully can have unlimited access to them. Parents need to set up certain safety precautions. Every state is different. I worked with some clients who had to do "no contact" agreements with a particular student or where we encouraged them to block specific numbers as they were not engaging in a safe and healthy relationship.

For individuals that engage in non-suicidal self-injury, research also shows that they typically have less dense social networks and are in a group of lower emotionally functioning individuals. Often in a lower-functioning group, other individuals within that group are also engaging in similar behaviors. With clients that present with non-suicidal self-injuries, I always want to know about their friends. We want to connect with them with other healthy peers at some point if we can. Again, we do not want to take away those people because it might be all they have, but we also want to try to add in some healthier people to expand their network.

Mood disorders, depression, anxiety, and psychosis are prevalent with non-suicidal self-injury. We also see substance abuse, either people using when they have the urge to use or possibly engaging in the behavior while using. I have seen it both ways. Sometimes with cannabis, I will see people not engage in the behavior when they are using, and then for other substances, they might be more likely to engage in the behavior while using.

As I mentioned earlier, a borderline personality disorder is common. I view that diagnosis as an inability to manage emotions and a skills deficit. Dialectical behavior therapy helps the person break some black-or-white thinking and address some underlying attachment issues. Fear of rejection or being left can sometimes trigger thoughts or engagement in non-suicidal self-injury.

Safety Planning (Harm Reduction)

• Identify an adult that the client will tell if they are having thoughts of self-injury
• Discuss if anyone else in the client's friend group engages in self-injury and encourage client/family to set boundaries in those relationships
• Identify what things the client should not have access to when upset
• Door open when upset
• Typical safety planning (lock up sharps)
• Identify their positive coping and discuss the times they are able to abstain from self-injury

(Dickens, Geoffrey & Hosie, Leah, 2018)

With safety planning, we take a harm reduction approach. In the next slide, we will talk more about educating clients, parents, and families, but with a harm reduction approach, the goal will always be zero self-harm. However, if I am working with somebody currently engaging in the behavior four times a week, I want to see that number or urge to engage in self-harm to be reduced. I also want to know if they have used skills because I want the client to feel some success along the way. I also do not wish to villainize them if they engage in the behavior.

Many clients will talk about non-suicidal self-harm as feeling like an addiction. If a client uses that language, I also use it with them. First, we want to identify an adult the client can tell if they have these thoughts. And whatever adult that is, I want to prepare that person to support the client, as some things can help and others can worsen it. I say an adult because kids going to kids or teens going to teens can be very triggering for the other individual. 

Discuss if anyone in the client's friend group is currently engaging in it, and then set some boundaries within those relationships. I have seen a teen dumping their problems on another without checking in to say, "Hey, are you in a good space where you can hear this?" Setting some emotional boundaries with their friends can be incredibly important.

Identifying what things the client should not have access to when upset is part of safety planning. Something that I have commonly instituted, especially for kids and teens, is if they are upset, their door is open. So if they go upstairs fuming and upset, they must leave the door open.

The next one is part of typical safety planning. We need to lock up sharp objects to help increase safety. I continually reaffirm that this is about safety and is not to punish them or because they did something wrong. What things do they already possess? Even within an initial session, if somebody is engaging in self-harm, I also want to hear about a time they had that thought and did not do it. We want to help them feel resilient and capable. You can also discuss how it may have been different at other times. They may have been under too much stress or were hungry and not sleeping well. These things can pile up. Identifying positive strengths within this individual can be so impactful as they are often very hard on themselves with some perfectionism and rigid thinking. 

Educating Clients, Parents, and Families

• Reviewing the myths, facts, and common reasons why other people engage in self-injury
• Start from place of understanding why and locating the pain (often families only want the behavior to stop)
• Addictive Quality
• Appropriate emotional expression (often comes from overly expressive or invalidating environments)
• Skills deficit versus manipulation

(Dickens, Geoffrey & Hosie, Leah, 2018; Nielsen, E., Sayal, K., & Townsend, E, 2017)

When educating clients, parents, and families throughout this process, I want to review some myths and facts about self-harm and common reasons why people engage in it. One of the biggest things I like to do is explain its biology. When we harm ourselves, our body releases happy thoughts. For example, if I fall and hurt my knee, my brain's coping mechanism is to release happy thoughts. Parents often struggle with this concept and do not understand how their children can do this. I do this in a one-on-one session with the individual and the parents because unless you have a good sense that this would work well, I will avoid doing it as a family session. I want the parents to ask certain questions to help them not react when the person does come to them with these thoughts or behaviors. Then we make a plan. I often encourage them to fake it. "You will be freaking out, but if you freak out on the outside, it will make them feel unsafe in the moment."

It is essential to get those needs met. We want the parents to start from a place of understanding and locating the pain. Families often want the behavior to stop, and that is where I explain that stopping the behavior may allow another negative response to occur. There is something under this, and it is not just a phase. Some people grow out of it, but others do not.

It can have that addictive quality that I mentioned earlier. A person can get into the cycle of use. People will talk about being clean from self-harm for three months, four months, or only one day. If they do like that addictive quality, language that is used in substance abuse treatment can be helpful. You want to help them find other ways to express their emotions.

They may come from environments where emotions are expressed in very big ways, and they may feel like their feelings are getting too big. Or they may come from an invalidating environment where emotions are seen as dumb or weak. We can teach parents, families, and clients how to validate their emotions. Depression and emotions are not good or bad; it is what we do with them. We want to talk about it from that perspective.

I also like to educate on the difference between a skills deficit versus manipulation. 'Parents may say they are being manipulative. I see manipulation as trying to get your needs met in inappropriate ways. It is always about a need, but they are not going about it correctly. Let's teach them healthier ways to get those needs met.

• Severe and Most Common Risks
  • Infection
  • Link between self-harm and suicide
  • Accidently harming self more than intended/lethal
• To hospitalize or not hospitalize (psychiatric) 
  • Clinical decision with client, family, and mental health provider
  • Consider potential for increased negative behaviors in psychiatric hospital
  • May require medical attention if significant physical injury
• Help client and family set appropriate boundaries

(Donath, C., Bergmann, M. C., Kliem, S., Hillemacher, T., & Baier, D., 2019; Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., ... & Green, K. L., 2018; Lloyd-Richardson, E. E., Lewis, S. P., Whitlock, J. L., Rodham, K., & Schatten, H. T., 2015).

The severe and most common risk with non-suicidal self-injury is infection. There is also a link between self-harm and suicide that has been shown in research. There is a difference between somebody that is practicing, trying to get used to the sight of blood, to be able to then complete a suicide versus somebody that is engaging in self-harm as a way to cope with emotions. The latter group has plans for the future. Another risk is that they might accidentally harm themselves when they did not intend to do so.

To hospitalize or not hospitalize is a clinician's decision with the client, family, and other mental health providers. Considering the potential for increased negative behaviors in the psychiatric setting is crucial. I have had clients go into psych hospitals for short-term stabilization and come out way worse. They learn new behaviors and connect with very low-functioning peers. We need to weigh if there is a way to maintain them at home safely. But if they require supervision or medical attention, a psychiatric stay may be appropriate. Individuals might also require medical treatment if they have a physical injury from engaging in the behavior.

We want to help the client and family set appropriate boundaries. I have seen a very entangled family where the child was taking on the parent's emotions and vice versa. We need to set some emotional boundaries.

Addiction

• Although there is conflicting research about whether non-suicidal self-harm is a behavioral addiction, many clients will describe it as addictive.
• Possible Treatment Interventions
  • Motivational Interviewing
  • 12 Steps
• Harm Reduction instead of harm elimination

(Blasco-Fontecilla, Hilario & Fernández-Fernández, Roberto & Colino, Laura & Fajardo Simón, Lourdes & Perteguer-Barrio, Rosa & de Leon, Jose, 2016)

When looking at self-harm through the lens of addiction, there is conflicting research about whether non-suicidal self-harm is a behavioral addiction. Many clients describe it as addictive, so some possible interventions might be motivational interviewing. A client may not intend to stop the behavior or see anything wrong with it. They may be seeing you because their parents want them to be there. With motivational interviewing, I want to take them through those stages of change. In the example, the individual is pre-contemplative and does not view their actions as a problem. There are also 12 steps programs if they identify with the language. Harm reduction versus harm elimination may also work.

The goal is always for the behavior to stop, but knowing it will be a process. We want them to reduce the harm by drawing with Sharpie where they would like to harm or using less harmful things like ice. Once again, they do less harm and not to the point where they are causing damage to the skin. The practitioner will partner to see what will work best for that client as it will differ between clients. It is partnering with them and saying, "Through this process, I might recommend something. It might not work, but we are going to keep trying. I have a lot of tools in my toolbox, and I will be able to support you in stopping." This is about their behavior, and they have to want to stop. In the resource section, there is a book that supports this message.

Grounding Techniques

• Trauma symptoms, including dissociation
• Examples of Grounding Techniques
  • Using the Senses: 5 Things you see, 4 things you feel, 3 things you hear, 2 things you smell, and 1 thing you taste
  • Butterfly Technique (also works with other animals, images, or name of someone in their family they care about)
  • Apps (e.g., Calm Harm)

(Grattan, R. E., Lara, N., Botello, R. M., Tryon, V. L., Maguire, A. M., Carter, C. S., & Niendam, T. A.; 2019)

An intervention that can be helpful is using grounding techniques. If a person feels emotionally overwhelmed, doing some grounding technique can often help them self-rescue and calm down. One example is using the 5, 4, 3, 2, 1 technique using the senses. I often explain to clients that the thinking brain is shut down when they are emotionally activated. We can calm the amygdala, the emotional part of the brain, by using our senses. This is where grounding techniques can be helpful, especially for individuals that have trauma symptoms like dissociation. The butterfly technique is where you fold your fingers, put your hands together, and tap back and forth like a butterfly hug. Another butterfly technique is where the client draws a butterfly or something on the place where they want to engage in self-harm. They can also use the name of a person that they care about in that spot. This externalizes it because the person will often not mind hurting themselves, but they do not want to hurt others or are protective of others. Some apps can be helpful. My clients have found the best apps, but Calm Harm is one example by the same company that does the Calm app. 

Dialectical Behavioral Therapy

• DBT was Developed by Marsha Linehan
• DBT Skills Training
  • Mindfulness Skills
  • Emotion Regulation Skills
  • Distress Tolerance Skills
  • Interpersonal Effectiveness Skills
• Full DBT program
  • Individual therapy, Group Therapy, & Crisis intervention

(Kothgassner, O., Goreis, A., Robinson, K., Huscsava, M., Schmahl, C., & Plener, P., 2021)

https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/

Dialectical Behavioral Therapy, DBT, was developed by Dr. Marsha Linehan. The skills training includes mindfulness, being present in the moment, regulating emotions, and distress tolerance. DBT also means being less judgemental of yourself and looking at facts versus our perception or interpretation of things. It also includes interpersonal effectiveness skills. The ones I have taught the most are mindfulness, emotion regulation, and distress tolerance.

Skills training is very different from a full DBT program. Some individuals need a full DBT program that includes individual therapy, group therapy, and crisis intervention, where if they are feeling suicidal, there is a therapist on call to be able to support them in those moments.

Other Types of Treatment

• Cognitive Behavior Therapy
• Applied Behavior Analysis (individuals with autism, developmental disorders, or intellectual disabilities)
• Eye Movement Desensitization and Reprocessing (EMDR)
• Psychotropic medication (refer to a psychiatrist or discuss concerns with a medical doctor)

(Bahji A, Pierce M, Wong J, Roberge JN, Ortega I, Patten S., 2021; Gonzales AH, Bergstrom L, 2013)

Other types of treatment are cognitive behavior therapy and applied behavior analysis (ABA). ABA might be helpful if an individual has autism developmental disorders or intellectual disabilities, but we want to replace it and find ways to calm the individual. One example is an individual banging their head, but now there is a pillow. We are gradually shifting the behavior to something that is not causing harm. Eye Movement Desensitization and Reprocessing (EMDR) can be helpful for this. Lastly, we can refer to a psychiatrist or medical doctor for a medication evaluation and psychotropic medication if needed.

Resources

• Free guide through SAMHSA Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-06-01-002.pdf
• Treating Self-Injury, Second Edition: A Practical Guide Second Edition by Barent W. Walsh  
• Helping Teens Who Cut, Second Edition: Using DBT Skills to End Self-Injury by Michael Hollander  
• Healing Self-Injury: A Compassionate Guide for Parents and Other Loved Ones 1st Edition by Janis Whitlock, Elizabeth E. Lloyd-Richardson 
• Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder by Paul T. T. Mason MS, Randi Kreger 
• Stopping the Pain: A Workbook for Teens Who Cut and Self Injure by Lawrence E. Shapiro PhD 
• Non-suicidal Self-Injury, in the series Advances in Psychotherapy, Evidence Based Practice by E. David Klonsky, Jennifer J. Muehlenkamp, et al. 
• Freedom from Self-harm: Overcoming Self-Injury with Skills from DBT and Other Treatments by Kim Gratz, Alexander Chapman, Barent Walsh (Foreword)

Here are some additional resources. There is a free guide through SAMHSA called Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts in Youth. I also mentioned the book, "Helping Teens Who Cut: Second Edition Using DBT Skills to End Self-Injury," and the other is stopping the pain. It is a workbook that I have frequently used. I always keep a list of resources to see what is a good fit for your clients. "Stop Walking on Eggshells" can often be a helpful book for teen clients and parents to set boundaries. 

Summary/Review of Learning Outcomes

Thank you so much for attending this training. My goal is that you now know how to explain non-suicidal self-injury, discuss different types of self-injury, and dispel common myths about it. I also want you to identify ways to assess for non-suicidal self-injury and have a safety plan. And then lastly, I hope you can identify clinical approaches to consider when treating non-suicidal self-injury.

Online References

• https://health.usnews.com/health-news/health-wellness/articles/2014/12/26/myths-and-facts-about-self-injury
• https://www.healthyplace.com/abuse/self-injury/10-ways-people-self-harm-self-injure
• https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/
• https://safeharborhouse.com/what-we-treat/co-occurring-disorders/self-harm/

References

Bahji, A., Pierce, M., Wong, J., Roberge, J.N., Ortega, I., Patten, S. (2021). Comparative efficacy and acceptability of psychotherapies for self-harm and suicidal behavior among children and adolescents: A systematic review and network meta-analysis. JAMA Netw Open, 4(4), e216614.

Blasco-Fontecilla, H., Fernández-Fernández, R., Colino, L., Fajardo Simón, L., Perteguer-Barrio, R., & de   Leon, J. (2016). The addictive model of self-harming (non-suicidal and suicidal) behavior. Frontiers in Psychiatry, 7.

Dickens, G. & Hosie, L. (2018). Self‐cutting and harm reduction: Evidence trumps values but both point forward. Journal of Psychiatric and Mental Health Nursing, 25, 10.

Donath, C., Bergmann, M. C., Kliem, S., Hillemacher, T., & Baier, D. (2019). Epidemiology of suicidal ideation, suicide attempts, and direct self-injurious behavior in adolescents with a migration background: a representative study. BMC pediatrics, 19(1), 45.

Franzen, M., Keller, F., Brown, R. C., & Plener, P. L. (2020). Emergency presentations to child and adolescent psychiatry: Non-suicidal self-injury and suicidality. Frontiers in Psychiatry, 10, 979. https://doi.org/10.3389/fpsyt.2019.00979

Glenn, C. R., Lanzillo, E. C., Esposito, E. C., Santee, A. C., Nock, M. K., & Auerbach, R. P. (2017). Examining the course of suicidal and non-suicidal self-injurious thoughts and behaviors in outpatient and inpatient adolescents. Journal of Abnormal Child Psychology, 45(5), 971–983.

Gonzales A. H., Bergstrom, L. (2013). Adolescent non-suicidal self-injury (NSSI) interventions. Journal of Child and Adolescent Psychiatric Nursing: Official Publication of the Association of Child and Adolescent Psychiatric Nurses, Inc., 26(2), 124-130.

Grattan, R. E., Lara, N., Botello, R. M., Tryon, V. L., Maguire, A. M., Carter, C. S., & Niendam, T. A. (2019). A history of trauma is associated with aggression, depression, non-suicidal self-injury behavior, and suicide ideation in first-episode psychosis. Journal of clinical medicine, 8(7), 1082.

Gratz, K. L., Dixon-Gordon, K. L., Chapman, A. L., & Tull, M. T. (2015). Diagnosis and characterization of DSM-5 non-suicidal self-injury disorder using the Clinician-Administered Non-suicidal Self-Injury Disorder Index. Assessment, 22(5), 527–539.

Hooley, J. M., Fox, K. R., & Boccagno, C. (2020). Non-suicidal self-injury: Diagnostic challenges and current perspectives. Neuropsychiatric Disease and Treatment, 16, 101–112.

Klonsky, E. D., Victor, S. E., & Saffer, B. Y. (2014). Non-suicidal self-injury: what we know, and what we need to know. Canadian Journal of Psychiatry, 59(11), 565–568.

Kothgassner, O., Goreis, A., Robinson, K., Huscsava, M., Schmahl, C., & Plener, P. (2021). Efficacy of dialectical behavior therapy for adolescent self-harm and suicidal ideation: A systematic review and meta-analysis. Psychological Medicine, 51(7), 1057-1067.

Laye-Gindhu, A. & Schonert-Reichl, K.A. (2005). Non-suicidal self-harm among community adolescents: Understanding the "whats" and "whys" of self-harm. Journal of Youth and Adolescence, 34(5), 447-457.

Lewis-Fernández, R., Aggarwal, N. K., Hinton, L., Hinton, D. E., & Kirmayer, L. J. (Eds.). (2016). DSM-5® handbook on the cultural formulation interview.

Lloyd-Richardson, E. E., Lewis, S. P., Whitlock, J. L., Rodham, K., & Schatten, H. T. (2015). Research with adolescents who engage in non-suicidal self-injury: ethical considerations and challenges. Child and Adolescent Psychiatry and Mental Health, 9, 37. 

Meszaros, G., Horvath, L. O., & Balazs, J. (2017). Self-injury and externalizing pathology: a systematic literature review. BMC Psychiatry, 17(1), 160.

Nielsen, E., Sayal, K., & Townsend, E. (2017). Functional coping dynamics and experiential avoidance in a community sample with no self-injury vs. non-suicidal self-injury only vs. those with both non-suicidal self-injury and suicidal behaviour. International journal of environmental research and public health, 14(6), 575.

Pritchard, T. R., Lewis, S. P., & Marcincinova, I. (2021). Needs of youth posting about non-suicidal self-injury: A time-trend analysis. The journal of adolescent health: Official publication of the Society for Adolescent Medicine, 68(3), 532–539.

Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., ... & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs. usual care of suicidal patients treated in the emergency department. JAMA psychiatry, 75(9), 894-900.

Solís-Bravo, M. A., Flores-Rodríguez, Y., Tapia-Guillen, L. G., Gatica-Hernández, A., Guzmán-Reséndiz, M., Salinas-Torres, L. A., Vargas-Rizo, T. L., & Albores-Gallo, L. (2019). Are tattoos an indicator of severity of non-suicidal self-injury behavior in adolescents? Psychiatry Investigation, 16(7), 504–512.

van der Kolk, B. A., Perry, J. C., & Herman, J. L. (1991). Childhood origins of self-destructive behavior. American Journal of Psychiatry, 148,1665-1671.

Editor's Note: This text-based course is a transcript of the webinar, Streamlined Suicide Assessment & Safety Planning, presented by Khara Croswaite Brindle, MA, LPC, ACS, CFT-I.

Learning Outcomes

• After this course, participants will be able to identify and explore the interaction between risk and protective factors when engaging a person at risk in a formal suicide assessment.
• After this course, participants will be able to identify engagement strategies for a person at risk in suicide assessment and safety planning to support symptom management.
• After this course, participants will be able to analyze a case study for application of suicide assessment and safety planning clinical steps.

Limitations/Risks

• Limitations include ongoing suicide prevention research additions impacting the relevance of the materials presented. A second limitation is that the current research reflects the white majority. Additionally, limitations of religious context can serve as a barrier to open dialogue around suicide.
• Risks include 1) clinician discomfort or lived experience with suicide and 2) Imposed subjective perspective.

I am excited to be here. This will be a lot of content, and hopefully, this will feel very relevant and empowering for all of you. 

Limitations include that ongoing suicide prevention research additions are impacting the relevance of the material presented. In other words, we are always learning something new about suicide assessment and risk. We want to ensure our information is updated, but we recognize that it changes constantly. A second limitation is that the current research reflects the white majority. Additionally, limitations of religious context can serve as a barrier to open dialogue around suicide. 

Risks include clinician discomfort or lived experience with suicide and imposed subjective perspective. In other words, this topic is heavy. I want to respect that for everyone. 

Introductions

• Lived Experience
• Professional Experience

I am talking to you about this topic because I have lived experience of suicide, like many of you who are taking this course. Several family members died by suicide before I was 18 years old. This shaped my family and professional life and why I became a counselor and a licensed professional therapist. It has been a passion of mine to talk about suicide with clinicians since 2017. I wanted to ensure clinicians had the strategies and tools to help clients.

Our Client

Throughout the presentation, here is the image I want you to think of for our case study.

Figure 1. Image of a sad woman for the case study.

For today, the case study is a 27-year-old female named Daphne. You have done an intake, another two sessions, and now you see her for a third session. As we can see in this image, she does not feel very well. There may be some questions you have for Daphne as we go forward and assess her for suicide. 

Suicide Response

• Suicide Assessment
• Crisis Response
• Verbal Contracts
• Safety Planning
• Referrals and Resources

As mental health professionals, there are several different suicide responses. Suicide assessment is where we will spend most of our time in today's presentation.

Another thing to note would be crisis response. What crisis response is available in your area? This is everything from a mobile crisis to a stabilization unit. Is there a specific mental health walk-in clinic that folks can go to that is a little more appropriate for suicidal thoughts than an ER? Is the local ER easily accessible for your clients? Knowing all those options can be valuable to you as a mental health professional.

I want to stir the pot by asking about verbal contracts. Verbal contracts were popular in the '80s and '90s; however, they were not effective. For example, verbal contracts have clients agreeing not to kill themselves within the next 24 hours. As a clinician, we would ask them to have a contract for safety. Unfortunately, the research shows that the contract does not prevent them from that attempt. Instead, it was just giving clinicians peace of mind. Verbal contracts do not save lives. Some of you were trained in contracts, but the data does not support them.

Instead, we want to focus on safety planning, a part of today's training. Safety planning is meant to be a collaborative empowerment tool to help the client figure out what can be done first, second, and third to help them feel safe before a suicide attempt is made. We are going to talk about those working components of a safety plan.

We must know the referrals and resources in your area. What are the higher levels of care and resources? The Suicide and Crisis Hotline is 988. There may also be a local hotline or a text line. 

As we talked about with risk, we all have our stuff that shows up with suicide. We may have lived or professional experiences with suicide, and this matters. The American Association of Suicidology says that each death by suicide impacts a minimum of 135 people. When we think about highly publicized suicides, we can see how the impact grows exponentially. Additionally, the data shows us that 25% of mental health professionals at the master's level will have a client die by suicide somewhere in their career.

This topic is relevant to all of us, and it feels a little heavy knowing that 25% of us will experience that. The fact that you are here is because you hope there is something you can do to save lives. With that being said, let's talk about engagement.

Engagement

• Space
• Mannerisms
• Tone
• How to ask the question

For engaging the client, there are things I want you to keep in mind. What space are you discussing suicide? Are you working in a community mental health center or a school? Knowing the space for confidentiality and safety helps the client either open up about their suicide story or stay clammed up. We want to have a safe space. Additionally, we want to consider the space in terms of lighting, exits/doors, and furniture. For example, is there a coffee table or something in between you that would be considered a physical barrier? 

How do you show up as a mental health professional in the room? What are your mannerisms when it comes to asking about suicide? For example, if you are asking about suicide with raised shoulders or a concerned look on your face, this might not encourage a client to share or disclose what is going on. You may think you are comfortable talking about suicide, but your body is saying something else. Are you recoiling, closed off, or have a protective pillow in front of you? These things are worth noting, just like we would note with a client.

We also want to pay attention to our tone. What is your tone of voice? You do not want to say, "You're not thinking of suicide, are you?" We want to normalize it by saying, "Other clients I have worked with have had this experience which has led them to some suicidal thoughts. Is that part of your experience?" Having a very warm tone without judgment, criticism, or shame is crucial. We also do not want to use double negatives. 

How do you even ask the question? One popular way is, "Are you thinking of hurting yourself?" The problem with that question is that many are concrete thinkers, especially teenagers and young adults. They might say, "No, I'm not thinking of hurting myself," but they are thinking of dying by suicide. They may think "hurt" versus suicide is two completely different things. Instead of circling the question, we want to directly state, "Are you thinking of suicide or having suicidal thoughts?" We want to ensure that the client truly understands what we are asking so that we can get a clear picture of their suicide story.

Returning to our client Daphne, we want to ask, "Are you thinking of suicide?" Practicing those direct questions is the first tip of this training.

Suicide Assessment

• A  Ask: Suicide Inquiry
• L  Listen: Risk Factors
• E  Engage: Protective Factors
• R  Respond: Safety Measures & Intervention/Plan
• T  Tasks: Next Steps/Documentation

As we move forward, I will break down suicide assessment into this ALERT acronym that I have used since 2017. "A" is for ask and the elements of a suicide inquiry or suicide story, which is the other way to label it. Listen is "L," which are the risk factors, and there are dozens. "E" is for engage and protective factors. You want to know what is keeping them alive. "R" is for respond, including safety measures and intervention/plans. Tasks are "T" because if we do not document them, it does not happen. We want to ensure that this is all reflected in the suicide assessment process.

Ask: Suicide Inquiry

• Direct Questions
• Frequency/Controllability/Duration
• Visual/Imagery
• Personal Meaning

(Freedenthal, S., 2018)

Ask is the suicide inquiry, and we already discussed using direct questions. We are not asking if they will hurt themself; we are asking directly about suicidal intent. Some trainings have clinicians practice this repeatedly until they are more comfortable with this question. By no means do we expect someone to be comfortable with this from the get-go unless you have had a lot of experience or training. We can still have a lot of compassion while asking questions.

Other things to ask as we start the conversation on suicide are frequency, controllability, and duration. How often are they having suicidal thoughts? They may say every moment, every day, or only when they were a teenager. Controllability is how easy or difficult it is to control suicidal thoughts. One person's response, "It's easy to control. I just push it out of my mind. I'm fine," feels very different than someone saying, "I can't control it at all as it's constant." Finally, duration is how long it lasts. Are the suicidal thoughts fleeting or every day, with no respite? As a clinician, we assess their suicidal risk based on the answer to these three questions.

Additionally, we want to ask about the visual or imagery, which is a more modern question in suicide assessment. When you think about suicide, what do you see? For the youngest generations, this is a compelling question. It could add a lot of context to what is going on for them. Perhaps the visual is that they see themselves at peace and are no longer tortured by something. They may see themselves reunited with a loved one. Maybe all of the stressors are gone, and they feel more relaxed. For someone else, it might be blank or blackness, which does not add a lot of context, but it does help us sit in the suicide story. We are showing the client that we are comfortable being here and having this conversation.

Lastly, personal meaning. When they think about suicide, what does this mean to them? Many times, you are going to hear, "This will bring me peace," "I'll no longer be tortured," or "I'll no longer be in pain." Suicide research shows that people who die by suicide are not focused on the death component but are thinking about inescapable pain, which increases suicidal risk. Looking at the personal meaning and the visual imagery is a critical component of what to ask.

• Suicidal Thoughts
  • Exposure to Suicide
  • Plan/Preparatory Acts
  • Lethality of Plan
  • Rehearsal
  • Intent

(Flemons, D., & Gralnik, L., 2013)

We need to talk about suicidal thoughts as it gives us more information about their context. It might surprise you, or maybe not, that 10.3 million people have had suicidal thoughts. This is an experience for many people so just having a suicidal thought is not enough to determine risk. Suicidal thought is part of the human experience. It is the thought of driving down a windy road and wondering what it would be like to lose control and fall off the side of a cliff. On a lighter note, it also can be a life phenomenon to think about what it would be like if I never existed or I was never born. Asking about suicidal thoughts here and now are helpful, but we need to go a little deeper than that.

What is their exposure to suicide? Are they suicide loss survivors with family members who have died by suicide or been exposed in their community? Exposure matters and will change the risk level for a client.

We also want to know if they have a plan. If they have a plan, what preparation or preparatory acts have they done? Maybe their goal is to stop eating, which feels like a different level of risk than someone who says, "I have a loaded firearm in the back of my car." What are their preparatory acts? They may have bought a firearm, gathered pills, or Googled how to tie a noose. These are things that a client might tell you if they feel safe.

Based on that plan, what is the lethality? The lethality of a firearm is pretty high. It sounds crass, but it is hard to mess that up or to miss. As such, guns continue to be the most lethal means of suicide. It is very different from someone who takes pills or tries hanging themselves.

Have they rehearsed their suicide plan, such as loading the firearm, tying the noose, putting it around their neck, or visiting a place where they want to die? For example, some of you are familiar with Kevin Hines' work, who is a world speaker on suicide prevention. When Kevin was young, he suffered from many different things, including decreased mental health, and he decided he did not want to live any longer. Part of his rehearsal was visiting the Golden Gate Bridge several times before he made his attempt. In his documentary, which is popular now, he says he got on a bus and decided he wanted to die. Part of his rehearsal was, "I'm here going through the motions, but if one person asks me if I'm okay, I won't go through with it." I am sure you are all hoping for a happy ending to this story, which is that someone saw him visibly upset and said, "Are you okay?" Unfortunately, that was not Kevin's experience. He went through the whole bus ride with no one asking, even though he was visibly upset, with tears falling down his cheeks. He got to the Golden Gate Bridge and decided, "This is the last chance for someone to ask if I'm okay." When he heard someone say, "Excuse me," he thought, "Good, someone's finally going to ask me, 'Are you okay?'" Instead, they asked, "Will you take my picture?" This question makes sense as it is a tourist trap, but it is still very painful. He takes the picture and then launches himself over the side of the bridge. Falling at 75 miles an hour, he breaks his back and survives. Since then, he has become a national speaker about suicide. As soon as his feet left that bridge, he realized he did not want to die but wanted the pain to stop. This story reinforces how suicide is about an inescapable pain more than it is about death.

When we think about intent, this is where a lot of clinicians have some gray areas regarding self-harming behaviors. It may or may not surprise you that suicide is one of nine reasons for self-harm. There is no cause-and-effect relationship between self-harm and suicide. We need to ask about intent. What was your intention for doing this behavior? What was your intention for scratching your arm, burning your arm, or doing other self-harming behaviors? Be upfront and direct with those questions.

As we take in the information about the ask, let's think about Daphne, our 27-year-old female client. She looked distressed, sad, and closed off in the third session. Imagine she is curled up in your chair or couch in your office. She is not making eye contact, and your gut says, "I need to figure out what is going on." You are going to ask Daphne a direct question about suicide. You want to know the context to see if something has happened. Let's assume that Daphne is telling you that she has ended a committed relationship recently, is struggling in her workplace, and her parents are getting a divorce. These are significant stressors. 

Listen: Risk Factors

• Suicidal Behaviors
• Current/Past Mental Health Disorders
• Symptoms

(Joiner, T., 2005)

As we move on to L for listen, there are a lot of risk factors. There is no cause-and-effect relationship where one risk factor equals suicide. If that were the case, this training would be over. Instead, we need to look at all those risk factors and how they interplay to say, "This is a cause for concern." There are certain signs.

Suicidal behaviors are the first one. Maybe this is the first time they have had a suicidal thought, and perhaps it is not. Have they had previous suicide attempts, plans, or thoughts? These are things to ask them.

You also want to know if they have any current or past mental health diagnoses. Any mental health diagnosis puts someone at greater risk for suicide. If they have a formal diagnosis, something is causing dysfunction or disruption to their life. It has to be significant enough to have a diagnosis. It might feel inescapable and painful and is part of the person's experience. That said, there are five mental health diagnoses at the top end of high risk for suicide. Number one is depression. The media latches onto depression and tries to say depression equals suicide, which we know is not that simple. It is much more complex than that. Number two is PTSD, three is substance use, four is bipolar disorder, and five is a borderline personality disorder. When you think about those top five, there is some overlap in those five diagnoses and things like disruptive sleep, insomnia, and hypersomnia when you think of depression. They may think, "This my third or fourth bout of depression in my lifetime," which may feel heavy. Things like loss of appetite, weight gain, and loss of pleasure are common with these five.

Additionally, people speak most freely about symptoms to mental health professionals and their doctors. They may say they feel lethargic or anxious or they cannot sleep. They might be verbally saying all of that, but the health professionals are not making the connection to suicide, which has been a problem in our mental health and medical arenas. This also contributes to the risks of folks that have gone to the ER or their doctor and then, within 30 days, have died by suicide. It is a small subset of people, but it comes from missed symptoms or missed opportunities to connect it back to suicide. Some people are dying by suicide because they feel like going to the ER or doctor was their last-ditch effort to get relief, to get a pill, or to have something change. The good news is that we recognize this from the data and are now trying to be more forthcoming with doctors and using screening tools in an intake. We are trying to reduce the risk of suicide as part of a 30-day turnaround for someone saying, "I need support" or "I need help."

• Other Risk Factors
  • Family History
  • Access to Firearms
  • Physical Illness
  • Lack of Social Connection/Support
  • Psychiatric Hospitalization

(Jointer, T., 2005)

Other risk factors include having a family history or being a suicide loss survivor. I was surprised that I was automatically put in a higher risk category just because my family members died by suicide. Yet, it is a factor. There are two components as to why this is a thing. The first of which is now it has been modeled as okay to die by suicide or that it is an option. The other factor is people who are very close to that family member might want to feel reunited or reconnected with them based on their spiritual beliefs. To die by suicide might feel like a justified response.

Access to firearms, as we mentioned, is the highest lethality regarding a suicide plan. People who have access to weapons and have the impulse to die by suicide scare mental health professionals. There is not much we can do when the firearm is easily accessible. We are advised to help clients to safety plan around a firearm. Reducing the risk may include having them hand the firearm to a trusted friend or family member, secure it in a gun safe, or move the ammunition. We are trying to deter people from having loaded firearms on their nightstands. Right now, if the client is not willing to surrender the firearm to a family member or friend, the best practice is to encourage them to store the ammunition separately from the firearm to reduce the impulsivity component. If we remove the firearm, they do not get creative and use a different means. Most people have been thinking about this for a while, even months or years. Reducing access to a firearm or ammunition can be part of an effective safety plan for folks. Police departments will no longer take people's firearms to hold them, so we must encourage them to find a trusty family member or friend.

Physical illness is also part of our risk factor combination due to inescapable pain. If we have someone with chronic pain or a terminal illness, suicide might show up as a possibility. Physical illness may feel like it will never change and puts the person at high risk for suicide.

Additionally, for our youngest populations, we're hearing a lot more about lack of social connection and support as a risk factor for suicide. Statements like, "No one would notice I'm gone," "People would be happier if I was away," or "I'd be less of a burden on my family" are statements you might hear. The statement that people would not notice they were gone is heartbreaking when you think of a teenager or a young person saying this with conviction and believing it to be true. They are saying they feel disconnected and that people do not care about them.

Lastly, psychiatric hospitalization is a factor. We want to make sure that we reflect on how often they are psychiatrically hospitalized and the impact on their functioning. For some folks, there is a disconnect between how they function at home versus the hospital experience. Maybe the hospital was supportive, and they got their needs met, but then they came back out, and nothing changed in their home environment. Perhaps they changed their medications, which now makes them more at risk for suicide because they have more energy to make an attempt. This is why many hospitals try to secure a visit with you, if they know you exist, to ensure that the client is seen within 24 hours of discharge. In those 24 hours, a client is most at risk for suicide.

Let's think about Daphne for a moment. Daphne tells you that in addition to her stressors (parents getting a divorce, struggling in the workplace, and ending a long-term relationship), she has an uncle who died by suicide. She does not have access to firearms. She is also physically healthy at 27 but feels disconnected without much social support. 

Engage: Stressors

• Work
• Home
• Relationships
• Financial

(Flemons, D., & Gralnik, L., 2013)

As we move to E of the ALERT acronym, we need to engage folks around stressors. Everything we have discussed so far in the ask and listen categories can be present in a person, and they may not be at risk for suicide. Plenty of people function with all those stressors and not be at risk of suicide until something is added, like more stressors or changes. For example, maybe a stressor is around work. Did they get laid off or passed up for promotion? Are they struggling with toxic workplaces and burnout? 

At home, are they feeling supported, or are they isolated? Are they struggling with someone's addiction at home? Or do they feel like they are a burden? We start hearing these things from clients when it comes to suicide.

Relationally, what is going on in their relationships? Do they feel supported there, or is it part of their stress? Is there domestic violence? Is there a financial hardship? We see this with people when there are stock market losses. They may feel like they have lost everything, and suicide becomes possible with someone impulsive and a fast burn versus a slow burn client.

We want to feel like we can have an intervention or do something about these stressors, but it depends on what is happening. I highlight stressors for teenagers specifically because community members will say, "They seemed so happy and put together," or "They are an A student and going to college." Then something in the stressor category happens, and they die by suicide the next day. They may experience a loss, a relationship breakup, or not get into a particular school. All sorts of stressors may contribute to suicide risk for a young person.

• Latest research
  • Veterans
  • GLBTQ
  • Burden
  • Isolation
  • Capacity to complete suicide (Joiner, 2005)
  • Technology Use

(Alter, A., 2018, Joiner, T., 2005, Twenge, J., 2017)

Something else to highlight in the E for engage is the latest research. Research changes all the time, but at this moment, there are some categories or risk groups worth naming as part of the suicide assessment presentation. Veterans continue to be an at-risk group for suicide. Part of that is the capacity to complete suicide, which is Dr. Thomas Joiner's work, and it is the second to last bullet point on this slide. When you look at Dr. Joiner's work, I want you to imagine a Venn diagram with three intersecting circles. The circles are burdensomeness, isolation, and fearlessness. Dr. Joiner would say, "When burdensomeness, fearlessness, and isolation are present, we have the capacity to complete suicide." I, as a professional, had a light bulb moment in how this applied to veterans. Veterans leave a close military community and try to acclimate to their past lives. They may struggle with addiction or PTSD and feel isolated in their current community. For fearlessness, they have seen things that I cannot even imagine, so death itself might not scare them. Veterans as a high-risk group make sense.

The GLBTQ+ community is also considered an at-risk group. Now, let me be clear. This is an at-risk group not because of their lifestyle, choices, beliefs, or identity but it is for how the community responds to them. There may be discrimination, harassment, and rejection. An example is a person who comes out to their family and is kicked out of their home. The fact that they are experiencing discrimination, homelessness, and rejection makes them an at-risk group, not because of their lifestyle or how they conduct themselves. Trevor Project came out with a research study that said that we could reduce young people's risks for suicide by 40% if they have just one well-meaning, positive adult in their life. It does not have to be a parent and could be a coach, mentor, teacher, or community member.

We have already named burden, isolation, and a capacity for suicide as a powerful combination. Last but not least would be technology use. Currently, we are still gathering a lot of data on technology and social media. What if I told you there was a certain number of hours of social media that subjects you to a higher risk for suicide? Some of you are hoping it is like six to 10 hours, but the magic number is three. Three or more hours of social media a day increases your risk for suicide. The researchers are saying part of it is where you fit it in. Let's apply this to teenagers once again. Teenagers, at this point, are overscheduled and do not have much extra time. Some work after school and have extracurricular activities, so their days are full. Many are not on social media until the wee hours of the morning, way past their bedtime. It may be 2 or 3 am, and they are sleep deprived. Now we have this vicious combination of not only comparing themselves to others through social media, but they are now sleep-deprived, anxious, and depressed. Teens are the most anxious and depressed we have ever seen, according to Dr. Jean Twenge's work. Three or more hours of social media a day increases our risk, not because of the social media itself, but what it does to us. It is worth thinking about as you work with clients to ask them about their technology use, specifically social media.

As we continue to engage, we also need to look at the other side of the coin. We have looked at risk and stressors, and now we must look at protective factors. What is keeping your client alive? If you are comfortable, you can outright say that. "Thank you so much for telling me what's going on. What's keeping you alive? What's keeping you here with me today?" 

• Suicide Protective Factors
  • External
  • Internal

(Flemons, D., & Gralnik, L., 2013)

We can break protective factors into external versus internal. External factors are things outside of them that are keeping them alive, like a job, a pet, a family member, a spouse, a child, religious beliefs, or a community. It might also be unfinished projects they want to complete before they die.

Internal examples would be things like spiritual beliefs. Religious or spiritual beliefs can be in both categories depending on the person. There could also be a fear of death and pain. Maybe they have a fear that if they make an attempt and survive it, their life will be worse than it is now. They may also not want to put their family through that. Sometimes, these are the deeper, darker conversations around protective factors. What we are doing impacts their emotions or state of mind. Internal could also be things like hope. Maybe they still have hope for something better. If they are a young 20-something, they may think, "I may get a great job," or, "If I find the love of my life, my life will change." Sometimes that shows up on the internal protective factors list.

With that being said, the one thing I can recommend to all of you is not to suggest protective factors to your clients. Learn from all of our mistakes. We cannot say that their family or a pet is a protective factor. This does not bode well for a client. They need to develop their protective factors as part of a safety plan. The idea here is quantity over quality. We want as many protective factors as possible. For example, a veteran on a crisis hotline days before I went into grad school said, "I'm suicidal, and I have a plan and a means, but I have one protective factor." His one protective factor was his dog. He was worried that if he died by suicide, no one would be there to take care of his dog. As you can imagine, if something happened to that dog, we would have problems keeping him safe—the more protective factors, the better. Helping the clients reflect on what is keeping them alive currently or even using memories of what would keep them alive is crucial.

Returning to Daphne, we are starting to talk about her stressors. She has some significant stressors around work, her relationship ending, and her parent's divorce. She also has anxiety and depression, so she started working with you. When asked about protective factors and she said, "I have two. I have my grandma and my cat." These are two things that are keeping her alive. We need to file this information away to work with our client around safety planning as that next step.

Respond: Level of Risk

• High Risk
• Moderate Risk
• Low Risk

(Erbacher, T., 2005)

Before we get to safety planning, we need to respond by identifying our clients' risk levels. The level of risk is problematic because the categories do not fit everyone. This is our best effort right now. These are subject to change because these three categories are not intuitive or helpful for all populations.

A high-risk person has suicidal thoughts, plans, means, and intent. All the boxes are checked, and they have many risk factors. They also may have minimal protective factors. There is immediacy, and we need to do something right now. An example is a client who says, "I'm going to die using that firearm that is loaded in the back of my car."

Additionally, if you have a client where everything feels like a risk or weapon for them to die by suicide, they are also high risk. This person may say, "I could take this pencil or paperclip and kill myself," or "I could jump off that overpass over there." This is also a high-risk individual because we cannot keep them safe if everything is a risk for their plan of suicide.

Moderate risk is the most challenging and tricky of all categories because anything can bump them up to high risk, like that veteran losing his dog. They may also bump down to low risk if they have a healthy relationship that keeps them present and with us. However, most of us will monitor their suicidal thoughts and provide resources. We may also schedule more sessions with them to have a clear view of what is happening and navigate their level of risk.

In contrast, the 10.3 million people who have had suicidal thoughts are automatically categorized as low risk. This is a problem with this rating system. It could have been decades ago that a person had a suicidal thought, but they are still low risk. I think these categories will change down the road, but for now, low risk is suicidal thoughts, even in the past. They need resources like a hotline, a text line, and plenty of protective factors.

• Acute vs. Chronic Risk
  • Acute
  • Chronic
  • Action Steps

(Freedenthal, S., 2018)

One thing to distinguish for this risk category is acute versus chronic. Acute is immediate. When we think about the medical model, acute is, "I have to respond immediately." This might be 911, an ambulance, someone coming to get them, hospitalization, M1 hold, 72-hour hold, or any of those things. Acute is immediate action taken by us.

Chronic, on the other hand, is a response to a population of people who are showing up saying, "I have had suicidal thoughts for many years. Currently, I am not at risk of myself or of others." How does this look? As comedian Frank King would say, "Suicide is always on the menu for someone who has chronic risk." An example is a flat tire. Your options are changing the tire, getting someone to help you change the tire, or you could die by suicide." This is the dark humor of Frank King. Many people with chronic suicidal thoughts say this is relatable because they are always there. If you are having a bad day, you could just die. However, there are no action steps. "I need to pursue this right now." For the chronic person, the action steps will look significantly different. We will not hospitalize someone with chronic suicidal thoughts because they are not at risk. We will monitor them and keep talking about it. But to this person, suicide is a comfort, almost like a last resort. Telling them to take it off the table or the menu is not worthwhile and not productive for a chronically suicidal person. Instead, we are going to look at their relationships and protective factors.

Action steps for acute and chronic are about relationship building, coping skills, etc. With Daphne, we know her risk factors, stressors, and protective factors. At this point, we are trying to figure out the risk level of what she has going on. As we talk more about suicide, she says, "I have a plan. I plan to jump off the overpass by my house." This is a significant plan because there are many overpasses where she lives. This puts her in a high-risk category because everything is a risk. A different client might say, "I plan to stop eating." This would be a different risk level as compared to Daphne. Hopefully, this is helping you to put all the puzzle pieces together. Next, we will see how to support Daphne with safety planning.

• Safety Planning
  • Baseline Wellness
  • Warning Signs and Triggers
  • Personal and Professional Supports
  • Make the Environment Safe
  • Action Plan

(Flemons, D., & Gralnik, L., 2013)

Daphne is at high risk because of the overpass plan. Let's say that she is coming back into care with you after a hospitalization, and she needs to have a safety plan in place. Frankly, safety plans are good for all sorts of things like domestic violence, addiction, substance use, and suicide. I think safety plans can be applicable in lots of different areas.

There are five components of a typical safety plan. The first is baseline wellness. What does it look like when they are well? Does the client have self-awareness? "When I am well, I am animated, take my medications, go to work on time, and am present in my relationships." You also want to see if they can identify specific, measurable things, like what it looks like when they are well versus unwell. Self-awareness can be powerful in starting the conversation of safety planning. It is not just about, "Let's keep you from killing yourself." It is asking how we know when you are functioning and well versus unwell.

From there, it transitions nicely into warning signs and triggers. Warning signs are internal things. What is happening inside that tells them they are not doing well? They may feel nervous, anxious, tearful, have a short fuse, and are angrier. They may be restless and not sleeping well.

In contrast, triggers are the things outside of them that are happening that could contribute to their risk for suicide but also contribute to safety needs. Triggers like relationship conflict, a significant other relapsing, or times of the year like holidays and trauma anniversaries. I cannot tell you how often clients have come in and said, "I do not feel good," or "I'm feeling down." I first ask, "Is there anything significant about today, this month, or this season that might be contributing to how you feel?" And nine times out of 10, the client says, "This was the season when I was sexually assaulted," "This is when my grandma died," or "This is when I got in a car accident." It may be the holidays, and the client has not seen their children in 10 years because they are estranged. Many triggers contribute to why someone is feeling unwell.

I want them to have that dialogue with us about what is on the inside and what is around them, not making them feel well. From there, we can talk about personal and professional support. Personal support for the youngest generation is critical because we often hear, "Nobody cares. I do not feel connected." We have to be careful how we frame this question. Personal support may be, "Who can you call or has distracted you in a healthy or lighthearted way?"

Although people are more willing to talk about their mental health, they are resistant to talking about suicide because they fear that someone will hospitalize them. Personal support might be more about healthy distraction than talking about suicidal thoughts. So I frame it as, "Who can distract you? Who sends you funny cat videos or memes that cheer you? Who can talk about themselves to get you out of your head?" When framed that way, all of a sudden, even that young person has somebody they have for their safety plan. Personal support does not have to be linked entirely to the suicidal component, but someone who can provide a healthy distraction can be helpful. Professional supports include you and me, the hotline, the text line, and other supports around suicide and mental health, like the ER. You can say, "These are your options when you are not feeling well mentally or suicidal."

What are the action steps that are going to support the person in making their environment safe? For example, are we making sure that the medications are secure, or do they have a partner or spouse that can monitor that those are not accessible? Do we need to remove firearms, sharp objects, or secure things that could be considered a weapon?

They may need to be supervised. After-school hours when there is no supervision, from 3 to 5 pm, are when most youths attempt suicide. Part of the safety plan may be that the client will hang out at a friend's house, go to grandma's, or stay in the after-school program. They need some structure to help them have a safe environment. For each client, that is going to be unique to them and customized to their experience. There is not a one-and-done plan for the environmental safety piece. It needs to be a collaborative element with your client. We want them to start talking about what they are willing to do or what they are resistant to doing so that it is feasible.

Last but not least, what are the action steps? What will they try first, second, and third to reduce their intensity of wanting to die by suicide? Is it calling a friend or using the hotline? Is it playing a sport or watching a show? What will help take some of that intensity or be a healthy distraction? Is the action plan going to go into a crisis stabilization unit? The plan may be that they will walk themselves into the ER, call support, and say, "I'm not okay. Help me."

The beauty of safety plans is that they can be changed and modified anytime. You may have a first draft with a client, and the next week, they say, "You know what, I tried those things, and they did not work." Updating or modifying the plan is always okay to ensure we try something else to meet the client's needs. Safety plans are all about empowering the client to have a choice other than dying by suicide via healthy coping skills.

Daphne's safety plan includes grandma and her cat because those are protective factors for her. We also identified that she enjoys being out in nature when she is not stressed out about work. Thus, part of her safety plan may include walking and being out in nature, calling grandma for a chat, and petting her cat. You want action steps customized to the client they are willing to try.

Anyone who is part of the safety plan or an action step should be informed. It would be best if you tried to get a release to talk to that person or encourage your client to tell them. In Daphne's case, grandma is not surprised to see her when she shows up. It is much easier for the client in a vulnerable place to do this if everyone is on the same page.

Tasks: Documentation

• Level of risk, including factors
• Steps taken by professional and/or family members
• Outcome

(Shea, S., 2011)

The last part of our acronym, of ALERT, is tasks. As I mentioned earlier, if you do not document it, it did not happen. We need to document the level of risk, including the factors, steps taken by other people or us, and hopefully an outcome. The steps taken by you or other people are crucial.

A formal suicide assessment and a note about your time with them should be in the file. If you have a family member coming to pick up the teenager to take them to the ER, we need to document that the family member verbally agreed to take them. You are not responsible for the family member not following through, which, unfortunately, does happen. They tell you one thing and do something else. It is crucial to document what they verbally agreed to do.

The outcome might be that they were evaluated in the ER and then sent home. You should update your documentation with this timestamp to show an outcome of what you did as a mental health professional assessing for suicide. In Daphe's case, they decided to hold her for a week to help her stabilize and adjust some medications for her depression and anxiety. The safety plan is in place for her release, with documented outcomes and conversations with the hospital staff.

That is a quick rundown of the ALERT acronym.

Summary

I have included the references I mentioned today in our presentation, which covers everything from that technology component we talked about to social media to tips and techniques for professionals asking someone about suicide. Check them out for further development of your professionalism around suicide. 

You can contact me, as I am always happy to be a resource for all of you. I hope you feel more confident about assessment and treatment using the ALERT acronym. This is the best practice response right now for suicide.

Frequently Asked Questions

One of the most common questions from our community is, "What if they do not have any warning signs?"

This is the type of client that scares us. We cannot help them or provide any helpful component to keep them alive if there are no warning signs. These clients are outliers, as most clients will have warning signs that we can see based on all the risk factors we discussed today. They are going to have different stressors even if they are hiding certain things from loved ones. Sometimes it is about putting puzzle pieces together.

The good news is if a client is talking about suicide, the hope is they want something to change. They are telling us that things are not good or that they feel hopeless. Hopefully, this is helping you feel reassured.

With the statistic that 25% of us that will have a client die by suicide, I want to ensure that there is a support network in place for all of us. There are many other trainings out there. It is essential to have these conversations about the impact. Cliniciansurvivor.org is a website for clinicians who have unfortunately had the experience of a client dying by suicide. The American Association of Suicidology, also known as suicidology.org, has lots of resources for clients, families, and us as clinicians.

References

Alter, Adam L. (2018). Irresistible: The rise of addictive technology and the business of keeping us hooked. Penguin Books.

Erbacher, T. A., Singer, J., & Poland, S. (2014). Suicide in schools: A practitioner's guide to multi-level prevention, assessment, intervention, and postvention (school-based practice in action) (1st ed.). Routledge.

Freedenthal, S. (2018). Helping the suicidal person: Tips and techniques for professionals. Routledge.

Flemons, D. G., & Gralnik, L. M. (2013). Relational suicide assessment: Risks, resources, and possibilities for safety. W.W. Norton & Company.

Joiner, T. E. (2005). Why people die by suicide. Harvard University Press. 

Shea, S. C. (2011). The practical art of suicide assessment: A guide for mental health professionals and substance abuse counselors. Mental Health Presses.

Twenge, J. M. (2017). IGEN Why today's super-connected kids are growing up less rebellious, more tolerant, less happy-and completely unprepared for adulthood and (what this means for the rest of us). Atria Books.