Harm avoidance

Transcription

Brandy Brooks: Good morning, and welcome to the Matters of Life and Death Suicide and Eating Disorders Webinar. My name is Brandy Brooks, and, aside from being the moderator this morning, I am a contract manager for the Massachusetts Department of Public Health Suicide Prevention Program, the sponsors of today's Webinar. Before I introduce our presenters, Dr. Mary Bartlett and Dr. Nicole Siegfried, I would like to go over a few housekeeping issues. First, to join the video portion of the Webinar, please, go to www.readytalk.com, and, under participant, join a conference. Enter 6245494. Again, you have to go to www.readytalk.com. And, under participant, join the conference. Enter 6245494. On the next screen, you'll be prompted to enter your name and e-mail address, and then you click - Join this meeting. Second, to join the audio portion of this Webinar, please, dial 1-866-740-1260. Again, that's 1-866-740-1260. And enter the pass code 6245494. Third, should anyone experience any technical difficulties with either the audio or video for this Webinar, please, dial 1-800-843-9166, and a ReadyTalk representative will be more than happy to help you. Lastly, all telephone lines are muted except mine, Mary, and Nicole's. So, please, use the chat function located in the lower, left corner to type in any questions or comments you may have. Given the number of participants, Dr. Bartlett and Dr. Siegfried will do their very best to answer as many questions as possible as they go along and at the end of the Webinar during the question and answer period. Now that I've gotten that out of the way, let me introduce our presenters this morning - Dr. Mary Bartlett and Dr. Nicole Siegfried. Dr. Bartlett earned her doctorate from Auburn University and is an independent consultant, suicidologist, and international speaker. She is the vice president of Behavioral Sciences at Cape Fox Professional Services and formerly served as the suicide prevention and risk consultant to a national treatment center for eating disorders. With 15 years clinical and teaching experience, she is in authorized training for the American Association of Suicidology and the Suicide Prevention Resource Center and is a qualified master resilience trainer. She and Dr. Nicole Siegfried are also investigators on a current research study with Dr. Thomas Joiner, examining risk factors of suicidology and eating disorders. Dr. Bartlett is also a member of the Academy of Eating Disorders and the National Eating Disorders Association and serves on the International Association of Eating Disorders Ethics Committee. Our second presenter this morning is Dr. Nicole Siegfried. Dr. Siegfried is a licensed clinical psychologist and certified eating disorder specialist currently employed at the Birmingham VA Medical Center. She is also co-founder and former clinical director of Magnolia Creek Treatment Center for Eating Disorders. Having served as an associate professor of psychology at Stanford University from 2001 to 2008, she is currently an adjunct assistant professor at UAV. Dr. Siegfried is also an international speaker and has published research, magazine articles, and book chapters in the field of eating disorders. Dr. Siegfried is also a member of the Academy of Eating Disorders, co-chair of the Eating Disorders and Suicide AED special interest group and is a member of the residential eating disorder coalition and chair of the REDC research committee. So, now that I have introduced both of our presenters for this morning's Webinar, I would like to go ahead and turn it over to them. Mary and Nicole, are you there? Mary and Nicole, are you there? Unidentified Participant: We are. Brandy Brooks: Can you hear us? Mary Bartlett: I can hear you. Wonderful. Nicole Siegfried: Wonderful. Well, we're ready and very excited to give this presentation this morning. I'm Dr. Nicole Siegfried. And my colleague, Dr. Mary Bartlett, is here with me as well. And we are ready to talk to you all about eating disorders and suicide, the relationship between those, and interventions that you can do with this population. Before we get started, we want to get a good idea of the kind of backgrounds that individuals have that we're talking to. So we have a poll that we'd like for you to complete. Going to pull that up here and what you all tell us what your background is, what the field is that you represent. And you can do that right there on your screen. And, if you'll go ahead and let us know that, we will pull that up. I have to give a side note. This is really cool the way that it's doing this. And so we can see right here. Okay. All right. So the majority of our audience today are mental health workers. And so that gives us a good idea of the people that we're talking to, and we'll gear things in that direction. Okay. And, then, the next question we have for you is: Have you ever had any training in suicide prevention? If you can, let us know that, as well. Okay. It sounds like a lot of you have had some training. So we hope that today will be a next step in that training for you. As we know, most mental health professionals have had fewer than two hours of training in suicide. And a lot of individuals are very frightened when it comes to working with suicidal clients. And so we want to make sure that we're able to provide some education today that will help people in that area-- they feel more confident with this population and that, hopefully, for those of you who had training, this will be a good next step in that. Okay. I'm going to turn this over to Dr. Bartlett. Mary Bartlett: We wanted to provide an overview for you, and we've actually selected the areas that we get input on in terms of what practitioners normally struggle with. Now, bear in mind that what we're going to present is just a snapshot. We could probably do an entire day workshop on each of these separate areas. But we hope that you'll have lots of takeaways in just the brief snapshot that we give you in these categories. Nicole Siegfried: All right. So just a little bit of background. I'm not going to go through the DSM criteria on eating disorders. You all, being in the mental health field, are familiar with that. But I do want to include that, when we're talking about eating disorders, we're also including the (inaudible) disorder, which will be included in the new DSM5. It's a separate diagnosis. As you know, right now, it is categorized under eating disorder not otherwise specified. And a lot of research still needs to be done in the area of binge eating disorder to look at its relationship between that disorder and suicide. But we are going to include some information on that as well and want to make sure that you all just have this background before we go to the next slide. What you may not be familiar with is that suicide rates are 23% higher in eating disorders than in the general population. Many people believe that-- know that eating disorders have one of the-- or the highest mortality rate of any psychiatric disorder. But what they may not realize is that that high mortality rate is more of a function of suicide than it is complications related to the disorder. In fact, the risk of death by suicide in, specifically, anorexia, is 58 times greater than that in the general population. Suicide alley (ph) is very common also in bulimia and eating disorders not otherwise specified. In fact, the mortality rate of eating disorders not otherwise specified-- the suicide rate-- excuse me-- is much more similar to that of anorexia than even bulimia is. So this eating NOS is a very high risk disorder in terms of suicide. And sometimes that gets overlooked. As I said, with eating disorders, we don't have as much information on the suicide rate in this disorder. But, hopefully, with the DSM5, we will have the-- have more data on that. Also, with the (inaudible) disorder, there is reason to believe, based on a high rate of bullying in their history, that they may be at high risk for suicide. So we'll be interested to see some of those results presented at conferences on bullying and suicide and binge eating disorder as an intervention area. Okay. We also want to talk a little bit about correcting some of those myths related to suicide and eating disorders. But one common myth is that individuals with eating disorders, because of their harm avoidance, are actually less likely to choose violent means of suicide. And, actually, research shows that the reason individuals with eating disorders die by suicide is that they choose very violent means-- means that would kill anyone, not necessarily just because they're already compromised or because they've-- or because they were already medically unstable. Thank you. Also, some people believe that eating disorders are a really slow suicide, sort of like smoking. Sometimes we'll hear people say that people choose to smoke; so, slow suicide. That actually isn't the case. The same reason that people choose smoking for different reasons rather than to kill themselves-- the same is true with eating disorders. People do not choose this as a way to kill themselves. The suicidality comes either before that or as they go along in their eating disorder. But the eating disorder is not a function to kill themselves. Mary Bartlett: And it's not uncommon for us to hear clients-- I'm sure this has been your experience too-- that they will very clearly articulate that it isn't their desire to die by suicide, but, rather, just to-- it's their desire to be dead. Their eating disorder stems from that desire to be dead, not to die by suicide. Nicole Siegfried: Now we're going to move into helping people understand the context of the suicidal mind. I really believe that it's important for people to understand how a person reaches that point of believing that suicide is their best option in order to implement some of the practical and evidence-based interventions. And this is an area that is often overlooked and not weaved into or woven into the training that a lot of mental health people receive. And so I just want to point out that Ed Shneidman is the founder of the American Association of Suicidology. And, if you ever have a chance to read some of his books, there are many, many good ones. And this is one of my favorites. And, in it, there's a quote where he indicates that suicide makes this statement. This is as far as I can go. I cannot carry this burden any further. And I think that's a very poignant introduction to helping people understand the suicidal mind. We also included some quotes that we have heard from different colleagues. And we just want you to take a-- I'm sorry-- from different clients. We just want you to take a look at some of the quotes because, again, they're very telling, very powerful in terms of them-- clients describing what their experience is about the eating disorder and their suicidality. So we're just going to give you a minute to look at those quotes; again, to give context to what they're telling us. Okay. In terms of understanding the suicidal mind and giving you a snapshot to give that context, we do know that, based on research, suicide is a decision primarily made by a person seeking relief from either real pain, the physical pain that they're experiencing perhaps as a result of their eating disorder, or some of the medical complications or perceived pain. And that pain, as you know, especially since many of you have had training in the area of suicide prevention-- that perceived pain is really defined by that person. And it's important to bear that in mind as you work with them because I think sometimes we tend to skew it, and our own biases come in in terms of why that should be so bothersome. And we question why it's bothersome, depending on where you are in your own capacity. We also know that suicide does not have a simple cause. It's a very complex developmental history, accompanied by factors related to biological, psychological, social, and existential factors. And I call it the un-perfect storm. It's when the sun, the moon, and the stars align in such a way that a person makes that decision that they are better off dead than alive-- that it is less painful to actually pursue death than it is to continue to get up each day and move forward. And that experience is what is defined-- it was coined, actually, by Ed Shneidman and Psychache. And it is, again, that psychological pain that leaves a person to seek death through suicide as an escape to relieve that profound pain. What I would submit to you is that suicide attempts are not attention seeking. They are help (ph) seeking. And, in fact, what was interesting is that, when we worked together as colleagues at the National Treatment Center for Eating Disorders at Magnolia Creek, we actually forbid our practitioners from talking about in the context of attention-seeking. It wasn't that common for someone to come up to us and say - But, really, doesn't it just feel attention-seeking? And my response to that was - It is only attention-seeking to the degree that the person is seeking your help. So, please, go back to that client, and help them articulate, put into words, what it is that they're seeking from you. If it feels attention-seeking, it really is help-seeking. And you need to help them give voice to that because, largely, it really is a client's incapacity, given their profound pain, to articulate the kind and the depth of pain that they're experiencing. Okay. Next slide. This slide is-- first of all, we've gotten a couple of comments if the slides are going to be made available. And they will be made available after the presentation. You will have access to these slides. But the next slide here is a diagram of Thomas Joiner's theory and conceptualization of suicide. And this is particularly applicable to eating disorders. You'll notice that-- I like the way that Dr. Bartlett was saying that the sun, moon, and stars align. Well, this is a picture of how those align. Basically, the person has perceived burdonsomeness, or he can look at that as psychache, and feel, basically, that he or she would be better off dead than alive, that everyone else would be better off with them dead versus alive. They also have the thwarted belongingness. We call that disconnectedness because that's kind of the term that our clients use. And so they feel very isolated and disconnected from others. We see that a lot in individuals who may not be suicidal, but they have this combination of burdonsomeness and thwarted belongingness. But, when those two things are combined with the acquired capacity for violence or for death, in this case, that's when the sun and the moon and the stars align. And you can see there in that red area-- I'm hoping that-- I forgot if I'm doing this right. If you see me pointing there in that red area-- that would show-- let me see if I'm doing this. Bear with me here. Okay. Here we go. In this red area, you can see where those all three come together. You may be wondering. What is acquired capacity? That could be something that is acquired previous to the eating disorder; so, for instance, if you're in the military or if you're in a profession that is violent or exposes you to violence. But, also, if you can imagine, eating disorders expose you to very violent methods. If you think about binging and purging-- also that they may have accompanying self harm, that may up the ante, so to speak. All of those things sort of put points in this box of acquired capacity and make it more likely that a person is at higher risk. I like to give a little quiz here of when-- What do people in the military, eating disorders, veterinarians, and dentists have initiative common? And the answer is they all have a high acquired capacity for violent behavior and high exposure to death. And that is one of the reasons that makes them high risk for suicide. As you know, those groups have higher rates of suicide. Mary Bartlett: I do want to point out, just to interject here, that this isn't a linear projection in terms of how this progresses-- that a person might actually begin to feel a disconnectedness socially through their eating disorder that they disconnect from activities like going out to restaurants and socializing. And so it might be that they feel disconnectedness first and then, as a result of that, feel this increased burdonsomeness of their eating disorder and of this experience of suicide creeping in. Or they might, as Nicole pointed out, if they're a military, for example, feel or have that acquired capacity for death and the fearlessness of death because they're trained to go into battle before they experience burdonsomeness or belongingness. And I know that we're focusing on eating disorders, but, because there's such a linkage between those two particular events, the member of the service and eating disorders, it's just an interesting kind of correlation that we want to point out. Nicole Siegfried: Yes. That was a side note that we wanted to include. You may notice that we're both in our new professions. Our new jobs are in the area of military. And there's a hypothesis that-- definitely, we already know that there's high suicide rates in the military. But there's a hypothesis that there's also high rates of eating disorders that have not yet been well recognized or well diagnosed. And this would be sort of a triple threat that, if you were in the military, you had an eating disorder and suicidal, that you would be at particularly high risk based on those being high risk groups. Mary Bartlett: So there's been research that supports the IPTS model, which is Joiner's model, the interpersonal psychological theory of suicide. You can see why we shorten it to IPTS. Research has demonstrated that individuals with eating disorders choose violent methods; also, that the relationship between eating disorders and suicide is mediated by acquired capacity. And acquired capacity can be defined as-- operationally defined as capitulation (ph) to pain or starvation. Research has shown that or even more provocative eating disorder behaviors in terms of purging when you're very-- (inaudible), for instance, using hard exercise. So those are examples of research that has delineated the relationship, the conceptualization of the IPTS in eating disorders. And, actually, as Brandy had said in our bios, we're actually doing research right now with Dr. Joiner looking at what those factors look like across treatments and how they may wax and wane and increase or decrease risk depending on that. Nicole Siegfried: And, before we move on, I just want to point out in terms of this theoretical conceptualization. There are other theories out there that some of you might be familiar with that help to explain suicidality. This is the one that we practice from because it seems to make the most sense. And, of course, we work with Thomas Joiner, so-- we choose to work with him because we buy into this particular theoretical approach. And the reason it makes so much sense to me is that we're hearing those words specifically, the disconnectedness, the burdonsomeness, just as a norm from our clients who experience eating disorders. And so, as I in my own journey as a suicidologist have examined different theoretical approaches to addressing this suicidal component in eating disorders, this particular makes the most sense. But I do want to point out that there are other conceptualization models that exist. Okay. And so we kind of transition into our next session-- our next section, if you will, with a quote each time. And this is, again, one that I find very poignant. In terms of treating eating disorders and suicidality or any kind of pain, two key questions as practitioners is to ask: Where does it hurt? And how can I help? And it's interesting because Shneidman points out in some of his literature that we don't tend to ask those questions as often as we should. Sometimes, that's a reflection of our own burnout or lack of compassion. And I'm not at all suggesting that practitioners that work with people with eating disorders lack compassion. But it's a very hard population to work with. And, in doing so, it's real important to keep yourself in check and balance. And, when you're not willing, when you find yourself not willing or not as apt to ask those two questions, then it's important to do a check for yourself, which is critical as we move into-- well, actually, as we move into the assessment side of things. But, before we do that, we want to collect some additional information as it relates to that. Have you ever lost a loved one or a coworker or someone close to you to suicide-- because that information, whether or not you have experienced it, really does impact how you ask the questions in the assessment process and, in fact, whether you will. It looks like the majority of you have had someone close to you, whether it is a client or if it is a relative/friend-- have had someone who has died by suicide, up to about 70% of you all. And Mary always shares the statistics that, when someone dies by suicide affects up to six people that are close to them. And so it doesn't surprise us that these results indicate that the majority of us have had someone close to us who have died by suicide, whether it's a client or a relative. Mary Bartlett: A second poll that we wanted to just gather some information on. Of course, the information that you're giving us will help guide us in our own continued research. What aspects of working with clients are the most challenging to you? And the reason we've included this particular question is that we hear most often as we're lecturing and traveling that it's the assessment component and determining risk level, selecting which risk level category to put a client in that has eating disorders and suicide, that brings the most angst to practitioners. Nicole Siegfried: We're curious for you all. In terms of working with clients with suicide and clients with eating disorders and suicide, what is the most challenging for you? Mary Bartlett: And we're beginning to see as the numbers come in that we're probably on target-- that, again, it's assessing that risk level, (inaudible) high, and then, because you have to know-- you have to make a determination of risk level in order to select the appropriate treatment. So these numbers don't actually surprise us. They validate what we know through our own research and practical experience. Nicole Siegfried: I'm hoping you all are able to see the results here. I'll read it just in case. But the majority of you, about 32%, assessment is kind of the tricky area-- that and then selecting a treatment course at 27% of you all. Mary Bartlett: And I find it interesting also that the execution of the plan is the third listed as highest. I wish that we could come back and actually gain more information on what part of the execution of the plan it is that makes it difficult for practitioners to implement it. Perhaps for another study and a future briefing. Okay. So, now that we have that information, I want to just give you an overview. This is a snapshot of what mental health professionals really-- evidence-based and literature shows need to be completed in that comprehensive assessment of suicidality. And so, very quickly, it is initially assessing and ruling out. Are they in immediate crisis, an acute crisis? Or is this a chronic experience? And bearing in mind, again, that, even if a client when they present is in a chronic scenario, they can become acute. It's important to conduct a multiple assessment; so, not just client report and family report and prior mental health history and services they've received and pen and paper type assessments. It's really, again, emphasizing multiple assessments so that you can demonstrate that you've really done a good job of comprehensively gathering data, and you're not relying just on that client information. Absolutely essential to integrate that risk assessment early and often. This is not a one-time deal. And I'm sure you're familiar with that. We are-- I once was asked: When do you begin to assess suicidality in your clients? And my response to that was: When I introduce myself. Hello, I'm Dr. Bartlett, and I've been assigned to your case. And, as I follow up with them, the only time that I end that assessment is when I'm shaking their hand again and saying - Thank you for working with me. I wish you every best in your life. So every single time you're working with a client, in some manner, you're assessing their suicidality. Key components also include in that package, if you will, a listing of risk factors, protective factors, their ideation, plans, warning signs, (inaudible) imminent risk, so you can determine as you're moving through the treatment if they're emerging into a chronic situation. Of course, it is critical to formulate your risk and make a clinical judgment. Can't emphasize enough how-- this is a lack area. This is a gap area that we often find with practitioners-- that they don't obtain the records from collateral sources. This is critical because, if a client dies by suicide and it's demonstrated that they have received past treatment and there's no evidence in your package that you worked and made an effort to obtain that record when it was indicated, you're going to be held liable if it goes to court. And so very, very critical and an area that often is overlooked. And bottom line in this entire process as you're working with a client that's eating disorders and suicide, I always say, whatever decision you make, just be able to justify it. You are probably doing a good job of making your decision if you're doing these things, if you're including all these things. And so the argument is, as long as you can, at the end of the day, go home and sleep well and be able to justify your decision should a client die by suicide, you're probably going to be okay in the course, recognizing that all of us can be held liable. All right. So let me walk you through in that assessment some of the things I just covered and what that would look like and sound like. So, risk factors and protective factors. Just as we need to remain updated on factors that put clients at risk for the suicide, it is equally important to identify what is keeping them safe. What is keeping them alive? And that's a large part of what you want to focus on. Certainly, you're keeping the risk factors in mind. But I want to speak to and continually assess what is keeping them protected so that, when I see their protective factors declining or being eliminated, I can also begin to identify or look for increased risk factors and gauge, again, that level of suicidality that they might be waxing and waning out of. A visual that we wanted to include is a decision tree. Again, this is a sample of one, and this is by David Rudd (ph), Dr. Rudd, who's also a leading suicidologist. It looks a little complicated, and so I always encourage people-- find a decision tree that makes sense and is comfortable to you. Once a person gets comfortable using a decision tree, it becomes an easier process. But you can see how this trajectory of moving through these questions is another method in which to help support and guide you in feeling more confident about what risk level you're putting them in. And the reason, as you know, it's essential to decide on a risk level is because what risk level you determine the client is at will determine the kinds of interventions and the treatment progress-- or treatment process that you give them. This goes back to incorporating multiple measures. If you're able to say - I didn't just make this decision that they were moderately suicidal willy nilly based on ABC; I actually followed an evidence-type decision tree. And, again, while this isn't steadfast, and I want to caution you-- while it isn't steadfast, it is something that perhaps will be useful in that determination. I do want to point out that the challenge with using a decision tree and relying on it too much, which is why you want to include many other factors in that decision, is that we don't want you to fall into the habit of pigeonholing into one category. Remember, it's a combination, and you have to look at the full spectrum of data that you're getting to give you that picture. So just relying on the decision tree and saying, well, I did my decision tree, and that's how they plugged into that category. A person might have some of these risk factors, but, based on your instinct and your intuition and your experience, you might rate them at a different level. Just be able to justify it. Next, we move into identifying suicidal desire and resolve (ph) plans and preparations. The only thing I want to point out here-- there's actually three basic things. When a person-- When you're assessing and feeling out and getting information about their desire and ideation, this often indicates that this is a place for them to talk, for you to expand the dialogue with them. They may be at risk, but you'll know they're at higher risk, and this gives you information for which category to place them in-- if you hear information related to resolve, plans, and preparation, that gives you more concrete data that you might need to place them in a higher risk category. You can see based on-- and this is, again, a snapshot. There are other things that might add to that list in terms of resolve plans. And, in order-- I just want to point out the link that we provided is a link that you can go to and obtain a sample of this assessment that was actually designed by David Rudd. And, if you look back on the decision tree, you can see here his part of the decision tree you will access that information, the resolve, plan, preparation and the suicidal desire and ideation. That's what we're talking about in these categories. But there's a questionnaire that you can complete for your client to give you that information a little bit more cut and dry. Nicole Siegfried: Yeah. And then it gives you a key. You can download the key. And that also will help you identify potential category of risk. Mary Bartlett: All right. This, very quickly, I just want to point out. Best practice indicates that you should follow a standard note process. And this is just one, as a sample. It's done by Simon. And you see the citation is a little bit old, but it is still very relevant, and it's the one, in fact, I use because it makes the most sense to me. I can move through it very quickly. In your risk/benefit notes when you're, again, directly discussing the suicidality, it's suggested that you include these components. At a time when, often, our notes on clients are getting shorter, the opposite is true when you're working with a suicidal client in that your note needs to become longer. We want to dispel the myth that the less information you have the better because it leaves you less liable. That's actually not true. Now, we're not suggesting that you take longer notes just for the heck of it-- that it should actually include these components. And you can see, if you do, your note will, by nature, be a little bit longer. But this rolls you through information that, if you gather, again, will help you make that determination. And there are other notes that exist, other samples. Like the decision tree, find a sample or model that works best for you. That just happens to be the one I like the most. All right. In terms of notes-- the note process, we want to point out briefly that there is a shift away from the use of no suicide contracts. The American Association of Suicidology has taken a position now and indicated that they no longer endorse the use of no suicide contracts. And, in fact, the shift is to a crisis plan, focusing, rather, on what the client will do than won't do. I would just caution you that, if you're in an environment or a venue or just personally as a professional, you are still using those suicide contracts. I encourage you to redo a literature review to really help you with that decision. And you'll see, if you do a literature review, that it is just, again-- it has never been demonstrated to be useful at reducing suicide. And, in fact, 50% of clients who sign a no suicide contract do complete suicide. That's been evident through studies. So you see there's really no concrete data to suggest that they're useful. And so, in this process of multiple things that you need to do in the assessment, I would rather not use something that's not evidenced based and, rather, use something that is. And a crisis client intervention has been demonstrated to do that. And you see the highlights, what you focus on - the collaboration, if you'll go back-- the collaboration that encourages good faith. It's treatment focused, and it really does help to work on the primary issue, which is the pain and distress. And then here is a sample safety plan that we've adapted when we worked at Magnolia Creek. We just wanted to show it to you to emphasize the collaboration in the process. At a time when the client is feeling the least empowered, review the safety plan and completion of it. I'm sorry it says safety plan. We since have modified it to be crisis plan. There was some debate whether or not it should be called safety plan or crisis plan. Ultimately, we've gone with crisis plan. But also note that the handwriting is from the client; again, as a mechanism to empower them at a time when they're feeling suicidal and feel somewhat disempowered to help drive home that this is collaborative and they are in the driver's seat, largely. So we now understand that-- we hope you've given context to the fact that suicide isn't a disease of the brain. It's that awful storm of the mind. And we want to catch this process when it's raining lightly before it merges into a full-blown storm. And that moves us into a discussion of evidence-based intervention. Nicole Siegfried: We're going to talk in terms of treatment intervention. We're going to talk about evidence-based interventions and then some more practical interventions that we used that may be helpful in working with your client. The first I'm going to talk about-- each of these. First, I'm going to talk about dialectical behavior therapy. And, in fact, DBT is the only intervention for suicide that's met the criteria as efficacious, meaning that it has been demonstrated as effective in randomly controlled designs by different research groups. And so this method is primary effective. They've actually done research, as well, that goes through looking at what components are the most effective. These have been identified as the four components of the individual therapy, the group skills training between group calls and team consultations-- that those things in tandem-- those things all together are what make this effective. Also, they've looked at individual factors that may make it effective, taking sort of a no blame, no judgment approach. The domains of mindfulness, emotion regulation, distress tolerance, interpersonal effectiveness-- if you're familiar with DBT, you know that those are the four different components, four different domains. Each of those may have a specific intervention with those-- hone in on suicidality to make it specifically effective for this population. Now, what's interesting-- there's been some research, too, that DBT is not only effective in suicide but also with specific eating disorders, including bulimia and some recent research on binge eating disorder. And so this might be sort of a double whammy, so to speak, by addressing both of those symptoms. Mary Bartlett: And I'd like to just intervene before she goes on to show you some samples of DBT approaches and, you know, live examples, to point out that the reason we broke this into evidence-based and practical-based is that, again, in terms of that comprehensive package, you want to be able to demonstrate that you're using evidence-based stuff as opposed to the practical interventions. But we include the practical interventions a little bit later because, again, as practitioners, we know, while those may not necessarily-- the techniques that we'll talk about may not be evidence-based yet. Intuitively, we have found them to strengthen the work and the process. So we just wanted to clarify that. That's why we broke it into two categories. But be sure that you are using an evidence-based approach with this. Nicole Siegfried: One of the interventions that we've found most helpful as part of the DBT package, so to speak, is the behavior chain analysis. And I use this now here at the VA. This is also-- We use this at-- in our eating disorder treatment center not only for suicidal behaviors but also eating disorder behaviors. And our clients became very, very proficient in completing these. And so you can see-- You'll start here. Let me do my little markup tool. Here we go. Whoops. Okay. You can start with the problem behavior and sort of backtrack through events that makes you at risk for that but also looking at consequences of the behavior. I think this is more helpful for us to just look at an example of someone who did this on a self-harm behavior. The reason I really like this one as an example is that this client, and this is where we try to get our clients to, is-- she was using this for-- on the (unintelligible) end for a possible self-harm behavior. So she was using the behavior chain analysis to look at-- okay, this is why I'm wanting to self harm. But, if I do, these might be the consequences. One of my favorite things that she has here, and you can tell that she had some good education-- she has here untimely death because it had been brought home to her that the more she self harms, although it may have helped her with symptoms in the moment, she realized that each time she self harmed that that made her more at risk in terms of her acquired capacity because she was engaging in more violent acts. You can also see here that she was able to go through the process of looking at the different events that placed her-- made her more vulnerable, the thoughts-- how those came in and really attenuated her response. I'm disgusting. I'm such a liar. And so she was able to see-- okay, this is why I want to do this but, also, based on looking at what's going to happen if I do, to keep herself from self harming and using this in that way. It can be used proactively as well as retroactively. So that was one example of-- from DBT. And, like we've said before, we could do an entire day where we would just look at DBT interventions for suicide and eating disorders, but we just wanted to, in this talk, since we just have an hour and a half, just to kind of hit the highlights and some things that may be helpful. Problem solving therapy has also been found to be effective in treatment of suicidality. And, specifically, the notion here is that individuals who choose suicide as an option do so because they are constricted in terms of their options. They are unable to solve the problems that they're hit with. And so, by helping them become better at solving problems and giving them more options for that, then they become a little bit more sophisticated in that process and would be less likely to choose suicide as the option. So defining-- and this is from David Rudd. But defining the problem, identifying the goal, looking at alternatives, evaluating the alternatives, implementing the alternatives, and evaluating and modifying the approach based on that-- And so this approach really hones in on making them feel a little bit more efficacious in their abilities, increasing that self efficacy, and then also widening, broadening that constricted thinking so they see other options. Cognitive therapy has also been found to be effective in the treatment of suicide. And there are some specifics. Again, like I did with DBT, I'm going to take out some specifics that we've used in cognitive therapy and some specifics that have been identified as particularly helpful in this population. And so this is an example of a hope kit. And you can have your clients kind of bring together things that-- those times when they're feeling the most hopeless. As we know, hopelessness is one of the main risk factors for suicidality. When they're feeling the most hopeless and they have that constricted thinking, that they can bring these things out as a reminder for their reasons for living and their reasons for not attempting suicide. I'd like to just mention here this is an example of somebody, and she would put a Starbucks card in there because she knew when she was feeling hopeless that she wouldn't think she deserved to go to Starbucks or to go and treat herself. So she already had the preloaded card in there so that when she was feeling that way that she could go and kind of take care of herself. Another example of a cognitive therapy intervention is a coping card. Again, knowing that our client's become very cognitively restricted during those times of suicidality, especially in those higher-risk times, giving them other ways to look at things that they've thought through at other times may be helpful. So this is an example of writing out this in that very classic, cognitive, behavioral way-- writing out the thought and coming up with alternative ways to look at it that they can keep with them when they can pull that out to look at things in a different way when they're feeling particularly hopeless. This is an example. One intervention that's particularly helpful, and, again, I'd love to be able to go through a guided imagery with this-- for this with you all. And maybe if we ever do another Webinar, we can do that as part of it. But the idea here is actually-- it's sort of an imaginal (ph) role play, where you will go through in your head with your client-- the client will go through in their head the scenario that would be high risk. So let's say they think of something that could possibly happen. They would get in an argument with their boyfriend, let's say. And there could be a time in the past where they would be more likely to act out on an urge to attempt suicide. They would talk through that process of things that they would do instead. And that rehearsal, that imaginal role play, has been shown to be effective as sort of cementing that in their mind. When that high-risk situation comes up, it can be a little bit more automatic in that way. Okay. Bear with me. Oh. There we go. All right. So we're going to now sort of guide ourselves into some more practical interventions. And we really like this quote by Helen Keller. "Although the world is full of suffering, it is also full of overcoming it." And that leads us into some of these practical interventions that may be particularly effective in this population. Mary Bartlett: So we've listed out some of the-- again, a snapshot of some practical interventions that we have used consistently and found to be useful that support our use of evidence-based techniques. And the first that I'm going to talk about, actually (unintelligible) to connected, are working to understand the role of suicide in the client, and what we do is a timeline on that suicide and eating disorder experience. So what we've done-- I actually created this. It was sort of-- I call this like a suicide trajectory. It is a timeline. This is a clean version. Categorize the boxes. I'm going to show you after I explain the component to you a completed version that I do in session. And it's not nearly this neat. And you can use this as a model and actually use it this way. Or you can use the practical model, which I'll show you in a minute. But I just wanted to give you a clean version, so you can see. On this timeline or in this process, we are looking-- gathering through that initial assessment dialogue all this information. By virtue of gathering the information, this is a mechanism-- a practical mechanism to give me information or give you information, hopefully, on identifying what risk level and how to proceed. With that being said, let me-- one of the components is determining the reasons for living. And so we have an example, completed, again, in the handwriting of the client. I'm doing this timeline in a 50-minute session. And so we get some initial information, but what we want to point out is that this list of reasons for living is something we have them continue to do throughout their entire treatment process so that, by the time they leave treatment, they have seen this reasons for living list grow and, again, like a health (ph) kit, can go back to it and, when they're feeling distressed and potentially suicidal or just having those thoughts creep in and remind themselves or see again that they actually had, in better moments, lots of reasons to live. Another component of that suicide timeline that you may have seen in categories was identifying, again, the protective factors and the risk factors. What I want to point out here-- two things. Again, it's done in the handwriting of the client because, through their continued treatment, we want them to see their list growing of what they've identified keeps them safe, as well as what puts them at risk. I want to point out that there's one area-- I think it's family-- that you see as a protective factor as well as a risk factor. It is not uncommon for clients to identify the same (unintelligible) in both of those categories. But it's also important not to challenge it-- to let it just sort of-- encourage them and use that as good, clinical information, that it can be a double-edged sword. It sometimes keeps them safe, but it's also something that makes them very upset. Now, let me show you a very convoluted-- 50-minute session. You can see I have terrible handwriting. But, just to walk you through this graph, I've circled to point out I basically take a line, and I draw it across the center. I first identify the suicide trajectory. This is as opposed to, specifically, a self-harm trajectory. I draw a line through the center of the sheet. And I first have them identify when. What age were they when they first remember having disordered eating thoughts? Then, on the other spectrum, what is the current age? I walk through all the components that you saw in the clean graph. What is keeping you alive? What are your reasons to live? What are your risk factors? What are your reasons for dying? When was the first time you were diagnosed with an eating disorder? How many times have you been in treatment? How many times have you attempted suicide? What age were you? What method did you use? Is it progressively getting more volatile? All of that gives me good, clinical, practical information in which to develop a risk level category and a treatment plan. Nicole Siegfried: And it's interesting. Again, we have some video that we show, but we don't have time for that in this presentation today. And it's interesting to be able to see this play out. We'll have clients often times say - No, I've never been suicidal before. This is it. This is the first time, right before I came in. And then, if they complete this, they're able to kind of go - Wait a minute! I did it! Yes! Actually, since I was 13, I've really wanted to die. And so it helps them to be able to sort of broaden their perspective and see, really, what their own risk level is. In fact, you'll see up at the top here-- this is a client who did that, who said - No, this is the first time I've ever entertained thoughts of suicide. And, as she continued to move through the session with me, I wrote a line. I drew the line. And I was able to very gently say - It's interesting to me because, initially, you said that this was the first time, but, as we look at the spectrum, in fact, your thoughts about suicide began when you were 16. You've had suicidal thoughts, it seems, based on your explanation for six years. No wonder you feel burdened and disconnected. Now we know where to go. And I just want to point, also, that you can make a decision whether or not you want to give them a copy of this. There are some clients that would rather not do that. But I will show it to them at the end of the session and then just simply say - We'll continue to use this as a guide in our treatment. If I know that that client has a propensity to ruminate about things or has severe OCD, then I would probably not want to give them a copy. The next practical intervention is-- Mary Bartlett: -- increasing experiences of connection. Nicole Siegfried: Okay. One of the questions we have here. Can you speak about spirituality and religious interventions with this population? Definitely. Let me do this next slide, and I will come back to that, along with body-centered therapy. Okay. Yes. Hold on one second. We'll come back to that. Increasing experiences of connection. There is evidence suggesting that this is one of the most important aspects of decreasing, over time-- decreasing suicidal risk-- that most people feel very disconnected. And, if you can increase those connections, that can be an important piece. So, first, what we do is diagram of their social support network. And, actually, we-- this is from Michael Barrett Center for Change Eating Disorder Treatment Center in Utah. And this diagram of your social support network-- it's important to realize that, when you do this with clients, that their support can be very (unintelligible). And that can be, often, even more depressing for them. But it's important for them to realize that, that, yes, maybe I'm isolated, or maybe I don't have a lot of close friendships. And maybe I also need to increase those. So we first-- let me do my-- whoops. Okay. So we first diagram those, looking at what are your most intimate relationships? And, obviously, there, by intimate, we mean very close, not necessarily sexual. And this kind of comes in for, Ms. Gordon, your question about spirituality. This is a good intervention for that, looking at however you may define higher power or God or where you are in that spiritual connection, knowing that our clients not only feel very disconnected from themselves-- I mean, the eating disorder really is a mind/body disconnection-- and very disconnected from others but then also very disconnected from God or their higher power, however they may define that. And this can be a first step in sort of diagramming, mapping out those connections or lack thereof. And so sometimes they'll say - Okay, yes, I have-- I'm really close to my mom. But then maybe that's it. Wow! All of that-- everything you're going through is just being funneled through that one relationship. And so you can see, then, okay, you've got some of these more casual relationships. Maybe there's some of those that you want to work on moving from casual to more intimate. How might we do that? And so then they can define ways that they will sort of bolster some of those connections. The second part of the question is along with body-centered therapy. And, specifically, for-- and, Mary, interject. I'm going to talk about this more from an eating disorder perspective. Definitely, this can be helpful for those individuals who feel very disconnected in terms of that mind/body relationship. And, a lot of times, body-centered therapies can be a first step and ongoing step at increasing that connection. Sometimes, at first, what we found with our clients is that this will need to depend on where they are in their own medical stability and where they are, really, in their own cognitive capacity. So these would need to be very much tailored based on that. So, for instance, yoga. Sometimes our clients-- At first, they're not at a place even to be able to yoga. They may only be able to do deep breathing. But, looking at that, even how deep breathing is a connection between the body and the mind, is a connection between you and those outside of you. Also, you can look at a just spiritual connection. The word "breath" comes from the Latin word spirit. And so we look at that as a spiritual way to connect in and outside of yourself. So those are some ways that we integrated spirituality as part of that. And, definitely, we could talk more about that. But this would be something from the eating disorder perspective. But then, also, we can talk about spirituality from a suicidal perspective because, a lot of times, that one relationship is the reason that people don't (unintelligible). Their faith or their religion is something that keeps them from doing that. So we can bolster than connection as part of the protective-- Mary Bartlett: Right. Research shows-- or literature demonstrates that-- or supports that having a spiritual component is actually a protective factor against suicide. And so, again, it's a clue, if you will, if there is no spiritual basis that that might be a risk factor and to engage in a discussion about it and how it applies to them. In terms of suicidality and body-centric therapy as it relates to that suicidal thinking, if a person is feeling disconnected and therefore has increased thoughts of suicide, they're disconnected, as Nicole pointed out, for many different aspects of themselves, including their body. So if a person with an eating disorder has developed that fearlessness, a capacity to self harm and is getting more severe, they may in fact disconnect from their body, and we know they do actually. And so having the discussion in terms of their disconnection and burdensomeness with the body aspect is crucial to hit that second (inaudible), in source as well as the suicidality. Okay. Another practical intervention that we're going to look at is means restriction. First, I want to point out that it's supported by research that discussions and utilizing and putting into place means restriction is the most effective preventive measure because more than half of all people who die by suicide are using guns. And it's particularly concerning to me as that relates to our news. So that's the first thing to point out, that-- think about it. If the research is showing that this is the most effective preventable measure, we would be remiss if we didn't have this discussion with our clients, who, by-- as you just learned, use severe measures to die. So I just want to give you a snapshot and some takeaways in terms of how to engage in the conversation. Please, be sure you always ask every client about their access to means. You really-- if you have a client dies by suicide, you want to be able to demonstrate, again, in that package that you asked that question and what their response was and that you did some means restriction counseling around that area. Nicole Siegfried: Just to interject, I know that many of us have heard those myths that, by talking about suicide, it increases risk or talking about means-- that that would increase their likelihood of using that. Obviously, that's a myth. And, definitely, I think that's been a take-home point that most people would have-- that you all would know by this point. But it's surprising to me that, even though, cognitively, people know that, they still are very hesitant to go down this path of talking about firearms or talking about what the means are that the person may have, if they have stockpiled meds or that kind of thing. So, keeping that in mind that there may be something that sort of turns you off against doing this, that you need to turn that back on-- Mary Bartlett: Right. This is the most important-- one of the most important aspects of preventing suicide. Nicole Siegfried: Absolutely. Okay. The last practical intervention that we're going to focus on is building resilience. And just want to point out that, at Magnolia Creek when we were there, the entire program was based on strength-based approaches. And so this push and development of a client's resilience level is critical and, in fact, really does speak to their protective factors. If they have not yet died by suicide or they have attempted two and three times and haven't died by suicide, this gives me information that, in fact, they're quite resilient, even though they don't recognize it. So, to build this in over the course of treatment is really crucial. Although it falls under the category of practical interventions, there is a lot of research being done to support. And, hopefully, we'll see in the future that it moves into an evidence-based practice. Okay. I just love this quote. Who doesn't like football, especially us here in Alabama. It's not whether you get knocked down; it's whether you're able to get up again. And that's, for me, the practical definition of building resilience. But the perfunctory definition from one resource-- I take it from the Defense Center of Excellence because of the very concise definition. It's whether or not you're able to have-- you'll go through adverse situations and come back from it. Mary Bartlett: What we want to point out is, while that's a perfunctory definition, look at the lower part. That's really what resilience building is. If you are building into your practice skills related to conflict resolution, self-regulation, which, if you do DBT, you'll be doing, optimism, effective communication, hardiness, and an awareness, those are the true components of developing resilience. So, basically, what I'm saying is build those into your treatment plans. And, if you don't have all the time with your clients, the research shows that the three most important things to focus on are connection, building positive emotion, and helping clients to develop trait flexibility. Now, again, you can see how that would benefit both from the eating disorder side as well as the suicidal side. We know that clients with eating disorders feel disconnected. We know that they often don't feel positive or any emotion, really, and that they are very rigid in their thinking and behaviors. From the suicidal part, again, now you know that they're feeling disconnected emotionally, that they are-- 90% of the people who die by suicide, depressed and that they get into, as Nicole pointed out earlier, that constricted thinking. And so developing that flexibility is really crucial. Nicole Siegfried: I'm going to talk about some ways, again, from a practical perspective-- acceptance and commitment therapy has been shown to be effective in anxiety and depression. And there's some recent evidence that-- in eating disorders. There hasn't yet been enough research to show that this is effective in suicidality, but you can see from a practical perspective that some of these interventions may be, again, sort of that double whammy, sort of hitting the eating disorder and hitting the suicidality. And so the overall goal of acceptance and commitment therapy is to develop psychological flexibility. And, if we know that, in eating disorders, that they have constricted thinking and in suicidality there's constricted thinking, this is the goal of therapy would be right on target. So something that's interesting. Research has shown, especially with anorexia, that individuals with anorexia are less likely to sort of see outside the box and can be very persistent, which can be a good thing, obviously. But a lot of times it can be a bad thing. And so, for instance, there's a study that shows that individuals with anorexia when they're on-- if they're given a task and they're on a computer and they're given a maze, they have to get out of the maze. And there's different buttons that they can push on the bottom of the screen to get out of the maze, like a blue, a green, an orange, and a red. And you quickly figure out that, if you push the blue button, you get of the maze. But the rules change as the activity goes on. And, all of a sudden, now the right button to push is green. Well, individuals with eating disorders, specifically anorexia, are less likely to figure out that they need to push green. Now, these are very intelligent individuals, and so this tendency is noteworthy. And it's defined as sort of an over persistence. So they'll keep pushing blue, blue, blue, blue, blue when there's other options there that other people maybe that don't have eating disorders-- that they figure that out. You can see that play out in their eating disorder, for instance. So, for instance, people without eating disorders say - Oh, gosh, things are terrible in my life. If I just lost five pounds, everything would be better. They lose five pounds. Things aren't better. They felt-- it must not be the weight. Maybe it's something else. I'll try something else. Well, people who may be predisposed to eating disorders say - I'll lose the weight. Oh, wait. I still don't feel better. Well, maybe I need to lose another five pounds. And so they keep pushing blue. So, using that as a metaphor for their lives, saying - Hey, you're still pushing blue. You're pushing blue - can be used as a way for them to think of looking at things in a different way. Metaphors are a really popular intervention as part of acceptance and commitment therapy. Something else that we help clients with is another cognitive diffusion technique that's part of decreasing that rigidity is by taking some words that are very powerful and emotionally laden and realizing they're just words. And, when those words float through your mind, you don't have to latch onto them. And so, just by saying these words over and over, they can lose their power. So, for instance, when our clients get the thought of - I'm fat or you should die, they (inaudible) act on it, not realizing that that's not a thought that they-- that that's not a thought they have to latch onto. And, just because it's so powerful doesn't mean that you have to latch onto it. And so, by just saying over and over and over - I'm fat, fat, fat, fat, fat, fat-- you start to say that word over and over. If you've ever done that with a word-- you say it so many times it starts to sound really strange. You can do that with some of these words that are really powerful for these clients. And they can lose their power in that way. So that's been used as a technique. Another technique that's one of my favorites is to think about thoughts as leaves on a stream. And you all may be familiar with this. You can choose whether or not to pick up that leaf or that thought off the stream to hold onto it. We have millions of thoughts that go through our minds each day, and we'd all be crazy if we latched onto each one of those thoughts. And so, when we learn that we don't have to latch onto the thought - I need to lose weight or I need to die - we can leave those on the stream kind of watching them go down over the waterfall. This can be a really effective metaphor and imagery technique that may be helpful with these clients. Another way to-- that we've talked about before building resilience was increasing positive emotion. And something that's interesting is that building positive emotion-- there's been an entire study of this that's separate from even acceptance and commitment therapy. But the gratitude is one of the most helpful ways to build emotion. This is one of the ways, just by thinking about things that you're grateful for, that can increase feelings of contentment and happiness there in the moment. Not only that, but individuals who do that on a regular basis-- those-- there's research evidence that shows that the effects of that still linger even up to three months. If you do that for a month, thinking of things that you're very grateful for-- three things each day, the effects of that linger three months later, even if you did it just for that one month. So that's sort of a counting-your-blessings exercise. The other-- I'll come back to the gratitude letter in a second. The other way that's been found to increase positive emotion in the moment is by helping others, sort of altruistic interventions have been found to be effective in, in the moment, increasing positive emotion. So doing things like volunteering or even small, random acts of kindness-- we remember that. That was something from the '80s. Small, random acts of kindness by doing something small and special for someone can actually increase your own positive emotion. Jumping back for a second onto the gratitude, one of my favorite exercises to have clients do is a gratitude letter. And this is something that you can do. You can decide whether or not you want to send it. This is what I'll tell clients. But someone that you're grateful in your life-- you can write a letter of gratitude to that person. Read it in group, where, then, they'll share it with the other group members. And they can decided, then, if they want to then send it to someone. And this is an example, an actual example from one of our clients that wrote something to her high school English teacher and how that person asked her if she ever needed to talk. And she remembered that teacher even years later and was really grateful for that. She never forgot that she was someone who took (unintelligible) but took some time out of her own life to recognize that this person was someone in distress. And so this can be very helpful in a group setting, or it can even be individually and they can read the letter. And then they can decide if they want to send them as well. Sometimes they'll read them over the phone to someone. That can be a really good way to increase that positive emotion as part of building resilience. Mary Bartlett: And, essentially, what Nicole's just done is broken down the three things that we highlighted under building resilience that research has shown to be the things you primarily want to focus on - the connection, the trait flexibility, and positive emotion. So, really, we were intentional about-- because, often times, I'm asked. How do you develop trait flexibility? And that's why we were specific in giving you examples on how to build that flexibility, build the connection, and build that positive emotion. So we hope that that was useful. We have covered an enormous amount of information. And, at this point, we were also intentional about trying to reserve the last ten minutes for Q&A or just responses and comments. And so we've got a couple minutes here. So, if you want to type in your questions, we would like to entertain those. And, if you don't, then I guess we just want to say thank you, really. Thank you very much for joining us and expressing an interest in working with this population. Again, as I mentioned much earlier, it takes a lot of fortitude in terms of a mental health provider to work with a very complicated-- actually, double complicated, the eating disorder side of it as well as the suicidality. What we hope we've accomplished in this Webinar is to help you gain a comfort with working with both sides of this, as well as familiarity with practices and, since so many of you indicated struggle or challenge with the assessment process, that you'll feel somewhat more directed in how to assess both those components. And, of course, we would be remiss if we didn't say thank you for your work. We recognize how incredibly challenging this is. And, from one practitioner to another, really, thank you, because it does-- not to sound cliché, but it really does take a village. And we recognize that when a person is in treatment for an eating disorder one-- the first time. We're grateful sometimes when we get them at the fourth level because you all have done some work that has been a precursor to getting them to a better place. Nicole Siegfried: And so one question is: Can we receive a hard copy of this? And the answer to that is yes. And, also, you'll see our e-mails up here. We also have some other copies of these assignments and interventions. And so we would be more than happy to provide you with those if you want to kind of put them in your toolbox for things to use with your clients. Mary Bartlett: The only thing I want to point out is that we'll provide the slides in PDF form, simply because we're very intentional about not-- wanting to make sure that people don't remove the citations. We want to make sure that Barrett receives credit for his social network diagram and that, if you use that decision tree, that people understand as you pass it along and share it that it came from David Rudd. So we'll provide it. It's not that you can't take something out of PDF. But we send it in PDF form for that reason. Nicole Siegfried: And so, Brandy, will they need to e-mail us for us to send that? Brandy Brooks: What I would do is, a few days from now, I'll be sending all the participants the PDF file that you are speaking of, as well as a link to the podcast so that they could listen and watch this presentation at a later time. Mary Bartlett: Okay. Wonderful. Thank you. Thanks for clarifying that. We have another question. Nicole Siegfried: The question is: Have you ever had a patient who tells you they are suicidal several months after it has passed but they were afraid to tell you for fear of hospitalization? I've tried to explain my philosophy of suicidal thoughts in advance to dispel this. But any advice you can provide would be great. Mary Bartlett: Yes. It is not uncommon for clients to wait-- to get through that suicidal episode for fear of hospitalization. There are a couple ways to respond to this. The first is weave into-- my suggestion is to weave into very early in your work with a client a discussion about when hospitalization would occur. This is what I tell clients, and it seems to be the most effective. My goal as we work together is not to put you in the hospital. If I put you in the hospital, I don't get to work with you. However, what you're paying me to do is to make observations at times when, in fact, you might be at risk. If I ever make a recommendation for you to go to the hospital, it is because I had truly determined that I can't do what is necessary to keep you safe during a crisis. And I want to do that collaboratively with you, with the goal being to re-stabilize you in that acute crisis so that you can return to work with me. Have that discussion early in the work together because I have found that, then, when suicide is introduced after you've established some trust, they might be more forthcoming. Nicole Siegfried: To interject, too, and I always like using this from Linehan with DBT-- It's her philosophy that suicidality is best treated on an outpatient basis. Now, that does not mean that we shouldn't use the hospital. But the hospital is not where they're going to necessarily get the treatment for this chronic suicidality. It's going to be with you. And the hospital can be a safe place. But what we know is, actually, when they leave the hospital, they're at higher risk for attempting suicide or dying by suicide than they were when they went in. In fact, the risk is 278 times greater when they leave the hospital. So the hospital-- again, I'm not saying don't send people to the hospital. That has to be an intervention when the person needs to be kept safe. But it is not the solution to this person's chronic suicidality. That work is going to be done with you. And so I think, if you can explain that to the client, as well, that you know that the hospital needs to be used as a safe place for you to be able to get through that time when you may not be making good decisions, but it's not going to be used for the treatment. That's what we will do. Mary Bartlett: And, in fact, to have this discussion and say to them - If you discuss your suicidal thinking ways, ideation, with me, more than likely, you're not going to need a referral to the hospital because we can work on a treatment plan and a safe-- a crisis plan for you. If you wait until you are in an acute crisis that you would likely need to be hospitalized-- so I want to encourage you to have the discussion with me when the thoughts are just beginning to roll through your head. Let's capture it then and attack it then so that we can avoid sending you to the hospital. But then I caveat that with-- but, please, know that, if at some point I really do think you need to have-- I really don't think-- I believe that there's a likelihood that you will kill yourself in the next 24 to 48 hours, then, absolutely, I would be remiss as a person serving as your mental health provider to not utilize that resource. Nicole Siegfried: And one other thing related to that that I try to tell clients is-- I don't want you to be afraid to talk about your suicidality. One of the things we-- Mary and I talk about a lot is we're shocked when a client comes to us who has an eating disorder and has a history of suicide they will say often times - No one has ever-- I've never talked about my suicide before. And, a lot of times, I think what clinicians think is that talking about suicide is - Do you have a plan? No? Okay. Check. Check. Check. That is not necessarily the best or not at all the best way to intervene. And so what we make sure our clients know is we want you to talk about it. Talking about it is not going to get you on a fast train to the hospital. What we know is talking about it actually may lessen your risk for suicide. I don't want you to be afraid to talk about that with me. However, at the same point, if I ever feel like you can't keep yourself safe, I will do everything I can to keep you safe, which may include the hospital. I hope that answers that for you, Elizabeth. Mary Bartlett: At this point, Brandy, can people take their mute off and actually give us a voiceover question? Nicole Siegfried: I think they have to type it in. Mary Bartlett: Oh. Okay. Brandy Brooks: They can actually do both, either/or. If they want to ask the question themselves, they have to press star, six. If they want to type it in, they can do that. Mary Bartlett: Okay. And it doesn't look like we're getting another question or call in. And we are-- we really pride ourselves as educators on hitting our mark in timeframe. It looks to me like we're like one minute from the end of this Webinar. And, with that being said, since you will have our contact information, if you have any future questions, we would look forward to your contacting us and having that dialogue with you. Thank you, again, for participating. And we just were delighted to be able to share this information. The more people that get this education, the better our clients are. And, really, it's a public health issue, the suicide issue. So we're delighted to share this with any audience. Brandy Brooks: Just (unintelligible), Mary and Nicole. I'd like to, again, thank them for presenting this morning into the afternoon. And I'd like to thank all the participants for participating as well. As Mary and Nicole stated, you will receive a PDF file of the slides from today's presentation, as well as a follow-up e-mail I'll be sending you in a few days. You'll receive a link to the podcast, so you could watch this broadcast at a later time. In addition, be on the lookout for e-mails about upcoming Webinars and training being sponsored by DPH. After you log off today, please, take a few moments and complete the evaluation, as we do use this information to put on additional Webinars and make sure that they're tailored to what you are interested in. As Mary and Nicole stated, I hope you gained more knowledge about how to assess suicide risk, suicidal crisis intervention, documentation guidelines, and evidence-based and practical treatment for individuals with eating disorders. Again, thank you, Mary and Nicole, and thank you, all, for participating. Have a wonderful day, everyone. Mary Bartlett: You too.