heather fiske and yvonne dolan bruges, belgium february 3

HOPE IN ACTION:HOPE IN ACTION: A SOLUTIONA SOLUTION--FOCUSED FOCUSED APPROACH TO THE PREVENTION APPROACH TO THE PREVENTION AND TREATMENT OF SUICIDAL AND TREATMENT OF SUICIDAL BEHAVIOURBEHAVIOUR

Heather Fiske and Yvonne DolanHeather Fiske and Yvonne Dolan

Bruges, BelgiumBruges, BelgiumFebruary 3, 2011February 3, 2011

Discussion QuestionsDiscussion Questions

What challenges have you witnessed What challenges have you witnessed your clients/patients overcoming?your clients/patients overcoming?

What has this stimulated in you that you What has this stimulated in you that you want to nurture and expand?want to nurture and expand?

----adapted from Hernandez, adapted from Hernandez, EngstromEngstrom, & , & GengseiGengsei, 2010, 2010

““Taking action with Taking action with imperfect knowledgeimperfect knowledge””

----Jennifer WhiteJennifer White

There is no Answer, There is no Answer, but there are answers. but there are answers.

----Rabbi KushnerRabbi Kushner

Often I have told of a phone call I received around three Often I have told of a phone call I received around three oo’’clock in the morning. This woman had decided to end clock in the morning. This woman had decided to end her life, and she was curious about what I had to say. I her life, and she was curious about what I had to say. I offered all the arguments against such a step and we offered all the arguments against such a step and we discussed the pros and cons. We finally reached the discussed the pros and cons. We finally reached the point where she promised to postpone her plans and to point where she promised to postpone her plans and to come to see me at nine. She appeared on time and come to see me at nine. She appeared on time and began: began: ““You would be mistaken, doctor, if you thought You would be mistaken, doctor, if you thought that any of your arguments last night had the least that any of your arguments last night had the least impact on me. If anything helped me, it was this. Here I impact on me. If anything helped me, it was this. Here I disturb a mandisturb a man’’s sleep in the middle of the night, and s sleep in the middle of the night, and instead of getting angry, he listens patiently to me for instead of getting angry, he listens patiently to me for half an hour and encourages me. I thought to myself: if half an hour and encourages me. I thought to myself: if this can happen, then it may be worthwhile to give my this can happen, then it may be worthwhile to give my life another chance.life another chance.””((FranklFrankl, 1997, p.12), 1997, p.12)

Warning Signs Mnemonic Warning Signs Mnemonic (created by Alan Berman, cited in Rudd, 2006)(created by Alan Berman, cited in Rudd, 2006)

II ideationideationSS substance abusesubstance abuse

PP purposelessnesspurposelessnessAA anxietyanxietyTT trappedtrappedHH hopelessnesshopelessness

WW withdrawalwithdrawalAA angerangerRR recklessnesrecklessnesMM mood Changesmood Changes

Three InterpersonalThree Interpersonal-- Psychological Factors that Psychological Factors that Contribute to SuicideContribute to Suicide

The The acquired abilityacquired ability to die by suicideto die by suicideThe perception of The perception of burdensomenessburdensomenessThwarted belongingThwarted belonging

----Thomas Joiner, 2005Thomas Joiner, 2005

Presentator

Presentatienotities

? Hopeful about this? --makes sense of literature --each of these factors suggests immediate actions we can take to reduce risk, to increase safety

Not just reducing riskNot just reducing risk

Real attention to protective factorsReal attention to protective factorsSupport reasons for livingSupport reasons for livingBalance acknowledgement and Balance acknowledgement and possibility (Opossibility (O’’Hanlon)Hanlon)Begin with hope and possibilityBegin with hope and possibility

““What worksWhat works””: Practice : Practice Principles 1Principles 1

UtilizeUtilize what the client bringswhat the client bringsFocus on Focus on reasons for livingreasons for livingMake every encounter therapeuticMake every encounter therapeuticTap into Tap into hopehope

Presentator

Presentatienotities

UTILIZE MILTON ERICKSONS GIFT FOUNDATION SFBT AFRICAN VIOLET STORY OR MRS BOOMER AND DAISY RSCH: LARGEST CONTR TO GOOD OUTCOME IS CLIENT FACTORS


ContainContain crisiscrisisWork with Work with systemssystemsCollaborateCollaborate: : --with clientswith clients

--with colleagueswith colleaguesBe Be mindfulmindful


Watch your Watch your languagelanguage!!Help clients setHelp clients set constructive goalsconstructive goalsEvaluate effectivenessEvaluate effectivenessDo what you can doDo what you can do

Wise wordsWise words

““There is a vital difference between There is a vital difference between ‘‘intolerableintolerable’’ and and ‘‘just barely tolerable after alljust barely tolerable after all’”’”

((ShneidmanShneidman, 2005, p.120)., 2005, p.120).

Helpful StrategiesHelpful Strategies

Listen reflectively: Practice Listen reflectively: Practice ““tingting””

Listen mindfullyListen mindfully

Listen for strengths, resources, Listen for strengths, resources, successessuccesses

Block the exit: Remove or limit meansBlock the exit: Remove or limit means

Helpful Strategies 2Helpful Strategies 2

Utilize strengths, resources, successesUtilize strengths, resources, successes——including including systemicsystemic onesones

Review list of options (creates Review list of options (creates choicechoice))

Identify and reinforce Identify and reinforce reasons for livingreasons for livingSupport any positive activitySupport any positive activitySupport any less negative activitySupport any less negative activity

“The [person] needs to experience her- or himself as being more than the sum of the problems.Only then will the person be motivated

to deal with his or her problematic sides.”

(Gassmann & Grawe, 2006, p.2)

Helpful Strategies 3Helpful Strategies 3Frame the clientFrame the client’’s problems in s problems in ““hopehope--friendlyfriendly””ways:ways:

as skills deficits (e.g. as skills deficits (e.g. LinehanLinehan))as naturally overwhelming the personas naturally overwhelming the person’’s coping s coping through sheer volume; implies that taken one at through sheer volume; implies that taken one at a time, they are solublea time, they are solubleas evidence of treatable illness; most helpful if as evidence of treatable illness; most helpful if can point to can point to ““livelive”” examples of others who have examples of others who have suffered and overcome such illnesses (suffered and overcome such illnesses (““solution solution filesfiles””))as as ““troublestroubles”” (S. (S. deShazerdeShazer, L. Taylor), L. Taylor)


Assume that clients make choices and Assume that clients make choices and take actions that make a difference:take actions that make a difference:

When the thoughts of suicide come, When the thoughts of suicide come, how long do they stay? how long do they stay? What are you doing to make them go What are you doing to make them go away?away?


Ask questions:Ask questions:----Directly about reasons for living Directly about reasons for living

What keeps you going?What keeps you going?...helps you fight back? ...helps you fight back? If there were one thing that might be worth living for If there were one thing that might be worth living for right now, what would it be? right now, what would it be? What kept you alive when you felt this way before?What kept you alive when you felt this way before?


AskAsk……hhowow clients account for their clients account for their strengths, resources, successes:strengths, resources, successes:

How did you know that How did you know that xx would would work/help/make a difference? work/help/make a difference?

What does What does xx tell you about yourself?tell you about yourself?


AskAsk……about about copingcopingHow have you managed to...despite these How have you managed to...despite these problems? problems? How have you kept going? How have you kept going? ——or evenor evenWhy arenWhy aren’’t things worse?t things worse?

Helpful Strategies 8Helpful Strategies 8AskAsk……aabout exceptions to the bout exceptions to the problem(sproblem(s):):

Tell me about the most recent time that you Tell me about the most recent time that you felt even a moment of satisfaction in your felt even a moment of satisfaction in your work (or closeness with your family or work (or closeness with your family or ……) ) despite the pain you are suffering. despite the pain you are suffering. What is one small sign that things are What is one small sign that things are beginning to get back on track?beginning to get back on track?What is different about those times when What is different about those times when you are not thinking about suicide?you are not thinking about suicide?


AskAsk……more about exceptions :more about exceptions :Out of 100%, how much of the time are you Out of 100%, how much of the time are you thinking about suicide? thinking about suicide? What is the highest percentage of time not What is the highest percentage of time not thinking about something else [other than thinking about something else [other than suicide] that you have had recently? suicide] that you have had recently? How did you manage that?How did you manage that?

Helpful Strategies 10Helpful Strategies 10AskAsk……““relationship questionsrelationship questions””, especially if , especially if clients have difficulty seeing their own clients have difficulty seeing their own reasons for livingreasons for living

What would your parent/friend/teacher/ What would your parent/friend/teacher/ employer/pet say was most important to you?employer/pet say was most important to you?...most likely to make a difference in how you ...most likely to make a difference in how you are feeling/thinking? are feeling/thinking? What would that person want you to What would that person want you to remember?remember?


AskAsk……about a possible positive future:about a possible positive future:

If a miracle happened...what would be If a miracle happened...what would be different? different?

Imagine yourself as an old wise Imagine yourself as an old wise person....what would you want to say to person....what would you want to say to yourself now? (Dolan, 1994)yourself now? (Dolan, 1994)

SupposeSuppose you begin to see another you begin to see another solution to your problem [other than solution to your problem [other than suicide]suicide]……what difference will that make?what difference will that make?

Helpful Strategies 12Helpful Strategies 12AskAsk……Scaling questions:Scaling questions:

On a scale from 1 to 10, if 1 stands for you are On a scale from 1 to 10, if 1 stands for you are definitely going to kill yourself today and 10 stands definitely going to kill yourself today and 10 stands for the day after the miracle, where were you before for the day after the miracle, where were you before you decided to come in, you decided to come in,

……and where are you now? and where are you now?

Where do you need to be on the scale to be safe Where do you need to be on the scale to be safe from killing yourself? from killing yourself?

……to be safe from thoughts of killing yourself?to be safe from thoughts of killing yourself?

Tips for working with Tips for working with families and friendsfamilies and friends

Follow up on recommendations to families Follow up on recommendations to families about removing suicide means about removing suicide means (Brent et al., 2000)(Brent et al., 2000)

Get everyone a jobGet everyone a jobInclude Rover and TabbyInclude Rover and TabbyNurture hopeNurture hope

By noticing, celebrating and reinforcing the smallest By noticing, celebrating and reinforcing the smallest signs of progress, recovery, healingsigns of progress, recovery, healingThrough persistent interest in their wellbeingThrough persistent interest in their wellbeingThrough direct and indirect compliments for their Through direct and indirect compliments for their effortsefforts

Repeat attempts or Repeat attempts or ““borderline pathologyborderline pathology””

Useful Foundations For The TherapistUseful Foundations For The Therapist::Hopeful story about Hopeful story about ““borderline borderline personality disorderpersonality disorder”” (e.g. (e.g. LinehanLinehan, , Herman)Herman)Good personal stress tolerance and Good personal stress tolerance and stress managementstress managementUnderstanding of complex posttraumatic Understanding of complex posttraumatic stressstress

The challenge of repeat The challenge of repeat attempts 2attempts 2

Useful StrategiesUseful StrategiesAcknowledge validity of clientAcknowledge validity of client’’s view, s view, clientclient’’s experiences experienceAcknowledge clientAcknowledge client’’s pain and struggles pain and struggleAcknowledge clientAcknowledge client’’s expertises expertiseEstablish therapeutic contract/structureEstablish therapeutic contract/structure


Establish crisis response plan Establish crisis response plan (e.g. J. Callahan, Chiles & (e.g. J. Callahan, Chiles & StrosahlStrosahl))DicussDicuss/confirm plans with all parties /confirm plans with all parties involvedinvolvedLook for Look for ““time outstime outs”” which do not which do not require hospitalizationrequire hospitalization


Explore Explore copingcopingAsk:Ask:

why arenwhy aren’’t things even worse?t things even worse?how is this view of things helpful to you?how is this view of things helpful to you?


Modify language according to clientModify language according to client’’s s tolerancetolerance----positive/negative wordspositive/negative words----references to futurereferences to future----negative scalingnegative scaling


Frame Frame ““thefttheft”” of ability to think positively, of ability to think positively, anticipate the future (Y. Dolan)anticipate the future (Y. Dolan)

Frame suicide as learned coping responseFrame suicide as learned coping response

Negotiate limits of tolerance for Negotiate limits of tolerance for ““solution talksolution talk””

Utilize concrete reminders of supports, Utilize concrete reminders of supports, resources, successesresources, successes


Build Build ““longer listlonger list”” of alternative coping skillsof alternative coping skills----inclincl. distress tolerance, interpersonal . distress tolerance, interpersonal effectiveness (effectiveness (LinehanLinehan))Teach selfTeach self--soothing, selfsoothing, self--carecareNotice and celebrate small improvements Notice and celebrate small improvements (incl. (incl. ““negative negative reinforcersreinforcers””))Monitor helpfulness of treatmentMonitor helpfulness of treatmentModel selfModel self--carecare

There are cracks, There are cracks, cracks in everything. cracks in everything. ThatThat’’s how the light gets in.s how the light gets in.

-Leonard Cohen, “Anthem”

How is my interaction How is my interaction with clients with clients ““hopehope-- friendlyfriendly””??

WhatWhat’’s working? s working? Keep in touch!Keep in touch!

[email protected]@yahoo.ca

[email protected]@solutionfocused.net

mailto:[email protected]

heather fiske and yvonne dolan bruges, belgium february 3

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