Barbara Stanley, Ph.D., “Suicidal Behavior in Borderline Personality Disorder”

dr. Stanley is the director of the suicide prevention training implementation evaluation program at New York State Psychiatric Institute she's a professor in the department of psychiatry and a visiting professor at the University of Oslo so we're very pleased to have her with us today I'll give you dr. Sam thank you very much for inviting me to speak today so I just want to put up my disclosure which is mostly my funding sources here and I want to start with what are the goals of my presentation first of all talk a little bit about suicide as a problem but in particular suicide as a problem in borderline personality disorder and [Music] what are some novel approaches to understanding suicidal behavior what are strategies that we have developed in working with suicidal individuals and I just want to say that in my presentation today I'm gonna really focus on the clinical side of things as opposed to presenting research data I have I where well actually now three hats but the you know mostly think of myself as a researcher but I'm also a clinician and I've worked with suicidal individuals particularly suicidal individuals with borderline personality disorder for many many years and so while I draw on both the research side and the clinical side I really want to kind of focus on the clinical side of things with that said I'm going to talk about some data in the beginning so one thing I'm gonna point out here to you is that earlier it was mentioned this is the funding for borderline personality disorder well I'm a borderline personality disorder but I'm also a suicide researcher and really down at the bottom of the barrel here is suicide research so if you are a researcher on suicidal behavior and borderline personality disorder you're really in trouble and and so if you compare it to for example and this is what what people have been talking about earlier about signing that petition and becoming an advocacy group I think it's incredibly important because look at what has happened with autism and this is a population that has been very very active in in demanding on that research be done and that funds be devoted and so you it is possible to increase the amount of funding so that's my pitch okay so suicide has taken on a lot of time in the press over the last few years and so I've been in the field for a really long time and and this was what it looked like and so this is really why it's really important to not assume kind of causality so over these years what happened here was there was the introduction of of SSRIs and so everybody thought oh look we have the suicide problem licked suicide rate is going down we have these great new antidepressants and then as everybody else has presented today already the suicide rate has gone up okay so oops I'm sorry so what I want to point out here is that over the last several years of the ten leading causes of death of which suicide is one the the numbers of those people who died by those leading causes has gone down in every single one or has at least stayed the same except in suicide suicide is the only one where it's going up so something is really wrong here okay so I'm not going to belabor this too much we are ready we heard earlier that we now have a problem and this is huge in the suicide field we have a problem in middle-aged group it was always the older white male that was our highest suicide risk group that no longer is the case so I put this out here for you because this is just looking at males and females and we know that females are much less likely to die by suicide and the people who we see in our clinical practice who have borderline personality disorder are much more likely to be female but if you look at what is happening over the last few years this is females only and you could see in this something is going on here not just with middle-aged men but also with middle-aged women where the suicide rate in middle-aged women is going up and so we would expect that that might translate into an increase in suicide and borderline - so as a suicide researcher one of the things that I always point out this year the 2014 the firearm rate goes just below 50% but um in the United States and this is particularly the United States about half the people who die by suicide do but die by firearms it's incredible and so when I talk about safety planning in a little while we always talk about access to firearms okay so this I think is really important for us to take a look at here so this is what is the if you try to kill yourself with the firearm what is the so-called success rate the fatality rate 85% of people die if you do try to kill yourself by poisoning which is a drug overdoses it's a much smaller rate of death so it's very hard to kill yourself by drugs it's very easy to kill yourself by suicide men use guns women use pills the other thing that I think is important for us to remember is kind of like the the incidence of substance use and and suicide and that's not it's it's not that so much that substances are used to die but but substances are often on board at the time of death in the the highest incidence of substances that death is is alcohol so about a third of people who die by alcohol have have who died by suicide have had alcohol before their death this is particularly alarming on twenty almost twenty one percent have opiates on board and this is probably going up with the increased use of opiates okay so we already know this I'm not going to go through all of these figures here um there are many many more males died by suicide females more often make suicide attempts and I will go through all of these figures here you have them in your brochure so do suicide attempts predict suicide and so if we we look at this case in in Europe where they looked at more than 21,000 cases individuals who self-harm and actually it's a little in the rest of the world people don't separate out self non-suicidal self-injury from suicide attempts typically they lumped self all kinds of self harm together so people who self-harm are twenty four point seven times more likely to die by suicide so that's a pretty high high rate but the thing that I think that's really important for us to think about because as clinicians when we when we're talking with people there is a kind of a tendency to kind of like formulate in your head okay is this person at risk or not at risk and so [Music] we pretty much know now that if somebody made a prior suicide attempt we should be worried about them making another suicide attempt however over fifty percent of people who die by suicide have made no prior attempt in other words on their first attempt they die and so it's if we can't rest easy in other words if if we say oh well that person doesn't have a prior attempt they're not going to be at risk for suicide okay so up to the 1980s suicidal behavior was seen as a symptom of depression a borderline personality disorder even though we then talked about borderline that much of schizophrenia or substance abuse in other words suicidal behavior was looked at only in the context of a formal diagnosis and and so the thinking was then the way to treat suicidal behaviors you treat the primary disorder and the suicidal behavior goes away but actually there was a change in perspective about this where we began to look at this in a little different way where we saw this is and this is kind of what the current thinking is that psychiatric disorder is a is is a necessary but it's not a sufficient condition and so we are trying to grapple with what is the other things that goes on here that make psychiatric disorders not the only but what else do we have to look for on and so the reason that we we know this is not everybody who is depressed dies by suicide or makes a suicide attempt or in fact is that is suicidal at all and so the so the way that we have started thinking about this is we're kind of going in a direction and and and Joe's talk is kind of giving me pause about this and I talked about this with a little bit of trepidation here with him in the audience but we're starting to think about suicidal subtypes that one size doesn't fit all and the place that we're starting from is this so I was lucky in a treatment study that we're just kind of wrapping up now we did we decided to do ecological momentary assessment which is you give somebody a little thing to carry around now when we use an iPod and they get paying several times a day and they fill out a bunch of ratings and so we gave these to our patients all of whom have borderline personality disorder we gave them to carry over the course of a week six times a day they were pinged and we looked at the character of their suicide ideation over the course of a week so what is interesting about it is these patients all had borderline personality disorder so I would have thought that this would be like what my borderline patients would be like but in fact that was not true this is a subgroup of people with borderline personality disorder and this is another subgroup so you have people who have ideation that is all over the place over the course of a week that's really tough if you're thinking about clinically they're up and then they're down and then they're up and then their town and then what do you do with those patients these were the people who I who go to the emergency room and and they convinced they try to convince the staff there that they're no longer suicidal and often they get shipped off to a hospital but in fact they are no longer suicidal because they're like this on and then there is this other kind of subgroup and so what we started thinking about is okay so how can we understand so say this is really an important meaningful difference in people and we really can identify these these highly variable from these not so variable and so this is where I were supposed to be getting funded any minute now to look at these two suicidal subtypes and so it's really I we we kind of have a sense of what this subtype is so this is kind of more the reactive one the one that goes up and down so the stress responsive subtype and in fact we have data now but I'm not going to show here that these people we've gave the tree err social stress test to these patients which is you it's it's kind of um you put people in in a room where they give they give a little bit of a speech and they they do what backwards arithmetic test and then you get their cortisol levels over time and so um and so you can look at their cortisol response over time and in fact what we found is these the highly variable type this one had a much higher cortisol response to to to the stress then these guys so so we're looking at this kind of stress response of stress reactive subtype and then we have played with what exactly is this one called and so well it I really think about it as kind of like the depressogenic subtype the more chronic or the non stress responsive and this was what we think about as having a more low serotonergic activity so that's kind of weird that's just a little bit of kind of give you a taste of like where our research is going and what we're thinking about it ok so now I'm just gonna kind of switch back to talking about suicidal behavior in the context of borderline personality disorder and then talk about strategies that we have for managing people with suicidality and you know one of the things that's really interesting the name of this conference is suicidality but from the CDC it's a no-no to say suicidality right and which I actually happen to really like that term because it really in compasses all of being suicidal okay so nearly ten percent of people with borderline personality disorder die by suicide so the the figures vary and this is probably the upper limit of it but it's a lot and if you kind of go backwards and look at the universe of people who die by suicide anywhere from nine to thirty three percent of individuals have borderline personality disorder so these figures actually are not that great because a lot of studies do not include looking at access - it just doesn't and and you still I still have colleagues at Columbia who think that borderline personality disorder does not really exist that if you treat the depression the borderline personality disorder will go away and and this is actually this is still or it's a variant on on bipolar disorder or it's some sort of atypical depression something like that um so um but the it's pretty striking that if you when you do look at studies that do look at access to diagnosis um there's a high rate of people who die by suicide um for in borderline personality disorder up to 70% of individuals with with BPD have cut burned hit or otherwise injured themselves self hitting is a very big problem we often don't ask about it but people take objects and hit themselves in the head or they hid themselves in the hair or they bang their heads against the wall and then non-suicidal self-injury does in fact predict future suicidal behavior so um what's the problem of working with suicidal behavior in the context of borderline personality disorder that's a little bit different say that in depression so suicide attempts occur at a much higher rate than suicide about ten times as many attempts for every suicide it's probably even a higher rate in BPD than in any their diagnosis the usual method of attempt um in BPD is overdosing so what happens is the high rate of attempts in the chronicity of suicide ideation in the borderline population makes for a very complex picture and difficulties assessing and managing risk so even for example when two hospitalized are not hospitalized when to send to the emergency room or not to and this is what you know we think about as the boy who cried wolf phenomenon and it's actually not faking it but I think that the clinician who is treating the person with borderline personality disorder who was suicidal kind of takes that frame of mind that well they they say they're suicidal they say they're suicidal they say they're suicidal and there's no attempt on or they make a low lethality attempt they make a low lethality attempt that's all they're gonna do and then they die by suicide and so but so it's this kind of figure ground thing that is very difficult in the context of Bourdon personality disorder of you know you have you have kind of like a high base of suicidality suicide ideation suicide attempts and low lethality attempts and then how do you know when it's going to be either a suicide death or a very serious attempt and so that the picture tends to lead to an underestimation I think of suicide risk in may and may in fact contributed to the high risk of completion and so this is kind of a a a poor explanation of this they're trying to figure out whether it's a chemical thing or I'm just a crybaby and I think that's what happens to a lot of people with borderline personality disorder they it's not real it's whatever it is it's not real and and and so the we tend to kind of like underestimate or undervalue the the role of this is in fact real ok non-suicidal self-injury and BPD occurs at a high rate um there is a big overlap between people who self-injure and the group would make suicide attempts and so there is some thinking about this that you know maybe there is a kind of like a gait theory that once you start one kind of self injurious behavior that it allows you to move to another level of self injurious behavior um also common as I mentioned before our self hitting head banging and skin picking so one thing that I think is interesting in suicidal behavior and boiling personality disorder that can be a little bit different than suicidal behavior in say in major depression often individuals with with BPD describe their suicide attempts in the same kind of way as self-injury episodes and it is a kind of a thing that then people tend not to believe that they were seriously suicidal and and so suicide attempts in this kind of strange way in the same way that self-injury selves serves as a emotion regulation function suicide attempts can serve as a self-regulation function and we really don't pay enough attention to this and this really takes me back all the way to my internship out at at lij on Long Island where I came in to my supervisor and I said like I don't understand this was the time when they it's a very long time ago they had still had cottages there that were not locked um and so somebody came in and he had made a suicide attempt and with an serious suicide attempt and within a week he was the president of the patient governance board and I said I went to my supervisor and I said like I don't understand this and she said ah that's just shallow depression and so it's like okay it's shallow depression actually it was borderline personality disorder on and so whatever the attempt whatever the function of the attempt was it served to kind of stabilize the person and so I mean I won't get into it but then there is a question of what is the underlying neurobiology what's happening in the context of and I have some research where I've looked at this in non-suicidal self-injury what's happening when somebody self injures this is not like oh it's just a learning function and we learn how to do something we are biological animals something is happening to us biologically when we self injure that is making us feel better what is that um and so the same thing kind of is happening often not all the time in people with borderline personality disorder okay so on the thing I think that is really important is that in our minds we often now probably not in this audience but in a general clinical audience I think we walk around with a model of suicidal behavior as kind of thinking about suicidal behavior as a aspect of major depression the depressed individual goes into a protracted period of depressed mood hopelessness withdrawal and isolation and it can culminate in feeling life is not worth living feeling hopeless and then lead to a suicide attempt following the attempt if you've spoken with people who have major depression every now and then somebody is glad that it wasn't successful often people talk about feeling sorry that it wasn't successful but the major depression model doesn't seem to apply to suicide attempts in BPD we try to apply it and it leads us to the notion that the BPD individual feels better afterwards because the attempt was just manipulative it was not really genuine it was designed to get attention and we just have to kind of move that model and not thinking that model at all this is an example I won't go through this this is a typical example you have it in your your handout of somebody on who made a pretty serious suicide attempt so if we compare on suicidal behavior and BPD and borderline personality disorder some of the questions we can ask is does it have a different phenomenology are the after-effects of suicide attempt in BPD different yes often people feel better is the behavior less serious um what do the precipitants differ and is there a different biology okay so this was a study that Beth Brodsky and I did a while ago if you look at people who have have a borderline personality disorder they have they start their career of suicidal behavior earlier they have more suicide attempts at any given age but it's really interesting if you look at like what's the most serious suicide attempt but they make it's the same as major depression so it isn't just like oh they just make a bunch of low lethality attempts who cares you know they're it's not good but it's not that serious it is serious there at lethality is exactly the same they're just making more low lethality attempts they have greater hostility greater impulsivity and greater history of aggressive behaviors so that's a kind of a difference between the two and you know it's interesting because when we that the model of those two type types that I was talking about the two endo phenotypes they actually when we start to look at our data you would think oh well maybe that's the borderline one and that's the non borderline one but it actually is not really true so you shouldn't just think that that reactive one is just borderline so if you think about interpersonal events as triggers for for suicide attempts in the borderline as we heard earlier today in the individual with borderline personality disorder much more often an interpersonal trigger on and so for their first attempt their most recent attempt in their most lethal attempt so the interpersonal interpersonal interactions are very complicated and stressful for individuals with BPD okay so so that kind of puts the context for how are people with borderline personality disorder different in terms of their suicidal behavior than other people on so now what how do we help them what do we do as clinicians in in treating individuals with BPD who are suicidal so we have some suicide specific psycho therapies there's DBT there's MBT there's cognitive therapy for suicide prevention but the reality is that many clinicians are not in the position to learn suicide specific psycho therapies you know now that I have this role within New York State of developing and implementing suicide prevention trainings throughout the state I see what clinics are are tasked with and what their workload is and the number of patients and the variety of patients that they see and so if I'm going around as the suicide prevention expert and say you know what you need to learn this specific therapy for your suicidal clients it's like you know it's really it's nice but it's not realistic however as somebody who has learned DBT and CT you can kind of glean from that what are some of the things that we can do that can help suicidal people and in fact in one of my treatment trials where we were kind of doing we were comparing DBT to clinical management I found that certain kinds of a clinical management makes led to very low incidence of suicidal behavior and that started us thinking of okay so what are those techniques what are we doing here um and so that's some of the things that I'm gonna talk about here so um so and I'll talk a little bit about each of these things explicitly inquire about suicide ideation now you would think that that is a no-brainer but it is not and somebody mentioned earlier that people feel funny asking about it sometimes and on and what happens is people assume that if it's not mentioned it's not present if in working with suicidal people and this is very hard often in clinical environments but I'm just gonna say it you need a flexibility in the clinical approach I'll talk about that in a moment you need to as like for me I was in charge of my treatment study so I could require documentation each and every time there was evidence of any suicide ideation of a collaborative plan for managing suicidality now at the time we hadn't developed the safety plan now we have this this small intervention but all I was asking the clinician to do was each time your patient says to you I am having suicide ideation I want the two of you to develop a plan together about how they're gonna manage it pretty simple right but it doesn't get done um consultation with colleagues is extraordinarily important therapeutic stance I'll talk a little bit about that and then structuring techniques to maintain the focus on suicidality so are there do clinicians who have had a suicidal who have had a patient who has died by suicide learn anything from that experience they there are tremendous terrible emotional sequel I of that for clinicians so um so these results actually were shocking to me these were this was not the intention of the article the article talked about about the how the clinician basically felt the same after a suicide of a patient as a family member did when when their loved one died by suicide so um so these are the results that were surprising to me so about 75% of them assess their patient as suicidal about when you put these two figures together about 50% of them had asked their patient about suicidality in their last appointment and in retrospect only about a third of them would have done anything different so I'm thinking like wait a minute only half of them asked a person who they had known to be suicidal um that about their suicidality and only about a third of them would have done anything different it's like oh wouldn't you think that you would begin to start asking about suicidality um so this is what we do um we do ongoing if you know you have somebody who has evidence of suicidality we do ongoing monitoring of their suicidality and that means cannot assuming if they're not talking about suicidal ideation that they're not suicidal we conduct an affirmative assessment of suicidal ideation on and conduct affirm an affirmative assessment of recent suicidal behavior so if you have if you work with individuals with borderline personality disorder you know that they can have made a suicide attempt a week ago two days ago come into your office and have zero suicidal ideation so if you just say are you feeling suicidal now and they say no you are missing you could be missing something very big about not asking them about their recent behavior and in fact I remember as we were developing the CSS RS I was insistent on putting recent behavior on the screening form of it because if you you can miss picking up somebody who is in a high-risk period if you do not ask about recent behavior this is especially true if you're working with borderline patients and so um I put up this up because this gives you a taste of me as a clinician refusing to discuss this is not an option on and so if you are my patient you are going to talk about this period you want to be my patient I am a good clinician you have to be willing to talk about this and there has to be this kind of level of kind of communication and trust that if I ask you this question you will give me an honest answer and so on so my patients know that I am willing to tolerate a high level of suicidality without hospitalizing as long as I can trust their honesty and these are like two very important dimensions that we have to take into account I and I and I have this discussion very explicitly and any you don't need to be doing DP thbbt NE b t to be able to do this this is really important to to establish when you're working with the suicidal person and so and this happens a lot if you work with adolescents you know they they don't want to talk about it you know and so um so you have to establish a climate where they they know that this is it's not an option to not talk about it so the other thing when I say affirmative assessment I mean affirmative assessment you ask about it on do not is assume that if patients do not express suicide ideation if they're not if they don't say so on in patient after patient with borderline personality disorder this is what I have the most experience with so really is speaking from the place of working with individuals with Boylan personality disorder so I will say hey why don't you tell the clinician about that well I didn't think the clinician care or the clinician doesn't want to hear about it so he or she doesn't have to do anything about the risk because it is a big pain to have to deal with somebody who is suicidal you have a this you know I've had it in my private practice where you know you're seeing patients one after another and somebody says they're suicidal and you feel like okay you know I I have decided that this person actually cannot leave now that they are so extraordinarily suicidal I cannot risk sending them home well that kind of like you know that interrupts your schedule and and so you have to be able to kind of like own up to that acknowledge that and not act on hey I don't want my schedule interrupted um and you know the interesting thing is that if my schedule gets interrupted in the context of this I never of course talked about it with the patients who are in the waiting room but they all know why it got interrupted and they all appreciate that I would do the same thing for them so um so you want to try to create a therapeutic environment that encourages disclosure and so I'll talk about that in a minute so flexibility and approach this is really tough for people who work in a clinic environment on you if you have if you are working with the suicidal population you have to provide for increased contact during periods of suicidal crisis so you increase the number of appointments you increase the intercession contact either by phone or if you're comfortable with email you can have patient check-in my patients find this incredibly helpful um they will call and leave me a message on my machine saying you know it's Sally I doing okay or I'm struggling but I'm okay and they and I they don't need me to call them back we we know in advance we've made a plan in advance and and it works out fine and they they know that somebody else knows how they're doing and then you need to consider options for other forms of therapeutic support hospitalization is always an option but there are other options short of hospitalization so of course there's groups and there's day programs but one of the things that I work on with my patients is increasing your structure in your day this seems pretty simple but it's like you know you have somebody who comes into your office and who is you know basically getting out of their apartment coming to their appointment with you and then going back to there it's like no that is not okay come up with a schedule of activities that you're going to because we know that number one not having social contact is a likelihood to increase depression and and staying in your apartment or your home alone leads you to stay within your head and in your thoughts and so so you you so you don't have to just think about sending somebody to a day program you can work with them on increasing their structure so clinician consultation and support are very very important I work at at New York State Psychiatric Institute and it happens that in our division along our corridor well everybody works on suicide we all we do trials we do biological studies and and so we're we've seen hundreds of suicidal individuals we are constantly knocking on each other's door asking about what do you think about this particular person I'm worried do you think I should do this do you think I should do that the person will often say would you like me to talk with them do you want another you know or or spend time so it's really important if you have a doubt in your mind have some colleagues that you can consult with knowing DBT we have a team you know but if you're not doing DBT you can still find a few colleagues that you can trust that you can kind of swap support with in consultation with and all I can say is that experience helps the more you work with suicidal people the better you are at it period the more that you work with suicidal people the less likely you are to hospitalize them because you have kind of a context and you have a feel for it's like I collect Crocs with blue designs these old you know from the 1700s 1800s in America they you put me you know flour or oil in these Crocs carried them home with the cork on top of them and so some of the Crocs have blue designs if you have collected enough of these Crocs looked at enough of these Crocs you know which is a fake blue design and which is a real blue design how does that happen you know I you don't naturally know oh this cobalt blue it looks this way and this way it's from experience so the more you work with suicidal people the more you know same as knowing which is a fake croc and which isn't um okay so this I want to talk about for a minute um is the therapists stance so it's you have to come and working with suicidal people from a position of strength you have to balance concern for the patient without being overly anxious this is not so easy and and the the reality is that I have worked I have supervised some clinicians who actually when you work with them and work with them they actually shouldn't be working with suicidal people because they they just don't have it in them my daughter-in-law is going to be is a surgeon it's like well I could never in my wildest dreams be a surgeon I can't stand the sight of blood and so on so part of it is knowing yourself and there are some people who just aren't made for working with suicidal people that's okay I'm not really made for working with people who are just anxious it's like I just want to say well hey stop that there's nothing to be anxious about but give me somebody who is cutting burning and acutely suicidal and I know what to do and I feel comfortable with that so part of it is kind of so in a clinic environment you may not have this option um but I in a private practice environment I think it's really important to kind of know yourself um so the type of inquiry when you're asking about suicidality people know if you are extremely anxious it's matter-of-fact but serious and so there is this kind of like tension you're asking this question about their suicide ideation and their suicidal behavior in the same way that you ask any other kind of question not more not less therapists need to not worry too much but yeah and and they and you have to develop a certain level of tolerance for suicidality and so this really comes into play if you have established a relationship with a patient where they are honest and so I can have I can tolerate your suicidality if I know you're being dead-on honest with me and so you need this kind of tolerance for a certain level of suicide suicidality so you hear it you acknowledge it you listen to it it isn't like you don't pay attention to it you say I see you're feeling suicidal and you and and so that's balancing it with a sense of caring about the suicide alledge so you care about it but you're not gonna go crazy about it and you're not going to and hospitalized the person this immediately this is really important because the more that you are anxious and moved to hospitalized the and you keep that person in your practice the less likely they are to tell you about their suicidality in the future I have patients who go to a particular day program and they say well I never tell the group about X Y or Z because I'll get kicked out they have been taught they've seen somebody get kicked out and they don't want to get kicked out and so they they don't disclose but get then they're walking around with this and so as a therapist we have to kind of walk this tightrope and then you take a collaborative problem-solving approach okay so discuss in advance how the two of you will handle suicidal crises develop a safety plan I think that no suicidal patients should ever leave a first appointment without some rudimentary safety plan so you know when you work in a clinic environment you have a first appointment how how much how thick is the stack of forms well now it's on the computer that you have to fill out you know so how important is it to get somebody's history of psychiatric hospitalization in that first appointment versus giving them a tool that they can leave with and possibly keep themselves alive till their next appointment and so this is a tough sell to clinics and hospitals but it's but it's kind of a to me in my mind it's a no-brainer so when we talk about a safety plan we really want to differentiate it from no suicide contracts we kind of don't do so with no suicide contracts anymore a no suicide contract asks a person to promise to stay alive without telling them how to do it we think we can do better in New York State we have adopted what we call this a model which is assess intervene and monitor and the and this is what we talk about when we go to clinics like this is like your Bay sick of suicide care you assess you do some sort of basic intervention and you do some sort of follow-up monitoring okay so I just want to talk for a little bit I know I don't have a lot of time left here about the safety plan intervention that my colleague Greg Brown and I developed on Seth mentioned it earlier we have data now supporting that we get a reduction in over a six-month period of time by about 45 percent in suicidal behaviors for people who have this they have a higher rate of engaging in further treatment so it's a it's a it's a clinical and intervention that develop that results in a one-page document to use when a suicidal crisis is emerging we are now doing it with a group from Braun and Michigan State in for suicidal people in jails and they are trying to implement this Edie Boudreaux and at the University of Massachusetts is trying to implement this in emergency rooms and actually the most difficult place to to get this administered is in the context of emergency departments who say they don't have time to to do this intervention okay so so what are the strategies that that are in on the safety plan what we did was we put the safety plan together we went to the literature and we just looked okay what's the evidence base what has some support in the literature for reducing suicide and so we means restriction was one of them brief problem-solving and coping including distraction I happen to be a huge fan of distraction in the context of a crisis enhancing social support is related to a protective factor of course identifying an emergency contacts and then a little bit of motivational enhancement for for further treatment so why a safety plan so one of the things that we know is that even for my group that had relatively stable suicide ideation and people that went up and down the actual period of risk for acting on a suicidal urge and it's so interesting in the field we don't we talk about behaviors and we talk about ideation we do not talk about urges we talk about you know urges to self injure why do we not talk about urges for a suicide attempt um because that's actually what people have they do have urges and so the the period of time where the urge is very strong is actually very limited and so when you talk with people who have who go through these crises they talk about kind of like white-knuckling it through that period of time like just kind of holding on till the urges pass and so what we decided to do was give them something to do while the urge is happening and so the the theoretical foundation and this isn't like a small t suicide risk fluctuates with time time is your friend if you are suicidal and we really forget that and that's why restricting access to means to firearms is so incredibly important it's really important because um if we get rid of that or put a distance between why why does that work if somebody wants to go out and kill themselves they can but but then the reason is because suicidal urges pass on problem-solving capacity diminishes with during crises so over practice or a specific template can help that's like um during Fire Prevention Week my kids we used to come we lived up on a hill they would come baby rolling down the hill it's like oh it's Fire Prevention Week because they learn to stop drop and roll and so why why is it so we we know that kind of like over practicing having a specific thing in when you're in emergency situation is helpful and so that's what the safety plan is about and one of the things that I would have you remember is how many of you have had a patient come into your office once and never saw them again so if that person is suicidal wouldn't you like to give them something that they might be able to use when they when they leave so um so we just have I'm going to just go through these what are the steps we do we have them recognize the warning signs they can't know to use a safety plan if they don't know when to use it we have them and we this is a stepwise thing and this comes from really kind of like trying to help shape behavior and from helping them learn the more that they do this the more they they have the capability to manage their suicidal feelings and so the idea is that they do this do this do this that it will kind of become automatic kind of like riding a bike so we we Furr we have them identify things they could do by themselves people that they can use as distractions who to contact that they um who can help them in a crisis so you can see that in New York I don't know if it's true up here but in New York everybody puts on their their answering machines at work a if you are in an emergency go to the nearest emergency room or call 9-1-1 actually I think we can do better than that you know what if you have if you have an anxious patient in your practice would you say um you know if you get we all think of it if you get suicidal call me or go to the emergency room if you if would you say to the anxious patient if you get anxious call me know you teach them skills so that's the idea be we can teach people skills suicidal feelings are just like any other feelings they're scarier they result in a horrible outcome but they're just like any other feelings that can also be managed so then we have them identify who their contacts are so in other words we as clinicians are not first on the list if it's a real emergency and they feel like they can handle anything yes of course we tell them to to contact them or go there near the nearest emergency room so then we also have them identify what are their access to means what would they use would have they used and we always talk about firearms this is an example of a safety plan you can go to our website and download these forms it's suicide safety plan calm okay and then lastly the only other thing that I'm going to mention here is using structure as a strategy for managing suicidality and the the reason is that when you work with people with continual crises and continual stressors you need to stay on the path where they to help them with their suicidality or you can get derailed this often happens with borderline patients by moment-to-moment crises okay so these are structuring techniques they are in in there and CBT or DBT setting an agenda conducting behavioral analyses and balancing validation with problem solving okay so I you have the other things in the the description of these things in your pamphlet I won't go through them in the interest of time here so just in conclusion I will say look we have a problem in the United States with suicide it's growing we haven't tackled it yet suicidality in the context of borderline personality disorder has to be taken seriously we cannot neglect it just because it occurs very often and while suicide specific psycho therapies have been developed most clinicians will not be able to learn them but we can all learn simple clinical strategies that can be used even in the absence of suicide specific psychotherapy training and then I found this quote by Karl Menninger hope is a necessity for normal life and the major weapon against the suicidal impulse and my patients would describe me as an eternal optimist or somebody once described me as stubbornly hopeful and I think if you are a clinician working with suicidal individuals you have to maintain that position of stubborn hopefulness and then I just want to thank my research team and all of my patients who have contributed to our research thank you Thank You dr. Stanley for an excellent talk on we have several questions here I'm going to go through a couple and then we'll hold the rest for the panel is there any research on the effectiveness of the safety planning yeah so um you know I did I purposely didn't do a data talk today but we have we have a lot of data on the acceptability and feasibility of it we have data now that it's like we have a parallel group design where we gave safety plans in the emergency department in the VA and then we had a comparison group where they didn't get them and that was the data that I referenced earlier where we have a 45 percent reduction in lower number of suicidal behaviors in the safety plan group in addition they're much more likely to engage in follow-up care we are now we think we're going to be funded to do a straight-up randomized control trial which we've been trying to do but because safety planning has become so broadly accepted it's been hard to get that trial funded but we think that it's really important to really just look at its efficacy alone in an RCT thank you how would you suggest that clinical staff shall determine lethality in the kind of boy who cried wolf cases that you're mentioning and and how can they kind of protect themselves legally when how can they protect themselves or colleagues legally if they determine that the patient is not really a high-risk oh gosh I mean legally you I mean you always take a risk and I don't know that it's and I'll put aside the the malpractice kind of thing which I gather is what you're talking about um you know it's as I said the more that you work with suicidal people the more you kind of get a feel for it the more you have established a an open and and trusting relationship and that comes in a bed of having patients feel comfortable talking about their suicidality with you and knowing that you won't just neglect it but also knowing that you won't overreact to it and so it's you know it's one of these things it's really a kind of a fine clinical distinction that you you have to make and and the other thing is what I would say is that if somebody is suicidal and they're suicidality is increasing I increase my monitoring in my contact so it isn't like I say oh I get that you're you're feeling suicidal but you're not that suicidal that you need to be hospitalized it isn't like an all-or-none thing it's like okay you're feeling suicidal you're suicidality has escalated what can we do to help you manage the suicidality now then we'll do another check in and see if it's lower and then again and again and so I I think that that's pretty protective I have I have a safety plan I have a plan for monitoring and I've never been sued and I've never had anybody who's died by suicide well thank you very much dr. Stanley we'll revisit the rest of the questions at the panel but thank you [Applause] [Music] you

Channel: Yale University

Views: 29,546

Keywords: NEA-BPD, Yale, Yale Psychiatry, Yale School of Medicine, Seth Axelrod, Emily Ansell, Borderline Personality Disorder, National Education Alliance, Yale NEA-BPD, mental health

Id: ft2wh2RTmlU

Length: 59min 52sec (3592 seconds)

Published: Tue Jun 07 2016