Monday, April 16, 2018

Helping the Suicidal Person: Interview with Stacey Freedenthal, Ph.D., LCSW

[Episode 119] Today's episode of the Social Work Podcast is an interview with Stacey Freedenthal, Ph.D., LCSW about her book, Helping the Suicidal Person: Tips and Techniques for Professionals

I was excited to talk with Dr. Freedenthal because she's come up with 89 tips and techniques that you can start using right away with suicidal clients.

In today’s episode, we talk about five of them:

Tip #10 – Embrace a Narrative Approach: “Suicidal Storytelling”
Tip #35 – Know When and Why to (and not to) Pursue Hospitalization
Tip #36 – Know Why not to Pursue Hospitalization
Tip #64 – Incorporate a Hope Kit
Tip #88 – Propose a Letter to the Suicidal Self


Dr. Freedenthal has been a faculty member at the University of Denver School of Social Work since 2005 and maintains a private practice. She’s the creator of the massively popular blog, SpeakingOfSuicide.com, and her writings have appeared in academic journals and media outlets like the New York Times. You can find her on Twitter @SFreedenthal

Download MP3 [32:24]


Resources and References

Freedenthal, S. (2017). Helping the Suicidal Person: Tips and Techniques for Professionals. New York: Routledge. Retrieved from https://amzn.to/2vibkAn

Stacey Freedenthal on Twitter: https://twitter.com/SFreedenthal

Stacey and Jonathan after the interview, comparing the VERY similar layouts of our books on suicide, both published by Routledge. 


Transcription

Introduction
Hey there podcast listeners, Jonathan here. Raise your hand if you were ever in a workshop, class, or lecture that should have been super practical, but wasn’t. Yup, my hand is straight up in the air. Which is fine because I’m all alone in a recording booth. But I hear this all the time from students and professionals. Right? Doesn’t matter if it’s graduate school or continuing education workshops, there is a disconnect between what is being taught and how we’re being taught, and what we’re expected to do with the people that we work for. Now, I’m not talking about theory—I’m not dissing theory—I’ve seen so many people have aha moments learning about, say, attachment theory, or cognitive constructivism, or—and I’m not making this up—the psychodynamic assumptions behind defense mechanisms. One of my big aha moments was learning the solution-focused axiom that the solution doesn’t have to be related to the problem. I was like… what??? And I think that one of the reasons why education isn’t always as practical as we’d like it to be is because, well, different things work for different people. Right? When I go to therapy I like my therapist to call BS, to challenge and confront me. But that technique doesn’t work for everyone, and it doesn’t work for me all the time either. Another reason is because sometimes there just isn’t a sense of urgency about our work, and so the education, right, the things that people are teaching us, doesn’t have to be urgent. Now, yes, people always come in with a crisis, but because it’s always a crisis, it stops being urgent for us, the providers, and starts being the norm.

But there are a couple of topics, there are a couple of situations, where the education should be super practical. And one of those is suicide. When you’re working with someone who is suicidal, knowing Joiner’s Interpersonal Theory of Suicide is less helpful than knowing the tips and techniques for uncovering the method that they’re planning on using to kill themselves. When you’re sitting with someone who can’t think of a reason to live, all of the PowerPoints in the world won’t help you as much as a tip or technique that can instill hope in that person.


And that’s why, for today’s episode, I’m talking with Dr. Stacey Freedenthal, associate professor of social work at the University of Denver and author of the 2017 Routledge Press text, Helping the Suicidal Person: Tips and Techniques for Professionals.  This book is great. There are 89 tips and techniques that you can start using right away. In today’s episode, Stacey and I talk about five of them:

Tip #10 – Embrace a Narrative Approach: “Suicidal Storytelling”
Tip #35 – Know When and Why to (and not to) Pursue Hospitalization
Tip #36 – Know Why not to Pursue Hospitalization
Tip #64 – Incorporate a Hope Kit
Tip #88 – Propose a Letter to the Suicidal Self

Now, before we hear Stacey talk about these—and I love how she talks about them—I wanted to say a few words about this interview. At one point, I use the term “glo up.” G-l-o up. At the time that I used it, I thought I did a really good job of making it clear what “glo up” means. But, as I listened back on the interview, I realize I didn’t. So “glo up” is adolescent slang for the transformation people go through from being kind of awkward, prepubescent people to grown up and attractive. Right? You don’t just grow up, you “glo up.”

Now, the other thing I wanted to say is that there are some times that Stacey and I laugh, a lot. And it might seem like it’s coming out of nowhere. True, we’re talking about kind of a heavy topic and one of the things that folks who work with suicide do a lot of is laugh. Right? Not necessarily with our clients, sometimes with our clients, but with each other. Right? Work hard, play hard. But the other thing is that Stacey and I have known each other for a really long time. Right? We were both MSW students at UT-Austin in the mid-1990s, we worked for the same community mental health agency in Austin, Texas – she was on the adult side and I was on the kid side. And when I was thinking about going back for my Ph.D. in social work so that I could do research with suicidal youth and their families, I learned that Stacey had already gone back for her Ph.D. at Washington University in St. Louis and she had studied youth suicide for her dissertation. And when I called her up, she gave me some great advice about doctoral programs, dissertations and academia.

She's been a faculty member at the University of Denver School of Social Work since 2005 and maintains a private practice. She’s the creator of the massively popular blog, SpeakingOfSuicide.com, and her writings have appeared in academic journals and media outlets like the New York Times. You can find her on Twitter @SFreedenthal.

And now, without further ado, on to episode 118 of the Social Work Podcast, Helping the Suicidal Person: Interview with Stacey Freedenthal, Ph.D.

Interview
[06:51]
Jonathan Singer:  Stacey, thanks so much for being here on the Social Work Podcast and talking with us about your book Helping the Suicidal Person: Tips and Techniques for Professionals.

Stacey Freedenthal:  Thank you for having me here Jonathan. It’s a delight to be here.

[07:06]
Jonathan Singer:  So one of the things that I think is really cool about this book is that you have, what is it, 86 tips and techniques?

Stacey Freedenthal:  Eighty-nine.

Jonathan Singer:  Eighty-nine! Eighty-nine.

Stacey Freedenthal:  But who’s counting.

[07:15]
Jonathan Singer:  [Laughs] Who’s counting. So you have all of these tips and techniques, and really there’s nothing else like this on the market for providers. And I love that you said tips and techniques, ‘cause it’s not only, like, things that people should know, but it’s also things that people should do. So what sort of things were you thinking about when you were writing the book?

Stacey Freedenthal:  Well first let me just say that’s such a great way to put it! I hadn’t thought of that myself.

So, an overriding thing for me was that so much of suicide prevention and so much of what we teach students, or people read about suicide prevention is around assessing risk and planning for safety. And those are very important topics, of course. But I was at a conference a few years ago where some people with lived experience with suicidality spoke at the conference, and one of them said something along the lines of: so much of suicide prevention is about keeping people alive and not about having a life. And so that was one of the things I was thinking about with this book, is risk assessment is very important, and there are tips and techniques about risk assessment in the book. Safety planning is very important, there are tips and techniques about that. But then I wanted to go further and talk about how to build hope.

[08:38]
Jonathan Singer:  So tip #10 is called, “Embrace a Narrative Approach: Suicidal Storytelling.” And I think this is so interesting because when I teach about suicide risk assessment and when folks go to workshops, the focus really is on assessing for ideation, intent, plan, and I don’t think we talk much about narrative or storytelling. So what do you mean by that? And why do you think that’s important?

Stacey Freedenthal:  Sure. Well first let me say I didn’t make up that phrase. I was quoting some other researchers who have created an approach centered on hearing the person’s story of how they came to think about suicide. And it’s so important to me because what I observe often, not only with the students I teach but even in the professional community among professionals who have years and years of experience, is there’s so much anxiety about “is this person in front of me going to die by suicide?” that the interview becomes more about meeting the professional’s anxiety than about meeting the needs of the suicidal person. So, you know, no one who is having suicidal thoughts wakes up in the morning and says, “God I really want answer 25 questions posed by a mental health professional today.” That’s not why they seek help, you know. They’re not coming into our office to calm us down. And what they are thinking—and I mean of course I can’t speak for everybody—but in many cases what people are thinking is: I feel hopeless, I feel alone, I feel like nobody could possibly understand what I’m going through, and I hope I’m wrong. I think many people are coming to a professional to connect and to feel some hope, and to feel that, you know, maybe they’re wrong and life can be lived. So with a narrative approach, with suicidal storytelling, the idea is not to make the focus on assessing risk at the exclusion of hearing the person’s story. So, often in video risk assessment interviews that my students do, when the person playing the role of the suicidal client discloses that they’re thinking of suicide, the very next question, you know, here this person says, “I’m thinking of killing myself,” or “I’m so unhappy I want to die.” And the very next question posed is: “Do you have a plan?”

Jonathan Singer:  Mmm.

Stacey Freedenthal:  “Do you have the means? Do you have the intent to act on the plan?” Somebody who is thinking of suicide, they disclose suicidal thoughts, that their desire isn’t to… to allay your anxiety. What they want to do is tell their story. And it’s so powerful, if instead of being interrogated, you know, and instead of being asked this checklist of questions, if the professional, if this social worker or whatever kind of professional could say, “Tell me more.” You know? “Tell me—tell me what’s happened that made you want to die.” So that would be the narrative approach, is tell me the story of how you came to think of suicide.

[12:18]
Jonathan Singer:  And that is such a different feel… I mean, if somebody said, “Oh, do you have a plan? Is it general? Is it specific?” Like, you know, all those sorts of things. Part of me would be, like, yay! Like, you know these essential questions to ask. You’re getting the data that you need to get.

Stacey Freedenthal:  Yeah, I mean, I think you know, often what the professional is getting at when they are asking all these questions is: I need to know that this person is safe to walk out the door. You know, because I’m scared as all get-out that this person will kill themselves when they leave my office. And, you know, that’s a fear so many people have. And, I mean it’s a natural fear, you know? It’s very humbling to sit with somebody who wants to end their life. And so often the questions revolve around that fear instead of around the person’s need for healing, empathy and connection. And validation I would add. But I do want to say too that you’re right. Those questions are good. How much danger is this person in? Is it somebody who when they walk out the door they’ve got a firearm in their car that they’re going to use against themselves. In asking people to tell their story, we often get the specifics organically, you know. Without there being an interrogation, the person in telling their story, and then being gently coaxed to tell more, you know, that they reveal: “Ugh, I just can’t stop thinking of this,” “This is what I would do,” “This is how I would attempt,” “This is when,” and you know, and then there can be follow-up questions like, “What other ways have you thought of?” “Well, you know, I want to understand better what’s going on for you, and I’m concerned about your safety, and so I’d like to ask you some more questions.” And that can be where, on a scale of 0 to 10, with 0 being “not at all” and 10 “Oh my gosh, 100%” how much do you intend to act on your suicidal thoughts? You know, so in follow up we can ask those questions that give us the information we need.

[14:41]
Jonathan Singer:  I really love the point that having a conversation with somebody who is suicidal ultimately has to be about that person being heard and knowing that somebody else gets them and understands where they are. And that the details of the ideation, the intent, the plan, they have to be there, but that’s not the essence of the interview. And then you talked about the anxiety that clinicians feel. And one of the tips—you actually have two tips, tips 35 and 36 about hospitalization. And I know that one of the things that happens all the time, is that people say, “Oh, you mentioned that you’re suicidal. Go to the hospital.” And… we’re both smiling. Can you talk about these two tips, the “Know When and Why to—” and “When Not to Pursue Hospitalization”?

Stacey Freedenthal:  Sure! Sure. Let me tell you that I was at a workshop a few years ago and a forensic psychologist—a very highly acclaimed forensic psychologist—was leading this. And he said the minute a client mentions that they are thinking of suicide, send them to the ER.

[16:10]
Jonathan Singer:  Mmm. [Laughs]. Ok, so you and I are laughing here, but can you talk through this for folks who are listening and saying, “But wait, that’s our agency’s policy!” or “That’s what I was taught.” Why, why is that not a good idea?

Stacey Freedenthal:  Sure, sure. Well and I think you’re right, many people they’re taught that’s what they’re to do, is this person is saying they want to die by suicide so I need to send them to the hospital, either for an evaluation or I’m going to call the police and have them taken involuntarily. And the problem with that is, whose needs are being met? If it’s meeting the clinician’s need to not feel anxious, then that’s not a good reason to proceed that way. If there really is clear evidence that this person is in danger of dying by suicide within hours, then yeah, hospitalization may be necessary. Might not be, but it may be. And the reason I say it might not be is there may be other options to pursue in terms of safety planning, rallying support for the person, seeing the person between sessions, having check-ins, things like that. But where hospitalization or sending someone to the ER, or really god forbid, calling the police, if that’s not 100% necessary, where that’s problematic is when it’s… when it’s not for the client’s needs, it’s for the clinician’s.

[17:52]
Jonathan Singer:  So you said, “god forbid call the police” [laughs]. You know, unless you’re like a Jewish mother, right—

Stacey Freedenthal:  You know I am Jewish and I am a mother. [laughs]

Jonathan Singer:  I know I know, you’re a Jewish mother. [laughs] So… so what should clinicians know about or think about with regard to calling the police?

Stacey Freedenthal:  Ok, how long is this podcast? [laughs] I’m very passionate about this. There’s so much potential, not only for harm, but for acute trauma to the person. And there’s actually something that’s been written about recently, it’s kind of a new concept, and that’s post-hospitalization PTSD. And the authors who are writing about it are really looking at people who were involuntarily committed to a hospital, and how incredibly traumatic that that is, for the obvious reasons of the person is being deprived of their civil rights, they’re not able to come and go as they please, they’re… they’re being kept from their family and pets and friends, but then also for reasons that a lot of people don’t consider, and that’s that… that it’s traumatic. I don’t mean to be circular, but there may be restraints, there may be very debasing treatment by the hospital, there may be fears about other patients. Assaults in hospitalizations are not uncommon. And so clinicians need to really, really think about what is the potential for harm and what is the potential for help in pursuing hospitalization. And if the potential for harm outweighs the potential for help, then it’s not a wise decision.

But the issue with police is, not only, you know, that now the person is being forcibly taken to a hospital, but it’s being done in a very public way, you know. A lot of people who are taken to an ER by the police, they’re handcuffed. And they’re handcuffed at a time where they feel incredibly vulnerable. They already want to die. And some people will come back later and say, “Oh! The police saved my life! Thank you for calling them.” And those are people where it really was necessary. But other people will come back and say… well they won’t come back, first of all. They won’t come back. But they’ll say to their friends or family, or they’ll post a comment on my website, because there have been many, many comments to this effect, of “I will never tell a mental health professional again that I’m thinking of suicide. I will never do that again.” And that’s not what we want.

Jonathan Singer:  Mhmm.

Stacey Freedenthal:  We want people to feel that they can tell us.

If somebody’s life is truly in danger, then this is kind of a trivial concern. But it’s expensive. And so, if someone’s taken to the hospital involuntarily for an evaluation—I don’t even mean in-patient, you know, this could be ER. So someone’s clinician is nervous, they call the police, they say, “I want you do a welfare check, because this person hasn’t answered my call for an hour and they were having suicidal thoughts in session, so please do a welfare check and take them to the ER.” Well now the police come, they take the person to the ER, and when the person is discharged there’s a $5000 bill! And there’s no kind of immunity or exemption if you didn’t ask to be taken to the ER. So, again, if someone is truly at imminent risk for dying by suicide, $5000 is a small…

Jonathan Singer:  …price to pay.

Stacey Freedenthal:  …thing on the list of priorities. Right. But if this is something that really isn’t necessary, you know, that combined with the mistrust it sews, the trauma it can create, you know, all those other things, then it all creates a compelling case for not involving the police or involuntary hospitalization unless it’s absolutely necessary.

[22:19]
Jonathan Singer:  So when we first started talking, you mentioned this thing that you heard at a conference which was this idea that it’s not just enough to focus on keeping people alive, it’s about giving hope. And you have a whole chapter about instilling hope. Can you talk about some of the things that you do, that things people can do, ways they can think about instilling hope with folks who are suicidal?

Stacey Freedenthal:  Mhmm sure. I mean I think, you know, one of the things that we know about working with people who are thinking of suicide is that they feel hopeless. And there’s even research that shows that hopelessness is a much bigger predictor of suicide than depression. Hope is sort of the antidote to suicidal thoughts, that if somebody can build hope then the suicidal thoughts will diminish because it refutes their idea that there’s no hope for them to feel better or to have a good life.

So a big piece of building hope is the hope kit. And the hope kit—I have a tip on that in the book—the hope kit can be whatever the person envisions it to be. It can be in a box, it can be on their phone, there are hope kit apps, but it’s a place to gather different souvenirs, songs, reminders that the person has for living. And it can be things that they’ve done, things that they want to do. It can be letters they’ve received from people, I mean really it can be anything. And whatever it is that can be a reminder, kind of a cue—a memory cue if you will—of why to stay alive.

[24:13]
Jonathan Singer:  So you mentioned that there’s the… that it can be a box, it could be this app, sort of a virtual hope box, which I think is great especially for teens because kids have so much of their life on their phone anyway, and so to be able to have access to that at-the-ready is really meeting them where they are.

Stacey Freedenthal:  Mhmm.

Jonathan Singer:  And it’s not just for teens, obviously, but it really meets that need. But you also mention about a shoe. Could you talk about the hope shoe? [laughs]

Stacey Freedenthal:  [laughs] Well that’s something in the book that actually I read in another book, and that’s that an adolescent decorated her high-top tennis shoes with reminders of all the things that gave her life meaning. And I really love that example because it really is just about whatever works for that person. And the thing about a hope kit—some people call it a hope box, but as we’re discussing it’s not always in a box—but the thing about a hope kit is, on the one hand it’s therapeutic because it gives people reminders for why to stay alive, but it’s also therapeutic ‘cause it gives people something to do. And it gives something people to do in two regards. One is the creation of the hope kit can be very generative. It really can get people’s imagination flowing and get them seeing things through different eyes. “Oh yeah! I could put that in!” “Oh wait, that’s a reason for living.” You know? So it can get them seeing things with a fresh perspective. But it also gives them something to do when they are caught in the grip of suicidal thoughts. And they can go through whatever it is they’ve collected, whether it’s on their phone, whether it’s in a box, whether it’s in a scrapbook, whether it’s on their high-top tennis shoes, you know? They can go through and review these different things they’ve collected, and it’s something they can do rather than perseverate about why they should die.

[26:20]
Jonathan Singer:  ‘Cause we know that research has said that when you’re feeling sad it’s easier to access memories about other times when you were feeling sad, and it’s harder to access memories of times when you were feeling happy. And so this, like you were saying, it is a touchpoint. It’s a way of saying, “Oh hey, happy—" Or maybe not happy is the right word. Hopeful. There’s something that’s affirming about this. And it’s theirs, like they actually chose it. And so it’s therapeutic for them to see that, because then they can start accessing those other memories. But I also really like what you said about how it’s therapeutic to do it. And as the therapist, being able to find out what is it that you would put in your hope kit. What inspires you? What do you find hopeful? You can’t, you can’t have that just as an academic, intellectual conversation and have it mean the same thing, as when you’re like, “Oh, what is that? Tell me about that,” “Why did you put that in there?” “What is it about this?” “Oh really?” Right? That is a beautiful conversation.

Stacey Freedenthal:  I agree. It’s definitely beautiful conversation. But I think there’s also a worthwhile conversation for people who don’t want to create a hope kit. You know, because some people they’re like, “No I don’t want to do that,” or “Oh that’s stupid,” or, you know, “How will that help me?” You know? I mean, there’s all sorts of refutations that somebody could have. And then to just ask, “Well, what would you put in if you were going to do it?” You know? And that can still help people thinking—get people thinking of, “Well… I would put in the ticket stub from when I went to such-and-such concert,” “I would put in a picture of this volcano in Hawaii I really want to see before I die.” You know? So then that can get people thinking, even if they don’t physically, or virtually, put together visual reminders of the things that give them hope.

[28:20]
Jonathan Singer:  So that’s a really good point about how some people might actually benefit from what I described as just kind of like an intellectual conversation about what would go in the hope kit. But towards the end of the book you actually talk about kind of a conversation that somebody would have with themselves.

Stacey Freedenthal:  You’re talking about the letter that they would write to themselves?

Jonathan Singer:  Yeah, which is a really interesting idea. I mean just in terms of a therapeutic thing in general, like, you know, letters to yourself. Right? And in fact, in internet culture, there’s the idea of, like, “glo up.” These pictures that somebody will post of me when I was 11, and now here’s me at age 24. Look how I’ve grown up! I’ve “glo’d up.” So there’s this sense that there is this future self. And so you speak to this. How would you write a letter to yourself at some time in the future?

Stacey Freedenthal:  Mhmm. Yeah and I mean I think it’s really important in several ways. And one is that it can engender self-compassion, or at least tap into self-compassion that may already be there, when a person is talking to themselves almost as a different entity. You know? So when they’re writing a letter to their future self, “Hey, if you’re thinking of suicide, these are the things I want to remind you about.” And that often people can say things in that context that are hard to say to themselves otherwise. So that’s one piece of it. And you know, like, in CBT, one of the… one of my go-to questions so-to-speak is, “What would you say to somebody you care about who’s going through the same thing that you’re going through?” And so... and then again, often people can summon much more compassion for another person than for themselves. So the letter to the compassionate—I’m sorry, a compassionate letter to the future self is sort of like talking to another person. And it’s similar to the hope kit in that this letter may contain reasons for living and things to hope for, but it also captures things that the person has learned from the suicidal crisis that they’ve just endured and survived. You know, so the hope kit is kind of, “Here are the reasons to live and stay alive in the future,” and this letter to the future self is “Here’s what I’ve learned in the past that can help you.” And when somebody does have a suicidal crisis again—and we know that many people who have thought of suicide will think of suicide again, and possibly many times again—often they can’t remember the good things or the things they’ve learned. And you talked about that earlier, about people being able to access sad memories when they’re sad more than they can access hope or memories of good times. So that’s another function that the letter to the future self serves.

[31:31]
Jonathan Singer:  Well, Stacey, thank you so much. I can’t believe that there are 89 tips in here and we’ve really only talked about 4 or 5 of them. It really is a phenomenal resource that you have created here and I really appreciate you taking the time to share some of your insights with us.

Stacey Freedenthal:  Well thank you very much Jonathan, it was very kind of you to say and also it was great being on this podcast.

Jonathan Singer:  I’m Jonathan Singer and thanks for being with me today for another episode of the Social Work Podcast. If you missed an episode, or have suggestions for future episodes, please visit SocialWorkPodcast.com. If you’d like to support the podcast, please visit our online store at cafepress.com/swpodcast. To all the social workers out there, keep up the good work! We’ll see you next time at the Social Work Podcast.

END


Transcription generously donated by David Viitala, 2018 MSW graduate of the University of Toronto.


APA (6th ed) citation for this podcast:

Singer, J. B. (Producer). (2018, April 16). #119 - Helping the Suicidal Person: Interview with Stacey Freedenthal, Ph.D., LCSW [Audio Podcast]. Social Work Podcast. Retrieved from http://www.socialworkpodcast.com/2018/04/freedenthal.html

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