Provides information on all things social work, including direct practice (both clinical and community organizing), research, policy, education... and everything in between.
[Episode 145] Today’s episode is the third of a three-part series on research design (and the second of a two-part series on Experimental Research Design) with Dr. Bruce Thyer, Distinguished Research Professor and former Dean with the College of Social Work at Florida State University.
Dr. Thyer is a Distinguished Research Professor and former Dean with the College of Social Work at Florida State University. He is also an Extra-Ordinary Professor with North-West University in the Republic of South Africa and an adjunct faculty member with the Tulane University School of Social Work. Previously he held the position of Distinguished Research Professor at the University of Georgia. Dr. Thyer received his MSW from the University of Georgia and his Ph.D. in Social Work and Psychology from the University of Michigan. He is a Licensed Clinical Social Worker in Florida and Georgia and he is a Board Certified Behavior Analyst. Dr. Thyer has been a long-term promoter of the evidence-based practice model within social work. His work is largely informed by social learning theory and has taken a recent turn in the direction of exposing and discouraging pseudoscientific theories, interventions and assessment methods within social work practice.
[Episode 142] Today's episode is an interview with sociologist, Anna S. Mueller, PhD. Luther Dana Waterman Associate Professor in the Department of Sociology and the Senior Research Program Leader of the Mental Illness, Suicide, and Addiction Section of the Irsay Institute at Indiana University. Anna and I spoke about why Anna and her colleague, Seth Abrutyn, looked at the social roots of youth suicide at Poplar Grove, the social factors that they found contributed to youth suicide contagion and clusters (including the rigid cultural expectations, mental health stigma, and high level of connectedness); the role of social workers in school-based multidisciplinary practice; and practical steps that schools and communities can take to address youth suicide.
[Episode 132] Today's episode of the Social Work Podcast is an interview with Stacey Freedenthal, Ph.D., LCSW about her book Loving Someone with Suicidal Thoughts: What Family, Friends, and Partners Can Say and Do (New Harbinger Publications, 2023). Stacey and I talk about how she drew on her personal and professional experiences to write a book for families, friends and parents of someone who is suicidal. She talks about why and how families can create support teams, when and why it might not be appropriate to reach out to others, and how to navigate reaching out even when the suicidal person doesn't want you to. We talked about how to find support on social networks like Facebook. She talks about how friends and family can feel manipulated by a suicidal loved one, even if the suicidal person isn't being manipulative. Throughout the interview, Stacey speaks to families AND social workers.
Dr. Freedenthal is an associate professor at the University of Denver Graduate School of Social Work, and a psychotherapist in private practice. She lives in Denver, CO, with her husband and their collection of cats.
So, so great to talk w/@socworkpodcast today abt my book Loving Someone w/Suicidal Thoughts. We had a rich conversation abt different things friends & family experience, like fear & guilt, *feeling * manipulated, secrecy vs. getting support, hope & recovery, & also how to help. pic.twitter.com/H3oZ2MAvOL
[Episode 125] In today's social work podcast, I speak with three men on a mission to prevent suicide. Matt Runnalls, Kevin Hines, and Greg Van Borssum shared their stories of managing suicidal thoughts, self-care, caring for others, and building a global network of support for suicide prevention.
I spoke with Matt, Kevin and Greg at the American Association of Suicidology annual conference in April 2018. Kevin's movie, Suicide: The Ripple Effect premiered the evening of our interview. These three guys were so pumped up about suicide prevention, so full of inspirational quotes and stories, that by the end of the interview I found myself speaking with the cadence and phrasing of a motivational speaker. Published on World Suicide Prevention Day 2019 as part of National Suicide Prevention Week 2019 and Suicide Prevention Month 2019.
#WSPD19 #NSPW19 #SPM19
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
[Episode 111] Today's episode of the Social Work Podcast is about engaging people who are suicidal into professional mental health services. I spoke with Dr. Dana Alonzo from Fordham University. We talked about some of the reasons why people might not want to seek professional mental health services when they are suicidal, and some of the things that mental health professionals do to make it hard for folks to want to stay in treatment. Dana sees this as a problem of engagement. She described the process of how she developed her intervention and what it entails. She ends with some tips on how to improve engagement in treatment for anyone, regardless of suicide risk.
If you’re feeling suicidal, please talk to somebody. You can reach the National Suicide Prevention Lifeline at 1-800-273-8255; the Trans Lifeline at 877-565-8860; or the Trevor Project at 866-488- 7386. Text “START” to Crisis Text Line at 741-741. If you don’t like the phone, consider using the Lifeline Crisis Chat at www.crisischat.org.
[Episode 106] Today's episode of the Social Work Podcast is about a healthcare initiative called Zero Suicide. In today’s episode, I spoke with David W. Covington, LPC, MBA who, along with Mike Hogan, developed the Zero Suicide initiative. We talked about how he went from clinician to health care executive, from running a crisis service to organizing Zero Suicide initiatives around the world. We talked about what Zero Suicide means for providers and health care leaders and ended with information about how you can get your healthcare organization involved in Zero Suicide.
So why should social workers care about Zero Suicide?
Zero Suicide fits social work values. Zero suicide can only happen in a culture where people are encouraged to reach for the moon – that is no suicide, but are not punished for falling short. This idea of a “just culture” comes from Henry Ford Health System’s “Perfect Depression Care.”
Zero Suicide can’t happen without social workers. Social workers provide more mental health services than all other professions combined. Social workers are team players and Zero Suicide is inherently interprofessional.
Social workers are advocates. What if health care organizations use best practices, but those best practices haven’t been developed with diverse racial and ethnic groups, or don’t into account complex medical or trauma histories? What if Zero Suicide means that health care organizations have to spend more on training and staffing? Who will advocate for consumers if those costs are passed along to consumers rather than investors? Social workers have a professional responsibility to be involved in those conversations.
Social workers are trained to identify and respond to issues at the practice – the micro, and policy – the macro – level. Well guess what – ZeroSuicide is like the holy grail of micro-macro integration: it requires coordinated changes in values, beliefs, and practices at the provider- and system-level. David will talk more about this during the interview, but in plain English it means that as a social worker I have to believe that suicide is preventable, know how to assess, intervene, and coordinate care, and trust that my organization will have my back. At a systems level, health care organizations have to make a multi-year commitment of time and resources to reduce suicide deaths, train and support clinical and non-clinical staff, screen and assess everyone in the system, and use data-driven quality improvement. It can’t work without changes at the micro and macro level.
[Episode 104] In today's episode of the Social Work Podcast I spoke with Kevin Briggs, retired Sergent with the California Highway Patrol. As part of his duties patroling Marin County, Sgt. Briggs responded to calls on the Golden Gate Bridge, one of the most lethal suicide spots in the world.
In April 2016 Sgt. Briggs and I talk about what it was like to be a negotiator working with people seconds away from jumping from the Golden Gate Bridge. Sgt. Briggs shared some of his strategies and his struggles working with hundreds of people, some of whom jumped and some of whom didn’t. He talked about getting famous and doing a TED talk. And then he shared something very personal – the story of how he found out that his son had been thinking of killing himself. Sgt. Briggs provides valuable insight in the professional and personal side of crisis work.
[Episode 97] Today’s episode of the Social Work Podcast answers that age-old question, how do I live tweet a conference? In April 2014, I recorded a conversation with members of the social media team that was live tweeting the 2014 American Association of Suicidology conference: April Foreman, Tony Wood, Quintin Hunt, Dese'Rae Stage, and Cara Anna. The conversation was recorded at the end of four intense days. You’ll hear team members talking about the personal and professional benefits of live tweeting, how they handled controversial comments, and what it was like to be part of an historic moment. I include a "best practice" guide to help you plan what to do before, during, and after a conference or event.
[Episode 96] In today's Social Work Podcast I speak with two of the three developers of Attachment-based Family Therapy (ABFT), Guy S. Diamond, Ph.D. and Suzanne Levy, Ph.D. The third developer Gary M. Diamond (no relation to Guy Diamond) lives in Israel and was unavailable for the interview.
ABFT is the only family-based psychotherapy with empirical support for reducing suicidal ideation in youth. In today's interview, Dr. Diamond and Dr. Levy discuss the theory and practice of Attachment-Based Family Therapy. Dr. Diamond mostly covers theory and concepts, and Dr. Levy addresses the question of "what does the therapist actually do in the therapy room."
"Attachment-Based Family Therapy (ABFT) is a treatment for adolescents ages 12-18 that is designed to treat clinically diagnosed major depressive disorder, eliminate suicidal ideation, and reduce dispositional anxiety. The model is based on an interpersonal theory of depression, which proposes that the quality of family relationships may precipitate, exacerbate, or prevent depression and suicidal ideation. In this model, ruptures in family relationships, such as those due to abandonment, neglect, or abuse or a harsh and negative parenting environment, influence the development of adolescent depression. Families with these attachment ruptures lack the normative secure base and safe haven context needed for an adolescent's healthy development, including the development of emotion regulation and problem-solving skills. These adolescents may experience depression resulting from the attachment ruptures themselves or from their inability to turn to the family for support in the face of trauma outside the home. ABFT aims to strengthen or repair parent-adolescent attachment bonds and improve family communication. As the normative secure base is restored, parents become a resource to help the adolescent cope with stress, experience competency, and explore autonomy.
ABFT is typically delivered in 60- to 90-minute sessions conducted weekly for 12-16 weeks. Treatment follows a semistructured protocol consisting of five sequential therapy tasks, each of which has clearly outlined processes and goals:
Task 1: The Relational Reframe Task, with the adolescent and parents (or parent) together, sets the foundation of the therapy. After an assessment of the history and nature of the depression, the therapist focuses on relational ruptures. This shift pivots on the therapeutic question, "When you feel so depressed or suicidal, why don't you go to your parents for help?" The progression of this conversation leads parents and the adolescent to agree that improving the quality of their relationship would be a good starting point for treatment.
Task 2: The Adolescent Alliance Task, with the adolescent alone, identifies relational ruptures in the family and links them to the depression. The adolescent is encouraged and prepared to discuss these often avoided feelings and memories with his or her parents.
Task 3: The Parent Alliance Task, with the parents alone, explores their current stressors and their own history of attachment disappointments. These conversations activate parental caregiving instincts to behaviorally and emotionally protect their child, which helps motivate parents to learn and use new attachment-promoting parenting skills.
Task 4: The Attachment Task, with the adolescent and parents together, creates an opportunity for the adolescent to directly express his or her thoughts and feelings about past and current relational injustices. Rather than defending themselves, parents help the adolescent fully express and explore these emotionally charged topics. This conversation helps the adolescent work through trauma, address negative patterns in the relationship, and practice new conflict resolution and emotion regulation skills.
Task 5: The Autonomy Task, with the adolescent and parents together, helps consolidate the new secure base. In solving day-to-day problems, parents provide support and expectations and the adolescent seeks to develop autonomy while remaining appropriately attached to his or her parents." (http://legacy.nreppadmin.net/ViewIntervention.aspx?id=314)
[Episode 95] Hey there podcast listeners. March is Social Work Month. I know, you’re saying, but every month is social work month. Yes… that’s true… for social workers. But, social work is one of those professions that, to misquote Ogden Rogers [Episode 88], if you’re doing it well, people don’t know you’re doing it. so, let’s have a month to remind the general public of what social workers do. In that spirit, today’s episode is a quick and dirty rundown of some of the things I do for social work and some of the things I’m involved in that make social work a better profession. So, this episode is a quick and dirty rundown of upcoming episodes, resources for social work and technology, and information about my book, Suicide in Schools, published by Routledge Press in December 2014.
NASW’s theme for Social Work Month 2015 is “social work paves the way for change.” I love our profession and all that we do to pave the way for change for the oppressed, marginalized, and underrepresented in our society. I also recognize that there are social workers who have paved the way for me to change. So, every day this month I’m honoring a different social worker who has inspired me and helped me to change so I can be a better social worker. You can see my list of social workers on the Social Work Podcast Facebook page at http://www.facebook.com/swpodcast, the Twitter feed @socworkpodcast.
Upcoming episodes:
•Attachment-Based Family Therapy: Guy Diamond & Suzanne Levy
•Cognitive Enhancement Therapy: Shaun Eack
•Working with Deaf People: Teresa Crowe Gualladet
•The Contribution of the Children's Bureau to Social Work Education: Alice Lieberman
•Social Innovation: Steve Anderson
•Suicide in Schools: Terri Erbacher
NASW is launching a series of Tweet Chats. Tweet chats are opportunities for people to gather on Twitter at a specified time and use a specific hashtag (that symbol that we used to call the “pound sign”) and discuss a specific topic. I’m honored to be the NASW Tweet Chat guest on April 2nd talking about “Suicide in Schools.” Laurel Hitchcock has a wonderful guide for how to participate in a Tweet Chat. If you like it, you can participate in lots of Tweet chats. Well-established tweet chats specific to social work include:
Suicide in Schools provides school-based professionals with practical, easy-to-use guidance on developing and implementing suicide prevention, assessment, intervention and postvention strategies at the individual, family, school, and community level. The book includes detailed case examples, guidelines, handouts, and internet resources on the best approaches to effectively working with youth who are experiencing a suicidal crisis as well as those students, families, school staff, and community members who have suffered the loss of a loved one to suicide. Here are some reviews of the book:
"This book provides the exact kind of practical information school staff need to know, from how to tell a parent his or her child is contemplating a suicidal act to what the school staff member's responsibility is to the child, the parent, and to the community to address suicidal risk. When combined with the detailed case examples that really bring an extra dimension to the step-by-step guides, this book becomes a must-read for any professional working in a school environment." Thomas Joiner, PhD, Robert O. Lawton Professor of Psychology at Florida State University and director of the Laboratory for the Study and Prevention of Suicide-Related Conditions and Behaviors
"A comprehensive guide for all educators seeking the current evidenced-based, model practices for suicide prevention in schools. The ‘expert tips’ reflect a wealth of knowledge gleaned from the front lines, where collaboration is essential between school psychologists, social workers, counselors, and their administrators. The authors paraphrase our national motto: ‘Everyone in the school plays a role in suicide prevention!’" Richard Lieberman, NCSP, school psychologist/consultant with the Los Angeles County Suicide Prevention Network
"Suicide in Schools is an essential, invaluable resource for all school personnel who are interested in preventing self-harm among their students. User-friendly, yet erudite, the book serves as a manual for evidence-based and innovative practices. If only this reference had been available when, as president of the National Association of School Psychologists, I issued a call to action to prevent suicide." Ralph E. (Gene) Cash, PhD, ABPP, professor at the Center for Psychological Studies and director of the School-related Psychological Assessments and Clinical Interventions Clinic at Nova Southeastern University
"This book provides a comprehensive examination of the many issues that schools face in working with suicidal youth and provides hands-on strategies that have been successfully implemented in school-based settings. The authors provide excellent case examples and practical information that aligns with clinical and research experts in the field of youth suicidal behavior. Finally, the authors structure their book to extensively explain how a multi-tiered approach can be implemented for suicide prevention, risk assessment, and management of youth suicidal behavior. This book provides exactly the help school personnel need to feel more confident in working with high-risk youth and thus is an invaluable resource for anyone working in the schools and/or working with them. It already has a place on my desk." James J. Mazza, PhD, professor and director of the school psychology program at the University of Washington
Thanks for all that you do, social workers. We’re an amazing and storied profession. Happy social work month. And keep up the good work.
[Episode 86] Hey there podcast listeners. Today's social work podcast is about addressing suicide risk in schools. When we think about suicidal youth, we tend to think about hospitals and emergency rooms, or outpatient therapy. When we think about schools we think about standardized testing, or unfortunately the increasingly common mass shooting. But schools are an ideal place to address suicide risk in schools. That's why I was so excited to talk with two of the leading experts on youth suicide in schools. Jim Mazza, Ph.D. and Dave Miller, Ph.D. Jim is at the University of Washington and director of their school psychology program. Jim is the past-president of the American Association of Suicidology. Dave Miller, is at SUNY Albany in the educational and counseling psychology program. He is the president-elect of the American Association of Suicidology and author the highly regarded text, Children and Adolescent Suicidal Behavior: School Based Prevention and Intervention published in 2011 by Guilford Press
I spoke with Jim and Dave in April 2014 at the American Association of Suicidology conference. We talked about what is known and not known about what works to address suicide risk in schools, some of the barriers to implementing effective suicide prevention programs, and the value in framing school-based suicide prevention and intervention in a broader context, both as a way of selling the idea to school administrators and parents, as well as to think beyond just addressing students in a suicidal crisis. As an example, Jim talked about a curriculum he has been developing that uses concepts from Dialectical Behavior Therapy that is intended to improve emotion regulation and other issues in all students. [Update May 2016: Now available: DBT® Skills in Schools: Skills Training for Emotional Problem Solving for Adolescents (DBT STEPS-A)]
A couple of notes about the interview. I recorded it in my conference hotel room and you might hear some street noises in the background. Right before we recorded the interview we had been in the hotel lobby talking with Marsha Linehan, developer of Dialectical Behavior Therapy. This is important, not because I like to name drop, but because you'll hear Dave and Jim reference Marsha and the conversation they were just having with Marsha downstairs. It all made great sense in the moment, but could understandably be a bit confusing if you weren't with us. Downstairs. With Marsha Linehan. At one point Jim mentions research that he is doing with his wife, but doesn't mention her name. She is Elizabeth Dexter-Mazza, licensed psychologist and expert in Dialectical Behavior Therapy.
And now, without further ado, on to episode 86 of the Social Work Podcast, Addressing suicide risk in schools: Interview with James Mazza, Ph.D. and David Miller, Ph.D.
[Episode 74] Today’s Social Work Podcast is an interview with Shawn Christopher Shea, M.D., developer of an approach to uncovering suicidal ideation and intent called the Chronological Assessment of Suicide Events (CASE) approach. In today’s episode, Shawn takes us through the CASE approach. He explains the value of assessing for suicidal content at different time points and emphasizes that eliciting suicidal ideation and intent is a difficult and sensitive topic. He talks about how moving through the CASE approach to help establish a therapeutic alliance and rapport with suicidal clients. He emphasizes the art of the interview, using validity techniques, and how we use words as central to uncovering suicidal ideation and intent. He talks about how the CASE approach is useful for any mental health provider. Shawn makes the argument that the CASE approach is an ideal approach to for assessing for suicidal risk that doesn’t sound like a pat suicide assessment. He emphasizes that the CASE approach is one-third of a thorough suicide assessment, the other two parts being identifying risk and protective factors, and the final part being developing a clinical formulation.
This figure represents the three components of a thorough suicide assessment. The CASE approach provides a framework for assessing the information in the red square (ideation, plan, behaviors, desire, and intent).
Shawn has written that a thorough suicide assessment has three parts: 1) Gathering information related to risk factors, protective factors, and warning signs of suicide; 2) Collecting information related to the patient’s suicidal ideation, planning, behaviors, desire, and intent; and 3) Making a clinical formulation of risk based on these 2 databases. He writes that in the “clinical and research literature, much attention has been given to the first and third tasks (gathering risk/protective factors/warning signs and clinical formulation). Significantly less attention has been given to the second task—the detailed set of interviewing skills needed to effectively elicit suicidal ideation, behaviors, and intent. But in many respects, it is the validity of the information from the second component that may yield the greatest hint of imminent suicide.” (Shea, 2009, p. 1).
My interview with Shawn is a single episode in two continuous parts. In Part I Shawn and I talk about the CASE approach, including some of the validity techniques he has developed or uses to elicit suicidal ideation and intent. In the second part Shawn and I do a role play where he uses the CASE approach.
[Episode 70] In today's episode of the Social Work Podcast is about loneliness. Since social workers don't talk much about loneliness (we'd rather talk about social isolation or social withdrawl), I spoke with Thomas Joiner, Ph.D., Robert O. Lawton Distinguished Professor of Psychology at Florida State University, and author of Lonely at the Top: The High Cost of Men's Success, published in 2011 by Palgrave Macmillan.
Today’s Social Work Podcast is on Suicide and Black American Males. Why suicide and Black Americans? Well, there is a belief among most Americans, and particularly among African American adults, that Black Americans do not kill themselves (Joe, 2006). When we think of violent death among Black Americans we think of homicide. Suicide is thought of as a “White” problem. While it is true that suicide was not a leading cause of death for African Americans 40 years ago, today it is the third leading cause of deaths among African Americans 15 – 24 years of age. So why Black American Males specifically? Well, among all racial and ethnic groups, the suicide rate is lowest among Black American females. Given that Black American males, particularly youth, are over-represented in social services, social workers need to be aware of the risk for suicide, and prepared to provide potentially life-saving services. One thing that makes social workers professionals is that we are trained to see things that others do not. Most of us have not been trained to see suicide as an important issue in the Black American community. It is my hope that after hearing today’s guest, Dr. Sean Joe, you will be more likely to see suicide among Black American males as an important clinical and programmatic issue.
Sean Joe, PhD, MSW, joined the Brown School in Fall 2014 as the Benjamin E. Youngdahl Professor of Social Development. His research focuses on Black adolescents' mental health service use patterns, the role of religion in Black suicidal behavior (NIMH), salivary biomarkers for suicidal behavior, and development of father-focused, family-based interventions to prevent urban African American adolescent males from engaging in multiple forms of self-destructive behaviors (e.g., suicidal behavior). When this interview was recorded, Dr. Joe held a joint position as associate professor in the School of Social Work and the Department of Psychiatry at the University of Michigan's School of Medicine. He also served as a faculty associate and Associate Director for Research and Training at the Program for Research on Black Americans at the Institute for Social Research, University of Michigan. Dr. Joe is a nationally recognized authority on suicidal behavior among African Americans. He is the 2009 recipient of the Edwin Shneidman Award from the American Association of Suicidology for outstanding contributions in research to the field of suicide studies and the 2008 recipient of the Early Career Achievement Award from the Society for Social Work and Research. He has published in the areas of suicide, violence, and firearm-related violence. Dr. Joe served on the board of the Suicide Prevention Action Network (SPAN USA), the scientific advisory board of the National Organization of People of Color Against Suicide, and the editorial board of Advancing Suicide Prevention, a policy magazine. He is the Founder and Director of the Emerging Scholars Interdisciplinary Network, a national interdisciplinary and mutli-ethnic professional development network for early career social and behavior scientist.
In today's podcast, Sean talks why it is important to look at the suicide rate among Black American males, specifically adolescent males. He talks about how recent research has started to put together a profile for Black American Males most at risk for suicide, and the factors that seem to protect against suicide. He talks about some of the social and historical factors associated with the increase in suicide rates among Black Americans. Sean gives an example of how he talks with Black Americans about suicide and stigma. We talked about recommendations for social workers who are working with Black American males who might be suicidal, including talking about faith, valuing that child, having a vision of that child as an adult, and healthy masculinity. Sean discussed some resources for social workers interested in learning more about this topic. We ended the interview with Sean extending an invitation to social work clinicians and researchers to join him to better understand suicide and suicidal behaviors in Black Americans.
One quick word about today’s podcast: I recorded today’s podcast using a Zoom H2 recorder on location at the Society for Social Work Research (SSWR) annual conference. If you listen closely you can hear the sounds of San Francisco in the background: a clock chiming, buses loading and unloading passengers, and even some pigeons congregating outside of the interview room. They don’t detract from the interview, but I wanted to give fair warning in case you were listening to this podcast anywhere were those sounds might be cause for alarm. So, without further ado, on to episode 56 of the social work podcast, Suicide and Black American Males: An Interview with Sean Joe, Ph.D., LMSW
[Episode 14] In today's podcast, we're going to talk about the therapies that take a cognitive-behavioral approach to working with people. I review the theoretical assumptions, therapeutic process, techniques, use in culturally competent practice, and strengths and limitations of CBT. This podcast is longer than most because I use a lot of clinical examples and dialogue to illustrate the concepts. [Pictured: Tim Beck, developer of CBT, and Albert Ellis, develop of REBT]
[Episode 4] This is part two of a two-part series on Crisis Intervention. In this lecture, I discuss individual crisis intervention within the context of Roberts's Seven-Stage Model of Crisis Intervention, and the most popular group crisis intervention model currently in use, Critical Incident Stress Debriefing. The podcast ends with a detailed review of suicide assessment.
Now that you’ve assessed the affective, behavioral and cognitive domains of your client, we're going to move to the intervention model for today’s lecture. And although there are a variety of intervention models, including James and Gilliland (they have a 6-stage intervention model) and Hillman (has a 14-stage model of intervention), I'm going to talk today about Roberts’ 7-stage model for crisis intervention. And I'm going to talk about it because it provides a useful framework for crisis intervention, but it's not prescriptive to the point where it can't be modified to be used in either a single session or over multiple sessions. And Congress in 2000 (the author Congress, not the governmental body, but Elaine Congress) noted that it is, its flexibility enables it to be used in a culturally competent manner.
On the first stage is the assessment of safety and lethality and when we talk about suicide and risk assessment later, you'll get a better idea of specifically how to do that. But suffice it to say that in Stage One, you want to make sure that you are safe, that the client is safe, that the surroundings are safe. So you want to identify whether the client is at risk for harm to self or others or whether someone or something is putting the client at risk.
In Stage Two, that’s the rapport building stage and Roberts notes that that often happens concurrently with Stage One. As you're establishing safety, you're building a rapport and rapport, as I mentioned in the beginning of lecture, is the foundation for any clinical intervention (crisis intervention included). The Third Stage is problem identification. This is where you really identify what the precipitating event was and what problem the crisis intervention will focus on.
In Stage Four, you address feelings and emotions and this is where your assessment of affective, behavioral and cognitive domains is useful. You can implement Myer’s Triage Assessment at this stage or you can use it throughout. In Stage Five, you generate and explore alternatives. Now, similar to the problem solving method, generating and exploring alternatives is an area where the crisis worker can be more active in the crisis intervention model without necessarily being directive.
Being directive in Stage Five would look like presenting the client with a list of possible actions that they could do or solutions to the problem. Active would be collaborating with the client to identify things that they could use. One technique in particular that’s very congruent with social work perspective is using a very solution-focused approach in Stage Five. For example, when you're generating and exploring alternatives, you can review exceptions or use the miracle question or use other techniques that enable the client to think about times when they have actually been successful in resolving issues and thereby drawing on those successful opportunities as a way of reminding them of things that they can do in the current situation.
In Stage Six, you develop an action plan and again the action plan is very specific. It's concrete. It's measurable and it usually has a very short time frame. When I was doing crisis intervention in Austin, Texas, our crisis plans often lasted no longer than 24 hours without meeting again. And so they would include things like: When I leave here I will drive my child home. We will do this, this and this and this and this. It was very prescriptive. It provided structure and it was organized and it enabled me to review with the parents and the children the plan to find out exactly where it worked and where it didn’t, both as a way of helping me gather information, but also as a way of letting the family know exactly what it was that they were and were not doing to resolve whatever crisis was at hand.
And the Final Stage is follow up, and this looks like the referral stage for most traditional treatments because crisis intervention is short term and does not address long term intrapsychic or interpersonal or social problems (social environmental problems). [00:05:00] The need for a referral is great and it is expected that in fact you will be referring your clients out once the crisis has been resolved. So for that reason, follow up is a significant part of crisis intervention.
In different cultures, follow up can look like different things. If you have a family from the dominant culture that does not demonstrate underlying psychopathology and once they’ve reestablished prior coping skills, they're fairly easily able to address their activities of daily living. Then referrals can be fairly traditionally professional and say: “Here’s a phone number. We’d like you to follow up with them.” They agree to it and then you check up and you say: “Did you call?” It's great.
In families that might not be from the dominant culture, for example let's say you have a Latino family that has recently immigrated to the United States: follow up might be more personal. For example, making personal introductions, (assuming that consents have been signed) and really being more active in the follow up to make sure that both the information has been transferred to the new clinician, but also that there's that sense of trust that the family can have in the new provider.
Those were the Seven Stages of Roberts’ crisis intervention model. And again, it's a very flexible and very useful framework to have in mind when doing crisis intervention. And Roberts discusses this model in numerous articles and publications and books most recently in the third edition of the Crisis Intervention Handbook and also in an article that he wrote for the journal Brief Treatment in Crisis Intervention.
A second approach to crisis intervention that’s commonly used with groups is Critical Incident Stress Debriefing (CISD) or Critical Incident Stress Management. Everly and Mitchell are the main authors and proponents of this model. Critical Incident Stress Debriefing is typically used with first responders, for example: firefighters, EMS workers, police officers and it follows a group format. The CISD occurs no later than one week after the critical incident and the debriefing is run by a first responder who’s trained in the model.
And so again, if we think back to Hillman’s critique of the current research on crisis intervention, the question is: Is a peer who has been trained actually better than a licensed professional doing crisis intervention? If you have a police officer that has been trained in Critical Incident Stress Debriefing and they run a group with other police officers who have been involved in a critical incident, then it is possible that they would be more effective in this particular type of crisis intervention.
The CISD centers on the workers and is sensory-based and it encourages the participants to report on what each of them saw during the critical incident, what they heard and what sort of physical and emotional feelings they had, as well as what they smelled and tasted. After a critical incident such as a multi-car pile-up with fatalities on a highway or a shooting or some other critical incident that first responders are involved in, this type of debriefing can have the effect of reducing anxiety, letting people know they're not “crazy.”
Also important in these debriefings is that information about the event is shared. Crisis situations are fast-paced and people are not always sure that what they're experiencing is actually true. And so if during a fire, a floor collapses and a firefighter falls three or four storeys and the other firefighters are called in for Critical Incident Stress Debriefing, some information can be shared about the nature of the fire, how it developed, what other people were doing at that time. And in this way, it can actually provide concrete information that can be useful for individuals in reducing anxiety and addressing this critical incident.
In the protocol for Critical Incident Stress Debriefing is that the trained mental health professional is a silent observer of the proceedings and his or her purpose is to identify first responders who might benefit from individualized crisis intervention and/or ongoing psychotherapy. So, again, Roberts’ model is typically used with individuals or families and if you're in a group situation, the most commonly used approach is the Critical Incident Stress Debriefing Model by Everly and Mitchell.
The final area we're going to cover today in our discussion of crisis intervention is suicide assessment and this is a special instance of crisis intervention, so don’t go anywhere. We'll be back after this [00:10:00] brief pause for the cause.
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Break
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Now, the purpose of suicide assessment is to determine the lethality and severity of suicidal behaviors. It's also to predict risk of imminent harm to self. Empirical evidence does not support that we know how to predict future suicidal behaviors. However, the courts and the public expect mental health professionals to be able to predict future behaviors.
The third purpose of suicide assessment is to gather information used for crisis planning and intervention and treatment and management of suicidal behaviors. Now, this is of course is only if suicidal behaviors are present and you won't know that if you do not do a crisis – rather if you do not do a suicide assessment. Because suicidal attempts are higher with people who have psychiatric disorders than in the general population, anytime you're working in a psychiatric setting, either outpatient or inpatient, and you're working with people with a diagnosis, it is important to do suicide assessments so that you can determine whether past suicidal behaviors have been present. If so, what those triggers were and/or if there is current suicidal ideation.
So, the basic suicide assessment covers three areas. It covers ideation (and those were thoughts), intent (which is how serious the thoughts are and how serious the person is about dying by suicide). And the third area is the plan (how, with what, when, access to the means, etc. etc.). During the suicide assessment, it's important to use the words kill and die and specific words like that, so that your client knows you're not afraid of the topic and they’ll be more likely to confide in you and also that you can gather more accurate information.
The father of suicidology, Edwin Shneidman, suggested that people choose suicide because it's a means to end intolerable psychic pain. And if you ask people if they want to hurt themselves, which is the more mild way of addressing suicide assessment that people who were not trained sometimes do, if you say – if you ask people if they want to hurt themselves, somebody who’s actively suicidal might honestly say no because in fact they do not want to inflict more pain on themselves. They do not want to hurt more. In fact, they want to end their pain. They want to end the hurt and that is why they're suicidal.
So, that’s just one example of – or one reason why it's important to be specific when talking with clients about suicidal ideation and why it's important to use the words such as: “Do you want to kill yourself? Have you thought of dying?”
Ideation: “Do you have thoughts of killing yourself? If so, how frequent do you think of killing yourself? Every hour, a couple of times a day, weekly or never? How long are your suicidal thoughts? What is the longest time period in which you’ve consistently thought of killing yourself and what is the shortest? And answers can range from you know: “It just flashed into my mind and then it was gone” to you know, “I was thinking about it constantly for eight hours. I just couldn’t get it out of my head.”
In intensity: “How strong or weak are these thoughts? Do they interfere with your activities of daily living?” For example: “Are you afraid to go into the kitchen because your suicidal thoughts are so intense that you're afraid you're going to do something like grab a knife from the kitchen and cut yourself?”
The intent areas, how serious and one way of using scaling questions for this area is to say: “On a scale of 1 to 3, how badly do you want to die?” When you're talking with someone who’s actively suicidal, it's not necessary to give a 1 to 10 scale, which can be difficult to interpret and also it can be a little overwhelming. But a 1 to 3 scale is not cognitively complex and also if somebody says that on a scale of 1 to 3, 1 being “I'm not serious at all” and 3 being “I'm totally serious,” if they give you 1, 2 or 3 then you pretty much know what they're talking about and you can ask more detailed questions at that point.
The third area is the plan: “Do you have a plan? Is your plan general or is it detailed? How will you do it? Do you have access to the means?” And that could be to the materials or the specific weapons. [00:15:00] “And when are you planning on killing yourself?” I've worked with a number of children who in response to that question would say: “Well, there's a party this weekend and so I'm not planning on killing myself until Monday.” Well, that was important and significant information for me to have because even though they might have had a detailed plan and they might have frequent thoughts, it provided information about how serious they were imminently ending their life.
After you talk about ideation, intent and plan, it's useful to talk about prior attempts, because prior attempts have been reported to be the single best indicator of a future death by suicide. So, you want to ask: “How recent was your prior attempt?” and because there's usually a limited time to discuss suicidal ideation with a client either because you're in a crisis situation or because that’s not the primary focus of your work with the client. Shawn Shea, who wrote a wonderful book on The Practical Art of Suicide Assessment, he suggests that the most valuable thing for a clinician is to find out what the most serious prior attempt was, as opposed to getting an exhaustive history of all the prior attempts.
And by getting details on the most important prior attempt, then you gather information on triggers, on what kept the person alive, how long it lasted, things like that. So, other questions to ask are: “Do you know somebody who has recently died by suicide? Do you have friends or family members who have died by suicide? Have you told anyone about your ideation, intent or plan?” Finally, you can ask the client who do they talk to when they're really down, when they're having thoughts of killing themselves, and this can give a lot of information about their social support or lack thereof.
It also provides information about resources for the clinician about who they can contact in the event of a suicidal emergency that would enable them to breach the limits of confidentiality and go outside of the client-therapist relationship.
At the end of the suicide assessment, you should be able to establish a severity rating. Rudd and his colleagues in 2001 recommended a five-level severity rating ranging from 1 (which is nonexistent) to 5 (which is extremely severe). The least and most severe ratings are relatively easy to establish and have clear plans of action.
Number one: nonexistent, there's no identifiable suicidal ideation. Number five is: there is extremely severe suicidal risk. And this looks like frequent, intense and enduring suicidal ideation, specific plans, clear subjective and objective intent, evidence of impaired self-control, severe dysphoria and symptomology and many risk factors and almost no protective factors.
The middle ratings are: mild, moderate and severe. Mild risk would look like: suicidal ideation of limited frequency, intensity and duration, no identifiable plans or intent, mild dysphoria and symptomology, good self-control, few risk factors and identifiable protective factors. Moderate suicidal risk looks like: frequent suicidal ideation with limited intensity and moderation. So, again, the distinction between mild and moderate is you have limited intensity and duration, but you have frequent ideation for the moderate, but for the mild it is limited ideation, frequency and intensity and duration. For the moderate, you also have good self-control, limited dysphoria and symptomology, some risk factors and identifiable protective factors.
Severe suicidal risk looks like: frequent, intense and enduring suicidal ideation, specific plans, no subjective intent, but some objective markers of intent for example: they talk about specific lethal methods, they know that the method is available and there are some limited behaviors in preparation for death by suicide. There's evidence of impaired self-control, severe dysphoria and symptomology and multiple risk factors present and few if any protective factors.
In summary, the big three areas to cover in a suicide assessment are suicidal ideation (that is thoughts of suicide), suicidal intent (that would be motivation to die by suicide) and plan (which looks at how and when somebody is going to try to kill themselves). Another area that’s also useful is prior attempts and prior attempts are useful because the best predictor for a future attempt is a past attempt.
Ultimately, the purpose of gathering information [00:20:00] about intent, ideation and plan is to be able to determine the client’s risk for imminent harm to self. Once you have a severity rating, such as the one developed by Rudd, Joiner and colleagues, you're able to quickly and easily identify what the next step is in terms of a treatment plan. This has the obvious benefit of providing safety for the client and has the less obvious, but no less important benefit of providing the clinician with solid clinical evidence to support their decision.
Well, that’s it. Congratulations. You’ve made it through Crisis Intervention. Today, we've talked about crisis intervention, crisis assessment and suicide assessment and all of these are invaluable skills for social workers. In fact, they're some of the few skills that you really want to memorize because well, during a crisis you don’t really have time to look things up.
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Transcription generously donated by Kelsi Macklin.
Simpson, S., and Stacy, M. (2004). Avoiding the malpractice snare: Documenting suicidal risk assessment. Journal of Psychiatric Practice, 10(3), 185-189.
Singer, J. B. (2006). Making stone soup: Evidence-based practice for a suicidal youth with comorbid ADHD and MDD. Brief Treatment and Crisis Intervention, 6(3), 234-247.
Weller, E. B., Young, K. M., Rohrbaugh, A. H., & Weller, R. A. (2001). Overview and assessment of the suicidal child. Depression and Anxiety 14,157-163.
Singer, J. B. (Host). (2007, January 29). Crisis intervention and suicide assessment: Part 2 - intervention and crisis assessment [Episode 4]. Social Work Podcast. https://socialworkpodcast.com/2007/02/crisis-intervention-and-suicide.html
