Suicide Prevention SummitManaging Helplessness, Hopelessness and Despair with our Younger Clients

Bonnie Goldstein, LCSW, Ed.M., Ph.DJuly 24th, 2021, Los Angeles, CA

www.drbonniegoldstein.com

Addressing Suicidal Ideation & Suicide Attempts

Suicide ideation and suicide attempts have almost doubled in 2015 in the United States; Worldwide, there has been steady increase, exacerbated by the Covid-19 pandemic.

All my adolescent clients have told me that they know someone that they are concerned about; many have expressed ongoing concerns for themselves.

Less than half of young people with a mental disorder seek treatment and only a small minority of individuals affected with depression receive care. (Plemmons & Hall Pediatrics 2018)

Why: consensus amongst professionalsis that we don’t know whyThe Many “why” suicide Q’s

Why did he?What about her family, her children…?I saw him yesterday and there was no indication?

Why is the wrong Question.

• Research shows that people actively experiencing some form of suicidality cannot give a clear or intelligible account of what is going on for them at the moment.

• All cultures, since the beginning of time, have had to deal with suicidality.

Teen Suicide Ideation & Behavior

Suicide Ideation: Thinking of wanting to die.

Suicide Behavior: Teens focusing on doing things that cause their own death.

CDC reports that suicide in America is the third leading cause of death in young people ages 15-24 (after accidents and homicide).

*Boys are more likely to die *Girls are more likely to attempt

Attempts to help: No Commonalities

1962 the first Suicide prevention center in America was established in Los Angeles, CA; They undertook research looking for commonalities-a perfectly good idea-however there have been no commonalities characterizing their research!

The clinician’s task is to reach, together with the patient, a shared understanding (intersubjective) of the patient’s suicidality.

Common Contagions suggest that exposure to the mention of suicide within a person’s family, peer group or in the media can lead to an increase in suicides.

When one teen takes their life, classmates are more at risk. Family history suggests that when one family member or an ancestor dies by suicide, other members are more likely to attempt.

Contemporary media, technology, internet, etc. has contributed significantly to at-risk behavior.

Mental Health Practitioners recognize the difficulty predicting:

Adolescent Suicide Risk Factors

• One or more mental or substance abuse problems• Impulsive behaviors• Undesirable life events such as being bullied or recent

losses such as death of a parent• Family History of mental or substance abuse problems• Family history of suicide• Past suicide attempt• Guns in the home• Imprisonment • Exposure to suicidal behavior of others

Warning Signs of teen suicide(Similar to signs of depression)

• Changes in eating (weight gain or loss) and sleeping habits• Loss of interest in normal activities, sports, social, etc.• Withdrawal from friends and families• Alcohol or drug use• Neglecting Personal appearance• Unnecessary risk-taking• Obsession with death and dying• More physical complaints often linked to emotional distress• Feeling bored, loss of interest in school/schoolwork• Lack of response to praise

Guidelines for CliniciansThe clinician’s task is to reach, together with the patient, a shared understanding of the patients care. (Aeschi, 2002)

The clinician should be aware that most suicidal patients suffer from a state of mental anguish or pain and a total loss of self respect.

There is no consistently reliable and empirically validated ways to predict or treat suicide, yet overtime mental health professionals and others in our communities have come together and have found ways to treat patients.

The Call of Darkness, Dr. Lawrence Hedges

Relational Listening Perspective, developed by Southern California psychoanalyst, Larry Hedges, seeks to explain how past relational traumas impact current relational contexts—which has promising power to shed light on many issues surrounding suicidality by paying close attention to the details of all the relational engagements in a person’s life, and engaging in relationships, and how those relational templates, and the scars that they leave, affect their lives. (Hedges, 2018)

The “unthought known”

Christopher Bollas first pointed to the unconscious as the ”unthought known”.

Donnel Stern: The Infinity of the Unsaid (2019) Somatic and affective memories repeatedly enacted in relationships until in a therapeutic relationship the dissociation from consciousness could be bridged and two could come to talk about the mutual enactments

Guidelines for clinicians (2)

We can’t be afraid that talking about suicide will lead to or foster or encourage suicide.

• @The Suicide Room• Arctic Monkeys, Leave before the light comes on

Farbarow, N and Shneidman, E. (1961) The Cry for Help, NY McGraw Hill, P 193-203. LA Suicide prevention center.

Reflects trauma and attachment history, related beliefs, expectations, emotional biases, and affect regulation capacities.

Continuously anticipates the future and powerfully determines behavior.

Communicates implicitly to self and to others (Ogden et. al 2006, Ogden and Fisher, 2015 Goldstein & Ogden in press).

The “Somatic Narrative”: Recognizing helplessness, hopelessness, and despair

Possible Physical Correlates Related to Adolescent Themes

Posture: Assertion vs. Helpless, Active vs. Passiveself-confidence/esteem vs. Hopelessness/depression.

Proximity seeking actions (reach, eye contact): social connection vs Isolation, support vs aloneness/loneliness.

Mobilizing actions of defense: Trauma, freezing, helplessness, shut down, empowerment.

Boundaries: Preferences, relationship, differentiation, identity, conflict.

Ogden et. al 2006, 2015, Ogden, Goldstein & Fisher 2012

Postures are positions from which only select emotions and behaviors can be possible(Barlow, 1973).

Habitual postures, such as a chronically slumped spine or “military” posture, influence our emotions, relationships, self image how we think.

Different postures are adaptive in different contexts (familial, cultural, professional, etc.). (Ogden, 2014)

Posture: an indicator of assessment & Rx

The Somatic Narrative:addressing helplessness/hopelessness

Through a supportive, collaborative atmosphere, aiming for a shared understanding in order to:

• Learn about their own somatic narrative• Explore the meaning of their somatic narrative • Try out new actions • Learn new actions through observation

Engaging the patient in a therapeutic relationship, where the relationship is prized, connectedness is paramount. (Mark-Goldstein & Ogden, 2013)

There is an Intersubjectivity of Sensorimotor Psychotherapy

Relational Listening approach Hedges, 1983, 2003, 2018.

“Tell me where it Hurts”: Shneidman’s intersubjective inquiry: These two questions are now the bywords of suicide workers everywhere because if asked persistently, these questions will inevitably lead to the epicenter of the individual’s suicidal urge. (Hedges, 2018, Shneidman, 1998)

Sensorimotor Psychotherapy’s foundations build upon interpersonal neurobiology, attachment theory, prizing the relationship between therapist and client, and building upon themes from early life & carried through life. (Ogden & Goldstein)

“Where does it hurt?”, “How can I help you?”

Our best route to understanding suicide is not through the study of the structure of the brain, nor the study of social statistics, nor the study of mental diseases, but directly through the study of human emotions described in plain English, in the words of the suicidal person.

The most important questions to a potentially suicidal person is not an inquiry about family history or laboratory tests of blood or spinal fluid, but “where do you hurt?” and “How can I help you”(Shneidman, The Suicidal Mind, 1998)

When working with an adolescent discussing helplessness and hopelessness, goals include creating safety, turning off Defenses, Regulating Dysregulated States, Increase Social Engagement.

Hyperarousal: activation exceeds capacity to integrate

Hypoarousal: insufficient activation to integrate

Siegel, 1999, Ogden 2008

Window of

Tolerance*

Dysregulated arousal

Regulated arousal

Sensorimotor-Somatic Resources help our younger clients stay within a Window of Tolerance

Window of Tolerance

Optimal Arousal Zone

Hyperarousal: activation exceeds capacity to integrate

Hypoarousal: insufficient activation to integrate

Ogden (2000)

Body awareness Grounding Boundaries Breath Containment Self-Soothing Movement Reaching Alignment Centering

Case Presentation: Donnatella, heartbreaking grief, hopelessness, healing from suicide attempt

• After heartbreaking grief, recent tragic loss and the aftermath of current trauma, which exacerbated earlier trauma - from adoption to childhood molestation - Donatella’s feelings of disconnection from herself, from her mother, from those around her.

• After hospitalization for suicide attempt, she was referred for somatic therapy through the lens of Sensorimotor Psychotherapy because traditional “talk therapy” did not help

• She was flooded with memories of her past experiences throughout our work, intermittently immobilized, frozen, “stuck”.

Working with Donnatella’s childhood memory of molestation: Goals for treatment

• Safety; initially collaborated to find resources to draw upon when the day-to-day memories ignited the pain.

• Staying within the window of tolerance - helping to titrate awareness without feeling overwhelmed by the present experience.

• Studying the organization of experience - taking time to collaboratively pause and bring curiosity to her thoughts, feelings, and body sensations (arising in the present moment/ here-and-now, in response to her recalling the past (aiming to deepen internal awareness, regulate emotions, and enable more adaptive choices).

Connectedness: Being there with someone who has thoughts of suicide is life-saving

• David Klonsky and Alexis May also theorize that “connectedness” is a key protective factor, not only against suicide as a whole, but in terms of the escalation of thoughts of suicide to action. Their research has also shown connectedness acts as a buffer against hopelessness and psychological pain.

• Post 9/11 research suggests the witnesses to the collapsing building, and those who lost loved ones were less likely to be diagnosed with Post Traumatic Stress Disorder, 6 plus months later, if they had someone that they could reach out to, connect with a friend or loved one.

Case Presentation: Sally Embracing the Connectedness of the Group experience

Presenting Issue:

• Adopted, Bi-racial parents (Sally is African American & First Nation) resulting in Sally’s questioning identity, feeling that she doesn’t fit in, excluded from peers.

• Older brother is a bully to her.

• Even when resting, Sally’s body continues to stay “on alert”-hypervigilance, etc., difficulty sleeping, easily agitated.

• Hopeless, suicidal ideation, immobilized (homebound, stopped going to school, etc.).

Case Presentation (cont.)

• Suicide intervention included Group and individual therapy through the lens of Sensorimotor Psychotherapy.

• Transformation (surprising) Spontaneous, fostered by the connectedness and support of the group.

• Sensorimotor Psychotherapy intervention: “Pushing” exercise.

• Sally reported, one week and one month later, that this group experience “felt like the moment everything changed”, propelling Sally to become more engaged in and connected with others, she returned to school, took steps to protect herself from her brother’s hostility, etc.

Summary

• Reduce the pain, remove the blinders, lighten the pressure—all three, even just a little bit. If you address the individual’s perturbation (sense of things being wrong), that person’s lethality (the pressure to get out of it by suicide) will decrease as the perturbation is reduced. That is the goal of therapy with a suicidal person. (Schneidman, The Suicidal Mind, 1998).

• Suicidologists around the world have identified trauma in early child development—especially abuse, neglect and abandonment— as the psychodynamic sources of suicidality.

• The clinician's task is to reach, together with the patient, a shared understanding of the patient’s suicidality. (Aeschi, 2002, Guidelines for Clinicians)

Sensorimotor Psychotherapy® Institute

Resources in the U.S.

Crisis Text Line, inspired by teenagers’ attachment to texting but open to people of all ages, provides free assistance to anyone who texts “help” to 741-741.

National Suicide Prevention Lifeline.

We can all help prevent suicide. The Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals: 1-800-273-8255.

Sensorimotorpsychotherapy.orgoffice@sensorimotor.org 303-447-3290

drbonniegoldstein@gmail.com

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