#140 Suicide Prevention for OT, PT and SLP with Christine Weible-Cruz

In the United States, approximately 49,000 people die by suicide each year. And, unfortunately, the rate of suicide has increased substantially since 2000, up about 30%. 

Suicide remains among the 10 leading causes of death among persons aged 10-64 years and is the second leading cause of death among those aged 10-14 and 25-34.

While these trends are multifactorial, they are particularly distressing because evidence-based approaches to screening and intervention are better established than ever. 

Yet confidence and training in these approaches remain too low — even among behavioral health workers. OTs, PTs, and SLPs are uniquely positioned to recognize warning signs through repeated, relationship-based care, but most receive little formal training in suicide prevention.

This course seeks to address that gap. We'll cover the basics of: 

• What to watch for
• Evidence based Screening
• Evidence based intervention 
• And, the role of the team. 

We'll anchor our discussion in one of the most comprehensive evidence-based frameworks available: the VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide (2024). And we'll be joined by Christine Weible-Cruz, LCSW, to get practical on what these guidelines look like in frontline care.

See full course details here:
https://otpotential.com/ceu-podcast-courses/suicide-prevention-for-ot-pt-and-slp 

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Transcript

SPEAKER_00 0:00

Here in the United States, approximately 49,000 people die by suicide each year. And unfortunately, the rate of suicide has increased substantially since 2000, up about 30%. Suicide remains among the 10 leading causes of death among persons ages 10 to 64 years. And it is the second leading cause of death among those ages 10 to 14 and those who are 25 to 34. While these trends are multifactoral, they are particularly distressing because evidence-based approaches to screening and intervention are better established than ever. Yet confidence in training in these approaches just remains too low, even among behavioral healthcare workers. OTs, PTs, and SLPs are uniquely positioned to recognize early warning signs through repeated relation-based care, but too often we receive little formal training in suicide prevention. Our episode today seeks to address that gap. We will cover the basics of what to watch for, evidence-based screening, evidence-based intervention, and the role of the healthcare team. We'll anchor our discussion in one of the most comprehensive evidence-based frameworks available, the VA Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide, which was published in 2024. And we'll be joined by Christine Weibel-Cruz, LCSW, to get practical on what these guidelines look like in frontline care. We have a lot of important information to cover today, so let's dive in. You are probably listening to this podcast on a free podcast platform, but to gain CEU credit, you will need to be a member of the OT Potential Club, our OT Continuing Education platform. You can go to OTPotential.com to learn more. Okay, here we go. As I mentioned at the top, joining us today is Christine Weibel-Cruz. Christine is a licensed clinical social worker with an MSW from Loyola University in Chicago. Christine runs her own psychotherapy practice where she helps individuals and couples. Her approach is grounded, attuned, and collaborative, bringing together psychoanalytic theory, emotionally focused therapy, and the Gottman method to create space for deep exploration and practical growth. Christine participates in ongoing training in psychoanalytic theory at the Chicago Center for Psychoanalysis and Psychotherapy. She is also certified in CAMS, the Collaborative Assessment and Management of Suicidality. So without further ado, I will patch Christine into our live studio. Welcome to OT Potential. Christine, it's so great to have you here. Thanks for having me. I am so thankful you are here. This is obviously just such an important topic. Probably everyone listening has had their life impacted by suicide in some way. So just the time covering it just feels so important today. And I'm so thankful for this conversation. This honestly is a topic that I've been avoiding doing just because it does feel so heavy. It feels hard to cover. I know it's a required continuing education topic for many therapists, but I had been hesitant to tackle it. But two things like really spurred me to do it. One was just like an intellectual curiosity. Probably two years ago, I had a psychologist on the podcast, and we were talking about AI and documentation. But I just remember so clearly he said about suicide prevention. He was like, we've gotten really good at knowing what to do when clients get on our caseload. But what we're struggling with is identifying those clients and getting them to our caseload. And that just like piqued my curiosity of like, oh, what are those things that we do? And um, what are the barriers to identification? So we'll talk a little bit about that today. The other thing that really drove me to do this episode from a personal level is uh I was going about my day one day and talking on the phone with a friend, and she said one of these warning signs, and I uh had the red flag or like felt the red flag, didn't know what to do. I just ended the conversation with her and I went online and I found this really helpful webpage that kind of walked me through the steps of what to do. Um and I cannot find that webpage again. But thankfully, um, the steps are pretty clear, even though they are in what we're looking at today in a 150-page guideline. Like there's uh a lot of details around them, but the broad steps are pretty consistent. So I'm just really thankful to be able to talk through those today. So we obviously have a lot of details to cover, but I just want to start with you and your story and going just back to what made you interested in social work and then hearing a little bit about your practice currently.

SPEAKER_02 5:15

Yeah, well, um, thanks again for having me. I'm really happy to have this conversation. I'm, you know, with you on the importance of it and the scarcity sometimes of resources. I came to social work kind of from a secretus root. I started out studying art history and Spanish. Um, really wanted to work in art museums, and I did that in both New York and Argentina. It um it was about learning about people's creative expression and how history and their lives kind of get connected through art and helping people experience that art. So there's always been kind of a basis of curiosity about people in the work that I've chosen to do. And when I decided I wanted to become a psychotherapist, you know, there's many different ways to do that. There's different um roads that get you there. I chose social work, I chose clinical social work because, first of all, there's a really strong stance and position of being um for social justice and being for equity and um really thinking about people that are um kind of not as resourced as others in our communities and in our culture. But I really am convinced by this kind of systemic lens that social work brings to everything. We think about the ways that systems impact the development of each human being and intersect in different ways that, you know, help us understand how we develop as people, how we develop a relationship to ourselves and how we relate to the world. You know, the family is usually the first and most consistent system that a child experiences. And there's a lot there that we can kind of learn from looking at it in that way. So it has become um something that I've brought my, you know, my former practice into of being curious and thinking creatively. And the therapeutic relationship for me is really the vehicle for healing. It's um it's about deep listening, it's about holding space for somebody, it's about saying things out loud that we can be scared to say, like what your friend said to you that day, and making meaning together. Um, so I I work with people um really in-depth and and can see a lot of transformation. And I'm changed by that process.

SPEAKER_00 7:49

I'm always so thankful when we get to have a um social worker on the podcast because there's such a shared lens um with us in rehab therapy, such a shared heart for like looking holistically. There's often that curiosity. I'm always surprised how many people have an art background too. I would love to take an informal survey, like the creativity um I feel like doesn't get associated with our professions that much, but I just see that as so deep. We're going to talk about curiosity so much today. Um, uh, that is not one of the words I would think of when I think suicide prevention, but that's definitely a theme that we're going to see throughout this conversation. Um, and also thinking on a systems level, I think when we think suicide prevention, I personally think of like high-stakes individual conversations. Um, but I want to start with like just zooming out to why it's important to think of this as a team approach and um just why it's important for all of us on the healthcare team to boost our confidence in our role in suicide prevention.

SPEAKER_02 8:58

Yeah, well, I I think going back to what you mentioned earlier, it can be really scary to hear somebody talking about um feeling like suicide is a compelling idea for them. And even as healthcare professionals, we can feel scared too. Um, and so we instinctively might avoid talking about things like death, feelings of alienation, feeling hopeless. Those are things that are very human to avoid talking about. Um, but as healthcare professionals, we can really find confidence in grounding and knowing there are real things we can do. It doesn't have to be super scary and overwhelming. We have a part to play. Um, and it is something that can be surprisingly simple. So, you know, having the sustained long-term, really strong relationships that OTs, PTs, LPs have with their patients, um, really being the ones who know them well is a unique position then to come and notice something going on, noticing a change from week to week or something happening in a session. You guys have a lot of um exposure to a person and a relationship that can position you to notice something going on. And you've established rapport and trust so that when you do decide to step in, you aren't coming in without any information. You're coming in with this history and this foundation. It's really just staying alert to the signs that we'll go over today, and then a few key steps that are really effective for getting people to the help that they need and thinking about ourselves as a bridge to a higher level of care, right? So that's our part in the team is noticing and then helping them to get connected with the right resources, the right kind of care. It's not up to you in the moment to do everything to solve the problem. It's really up to you to be compassionate and curious and help somebody think through what they might need next.

SPEAKER_00 11:08

We're going to, I love that answer. We're going to spend quite a bit of time today just talking about the details of what that effective treatment looks like. And to anchor that, we're going to use a clinical practice guideline from our VA, the Veterans Affairs Office. Uh, it's called the Assessment and Management of Patients at Risk of Suicide. It is 151 pages long. So there are all kinds of details. This is a highly studied topic. And uh something that just stands out to me as I'm looking at it. I'm like, there are broad strokes for us to follow, like broad steps, but there's not like the exact right thing to say or the exact right thing to do. Like it's more these general steps that's in the context of a relationship, in the context of the team. And uh I don't know, that's just helpful to me to think about. There's guidance, um, but there's also it's in the context of this relationship. One of the things it starts out with is that first step is just scanning for warning signs. Um and it uh lists direct warning signs and indirect warning signs. The direct warning signs that lists are suicide-related communication, such as a suicide, finding a suicide note, or just someone who mentions that they wish to die. Um, someone mentioned a preparation for suicide, like giving their items away, or someone seeking access to lethal means. So those are like the direct, like big red flags for us. Um, less direct warning signs, which uh definitely makes me think of patients on our caseload are substance use, hopelessness, purposelessness, anger, recklessness, feeling trapped, social withdrawal, anxiety, mood changes, sleep disturbances, and guilt and shame. I just wanted to say those out loud because, as I mentioned, like I was in um a conversation that was in my personal life, not in my work life. And someone mentioned uh that they thought the world would be better off without them. And I was really surprised how that like set off so many bells in my like in my body and so many red flags. I was trying to think back and I was like, I don't even know if I've been trained in these warning signs, but like somehow when I saw one of them, it really struck me. Um, and in that moment, I finished the conversation. And then I remember standing with my phone and being like, oh my goodness, I need to call that person back. But I didn't do it in the moment. So I wanted to linger just a little bit and ask about that moment of when we see a warning sign, um, just how that might feel and your advice for that critical moment of seeing one and recognizing it.

SPEAKER_02 14:06

Yeah. Well, I think what you're talking about, Sarah, that kind of bodily reaction is the result of being attuned, right? Of being in touch with yourself in a way that allows you to notice what's going on and being open to another person's, you know, communications of what's going on. And that's really as healthcare workers, a big part of our job is like we are the instrument, we are the tool. And so noticing the feelings that come up for us when we're with our patients is information, it's data. If you were with somebody who was feeling hopeless, you might feel hopeless yourself, you might feel agitated, you might feel fear, you might even feel irritation or discomfort in your body, you might feel tension, you might notice like, oh, I'm like this. Um, like, ooh, what is this coming from, right? So that curiosity, I'm noticing, I'm on a label like, what is this feeling like? And then where is this coming from? What is this about? It might be something that's coming from within, you know, you might have agitation from your own life, but you might be able to identify that it's not really your feeling and that it's really something that's being communicated to you by your patient. And so we need to be able to trust ourselves that, you know, there is something here, and we might not immediately know what it is, but we want to stay open to the possibility that it could be important. So, you know, we want to ask what our patient is communicating and we want to wonder about what more do I want to know about this? And something else that I thought, Sarah, when you mentioned, um, you know, you ended that conversation and but then you decided to follow up, right? So we might sit for a few minutes with somebody and we might notice something's going on, and we might need some time to find the moment to be able to reference it and and ask more about it. We might miss a moment, but that doesn't mean we can't say like, hey, I actually you said something earlier, or I picked up on something earlier. I want to go back to it. So, you know, it doesn't have to be an immediate recognition and then a movement. You can come back to something if it really stays with you and you're able to kind of identify that it's something that needs exploration.

SPEAKER_00 16:43

Yeah, we see, we can see or feel that warning sign. As with all the steps we'll talk about, the next step is kind of simple, but it feels deeply counterintuitive because the next step after you see or recognize a warning sign is to ask about suicide. Um, and that just honestly feels counterintuitive. That feels like a subject we want to avoid. There can be this fear of like, what if they're not thinking about it? And then I put the idea in their head, or what where does a conversation go from there? It feels deeply counterintuitive to actually ask the question. But that is the next step is either an informal, uh, we'll talk about both an informal conversation and uh the use of a screener. But what advice do you just have for that very next step? Of do I just say, are you thinking about suicide? Like what can that next step look like? Um, and what do we need to be considering in that next step?

SPEAKER_02 17:44

Sure, yeah. Um, that's so relatable. It's not a question that we are used to thinking about asking, and it can feel really uncomfortable. Um, a lot of our work can feel uncomfortable. So knowing that you might be uncomfortable, you might be scared, it doesn't necessarily mean that there's anything wrong with what you are pursuing. A big concern that a lot of people have is that you might plant an idea in someone's head. Um, and that we that falls under this heading of iatrogenic harm, which is basically the idea that certain um medical care or treatment or advice can create negative health effects. That is a true effect that exists in the world, but it's been really studied and there are robust um studies that have shown that it does not do that. Naming suicide, asking somebody if they are thinking about suicide does not plant a risk or does not plant that idea in their head. It does not make it compelling to them. Actually, it can reduce people's distress to hear this forbidden thing spoken out loud and to have it named. It can be um comforting in a way because that person is no longer alone with those thoughts. And then, you know, to the real risk that we want to be aware of and that we want to be trying to mitigate is the risk of not asking if there really is some sort of suicidal thinking or feeling going on with our patients because we might signal to them by not naming the thing that it's too scary or it's shameful, it's not something you can ask for help with or get help with, because we don't speak of it, right? Silences are often our ways of responding to discomfort in our culture, um, in many cultures. And so we want to go against that and say, like, we can talk about this actually, because if not, our patients might be left feeling really isolated. And if we ask the question, we can really use what we're hearing to kind of set up and and hold the question that we're asking. So we might say something like, Hey, I hear that you know you're really having a hard time with this new diagnosis. And some of what you're saying, it's making me wonder, are you thinking about suicide? Or some people in this situation, they they start thinking that suicide sounds compelling to them. Are what are you thinking about? You can kind of tie it to to what you're noticing so that it is um anchored into what's going on and the information that the patient has actually already given you. It's not out of nowhere, it's tied to something, even like, oh, I'm I'm really feeling your sadness, I'm really feeling your loneliness. And I'm wondering, is this isolation creating any thoughts of suicide for you? If the answer is no, okay. But if the answer is yes, then now we have something that we can work with. Now that conversation has worked to get us some really crucial information, you know, and we we have a lot of trust invested in us by our patients. It's something we work towards building and then maintaining with them. And so if we are addressing something like this with them, it's because we have a foundation already of knowing one another. Um, and it might be awkward the way that you say it, right? You might ask a question in a way that you're like, oh, that wasn't the best way. But because we have that trust, we might be able to just acknowledge that, like, oh, my words came out a little funny. But what I'm really trying to get to is, right? We hopefully have developed enough rapport with our patient that they know that. That we're really well intentioned, we're doing our best. And as professionals, you know, we really need to be able to say the quiet part out loud because we're empowered to do that by virtue of our position and by virtue of our relationship to our patients.

SPEAKER_00 22:20

Yeah, if someone has let you see one of those warning signs, you are probably in a trusted relationship. And it is so hard to ask that question point blank. I feel like even if you practice it, it will feel awkward because it's not a question that we're used to asking. Um, but I just remember in like my own circumstance, like almost felt relieving then because then it opened up the conversation more. So it's a simple next step to ask about it, but feels counterintuitive. It feels hard. Once you ask about it, you go down the flow chart. You or the flow chart is like you see the warning sign, you ask about it. If yes, then there's more steps that are also pretty simple, but also feel really hard. And this was the part where when I was Googling, I was like, are you sure this is what I do? Because it feels so counterintuitive. Because then after asking the next, there's like an just an information gathering stage that happens almost where you're trying to assess then um what calls like the level of risk. And two of the big uh factors there are are there, is there a concrete plan and does the person feel immediately safe? What does that look like to try to uncover that next layer of data? What again, just like the step before it, it feels so counterintuitive. What does that look like? Um, how do we gather that information?

SPEAKER_02 23:53

Yeah. I just wanted to point out, I loved what you said that like if someone lets you see that red flag, um, yeah, it is it, it you're being entrusted with something. Um, and that's important. Um Yeah. So if if a patient says, like, you know, I have been thinking about suicide. I haven't hurt, I've been thinking about hurting myself. Yeah, that opens up, then we want to look at that. We want to examine it and kind of understand what it's comprised of so we can really get a sense of what we're talking about. Um, because it doesn't mean the same thing to every person, and not every person is in the same place thinking about suicide. So one thing that can come up is patients might feel both relief that they've been able to tell you this, but they also might immediately feel fearful, like, what happens next? Um, are you just gonna dial 911 right now? And so we want to communicate like, I want to ask you some more questions about this. I really want to understand it. We're gonna collaborate together and and make decisions together, right? Based on what we find out about this. Is that okay? Really getting their buy-in to a process that is about understanding and exploration. Um, so we want to discern is it passive ideation or is it active ideation? Passive might sound more like, I wish that I just would go to sleep and not wake up tomorrow, versus an active ideation is more like I'm going to kill myself and I bought a rope to do it. So there's there's a different level of risk with passive versus active. And it doesn't always fall clearly into one or another bucket, but we want to kind of um be using those terms to think about where this person is in terms of acting on something versus letting something happen to them. And we might want to find, oh well, we do want to find out um, do they have a plan? So I hear you saying that this new diagnosis is making you feel like suicide is an option. Can you tell me more about that? Can you walk me through what you've been thinking? Have you thought about how or when or whether you have access to something that you would use for suicide? When do you think you would do that? Is there a time frame? Um I hear you saying you've fantasized about jumping off a bridge. Are there bridges within, you know, accessible distance from where you live or from where you work? Or I hear you saying you thought about overdosing on pills. Do you have pills that you could do that with in your home accessible to you? There's no, again, there's no iatrogenic harm in getting specific. And so we really want to ask questions that, like you said, feel counterintuitive, but um can help us really understand what we're working with and also can help the patient to kind of hear themselves saying these things so that you start to create this shared set of facts, the shared reality. We both know what it is we're looking at and talking about here. Um we're being specific. And the point of this is not to solve any of you know the problems that are being named here. We're not looking for an immediate solution. We're just looking for understanding so that we can start to make a plan to get that patient somewhere where they can solve some of these problems that are making them feel suicidal.

SPEAKER_00 27:43

Like I said, that again just feels so counterintuitive, intuitive to ask about it and then talk about the details of what the plan might be. Like that, again, that's like a simple step, but this whole process is just going to feel counterintuitive. Once we do these things you talked about, um, there are some things that we can move to immediately as far as management. But I want to linger a little bit more on the information gathering because we are talking about this in our role as OT's PT's SLPs. We're probably in a medical or school setting, which means we likely have access to suicide screeners. And that is something that is explicitly mentioned in this clinical practice guideline in this part of the flow chart. They specifically mentioned the Columbia Suicide Severity Rating Scale Screener, the Suicide Cognitive Scale, the Patient Health Questionnaire 9, and Beck's suicide intent scale and the Columbia Suicide Severity Severity Rating Scale Screener. Um, so there's multiple screeners that are available to us, can be a tool. What do you see as the role of a standardized screener in this part of the process?

SPEAKER_02 28:55

Yeah, um, so it can be a really important piece of the puzzle, not only like you said, Sarah, because some of the settings that people work in might require it, but because they can really supplement the conversation, add um like a shape to the questions that we might ask a patient who's presenting in this way. Um, it's not meant to replace the conversation, right? We always want to make sure that we're we're having a more conversational approach and using our own curiosity. But especially if this is something you haven't encountered before as a clinician, or if you're feeling flooded, um, which can happen when there's intense emotion like this. It can be a fallback if you're less confident in like, what questions do I need to ask? What do I need to make sure I know? Um, a screener can provide a way to get all that information down. So we want to, we want to introduce it in a way that's really um not gonna put like a distance like between you and the patient. You want to say something to the effect of like, you know, if it's okay with you, like I've got a set of questions that can really help us learn more about what's going on, really help me to understand your experience and um and can help us understand where you're at. Would it be okay if I went through these questions with you? And then, you know, we we want to be really aware that a screener is a tool, it's not a diagnosis. Um, and so our clinical judgment really still matters, our relationship still really matters. And some of these questions, like the ones that we have already talked about asking, might feel counterintuitive. And, you know, you know your patient, you probably have a shared language, you probably have ways of acknowledging things together. And so finding a way to say, like, hey, I know this is a tough question that I'm gonna ask you. Like, I'm I'm just so aware of that right now. Like, how does it feel to be talking about this, to have me asking you these questions? Um, you don't have to ignore it or pretend it's not hard or awkward or a little scary. You want to you want to be um as human as possible with your patient who's having a deeply human experience of of of suicidality.

SPEAKER_00 31:30

I'm also thinking about this screener to as the beginnings of a communication tool with the team. Like right away, you're giving a shared language that you can be using with the team. Um, someone just said that at their work they were provided with a badge card that has the CSSR and helps them like ask through the questions and determine the level of risk. Like that's just part of what's really nice about screeners or these standardized approaches, is it creates a shared language to then um to use with the team. So truly are like just great resources for us. Um, and especially if your team is all on the same page using the same language and the same framework. So that's kind of the screening and assessment piece. Um if uh we've uh gone through the flow chart and um they're still on the flow chart, which would means that uh we saw the warning sign, there is suicide ideation, suicidal ideation. And then if we get to the point where we've ascertained that that there's an active plan, um there are multiple management strategies that are mentioned in this clinical practice guideline. Uh I just really wanted to linger on lethal mean safety because it's so um concrete and just like a really next natural follow-up. So I wanted to ask about that and um also ask about maybe a scenario where the patient says that they feel like they can remain safe until there's a doctor's visit or the next level of care is initiated. Um, what what can those two things look like? Just the lethal means safety, uh, but also they're in a scenario where they feel like they can be safe until the next visit.

SPEAKER_02 33:23

Sure, yeah. Um yeah, it is it's really concrete in a way that can have really important results. So if we find out that there is a plan and there is an idea that, you know, your your patient is thinking, um, the example um I might give is my patient is thinking of overdosing on some prescription pills that they have in their home. We would want to notice that um that ready availability of the lethal means really heightens the risk that somebody could complete suicide because most suicidal crises, they're time limited. They're not going to pass a certain amount of time. But in that time frame, if you can easily go and grab the thing that will, you know, ultimately be lethal to you, that's a really big risk. So we want to create friction. We want to put obstacles in the way of the patient's access to these materials or objects that um could end up killing them. And so again, we want it to be really collaborative. We want to respect our patient's agency and we want to name the thing directly. We want to say, it sounds like you've imagined killing yourself by um overdosing on some of your prescription medications. Can you think of a way that we could remove them from your home so that you can avoid temptation? Uh, what are your ideas about how you could get rid of these pills? Or is there somebody that you trust that you could ask to hold on to them for you and let them know what's going on so that they can keep them out of reach in those moments when you're feeling pretty um suicidal? Keeping the power in the patient's hands, we're not directing them, but we are emphasizing that um there are things they can do to keep themselves safe. Um, so it's still a conversation, it's still collaborative. And depending on what we find out, if they have lethal means within reach in their homes, we're gonna want to know are they willing to do something to put them out of reach? They might be able to generate ideas for what that would look like. But if they're not willing to do those things, that's important information. If they could imagine calling a friend and asking that friend to come and take something out of their home, but they're unwilling to do that, well, then we know that they're not going to be able to keep themselves safe. Versus if they're willing to say, you know, I do have this friend, they they they won't judge me. They'll, you know, they'll come and they'll take the stuff. Um, I'm gonna call them and I'm gonna do that. That's a great sign that they are willing to engage in some of the actions necessary to um to keep themselves safe until they can get, you know, connected to their doctor, to a psychotherapist, to some sort of other treatment that can really, you know, help them work through what's going on that's making them feel suicidal.

SPEAKER_00 36:40

The can the clinical practice guideline doesn't have this language, but I'm going to layer it on. But it's almost like during assessment and screening, we're really using like our curiosity lens to um gain more information. And then as we enter into management, you're really going into shared decision-making mode, which actually it does use that language. The clinical practice guideline actually does use that shared decision-making um language. Um, that feels like such an important part of the lethal means safety of making a plan there and then just making a plan to get to the next scheduled appointments where they can be safe to that uh until that point. I think that will probably capture, like the steps that we've gone through so far will honestly probably capture most circumstances of talking about suicide as we keep going down the flow chart. These circumstances are getting less and less. But I want to move to if uh we've seen the warning sign, we've asked about it, there's a plan. Um, we've talked about lethal means safety and if they can make a plan to keep themselves safe. And the answer is no, then we're moving into a potential hospitalization. Um, what can shared decision making look like in that part of the flow chart? Yeah.

SPEAKER_02 38:03

Um so, you know, we even as they might not be able to commit to keeping themselves safe in their home, we want to keep the emphasis on their ability to know things about themselves and to generate creative ideas about potential solutions. And we want to make sure that we stay in that shared reality. Like I'm hearing you say that you're not willing to call somebody to come take these pills and keep them, or you're not willing to remove yourself and go stay with a friend until your home can be made safe, right? Um so you know, we need to talk about the reality that suicide means death and death lasts for a long time. Um so why wouldn't we find out more about, you know, whether there's really any other option for you to get some help before making that, you know, really final decision. Let's talk about what it would be like to explore what's available to you before you take that step that's irreversible. What is it like to talk about this? You know, checking in, like this is a hard conversation. Um, we're talking about things that are um uncomfortable. What is it like? And then validating that. Um, and you might need to say, my workplace has a protocol that we are obligated to follow in situations where people come in and they're talking, um, they're naming some of the things that you're naming here. So I have an obligation to, for example, um, contact my supervisor. I know this is somebody that you don't know. You're not familiar with them. I know that might feel uncomfortable. And I want to do as much as I can to make you feel comfortable. Is there anything you want to know about the next step? Um, how can we make this a bit easier for you? And and we also want to be aware that, you know, in having this conversation about what comes next, there might be, there probably will be a lot of ambivalence and it might go back and forth between a relief and a trust and also a fear and a defensiveness or a resistance. Um, that suicide is something that is complex and is is feeling compelling in the moment. And we know that that's for a reason. We know that there's many good reasons that somebody might come to the conclusion that suicide is something that could help them get out of the pain that they're in. And we want to really be respectful of that while also gently inquiring about if there's any other way that they might be able to get some help with that short of suicide.

SPEAKER_00 41:00

And if the patient is open to that hospitalization, I feel like then my role then becomes to be like, okay, how can I make that transition as non-traumatic as possible? Like, how can we just take one step after another? And if they feel like that's the right step for them, just how do we just go through the steps? Um, I want to pause too on the most rare case where you've gone all the way through the flow chart. Uh, the patient does not feel safe, does not want to be hospitalized, and we believe that they are an active threat to themselves or um potentially another person. That's when most of our states have duty-to-warn laws. Um, once you get to this like very rare uh, we actually have laws and like pretty concrete steps of what to do. For us as rehab therapists, it's very unclear usually if we are covered in these duty-to-warn laws. We'll talk about this more a little bit later, but understanding um what your legal obligations are in that state, that uh those regulations give you clear guidance. They also give you like a layer of protection, too, because when you warn, you might be breaking patient confidentiality, and we have a set of rules that says in this case, that's okay. Anything to mention about that? I know social workers are just much more covered in these duty to warn laws than we are.

SPEAKER_02 42:30

Yeah, we are, um, which in some ways is helpful because clarity is helpful, right? Um, but but it's also it's it's one of the hardest decisions to make. And I think knowing that involuntary hospitalization does exist in these cases, um, it's not what we're aiming for. We want to get them to the help they need with agreement and collaboration. Um, but it is our obligation to keep somebody alive, right? As healthcare workers, our highest goal is for our patients to live healthy and long and good lives. Um, so in that case, I think again, the the shared decision making includes being transparent about what your obligations are and also being part of an organization that will hopefully give you the chance to consult. Um, probably before you make a decision like this, you're gonna want to talk to colleagues or supervisors and and get another opinion about what's happening and what your duties are and what the best measures are to take. Um, so taking the time to really allow for some consultation that can provide clarity um so that you're not all alone is is really important. And um, hopefully that's part of the protocol of any workplace, but also just knowing um Within yourself, that like that's something that you have a right to do, and that it's important that you also are getting support in a moment like this. You might break your patient's trust. Um, and ultimately that you know can go different ways. It might end up being something you can rebuild with them, it might not. Um, but in a moment where it's about saving somebody's life, you can both acknowledge that this is not what you want, this is not what we hoped for. I understand this is not, you know, ideal. And also my my commitment is to keeping you alive until we can find a way to connect you to services to really help work through these things. It's just really hard. I just want to acknowledge that. And there's no perfect way to do it. And our systems that we're working within fall really short in ways that we wish that they didn't. And you being a grounded, truthful, compassionate person, even while doing something that your patient doesn't um want is is still really, really important and and powerful.

SPEAKER_00 45:14

Yeah, you irregardless of whether we're covered by these duty-to-warn laws, we all have our code of ethics as medical professionals. And I think across boards, we all have do not harm. Um, and this is um good just getting down to that core ethical uh principle. And yeah, it is a very tough decision. Um, but again, why we're part of this team and hopefully have a supportive healthcare team to navigate through this with. We've gone all the way from the flow chart from thinking of suicidal ideation, which lots of people experience, um, down to we are now talking about the most rare cases. I want to come back up to the middle, which is probably where most of these conversations go, where someone then gets to go see um a doctor or someone like you for further therapy. And then there's this like swath of different evidence-based interventions that um can happen. I think I might make a resource to go with this where um I actually like list out uh what this clinical practice guideline recommends about the different evidence for different types of interventions, because there's like I don't know, like 20 different. Um, we won't get to all of those today. I would love to have a whole additional podcast dedicated to more of these interventions, but for the purposes of our um time today, if someone came to got on your caseload through this uh flow chart, what what would that intervention look like just for you personally? Um uh what do those sessions look like?

SPEAKER_02 46:58

Yeah, sure. Um yeah, so like you said, there are a number of evidence-based ways to manage suicidality. So that's the good thing is it's it's not a one size fits all. Um I am personally certified in a program called CAMS, which stands for collaborative assessment and management of suicidality. Um it's evidence-based, it's well researched, and something I really love about it is that the emphasis is on collaborating, the clinician and the patient working together to identify and treat what um what are called in CAMS the drivers of suicidality, which are patient-identified issues that fuel SIs, suicidal ideation. Um, so these are treatable and they're specific and they come from the patient. The clinician can work with the patient to identify them and to often to refine them to really get at like what are the two or three things that just make you think the only way to solve this problem is suicide. So we we identify them, the patient is contributing their own words, their own ideas. You're developing a shared language around what these drivers are, and we build a unique treatment plan based on treating those two or three um specific drivers. And this is the part where the clinician gets to choose the modality that they, you know, think is most effective for treating these drivers. In my case, it's a lot of psychoanalytic um approaches, but also using DBT skills, um, among others. And so um you're checking in along the way. You are documenting its built-in. So there's um a number of scales that are meant to kind of track the different um symptoms of suicidality and kind of how they're going up and down during the week-to-week sessions, and then kind of tracking the overall risk for suicide that the patient is presenting with, um, looking for it to go down over time and remain down for at least three sessions in a row, um, which is considered like a resolution of the suicidal ideation. Um, so there's a check-in, we're checking in every session and we're saying, like, is this working? Have we got the drivers right? Is our approach to dealing with these drivers having an effect? If not, what might we try? We're also creating a stabilization plan from the very first moment or the very first session, which is a plan that is a living document. So it's up for changes, it's up for refinement. Um, this document is for the patient to use in moments of crisis. So it's basically a list of activities or actions or things the patient can engage in in a moment when they're noticing, oh, I'm having more suicidal thinking, I'm feeling more compelled, or I started to kind of behave in a way that I know is um connected to suicidal thinking. Now they can go and they can say, you know, what are the things that I can do that can distract me, that can calm me down, that can get me connected to my body, or to get connected to trusted others who I know can kind of help me get through this moment. And it's it's um a resource that hopefully the patient learns to go to over time. And of course, if it becomes um if they've used all of the stabilization plan and they're still feeling suicidal, they call me. And if they can't get me, they call 911, right? We have kind of an escalating plan for um if things don't resolve. And the typical resolution of the suicidal ideation for patients is around four sessions, but you can go up to 12 sessions for complex cases, and that's been really um confirmed by research that that's um really effective for most people. And it's a really focused, collaborative way of working with patients and being creative and creating like a really unique treatment plan that only works for this one person because each person is unique and has all sorts of layers and things that respond in ways that only they will. And and so it's it's really meant to be shaped um by the patient over time and really, really easy to utilize for them.

SPEAKER_00 51:37

That really surprises me that just thinking that length of four sessions and just how high impact that can be. Um, and that just speaks to at the top where I said I heard that psychologist feel like once people get on our caseload, like we do have like a clear flow of what to do. I'm thinking of a couple of uh possible action steps for people from here. One, there are more ongoing in-depth training, um, like CAMS, like you mentioned. I'm going to try and create a list of four people who are interested in doing uh more in-depth trainings. I'll use a clinical practice guideline as like my uh checklist, and I'll try to go find those actual trainings that they mention in there. Um, the other concrete I hope some people consider doing the next level of training. I hope that one thing that probably everyone does is dig a little bit into their safety procedures at their own facility. That should give you a lot of guidance, hopefully, on what resources are available to you, what the expectation of the facility is. Um, if you don't have safety procedures, sign yourself up to be on the team. We will have this clinical practice guideline. You'll have guidance from your duty to warn laws in your state. Like a lot of the information will be there for you, and it will just help your team so much to have those safety procedures written down. Uh, I wish that I had asked about those at every single onboarding. Uh, and maybe they told them to me and I forgot, but that is definitely something I would keep top of mind in an onboarding. Those are kind of my two big picture action steps and takeaways. Um, we've talked about so many things today. What is the final thought that you want to leave people on from this conversation?

SPEAKER_02 53:28

I think the the final thought is really some encouragement that as healthcare professionals, um real concrete things that we can do for our patients when they show up in um real distress and and and suicidal. Um, we don't have to look away, we don't have to be scared or feel helpless because here are these things we can do, here are these questions we can ask. Um, we already know how to be curious, we already know how to help ourselves stay present in the moment. We know how to build trusting, collaborative relationships. Um, those are the hard things. And now, you know, thanks to these guidelines, um, there's there's real concrete steps that we, you know, know that we can take to connect people to um a higher level of care to really help treat suicidality and save patients' lives.

SPEAKER_00 54:26

Well, Christine, this was or is a hard topic. Um, it's hard to talk about. I'm so encouraged by um the steps that we can do. I'm so thankful for the opportunity to talk them through, as we've said throughout. Like they are pretty simple steps, but they're not easy. Um, they feel counterintuitive. So I'm so thankful for the time today to just talk them through. Um, and as you've said, I hope people uh feel encouraged about the resources that that are out there, about the support that's out there, and about the tool set that we already possess to have these conversations. Um, thank you so much for just being willing to dive into all this today. I just so appreciate your time and this conversation. Thank you, Sarah. Thank you for joining us on the OT Potential podcast. To earn one hour of AOTA approved continuing education for your time today, you will need to sign in or sign up at OTPotential.com. Once you're in the OT Potential Club, you will find a five-question post-course quiz connected to this episode. When you pass the quiz with a score of 75% or higher, you will be able to download a PDF certificate that certifies your completion of this course. Okay, I want to thank you for joining us today, and we'll see you next time.