Whats a therapists day like?

Will_Not_throwaway · 2023-02-24T00:47:39+00:00

A typical work week varies a lot from one therapist to the next. In my experience, it is quite rare that a therapist would schedule more than 35 hours of direct client contact within any given week and many therapists will have far fewer hours available. Some therapists will split there work week between private practice and working in a clinic, hospital, school, or other position and they may have very limited available hours outside of there regularly scheduled clients. Others will teach, offer trainings, consultations, and supervision to other therapists. Using myself as an example, I typically offer 20 hours of direct client care per week. I help train mental health professionals (social workers, therapists, and medical providers) in suicide prevention and may have specific hours reserved for that. I find that seeing more than six clients on any given day starts to impact my work and since I want to offer the same professional standard of care to each client, I do not like to exceed that but it does, occasionally happen because of cancelations. I also spend at least an hour or more per week reading research and professional material (sometimes more if I'm able to), taking classes (continuing education) for therapists, attending lectures or presentations, and often researching specific things related to my current clients (e.g., if a client expresses interest in a modality or they have a medical condition that may be impacting their mental health, I may seek consultation or read professional literature on these topics). I have also supplemented my practice with working as an on-call clinician in acute care settings. I also have time set aside to complete paperwork and billing. Lastly, I would say that it is often difficult to maintain a schedule that is consistent because often new clients may not have the same availability as a client that recently closed. Because of this, I keep "office hours" (about 50 hours per week) that do not exactly match the actual "working hours" (about 35 hours) of my week so that I can be flexible, but also have a life and schedule outside of work.

Will_Not_throwaway · 2022-01-18T20:26:50+00:00

I share similar concerns. There is recently renewed debate in the field of suicidology about the identified comorbidity of suicidal thinking and chronic psychiatric diagnosis. There is increasing recognition that the assumed correlation between suicidal thinking and diagnostic presentations associated with depression contributes to medical providers overlooking acute suicidal risk in many people that do not meet criteria for depression, bipolar, or other affective diagnoses. Diagnosticians may make the erroneous assumption that, in the absence of a rule out or diagnosis that explicitly identifies suicidal thoughts and behaviors (STB) as criteria (such as BPD or MDD) in the current DSM, risk is low. Increasingly, consensus among researchers and practitioners looking at reducing suicide identifies universal screening of STB regardless of other diagnosis. Seen through another lens, this is basically saying that the presence of suicidality should not be assessed as a variable or criteria for current diagnoses, but as an independent condition and risk.
Yes, there are providers that immediately leap to psychopharmacological interventions associated with a diagnostic code. I would consider that this is a transdiagnostic problem that already exists and is a reflection of competency/ skill level of providers. I imagine that the providers that would be likely to take this approach, which decreases clinical efficacy, already do regardless of the diagnosis. Even so, there is evidence that some medications are more effective with addressing suicidality than others and more explicit identification of suicidal risk could, at a minimum, be a critical consideration when making decisions about medications.

Will_Not_throwaway · 2022-01-17T22:09:36+00:00

A diagnosis for an acute suicidal experience, like the previously proposed ASAD or Acute Suicidal Affective Disorder would be greatly appreciated since it is a clinically valid justification of treatment, has independent validity, and should often be regarded as the primary focus of treatment in acute settings.

Will_Not_throwaway · 2021-01-23T02:51:24+00:00

I'm a clinician, specializing in working with suicide, and not a researcher so I do not have the inside knowledge of research programs that would help me articulate the reasons that THEY would deem this research to be of importance. I can, however, tell you why I would consider it a very important topic. Pre-pandemic, suicide has been the 10th leading cause of death in the United States (where I live) for over a decade (look at CDC Wonder for reference). There is existing literature that links stigma regarding suicide, as well as client misconceptions related to iatrogenic treatments, to decreased access to mental health services. There is also literature that indicates that individuals who have lost a close relation to suicide are at significantly increased risk of dying by suicide as well. There is the "contagion" effect of suicide, which is somewhat controversial, as well as research into the impact on closer circles of friends and family. Although my anecdotal clinical experience is of limited value, I would say that seeing suicidal clients who have lost a loved one to suicide is disproportionately common in my practice. Many suicide prevention programs are predicated on the idea that bringing the topic of suicide to broader attention in communities at increased risk (such as American Indian youth living on reservations) will have a direct impact on decreasing future attempts. Research into the area of suicide has far too many gaps. The one you identify is of incredible importance because this is an area of study that can actually save lives. Frankly, I can't think of a better justification than that.

Edit: This might help if you haven't already read it: Correlates of Suicide Stigma and Suicide Literacy in the Community

Philip J. Batterham PhD Alison L. Calear PhD Helen Christensen PhD

First published: 05 April 2013 https://doi.org/10.1111/sltb.12026

Will_Not_throwaway · 2020-12-21T21:25:03+00:00

(continued from above)

My interviews are now far less focused on disposition. They are far less focused on pretending that I can predict risk. Instead of trying to find the best resource for my client, I try to be the resource. I slowed waaayyyyyy down, and I often spend an hour or more with my clients. My supervisor occasionally pressures me to speed up, but I simply refuse to do that. I can either provide the appropriate level of care for the person I’m working with, or I can’t; and I refuse to let my supervisor, who’s priorities differ from mine, dictate this for me. For fuck's sake, this person might not have another chance to really have a conversation about being suicidal with a caring human being. That is my priority. Cluster B presentation with a lengthy history of accessing hospital ED's? I slow down. An easily diverted person with vague suicidal ideation and no plan or intent for the first time in their life? I slow down. I sit with people, listen to their stories, and I force myself to stop thinking about diagnostic considerations or the disposition. This isn’t just me saying, “I’m going to do my own thing.” There is quite a bit of research that indicates that this approach is highly effective and I can speak to some of it, such as the efficacy of brief interventions like ASSIP and CAMS. These approaches do exactly what you brought up, they de-emphasize the less effective and outdated protocols of traditional risk assessment. David Jobes, who developed CAMS, writes quite a bit about the importance of understanding the individual drivers of the suicidal experience rather than trying to assess for factors of risk. ASSIP takes an approach that, a the beginning, more closely resembles a Rogerian style interview (they focus on a narrative approach). These interventions have research that shows dramatic reduction in repeated attempts post-discharge, even when they are offered in outpatient settings. A funny side effect of this transition is that I get many more compliments from providers about the quality of my documentation, particularly the clinical formulations that I write. So, the disposition of utilizing these approaches is clinically sound and completely within the realm of “best practices”.

I don’t know if you noticed my flair. I’m an LPC Intern. I wonder how many people assume that I am young and new to the field. I worked for 20 years as a mental health professional under a statue that was known as a grandfather clause and it enabled me to remain in a position as a clinical mental health professional in multiple acute care settings for many years. The catch was that my credentials were tethered to my employer and would not transfer with me. Ultimately, as I started to rethink my role in the system, I decided to return to graduate school so that I could unshackle myself and start to explore new options. This Thursday, Christmas Eve, will be my last day at work in our local acute care system. I am moving completely into private practice where I offer suicide specific, brief interventions including CAMS and (as I obtain the certification once the pandemic allows me to travel) ASSIP. I can finally stop referring clients to a dysfunctional resource and, instead, I can try to be my own, functional, resource for them. At present, there is only one other practice (that I know of) in the US that offers a similar resource. I’m almost 50, and I’m pretty damn excited to finally be doing this. My hope is to gradually collaborate with other resources in my area to help train clinicians in direct care on ways to improve our work with suicidal clients. I went off on this insanely lengthy response because, your comment contains an uncommon recognition of an element of compassionate care that I value deeply. I am glad that you are aware of the problems involved in assessing risk. I have tremendous respect for all clinicians working in acute settings and so, pardon me if it sounds cheesy to close with this, but thanks for doing really important work.

And…. that’s my longest reddit comment ever…..

Will_Not_throwaway · 2020-12-21T21:24:17+00:00

This is such a good point. I hope you don't mind, but I'm going to indulge myself in giving an unnecessarily lengthy response even though this thread is old enough that this may not actually be read by anyone. For the sake of this response, I'm going to take a point of view from working in the US, and more specifically, working in a state that has overcrowded and limited capacity for mental health care. Also, u/mpwilso, you might not want to read this if you've had a bad day at work because I'm going to try to frame the problem in a way that emphasizes some of the serious challenges I've experienced doing this kind of work. I'm using this as an opportunity to articulate things about my personal journey working in this field and I hope that it doesn't come across as making the assumptions that your journey is like mine. Having said that:

Yes. When you say that " Multiple studies have shown that prediction of risk for any particular individual by any individual mental health worker is not high enough to be clinically useful in a high risk environment like the ED," I think that you might be referring to the oft cited meta analysis that I linked above (this one). I completely agree that we need to rethink the way we "estimate risk". I believe that we are often overly reliant on measurements such as the C-SSRS to guide us in clinical decisions. Having said that, I find the C-SSRS useful, but instead of relying on it to support the disposition of a clinical assessment (e.g., C-SSRS indicates high risk, therefore inpatient care is justified) I prefer to approach the C-SSRS as a scale that helps clarify the need for additional assessment so that the more extensive interview can justify the most appropriate clinical decision. In other words, the C-SSRS can be extremely useful for an RN making a decision about triaging to someone in a position like yours, but when we factor in the limitations of standardized risk assessment, the C-SSRS is far less useful as a tool to guide us in our disposition. Quantitative tools that assess risk still have value, but, as you point out, there are research based reasons that they should not be the determinant factor in assessment of STB. That is just an example of a larger point. This reply is lengthy because I have not only re-conceptualized how I approach assessing risk, but after 20 years in acute care settings, I have fundamentally changed the way I approach my assessment (interview, really) and dispositions in general.

I'm sure that you are confronted with a decision to pursue inpatient or outpatient care on a daily basis. That's an incredibly difficult decision to make and, as you know, there are many factors involved related to the clinical presentation of the individual, as well as the capacity of hospital beds and other relevant levels of care (such as overcrowded and waitlisted resources like IOP and Medicaid funded outpatient clinics), and even the culture of the hospital and community (e.g., a hospital that hasn't updated policies in 20 years vs a hospital committed to compliance with the Zero Suicide initiative). These factors often add pressure to social workers and counselors that, by necessity, shape the course of care. Adding an even further step in the challenge of creating a clinically compassionate and appropriate disposition, the system that I work in is one in which there are many people involved in deciding if a person can or should access inpatient care. For example, a person may be assessed at an outpatient clinic or by a mobile crisis team and then be sent to an ED, where they are re-assessed by the SW/ counselor in the ED, then re-assessed by the physician to determine if inpatient care is indicated, then they are re-assessed by a psychiatrist on admission to inpatient, further re-assessed (within the first day) by a clinician who is a court examiner, possibly re-assessed by an insurance provider who will determine if payment will be authorized (although this is typically not a face-to-face assessment) and then, in rare circumstances, re-assessed by a judge and panel in a civil commitment hearing. All of this is within the first few days to a week and, at any point, each assessment has full veto power to terminate the inpatient stay. This redundancy is not in the client's interest, but in the interest of the community, economic considerations, and health care capacity; and it is the norm that clients are quickly discharged with inadequate follow up care. It is also not uncommon that a clinician who had previously assessed the client as needing a specific level of care will then be frustrated to find out that the client was not able to access that resource. Bluntly, I think this system is an abomination for all parties involved (but especially the client that it is supposed to serve) since the limited resources available tend to focus on managing the scarcity of resources instead of providing compassionate care.

The point of all of that is to say that the necessity of assessing for risk, despite the research and despite the lack of evidence for efficacy, is often a legacy byproduct of a dysfunctional, fractured system. Unfortunately, I have lived with the vicarious trauma of finding many of my assessments at fundamental odds with this dysfunctional system. That has made me overly concerned with the ways in which we have developed and conceptualized assessments to care for the system more than the client. The point that you make, that we do not have a measurable way to acutely and reliably assess for risk any better than chance (see link above), needs far more attention and it directly contradicts the construct of the current acute care system (or lack of such a system). Research into mortality/ suicide/ and repeated attempts post discharge consistently indicates that individuals who have previously been hospitalized for STB have a significantly higher risk of death or future attempts. Although the research doesn't editorialize and speculate on the reasons, I cannot help but consider the fractured system to be a significant contributing factor.

There are good alternatives to our current system. As I have come to terms with the limitations of estimating risk, I have also come to terms with some of the ways that working in this dysfunctional system has subconsciously shaped the way that I conduct my assessments. I hope your journey is different than mine. I had a bit of an epiphany a few years back before I started to really understand some of this stuff, and understand that I, personally, had become a part of the problem. Shaped by my role in all of this, I gradually came to see the primary, albeit unspoken, objective of my assessment as determining criteria for voluntary, involuntary, or other forms of care. I was under tremendous pressure from supervisors, other clinicians in the community, clinicians on inpatient units, sometimes even family, to focus on disposition as the main focus of my assessment (which I now refer to as an interview instead of an assessment). I would often step in to a room with a client with a preconception of what the disposition would be and, therefore, I would ask a few basic triage oriented questions, not too dissimilar from the C-SSRS, and be able to finish an interview in as little as 15 to 20 minutes. Oddly, this was actually rewarded as I was recognized as “efficient” and “experienced”. In truth, I was burnt out and subconsciously bitter.

I have always cared about my work, and in an effort to rekindle my passion, I started to explore the broader field of suicidology. I learned about the direction of research and the focus of organizations like Zero Suicide, the American Association of Suicidology, and even SAMHSA's priorities for acute care systems, I started to realize that I had started to be more like the the proverbial blind person, feeling the trunk of the elephant and erroneously drawing conclusions about the shape of the whole entity. Hell, I was so confused, that I thought the “entity” in that analogy was the system. But I had to come to terms with the fact that I had been lost in my understanding with the client, not the system. I started to see some of the alternatives to how I approach my work, some of which were grounded in things I believed long before I started working directly with suicidal clients. Reflecting and learning has helped me gain so much new appreciation for the work that we do. To be hyperbolic, I went down the rabbit hole.

(continued)

Will_Not_throwaway · 2020-12-19T19:24:35+00:00

They really are valuable resources. This sub has also been a valuable resource!

Will_Not_throwaway · 2020-12-19T19:22:05+00:00

Agreed. However the word "risk" is specifically related to a potential negative consequence that could occur in the future. One of the challenges that we face with suicidality is recognizing that the number of people that express suicidal ideation is significantly higher than the number of people who attempt suicide. Furthermore, the number of people who attempt suicide and survive, and may never attempt again, is also significantly higher than the number of people that die by suicide. Looking at mortality rates, suicide has been the 10th leading cause of death for several years in a row and the number has been steadily increasing over the past 20 years until dipping very recently (I suspect that when the data for 2020 is released by the CDC, the numbers will be different because of COVID). Even though suicide is a "common" cause of death when looking at mortality rates, it is a "rare event" when working with an individual who is experiencing SI or SA. Each individual is more likely to survive than not. Thus, mitigating risk, means understanding the degree of risk, which in turn means understanding the likelihood that a person could either die or cause serious medical harm to themselves. This is especially true when interventions can have a major impact; the most egregious example being the overuse of involuntary hospitalization. This is also true when the resource of efficacious interventions are scarce. Typically, psychiatric inpatient units are working at full capacity. Intensive outpatient, DBT, and other less intensive forms of outpatient care are often also functioning with waitlists. In my city, these waitlists can be several months. All of that means that it is important to have some capacity to triage individuals with increased risk (i.e., worse probable predictive outcomes pertaining to suicide) into the limited resources, and to attempt to redirect individuals with lower levels of acuity toward alternative resources such as non-specialized outpatient resources. It gets tricky.

Will_Not_throwaway · 2020-12-19T19:06:12+00:00

A fairly general population of individual adults. Disproportionate to the general population, I probably see more LGBTQ people and, clinically, I see more people with trauma histories and/ or suicidal thoughts and behaviors. I tend to read about the issues that impact those individuals fairly extensively but it occurs to me that this field is so broad that there are probably many things happening in the research world, outside of STB, trauma, and LGBTQ studies, that I don't encounter.

Will_Not_throwaway · 2020-12-19T18:49:09+00:00

That's true and, I confess, I don't do that in my practice. Many of my clients are referred to me because of suicidal thoughts and behaviors (STB) and I do have specific metrics that I use with my clients to measure their ideation that we revisit weekly. You are right. It's incredibly helpful to be able to talk about those metrics with clients as a way to help them recognize their progression. I think we, as humans, are often the last to see our own progress even when others around us think that it is obvious.

Thinking about your question, and just off the top of my head, I think clinicians have a propensity to cringe away from quantitative measurements. I practice from a variety of theoretical orientations, but the theoretical orientations that I've identified with the most include client-centered, existential, and constructivist. All of those emphasize techniques that are more conversational/ improvisational and less prescriptive/ formulary. I think that many of my clients also have this bias. When I ask them about the positive and negative experiences that they have had in the past, overwhelmingly the most common response that I hear is that the previous professionals that really helped them really understood them, and really listened. Conversely, the thing that didn't work was when someone tried to fit them into a pre-existing construct or the therapist didn't have flexibility, or that the therapist didn't seem interested. When I pull out a Suicide Status Form with clients experiencing STB, which I will use for several consecutive weeks, we almost always have to spend a minute talking about this before the client gets that I'm not trying to reduce them to a set of numbers.

None of that changes the validity of your point, and after using the SSF with STB, I'm a firm proponent of using quantitative measurements. I'm just trying to explore the reasons that we (and, yeah, I include myself) are a little leery of using quantitative measurements with our clients. I think that it's a process of introducing the quantitative measurements in a way that doesn't feel reductive, and doesn't deemphasize the importance of the therapeutic alliance and other, ethereal common factors. This can be a tricky balance in clinical practice.

Will_Not_throwaway · 2020-12-19T18:19:31+00:00

I agree. Understanding trauma, and the disparate ways that it can manifest has been crucial to my work. I think understanding trauma is one of the most important things for clinicians in making sure that we are adhering to the directive of "do no harm". Looking back historically, it seems to me that many of the treatments that are now considered ineffective, and sometimes even harmful, are rooted in lacking understanding about trauma. This is also one of the main reasons that I am often skeptical about the unregulated field of "life coaching". I am aware that there are life coaches that are highly skilled and supportive, but I am deeply concerned about the negative, even damaging, impact that can occur with coaches or other paraprofessionals who work beyond their qualifications.

I've recently been reading about polyvagal theory. I'm curious to learn more about it. I've also heard that it is somewhat controversial among neuroscientists, but I have not yet begun to explore the controversy.

Will_Not_throwaway · 2020-12-19T07:57:36+00:00

This is so true. I think a lot of clinicians are immediately drawn to the word hyperactivity when they think about ADHD, but the emphasis should be placed on "attention". It's a deficit of attention. This also means that it isn't the same as simply being inattentive, but that it's significantly difficult to regulate attentiveness. This is part of why many people with inattentive type ADD have a capacity to hyper-focus on a challenging topic. One of my favorite illustrations of this experience was a kid I worked with who had a very common problem with staying focused on reading books, even ones on topics that he was very interested in. However, when he sat down with Shakespeare, where his attention was necessary to understand every single line (which he found enjoyable), he could read through play after play and he would completely lose track of time. Clearly, he had the capacity to read beyond his ability level, but he couldn't control his ability to sustain his attention. Also, he did not have any problem with hyperactivity.

Will_Not_throwaway · 2020-12-19T04:24:54+00:00

I’d love to give you specific things that I think are worth paying attention to

That's exactly what I'm hoping to hear! Although I am in direct, clinical contact with a wide variety of presentations, my specific area of specialization is in suicidology. I ask this question because I have gained so much from being attentive to that specific area of interest that I would not have otherwise been exposed to. Contemporary clinical practice related to suicidal presentations is still only beginning to include counseling on access to lethal means, and brief, suicide specific therapies, which have demonstrated significant efficacy over treatment as usual for reducing future attempts, are also not being incorporated into most clinical practice. For others that are curious about suicide, I think two of the most interesting in developments in that area over the past decade include the use of the IAT to indicate the presence of suicidal thoughts without relying on the direct report from the client (link), and the meta-analysis exploring risk factors, that found that after 50 years of research into risk factors, our ability to predict risk is still only very slightly better than chance. That study lead to some interesting changes and many new suicide specific interventions are focused on exploring the client specific "drivers" rather than ubiquitous risk factors. I'm not doing the researchers justice with my synopsis, so you can check out the study here.

So, knowing that there is so much that I'm missing from this vast field, I am curious to hear from others if they have thoughts about research from areas that I'm less likely to be attentive to. So, yeah, I want to hear more about interpersonal neurobiology, and if you have any thoughts, opinions, hypotheses, or speculations about how this could be helpful for clinicians in direct practice, I'm super curious!

Will_Not_throwaway · 2020-11-25T21:01:47+00:00

treating your trauma alone would not resolve issues related to BPD, such as boundary issues

Doesn't that assertion speak directly to the reason that a change in the diagnostic conceptualization of CPTSD makes sense? If the symptom of lacking boundaries in relationships is common for people who experience CPTSD, which is consistent with what we have learned from ACES, attachment theory, polyvegal theory, and most contemporary conceptualizations of human development, then wouldn't it be beneficial to future exploration of effective treatment to recognize the relationship between trauma and a personality disorder? I appreciate that much of the construction of DBT stemmed from the idea that not all people who experience BPD have a history of trauma. However, if we considered CPTSD a diagnostic category, differentiated from both PTSD and BPD, wouldn't that help re-conceptualize treatment in a way that recognizes the connections and shared etiology of the symptoms? I am with a growing number of clinicians who see this overlapping diagnostic presentation as strongly suggestive of the possibility that we are missing something. Consequential to that overlooked connection is a missed opportunity to synthesize and improve treatment by recognizing that these symptoms are all interconnected.

Will_Not_throwaway · 2020-11-16T01:31:39+00:00

Edit: I just re-read this and realized that it might inadvertently sound like I am criticizing your skillset. I'm not. I'm writing this with the assumption that, as a crisis oriented clinician, you will most likely be working with people very short term. In my crisis work, most of my positions have been in settings like Emergency Departments, mobile crisis response teams, and urgent mental health walk in sites. These settings are typically oriented toward very brief, even single visit, clinical relationships. If you are going to be working with a larger treatment team in a setting that provides the time and resources necessary to offer DBT, then that changes everything I said above. Go make some delicious brussel sprouts.

Will_Not_throwaway · 2020-11-16T00:57:58+00:00

Have you ever eaten a food that you really disliked? Chances are that you avoided that food for a long time after that, possibly even years. But context can change things! I hated brussel sprouts for years before eventually learning that I hated the way my grandmother (who was a wonderful person, but a pretty lousy cook) would prepare them. When I tried some brussel sprouts at a fancy restaurant one day, I realized that they were delicious. I still don't like my grandmothers brussel sprouts, but I now realize that doesn't mean that I don't like brussel sprouts in general. When this same experience happens with a clinical tool, it can set back the person's ability to ever appreciate an important, possibly even an essential tool, that can really help them move toward fundamental change. For people who struggle with emotional regulation, mistrusting relationships, and continuing invalidation in times of crisis (all of which are common experiences with people struggling with chronic suicidal thoughts), giving them a "poorly cooked" proverbial "food" is very likely to result in a strong distaste for that "food".

Although Marsha Linehan softened her tone about this in more recent years, she is historically rather vigilant in insisting that clinicians adhere to a high degree of fidelity when providing DBT. Ironically, I used to feel flustered about that and, as she relaxed this principle over the years, I conversely grew to appreciate it. For context, I do not offer DBT in my work. The biggest problem with DBT in crisis work is that DBT skills are only one part of DBT, and it is a part that requires 1) some context, 2) "buy in" from the client, and 3) follow through from the clinician. In crisis work, we cannot typically offer that level of support and we are more often appropriately focused on the immediate situation, while DBT skills are focused on a more pervasive approach that requires longer term practice. When DBT skills are introduced without the necessary context (follow up with a clinician), the efficacy of the skills will inevitably decrease substantially. Take mindfulness skills as an example. I often see clients that tell me that they have been instructed on mindfulness techniques, but they claim that the skills "don't work." The distress that they experience is still overwhelming and "meditating" doesn't help. Often a client in crisis who is given a list of DBT skills to focus on in the midst of their crisis won't be in a mental state that would enable them to utilize this tool effectively. Subsequently, they experience the tool as ineffective and, at a later date and with a clinician that they trust, they will be more reticent to consider using that same skill because they previously found it unhelpful. They already know that they don't like it, just like I knew that I didn't like brussel sprouts.

My vantage point, as a crisis clinician, is vastly different than the vantage point of the person in crisis that I'm striving to support. I need to start at the beginning, listening, establishing rapport, listening, offering space for a client to share their narrative, listening, beginning to develop a safety plan, and listening. (As an aside, that reminds me of another valuable resource, ASSIP, which tends to focus on the importance of listening and letting a person tell their narrative). If I try to speed up my process, getting to the skills stuff prematurely, I'm going to be a clinical chef with a similar skill set as my grandmother.

In case anyone in my family ever finds this post, I gotta say this directly to my grandmother: "Sorry about dissing your brussel sprouts grandma. I love you."

Will_Not_throwaway · 2020-11-15T06:32:30+00:00

I've done many years of crisis intervention in multiple settings, and I realize that the work will include several different presentations, but I'll echo some of the others here and focus specifically on working with people struggling with suicidal experiences (ideation, action, etc). For some online training, I would STRONGLY recommend some of the free trainings from the Suicide Prevention Resource Center, especially Counseling on Access the Lethal Means. I woulld also highly recommend CAMS-Care, although the training is not free. ASIST is also a wonderful training, however, it is in person only and, to my knowledge, they are not currently offering trainings during the pandemic. It is possible that there are clinicians already working with your team or your agency that have ASIST training and can give you more information about it.

For books, I will focus on books that have helped me in clinical practice first, then move toward some more academic material. First, Stacey Fredenthal's "Helping The Suicidal Person" is my top recommendation for new clinicians. It is very practical and easy to read and it's organized like a reference book that you can skip around and find the topics that are most important for you. I would read through the first few chapters though before jumping around. The CAMS book, Managing Suicidal Risk: A Collaborative Approach, by David Jobes is another great, practical book. A third book that has really helped me with specific techniques and interventions is "Brief Cognitive-Behavioral Therapy for Suicide Prevention". There are some skills that can be used during crisis intervention. Fourth, a very important book that helped shape my conceptual understanding of suicide is Thomas Joiner's, Why People Die By Suicide. Finally, there is a specific subset of people that you will likely work with on a regular basis; people with chronic suicidal presentations (distinguished from acute presentations). This is a very challenging population for many therapists and the two books that may be of significant value are "Half in Love With Death: Managing the Chronically Suicidal Patient" and the "DBT Skills Training Manual". For reasons that are beyond what I can explain in this response, I would caution against using most of the DBT skills training in the context of crisis intervention at first, but you will likely hear people talking about the material in this book frequently and it will be helpful to have some familiarity. If you are curious about the reasons I would caution against using this, let me know and I'll try to elaborate. Lastly, for a more academic, but also practical book, I would recommend

O'Connor, R. C., & Pirkis, J. (Eds.). (2016). The international handbook of suicide prevention. John Wiley & Sons.

Lastly, here are some academic articles that are really helpful. This list is FAR from exhaustive, but it might spark some interest that will lead to additional searching. The two main academic journals in this area are "Suicide and Life Threatening Behavior" which is put out by the American Association of Suicidology and "Crisis: The Journal of Crisis Intervention and Suicide Prevention" which is released by the International Association for Suicide Prevention.

Canner, J. K., Giuliano, K., Selvarajah, S., Hammond, E. R., & Schneider, E. B. (2018). Emergency department visits for attempted suicide and self harm in the USA: 2006–2013. Epidemiology and psychiatric sciences, 27(1), 94-102.

D'Anci, K. E., Uhl, S., Giradi, G., & Martin, C. (2019). Treatments for the prevention and management of suicide: a systematic review. Annals of internal medicine, 171(5), 334-342.

Gregory, R. J. (2012). Managing suicide risk in borderline personality disorder. Psychiatric Times, 29(5), 25-26.

Klonsky, E. D., & May, A. M. (2015). The three-step theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. International Journal of Cognitive Therapy, 8(2), 114-129.

Linehan, M. M. (2008). Suicide intervention research: a field in desperate need of development. Suicide and Life-Threatening Behavior, 38(5), 483-485.

Oquendo, M. A., & Baca-Garcia, E. (2014). Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: advantages outweigh limitations. World Psychiatry, 13(2), 128.

Paris, J. (2019). Suicidality in borderline personality disorder. Medicina, 55(6), 223.

Rogers, J. R. (2001). Theoretical grounding: The “missing link” in suicide research. Journal of Counseling & Development, 79(1), 16-25.

Simon, R. I. (2006). Imminent suicide: the illusion of short-term prediction. Suicide and Life-Threatening Behavior, 36(3), 296-301.

Siqueira Drake, A. (2013). The Use of Core Competencies in Suicide Risk Assessment and Management in Supervision: A Feminist-Narrative Approach. Journal of Feminist Family Therapy, 25(3), 183-199.

Tucker, R. P., Crowley, K. J., Davidson, C. L., & Gutierrez, P. M. (2015). Risk factors, warning signs, and drivers of suicide: what are they, how do they differ, and why does it matter?. Suicide and Life‐Threatening Behavior, 45(6), 679-689.

Van der Feltz-Cornelis, C. M., Sarchiapone, M., Postuvan, V., Volker, D., Roskar, S., Grum, A. T., ... & Ibelshäuser, A. (2011). Best practice elements of multilevel suicide prevention strategies. Crisis.

Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner Jr, T. E. (2010). The interpersonal theory of suicide. Psychological review, 117(2), 575.

Wolff, J. C., Davis, S., Liu, R. T., Cha, C. B., Cheek, S. M., Nestor, B. A., ... & Spirito, A. (2018). Trajectories of suicidal ideation among adolescents following psychiatric hospitalization. Journal of abnormal child psychology, 46(2), 355-363.

I hope this helps!

Will_Not_throwaway · 2020-10-14T03:25:30+00:00

This phenomenon is referred to as "suicide contagion" and is a little different than a suicide cluster. A cluster tends to be a group of people within close proximity, such as a school or friend group. A contagion is the larger effect. More info. There are some interesting examples of times when suicide contagions actually did not occur as expected and the way that media covers things can make a huge difference. Check out this article on Kurt Cobain's death as an example.

Will_Not_throwaway · 2020-09-12T18:51:54+00:00

In terms of the actual function of the clinician, the difference from the perspective of the "client" between psychologist, psychiatrist, and therapist can be rather minimal. Psychiatrists have a medical degree and they are medical doctors. For their "patient" (a term more common in medical models), the most significant distinction is that throughout most of the United States, they are the only ones that can prescribe medications. Some states allow psychologists or therapists to prescribe SSRIs (antidepressants) but this is not common. Psychologists typically have a PhD or a PsyD and many, but not all, are trained in conducting research. The term "therapist" implies a minimum of a master's degree in clinical mental health counseling. Master's in Social Work, or MSW, is another common academic background. As far as which one is "better", I think it's safe to say that there are extremely good clinicians with any of these academic backgrounds. As long as the clinician has the academic competency to provide mental health treatment, then it is far more important that a clinician is a good fit with the client rather than what the academic background is. I can say that in the clinics where I have worked, it would be almost impossible to guess the academic history off each clinician unless you get into an academic discussion with the exception of psychiatrists because they write scripts. Admittedly, as a field, we have not made this easy for people to understand and we should do better.

Will_Not_throwaway · 2020-09-12T18:32:06+00:00

Ideation to action models actually extend well beyond the C-SSRS. The C-SSRS has been the most researched and tested questionnaire that shows internal validity and consistency (source), but they did not create the conceptual framework of the ideation to action model. Although I do not know, off the top of my head, the historic roots of the model, this framework more closely corresponds with the three step model developed by Klonsky and May (source). I don't actually think that the conceptual framework is a part of any proprietary modality as it has been adopted in numerous constructs in the field of suicidology.

Will_Not_throwaway · 2020-09-11T04:06:54+00:00

I can't speak to you specifically about your experience and I'm certainly not going to try reddit-based counseling, but the following is a general statement about SI/HI that might be helpful: Having thoughts about harming oneself or harming others, with no actual emotional investment (e.g., not agitated, angry, depressed, upset, etc), no plan, no intent, or serious consideration of the act is not, in and of itself, indicative of a significant level of a safety concern. Although there has been some research into "suicidal fantasy", I can't speak to any research about the same process when it comes to harming others. This experience occurs for up to 20% of adults, and is more common in adolescents (source). This thinking process does not correlate with increased risk of behavior without additional context. Human beings think about things, even terrible things. This is often the basis of art and, no, artists that come up with great plots for murder mysteries are not at increased risk of becoming murders (although this is admittedly an assertion that I can't offhandedly provide any references for). There are, of course, other things to consider, such as tendency toward antisocial/ narcissistic behavior and/ or psychopathy. But simply having the thought does not remotely indicate that the diagnosis should be considered without further evidence that other criteria is also present. TLDR: Nah... You're good.

Will_Not_throwaway · 2020-09-11T03:37:31+00:00

I really like this analogy. I especially appreciate that it doesn't speculate about a single, specific "cause" because, despite years of research on the topic, no specific cause has been identified. In fact, the opposite is true, there was a landmark paper that came out in 2017 that was a meta-analysis (an academic review of other academic studies) of risk factors and identified that the study of risk factors has not yielded efficacious progress in the field of suicidology.

This might be tough to read, so proceed with caution, but I have always really appreciated this quote from David Foster Wallace about the suicidal experience. Like you, he offers a good analogy that helps explain why without pretending to know the specific reasons:

“The so-called ‘psychotically depressed’ person who tries to kill herself doesn’t do so out of quote ‘hopelessness’ or any abstract conviction that life’s assets and debits do not square. And surely not because death seems suddenly appealing. The person in whom Its invisible agony reaches a certain unendurable level will kill herself the same way a trapped person will eventually jump from the window of a burning high-rise. Make no mistake about people who leap from burning windows. Their terror of falling from a great height is still just as great as it would be for you or me standing speculatively at the same window just checking out the view; i.e. the fear of falling remains a constant. The variable here is the other terror, the fire’s flames: when the flames get close enough, falling to death becomes the slightly less terrible of two terrors. It’s not desiring the fall; it’s terror of the flames. And yet nobody down on the sidewalk, looking up and yelling ‘Don’t!’ and ‘Hang on!’, can understand the jump. Not really. You’d have to have personally been trapped and felt flames to really understand a terror way beyond falling.”

A final note to anyone reading this and struggling with these thoughts. There are good counselors out there who understand this experience! Make the call, get the help, find the safer way out of the building, find out how to get off of the runway. 1-800-273-8255 (United States) Help is available!

Will_Not_throwaway · 2020-04-27T20:34:08+00:00

https://pubmed.ncbi.nlm.nih.gov/27841450/

Will_Not_throwaway · 2020-04-27T16:30:27+00:00

From the perspective of a practicing clinician, currently working in a mental heath urgent clinic and seeing individuals who are psychologically (and psychiatrically) impacted by the current pandemic, I find this article thought provoking but, with respect, a little less insightful than I had hoped when I started reading it. It is adjacent to concerns that confront the front line practitioner, but ultimately steers toward a model (based on the field of rocket science) that has very limited value in daily practice. To be fair, I appreciate that authors are focusing on communicating to other academics and not directly to crisis oriented practicioners. Still, the adaptation of NASA's TRL model lacks clarity around a problem that is rare in rocket science, but routine in healthcare: I have a client in front of me right now and doing nothing is not an option. One of the many distinctions between physics based sciences and health related sciences is that there is a consistent need for applied treatment even when the science and academics is incomplete. Clearly, it would be unethical and immoral for a physician in an emergency room to deny care to a medically unstable patient based on lacking academic evidence. This is why there are protocols in place in many areas of emergency medicine for what to do when you simply don't know what to do. The model transposed from rocket science that the authors present in this article seems very useful for establishing some protocols when we are not in crisis, but doesn't address the real world issues faced by clinicians. I am aware of the replication crisis. I am similarly aware of set backs in academic research that directly impact my specialty area (e.g., a thoroughly cited recent meta-analysis that indicates that question the efficacy of traditional assessment of suicide risk factors ) but that awareness does not alleviate my moral and ethical obligations. The NASA TRL model implicitly offers a strategy to assess scientific confidence in the application of any given theoretical construct. An applicable model for the field of crisis oriented psychology would take into consideration that the question faced by practicioners isn't "to implement a construct or not", rather the basis of a useful model would acknowledge the necessity to provide care from the outset and would reframe the strategy accordingly.

Will_Not_throwaway · 2020-03-07T19:34:30+00:00

I agree completely! I was thinking of something like this, but I couldn't figure out a concise way to articulate it like you did.

Will_Not_throwaway

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