Matthew Wintersteen, Ph.D., returned to the FCP Behavioral Health Workshop series with “Clinical Approaches to Youth Suicide Screening and Brief Intervention.” As in the past, his easygoing and relaxed style allowed his mastery of the material to quickly become evident. Using appropriate humor (considering the topic), and quickly moving through any material that may have otherwise been redundant for most of the audience, Dr. Wintersteen’s three-hour presentation went by quickly.

Learning Objectives Included:

1. Identify warning signs for youth suicide
2. Utilize evidence‐based approaches while collecting valid data on suicide risk
3. Implement an evidence‐based approach to suicide risk assessment
4. Conduct an evidence‐based safety plan for youth at risk for suicide

These goals were easily met.

Dr. Wintersteen began the workshop by “debunking” seven common myths about suicide.

Myth #1: Suicides happen without warning

• Most people who attempt or die by suicide have communicated their distress or plans to at least one other person.

Myth #2: Suicide is an act of aggression, anger, or revenge

• Most people who kill themselves do so because they feel they do not belong or are a burden on others.

Myth #3: Talking about suicide makes people more likely to kill themselves

• Talking about suicide gives one an opportunity to express thoughts and feelings about something they may have been keeping secret.

Myth #4: People who talk about suicide are not serious about killing themselves

• Many people who are considering suicide tell others about these thoughts.

Myth #5: Suicidal thoughts and behaviors are ways to get attention

• Take any mention of suicide or suicidal behavior seriously regardless of your thoughts about their true motives.

Myth #6: Suicidal teens overreact to life events

• Problems that may not seem like a big deal to one person, particularly adults, may be causing a great deal of distress for the suicidal teen.

Myth #7: Suicide cannot be prevented

• Most people are acutely suicidal between 24-72 hours. Providing help and intervention during this time makes it less likely that they will make another attempt.

Statistically, Dr. Wintersteen reported that:

• Suicide is the 2nd leading cause of death from birth to age 46
• 78% of all U.S. suicides are, men with 89% white men
• Woman make 3 times as many attempts as men
• Suicides decreased in 2o2o by almost 5% overall, but increased for some minority populations.
• 82% of suicides in the United States are high school age boys

Dr. Wintersteen emphasized that restricting lethal means for those at risk and developing a safety plan, substantially reduces successful suicides.

He discussed warning signs for youth suicide including:

1. Talking about or making plans for suicide

2. Expressing hopelessness about the future

3. Displaying severe/overwhelming emotional pain or distress

4. Showing worrisome behavioral cues or marked changes in behavior, particularly in the presence of the warning signs above. Specifically, this includes significant:

• Withdrawal from or changing in social connections/situations
• Recent increased agitation or irritability
• Anger or hostility that seems out of character or out of context
• Changes in sleep (increased or decreased)

Dr. Wintersteen presented tips for collecting valid data when working with individuals at risk for suicide. These tips (Shea, 2002) include:

1. Any hesitancy may = suicidal thoughts, even if followed by denial of these thoughts.

2. “No, not really” may = SI, but clinician may not be interested due to lack of serious consideration

3. Pay attention to body language indicative of deception or anxiety

4. Taking notes during assessment may = clinician disinterest

• The clinician can document the assessment while also reviewing the accuracy of the information during a summary

5. Avoid any evidence of personal discomfort during the assessment interview.

6. Avoid appearing hurried

• Individuals with borderline personality disorder, in particular, may be thrown into a state of emotional dysregulation when feeling rushed (Linehan, 1993).

Dr. Wintersteen provided 6 key points specific to adolescents:

1. Confidentiality limitations

• Ethical obligation to inform, and the adolescent’s and parents’ right to know, about the limits of confidentiality prior to conducting any interviews.
• Developing a strong therapeutic relationship may help reduce an adolescent’s underreporting and improve help seeking behaviors.

2. Strengthening interpersonal connections is a developmental marker of adolescence, thus their ability to talk about interpersonal experiences and to do so in an interpersonal context may be underdeveloped.

3. It can be helpful to talk about the adolescent’s fears of disclosing how he or she really feels.

4. Emphasize a team approach to managing the crisis.

5. Clinicians should always model hopefulness.

6. Do not be afraid to say the word “suicide”

As part of this section, Dr. Wintersteen also discussed interview techniques to use when interviewing youth at risk for suicide.

Dr. Wintersteen presented the items that should be included in a suicide risk assessment. The discussion started with a brief psychosocial assessment which included a question about the youth’s mood. In fact, he said that if he were limited to one question it would be about mood.

While I usually do not include the presenters slide information in detail, the importance of this topic requires an exception. Dr. Wintersteen presented the work of Joiner et al. (2009) as the model for suicide risk assessment. The assessment includes:

Assess Suicidal Desire and Ideation

1. Have you been having thoughts or images of suicide?

2. Do you think about wanting to be dead?

3. Thwarted Belongingness Do you feel connected to other people? Do you have someone you can talk to when you are feeling bad?

4. Perceived Burdensomeness Sometimes people think, “the people in my life would be better off if I were gone.” Do you ever think that?

Assess Resolved Plans and Preparations

5. When you have these thoughts, how long do they last (duration)?

6. How strong is your intent to kill yourself (0 = not intense at all; 10 = very intense)?

7. Past suicidal behavior:

• Have you attempted suicide in the past?
• How many times?
• Methods used?
• What happened (e.g., hospitalization)?
• Feelings about past attempts?
• Non‐suicidal self‐injury?
• Family history of suicide?

8. Do you have a specific plan of how you would kill yourself?

• Look for vividness and detail

9. Means and opportunity:

• Do you have the pills (gun, etc.)?
• Do you think you’ll have the opportunity to do this?

10. Have you made preparations for a suicide attempt (e.g., buying gun)?

11. Do you know when you expect to use your plan?

12. Fearlessness:

Thinking about suicide, do you feel afraid (0 = very afraid; 10 = not at all afraid)?

Assess Other Significant Findings

13. Precipitant stressors: Has anything especially stressful happened to you recently?

14. Do you feel hopeless?

15. Impulsivity:

• When you’re feeling bad, how do you cope?
• Sometimes when people feel bad they do impulsive things to help them feel better. Has this ever happened to you?

16. Presence of psychopathology

• As indicated by psychiatric assessment

Dr. Wintersteen mentioned that there is often a time period between suicide risk assessment and mental health treatment. He strongly advised against the use of a Safety or No-Suicide contract as dangerous. These contracts do not protect anyone from the responsibility to protect the youth and may provide a false sense of assurance to the clinician. Dr. Wintersteen presented a safety plan which he uses as a model to be developed with the youth and the clinician side by side. This plan is presented below.

Step 1:

Recognizing Warning Signs

• Safety plan is only useful if youth can recognize the warning signs
• Accurate account of the events that transpired before, during, and after the most recent suicidal crisis
• “How will you know when the safety plan should be used?”
• “What do you experience when you start to think about suicide or feel extremely distressed?”
• Write down the warning signs (thoughts, images, thinking processes, mood, and/or behaviors) using the youths’ own words

Recognizing Warning Signs Examples

• Thoughts
  • “I am a nobody.”
  • “I am a failure.”
  • “I don’t make a difference.”
  • “I am worthless.”
  • “I can’t cope with my problems.”
  • “Things aren’t going to get better.”
• Images
  • Flashbacks
• Thinking Processes
  • “Having racing thoughts”
  • “Thinking about a whole bunch of problems”
  • Mood
  • “Feeling depressed”
  • “Intense worry”
  • “Intense anger”
• Behavior
  • “Crying spells”
  • “Isolating myself”
  • “Using drugs”

Step 2: Using Internal Coping Strategies

List activities that youth can do without contacting another person. Activities function as a way to help youth take their minds off their problems and promote meaning in the youth’s life.

• Coping strategies prevent suicidal ideation from escalating
• It is useful to try to have youth cope on their own with their suicidal feelings, even if it is just for a brief time
• “What can you do, on your own, if you become suicidal again, to help yourself not to act on your thoughts or urges?”
  • Examples
  • Going for a walk
  • Listening to music
  • Playing an instrument
  • Take a hot shower
  • Walking the dog
• Ask “How likely do you think you would be able to do this step during a time of crisis?”
• Ask “What might stand in the way of you thinking of these activities or doing them if you think of them?”
• Use a collaborative, problem solving approach to address potential roadblocks

Step 3: Socializing with Family Members or Others

Coach youth to use Step 3 if Step 2 does not resolve the crisis or lower the risk. Family, friends, and acquaintances who may offer support and distraction from the crisis.

• Ask “Who do you enjoy socializing with?”
• Ask “Who helps you take your mind off your problems, at least for a little while?”
• Ask youth to list several people in case they cannot reach the first person on the list

Step 4: Contacting Family Members or Friends for Help

Coach youth to use Step 4 if Step 3 does not resolve the crisis or lower risk

• Ask “How likely would you be willing to contact these individuals?”
• Identify potential obstacles and problem solve ways to overcome them
• WARNING: Always include adults on the list!

Step 5: Contacting Professionals and Agencies

Coach youth to use Step 5 if Step 4 does not resolve the crisis or lower risk

• Ask “Which clinicians should be on your safety plan?”
• Identify potential obstacles and problem solve ways to overcome them
• List names, numbers, and/or locations of
• Clinicians • Urgent care centers
• Local Crisis Number
• National Suicide Prevention Lifeline
• 1‐800‐273‐TALK (8255) (press “1” if veteran)

Step 6: Reducing the Potential for Use of Lethal Means

Ask youth what means they would consider using during a suicidal crisis. Regardless, the clinician should always ask whether the patient has access to a firearm. For methods of low lethality, clinicians may ask youth to remove or restrict their access to these methods themselves.

• For example, if youth are considering overdosing, discuss throwing out any unnecessary medication

For methods of high lethality, collaboratively identify ways for a responsible person to secure or limit access

• For example, if youth are considering shooting themselves, suggest that they ask a trusted family member to store the gun in a secure place.

Implementation: What is the Likelihood of Use?

1. Ask: “Where will you keep your safety plan?”

2. Ask: “How likely is it that you will use the Safety Plan when you notice the warning signs that we discussed?”

3. Ask: “What might get in the way or serve as a barrier to your using the safety plan?”

• Help the youth find ways to overcome these barriers
• May be adapted to brief crisis cards, cell phones or other portable electronic devices, must be readily accessible and easy‐to‐use.

Implementation: Review the Safety Plan Periodically

• Periodically review, discuss, and possibly revise the safety plan after each time it is used
• The plan is not a static document
• It should be revised as youth’s circumstances and needs change over time

Dr. Wintersteen provided resources for safety plan templates and apps available online and in .pdf formats.

This was a very successful workshop, as evidenced by the number of “thanks” and other positive comments in the chat area during and after the workshop. Yes, FCP is still presenting webinars due to the continued pandemic. Despite the online format and some brief technical difficulties, there appeared to be high energy with the participant questions. Dr. Wintersteen answered each question promptly and completely. I felt that this was one of the better workshops on this topic I have attended. What were your thoughts?