State of the art early on. Today the field is exploding. Joiner s Interpersonal Theory

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1 Suicide Preventio n Lab State of the art early on Psychological autopsy studies of completed suicides Innovations in Clinical Suicidology: CAMS as an Alternative Model David A. Jobes, Ph.D., ABPP Professor of Psychology Associate Director of Clinical Training Director of the Suicide Prevention Laboratory The Catholic University of America Oslo, Norway September 15, 2017 Establishing the key role of psychopathology and suicide The epidemiology of suicide and suicidal behaviors Youth suicide focus (Secretary s Task Force) The birth of the suicide survivor movement Routine use of lengthy inpatient hospitalization Routine use of no-suicide contracts commitment to safety Today the field is exploding Suicide research is increasing exponentially VA and DOD are spending multi-millions on suicide prevention State legislation requiring suicide-specific training for mental health professionals continuing education (e.g., Washington) The potential impact of the lived-experience and attempt survivor movement National Action Alliance (Clinical Care Task Force Zero Suicide movement to raise the standard of clinical care) An increasing emphasis on evidence-based treatments What is Clinical Suicidology? Clinical theories that help guide practice The clinical assessment of suicidal states The clinical treatment of suicidal states Professional training in clinical care of suicidal patients Suicide-specific clinical risk management across systems of care (process-improvement) Ethical and legal considerations of clinical practices related to suicidal risk Shneidman s Cubic Model of Suicide Joiner s Interpersonal Theory Pain (Psychache) Low pain Press (stress)) intolerable high low Perturbation Completed SUICIDE Perceived Burdensomeness Thwarted Belongingness Those Who Are Capable of Suicide Serious Attempt or Death by Suicide (Shneidman, 1987) 1

2 M. David Rudd and Craig Bryan: Fluid Vulnerability Theory (Suicidal Mode, Acute vs. Chronic Risk, and Warning Signs) Integrated Motivational Volitional Model (IMV) O Connor (2011). In O Connor, Platt & Gordon (Eds.). International Handbook of Suicide Prevention: Research, Policy & Practice Wiley-Blackwell Fundamental Assumptions: Baseline risk varies from individual to individual Patients have different levels of vulnerability to a suicidal crisis Vulnerability is manifest across multiple domains Cognitive (impaired problem solving, limited cognitive flexibility, rigidity, distortions) Biological and Physiological (Axis I symptoms) Behavioral/Motivational (deficient coping skills such as selfsoothing, emotion regulation, interpersonal) Baseline risk is determined by static factors You can t escape your history Psychiatric diagnoses, prior attempts, abuse Klonksy & May Ideation-to Action Framework Suicide-Specific Assessment Measures (from Brown, 2001) Scale for Suicide Ideation Beck Scale for Suicide Ideation Modified Scale for Suicide Ideation Self-Monitoring Suicide Ideation Scale Suicide Intent Scale Parasuicide History Inventory Suicide Behavior Questionnaire Suicide Behavior Questionnaire-Revised Suicide Behavior Interview Suicide Probability Scale Positive and Negative Suicide Ideation Adult Suicide Ideation Questionnaire Suicide Ideation Scale Suicide Status Form Firestone Assessment of Self-Destructive Thoughts Risk-Rescue Self-Inflicted Injury Severity Form Lethality Scales Paykel Suicide Items Symptom Driven Diagnostic System for Primary Care (Suicide Items) Assessment Measures Continued Self-Inflicted Injury Severity Form Lethality Scales Paykel Suicide Items Symptom Driven Diagnostic System for Primary Care (Suicide Items) Suicide Ideation Screening Questionnaire Hamilton Rating Scale for Depression (Suicide Item) Beck Hopelessness Scale Beck Depression Inventory (Suicide Item) Linehan Reasons for Living Inventory Brief Reasons for Living Inventory College Student Reasons for Living Suicide Opinion Questionnaire Suicide Potential Lethality Scale Quiz on Depression & Suicide in Late Life Suicide Intervention Response Inventory Mayo Clinic n=105 inpatients (O Connor et al., 2012) 2

3 Mayo Clinic Suicidal Inpatients RFL/RFD Cross Sectional Results (Jobes, Stone, & Wagner, 2010) Suicidal Inpatients n = 108 Mayo Clinic RFL/RFD Cross Sectional Data (n=108) (Jobes, Stone, Wagner, & Lineberry, 2010) Measures RFL AMB RFD Test Beck Hopelessness Scale F = 5.23** Reasons for Living Inventory F = 5.14** WTL/WTD Suicide Index Score F = 18.24*** RFL n = 27 AMB n = 31 RFD n = 28 Missing Data n = 22 Suicide Attempts RFL AMB RFD Test 0-1 Attempts or more Attempts Chi-Sq = 7.83* * p <.05, ** p <.01, *** p <.001 SSF Qualitative Responses and Behavioral Content Rumination (OWL Army sample n=92) Non-Ruminators Diffuse Ruminators Perseverative Ruminators The Relationship Between Qualitative Ruminative SSF Content and Suicide Ideation * Range SSI Scores 10 Frequency n = 46 n = 36 n = Non-repeaters Diffusive Repeaters Perseverative Repeaters Figure 1. Mean suicide ideation scores between groups with no-ruminations, diffuse ruminations, and perseverative ruminations at baseline Between-Group Changes in Suicide Ideation Over Time Suicide IAT Does S-IAT add incrementally to prediction of future suicide attempts? SSI Scores * baseline 12 months Time point non-repeaters diffusive repeaters perseverative repeaters Figure 2. The change in mean suicide ideation scores between groups with no-repetitions, diffusive repetitions, and perseverative repetitions at baseline and 12 months. *Those with death ID were more likely to make an attempt after discharge *IAT added incrementally to prediction of SA beyond diagnosis, clinician, patient, and SSI (OR=5.9, p<.05) 3

4 Matt Nock: Suicide Stroop Suicide Stroop Does the suicide Stroop distinguish between suicide attempters (n=68) and non-attempters presenting to the ED (n=56)? suicide *SAs had a stronger attentional bias toward suicide (t=2.37, p<.05) *Stroop interference predicts 6-month SA beyond all other clinical predictors Cha et al (2010). Journal of Abnormal Psychology. Affective Startle and Suicide Risk (PI: Goodman/Hazlett) Safety Planning Intervention (Stanley & Brown, 2008; 2012) Similar to other emergency plans (e.g., do x, y and z in a certain order in case of low cabin pressure on a plane) Compilation of evidenced-based strategies (e.g., means restriction, social support) A collaboratively developed prioritized written plan that can be used during or preceding a suicidal crisis Helps individuals identify personal warning signs for suicidal crises Lists internal & external coping strategies Identifies sources of support-peer, family, superiors, professionals Provides guidance on making one s environment safe Conveys that suicidal feelings and urges can be survived and controlled Adopted nationwide across VAMCs for high suicide risk Veterans Recognized by Best Practice Registry for Suicide Prevention Requires minimum of training; Can be used by a wide range of helping services professionals with varying degrees of education Phone app site: VA Safety Plan Craig Bryan, Psy.D. Crisis Response Plan + Reasons for Living with suicidal Soldiers 4

5 25 Crisis Response Planning (CRP) Time to First Suicide Attempt by Study Condition Crisis Response Plan No Suicide Contract Evidence-Based Treatments for Suicidality There are RCT s with suicidal ideation and behaviors as treatment outcomes There is no support for the use of inpatient hospitalization; there are concerns about increased risk for suicide post-discharge RCT s with replicated support: Dialectical Behavior Therapy (DBT) Two types of suicide-specific CBT (CT-SP & B-CBT) Source: Bryan CJ et al. (2017) log-rank χ 2 (1) = 4.85, p =.028 Slide courtesy EDC, of Inc. Craig 2016 Bryan All Rights Reserved. Collaborative Assessment and Management of Suicidality (CAMS) Non-demand follow-up caring contact Medications for Suicidal Risk? Mann et al (2005): Treating mood and the underlying psychiatric disorder is a central component of suicide prevention. DBT s impact on Non- Suicidal Self-Injury Behavior Un-replicated RCT evidence for lithium (Tondo et al., 2001) and clozapine (Meltzer et al., 2003 only FDA approved Rx). RCT s not finding a SSRI effect on suicide ideation/behavior: Gunnell et al (2005) Ferusson et al (2005) RCT s that did find a SSRI effect on suicide ideation/behavior: Zisook et al (2011) Gibbons et al (2012) Ketamine? RCT data supporting medications are mixed at best DBT s Impact on Suicide Attempt Behavior Resources for Dialectical Behavior Therapy Source Texts: Participant Flow 350 Assessed for Eligibility 120 Randomized 250 Excluded 164 Did not meet Inclusion Criteria 66 Refused 60 Assigned to Cognitive Therapy + Usual Care 58 Received CT 2 Did not receive CT 60 Assigned to Usual Care 60 Received Usual Care Follow-up Assessments 1, 3, 6, 12, 18 Months Follow-up Assessments 1, 3, 6, 12, 18 Months Training Website: 15 Lost to Follow-up at 18 mo 12 No Contact 1 Died Natural Causes 2 Refused Center for the Treatment and Prevention of Suicide (2006) 20 Lost to Follow-up at 18 mo 16 No Contact 2 Died Natural Causes 1 Died Suicide 1 Refused Source: Brown, G. K. et al. (2005). JAMA, 294,

6 Survival Functions for Repeat Suicide Attempt by Study Condition Phased Approach to Treatment Cumulative Survival Cognitive Therapy Intervention Control Phase I: Engagement Phase II: Self-management Phase III: Skill development Phase IV: Relapse prevention Exposure Center for the Treatment and Prevention of Suicide Source: (2006) Brown, G. K. et al. (2005). JAMA, 294, Days *p < Brief Cognitive Behavioral Therapy (B-CBT) 33 Time to First Suicide Attempt by Study Condition BCBT TAU Source: Rudd MD et al. (2015). Am J Psychiatry, 172, log-rank χ 2 (1) = 5.28, p =.022 Slide courtesy EDC, of Inc. Craig 2016 Bryan All Rights Reserved. Treatment Phase Phase I Sessions 1 and 2 Phase II Sessions 3 and 4 Phase III Sessions 5 and 6 Therapeutic Goals Build Therapeutic Alliance Provide Psychoeducation Develop Collaborative Safety Plan Construct Suicide Attempt Story Instill Hope Increase Reasons for Living Teach Adaptive Coping Strategies Target Deficits in Problem Solving Promote Linkage to Outpatient Aftercare Teach Relapse Prevention Strategies Refine Safety Plan before Discharge Resources for Cognitive Behavioral Therapy Source Text: Cognitive Therapy Training: Other Key Websites:

7 Critique of Current Approach to Suicide Risk: THE REDUCTIONISTIC MODEL (Suicide = Symptom of Psychopathology) The Collaborative Assessment and Management of Suicidality (CAMS) identifies and targets Suicide as the primary focus of assessment and intervention?????? DEPRESSION LACK OF SLEEP Suicidality Mood THERAPIST PATIENT POOR APPETITE ANHEDONIA...? SUICIDALITY? THERAPIST & PATIENT PAIN STRESS AGITATION HOPELESSNESS SELF-HATE REASONS FOR LIVING VS. REASONS FOR DYING Traditional treatment = inpatient hospitalization, treating the psychiatric disorder, and using no suicide contracts CAMS assessment uses the Suicide Status Form (SSF) as a means of deconstructing the functional utility of suicidality; CAMS as an intervention emphasizes a problem-focused intensive outpatient approach that is suicide-specific and co-authored with the patient Shneidman Award Address (Jobes, 1995) Could differential assessments of suicidal states lead to different prescriptive treatments? Psychometrics of the Core SSF (Jobes et al., 1997; Conrad et al., 2009) SSF Reasons for Living vs. Reasons for Dying (Jobes & Mann, 1999; Jobes & Mann, 2000) Reliable coding categories (Kappa s >.80) Reasons for Living Family Friends Responsibility to Others Burdening Others with Suicide Unrealized Plans and Goals Hope for the Future Enjoyable Things Beliefs (Religion) Preservation of Self Reasons for Dying Others (Retribution) Unburdening Others Loneliness Hopelessness Issues about Self General Escape Escape the Past Escape the Pain Escape Responsibility Reasons for Living Frequencies and Percentages of Reasons for Living and Reasons for Dying College Counseling Center Data (n=201) Reasons For Dying Category Frequency Percent Category Frequency Percent Plans and Goals % General Descriptors of Self % Family % Escape in General % Enjoyable Things % Others/Relationships % Hopefulness for Future % Escape Pain % Friends % Hopelessness % Self % Unburdening Others % Burdening Others % Escape Responsibilities % Beliefs % Loneliness % Responsibility to Others % Escape Past 3.6% Note: Total number of RFL responses = 598; χ 2 (8) = 98.10, p <.001. Total number of RFD responses = 514; χ 2 (8) = , p <.001 Source: Peterson, E. M., Mann, R. E., Jobes, D. A., & Kiernan, A. (2002, April). Reasons for Living vs. Reasons for Dying. Paper presented at the Annual Conference of the American Association of Suicidology, Washington, DC. Note: Opinions expressed in this presentation are the authors and do not reflect the official policy of the United States Air Force or Department of Defense 7

8 Reasons for Living Frequencies and Percentages of Reasons for Living and Reasons for Dying U.S. Air Force Personnel Data (n=30) Reasons For Dying Category Frequency Percent Category Frequency Percent Family % Escape General % Plans and Goals % General Descriptors of Self % Enjoyable Things % Escape Pain % Friends 8 9.8% Others % Burdening Others 6 7.3% Escape- Responsibilities % Hopelessness For Future 4 4.9% Hopelessness 3 5.6% Responsibility to Others 3 3.7% Unburdening Others 3 5.6% Beliefs 3 3.7% Loneliness 2 3.7% Self 2 2.4% Escape Past 1 1.9% Note: Total number of RFL responses = 82. Total number of RFD responses= 54. Source: Peterson, E. M., Mann, R. E., Jobes, D. A., & Kiernan, A. (2002, April). Reasons for Living vs. Reasons for Dying. Paper presented at the Annual Conference of the American Association of Suicidology, Washington, DC. Note: Opinions expressed in this presentation are the authors and do not reflect the official policy of the United States Air Force or Department of Defense Reasons for Living: Non-Suicidal vs. Suicidal Samples (Nademin, Jobes, Downing, & Mann, 2005) Reasons for Living Frequency: Contrasts Between Non-Clinical and Clinical Samples Non-Clinical Sample (n=201) Clinical Sample (n=201) Frequency Percentage Frequency Percentage Chi-Square Family * Friends Responsibility to Others Burdening Others * Plans and Goals * Hopefulness for the Future * Enjoyable Things * Beliefs * Self p <.05 Frequency = 1004 Frequency = 598 Adherence to the CAMS Approach CAMS is a therapeutic framework, used until suicidal risk resolves. Adherence requires thorough suicide assessment and problem-focused interventions that target and treat patient-defined suicidal drivers CAMS Philosophy Empathy for suicidal states no shame, no blame Collaboration with suicidal patient in all aspects of the intervention Honesty and transparency throughout clinical care CAMS as Therapeutic Framework Focus on Suicide from beginning to middle to end Outpatient Oriented goal is to keep a suicidal patient in outpatient care Flexible and Nondenominational across theories and techniques Overview to CAMS Assessment and Care CAMS is a suicide-specific therapeutic framework, emphasizing five core components of collaborative clinical care (over sessions/3 months). Component I. Collaborative Assessment of Suicidal Risk Component II. Collaborative Treatment Planning Attend treatment reliably as scheduled over the next three months Reduce access to lethal means Develop a self-oriented coping strategy on CAMS Stabilization Plan Create interpersonal supports and connectedness Component III. Collaborative Understanding of the Patient s Suicidal Drivers Relationship issues (especially family) Vocational issues (what do they do?) Self-related issues (self-worth/self-esteem) Pain and suffering general and specific Component IV. Collaborative Problem-Focused Interventions Component V. Collaborative Development of Reasons for Living Develop plans, goals, and hope for the future Develop guiding beliefs a post-suicidal life (e.g., lessons in living) Beyond Stability: Treating the Drivers DBT chain analysis to identify triggers and points of intervention Teach 4-step problem solving Teach mindfulness and mentalization Various covert sensitization techniques Assertiveness training/role plays Najavits (2002) Seeking Safety Treatment Safe coping skills (Part I) Safe coping skills (Part 2) Detaching from emotional pain (grounding) Mental grounding Physical grounding Taking Good Care of Yourself CAMS-Guided Care and a Life Worth Living There should be an overt emphasis on developing and consolidating coping and problem-solving skills and techniques. There should be an overt emphasis on actively developing Reasons for Living and systematically eliminating existing Reasons for Dying. There should be an emphasis on future thinking/planning (protective factors) including: The development of short and long term plans and goals. The development of hope for the future. The development or further consolidation of guiding beliefs. Developing a life worth living. 8

9 Resolution and Clinical Outcomes Over three month of CAMS-guided care, we are seeking: Completion of Sections A-B of the SSF Outcome/Disposition Resolution of suicidality if: 1) current overall risk of suicide <3; 2) in past week, no suicidal behavior and 3) effectively managed suicidal thoughts/feelings Patient s CAMS-guided care comes to an end; the patient is appropriately debriefed and referred to further care if indicated. SSF Outcome Form HIPAA page is completed after final CAMS session (Section C). Correlational and Open Clinical Trial Support for SSF/CAMS Authors Sample/Setting n = Significant Results Jobes et al., 1997 College Students 106 Pre/Post Distress Univ. Counseling Ctr. Pre/Post Core SSF Jobes et al., 2005 Air Force Personnel 56 Between Group Suicide Outpatient Clinic Ideation, ED/PC Appts. Arkov et al., 2008 Danish Outpatients 27 Pre/Post Core SSF CMH Clinic Qualitative findings Jobes et al., 2009 College Students 55 Linear reductions Univ. Counseling Ctr. Distress/Ideation Nielsen et al., 2011 Danish Outpatients 42 Pre/Post Core SSF CMH Clinic Ellis et al., 2012 Psychiatric Inpatients 20 Pre/Post Core SSF Suicidal Ideation, depression, hopelessness Ellis et al., 2015 Psychiatric Inpatients 52 Suicide ideation and cognitions Ellis et al., 2017 Inpatients (& post-discharge) 104 SI, cognitions, depression, hopelessness, funct. impare, well-being, psych flexibility Empirical research from USAF 10 th Medical Group (n=55) has shown that CAMS patients reach complete resolution of suicidality about 4-6 weeks more quickly than treatment as usual patients (Jobes et al., 2005; Wong, 2003) 10 th Medical Group Research: Six Month Period After the Start of Mental Health Care Mean Health Care Costs CAMS/SSF as a Therapeutic Assessment Menninger Post-D/C (Ellis, Rufino, & Allen, 2017) Meta-Analysis Results: Taken together, they suggest that psychological assessment procedures when combined with personalized, collaborative, and highly involving test feedback have positive, clinically meaningful effects on treatment, especially regarding treatment processes. 9

10 9/16/2017 Randomized Controlled Trials of CAMS Principal Setting & Design & Sample Status Investigator Population Method Size Update Comtois Harborview/Seattle CAMS vs. TAU published (Jobes) CMH patients Next-day appts. article Andreasson Danish Centers DBT vs. CAMS published (Nordentoft) CMH patients superiority trial article Jobes Ft. Stewart, GA CAMS vs. E-CAU 148 in press; (Comtois et al) US Army Soldiers in preparation Pistorello Univ. Nevada (Reno) SMART Design 62 Manuscripts (Jobes) College Students TAU/CAMS/DBT in preparation Fosse Norwegian Centers CAMS vs. TAU 100 ITT done; evals CMH patients on-going Comtois Harborview/Seattle CAMS vs. TAU 200 Intent to treat (Jobes) Suicide attempters Post-Hosp. D/C underway Santel et al German Crisis Unit CAMS vs. TAU 110 ITT underway Inpatients CAMS Next-Day-Appointment RCT CAMS RCT (Comtois et al., 2011) Andreasson et al (2014; 2016) Method and design of the DiaS trial* DBT vs. CAMS Superiority RCT Figure 1. Odds ratio with 95% confidence intervals of non-suicidal self-injury and suicide attempts, favoring CAMS treatment. 154 participants with borderline personality traits and recent suicide attempt DBT CAMS treatment 54 participants receiving 16 weeks of Dialectical Behavior Therapy (DBT) 54 participants receiving approx. 10 sessions of Collaborative Assessment and Management of Suicidality (CAMS) Table 3. Distribution of BPD criteria in the trial population * Andreasson et al. The Dias trial: dialectical behavior therapy versus collaborative assessment and management of suicidality on self-harm in patients with a recent suicide attempt and borderline personality disorder traits- study protocol for a randomized controlled trial. Trials 2014; 15:194 DiaS trial At 28 weeks: DBT Self Harm = 21; CAMS = 12 DBT Attempts = 12; CAMS = 5 ) 10

11 Thesis of CAMS-DiaS patients (n=20) Operation Worth Living (OWL) Consenting Suicidal Soldiers (n=148) Experimental Group CAMS 3 months of outpatient care (n=73) Control Group E-CAU 3 months of outpatient care (n=75) Dependent Variables: Suicidal Ideation/Attempts, Symptom Distress, Resiliency, Primary Care visits, Emergency Department Visits, and Hospitalizations. Measures: SSI, OQ-45, SASI-Count, CDRISC, PCL-M, SF-36, NSI, THI (at 1, 3, 6, 12 months) Operation Worth Living RCT 78% participant retention at 12 months follow-up Excellent between-group treatment fidelity using the CAMS Rating Scale (CRS) Inter-rater reliability using CRS was excellent with ICC s range in the.9 s Outcome CAMS E-CAU Any suicidal ideation (SSI) Any suicide-related episode Any behavioral health-related episode Any suicide-related wellness check/escort Any behavioral health-related wellness check/escort Any suicide-related ER visit Any behavioral health-related ER visit Any suicide-related IPU admission Any behavioral health-related IPU admission Any suicide attempt/hospitalization Symptom distress (OQ-45) PTSD symptoms (PCL-M) Pre-Post Effect Sizes Per Cohen (1988) small effect = 0.2 medium effect = 0.5 large effect = 0.8 CAMS had large effects But so did E-CAU Note. Post-intervention assessed at 3 months. Treatment Outcome Results (n=148) Moderator Analyses supporting CAMS Significant 3 month finding for CAMS eliminating suicidal ideation No significant between-group differences on suicide attempts (only 9 in the study) 11

12 Moderator outcome: Any Behavioral Health ED Admission Comments: There is a more rapid decrease in the likelihood of any behavioral health-related ED admission among those receiving CAMS at lower levels of symptoms distress. This finding is important as partially replicated 2005 Air Force data. Resiliency x marital status NIMH-Funded R-34; PI: Jacque Pistorello, Ph.D.; Co-I: David Jobes, Ph.D. SMART Results (Stage 1 only) CCAPS findings with n=62 suicidal students Stage 1 Stage 2 Significant results supporting CAMS for suicidal ideation, depression, and anxiety 12

13 CAMS for Teens and Young Children Aftercare Focus Study (AFS) PI: Kate Comtois Co-PIs: David Atkins, Heidi Combs, Shaune Demers, Ryan Kimmell, Jagoda Pasic, David Jobes Research Coordinator: Karin Hendricks Patients admitted to hospital with suicide attempt in past month referred by inpatient/er staff Study assessor conducts informed consent and conducts baseline, randomizes, provides patient and clinical team with Next Day Appointment CAMS Next Day Appt and Aftercare TAU Next Day Appt and Aftercare Funded by AFSP from Target sample size = 200 Primary Aims: 1. Evaluate whether CAMS for suicidal NDA patients results in a significant reduction in suicidal behavior compared to TAU. 2. Evaluate whether CAMS for suicidal NDA patients results in significant reductions in suicidal ideation and intent as well as related improvements in other mental health markers compared to TAU. 1,3,6 & 12 month blind outcome assessments State hospital and death certificate records 1,3,6 & 12 month blind outcome assessments State hospital and death certificate records 3. Evaluate whether CAMS for suicidal NDA patients is more satisfactory to patients than TAU. For more information, contact mhsrtlab@uw.edu CAMS Didactic Training (VISN 7) Twelve workshops were given across nine VA Medical Centers in Georgia, Alabama, and South Carolina. Example of VISN 7 Post Training Evaluation Clinicians (n=165) across professional disciplines were trained in a day long workshop. Beyond needs assessment, pre/post training evaluations were completed by clinician trainees. A final post/post training evaluation were administered in July 2008 (approximately three months after original training). Self-Report Research: Great! On-line training + live role-playing + coaching calls = CAMS adherence ACTUAL USE: < n=10 clinicians were using CAMS in VISN 7 a year later! 13

14 The evolution of CAMS The neuroscience of treatments 3 rd Edition Assessment Treatment Outcomes DBT Chain Analysis Cognition Predispositions I m a terrible person. I m a burden on others. I can never be forgiven. I can t take this anymore. Things will never get better. Prior suicide attempts Abuse history Impulsivity Genetic vulnerabilities Trigger Behavior Substance abuse Social withdrawal Nonsuicidal self-injury Rehearsal behaviors Suicidal Mode Emotion Shame Guilt Anger Anxiety Depression Job loss Relationship problem Financial stress Physiology Agitation Sleep disturbance Concentration problems Physical pain 82 ACC WHERE IS EMOTION REGULATION PROCESSED IN THE BRAIN? VMPFC Insular Cortex below here Amygdala Anterior Cingulate Cortex (ACC) Assesses stimuli salience Attentional deployment Ventromedial Prefrontal Cortex (VMPFC) Cognitive change Amygdala Response/Response modification Insular Cortex Interoception Safety Planning CRP + RFL Means Restriction can be used through out CAMS DBT, CT-SP Safety Planning, ASSIP, TMBI MI PACT TMBI Allman et al., 2001; Diekof et al., 2011; Shackman et al., 2011 Page 83 14

15 Thank You! 15