Functional Analysis of Suicidal Behavior - PowerPoint Presentation

Functional Analysis of Suicidal BehaviorA Clinical Intervention for Suicide PreventionBeth S. Brodsky, Ph.D.Cory Cunningham, LCSWNYS Suicide Prevention ConferenceAlbany, New YorkSeptember 18, 2017

Treating Suicidal Behavior is a ChallengeWorking with individuals at risk for suicide is one of the most anxiety -producing aspects of mental health work.Learning how to better understand and clinically manage suicidal behavior can:increase effectiveness in suicide prevention reduce some of the stress related to treating at- risk individuals.

What is a Functional Analysis?A step by step in-depth examination of the triggers, events, thoughts, feelings, body sensations and behaviors that lead to self-harm urges and behaviorsAn effective clinical tool for targeting and decreasing suicidal ideation and behaviors in at-risk clients. For use in ongoing outpatient treatment settingsFunctional analysis increases awareness of patterns and consequences that reinforce behaviors and provides opportunity for problem solvingNot a one time intervention – can be used whenever there is a self-harm behavior or urge

Learning ObjectivesYou will learn how to use functional analysis to:understand the function of suicidal behaviors;identify and analyze client risk factors: environmental triggers, thoughts, feelings, body sensations and behaviors, that lead to a suicide act;Collaborate with clients to identify and apply problem- solving suicide prevention interventions.

AliceAlice is a 29 -year old woman with a college degree who works as an administrative assistant. She is in a serious relationship with her boyfriend, whom she has been dating for 1 year.On Thursday of last week, she attended her therapy session and revealed that she had taken an overdose (with intent to die) of about 12 pills of Klonopin two days earlier. She slept it off and did not receive any medical attention at the time. She and her therapist agreed to do a functional analysis in order to better understand why she made the overdose, and to problem solve to avoid doing so in the future.

Function of a Suicidal Behavior Understanding the function of a suicidal act can help make sense of the behavior. The theory of Operant Conditioning helps us understand the function of a behaviorIf something positive results from a behavior, that behavior is more likely to occur againIf something negative results from a behavior, that behavior is less likely to occur againOften there are (short-term) “positive” consequences to suicidal behaviors

Function of a Suicidal Behavior-Immediate relief from painFor example, immediately following her overdose, Alice fell asleep and experienced an “escape” from intense feelings of distress.This is an example of negative reinforcement, which is often the case with self-injurious and suicidal behaviors – they result in an immediate sense of relief from emotional pain, therefore increasing the likelihood of these behaviors, by removing a negative situation or experience.Therefore, the self-harm act serves the function of reducing distress, at least in the short term.

The ABC Model of Operant ConditioningA: Antecedents: Events that lead toB: Behaviors: Actions that result inC: Consequences: Either reinforcing or punishing, thus affecting future behaviors. NYASSC2016 NYASSC2016 NYASSC2016 NYASSC2016

Classical ConditioningThe theory of Classical Conditioning helps us to identify antecedents and cognitive interpretations that lead to suicidal behaviors. Remember Pavlov’s dog?

A: Antecedents and Classical conditioningThis model helps us understand and identify triggers (antecedents) for emotional reactions that can lead to suicidal acts For example, the aroma of baking bread might be paired with a traumatic childhood event, and therefore might be the antecedent to a flashback, even in the absence of the traumatic event

B: BehaviorsWe are focusing on using functional analysis to decrease undesired suicidal behaviors:Suicide attemptsNon-suicidal self-injurySuicidal urges and ideationSuicidal communicationsPreparatory behaviorsOther impulsive/destructive behaviors related to suicidal behavior, such as drug abuse, promiscuity, violence

C: ConsequencesReinforcing and PunishingPositive Reinforcement (increases chance of a behavior re-occurring) A consequence that is experienced as positive following a behavior. Example: Child receiving praise after doing a choreNegative Reinforcement (also increases chance of behavior re-occurring) The removal of an uncomfortable feeling or stimulus after engaging in a behavior. Example: Teen cleans room and parent stops naggingPunishment (decreases chance of behavior re-occurring) A consequence that is experienced as negative following a behavior. Example: Being arrested for drunk driving Extinction The disappearance of a previously learned behavior due to lack of reinforcement of that behavior. Example: Workers stop asking for a raise when it falls on deaf ears

Components of a Functional Analysis Choose a target behavior Identify antecedent/environmental trigger Identify pre-existing vulnerability Choose a starting point Conduct a chain analysis Identify consequences Highlight points on the chain for problem solving Problem solve by offering alternative skillful responses Maintain a validating stance and attending to affect throughout the process

Chain Analysis Worksheet

Target BehaviorWhat is the behavior that is being subjected to the functional analysis?When did it occur?Examples of behaviors to target:OverdoseSelf-cuttingHead banging Spike in suicidal ideation or urges to act on a plan Self-poisoning Self-choking Standing and contemplating jumping from a bridge or other high perch (roof, edge of subway platform, terrace) Preparatory behaviors Suicidal communications Others?

Pre-existing VulnerabilityWhat the individual brings to the current moment in which the trigger occursWithin-self Sleep deprivationPMSRejection sensitivityEnvironmentalDeadlineStress at work Vulnerability interacts with the trigger Trigger alone does not always lead to behavior

Antecedents:Environmental Precipitants/TriggersPrecipitants/triggers are often specific to the individual, based on their past history (classical conditioning for example). Obstacles to identifying trigger - feelings are experienced as coming out of the blue, clients dismiss what could be a trigger because its “too small” or the particular event doesn’t always trigger unskillfulnessCommon triggers:Break up of romantic relationshipsOther interpersonal disappointments/real or perceived rejection Unexpected bad newsTriggers of past traumatic events

Choosing a starting pointHow to decide where to start chain analysis?First awareness that things are headed for troubleFrom moment of waking up the morning of the day of the target behaviorWork backwards from the target behavior

Chain Analysis Method of inquiry Ask for first awareness – a thought, feeling, physical sensation, event, behavior?Cognitions, feelings, events, behaviors – what did you do, think, feel, what happened, next? As much detail as possible – do not assume you understand how one step leads to another For example, how exactly does feeling depressed lead to suicidal thoughts or urges?

Chain Analysis - continuedCollaborative effort between client and clinicianAttentive to affectBalance with validationSolution Analysis – weaving in skillsCorrection/overcorrection – making repairs and managing consequencesAvoiding vulnerability in the future

Consequences of target behaviorIn selfPositive (reinforcing) – immediate reliefNegative (aversive) - shame (often not as immediate – kicks in later)In the environmentPositive – attentionNegative – fear of losing peopleShort term – often only positive Immediate relief (very strong positive reinforcer) Long term – often more negative Shame Scars Loss Identifying consequences normalizes, validates, helps with contingency management and problem solving

Alice’s Behavioral AnalysisProblem Behavior – Overdose of 12 pills of Klonopin, with some intent to dieVulnerability factors –hangover headache, 4 drinks, work stressfulTrigger/precipitating event – boyfriend cancelled dinner plans

Alice’s Chain Analysis Chain of eventsClinician: When did your first notice your feelings change?Monday feeling stressed at work (feeling)But also Looking forward to seeing boyfriend for dinner (thought)Clinician: And then? Boyfriend called to say he was too tired (event - Antecedent) I started screaming at him, hung up (behavior) Clinician: What were your thoughts? Thought if he really loved me he wouldn ’ t be too tired (thought) Felt disappointed and angry (feeling) Clinician: What happened after that? He called back to try to apologize and said he wasn ’ t feeling well (event) Problem solvingn/aNa/n/ How to express self more skillfully?Check the facts – is that really true?Self-validate – I’m allowed to feel angry and disappointed

Alice’s Chain Analysis 2/4CHAIN OF EVENTSI yelled at him again (Behavior)Clinician: Did you not believe him? (Inquiry into thinking)Right, I thought if he really wanted to he would figure out how to make it (thought)Anyway, after I yelled he got angry and he hung up (event)Clinician: What were you feeling? Frustration, anger. I started crying, feeling guilty, confused (feelings and behavior) Clinician : What did you do then? Called my best friend for help to sort out feelings – she wasn’t available (behavior) Clinician: That was skillful, you were enlisting help to calm down. Yeah I guess. Then I left work for home. PROBLEM SOLVING Take a time out Check the facts Allow myself to have my feelings SKILLFUL! NYASSC2016 NYASSC2016 NYASSC2016

Alice’s Chain Analysis 3/4CHAIN OF EVENTSClinician: And how were you feeling once you got home?Felt empty, agitated, needed to calm down (body sensation) Started eating a lot of cereal that was in my cabinet (behavior)Friend called and asked me to come out (event)Clinician: And what happened then? Had four drinks – got drunk (behavior) Clinician: And then? Woke up with a hangover (body sensation) Felt miserable – kept having urges to call bf (feeling, actions urges) Clinician: What stopped you? Didn’t know what to say, hoped he would call (thoughts) Then I felt guilt, shame at my behavior (feelings) PROBLEM SOLVING hold ice/intense exercise, muscle relaxation pros and cons of binge eating – awareness of long range consequences Awareness of long range consequences of drinking Think about what you might want to say to him Guilt can be justified and can help to form apology and relationship repair

Alice’s chain analysis 4/4CHAIN OF EVENTSClinician: What was going through your mind? Fear that he would leave me (thought/feeling)Clinician: Then what were you thinking? I ’ ll never be able to keep a boyfriend (thought) Clinician And was there another thought or physical feeling connected to that first thought? I hate myself, I’m hopeless. I can’t change (feeling, thought) I would be better off dead (thought) Head felt as if it would explode (body sensation) Clinician: And then? I don’t want to feel this way forever, can’t stand feeling this way anymore (thought) I can take pills so I don’t have to feel this anymore (thought/action urge) PROBLEM SOLVING Check the facts Be in the moment – don’t project into the future - mindfulness Hold ice/intense exercise, muscle relaxationAgain avoid projecting too far into the futurePros and Cons – what are the long range consequences

Hopeless, thinking I would be better off dead, pressure in head, don’t want to feel this way anymore Miserable. urges to call boyfriend Monday felt stressed at work, looking forward to seeing boyfriend, he cancelled Argument I yelled at him and hung up phone Physical relief at first, then self- hate OVERDOSE Afraid boyfriend will leave me, I will never be able to keep a boyfriend Friend called, went drinking Feelings: disappointed, angry, guilty Thoughts: if he loved me he would not cancel, he won’ t love me if I behave this way Agitated, needed to calm down BINGE EATING CHAIN ANALYSIS: Called but could not reach friend, went home Body sensations: empty

The ABC’s of Alice’s Functional AnalysisAntecedent: Boyfriend cancelledClassical conditioning: In Alice’s previous relationships, cancelled plans signaled the beginning of the end of the relationshipBehavior: OverdoseAnd the consequences…

Alice’s ConsequencesConsequences in self: Short- term fell asleep – which gave me immediate relief of intense pressure in my head, and validation of how upset I was Long- term : shame, self-hate, feeling like a loser, feeling hopeless about being able to get better Consequences in environment: Short -term boyfriend promised never to cancel plans in the future when he found out that I overdosed Long- term having to do this analysis, guilty that boyfriend feels responsible for my overdose

What we learned from conducting this chain analysis with Alice“Rejecting” behaviors by boyfriend are triggers (antecedents) for suicidal behaviorEspecially when she is already stressed (vulnerability)She makes assumptions about the intentions of others and doesn’t always check the facts (cognitive error)Cognitive errors around black/white, all/nothing, always/never thinkingErroneously equates feelings with behaviors – self-invalidates her feelings when they lead to unskillful behaviors (cognitive errors and emotional self-invalidation/dysregulation)Impulsive eating and drinking behaviors to momentarily self-soothe can contribute to suicidal risk (behaviors)Body sensations accompany emotional dysregulation – can be warning signs There are strong, immediate positive and negative reinforcers for her overdose behaviors and therefore these suicidal behaviors serve an emotion regulation function for Alice. (understanding the function)

Alice’s Solution analysisEmotion regulation skillsself-validation, opposite actions, mindful of current emotion, check the facts, avoid all/nothing, black/white thinkingMindfulnessavoid projecting into the futureDistress toleranceSelf-soothe, pros and cons, time out, reduce intensity of body sensationsInterpersonal effectivenessClarify what I want to ask forAsk for what I want skillfully Learn how to accept noHow to avoid vulnerability deal with stress at work more effectively

Break Out Group: Functional Analysis of Caitlyn Review Caitlyn’s case and discuss among yourselves to identify the following: Target Behavior Trigger Vulnerability Relevant thought patterns Relevant behaviors Relevant feelings  Relevant body sensations  Immediate short term consequences in herself Immediate short term consequences in the environment Longer-term consequences in self/environment   Problem solving around means restriction, avoiding triggers/reducing vulnerabilities Any other questions you want to ask/information you would like to know

Caitlyn’s Case Caitlyn is a 21- year old mixed race female, lives with her mother and elder brother, just completed an Associates’ Degree and works at Payless Shoes. Caitlyn was brought into her local ER by her mother after she admitted taking an overdose of allergy medication. After being medically stabilized, Caitlyn met with an ER social worker, who administered a Columbia Suicide Severity Rating Scale. On it, Caitlyn admitted she had overdosed on the allergy medication with intent to die, but became alarmed after she took a few pills and went to her mother for help. The social worker takes a suicide history. Caitlyn reports that her severest episode of suicidal thinking was just before taking the pills. She recalls feeling sadness and anger, noticing tightness in her throat and thoughts that she was ‘useless’ and that her ‘life was hopeless.’ She felt hopeless because she works at Payless Shoes, the only place where she can get a job despite just graduating with an Associates’ Degree. Early on the day she took the pills, she overheard a customer saying, her job was for “dumbass losers”. She had spent the rest of the day feeling angry and sad, repeating the customer’s words over and over in her mind. Once she arrived home, her elder brother began pestering her about how little rent she paid their mother, calling her a “lazy bum”. Overwhelmed, Caitlyn slammed the door to her room, thought ‘I’m a useless waste of space’, found her allergy medication and gulped a mouthful. Caitlyn was admitted to the hospital. While on the unit, she recognized that she had experienced trouble sleeping for weeks, spent hours browsing the Facebook pages of friends with “better” jobs, calling herself a “worthless idiot” in comparison and avoiding them. Several of her friends visited her in the hospital and express sadness over what she had done. Her expresses sadness and alarm. Her brother visits and apologizes for calling her a lazy bum. She speaks to her boss several times from the hospital and though he grudgingly gives her the time off, warns he may not be able to guarantee her shift when she returns.

Summary of Functional AnalysisCollaboration between client and clinician to identify the events that lead to suicidal behavior, the functions of suicidal behavior, and problem solving strategies that may stop clients from attempting suicide in the futureIncreases awareness of events, thoughts, feelings and body sensations that lead to suicidal behaviorsIncreases empathy and non-judgment regarding suicidal behaviorsProblem solving strategies identified during solution analysis can be derived from DBT skills: mindfulness, distress tolerance, emotional regulation and interpersonal effectiveness Can be used multiple times and on any behavior a client wishes to alter. Analysis is comprehensive but easily organized on functional analysis worksheets. Teaches clients that urges and behaviors have causes and consequences, and can be changed.

Resource ListDBT Skills Training Manual, Second Edition, Marsha Linehanhttp://il.nami.org/ABCs%20of%20DBT.pdfTo see a demonstration of these skillshttps://www.youtube.com/watch?v=V1GBvPVvOhA For more on the coping skills referenced

Suicide-Prevention: Training, Implementation and EvaluationCPI InitiativeBarbara Stanley, PhD, DirectorBeth Brodsky, PhD, Associate DirectorChrista Labouliere, PhDCory Cunningham, LCSWYvonne Noriega, MPA