Sitting in on therapy with Marsha m Linehan, session 1

[Music] Welcome to Sitting in on Therapy with Marsha Linehan, Part Two: Assessing and Treating Suicidal Behaviors.

Session One. I'm Alex Chapman, and I'm a postdoctoral research fellow at the University of Washington with Marcia Linehan. And I also see clients as a DBT research therapist. We appreciate all of your support and are very pleased that you could join us today. This is our second series of distance learning programs. This two-session series will be focused on assessing and treating suicidal behaviors. For these two sessions, Marcia will be working with a client, Katie. For a profile of the client and handouts, please go to login at behavioraltech.org.

During the show, Marsha will do a brief introduction, then 40 minutes of unscripted role play. There will be a true-to-life portrayal of therapy with a client in DBT. After the role play, the webcast will conclude with a discussion about the session. While you're watching the webcast, if you have any questions, please email them to us at Q live behavioraltech.org. The questions will be included in the toolkit along with the answers from our team of experts. I will now turn the show over to Marcia.

As you can see, client who I got referred in our research study, and we have several studies going on, but she got referred to me in our study of highly suicidal people meeting criteria for borderline personality disorder. And I was the first therapist to get assigned a client, and I got Katie. So I knew nothing about her before I saw her. Now, my job as a therapist in this particular study is to try to do Dialectical Behavior Therapy, or DBT, to the very best of my ability. And I'm trying to do a first session. And not only are you watching the first session, but frankly, all of my research team is watching this session, and the adherence coders are watching this session. And I've been told by myself and my team, I am to try to do the perfect session. So you can just imagine a little bit on the nervous side. So you can watch and see what happens when you're doing a session and you're being recorded and your team is going to see you, because that's what's going to happen to me. And I certainly hope that's what's going to happen to you, that you actually have the courage and the guts to get yourself taped so someone can watch you. So that's what's happening now.

In our clinic, the way we work is a patient comes in and they get an intake assessment. And in the intake assessment, one of the major parts of that evaluation is that they're evaluated to see if they meet criteria for borderline personality disorder. And just a little bit of history is taken. And the intake person then writes up a one-page report that doesn't say too much that they send to the therapist and to the team. And so I got a one-page report. So I'm going to tell you a little bit about what I know about Katie. And what I know about her is that she's 30. I knew this before this session started, that she's 34. She's been married three times and she's been divorced three times. But I'm not certain if she's married now or single when I start the session, but I'm pretty sure she's the divorce is finished and she's not married. She is living in a basement apartment at her dad's house. And she previously owned a company that was a house cleaning company. And she had an accident about seven or eight months ago where she was pretty seriously hurt and couldn't go back to do all this heavy lifting in the house cleaning business. And the business, even though she actually had a fair amount of people working for the business, because she couldn't do any house cleaning herself, the business slowly fell apart. And apparently it fell apart and that's why she's ending up living in the basement of her dad's house. She meets eight out of nine criteria for borderline personality disorder. The only criteria that she doesn't meet is dissociation, dissociative criteria, and paranoid ideation. And she's had two suicide attempts. At least, I think there might have been one further in the past. It said that she had some sort of self-injury further in the past, but the report didn't tell me whether the first one was a suicide attempt or not. But the report said that she had two suicide attempts in the last eight weeks right before she came into treatment with me. And that both of these suicide attempts, she ended up in the critical care unit of a local hospital. So I'm not, I don't really have a lot of information about those, but I'm going to try to get something. She was referred by the hospital to me. And that's pretty much what I knew. I knew, you know, a few more things, but not a whole lot more. She doesn't meet criteria for major depressive disorder. She doesn't meet criteria for a schizophrenic disorder. And I don't know whether what she meets criteria for other than that, or whether she has other significant diagnostic criteria because I haven't gotten a diagnostic interview report and I myself haven't done a diagnostic interview with her yet. So what you're coming into now is the first session that I have with her.

So what are my goals in a first session? My goals in a first session, the main goal is to find out why she came now. I've already been meeting with her for about 20 minutes, 15 or 20 minutes when you're coming into this tape. And so I've already asked her why she came and what she's doing here. And what I found out was that on her last suicide attempt, the inpatient hospital in town told her that her, she was there for almost a week on a medical unit. And they then told her that she could go to a psychiatric unit. She didn't want to go to a psychiatric unit. So they told her her options were that she was either going to be involuntarily committed to the psychiatric unit, or she could come over to our treatment program. And so she decided to come here instead of to go on to the inpatient unit. When I asked her what she was hoping to get out of therapy, I found out one, she'd never been to therapy before in her life. She's never heard any good reports on therapy and doesn't really have a particularly positive opinion of therapy. But that what she wants, and the reason she's willing to come, is she wants to get her old life back. Of course, I asked what in the world was her old life back. And what she wants is to be able to get her company back or to start another company. She wants to be a business owner, financially independent, out of living with her dad and living on her own again and supporting herself. So that's really what she's looking for. And we've talked about that and tried to get that narrowed down. And I'm now going to move into trying to get some history, which would be the second thing you'd want to do in a first session, is get some history of the suicidal behavior. At least you want to know kind of what are you dealing with. And I'm going to try to do some crisis assessment to find out how suicidal is this patient. Your other goal in a first session is to get a commitment to treatment. Now, she's asked me what is this treatment because she actually, that was one of the first questions. So I've already told her we meet twice a week, once for individual, once for group therapy. That she can call me and that we have a team. And I gave her a list of the members of the team. So I've talked to her about what the treatment is. And you want to do that in your first session. So what I have left to do is to evaluate how suicidal she is and what do I have to worry about this week and until I see her again. And I want to get a commitment that she isn't going to kill herself. And is she willing to work on not being so suicidal? And I want to be sure to have another appointment already set up with her. And in fact, I want to have four appointments already set up with her. Other than that, I'll have to wait and see sort of what shows up so they can figure out what I have to do. So you're coming in not in the middle of the session, but somewhat in the middle. I've already asked her if it's, sorry, if I take notes, as she said it was all right. And I told her that I had this information, so she kind of knows some of the information I have. Okay.

So one of the things you want to do is get out of your debts, get out of this basement, and kind of get living on your own again. Yeah, it, it's more, it's like I've got to get out of there. It's more than want. I just want to make sure you really understand that I've got to get out of there. Okay. So you know, um, given that you have this really bad accident, I forgot to ask you earlier, but when we were talking about, but did you have health insurance in your company? Yes. Okay. And first out, it's gone. There's nothing left. All right. So you don't have any health insurance now? I last of it's gone. And did you, had you been playing into the unemployment state system? Are you on unemployment? Yeah, it's about to run out. Okay. And so when you're on unemployment though, you did you have to be looking for some sort of job because of medical problems? They, they didn't require it. Okay. So if you want to get a job now, can you get, are you disabled in the sense that you could get medical disability to kind of type for a while here? You know, it's, it's like I'm gonna make a recovery. It's just that it's taking a long time. And I'm never going to be the way that I was. I'm never going to be able to do, you know, my work has always been really physical. I'm never going to be able to do that again. But it's not like I'm, you know, disabled according to standards that would count. And it's just the problem is, I just, I've got no training. I don't have, I don't know. That's all I've ever done is work with my hands. Okay. So in other words, you're feeling like you're not physically going to be able to go back to house cleaning? Right. I mean, there's just no way. There's no way to carry the supplies in. There's no way to be carrying vacuum cleaners around. I mean, it's like the car wreck, you know, it like it damaged my chest. It, it essentially I had a heart attack as a result of the impact of this car crash. And they said that now it's like I've got this heart of this, you know, really old person. And it's fragile. And, you know, I'm just never going to be able to do a lot of the physical work. Okay. So one of our goals then is to sort of figure out what you could do. Yes, ma'am. And then try to figure out a way to get you employed. Yes, ma'am. Okay. So, and your dad is giving you living for free, right? If you can call it for free. There's a, you know, there's, there's never anything free with that man. There's always some string attached. But if you mean, do I have to come up with any money to be there? No. Okay. No, ma'am. Now, do you have, so only do you have income other right now than what you're getting from the state? No. Okay. And how many weeks do you have on that? I've got like two left. All right. Believe me, if I had any other money, I would not be living with my father. Okay. So one thing we probably have to do, if not today, next week, we've got to start figuring out what you're going to do when you actually get zero from the state. Yes. All right. So that time is coming. Okay. You're getting free living. Is your dad helping you with food or any other expenses? Yeah, I mean, it doesn't cost me anything to be there in terms of money. There's no, there's no problems with that at all. It's just, it's just being under his roof is, you know, that costs. All right. It costs more than I have to give, frankly. Okay. Well, I want to hear about that. I do. I do. But first, I want to hear about the fact that, you know, I, you know, this written report I got, my report said that you'd had two suicide attempts in the last eight weeks. So one thing we need to talk about is those suicide attempts. And I, in particular, need to know where you're at right now and how suicidal you are. Um, why don't we start with you just telling me about these two suicide attempts, because they seem like they're pretty serious. What happened? Well, the first one, I took half a bottle of Tylenol and wound up my, my dad's mom, I mean, my dad's wife found me and they took me to the hospital. And, uh, you know, I realized that it was there that somebody was actually, you know, kind of stupid enough to mention that if I was still on some of my heart medicine, that that with the Tylenol probably would have been enough to kill me. So I tucked that little detail away. Pride myself on being smart, you know. Not like a heart medicine. Well, it's this muscle contraction relaxing thing. I don't know exactly what they call it. But they had said if I was still taking it and had the Tylenol, it would have been a problem. But I thought, my dad has heart medicine. So thought, well, all right. Until the next time, took what was left of the Tylenol, and I took his Coumadin, which I don't know if you know what that is, but that's basically it's rat poison. Yeah, you know, when they, when you want to kill a bunch of rats, you give them rat poison, and basically, they just bleed until they die. So that was number two.

Okay, so let's go back to this first one, though. So what happened on the first one? How did you end up taking a half a bottle of Tylenol? I mean, what was, um, is that the first suicide attempt you've ever had? Yeah, I mean, no, it's the first one where I knew, you know, this was it. This, that, that I was going to kill myself. I mean, when, when I was a kid growing up, I mean, it's always been in the back of my mind. It's always like, you know, like, like the trap door or the escape hatch. But, I mean, yeah, this is the first time where, you know, I mean, I was, you know, planning. You know, like, I wrote a note, you know, so that if someday, you know, my son wants to find me, you know, that there's some explanation as to, you know, what I was thinking about and stuff like that. So, I mean, this was, I was done. So what happened? I mean, how did you, how did you get to that point? What set this off? You know, it's living in my dad's house. It's like, I mean, my growing up years were not pretty at all. And now I'm forced to be there. And it's, it's as if, you know, it's as if nothing ever happened. I mean, he just, he's just, I mean, you would think from the outside that he's this really great father to be helping me out like this. And, you know, the neighbors and his wife and everyone says, oh, okay, you should, you know, it's so great that you've got a dad like this in your life to help take care of you right now. And I don't know, it just, I just, you know, the hypocrisy, it just, I couldn't, I don't know, just so [expletive] pissed me off. I just thought, I just cannot stand to be around this man and these lies anymore. And I just said, [expletive], I'm done. So what's the hypocrisy? You know, it's like, you know, Uncle Tommy started touching me and stuff when I was, you know, a kid. And I tell my dad, and he beats me up for it. And then the rest of my life, it's like, it's like I'm the one that's insane. I'm the one that's crazy. That, you know, none of this [expletive] happened. And somehow it's all just, it's just all in my head. And so I don't know. And now I don't know. Like, I'm the one that's all screwed up. And yet, there I am in his house. And now he's like, I don't know how to describe it because this like look on his face. And it just, it's like, it's like when I was a kid. Yeah. Have you, um, are you back in your father's, back into a relationship with your father? And you haven't been in one? Are you back into your relation? And you've had one all along, but you didn't live with him? You know, it's been one of those things like every couple years, maybe, you know, his wife will try to like, you know, have a family thing. Um, so like they'll be maybe like, you know, some dinner at the holidays or something like that. But we pretty much, you know, I took off out of there when I was, you know, 18. And we pretty much have just kind of been civil when we've been in the same space. But I don't think that there's really ever been a relationship between two of us. Have you felt like the way you feel now about him, kind of all along, though? Yeah. Okay. And so it's one of the things you've done this, are you the one who's kept a distance from him? Or has he kept a distance from you? I've kept a distance from him. All right. So how'd you end up living there? I have no choice. I have no business, and my work's gone after this car accident. I can't do what I know how to do. I watched my, you know, my business crumble. I've got no skills to have a job. And, you know, my current, you know, boyfriend, you know, it's, he doesn't make any money. And he doesn't really have any place to live. It's like I had no other place to go. And I thought, well, you know, he's got this basement apartment, you know, maybe, maybe somehow things have changed. Maybe somehow, you know, I can live there until I get some sort of, you know, physical strength back. Okay. So once you move in, probably just after the accident? I mean, it's all kind of, it's all kind of fuzzy. But I don't know, maybe like six, maybe six months ago, five years ago. So you've been living with your dad for six months. And how is it that you didn't attempt suicide for the first time until like a month ago? Yeah. So what happened? What, something must have changed. Yeah, it did. I mean, it's like the first, the first couple months, um, I was so out of it, you know, I mean, it's like they had to do, you know, like a lot of surgery at the time, you know, of the car wreck. And I mean, I had, I mean, I was really, really badly injured. And so I was in the hospital for a long time. And then most of my day was like going to medical appointments and going to physical therapy. And I still go to physical therapy a couple times a week. And, um, so it was kind of like I wasn't, I was living there, but I wasn't really there because I was at all these appointments. And it's just, is that me? I don't know. What is that? Oh my God, this is that you're fine. I'm sorry, sorry. Just, um, yeah, yeah. Um, I'm at an appointment. Yeah. Um, I'm going to be here in just a second. How long do you think we're going to be? Why don't you say about, about 30 more minutes? But why don't you go ahead and get off? Okay. Um, I'll be about 30 more minutes and then I'll give you a call. We can hook up. Is that okay? What area are you in? Well, I kind of got to go. I'm in the middle of something. But, um, I'll catch up with you like in 30 minutes. Okay. Bye. Thanks. Bye. Oh, yeah, I'm really sorry. I don't, um, it was just kind of, we got it off. Yeah. Okay. Your pager's not by chance, not new. So you want to turn that off too? All right. All right. I'm okay. Sorry. Okay. So back, back to where we were. We're at, um, so we're trying to figure out how it is that you lived with your dad and then you, what happens such that you tried to kill yourself a month ago, right? Okay. Right. So what changed? So basically, a lot of my appointments sort of dropped off. That, you know, I'm kind of, you know, physically stable now. And, um, I only have a couple of appointments. So I'm home more. And, you know, he's home more. He, um, he's a teacher. Uh-huh. So he's got summer off. And so he's home more. And I'm home more. And I think it's just that we're around each other. And I don't know, that's the only thing I can think of is that we're just around each other more. And some of the stuff he says, I think it just, you know, it just gets to me. It just starts, like it's not like there's any one thing. It's like it just kind of is all coming together and adding up and adding up. And, you know, like it says stuff like, you know, "Will you, you've got to find your part in all this." You know, I mean, people's lives just don't fall apart because of a car accident. So, you know, you've got to sit down and figure out your part in all of this. You know, "I've found God, and I've found religion, and my life turned around. And if you found God and you found religion, you know, maybe your life would turn around. If, you know, if you were just trying harder, you know, you wouldn't be in this predicament now."

When you took this half bottle of Tylenol about a month ago, at the time you took it, were you thinking you'd be dead? Oh, absolutely, yes, ma'am. So think back to then. Okay. What time of day did you do this? It was in the evening. All right. Do you remember what time? It was after dinner. They'd gone off on a walk. So probably like six. Okay. So tell me something. When did you decide to do it? Like, when, when was the moment that you knew you were going to do it? At dinner. At dinner. At dinner. Okay. So you hadn't actually decided yet before dinner, right? No. Okay. Absolutely at dinner. Okay. So what happened? Joe, he, it, you know, this is going to sound really pathetic, but it was a look on his face. It was a look on his face that I remember so clearly from being a kid. And I was like, [expletive], I'm out of here. What was the look? It was like, it's the look that he used to get when I was still stupid enough to tell him about being touched. Like he just didn't believe anything I said. And that it was all my fault. I mean, it's hard to describe, but it's just, it just sets all my hair on edge. And I just faked my way through the last few minutes of dinner. And it was kind of not all that hard once I decided because I knew I was like, [expletive], I'm out of here. I'm not, I'm not doing this. And I thought, I'll just go. So tell me something then, when you get, when your dad gave you that look, was the main, you sound like the main response was you got angry? I got pissed. Okay. So really angry. Yeah. Okay. And so one of the thought, I'm out of here, I'll just kill myself, into your mind, bam, at dinner? Yeah. It was right there. Okay. And so, um, so you wait until the end of dinner. So what made you think of taking Tylenol? Something I knew we had. You had it in your apartment? Were you, were you up at your parents? Here? Okay. Is that where you usually? Yeah, there's not really like a kitchen. There's just like a, like a mini fridge and a microwave in my place. Okay. So you're up there eating. So you went and got their Tylenol. All right. And how come you only took half a bottle instead of the whole thing? You know, I thought that if I took the whole thing, I'd probably just puke. And then, you know, the whole point would be gone. Okay. So once you write a note and do all that stuff, that was with the second one? Oh, all right. So the first one. So the first one, that sounds a little on the impulsive side. You would not be the first person who said that. Perhaps I have an impulsive streak. I think you're right. Okay. I think you're right. Had you been thinking about suicide before that? You know, I, I can't honestly think of a time where I haven't been thinking about suicide. But, you know, I mean, it's kind of like there have been times. I mean, my entire life, it's kind of like been thinking about suicide. Maybe it's sometimes the only way I can get to sleep at night, just knowing that, you know, that there is a way out. But I hadn't really been thinking about like, you know, trying to be dead. All right. Okay. So you take the half a bottle of Tylenol, then what'd you do? And then I went to my room, going to bed, sat down on the bed and just kind of waited to die. So were you thinking that if you just stayed there long enough, you'd end up dead? Okay. So how come you didn't end up dead? That nagging woman that is married to my father, she's such a busybody. She comes down to say, "Katie, your father and I are going to go for a walk. We think that with the mood you've been in, it would be so nice to have you come." So she apparently, you know, she comes in and she finds me. And I'm kind of half in, kind of half out of it. How much long? How far was this? I, you know, it's like, it's so sketchy. I don't really know. I'm just kind of like patching it together from what people have told me. But I know that, you know, despite the fact that they're all worried that I was going to be dead, do they call an ambulance? No. They throw me in the back of the car, drive me to the, uh-huh. You know, you think people were really that concerned that, you know, they call an ambulance. Okay. So they take you to the ER and, um, I mean, I guess they like, you know, pump my stomach there and, you know, and, and I was, you know, I got medical treatment and stuff. And how'd you end up in our intensive care then? I really, you know, you'd have to talk to the doctors. I really don't know. Okay. And how, so in and out and in and out. And I know that they pumped my stomach because I remember that charcoal stuff. And I remember being, you know, like in a couple of different rooms. Um, and then the next thing I know, they're talking about, you know, sending me to a, you know, a psych unit or something. And, you know, that was, and that was a cue to me that I'd better convince these people I wasn't nuts because if I was going to, um, you know, fix it right the next time, you know, I've seen enough movies to know, yeah, they're not gonna let you do this in a hospital. But it was, uh, so in other words, you still wanted to kill yourself? Oh, absolutely. So even though it was impulsive to start with, once you've kind of impulsively decided to do it, you still wanted to do it? Oh, absolutely. I was furious when I realized I wasn't dead. All right. So you were mad at the hospital people? Oh, mad. Yes. And it's still at your parents? Oh, yes. And you decided to lie? Oh, yeah. To get yourself out of there? Yes. Okay. So I'm going to have to be careful because you might lie to me, huh? Kind of a ballsy thing to say. Um, yeah, but that's what's making me think, you know, I, you know, I guess about this. Yeah. Maybe. All right. So how did you end up back in the hospital again? Another suicide attempt? What happened? Well, that's where this nurse reading my, you know, my medical chart and knowing, you know, about my heart problem, she said, "Oh, you know, you're one lucky, you're one lucky young lady. If you'd still been taking this other heart medicine, you know, that Tylenol, that would have killed you for sure." And I just thought, lady, you're talking to a woman who's sitting here in the hospital having just tried to off herself, but you're giving me, you know, recipe tips for how to do this better. And I just tucked that away. And, you know, just kind of waited. You know, waited very planfully. Knew I had to kind of get everybody sort of, you know, alert down if I was going to make this one work. Um, so I tucked that little information away. And then thought, okay, I'll learn. You know, I'll learn from my past mistakes. And my dad's on heart medicine or blood medicine or, you know, something. Coumadin. And I thought, okay, that's what it takes. That's what I'll do. So you took that. So I took that. So how'd you end up not dying? Well, if you ask my dad, it's because he and his wife prayed for me. What was that? I don't know. Probably some sort of screw-up on my part again. Everything that doesn't work out well is usually some sort of a screw-up on my part. I probably just didn't have the right balance and [expletive]. But, um, well, how did you end up in the hospital again? Well, I went to the critical care unit. I mean, how did you get there? I have no idea. I have no idea. I mean, so as you take them, did you try to kill yourself at home? At home. Yeah. I mean, they put me in an ambulance this time. But I, I remember, you know, being in my room and starting to kind of not feel so well. And, uh, I remember I kind of had like a smile, like I was in, it was kind of weird now, I think about it. I was like, I was starting to get into some real, you know, kind of like pain. But, um, I thought, the more it hurts, the more it's working. Okay. So you did this twice. So when you woke up the second time, were you glad you were alive or did you wish you were dead? You know, it's kind of weird. It's like the second time worked and didn't work in that, you know, clearly I'm not dead because I'm sitting here with you. But it worked in that, I don't know, I'm, I'm totally okay with the fact I'm not dead. It's like I was even more planful and more sure that I was going to die this time. This is the one that I wrote the letter. And it's so, it's so weird to me because when I realized I wasn't dead, I was like, you know, that's cool too. That's cool too. So like right now, while we sit here, I mean, this seems so weird that I'm in this like, you know, suicide prevention research. Because, yeah, I absolutely hate my life and I hate my circumstances and I hate everything right now. But it's like I don't have any desire at all, um, to be dead. It's like, I don't know, it's like it kind of like cured me or something. Like now it's like it just seems like, well, there's some problems to be solved. I mean, then suicide was my solution. I mean, I'm very clear about that. But now it's like, you know, I, I've always been like, you know, like a business person, you know, I've got my company and I figure things out. And now it's just one more thing to figure out. Well, listen, I'm thrilled that you're in this program and I'm happy you're in therapy with me. But we have a really serious problem. And our problem is that you lied at the hospital. Not the second time. Glad to hear that. So we've got to be sure now that you are being honest, not only with me, but with yourself. Yes, ma'am. And so when you tried to convince the hospitals after the first one that you weren't suicidal and they should let you go, then I have to say the second time, you convinced them of the same thing because you convinced them that you should be able to come to our program rather than go on involuntary. When there's something pretty clear to me, I can work hard for it. And on the first one, though, and you, when you convinced them you weren't suicidal, did you convince yourself also? Or did you know you were suicidal and knew you were lying? Oh, I knew I was suicidal. I knew I was lying. Okay. So why, my worry is that you're convincing me now. So let me just ask you something. Why? What's changed? I mean, why not kill yourself now? I mean, it just made things worse. I mean, it didn't change anything for the better. Now, not only am I in my father's house, but people hover. I mean, I had zero privacy before. I had zero independence because I'm still getting my physical strength back. I relied on them for everything. And now they hover. It did not, it fixed nothing. It made everything worse. And, uh, I mean, I, I was so sure I was going to be dead. I mean, I had a medical person tell me the recipe for how to be dead. I was so sure I was going to be dead. And I'm not. And I mean, the only way I could guarantee being dead would be like to, you know, like blow my head off or something. But I'm, you know, I don't like pain. I've had enough of it. And there's certain kind of pain, you know, you can kind of handle, like having your body beat up and stuff from a car wreck. But I mean, the, oh, it just, oh, it just sounds like it wouldn't just be so painful to like, you know, like stab yourself or shoot yourself. And, you know, I'm just kind of, you know, I'm just kind of chicken when it comes to that stuff. It's like I don't want, you know. Okay. So let's talk about this because here's the thing. There's no way for me to know for sure how suicidal you are. So my only option is going to be to simply believe what you tell me. And either you're going to tell me the truth, and if you do, this therapy is really going to be useful. Or you're not going to tell me the truth, and the therapy in our relationship will sort of go downhill. So all I can tell you is that it's up to you to somewhat decide how honest you want to be with me. But my only option is to actually just believe you. So I'm going to believe that right now, you don't want to kill yourself. Is that true? That is true. Okay. Wouldn't want to be you, huh? I wouldn't want to be in your position. I can, I mean, I, I mean, I'm sorry. I, I can completely see how hard of a position I'm putting you in. Yeah, you're right. It's true. Okay. So you don't want to be dead. Um, because your parents hover, father and his wife. I'm not my parents. That, that, that's a good reason not to attempt suicide again and fail because they'll just keep hovering, hovering, hovering, hovering. But that's not a very good reason not to actually kill yourself. So the next time you feel the same way, why wouldn't you just do a better job? Unless somebody gives me the better recipe. I thought I had done everything. You're not going to try to kill yourself again because you, you're thinking that it won't succeed, no matter what you do? Well, there's that, and it didn't fix anything. And I've never been a person who's afraid of hard work. I mean, I work with my hands all my life. Hard work doesn't scare me any. And it's been hard work to try to be dead. I figure what worked just as hard and try to get my old life back. I mean, it just, it seems, hahaha, I mean, it's just, give me a Kleenex. Okay. If we could just get my old life back or where I get, or I can have my house back, uh-huh, have my animals, be independent. That's what I want. So in other words, all things being equal, you'd rather have a life worth living than be dead? Definitely. Know how to do it? Okay. Well, let's talk about how to keep you alive because if you're dead, you will not get a life worth living. And so the first thing we have to, I have to go through is one, now that you've mentioned guns and knives, do you have any guns? Do you have a gun permit? No. I don't even know how to get one. Okay. Is your dad have guns? Oh, okay. So, um, we can't really keep you from having Tylenol around. But how about your dad's heart medicine? Where's that now? I don't know. I haven't looked for it. All right. You realize though, that if his heart medicine stays where it was, and you impulsively decide to kill yourself again, you could just easily get it. So one of the things that sounds to me like we need to do, if you decide to be in this therapy and to keep yourself alive, is we're going to have to figure out a way to make it not so available. Right. Get a distance between me and it. But that makes sense to me. Okay. And we've already gone over that you're not on any medications, right? Right. I want to keep it that. I don't know if you're that kind of doctor, but I don't know. I don't want anything. Okay. But they haven't given you any pain medication? Well, yeah, but, well, what do you have? Well, from time to time, they'll give me, you know, some like, I think it's like codeine-based stuff. But when, when I came out of the hospital after the last suicide attempt, um, they didn't send me home with any prescriptions. And my dad has my pain medicine now. So if it gets really bad, I can ask for pain medicine. But I don't have it. That was very smart, I think, from them. Okay. So you don't have pain medicine, but you have access to wherever your dad's got the medication? Yeah, I mean, I don't know where it is. I haven't, I've asked for pain medicine twice and he said, "Yeah, I'll get it for you." And he just brings me one. I mean, I think that they're sort of on the same wavelength as you, that they, you know, they don't want to, I don't think they want to have me try to kill myself again. Okay. So listen, this is, as I said earlier, it's a life worth living program. But to get a life worth living, we've got to stop suicide attempts. That makes sense to me. And so one of the first things we have to do is work on the fact that you've been suicidal. Now, my approach is suicidal behavior and you have to tell me whether you agree with this or not, okay? Is that suicidal behavior, suicide attempts, and even suicide, rather than being the problem, they're a solution. That was definitely it. It was the solution. Yeah. The problem with the solution is there's a solution that doesn't work, right? So certainly trying to kill yourself and staying alive doesn't work because you're already seeing that yourself. So you've got that experience. Okay. And it sounds to me, just listening to you, that you think that if you try to kill yourself again, you wouldn't succeed. And so there's no point in trying, right? Right. Okay. But let's talk about whether my worry, to tell you the truth, is my worry in the back of my mind is that you're someone's going to tell you a way to kill yourself that you're going to start believing will work. So let's talk about whether killing yourself would actually work and whether you've got any reasons to stay alive other than you've got right now hope for a life worth living to get your old life back, which is really great, and that's your strength. That's what's going to keep you alive. And we have to figure out a way to keep that. But we've also got to work on this impulsive sitting at dinner and not getting another, aha. I mean, how do I know you're not gonna watch a TV show that'll show you some way to kill yourself that you'll start thinking works? Yeah. Okay. So let's discuss what you're going to do if you come up in your mind with the way that you now are sure is going to work, like you were the last time. What about that? You think you'll just try to kill yourself if that happens? I think I'll remind myself that I could be wrong. That probably wouldn't work. That's very good. You do want to remind yourself of that. I once treated a patient who shot herself in the head with a gun and lived. No way. Right. Then she just had brain damage, and her life is a whole lot worse than it was before she shot herself in the head. So getting a gun and shooting yourself is no guarantee of being dead. In fact, I can't think of any guarantee. There are lots of ways that if they work, they kill you. But almost every way that if it works and you end up dead is a way that when it doesn't work, you end up in a bad check. Yeah, a lot. So, yeah, no, very good. Life's hard enough right now. Okay. Yeah. Okay. So can we agree at a minimum, this one year, we're going to make an agreement for one year in this treatment, and that's a minimum of one year. You, you will absolutely not kill yourself, even if you come up with the way to do it that will work. Yes. Perfect. Well, you know, did I tell you we have a one-year follow-up where we try to monitor you for a year after treatment? I remember reading that. Yeah. So how about if we agree on two years not killing yourself? Because it would be a shame to go through a whole year of therapy and then knock yourself off. So let's agree to two years. Why not? Okay. Good. So we've got two years, no suicide. Yeah. Okay. Now, the other thing we have to work on is if you have any urges to harm yourself, not so subtly. Have you ever done that before? Your notes said you didn't, but I want to be sure you didn't. No. I mean, like, have I done stuff that's stupid that resulted in me being harmed? Yeah. You know, like.

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Okay, so what did I do in this session? I'm just getting ready to close off the session. I have about five more minutes in the session, and I'm getting ready to close it off by making sure she doesn't want to harm herself. And then what I'm going to do is review with her that we've agreed that she'll, we'll work on making sure she doesn't have access to meds. Will she talk to her dad? Make sure she doesn't. And I'm going to make an appointment for our next session. So what have I done during this session? The main thing I did was try to understand her most recent suicidal behavior and what the predictors of that were. And what I found was that one of the predictors was simply sitting with her dad, and she had an impulsive decision to kill herself, which kind of unfortunately is somewhat dangerously. She then held on to that motivation for quite a while. And so right now, I'm dealing with a person who I have no good reason to believe won't impulsively once again get the motivation or the impulse to kill herself again. And the only good reason that she seems to have for not killing herself is her belief that if she tries to kill herself, it will just make things worse because she won't manage to get it to work. And she seems to have some slight belief that she might be able to get a life worth living, uh, because she wants to start getting her old life back. So one of the things I'll try to do before the end of this session is try to work with making sure she walks out with some hope. Now, in a first session with a highly suicidal client, I usually go 90 minutes. So I usually do one and a half sessions rather than just a short session. So I told the client at the beginning that we would probably go for that much time. And so what I'm going to try to do at the end of this session is give things more or less tied together. I'm feeling that she's made a reasonably strong commitment to stay alive. And my only real question is whether she's fooling me or not fooling me, given that she just ruled the hospital. But there's really not a whole lot I can do about that because there's no way for me to actually know whether she's lying or not lying. So what's going through my mind is I'm thinking about it in a session with her is whether I want to talk to her father and her, her father's wife, and have them come in just to talk to them about the high risk and high dangers that we're in. But I'm trying to debate whether I'd want to bring that up or not. And I doubt that I would bring that up in the first session. So she's walking out saying that she's decided not to kill herself. I don't give her a diary card on the first session. And, um, but I do give her my phone number. And she knows that if anything changes or she gets more suicidal, she can call me. But I don't have any great belief that she's going to call me. She doesn't seem right now the type that naturally would call me. So by the end of the session, what I've done is we've, we have this commitment that she'll stay alive. We have a commitment that if she gets the impulse to call me, she will call me. And we've got that commitment from her that she will make sure that her dad has taken the medication, his heart medication, and put it somewhere where she won't be able to find it. We know that he's already got the codeine somewhere that she can't find it. And we have an appointment to get together again next week. So that's pretty much what happens by the end of this session. Got further questions or thoughts or concerns about this? Be sure to send an email. Put down your question. We won't be able to answer them on the webcast, but we will put some answers to those questions in the toolkit that you get. So thank you. We have now come to the end of this session. Thank you for joining us in the first session in this series on assessing and treating suicidal behaviors. Please check our website at www.behavioraltech.org for the date of the second session in this series. If you would like CE credits for today's program, you can request those by contacting CE info behavioraltech.org. We would love to hear your feedback or questions on what your educational experience has been like through our distance learning programs. Please send those comments to webcast behavioraltech.org. I would like to take a moment to thank Marcia and Katie for all of their hard work and to thank ELN for their assistance in producing this webcast. I would also like to thank all of you for joining us, and we look forward to seeing you at the next webcast.