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Additional notes from a class speaking on mental health issues ...

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Week Two I.

II.

Exploring & Identifying the Precipitating Event Video o The goal is Stage two is to allow the person in crisis to share their experience and emotions o While exploring, we should have a focus on what caused the texter to call in. Do not forget to use the GCTs ( reflections/ paraphrasing, strong feeling words, validation, testifiers, open-ended questions, and Strength IDS ). o During this stage open ended questions are useful here. o Focus on emotions rather than situations and facts. Only probe the facts and situations in service of understanding the emotions. o Give them space so that you can meet the texter where they are. You should provided the road and the texter is the driver. o DO NOT BE AFRIAD TO COME RIGHT OUT AND ASK ? o Understand that a few answers can’t provide you a fully questions. o Be patient! Fight the urge to jump into problem solving Active Listening

Approaching a Texter + Active Listening All of the awesome skills you’re about to learn require flexibility (nope, it’s not about touching your toes). Flexibility means we’ll give you example phrases and conversation suggestions, but in real conversations with texters, there is no one correct or exact response. As you grow into a super ninja Crisis Counselor, you’ll learn to be flexible—taking bits and pieces of what you learn here and weaving them into a conversation, using your own voice. This shows a texter you’re human (not a robot!) who is actually listening. In the face of more serious issues, we tend to panic and think about ourselves. It turns into:

The focus is on you in those situations, and not the person in pain. This is understandable. At first, talking about crisis can be terrifying. That’s why you’re in training: to learn how to actively listen rather than passively listen. Active listening is truly hearing what the person is saying, not listening in order to speak. Passive listening is when you’re only listening to figure out when you can speak next. This isn’t really listening. When we use active listening, it shifts the focus from us to them. It turns into:

Our data show that the top three things that texters get out of a conversation are: feeling less alone (56%), less overwhelmed (51%), and more hopeful (39%). If you are genuinely concerned for the texter’s well-being and have explored their pain, they will feel understood. III.

Identifying the Precipitating Event

The second stage of a conversation focuses on understanding the specific event that caused the texter to reach out while assessing their level of risk. Identifying the problem isn’t just to help us as Crisis Counselors understand;

it often allows the texter to comprehend their feelings on a deeper level and gain better insight into why they’re feeling those feels. Continue to build rapport and use good contact techniques and active listening skills as you explore a texter’s situation. A key Good Contact Technique for this stage of the conversation is the open-ended question. Allow the texter to drive the conversation in this stage. We call this, “meeting the texter where they are.” As Crisis Counselors, we don’t take the wheel, it’s more like we provide the road and the guard rails, and the texter is the one in the driver’s seat; Your open-ended questions will act as the guard rails. When exploring, it can be tempting to ask several questions in a row. We call this “interrogating”. We don’t want to interrogate texters! Interrogation puts the Crisis Counselor in the driver’s seat because the texter is merely responding to what you want to know. To avoid this, it helps to ensure your messages have variety. For example, after asking one or two open ended questions, you can add diversity by using the empathetic formula or a simple validation in the following message. Responding with statements allows the texter to elaborate on what they think and feel based on what is important to them rather than merely respond to your questions. Step 1: Identify the precipitating event. Crisis is often precipitated by a sudden and significant change, so try to find out what that was. What was the trigger that led them to text in? Step 2: Dive deeper into the central problem. A texter will often identify a scenario that involves various problems. It’s your job as a Crisis Counselor to help figure out the central problem. For example, a texter may share that he is getting bullied at school because he constantly has dirty clothes. The central problem here may not be bullying, but rather a parental neglect situation. If this central problem seems to be disconnected from the precipitating event, try to get a full understanding by:   

Asking and encouraging them to elaborate (For example “Tell me more”, “Go ahead..”) Exploring emotions around the crisis, not just facts! And lastly, understanding the history (e.g. How long has this problem existed?)

Step 3: Assess for Risk: 

It’s important to note that not every texter will need a risk assessment. Also, the assessment can happen in any stage of the conversation if the texter says something that implies risk.

The following content is heavy, so check in with yourself as you’re going through this section. It’s important to pay attention to your self-care needs while absorbing this material. IIV. Ladder up Risk Assessment Video o Four clear steps to a ladder up Risk assessment (1)Ideation: Are they thinking about suicide ? - You must explore this feeling. You can ask outright. - in introduction, introduct yourself, created rapport and risk assess. (2)Plan: Do they have a plan for how they would go through with it? - Once again, you can outright ask if there is a plan. (3)Means: Do they have access to what they would need to implement their plan? - There must be clear and accessible means. Questioning that is to ask! (4)Timeframe: Have they set a time to carry out their plan within 24 hours ? - Ask directly! o All four steps being met classifies them as an imminent risk . o At this point you reach out to a supervisor. o If X doesn’t have a plan, the ladder up assessment ends. Then , focuses on X plan. o If the texter has the means with them, It is best to ask the texter to separate the means then ask about the texters plan. o Key aspect is to be direct and clear. o All RAQ should be open ended. We strive to understand. o Not all conversations require a RA. o Some Xs are explicit or far from it. o Couple RA with good GCT. Provides warmt. o If the X answers no at any rung then stop the assessment o I am never alone!

IV.

Ladder-up Risk Assessment

One of the main goals of the exploration stage of the conversation is to identify if a texter is at Imminent Risk of suicide or homicide through a Ladder-Up Risk Assessment.

Imminent Risk means the texter has the desire, a plan, the means, and a timeframe in mind to die by suicide or kill by homicide within the next 24 hours. Desire: The texter has directly or indirectly expressed a desire to die, such as saying “I wish I were dead” or “I should just disappear.” Plan: The texter has expressed a specific plan for how they would kill themselves saying something like, “I would swallow a bottle of pills” or “I would shoot myself in the head.” Means: The texter has access to means to follow through on the plan— meaning a method or tool that is easily accessible to them. They might say, “There is a gun in my dad’s office downstairs.” Timeframe (24hrs): Finally, the plan must include an imminent timeframe. If an attempt is already in progress, or will be within 24 hours, the texter is at Imminent Risk and may require an active rescue. For example, “I’m going to take the pills tonight when everyone is sleeping.” The assessment is “ladder-up” because there are four specific steps to the assessment, and you move up the steps as if they were four rungs on a ladder. If the texter answers “yes” to a step, then we move up the ladder to ask the next question. If they answer “no,” then we typically stop climbing and continue to explore. Though these questions can appear closed ended, you don’t want a simple “yes” answer when asking about plan or timeframe. You want to know their specific plan and when they plan to implement it. Ladder-Up Risk Assessment: A Visual Aid 

 

If a texter answers “yes” to all four of these ladder-up risk assessment questions, the texter is considered to be Imminent Risk. Reach out to your supervisor if the texter is at Imminent Risk, but make sure to keep communicating and supporting your texter What is Imminent Risk? Imminent Risk means that a suicide attempt is already in progress or is planned with access to means for the next 24 hours. Ask the questions in this order, starting at the bottom of the ladder!

In order to assess for risk, Crisis Counselors should have an awareness of the risk factors and warning signs for high-risk crises such as suicide, self-harm, abuse, and homicide. Risk factors are characteristics that increase the likelihood of an event. A warning sign is an observable behavior that suggests an event might occur. When interacting with a texter, it’s important to always assess the situation by keeping track of risk factors and warning signs. For example, one risk factor for suicide is a family history of suicide, while a warning sign for suicide is gaining access to a lethal weapon. Neither guarantee suicide, but both give clues and help Crisis Counselors assess for risk. 26% of our texters that mention suicide or homicide are considered at risk. July through October have 20% more Active Rescues than other seasons. That’s why assessing for risk is so important!

Major Risk Factors and Warning Signs for Suicide Individual Risk Factors       

Family history of suicide Previous suicide attempt(s) History of other mental illness, specifically individuals who may be experiencing symptoms of depression Feelings of shame, hopelessness, or loss Identifies as a member of the LGBTQ+ community History of alcohol or other substance use disorder School recently experienced a suicide

Social & Environmental Risk Factors     

Lack of social support Increasing isolation Easy access to or familiarity with lethal means (gun, pills, etc.) Recent stressors such as breakup, or arguments with friends or parents Any event that leads to loss or humiliation

Active Rescues are 110% more likely to occur in a cyber bullying conversation. In fact, a whopping 43% of conversations that Crisis Counselors tag as “Bullying” mentioned social media, and nearly 40% of these conversations explicitly mentioned Facebook. Before The Assessment It’s important to build trust and rapport before you start the Ladder-Up Risk Assessment. We’re assessing for risk in every conversation, in our heads, but the level of questioning and exploration depends on a texter’s responses. The ladder-up approach ensures that we only ask questions that are relevant. Listen for references to feeling hopeless, trapped, or like a burden; or suffering unbearable pain; or having no reason to live. If you notice these things, ask them to expand with open-ended questions. If you’re ever unsure about something the texter says, ask for clarification. It’s always okay to kindly ask the texter to clarify or explain what they mean; they will appreciate your commitment to understanding them and it shows that we’re human.

To help you practice identifying these clues, here are a couple of of example phrases from conversations that we ultimately contacted emergency services for:     

I just don’t have a reason to go on living I’ve basically just cut myself off from the world I just want to die seriously How am I supposed to live my life like this No one cares

Texter: “I don’t know. I’m so overwhelmed and there’s really no point to anything.” Crisis Counselor: “Feeling overwhelmed can be difficult to deal with. Can you tell me more about what you mean when you say “there is no point to anything?” In this example, the texter’s phrase, “no point to anything” is a clue that the texter might be feeling hopeless and having suicidal thoughts. the Crisis Counselor is using a validation and an open-ended question to explore the texter’s pain by asking specifically what is going on. The Crisis Counselor follows up with a clarifying question to get a better indication of risk before leaning into the Ladder-Up Risk Assessment. Notice that most of these do not reference dying directly. Err on the side of caution and ask for clarification from the texter if you suspect the texter has any thoughts of suicide (also known as suicidal ideation). It is a myth that by asking about suicide, you will plant the idea in the texter’s mind. Our examples show that texters will often not bring up the idea of suicide first. It’s up to you to pick up on these subtle clues, and then ask. When you ask directly, you open the door to the texter, letting them know it’s okay to share. In some cases, the texter’s first message is about suicide. We know this can be jarring! In this case, you want to build rapport very quickly so that you can assess their risk. Use one or two messages to introduce yourself and express your empathy and understanding, then go right into risk assessing. You will have the opportunity to explore and build more rapport after the assessment is completed. Here is an example: Texter: “What’s the point in living? I don’t want to do this anymore.” Crisis Counselor: “Hi there, I’m Abby. I see that you are questioning your life right now. It sounds like you may be feeling hopeless.”

Plus: the Crisis Counselor introduces themself and builds rapport with a thoughtful response to the texter’s initial message. Texter: “Yeah, I guess hopeless is the word. I screwed everything up and it will never be right again…” Crisis Counselor: “It can be difficult to see a future for yourself when everything seems so dark. When you say you don’t want to do this anymore, are you thinking about suicide?” Plus: the Crisis Counselor loops back to the texter’s initial message for clarity on potential thoughts of suicide. If you’re still nervous about saying the wrong thing, just remember you’re never alone on the platform. You will have help in the form of your Supervisor, fellow Crisis Counselors, and Toolbox resources. Our most effective Crisis Counselors are 30% more likely to check for suicidal thoughts early in the conversation if clear warning signs present. If the texter says something ambiguous, our most effective Crisis Counselors are 3x as likely to respond with a clarifying question. In conclusion: as soon as there’s a clear warning sign, ask!

During Assessment Risk assessments are most effective when the questions are coupled with Good Contact Techniques. For instance, “You are brave to share that with me. I’m wondering, have you thought about how you would do it?” is a stronger way to assess for a plan than only saying, “Have you thought about how you would do it?” Building rapport this way will ultimately help create a safe space for them to talk, and share their pain.

Ladder-Up Risk Assessment: Cheat Sheet 1. DESIRE - Is the texter thinking of suicide? Crisis Counselor: “You mentioned feeling like your family would be better off without you. Can I ask, are you thinking of killing yourself?” Texter: “I mean, yeah… I’ve thought about it before.”

2. PLAN - Does the texter have a plan for completing suicide? Crisis Counselor: “I know this can be hard to talk about, and I appreciate you sharing that with me. Do you have a plan for how you might do it?” Texter: “Yeah. I’d drive my car off the highway or take a bunch of pills.” 3. MEANS - Does the texter have access to what they would use to kill themself? Crisis Counselor: “I’m concerned about your safety. Would you be willing to share whether or not you have access to your car or to the pills right now?” Texter: “No, my dad has the car and he won’t be back until late. I have the pills, though. They are just in the bathroom- my mom wouldn’t notice.” 4. TIMEFRAME (NEXT 24 HOURS) - Does the texter have a time set, and is it within the next 24 hours? Crisis Counselor: “I want to make sure that you are safe. Do you have a time in mind for when you might take those pills?” Texter: “Yeah, I figured that I’d go get them once we were done talking tonight, since no one else cares.” If a texter has an affirmative response to all four of these questions, the texter is considered to be at Imminent Risk. Flag your Supervisor if the texter is at Imminent Risk, but make sure to ask the texter to separate from the means and keep communicating with your texter. 1. DESIRE Example 1 Crisis Counselor: “(1/2) We’ve been talking about how terrifying it is to feel this overwhelmed with work, and how stressful it’s been to deal with that on top of” Crisis Counselor: “(2/2) your breakup. Through all of this pain, has it gotten to the point where you’ve thought about suicide?”

Texter: “I dunno. Kind of.” This happens. Don’t breathe a sigh of relief quite yet. Ask a clarifying question to eliminate ambiguity. Crisis Counselor: “Just to clarify, are you saying you’re not having any thoughts of suicide?” Texter : “I guess I have been thinking about it.” Example 2 Crisis Counselor: “(1/2) We’ve been talking about how terrifying it is to feel this overwhelmed with work, and how stressful it’s been to deal with that on top of” Crisis Counselor: “(2/2) your breakup. Through all of this pain, has it gotten to the point where you’ve thought about suicide?” Texter: “No.” Crisis Counselor : “I want you to know that if you ever do, you can always tell us.” It’s important here that you don’t say “good” or just move on. If you’re overtly glad they don’t have those thoughts, they might be less likely to tell someone if they do in the future. 2. PLAN Example 1 Crisis Counselor: “I know this is tough to share. You’re so brave for opening up. Do you think about how you would end your life?” Texter: “I would do it quickly, with a gun.” Because the texter shared that they are thinking about shooting themself you can move on to the next rung of the ladder. Example 2 Crisis Counselor: “I know this is tough to share. You’re so brave for opening up. I’m wondering how you would end your life?”

Texter: “I haven’t thought about it that much, no. It seems scary to let myself think that way.” You may be done with your risk assessment, but your time supporting them is not through! Respond using your Good Contact Techniques, and let them know you’re there to listen Crisis Counselor: “It sounds like even though there is a part of you that wants to die, there is also a part of you that wants to live.” 3. MEANS Example 1 Crisis Counselor: “I can see you’ve put a lot of thoughts into this. Do you have the gun you would need to do this?” Texter: “Yeah I have a gun on the table in front of me.” If a texter has access to means, then their plan for suicide is possible and it’s time to move up to the next rung in the ladder: timeframe. Example 2 Crisis Counselor: “I can see you’ve put a lot of thoughts into this. Do you have the gun you would need to do this?” Texter: “Yeah my parents have a gun in their closet.” Here, we know that the gun is always sitting in the closet, but that doesn’t mean that the texter has access to it. Before moving up the ladder of risk assessment, get more details about the texter’s immediate access to and intent. Crisis Counselor: “I appreciate you telling me that; I know how difficult talking about this can be. Can I ask, do you have access to your parents’ gun now?” If yes: continue to the timeframe portion of the ladder-up risk assessment. If no: continue to support the texter. 4. 24 HOUR TIMEFRAME Example 1

Crisis Counselor: “I want to help you stay safe tonight. Have you set a time to go through with your plan?” Texter: “I wrote a note earlier, I’m thinking about doing it tonight after everyone is asleep.” If a texter says they have access to means and an imminent timeframe within the next 24 hours, then it’s always a good idea to ask them to move the means...