In this video, Donald Meichenbaum, PhD, addresses the treatment of patients with prolonged and complicated grief and suicidality and the impact of the COVID-19 pandemic on depression. He discusses evidence-based psychotherapeutic interventions to address these challenging clinical problems.
Dr. Meichenbaum is a clinical psychologist and research director of the Melissa Institute for Violence Prevention in Miami, Florida. He presented a session on these topics at the 2020 Evolution of Psychotherapy virtual conference.
Read the transcript:
Hello my name is Don Meichenbaum. I'm a clinical psychologist who for 45 years worked at the University of Waterloo in Ontario, Canada, where we developed evidence-based cognitive behavioral interventions, and evaluated them. I took early retirement, and for the last 25 years, I've been research director of the Melissa Institute for Violence Prevention in Miami, Florida.
In fact, I'm going to direct you to the Melissa Institute website at www.MelissaInstitute.org where I just gave a 3‑hour webinar on this topic of treating individuals who are suicidal and depressed, as well as those individuals who are experiencing prolonged and complicated grief and traumatic bereavement.
The Melissa Institute has 2 major goals. One is, in fact, to reduce the likelihood of violence towards oneself in the form of self‑injurious behavior or suicidal acts, as well as violence towards significant others. In fact, we've just put together a anger management and bystander intervention program to address the issue of police misconduct, and I hope you will visit the Melissa Institute website to take advantage of that as well.
The second objective that the Melissa Institute, and all I have been focusing on, has to do with the issue of ways in which one can boast of resilience across the entire lifespan. In fact, this is a very timely topic, given that we're all living in the moments of a pandemic where well over 250,000 US citizens have already died alone, not in the presence of their loved ones. There's a great deal of economic uncertainty that has increased likelihood of anxiety and depression.
In addition, there is increased loneliness and social isolation, given the need to remain at distance from one's loved ones has increased likelihood of family violence with shelter in place, the likelihood of substance abuse, and the sale of guns. So this is as timely a topic as possible, and as you will see on the Melissa Institute website, I've put together detailed therapist manuals by myself and others that will be helpful for you to address this.
Perhaps this gets most highlighted with regard to the recent violent suicidal death of Dr. Lorna Breen who was a physician in Manhattan in New York City, and treating individuals who had COVID virus. Given her being overwhelmed by these events, she took her life. So how can we as clinicians identify individuals who are high risk in terms of the risk factors, warning signs, and protective buffering factors? How do we ensure safety and the like?
This is particularly of concern when we think of the vulnerability of individuals in terms of their suicidal potential. In fact, prior to the pandemic, some 40,000 individuals in the United States have taken their own lives, and it's estimated that for every individual who takes their own life, there are 20 other individuals who have attempted.
The vulnerability indicates that in terms of suicidal ideation, some 10 million American adults and 2 million adolescents have contemplated the issue of suicide. When you get to the materials that are on the Melissa Institute website with regard to this topic, you'll see that there is a discussion of the characteristic thinking and affective processes of suicidal individuals, that these individuals are suffering from emotional pain, and moreover having powerful ideation and feelings of hopelessness.
In fact, hopelessness is a better predictor of suicide than is the level of depression—the sense of powerlessness, the thinking that they are a burden on others, and that others would benefit from their own personal death, degree to which they have what [Thomas] Joiner calls a “thwarted belongingness” that they're marginalized, and that no one understands them.
They're particularly at high risk, if they have a prior history of suicidal attempts or self‑injurious behaviors and moreover, the degree to which they feel sorry that those previous events, suicidal acts, were not successful.
There is included on the Melissa Institute website ways in which you can assess suicidal potential using telehealth procedures as enumerated by David Jobes, his CAMS measures of collaborative assessment and management of suicidality. I've included a number of ways in which you could assess suicidal risk.
The first goal, obviously, in any intervention as we enumerate, is to ensure safety, and make sure the individual has a safety plan and a crisis plan, and that you've increased the likelihood, as a therapist, in removing their ability to kill themselves.
Moreover, there is a need to incorporate in your therapeutic process a critical therapeutic alliance. In fact, it's judged by many in the area that a sensitive and deeply caring therapeutic relationship is still the best form of suicide prevention. In fact, the critical need of a therapeutic alliance is underscored by a VA Project now where they are sending individuals who are leaving the hospital for suicide attempts what they call a "caring card."
These are the degree to which the hospital staff are, in fact, interested, and want to maintain an ongoing contact. Unfortunately, most therapists overestimate the quality and nature of the therapeutic alliance.
As I highlight in the therapeutic manuals, there is a need to use what is called "feedback informed treatment," whereby the therapist, on a session‑by‑session basis, actually assesses the degree to which clients are, in fact, perceived benefiting, and a fit between their particular form of needs and that which the therapist is providing.
Over and above, establishing, maintaining, and monitoring the therapeutic alliance, over and above trying to ensure and monitoring safety on an ongoing basis, there is a need to look at the pattern of suicidality, to look at the kind of risk factors that are evident.
I enumerate the variety of cognitive behavioral procedures, and related interventions. In fact, the good news is that these interventions have proven to be somewhat successful in that they have been able to reduce the likelihood of suicidal behavior by up to 50 percent.
These interventions share a number of communalities. They include, for example, teaching various affect regulation, distress tolerance, emotion regulation kinds of skills. They even encourage individuals to engage in some kind of behavioral activation of exercise that will have neurological sequelae of a beneficial variety. They use cognitive restructuring procedures and involves social supports.
The challenge in working with suicidal patients, as you'll read in the manuals, is that there is often a high incidence of comorbid disorders. This may be major depressive disorders, or it may be post‑traumatic stress disorders, or substance abuse disorders. There is a need to provide integrative treatments in this domain. In fact, I recently finished a book that Routledge is publishing, called Treating Individuals With Substance Abuse Disorders.
One of the additional complicating issues with regard to suicidality is the presence of a number of co‑occurring emotional responses of guilt, humiliation, anger and especially grief. We have developed, and you will find it on the website a coping with grief checklist. There is no magic bullet or one way to cope with grief. In fact, the therapist needs to be very sensitive, both culturally and racially, and religiously to the forms and ways in which individuals cope with grief.
We summarize this by noting that there are 2 classes of coping responses. One of these are dealing with the various loss- oriented elements of the death of a loved one, and the other is the restorative kinds of coping techniques of how does one still maintain a relationship with the individual who dies, and their meaning in what you take away from that relationship? And also how do you create a life worth living in spite of these significant losses?
The final element that I want to draw to your attention, if I may, is there’s good news, not only on your effective interventions as I noted with regard to treating depressed and suicidal individuals.
The good news is that if you look at the literature on resilience, you will see that no matter what the form of the stressor is, whether it's a natural disaster, interpersonal violence or living through the pandemic, while most people are affected, some 75 percent of individuals will evidence resilience, that is the ability to bounce back and deal with the ongoing adversities. In some instances, they may even go on and evidence what [Richard] Tedeschi and [Lawrence] Calhoun call post‑traumatic growth. Twenty-five percent of people sort of get stuck and evidence chronic disabilities.
What distinguishes these 2 groups is a key element. In fact, I wrote a book called Roadmap to Resilience that discusses what distinguishes these 2 groups in terms of the nature of the stories they tell themselves, and that they tell others and the accompanying coping techniques. I made that book available for free on the Internet, and as you will see, I've included ways in which you can download my book that discusses how to bolster resilience.
The website as you'll see is RoadmapToResilience.WordPress.com. I'm really proud to say that since I put that book on the Internet for free, it has had 22,000 visitors from 114 countries. So in short, I am at a point in my life, I'm now 80 years of age, and I'm in the midst of trying to give science away.
So please visit the Melissa Institute website. Listen to the webinar that I did on this topic, and moreover, look at the therapist manuals, not only by myself, but there are a number of therapists' manuals and ways to cope with COVID‑19 resources.
Thank you for your attention and interest, and I hope that this brief presentation will stimulate you to obtain further materials. Stay safe and have a happy holiday.
For detailed therapist manuals, visit melissainstitute.org, click on Resilience Resources, and scroll to "Violence to others and toward oneself in the aftermath of the pandemic."