Risk factors for Robert Things you would like to know about Robert (i.e., what information is missing?) Components you think will be important to include in a safety plan for Ro

FEMALE SPEAKER: So, Robert, did you understand the confidentiality I just presented? ROBERT: Yeah. It's fine. FEMALE SPEAKER: Do you have any questions before we get started? ROBERT: No, no. I mean, that was pretty clear. FEMALE SPEAKER: OK. So why don't you tell me a little bit about your background growing up? ROBERT: Background. Well, growing up was– I mean, it was– what do people do? We grow up, right? It wasn't– it was tough. My dad, he was really tough on me. I was the oldest. Little sister. So she didn't see much of what happened. And eventually what happened was, we left. They were never married, so my mom didn't feel a commitment to stay. They had me. That didn't keep them together, so we left. Went to stay with some cousins in Virginia. FEMALE SPEAKER: So your dad was abusive? ROBERT: Very, I would say. I mean, I would get– there was this one Christmas where I opened up a packet. And all I think was to open up the package, right? And he was like, did you give me the finger? I'm like– I'm like a kid, right? And I'm like, this isn't even– I knew as a child that it didn't make any sense, right? He's like, how would I give a– I didn't even know what a finger was. I mean. It was just scary to live in the house. So you would just get beat for nothing. And my mom would stop it. She would come in time to try to stop him from spanking me. So she did what she– she did the best she could. Everybody did the best they could with what they had at the time. So– FEMALE SPEAKER: Yeah. So it says on your intake form that you were in the military. Can you tell me a little bit more about your experience in service? ROBERT: Yeah. Well, we didn't have any money and I knew that they would pay for schooling. So I was always taking things apart and putting them back together. So I went into combat engineering. We would build things and blow things up. That was always fun. Now, I like to know how people think, so my backup was like psy-ops, which is– people hear psy-ops. They think, oh, crazy strange stuff. But it's not crazy strange. It's just how people think. The methodologies and modalities of how people make decisions. So combat engineers was first, psy-ops was second. I grew up near Norfolk. And I don't know if you ever been to the area, but it's nothing but jets all the time, right? So I never wanted to fly, but I think that's what pushed me towards the military. So I chose the Army and enlisted when I was 18. Went on from there. FEMALE SPEAKER: And when you enlisted, where did you head from there? What were your experiences? ROBERT: I had two tours. The first one was Afghanistan, the second was Iraq. And the second one is where I ended my career and left. FEMALE SPEAKER: I can see as you're talking about that that it's painful. I'm wondering if you'd be willing to talk to me a little bit about that. ROBERT: What would you like to know? FEMALE SPEAKER: I guess I'm most interested in what you experienced there. It's part of who you are sitting in front of me today. And I'd like to understand what that experience was like for you. ROBERT: [clears throat] OK. We can. So headed back to base. Not far away, like five clicks. There was debris on the road in front of us. It wasn't enough that it looked like it was intentionally placed, but I knew that it didn't belong there. We could not sit there because, of course, they could come on our six, have us trapped. So what we did was we reversed about 50 feet, made a k-point turn. And when we made the k-point turn, that was when we hit the IED. And the way the vehicle slipped back onto its left side. I was pinned down. My mother says– [laughs briefly] she always talks about how she would pray for me and stuff, but– so not everybody that day was protected, though. FEMALE SPEAKER: Yeah. And you carry that pain with you. ROBERT: Yeah. I would say so. Ramirez– and he was having a baby girl. I don't know why I– I was allowed to live, you know? That's– I mean, it's not fair. FEMALE SPEAKER: Yeah. ROBERT: But I don't make the rules, so– FEMALE SPEAKER: Yeah. But you ask yourself that. Why? Why him? Why them? Why not me? ROBERT: I do. I mean, I do. I– what makes me deserving? It sounds cliche when people say survivor's guilt. I mean, it's– I'm not guilty, it just doesn't make– what if I was sitting on the right-hand side, you know? It's little decisions like that that makes you think about what you do and don't do. FEMALE SPEAKER: Yeah. And does it matter at all? Sounds like it's left you with a lot of confusion and questions, and now what? ROBERT: [laughs briefly] Exactly. I mean, like, now what? FEMALE SPEAKER: You were protected and it sounds like you're struggling even to understand why or what you're supposed to do with this life that you got saved. ROBERT: Yes, ma'am. FEMALE SPEAKER: So, I'm sorry. I'm sorry to hear about that experience for you. And I can't imagine what it's been like to cope with that. And can you tell me a little bit about what it's been like since you came home? After you had discharged? ROBERT: [exhales] Not the same. [exhales] FEMALE SPEAKER: Yeah. How could that be? ROBERT: I have no freaking idea how that could be. My joy is there. John is fine. You know? I mean, I missed his birth, but he's good. Tess is great. She works at the hospital. She's what keeps us going because where we're at is rural, so there's not a lot to do. It's farms, it's this– it's– she'll always have a job. I mean, nurses can go anywhere. Backwoods, they'll be fine. Me, like I said, with the combat engineering, I'm good with my hands, right? With the psy-ops, that's like marketing. Big city, New York stuff, so– we're not in the big city, we're not in New York, work is hard to come by. I just had a online sites Craigslist list to try to find stuff to do. And we fight a lot because she– I mean, she didn't sign up to be the breadwinner. That's my job. I'm the man. I'm supposed to do that, so– FEMALE SPEAKER: Yeah. And it sounds like you're having a hard time finding your place. ROBERT: It's tough. I mean, I get to see John all the time because I'm the babysitter, but I'm not supposed to be the babysitter, you know? I was supposed to be out there and doing, so– FEMALE SPEAKER: Yeah. It's creating a lot of tension at home? ROBERT: We go at it. [laughs] We do go at it. It gets intense. The other day, it was about, like, nothing, you know? She said something, I said something, he's crying, and then it just blew up into a whole bunch of nothing. And it was like all this red flash, right? And then I blanked out for a second. Not blanked out like on the floor. Just like I wasn't me and like I just saw– I just saw my hand like moving towards her and I was like, I– I can't do that. It's– you know? FEMALE SPEAKER: Like it was happening outside of you. And that's not the person– ROBERT: No. FEMALE SPEAKER: you want to be, that you know yourself to be. ROBERT: No, no. That's totally– that's totally out of character for me. That's not– FEMALE SPEAKER: What else is different since you've gotten back? ROBERT: No friends. Nothing happening. No hanging out. I mean, it's TV. I would never even start video games because I know my addictions. [laughs] You know? Just trying to find stuff to do. Trying to find work. FEMALE SPEAKER: Pretty isolated. ROBERT: That's a very good word. Isolated. And she comes home and she doesn't want to talk because she's had a tough day. I don't want to talk. So she'll eat, I'll eat downstairs. She'll go to bed and then she would be like (IMITATING FEMALE VOICE) can you go to bed? And then I'm like, I'm coming to bed, but– I'll go to bed but I'll get back out of bed because I can't sleep, right? So then, what will happen next is– let's open a beer. It's beer, beer, beer, beer. And just– you know, six, eight. Even numbers is good, right? So a 12 pack, you know? Just– FEMALE SPEAKER: Whatever it takes to be able to get to sleep. Shut it off. ROBERT: Shut it off. Yeah. That's a good way to put it. FEMALE SPEAKER: That's causing problems at home. ROBERT: Oh, definitely. Because, I mean, how can you pay for beer when you don't have work, right? [laughs] So it's like a cycle, you know? Trying to break the cycle. FEMALE SPEAKER: Yeah. So, tell me, Robert, I'm getting this picture of some of the trauma that you've gone through and what you've experienced since you were discharged. What specifically caused you to seek help today? ROBERT: I almost hit my wife. FEMALE SPEAKER: It scared you. ROBERT: It scared the hell out of me. That's not me. Like, I know that's not me. So that's not me. FEMALE SPEAKER: What else is not you? Are there other things that you're concerned about? Sounds like there's a lot of things you've said a couple of times that are out of character for you. ROBERT: But– I mean, why– my thing is, why– I'm sorry. I'm just thinking about the confidentiality thing. What I share between you and I, right? FEMALE SPEAKER: Everything that you share in here is confidential unless you're talking about hurting yourself or someone else, then we would have to have another conversation. Is there's something that you're afraid to share, that you're afraid you can't talk about with me? ROBERT: It's not that I'm afraid to talk about it, it's just– sometimes I feel like why even keep going on, you know? Like, why– I guess it goes back to that whole protection thing. Like, why was I protected? Why was I spared? Maybe it would just be better for everybody, you know– Tess will always have work. John will always be OK. We have a family that will take care of them, you know? Like, if I'm the problem, well, you do the math, right? You solve the problem. So if I wasn't around, it would be– maybe it would be better for everybody. You know? FEMALE SPEAKER: If you took yourself out of the equation. ROBERT: Yes, ma'am. I mean, I have a gun. I would– I'm not saying I'm going to walk around and do anything crazy, I'm not just– I'm not saying that, but I'm just saying, why? FEMALE SPEAKER: Because you're having a hard time understanding why you're here and why it's all worth it. Or thinking that it's not. ROBERT: Is it even worth it? FEMALE SPEAKER: Yeah. ROBERT: That's question, right? FEMALE SPEAKER: Sounds like you really are struggling with that. Trying to answer that question. ROBERT: Yes, ma'am.

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SUE BANKS: At this time, Dr. Slater and I want to discuss some issues that we think are important to consider when we're dealing with clients who present with serious issues like suicidality. So, Dr. Slater, why don't you tell me a little bit about your practice, and why you became interested in this topic of suicide? MICHELLE SLATER: Well, I got started in my first semester of graduate school. And my instructor was the director of the local crisis center, so I went through the training there. And, honestly, I was hooked on it from then. So there was an extensive training program, and we trained to answer the 24-hour suicide hotline. As I worked my way into the center, over the years I became part of the outreach team in the community– responding in person to suicidal clients, doing death notifications with local law enforcement, and following up in the community after a completed suicide death. And then I ended my stint there as a trainer– kind of training new phone volunteers and practicum students and crisis response. SUE BANKS: That's interesting. My background is a little bit different. I work with the chronically mentally ill individuals– SPMI. And so I went through the ASIST training. I don't know if you're familiar with that. MICHELLE SLATER: Oh, yeah. SUE BANKS: So my training and background came through learning how to work with and assess individuals who came in for standard treatment and services. And so the ASIST model was really effective for me. I learned quite a bit using that model. Now, you mentioned that you learned then through the suicide hotline, and your work with clients currently consists of– MICHELLE SLATER: Currently, I have a private practice office location, and I see suicidal clients more in acute crisis– not really dealing as much with chronically suicidal or with severe mental health issues. So fairly frequently, I get the opportunity to work with a client who's just hit a crisis point in their life– a rock bottom– struggling with some feelings of hopelessness and depression– and working through that is commonplace. We teach our students, obviously, that nobody escapes the need to have to deal with clients in crisis. You can't really predict exactly when or what that will look like, which is why it's so important to have exposure to how to assess and how to deal with suicidal clients. SUE BANKS: And so what would you say your approach to assessing your clients in suiciding your clients? MICHELLE SLATER: Having started my mental health career working with high-risk and suicidal clients, it seems to be such a natural part of what I do. And I think the first thing that jumps out when I think about what my approach is like I'm listening for the hallmarks of suicide. So emotionally, that's hopelessness, despair, ambivalence. People want to live, but they don't know how. And so that's part of, I think, when I'm assessing lethality– I'm hearing hopelessness. A lot of students are afraid we're planting those ideas. It's a reflection. So I'm hearing that, and then saying back, you're feeling helpless. If a client responds to that in the affirmative, then I'm going to go ahead and put out there– you're thinking of killing yourself. And that's really hard for students to get used to the idea of– there's a boldness and a confidence to doing that. I think it's a good time to, sort of, add– I've never had clients be mad at me for doing that. That that is, at least, demonstrates a willingness to go there. And early on the hotline, I can remember saying that with a client who seemed very hopeless and crying. And so when I had said that, there was silence, and then she kind of chuckled a little and said, oh, my gosh. I must sound terrible. And it gave us an opportunity to say, you sound like you're in a really bad space. And so it didn't turn out that she was actively lethal or considering it, but what a great conversation and a great opportunity to assess it. Even if it's not necessarily heading in that direction. SUE BANKS: When I think about my approach, I tend to be very narrative focused. So it's important for me to allow the client an opportunity to tell the story as much as they're able to. Because I don't know how much of an opportunity they've had in the past, to just– to talk about what they're experiencing. So I try to just go with them and allow them to tell as much of their story as I can. And as I'm listening for their story, then I'm assessing the risk, the opportunities to plan. And so from there, I'm able to determine– or just, kind of, like process with them where they are in their plan. To the point that, again, once I am satisfied that the risks are present, then I do just initially ask, do you want to kill yourself, or are you thinking about suicide, to see how they will respond. MICHELLE SLATER: One thing that I have happen quite a bit is the struggle with people who are having suicidal thoughts or feeling really trapped or hopeless but not actively wanting to kill themselves. And as that comes up in assessment, I think has been really helpful for me over the years to kind of present to clients this continuum. We're all on the same health and wellness continuum. It's very easy for– particularly, beginning counselors and counselors in training– to inadvertently have an us and them, so those people that struggle with feeling hopeless or those people who are suicidal. As opposed to that's us– what would it take on any given day, when you are here at this end, feeling healthy and well, and on this end, giving up hope. And that any given time, we could be sliding on that continuum. So I have found it really powerful to present that to clients in a way that helps normalize it. And that allows me then to assess do you want to die, or is it just that you're having a hard time figuring out how to live? SUE BANKS: Yes. MICHELLE SLATER: And I get a lot more, in my practice now, I get a lot more clients that will say, no, I don't want to die. It's just none of this makes sense. I cannot figure out how to cope with this pain. And that that's a real nuanced part of an assessment that I don't I don't think you always get that in the textbook about asking the questions. SUE BANKS: Exactly and separating depression or assessing for depression and suicide because sometimes the hopelessness can display as signs of depression. But, yet, you pinpoint that depression, however, you don't go a step further to assess and continue forward with suicidality. And that's really important as well. MICHELLE SLATER: Yes. SUE BANKS: That continuum. MICHELLE SLATER: And I think to what you said about letting them tell their stories, a lot of mistakes that I have seen over the years in training students and phone volunteers to assess, it's that it turns into an interview– an interrogation. So you're thinking about killing yourself– when, how– all the questions that you learn how to do but don't quite learn exactly that how of it, the nuanced way. That's that art and science and a balance when you're learning to be a counselor and letting them tell their story. Then finding out another piece of that puzzle and a very natural, you're thinking about killing yourself? Yes, and tell me more, instead of getting triggered and scared of what the client said, sitting back. SUE BANKS: And as we're talking, I often think about the interplay, or the change between transference and countertransference, when you're talking about, do we hear, get the sense that there are some suicidal ideations going on. And then we go into interrogation mode, and start to question, answer process. And how much does transference and countertransference really impact the whole process that is occurring? Sometimes, it's– I have to be careful not to allow my own views or thoughts about how a client presents in practice with me, and really miss what's going on, or what their story is, or what they're communicating to me because I've already framed them based on their appearance, or based on how they present– some of the stereotypes. Oftentimes, as well, I have to be mindful of how clients frame me and their view of me because it really does impact and affect how much they will share with me, or how willing they are to really disclose their story, or what they're dealing with. MICHELLE SLATER: People are therapy wise. We go over the limits of confidentiality– what you see in movies, what you know that there can be consequences if you are honest. And a lot of times, beginning counselors are real concerned about that. And our clients are hypervigilant about that. And I do think being able to really explain to clients that, so something like that continuum of where they are on that. Also being aware of how we're triggered, and how we're reacting, and being able to express genuine concern for clients that help me– like help me understand how you're going to stay safe. That being able to speak to that part of them that does want to live. Certainly, we don't want to underreact, and we don't want to overreact. And I think to your point, really, it's about that moment of connection and staying in the fray with them. SUE BANKS: Yes. MICHELLE SLATER: Being in that session can be scary and uncomfortable for both parties. SUE BANKS: Yes and maintaining the boundaries or having the clear boundaries without verbalizing what those boundaries are. It's very important because, again, the safety of the client is what's– the main focus from the therapist's perspective, the counselor's perspective. But at the same time, you want the client to feel comfortable enough to really express and to open up and talk about what they're struggling with. MICHELLE SLATER: And how do we do that? How do we– that, again, our preoccupation with the safety concerns that a suicidal client presents with can really be a barrier to the advanced empathy, to the depths that we need to be able to connect. It's that well theory of we have to be willing to get into the well with our clients. SUE BANKS: Absolutely. You call it getting into the well. I call it going around the bin. I use the analogy of the three-legged race, and walking, running that three-legged race with that client and not dragging the client– staying with them. And at that– in that case, you are able to, again, communicate the safety concerns that you have as a counselor, and then offer them an opportunity to share more in-depth what they're experiencing, and get the help that they need because that's what they're really there for. MICHELLE SLATER: Yeah, and I think really that's the primary concern for a lot of our students from beginning counselors– am I going to be able to handle it? Am I going to be able to– whether it's your legs strapped together in a three-legged race– or am I going to be able to go into this dark, deep well where it feels scary and painful? Am I going to– not only can I go in, but am I going to be able to get out? Or what's going to happen to me if I join into that type of pain? And you had mentioned boundaries. We talk so much in this program about self-care, confidence, experience, training. All of those things, I think, help us know that we're not alone in it. That we have what it takes to engage that level of intensity and be OK. But your client is struggling in that well, and I like to remind my students that this is part of what we've signed up for. Not to join in with someone's distress when it's convenient for us, but when they show up, we show up, and meet them there. It does no good to stand at the edge of the well and yell down, you're going to be fine. Or I sometimes in my mind think– I'm a very visual person– of this idea of when people are drowning, and the Coast Guard is rescuing them, so they lower a basket down, and they come with them, and they secure the person in the basket. They don't just lower it down on top of them. SUE BANKS: It's a process, and reminding students that there is a process to assessing risk– suicide risk. There's a process in everything that we do, or method to everything that we do. But at the same time, we are to be human. I think sometimes we get so– or it's an opportunity for students to become so theoretical or so focused on the process and the steps and what you do, that they forget the human part in being with the client as you go through that. The more human you are, the more you respond to what is actually happening in the client's experience, then it makes the process or the steps that you have to take through suicidality, or whatever the other risk is more personal, more relatable. MICHELLE SLATER: Authenticity is critical. A lot of times, I think, beginning counselors trying to pretend that they're not freaking out about this person is really in despair. And I'm looking down, and realize I have to go into the well. But to be able to say– and I, over the years in very genuine moments, I can think of a couple of different situations with clients that were in intense pain, where I have just naturally, my hand just goes to my heart. It sounds unbearable. I can't even imagine how you're carrying that type of pain. I don't know if that response is in a textbook somewhere, but I know that in the moment, that's my honest reaction to what they've shared. And being able to say, I don't have all the answers. The scariest clients for me have asked very directly, give me a reason to live. When I share that with students in training situations, you can see the look on their face. Oh my gosh, if a client ever asks me that, it sounds like, what would you do in that situation? SUE BANKS: So what do you have to say, or what are your thoughts about vicarious trauma and clients who have attempted suicide? MICHELLE SLATER: For me, boundaries, of course, self-care, compartmentalizing– some of that is essential. But also, I have a way a of viewing– people have said over the years, how could you do that kind of work, or how could you respond to a completed suicide and not just be devastated? Or how do you not take that home with you? And I think, honestly for me, it's the way that I look at it. I see it as a growth. Crisis is danger and opportunity. And I see a lot of pain. But I also see a lot of people overcoming and coping and surviving and growing. And reminders of that give me perspective. I can't save anyone. SUE BANKS: Yes. MICHELLE SLATER: That's not my job, but I'm walking alongside of you in your pain. I do a disservice to my clients if I try to carry that for them. They don't get stronger. SUE BANKS: Absolutely. MICHELLE SLATER: And so perspective really helps me to be aware of what's mine to carry and what's theirs? And that it's patronizing to assume that they need me to save them or take care of them or to care– I'm empowering them. So knowing my role and my limits, I think, is really the most important part of how I'm able to, at the end of the day, I know. And I'm asking myself that if I were to see this on the news, what would I have wanted to do differently? Is there anything I would have wanted to say or do? And to the best of my ability, I finish my day, I finish my session, not having regrets about things that I could've, would've, should've said or done. And that would really be my advice to any counselors that are working with high-risk clients. Just know that in that moment, you're pushing yourself to do the uncomfortable things, to ask the questions that need to be asked, and that you're willing to risk. And that that leaves me feeling satisfied at the end of what I've done. SUE BANKS: Yeah, I agree. I agree with the boundaries– understanding your role as a counselor and not believing that you are there to solve any of the client problems or to be that fairy who fixes it all. MICHELLE SLATER: The nature of crisis really is that there are no easy fixes. And for beginning and counselors in training, I think that's really the tricky part. There's still a tendency to want to solve the problem. And there isn't an easy answer. The only way is to connect. And so in the absence of that, if you're doing the best you can to connect, then you've done all you need to do– all you can do. With the clients that I referenced, they are asking, looking for a reason to live. The answer then is I would if I could. But what can I do for you? I can sit through this with you. I can journey alongside you, and I can help you try to find the hope that's going to keep you going. And I would think that really a part of being able to cope with this type of intense work is knowing what you can do. SUE BANKS: Yeah, I think that sometimes students– especially beginning students– really seek for something to do. They feel like they have to be doing something. MICHELLE SLATER: They're not doing enough. SUE BANKS: As opposed to being. I focus on just being– being with, being there, being human. And that, oftentimes, is what gets clients through crisis, as opposed to doing something. MICHELLE SLATER: Absolutely. SUE BANKS: So in that, I think that there are no steps, finite steps, that we can suggest to say– do this and this is the outcome. But to be mindful, again, what the role is, what their boundaries are. Having the approach, how do you address certain things? There are approaches and steps to take. And just being mindful of that and then being– being with. MICHELLE SLATER: That's great, great advice. And just even talking with you about it, you realize it emphasizes the importance of consultation, peer support, of connecting with people who understand what you're going through. So there are opportunities to a long day, you vent with family or friends, or it's really, it was just a hard day, or it was a difficult client. But really it is important to have your own network too of– I have fabulous counselor that are friends and our colleagues at Walden are an amazing source of support. Even in private practice, I have people that I can call up if I need to process. And that's with regular clients, and then I have people who specialize in crisis work and have the same background. And diversifying that, and making sure that you have a good support system of people who understand you. Sometimes, I don't want to talk about it at all. So I've got those friends too, and just crafting a good network, I think, is so important. SUE BANKS: When I have clients who present with suicide, I tend to always conference those– just in case there's something that I missed. Or that there's some precaution that I should take, or something that I should think about the next time that I meet with them, or in the next situation beyond when they leave my office. So just having the network to discuss and to conference cases is what is important. MICHELLE SLATER: And the value is twofold. You get to learn from your experiences if needed, and then just debriefing. SUE BANKS: Yes. MICHELLE SLATER: In my crisis work, I do a lot of debriefings in response to crisis in the community. And I never underestimate the power of bringing people together and just letting them, like you said, tell their stories, share what impacted them, and we need to do that as counselors too. SUE BANKS: Yes. MICHELLE SLATER: Tackle that continuum. Sometimes helping professionals are guilty of– we're on a different category as well. We're supposed to be able to handle this. And I do think that is it gets to a, speaks to a fear, that a lot of students may have as well. That they're going to get out there, and be on their own not– overwhelmed and not able to cope with it. And I mean, we have to work to build that network. And we have to allow ourselves to be vulnerable to access support. SUE BANKS: So we have a few more minutes left, and I do want to know what are your thoughts about suicide contracts? MICHELLE SLATER: Well, I do not use a written contract. I think it's critical to get some verbal agreement. There's research out there that confirms getting clients to agree to a plan, a safety plan, does impact their safety. And, again, that plays to the ambivalence. They want to live, and so they follow through with the plan because it gives them a sense of security– something to count on. And I can't tell you how many times in my work at the Crisis Center, I've been working the phone lines and had someone call back in and just say, I'm calling because I said I would or I agreed. Sometimes, they're even annoyed. And, yet, this sort of drive to want to stay alive compels them to do what they've agreed to do. So, I mean, I think it's absolutely critical. I'm glad that there has been a move away from written contracts in a lot of places. It doesn't seem to work for me, in terms of the relationship nature of what I'm doing with my clients. If I ask you to do something and you say yes, then I'm not going to have you sign it. I'm going to believe you would do it. And so that the spirit of it feels very important to me and how you communicate that to your client. SUE BANKS: I– my experience is a little

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