An Interview with a Suicide Expert

The following article is a transcript from an interview with Ofer Zur and suicide expert, Dr. Brent Potter.

Ofer Zur:  Welcome to an audio recording with Dr. Brent Potter.  I’m your host Ofer Zur, the Director of the Zur Institute LLC.  This audio program is part of an online continuing education course on suicide offered by the Zur Institute at www.zurinstitute.com.

The Zur Institute offers over 150 online courses for psychologists, counselors, nurses, social workers, MFT’s and other mental health practitioners.  Today it is my honor to interview Dr. Brent Potter.  Hi Brent, if I may call you Brent.

Brent Potter:  Of course.

Ofer Zur:  Thank you.  Dr. Brent Potter is a Psychotherapist with 20 years of direct clinical service.  He is the Director of the society for Laing.  Did I say it right?

Brent Potter:  Correct.

Ofer Zur:  Brent is authors of numerous articles whose topics include a wide range of topics such as analytical psychology, humanistic psychology, existential phenomenology psychology, character and personality disorder, chemical dependency and child adolescence mental health’s concerns, really incredible, fantastic range.  His first book, Elements of Self-Destruction was just published.  Am I correct?  It just came out and not too long ago.

Brent Potter:  That’s correct, yeah.

Ofer Zur:  Okay.  So perhaps a good place to start Brent is how is your book with intriguing of Elements of Self-Destruction is relevant and related to today’s topic of suicide?

Brent Potter:  Well it thrills and I’ve been interested in destructiveness for quite a long time.  I came to the topic of that book by – I’ve worked in a lot of clinical settings, community mental health and patient settings hospitals, things like that and extended to work with very distressed populations.  And so I was – I had all of that experience and then at the same time I was getting my doctorate in clinical psychology and I was preparing for my comprehensive exams.

And so I was studying the DSM, the Diagnostic and Statistical Manual Mental Disorders a lot and I was thinking to myself what is the essential kind of characteristic of a lot of these labels that are listed in this book.  It was just – I was curious about that and also matching it up to my experience of working with others and it just occurred to me that destructiveness was really an essential element of that and I just kind of scratched the surface there.

And then I went back to a lot of my reading of Freud and sure enough there you find a notion of anecdotes, kind of a test drive in the personality, and then from there it goes on to what it claims to be – it’s taken up in a variety of different ways.  But it seems to be an essential feature, so that’s how that sparked my interest in that.  And also it seems…

Ofer Zur:  Even just to kind of – we share this interest in human destructiveness because before I became a clinical psychologist I was more in social psych studying – my dissertation was on the psychology of war.  And so my paper was the love of hating and being a war veteran in combat, I was a lieutenant and was wounded in the war.

So I know combat and I know it kind of – in war it bought a destructiveness of both, it destructiveness of other and destructiveness of the self.  So we kind of – we haven’t talked about it before, but we share this background of fascinating with elements of self-destruction as the title of the book.

Brent Potter:  Yeah, I had no idea.  That’s really interesting to me and you point towards some things that I’m working on for my next book.  It really does seem like destructiveness seems to have an impact that isn’t just directed at self, but it can be – it’s almost always projected outward.  And so it’s kind of destructiveness of self is a destructiveness of other, so that’s…

Ofer Zur:  And in war, it’s definitely an element of projection is if I project evil and badness and ungodliness on to the other and I can kill it, it may – so – but that’s kind of brings us a little bit closer to harm to what the topic today as the clinicians who are recording to this recording often facing with probably one of the most dreaded experience in one’s clinical career unless somebody prepared for that, unless somebody is ready trained in a special way.

You’re telling the suicide, it brings issues of loss of somebody who we may have worked for a long time, the fear of course of litigation that goes with it.  And tied to that is also the whole notion that death is a failure of some sort.  So kind of – I mean it’s very complex.

But let’s kind of start with – you have such a broad background to start this topic.  But that start is more kind of – was an epidemiology, neology approach to suicide.  And how would you characterize this approach?  And then we will talk about kind of perhaps later on the disorders and medical disorder and screening, we’ll cover other issues.  But let’s start with the epidemiology.

Brent Potter:  Okay, that sounds good.  And so a few things that tie into that of course is that this is just a very fascinating topic on to itself.  And it’s also has a lot of just practical import.  This is something that clinicians of every sort are going to see one time or another probably with some frequency.  And this also kind of links to what you were saying about, what sounds like a mutual interest with and this is something I just did right before we talked as I hold up.

It seems like this phenomenon is very, very pervasive and it’s so pervasive that at almost any given time I can just open up a major news link on the internet and I did that right before we talked and sure enough top two headlines a fired employee shoots four people, two fatally including company owner in Florida before killing himself.  Second headline is sportscaster suicides.

And I of course have no idea that that was going to be there, but I just knew this phenomenon was so pervasive.  I can just open a window to some news and it’s going to be right there.  So it’s something that really has to be addressed.

So in terms of concrete clinical import for a clinician, I have formulated a lot of things that are based upon the research, that are based upon kind of standards in practices, and then also some of my experiences you’ve pointed out has been in areas outside of natural science psychology including like psychoanalysis, humanistic psychology.

And so there are few things I think I can interject that have practical import just for my experience in those perspectives.  And then mostly it will be like from the research and things that are very concrete.

So in terms of what you are asking, my approach is pretty conservative.  This goes across the board.  My sort of session with a client begins before I even go into the room.  I think it’s important especially for people working in community mental health, hospitals, inpatient settings if there is a new intake during the assessment to stop for a minute and really check in with themselves and see how are they doing, are we centered as clinicians, are we focused.

And that might seem like a very obvious thing to do, but in the busyness of a lot of work we can rush from one thing to another.  And I think that our way of being with the client especially during an initial assessment or just general assessment really has an impact on what they – how they present themselves to us.

Ofer Zur:  And this is important also in relation to suicide?

Brent Potter:  Yes, I think this is, because sometimes clients may not be wanting to talk about that.  Some people might be ashamed of it or might be less open. And so that’s one part of it.

And then also the second part of it is I’m also looking at usually records and things of that nature prior to seeing them to get in an understanding of some of the things historically, but maybe in the chart.  So those are two things that may seem obvious, but a lot of times I’ve noticed clinicians can just kind of rush into…

Ofer Zur:  In the relevance that you emphasize around suicide kind of implied to me what you said.  First of all, if there is a centered – certain ambiance of the interview, we are more likely to get clinical data around the suicide.  The second one, of course, is past records which we’ll talk about later on that – one of the better predictors of suicide behavior is past behavior through the form of other things.

Brent Potter:  Correct.

Ofer Zur:  So you say kind of the look for the records of – if we’re going to – if we’re focused to there about suicide is to look for suicidal ideation and plans means at attempt in the past which is extremely important.

Brent Potter:  Yes and so this leads to the next thing that I was going to tie up into around this is some things to know is that overall suicide rates that I could find were 11.2 per 100,000 persons, ranking suicide as the ninth leading cause of death.  Although age-specific rates of suicide have consistently been highest in the elderly, the incidents of suicide among adolescents and young adults have tripled since 1955.

Suicide is more common in whites and Native Americans.  Higher rates of suicide are reported in western states.  And so in terms of psychiatric disorders, finding some site – well I found this research that was interesting, finding it from autopsy studies consistently indicate that more than 90% of completed suicide in all ages groups were associated with a psychiatric disorder.

The most common psychiatric disorders associated with completed suicides are major depression in alcohol use.  The risk of suicide in patients with new disorders that’s like major depressive disorder, bipolar disorder, they’re 15% and the high – and the risks are highest in the earlier stages of illness.

Ofer Zur:  Okay.

Brent Potter:  So there is a lot of information.

Ofer Zur:  Perhaps you – if you can explain a little bit when you say autopsy, what you mean by psychological – I mean I think you meant psychological autopsy and tell us a little bit what you mean by that.

Brent Potter:  Correct.  That’s how the research – how they stated, correct.

Ofer Zur:  So psychological autopsy means that after the death that you go back to all the records and you try to reconstruct kind of this person’s journey towards suicide, what was the element and just as what…

Brent Potter:  Correct.  And then the data is compiled along certain lines of consistency or certain factors that are in common.

Ofer Zur:  And some of them the people are looking at are of course the psychiatric disorders as well as drug and alcohol use.

Brent Potter:  Correct.  And so it turns out that the major ones are mood disorders and also substance abuse or dependence.  Okay, so some other common ones that they found, these are the most common risk factors are prior suicide attempts, intimate partner conflict, social isolation, family history of suicide…

Ofer Zur:  Again let’s do it again, prior – start again, I lost you a little bit, prior?

Brent Potter:  Okay.  So these are the most common risk factors that are found across the board.

Ofer Zur:  Okay.

Brent Potter:  And this is a prior suicide attempt, intimate partner conflict.

Ofer Zur:  Okay.

Brent Potter:  Social isolation, family history of suicide, mental disorder, or substance abuse.

Ofer Zur:  So all three in family history, okay.

Brent Potter:  Correct.  Family violence including physical or sexual abuse, firearms in the home, legal charges or financial problems, incarceration, exposure to the suicidal behavior of others such as family members, peers or media figures, and physical illness and functional impairment especially in older people.

Ofer Zur:  I would add here when you talk about exposure and I wonder if ties this increase of suicide behavior amongst the youth, now exposure, you have an incredible amount of online exposure that used to be you need to be in the presence of somebody in your high school, somebody in your family or somebody kind of in the community.

But now with a click of a button, you can be exposed to suicidal thoughts, suicidal behaviors, means and tactics, and all the stuff with a click of a button.  So exposure probably is an element that’s kind of part of this digital age.

Brent Potter:  Oh goodness.  I mean I honestly didn’t give much thought to that.  But given the exposure that people of all ages have to unfettered information, goodness, one we guess is just a learning aspect.

Ofer Zur:  Oh absolutely.  Yeah, my daughter and I are working and writing on the topic of psychology as a web and the statistics of the people who watch and kind of are exposed so to speak.  .  So we talk about exposure, it is huge and it’s growing.  And as you say the number of youths who are committing suicide also have increased and I wonder there is a correlation in the last 10 years since the internet kind of dominated so much part of our life.

Brent Potter:  That will be interesting to look at and it seems to have some commonsense impart.  I think that it would only make sense that within and it’s not just access to information, but its access to unlimited information.  There is really nothing or close to nothing that people can’t find and around the mystique of suicide.

I’ll interject as a brief kind of point from my experience perhaps, from a psychoanalytic perspective is that with some of the people went through my work, a question I have in my mind with suicidality is around the fantasy.  I people that a lot of people can feel a lot of suicidal ideation.  But when you talk to them it’s important to ask what it means for them to die.

For example, a lot of times with the label of borderline personality disorder, what the person is wanting to chill off is a pain – emotionally painful aspect of themselves or they’re feeling so tortured by their emotions that they want a new beginning.  So the fantasy is that they will commit suicide and it’s a part of them, it’s the unwanted part of them or a painful experience that will die.

Ofer Zur:  It makes so much sense in some regard because the people that I have encountered working in a jail setting and in being a therapist as long as you have been that – it’s kind of – when people want to die, it’s often they just want to stop the pain.

Brent Potter:  Yeah.

Ofer Zur:  And if they have a fantasy off kind of rebirth though, kind of a new beginning and which in stressful time can make sense or perhaps can make sense for many people who just believe in new beginnings.  And some kind of suicide may seem to be an option, a valid solution, a valid way to relieve oneself from pain.  It makes perfect sense.

Brent Potter:  Yeah.  I think that it’s sort of like – and I have noticed suicidal ideation also tends to come up during periods of transition.  If someone feels like there is a big transition in their life that suicidal ideation will come up to and so the fantasy is around transition.  But the suicide is a literalism of the fantasy.

Ofer Zur:  Yeah.  That’s a very – it’s a very good way to say.  But once kind of we talk, perhaps say I would like to make sure we have enough time to talk about is a screening kind of issues and guidelines and your approach to both screening and it ties to the topic of interview guidelines kind of.

If you can just cover these two issues next, even though you and I can probably talk for many hours about the psychoanalytic, the fascinating psychodynamic approach – kind of analysis of people who have suicidal ideation or acted it out.  But let’s go a little bit to the kind of the screening and the interview.

Brent Potter:  Okay.  So in regard to suicidal ideation, we’ve looked at – let’s see.  So we’ve looked at some of the diagnoses that are major and then we’ve looked also at some of the risk factors and so in regards to evaluation, with new clients.  Okay, so I ask about a history of psychiatric illness and substance abuse.  If it’s present, I ask about a history of suicidal ideas and attempts.

And so that’s more history.  And then I also do a very – at least when I do it, I do a very careful substance screening because substances are almost always onboard whenever someone completes a suicide.  At a minimum, I do a CAGE assessment.  The CAGE assessment is kind of a standard brief form for a substance abused screening tool.

Ofer Zur:  CAGE, how do you spell CAGE?

Brent Potter:  C-A-G-E.

Ofer Zur:  Okay.

Brent Potter:  The C stands for have you ever tried to cut back on your use.

Ofer Zur:  Okay.

Brent Potter:  The A stands for have you ever been annoyed or angered when questioned about your use.  G stands for have you ever felt Guilty about your use.  E, have you ever had an Eye-opener the get started in the morning.

Ofer Zur:  Is this a standard in the history?

Brent Potter:  Yes.

Ofer Zur:  Okay.

Brent Potter:  This is called CAGE assessment.

Ofer Zur:  Okay, excellent.  I like this for construct.

Brent Potter:  Yes, it’s actually really helpful, because – but it’s also important not to rely too heavily upon this tool that is given to us.  We use them and they are helpful, but I tend to go a little bit deeper with the substance used stuff.

When I speak to a client I will usually ask about when is I will go by substance I will take alcohol first usually and I will say when is the first time that you remember having a drink.  And then I will usually ask what time in your life where you drinking the most.

Ofer Zur:  Okay.

Brent Potter:  How much at present would you say that you’re drinking on average?

Ofer Zur:  So you make sure they’re not defensive in the thing.  You just ask for the facts about…

Brent Potter:  Yes.

Ofer Zur:  Okay.  There is no blames, there is no guilt, there is no – kind of you just ask for history here and the fact.

Brent Potter:  Correct.  I do a much more thorough screening because I take substance use very seriously because it is one of the big not just diagnostic labels that’s a predictor, but also the – it’s almost always present in completed suicides.  And so I do a CAGE and I document that and then I go through the major substances and I ask just in the order that I already said.

When is the first time, what time are you using the most, and then how much would you say that you’re using on average, and then the last one when is the last time you had a drink?  And then I move from that and I move through the major substances and I document all of that.

I find that that method has been extremely helpful because you can guess from the responses that you during this will pick up something that may have been missed in past treatment episodes or past counseling visits or things like that.  So substance use is terribly important at least in my mind to assess.  And people often underreport their substance use.

Ofer Zur:  Of course.  So we talk about screening, so we talk about – two things you mentioned kind of in the screening, the mental illness primarily with mood disorders and alcohol and drug use.

Brent Potter:  That is correct.  So in regards to the evaluation what I do is I ask about the history of psychiatric illness and substance abuse.  If present I ask about a history of suicidal ideas and attempts and then I use a CAGE and then I go into a more detailed substance used history.

Ofer Zur:  When you talk about ideas and attempts, most people thought about dying consciously or unconsciously I think, I personally live my life as if it’s my last day, so I use – kind of I give you my best right now in the audience in this interview and after that, I will be with my dogs and my family and I will be as pleasant to them as I can.

So kind of living, I kind of put death in front of me on a daily basis kind of – treating it as if my last day, and it kind of helps me prioritize what’s important, what’s not, and how to live life with meaning and joy.  But most people kind of as they didn’t think about death this way, as they’ve thought about kind of death in some ways and perhaps even about suicide.  Do you – when you talk about ideal – ideation, how – what are you after when you explore this area?

Brent Potter:  Okay.  Well you’ve pointed out a couple of things that is really accurate and that is suicidal – well I mean suicidal ideation ranges from suicidal thoughts to completed suicide, it’s on a spectrum.  And I think that during times of extreme stress and things like that, ideas or even passing ideas of suicide I think are common because it’s the human experience.

As you point out I don’t think that it necessarily implies that there is a psychiatric issue at work.  But given that we’re clinicians we got to really be careful about this.  So in looking at suicidal ideation it’s really important to ask them to delineate the extent of the suicidal ideation.

So I may ask things like “When did you begin having suicidal thoughts? Did any event or stress precipitate suicidal thoughts?  How often do you think about suicide?  Do you feel as if you’re burdened or life isn’t worth living?  What makes you feel better?  Is it contact with family?”

Maybe substance use, not contact with family which should be healthy, but substance use helps them feel better.  What makes them feel worse?  “Do you have a plan to end your life?  How much control of your suicidal ideas do you have?  Can you suppress them or call someone for help?  What stops you from killing yourself?”

Sometimes there are family, religious beliefs, a community, something like that that helps them stop.  But I’m curious about that, because did they imagine their funeral and how people will react to their death.  Is there a strong fantasy life around endings?  And then sometimes I will ask them “Have you practiced your suicide?” depending upon the levels that they’re recording.

Some people I’m sure you had in your experience, if you have the comfortable report with them, you’re centered, you’re focused, they feel comfortable.  It’s not uncommon in my experience for someone to say yes, I’ve put a gun in my mouth or yes, I’ve put a gun to my head just to see what it felt like or they will say something like yeah I’ve got that full prescription of dah, dah, dah, whatever that may be and I really thought how easy it will be to – you see you can really get a lot of information if you ask these kinds of questions.

Ofer Zur:  Yeah.  I know this makes a lot of sense.  Many years ago I worked with a jail and sometimes I have a total of twenty seconds to do suicide evaluations through the hall, just the interview.  So not even in the cell with them and not definitely in my office.

So I’m just walking in the hall and the deputy asked me at the end of the day to do three or four suicide evaluations in literally twenty seconds.  And it was – and some people that I knew before, some people that I didn’t, and then I had to make a decision whether I’m going to put them on suicide watch or not which was a – to talk about it was impossible.

And what I found out as a young psychologist that I want to check primarily on their level of cognition and versus kind of how much clear thinkings they have at the moment of the interview.  And what I did, I opened a port hall and introduced myself and also the deputy introduced me.

And I told them I don’t want to put you on suicide watch, but if you’re going to kill yourself and I didn’t put you on suicide watch I’m going to kill you.  So I’m kind of twisting.  So if the guy will tell his cellmate the doc is not, the doc really had a long day, he kind of doesn’t make any sense or they will be laughing, they say doc, this is really funny, isn’t it?

So I knew that the cognition is intact, but – and I – if I didn’t pick up any other things, I sometimes will not put them on suicide watch, again that’s what I have, twenty seconds.  Or but if you would say something like “Doctor, you can’t do that to me,” I say “Oh-oh, I didn’t.

I say my sense is that the cognition is really impaired at this point, the person must be really stressed and they’re not thinking clearly because my statement was pretty idiotic.  And in this case, I will be more concerned and perhaps do even a little bit more evaluation.  But this is what I came to in twenty seconds, a suicide evaluation.

Brent Potter:  Well that’s a really good point because I’ve worked in jails very briefly too.  It doesn’t sound like I have the amount of experience that you did.  But there is a very limited kind of contact and also not the kind of time often even in a hospital or community mental health setting where you can sit and really talk to someone and get a sense, gather a lot of information.

It seems my guess would be or at least in my little bit of experience that a lot of the substance stuff can be ruled out and then you can do more of a brief mental status exam or something like that.  And in those terms and it’s kind of like how you point out, it’s acuity and also how oriented.

Ofer Zur:  Yeah, that’s what they said.  It was a mental status exam.

Brent Potter:  Yeah.

Ofer Zur:  By the way, in my licensing exams they asked me about suicide, from all the things I needed to ask, to what we know from research and how to connect this.  And then I told them, but put all this aside, let me tell you how I did it yesterday in the jail.  And they listened very carefully and passed me.  So I remember that from 19-…well this was in the 80s.

Anyway back to our topic at hand, so we’re talking about interview guidelines and some screening guidelines and what do we really need to cover.  And anything else that we need to think about because one of the things that I would like to be able to talk to you about today is about we baby-boomers kind of leading their way in assisted suicide. Oregon has legalized it and other states are kind of waiting to do it too.

So it’s like how I’m working with a 93-year-old man and he tells me that he has a plan when the time comes.  So is he a danger to himself or others? Somebody may say he is.  Where are we in our need to respect people and end-of-life decisions? How does it tie to the ethical or even the legal if you can play with life? I’m not sure if it’s an area that you would like to get into or not, but I’m fascinated by that.

Brent Potter:  Yeah. But you’re asking some really hard questions because I think a lot about that too and I don’t mind sharing that.  I have had in my close family a suicide that impacted me very much as it did many people.  And so I really recognize from that experience just how real of a phenomenon this is.

Also, at least for me, it brings home a kind of existential truth if you will, that the notion of taking one’s life really is up to the individual. Now having said that I’m not saying that that should be encouraged. I’m not saying that because they have that capacity that that means anything; it’s just sort of a bare existential fact.

Ofer Zur:  Beautiful.

Brent Potter:  And…

Ofer Zur:  Yeah and not always to…

Brent Potter:  Yeah.  It’s kind of like – yeah.

Ofer Zur:  Not always to be pathologized …

Brent Potter:  Yeah, I don’t believe that it needs to be pathologized.  And in my book I explore – because I didn’t just go back to Freud – I was like this sort of thing existed long before Freud did, right?  So I went back in history and looked at different societies. I was really interested in the way its religion took it up because it does kind of have a moral connotation.  And the more you go back in the history the more important social perspectives were – what that meant and so…

Ofer Zur:  In what ways?  Tell us a little bit more of that.

Brent Potter:  Well, I mean it’s interesting especially if you look back into antiquity.  People’s place in society and their value in society were also tied to a lot of other things such as land.

Family connections meant different things, as far as I can tell, than a lot of them do today where families are very good supports and there is that connection that seems to be present a long time ago.  And so I was curious how religion and society took up something – let’s say suicide – back when there were strong familial, social, and often religious ties…

Ofer Zur:  So in this…

Brent Potter:  And those seem to be constant today.

Ofer Zur:  Is this closure more spiritually oriented? In more socially intact communities what was suicide viewed as?

Brent Potter:  Right, that is exactly the question I was interested in.

Ofer Zur:  And what did you find out?

Brent Potter:  I found out that it was fascinating.  I didn’t find one thing, I found many things.  In some religions, there were, as far back as I could look, very strict prohibitions on suicide.  For people who are of the Jewish faith, there are very strict cultural and religious prohibitions against that; also in the Islamic faith there seem to be. It seemed as I look into Christian history that there were movements in their history where people were committing suicide quite often.

The belief with some of those people was that Jesus died, sort of sacrificed himself, and also kind of this belief that the world is a sin-ridden way station on the way to heaven, so why not expedite the process.  And so there wasn’t as much of a prohibition early on in Christianity.

There were a lot of people who embraced it in various ways.  And as the churches were losing some of their best members, they translated that into a prohibition which eventually translated into legislation that we even have today that there are laws against suicide.

Ofer Zur:  Yeah.  It’s a crime in many states too to commit suicide. It’s illegal.

Brent Potter:  That is correct, it is illegal and it has happened not with the clients with whom I have worked, but with colleagues that a client will go to jail for a suicide attempt after the fact.

Ofer Zur:  That’s incredible! So what would clinicians who listen to this conversation if you feel comfortable going to the survey now and like me, and so it’s a 93 years old man, he got – I think he already got to Hemlock society, now he have a different name, Kit.  And he is thoughtful, he is logical; he doesn’t want to be a burdened.  He mapped it in a kind of a very thoughtful way, what –clinicians are not really –…

Brent Potter:  Yeah, sure that – yeah.

Ofer Zur:  What would you say a little bit if kind of some, because kind of you have this humanistic and existential and spiritual and analytical background, this kind of – you are equipped to look at phenomenon like that.  So give us so fast…

Brent Potter:  Well yeah, again that’s a really, really hard question in the sense that for example, it’s kind of the accent that you’re placing is on orientation rationality and clarity of thought that this person has.  But one interesting thing, I think I – I don’t have it open in front of me, but I think in Roman culture you could make an argument with the senates for your own suicide and if it was clear, organized and rational then that could be granted.  But today in 2013 one aspect that we are required to pay attention to are any legal standards that are there.

So in Washington State, that’s RCW7105, here in California that can be along the lines 5150 where there are cases where people present with imminent harm to self, others or property in Washington I believe unless it’s changed, it also extended to states of extreme inebriation that then there are requirements that we have as clinicians and again this depends upon our role.  If we’re an emergency services worker, if we’re a psychotherapist, if we’re a case manager, but there are generally speaking not just in those two states that I’m familiar with, but in other states as well the requirements and protocols that we do in fact have to follow around that to security the safety of the individual.

So while I recognize that it is kind of a bare existential fact that people do have that capacity, I am also obligated to follow the law and anyone who as a clinician or a human services provider really needs to be familiar with laws at their area and to follow those.  Even though we may have personal beliefs perhaps that one especially who is older like this person you’re describing, it seems arguable that that person would seem to have a right to his own life and the choices that are made him that.  I mean that makes a lot of sense to me, but I always have to look to the legal first before my personal thoughts on it.

Ofer Zur:  Yeah.  And there kind of ways to think about it to kind of what is eminent danger and kind of just heading means does not mean that the person present an eminent danger to self.  So there are ways to think about it, so we end up respecting the individual.

Brent Potter:  As much as possible.

Ofer Zur:  Yeah.

Brent Potter:  Yes, of course that is the highest thing.  And even when I remember doing emergency room work, I really – again going back to the comportment and that you just treating someone as compassionately as possible.

Ofer Zur:  And respectful – and definitely respectful to…

Brent Potter:  Maximum amount of respect.

Ofer Zur:  To their journey.  So kind of as we’re moving along here, what about interventions?  Where do we kind of – what are some of – what are treatment strategies, so treatment plan strategies with people who are suicidal if we can spend a few minutes on that?

Brent Potter:  Okay.  So I tend to think along a decision tree.  So here is how I tend to think about it.  If a client express a suicidal ideation, if the client has a plan then that leads to a few different things and that of course is important to ask about.  I mentioned that before, I can’t emphasize it enough proximity to firearms, what their plan is, what their fantasy around the future is if it’s hopeful or hopeless.  So if the client has access to lethal means that’s poor social support and poor judgment and cannot make a contract for safety.  That may mean depending upon your state with the laws are that hospitalization maybe mandated, it maybe a case where emergency services need to be contacted.  So if a patient does not have access to lethal means has a good social support and good judgment and is able to make a contract for safety then it’s appropriate to evaluate for psychiatric distress or stressors that maybe going on in their environment.

So to get back up sort of to the top, if a patient does not have suicidal intent or plan then again you land at the same place of evaluating for distress, for some clinicians that maybe a history of a psychiatric disorder and also stressors in their environment.

Ofer Zur:  And then also an intervention I could imagine.  So if the idea of the substance abuse, this intervention will be around – along the lines of treating the substance abuse if the hospitalization is not needed, if it’s medicate – if it’s – which can be whether it’s well stab or rehab or impatient or whatever…

Brent Potter:  Yeah.  I am so happy you brought that up actually, because I forgot to make a note about that.

Ofer Zur:  Or even neither or all of them perhaps say a harm reduction, whatever kind of – kind of control used.  Whatever modality will be appropriate to who is an individual…

Brent Potter:  Yeah.

Ofer Zur:  And if it’s depression what I hear from you, you – and there is no really granite home and no really stuck – nobody stuck there on a stock medication so they can mix with alcohol and carry out a suicide, you will treat a depression whether it’s cognitive behavioral or analytic or mitigation or combination of the above.  So am I getting it right kind of the way you are thinking about it?

Brent Potter:  Yeah.  I am so happy you brought that up, because I forgot to make a note about that, yes.  Often times with the more comprehensive substance used screening that I described earlier, it’s not uncommon for something to show remarkable there.  And then in that case if someone has been previously underreporting for example substance used, alcohol used or otherwise, then the next thing that I do is I consult with someone who specializes in chemical dependency things and look at options that maybe available to the client relative to his or her resources.  And you’re absolutely correct, if substance is onboard the appropriate protocol depending upon that will be to have a substance used assessment which can lead to an appropriate level of care which maybe detox, might be outpatient treatment, might inpatient treatment, might be groups.  A lot of people benefit from 12-step groups or there is – I think they call it like Smart Recovery for people who do not want to do 12-step.  But yeah, that’s an excellent point.  And then if it’s mental health, of course and then I go through the options from there and…

Ofer Zur:  We need to kind of – perhaps important to mention here, when we talk about hospitalization or calling kind of referring to emergency services, we need to watch out, because suicide in hospitals or after leaving the hospital is high compared to other kind of period in people’s life.  So it is maybe safe in the hospital for three days as the insurance may allow it, but we have some stat that actually it can increase danger as well in the hospital or right after the hospital.  So we need kind of to be cautious about hospitalization.  The other things that you mentioned that I think would like to have a word of caution is the suicide contract, kind of no harm contract.  You and I probably know that there have been a lot of discussions about sometimes clinicians do the suicide contract and then they just feel oh everything is safe after that.  And so some people have suggested suicide contract actually are increasing the amount of danger because the therapist becoming a little bit less worried about the potentiality of suicide.  It gives them a full sense of security.  So when we talk about suicide contract…

Brent Potter:  Yeah, that’s absolutely correct.  And suicide contracts have no legal merit whatsoever.  What I’m looking for if that comes up or something like it is a person’s willingness to talk about being safe and that in and of itself is an indicator to what direction I’m going and also on the node of hospitalization.  I’ve got a few just from my perspective things to say about that, I am very critical of psychiatry.  I’m not a fan of psychiatric labels.  I’m not at all a fan of hospitalizing clients at all.  I think that part of the importance of doing a proper suicide assessment if that is present is that it actually becomes a therapeutic session in and of itself.

Ofer Zur:  Beautiful.

Brent Potter:  If I can do a proper suicide assessment in the correct way with all the things that I mentioned before that in and of itself…

Ofer Zur:  It’s an intervention.

Brent Potter:  Will become a therapeutic moment which will leave out the need for emergency services.  It will create hope in the client; hopefully I can see them again.  Hopefully they will look forward to setting up a time with me; maybe I can setup a time with them sooner than later.  So then it’s such emotion across us of support, of respect, of compassion and these are the things that I want to do really within the hour or as quickly as I can, sometimes you have 20 seconds, sometimes you have an hour and half.  But to the best of my ability I set that as the standard.  I see this kind of assessment as in and of itself a therapeutic moment.

Ofer Zur:  You know what, I’m so impressed…

Brent Potter:  But I hope that is.

Ofer Zur:  I’m so impressed, because you – it seems like you are a rare combination that you can really – your methodology and your thinking can embrace existential and humanistic and analytical in one breath which is usually not how it works.  There is big fights with the analysts and the existentialists, et cetera and you have an embracement of this different complementary ways of looking at people experience which is I can see how it’s being oven into your clinical assessment and looking at the assessment evaluation as an intervention, as what you call therapeutic moment in a much more poetic way.  And that’s – and again you also emphasize the relationships as well and that’s going to – I’m touched by that, to see that how – and I share with you this skepticism about things and the DSM and hospitalization.  So I do share of course kind of it’s the last resource that we need to know.  But I like how the encompassing of your attitude into human experience and into healing how you can hold it all together.

Brent Potter:  Wow!  Well thank you very much.  I really appreciate that.  And that’s really what I’m hoping for.  I mean I don’t know, the reason I got into the field is to explore psychology.  I was just always fascinated with that.  But above all I want to help people.  I got into the field to alleviate suffering hopefully with others.  And so I try to see no matter what theoretical perspective I’m coming from or what the context is, I’m trying to work towards a wellness…

Ofer Zur:  What about…

Brent Potter:  With the person to connect with them and to be a service to them, I mean…

Ofer Zur:  But you’re also tolerating a lot of anxiety and suffering with your existential, I mean you kind of evolved it in to your presentation today that suffering is part of our existence and…

Brent Potter:  Yes.

Ofer Zur:  R.D. Laing kind of fit into suicide and human suffering?  I mean you’re kind of a rare expert on this topic, because we don’t see too many kind of R.D. Laing names, but you’ve got a chance.  So I don’t want to miss the opportunity to talk.  What will R.D. Laing will talk about?

Brent Potter:  Well my guess would be Laing’s approach actually reflects.  A lot of what I do reflects things that I’ve read with him.  He’s been the big inspiration to me.  And so some of the things that I say come clearly from his inspiration through the things that I’ve read and that is he seemed to have the ability to connect with people very, very quickly.  He seem to be able to really be with people in the mix, in the suffering.  The word compassion means to suffer with.  He really seem to be there with people.

Ofer Zur:  And that’s highly relevant to suicide, because the compassion is kind of one of the way to connect and you mentioned right away when you have this compassioned approach you’re likely to get more history and more relevant information and data.  But also you and I know that compassion is also a healing force, very powerful needless to say, so – and it also – I think you said Laing right now, it’s highly applied to working with people as a suicide.

Brent Potter:  Yes.  And he also had fence of depathologizing to see this suffering and even suicidal feelings and thoughts at time as a normal part of the human experience that maybe more amplified in other people at various times, but it is inherent in all of us.  So he had a way of depathologizing that.  He also had a way of trying to remove the stigma and also to take the moralism out of that…

Ofer Zur:  And it’s beautiful because…

Brent Potter:  Because someone is suffering that they’re bad and they’re sick and they’re wrong and they’re a patient and they’re mentally ill…

Ofer Zur:  Yeah.  And it’s so important when you work with people you normalize the suicidal idealization…

Brent Potter:  Yes.

Ofer Zur:  It’s just so powerful on its own and so you’re absolutely right, kind of depathologizing it theoretical was his writing and perhaps existential his writing as well as us doing it with our clients can be a very powerful way to help people deal with suicidal thoughts when we normalize it for them.

Brent Potter:  Yes.  That in and of itself more than once for me it’s been actually a therapeutic thing is that if I say – I think that it – let me think, I might say something to the effect of I think that that’s a really understandable feeling for you to be having right now.  I think a lot of people, I think almost everyone has feelings of – feeling depressed and feeling hopeless and like they want to end it all.  I think that that’s something that most people experienced.  You’re saying something that is empathic like that.  A lot of times people say really, because I feel like I’m losing my mind.  I feel I…

Ofer Zur:  Exactly.

Brent Potter:  I’m scared of – I hear this, I’m scared of these thoughts like I really don’t want to kill myself, it’s just – but I think about it and it scares me.  I think you could say I can understand how that – I can understand…

Ofer Zur:  Or you could say I know how you feel, I know that, I experienced like that.  I have people that I work and most people sometimes in their life have a suicidal thought and just as – and that is where you will hope…

Brent Potter:  Yes and people can recover from that that it can better, there is hope…

Ofer Zur:  Yeah, normalize is equated with hope.  We can talk for probably for a few more days in this topic, but…

Brent Potter:  Oh my goodness, yes we could.

Ofer Zur:  Yeah.  We need to make a transition here.  And I’m going to say thank you so much.  We spent almost an hour with Dr. Brent Potter and his latest book is Elements of Self-Destruction. And I would like to thank you of thoughtful and beautifully integrated kind of approach both to humanity, to our clients and to suicidality issue kind of based on the fact and based on kind of broad theoretical orientation.  It was kind of really refreshing.  I would like to thank you so much for being with us.

Brent Potter:  Well I’m really grateful for the insight.  And that was I think – I really appreciated the conversation.  It’s such an important topic and it was a real pleasure to speak to you.  Thank you so much.

Ofer Zur:  More than welcome, bye-bye.

Brent Potter:  Bye.