Katie Lemieux (2:13)

Bring back some good memories. But before we jump into today's episode, I just wanted to say if you are brand new to our podcast, we want to say welcome to the Startup Nation family. And if you're a loyal listener, we appreciate you being part of the family. For those new to our podcast, you are our very important guest and we want to gift you with something and that is our Free HIPAA download. So just head over to private practicesartup.com head over to the Resources tab, and go ahead and download that HIPAA form. So let's kind of dive in. And I guess, Doreen, I guess where I'd like to start is how did you kind of become an expert in this area?

Noreen Van Der Heven (2:52)

Really, it was by fluke that I went back to work. I stayed home with my kids for about 10 years and went back to work and got a job as a clinical supervisor on this mobile crisis team. Really had no idea what was involved. And it was really. I was a 247 hotline. And we would go out to assess kids who are at risk for suicide, who've attempted suicide, gravely disabled, like, really seriously mentally ill. And so what would happen is, as we continue doing it, I would learn more and more and more. And I thought, gosh, there's a lot to learn about this. And six months after I started, the American association of Suicidology had their conference in Los Angeles. So I told my boss, I'm like, I think we need to go to this. This is what we do. We can get some really good information. So we did, and that was just kind of how it took off for me. And I've been involved with them now for seven years. Our conference is in a couple weeks, and it's like going home to a family. It's people that I only see once a year. And every year I just learn more and more and more stuff about suicide prevention.

Katie Lemieux (4:04)

Wow. And it is one of those can be very heavy topics and uncomfortable to navigate, like child abuse or making abuse calls, you know, And I remember when sitting in, you know, our required CE courses and people saying, it's not if, it's when. And I was like, okay, yeah, yeah, whatever. And unfortunately, I did have two clients die by suicide. And it was very impactful, you know, And. Yeah, and one of them, I had, like, zero clue. Like, there was no reference. He answered all the questions. No. And I saw him for three sessions and like, that was it. But the other one I had worked with for a while, and I was actually unaware. And even though I had asked, I remember he was seeing an individual therapist for suicidal ideations, and the couple never told me, but it was really. It was traumatic for me.

Noreen Van Der Heven (4:51)

Yeah. It's devastating.

Katie Lemieux (4:52)

Yeah. And, you know, when we talk about, like, you know, suicide risk assessment, and a lot of us have come from agency or hospitals and things like that, where we have a team where we can run things by where the whole team is, like, Assessing and there's like checks and balances and things like that. And then sometimes when you go into private practice, it's a little bit different. Like, even though you know the skills, you know, I love that you say every year you go, you learn something new. And I'm really looking for you to share with us how we can, you know, support this in our practice and feel more comfortable kind of being solo. Because I know I always joke around with my colleague Susan. I say, even though I don't see you sometimes, I love to hear the click of your shoes because I know that you're in the hall or you're next to me, I might not be able to say hi to you. And I know for me and you and I talked a little bit about this as we decided to do this topic. And also this topic is something that you guys doctrination had asked for is I remember when Kate and I decided to create our private practice paperwork, our attorney approved private practice paperwork. And one of the reasons, one of the main reasons was my intern was getting ready to go into private practice. She was like hours away from being licensed. And we had talked about paperwork, and she said, no, I don't have any. And at this time, we didn't sell ours. And she said, but the woman that I'm gonna run from says I could use hers. And I said, okay, great. Did you ever reviewed by an attorney? Did you look it over? And she said, no. And I said, well, you know, you need to do that. And she's like, well, it's actually online. I said, okay, great, let's, let's check it out. And the thing, the thing that really actually prompted us to create attorney approved private practice paperwork, I remember reading her paperwork and this person had missing questions, definitely about suicidality, homicidality, violent behaviors, those types of things. And that was really the main thing that prompted us to go on this months and months journey of really bringing our paperwork up to the highest standard. And because if we're not asking those questions and we don't ask and something happens like, oh, yeah, I'm going to turn it over to you from here.

Noreen Van Der Heven (6:54)

It's scary because that's so true, you know, and actually, when I went into private practice, I bought your paperwork because even though I felt like I had a sufficient amount of paperwork, I just wanted to make sure I really liked the fact that yours was reviewed by a lawyer and that it, you know, kind of covered everything and just asking the question. See, and this is the other thing is people are so Afraid to ask their clients, you know, do you feel like you want to kill yourself? And you have to be direct. You can't say, do you feel like you want to hurt yourself? Do you feel like you want to harm yourself? Because harming yourself and killing yourself are two different things. So they could say, no, I don't want to harm myself, but they want to die, you know, or vice versa. So you're asking apples and oranges question, really? And people think that there's this myth that if you ask someone about suicide, you're gonna put it in their head.

Katie Lemieux (7:58)

That's interesting.

Noreen Van Der Heven (7:59)

Where does that come from? You know what? I just. It's kind of a global thing at this point. Like, I hear it from so many clinicians. It's always talked about at our conference, and when I was on the hotline, since I was a supervisor, I didn't answer it, like, consistently, but I was on there pretty regularly covering for other people and stuff. And inevitably, at least once a day. Once a day, at least. And I was there for almost five years. You can imagine clinicians would call and say, I don't want to ask them that, because I don't want them to do that. And I said, well, of course we don't want them to do that. I said, but don't think that they haven't thought about it already. So either they've thought about it and they're going to give you an answer, or if they haven't thought about it, they're going to say no. And you're, you know, generally you're going to be able to tell by their reaction. Sometimes people are very stoic and they will say no. And just like you, you ask all the right questions. And that's happened to a couple of clinicians that I've supervised. They've asked all the right questions, and the person is just dead set on not wanting to live. So they're not going to tell you the truth. But you have to ask, and you have to just be direct about it. In all the trainings I do, because I train counselors all over throughout our counties, and I train other therapists. I make them in the trainings ask each other that question because it's so hard to say, you know, you've never said it before. It's just so hard for those words to come out of your mouth.

Katie Lemieux (9:33)

Wow, that's great. I love that you do that. I don't know why, like, I had this, like, thought in my mind. I remember watching some TV show. I don't this Guy was, like, uncomfortable about sex, and the woman kept making him, like, say, vagina, vagina, vagina.

Dr. Kate Campbell (9:48)

Right.

Katie Lemieux (9:48)

Like, he'd stand in the mirror and say those things, like, why is this popping in my head right now? You know, decrease that and create neutrality around it. And so I love that you do that.

Noreen Van Der Heven (9:59)

And really, the other thing that kind of goes with that is a lot of people, even the media, and we've put out, because I'm also on the communications committee for American association of Suicidality. So we release all the press releases, and we release the standards for language, you know, for media to use and everything. And a lot of people still say committed suicide. And that's just so derogatory. And we're really trying to change the language so it's more compassionate. And people say died by suicide, you know, or ended their life. But, like, if you say you committed suicide, it sounds like you did something wrong. And it's. It's not wrong. It's sad and it's tragic, but, you know, there's no right and wrong in it.

Katie Lemieux (10:46)

Yeah, when we talk about committed, it's usually like, committed a crime or something like that.

Noreen Van Der Heven (10:50)

Yeah, exactly.

Katie Lemieux (10:51)

I remember learning that. I feel like I learned that from the folks here at Tomorrow's Rainbow while back. So really try to assure that I use that. And it's interesting because I don't think anyone really picks up on that. They don't say, oh, that you said died by suicide instead of committed. Like, no, I don't. You know, So I think there's a lot of education and learning to do about that. So what are some of the things that, you know, we can do in private practice? I mean, obviously, to protect our clients, but also help ourselves clinically and things like that. Like, what are the differences between stuff we have at an agency and what we need to assure that we're doing having in private practice?

Noreen Van Der Heven (11:24)

Well, I think the first thing is kind of we talked about earlier is not only in your paperwork, have the questions in your intake paperwork, but in your first session. I always assess for suicidal ideation, and I ask them, you know, on a scale of 1 to 5, because if you say 1 to 10, it gives such a range and it really isn't as clear. So National Suicide Prevention Lifeline and D.D. hirsch Mental Health Services, who. They're in Los Angeles. They run the hub of National Suicide Prevention Lifeline for Los Angeles, like, for the country. They kind of ferret out all the calls. But they came when I was on the crisis team and they did a training for us. And that's when they kind of said, use this one to five scale. One meaning that you have no thoughts of suicide and it's not in your mind right now. And five meaning you are going to end your life and follow through and do something today, you know, to kill yourself. And then whatever number they give you, I know. So someone says a three. I'll say, well, what does a three mean to you? Because a three is different for everybody. Like, I have a client who her baseline is a 2. She is always at a 2. So she always has like these low level suicidal thoughts, but never any action. Like, she's just so unhappy, she doesn't want to live. But that doesn't mean she wants to end her life. You know, she just wishes or pain would go away. Yeah, so that. That's pretty critical.

Katie Lemieux (12:51)

One thing that I've found just being a clinician is when, you know, in our paperwork, we label it important questions I must ask. Right. And then it's just easy because, well, it says yes or no, but then it says explain. And so anytime that I have a client, I immediately turn there to assess that. So I know in that first session if I'm really needing to address anything. And one thing that I find that clients who either are having ideations or having some suicidal thoughts or feelings, plans or whatever, sometimes they don't answer the question. So what I'll do is I scan that really quickly, and if it's blank, I know to go back there because I know that they probably are struggling. Most people don't forget, you know, like other things that people forget to answer, like, do you use illegal drugs, child abuse, like those, you know, things like that. So that's always so that, like clinician to clinician. I'm talking like, if it's not totally checked off on the thing, you definitely need to be asking about. And I mean, you ask.

Noreen Van Der Heven (13:47)

Absolutely.

Katie Lemieux (13:49)

Yeah, I like that practice.

Noreen Van Der Heven (13:51)

Yeah, yeah. And I think, you know, the other thing is make sure that you have all of the numbers for the county where you live. So, like in Ventura county, we're really fortunate because we have the local crisis team and they will respond anywhere within our county. Usually when it was just the children's crisis team and they were divided, children and adult, it was within an hour, we would respond anywhere in the county. Now because children and adults are all together, it's really anywhere from an hour and a half to two, two and a half hours. Los Angeles has their own crisis team. It's called pmrt, I believe. But they Run theirs very differently. So, you know, check and see if your county has a crisis team that if something comes up, you can call with your client in the office after you've assessed it and know you know what your client needs. And the other thing is always, you know, 911 is if you don't have a local crisis team. 911 is a great resource if you think they are imminently in danger of killing themselves.

Katie Lemieux (14:58)

I love that you say that. I know that we referenced that because obviously everyone's crisis team outreach is different. To put that in your paperwork, you could put it on your website. Most importantly is that you know the numbers so they come up. You can even post it in your office, right in the lobby or something like that, if a client is thinking about that or they're worried about someone in their life, you know, potentially killing themselves in regards to suicide. So what other things can we assure to do in our private practice that are a little bit different from agency work that we want to help our clients?

Noreen Van Der Heven (15:29)

And, you know, I think the one thing that you kind of said earlier, which is interesting, is, and you just referenced it is different than agency work. And I know that before I moved into private practice, I was in a group practice, so there was regular weekly group consults, and you always had someone to consult with. But when you're in private practice, some people are in their own offices, you know, or like, I'm with two other women, and I love being with them because I know that I can go in there at any time to say, hey, I need to run something by you, but maybe they're in session. I can't go in. Maybe they're not there. I really can't go in. You know, so have some other resources of therapists that you trust that you can always call to consult with and always know you can always call the National Suicide Prevention Lifeline to ask any questions because they'll be able to answer it. Like, if you're kind of, you know, hemming and hawing and you just don't know. So you can always call, you know, if it's like a legal issue surrounding it, because people just don't even think about that, too, that you can always call your, you know, CAMP or NASW or your liability insurance to consult with them. But I think that it's critical that you do have those resources for yourself. And a lot of people that I've talked to just don't think about that. They're like, oh, well, yeah, you know, they know they can call me like I get calls, I get calls, I get Facebook messages, I get emails, texts. But same, it's like, so what if I'm not available? You know, have at least a few people that you can check in with. I think that, you know, those things are really critical.

Katie Lemieux (17:08)

Yeah. It would be a great time for us to just take a quick break for our sponsor.

Dr. Kate Campbell (17:13)

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Katie Lemieux (17:21)

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Dr. Kate Campbell (17:23)

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Katie Lemieux (17:30)

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Dr. Kate Campbell (18:15)

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Noreen Van Der Heven (18:34)

Enjoy.

Katie Lemieux (18:36)

Noreen, I'm really glad that you had mentioned that because, you know, when that had occurred with my client, I remember the feeling was panic, right? Was like, oh my God, did I miss something? Did I do something wrong? Like, you go into shock, right? And thank God I have a lot of attorney friends and a lot of attorneys that I trust. One gentleman that I had met a while back is a family law attorney and he's also a therapist. So he was actually one of my first calls because immediately, of course, I thought I did something wrong, I missed something. And then you're afraid of legal action and all of this crazy stuff. And one of the things P said is you need to call your liability insurance and the Reason being, and this is really important to know is if it's not suicide or something like that, but anyone takes an action or, you know, creates a claim against you or something like that is if you do not let your liability insurance know and you act without them knowing. I think there's like some type of clause in there where they like could not represent you or not pay your claim or something like that. So just a recommendation is to, you know, check with the trusted attorney and check with a liability insurance company. And you know what? Honestly. So I have American Professional. I used to have CPH ins and the people there were actually so kind. I remember speaking to the gentleman and he said, you know, what we're going to do is we're just going to put it as an open not claim. But I forget exactly what it was called. And it was open for two years in case anything had happened. And he said, but I want you to feel like you do whatever you need to do as a human. He's like, if you feel like you need to go to the funeral and support the family, and that feels right to them. And I was just like, wow. Like, that was just really supportive, especially through such a difficult time, you know, during my clinical practice. And just time is injured, so those are really important. You know, unfortunately, that's kind of like after, you know, the aftermath. But what you're saying is to be able to reach out to those clinical supports, colleagues, supervisors, but also your professional association to navigate those types of things. And I know that you also gave us some resources which we'll also put in the show notes, so you guys can utilize that as well.

Noreen Van Der Heven (20:46)

Yeah. And I think, you know, there's a couple of other things. One thing is every therapist thinks, oh, that's never going to happen to me. Hi. The truth is that it's the. I wouldn't say the most recent statistic. The statistic I heard a few years ago was one in seven therapists will lose a client to suicide. And unfortunately, suicide has risen in the last several years. And so as much as we're working so hard, you know, against it, so I have to imagine that those numbers might have risen too. You know, make sure that you're getting the proper training. And I know in some states that they are now requiring training. Like, unfortunately, it's only like six hours. Fortunately, it's something. So you at least get a basis. But, you know, make sure that you're comfortable in that. Even though you think, oh, I just see some clients that, you know, they come in for like low level issues or, you know, adjustment disorder things, it's going to be no thing. You just don't know. You just never know. And the other thing is when you ever feel loose, two things if you feel that you have a client at risk. One of the things of the giveaways that I have put up on my website is a safety plan. And basically it goes through all of the steps of, you know, what are your triggers? What are your internal coping skills? Like, what can you do without contacting anybody else to help yourself cope? Who can you contact? Who's your therapist? What's the local emergency room? If you're a minor, what can your parents do to help support you? Or if you're an adult, what can other friends or family do to support you? And how long do you think you can actually abide by this? And that's key because you don't want to say, oh, a month, like the longest we would ever go is seven days. But the other thing I want to clarify is there's a huge difference between a safety contract and a safety plan. This is not a contract because first of all, it's not legal in binding anyhow. If they say, okay, I won't kill myself and you both sign it, that's not helpful, number one. And number two, it's not providing them with anything and it's, it's more coercive. You know, here's sign this. But the safety plan is collaborative and you're finding out from them what is it that helps them when they're in distress. You know, you can list 10 things and maybe none of them are things that are helpful to them.

Katie Lemieux (23:25)

So, you know, I think about things like eating chocolate. Another one of my coping mechanisms.

Noreen Van Der Heven (23:33)

You know. And the other thing is, interestingly enough, so through the Youth Suicide Prevention Committee, right now we're on this project that's going to take place with the Boys and Girls Club. I can't disclose where, but it's going to take place with other boys and Girls clubs. And we're doing kind of like a universal safety plan. So it's not even really saying like anything about suicide, but it's like when you start to get upset, what is it that you can do? And we're calling it like Code Red. So there are like four different, you know, areas that they can fill out. And these are all for, you know, teens really. But what we're looking to do is expand that then eventually and have like everybody who sees a client when they first come in, you fill it out, you don't wait for a crisis to happen. So because that right then and there, you're already giving them coping skills to use and to, you know, have them make aware of and what resources they have and stuff. Right.

Katie Lemieux (24:30)

Just kind of making the discussion about suicide as part of the talk. Noreen, what suggestions do you have? I always, not always find, but I sometimes find, you know, on the initial session, like clients will wait till the last 5, 10 minutes of the session to reference their feelings. Suicidal or there's an abuse allegation or something big. Right. Or I know sometimes like something will be said at the beginning of session. And in my mind, you know, I think I shared this with you when we spoke. I always like feel like it was through the time work. I'm like, did they just say child abuse? And then it's like you're not trying to stay present and your mind is trying to process things and you're like, but I haven't even built rapport yet. Like all this stuff is going on as a clinician and it's like tenderly, especially during that first session, it's being able to build a little bit of rapport to be able to address the issue. Well, that's how I see it. I'm sure you're probably going to tell me you're just pretty direct with it because you've had so much practice. So how do you like say it's the first session, like, how do you navigate some of that stuff? What are some of your skills that you would share with us?

Noreen Van Der Heven (25:29)

You know, I just let them know that I want to go back through some of the questions that they answered in the intake and you know, on the forum. And even if they said no to these questions, I still just kind of want to touch base with them about it. So, you know, it's not like I think maybe that they're suicidal or I don't think or, you know, I think that there's child abuse or not. It's just I just want to make sure to cover everything and have them feel comfortable to be able to that ask, you know, to talk about it, whether it be now or whether it be they leave my office and they call me five minutes later. I want it to be a comfortable conversation. But yes, I am very direct about it, especially because in crisis, when you're in going into an emergency room to assess somebody, you don't have time to build rapport. You know, it's like you just need to get down to brass tacks and there you could do it, empathically still, you know, but you do need to ask.

Katie Lemieux (26:24)

And I love how you say that. Like, you just kind of make it part of the conversation and you make it like this okay thing, like, if it's now or never or in five minutes or next week, hey, I just like to ask these questions and you know that I'm a safe person, you know, because also to it, it's going to be how we ask the question, right?

Noreen Van Der Heven (26:41)

Yeah, absolutely.

Katie Lemieux (26:42)

Same with our poker face. And like, that's okay. And okay, great. Let's take the next step. So.

Noreen Van Der Heven (26:46)

Yeah, well, and I think the other thing is that it's if you don't feel comfortable asking it, they're going to pick up on that and they're not going to feel comfortable sharing with you. And I've had many clients come to me to tell me that about anything, you know, recently. Well, last year with the Route 91 shooting in Las Vegas, the concert, and this year with the Borderline bar shooting where 12 people were killed. That was like 10 minutes from my office. So I have a lot of clients coming in to see me for that, whether they were there or they weren't. And they're just affected by it. But they will tell me that they've seen other therapists before who they're just not comfortable telling them because they don't feel that the person is comfortable hearing it or might not know what to do with it. I have a few clients like that right now that have come to me recently from that. So just make sure that your affect is genuine, empathic, and, you know, calm, because they pick up on that very easily.

Katie Lemieux (27:49)

What are some of the trainings that you actually like to point clinicians to in regards to helping them have better skills in this area?

Noreen Van Der Heven (27:58)

I've done well, I've done a lot of reading, which was really key and important. And a newer book that just came out is by Susan Friedenthal, and I also put it in the show notes.

Katie Lemieux (28:15)

So what's the name of the book?

Noreen Van Der Heven (28:18)

Helping the Suicidal Person. All of a sudden I blinked on that. But she's amazing. And she lives in Colorado, in Denver, I think. And she was an attempt survivor and she's a psychologist. And so she kind of talks about that and, you know, talks about, like, how to be able to help people like that. And, you know, I've taken like a lot of trauma workshops and classes. The Trauma focused cbt I've done. I done emdr. And through that I have, you know, really learned a lot about trauma. I'm trying to think through. LA has Los Angeles has Los Angeles county. Every year they have a consortium that they have a one day training and then really the American association of Suicidology is three days just for the conference and they also have two days of pre conferences if you want to take. So I have, I'm telling you. And it goes from 8:30 in the morning until like 6:00 clock at night and there's no breaks, they just keep going. And there's such like a plethora of things to choose from. So it doesn't matter if you're in research, if you're a clinician, if you're a loss survivor, if you're an attempt survivor, it doesn't matter who you are. Anyone in the suicide prevention community really has something to learn there. And really a lot of what I've learned also is from people who have lived experience. So people who have attempted and they do a lot of the workshops at our conferences and you just learn so much, it's coming right from them. So, so that's just been incredible.

Katie Lemieux (30:09)

Nice. I'm sure that creates a really cool experience. This has been really great and helpful for me and even learning from you and what we can all do better. And for those of you who may have had a client die by suicide, my heart goes out to you, I feel you. Or even a loved one or someone you care about. So I know that this can be a difficult topic for us. But as Noreen says, as if we're practicing certain things. Are you thinking about killing yourself? And being really clear and direct, knowing the resources, having support, talking through, getting the right training and feeling comfortable with this often uncomfortable topic. Most often it would really help our own clinical practice, but really help and support our clients. So Noreen, what do you want people to take away from your message today.

Noreen Van Der Heven (30:58)

That this is a critical topic to address with every single client because you just never know. And really to get the education and feel comfortable, you know, asking the questions, knowing what to do when someone says yes, I feel, you know, like I want to kill myself or even if they say yes, I want to harm myself, you know, that you know, just self injurious behavior, that's important too. So read, read, read. There are so many good books out there and the American association of Suicidology, their website is suicidology. And they have wonderful resources, lots of different books on it and they have great conferences too. So it's every year, this year it's in Denver, it rotates around the country from Midwest to the west coast to the East Coast. So if it's in your area, really, I'd suggest trying going. You will. It's fascinating. You'll just really learn so much.

Katie Lemieux (32:00)

Awesome. So I know the book that you referenced, helping the Suicidal Person. And actually one of our old professors.

Noreen Van Der Heven (32:05)

Here at Nova created a book book.

Katie Lemieux (32:08)

Along with Dr. Gralnick called Relational Suicide Assessment. I think that's what it's called. Of course, I'll look it up and we'll place that on the Show Notes page. And that actually helped me gain some better understanding as well as other questions to ask and really influenced our risk assessment in regards to suicide. So, you know, Doreen, thank you so much for being here with us today and your expertise. And I really hope this has helped you guys because I know sometimes in regards to thinking about this topic, it's uncomfortable, maybe it's a little embarrassing. You don't want to share how much you don't know or you do know. Maybe you're uncomfortable asking these things. We just hope that we shed some light in regards to this really important topic. I know we're usually talking about practice building, but this is also an important topic. So we hope that you guys join us next time for another important topic that I think I requested this one because I wanted to know more from Dr. Andre Caruso on creating a transgender and inclusive affirmative practice. So another important area in regards to building your practice and working with certain populations and how we can serve folks better. Before we go today, I just wanted to give a Stardew Nation superhero shout out to Yo Lavi. Yolavi says Kate and Katie offer valuable information with every episode. A super fun and engaging format. I look forward to release of each episode. Valuable information for clinicians and private practice. And we say cheers to your private practice success. And Noreen, you have a giveaway that we're going to add to our Show Notes page. But why don't you. I know you referenced as we were talking, but why don't you share with everyone what that is?

Noreen Van Der Heven (33:44)

So it's under my resources page. You can find it@noreenvanderhoeven.com and there's two things. There's one is kind of the five things that I've talked about to be able to know and the other is the safety plan. So, you know, feel free to download those and use them in your practice and I hope they're helpful.

Katie Lemieux (34:07)

Awesome. Thank you so much. Like I said, we'll put that on our Show Notes page and Startup Nation, thank you again. For always allowing us to inspire you from Startup to Mastery. We really hope that this episode was super helpful for you today and we look forward to catching you later on another podcast. Take care everybody. Have an awesome and inspired day.

Dr. Kate Campbell (34:26)

Thanks for joining us on the Private practice startup. Visit theprivatepracticestartup.com for awesome resources, free trainings, attorney approved private practice paperwork, and so much more.

Noreen Van Der Heven (34:48)

Sam.