21/07 - Risco de Suicídio no Luto - Saudade, ideação de morte e avaliação de risco. | BRAPSI

[00:00:03]Hi everyone, good evening. We are starting another lecture here at Brapse. I see people are commenting already, the comments have already started. Welcome!

[00:00:13]Today we'll talk about suicide in the context of grief, right? So, suicidal ideation that arises during the grieving process—how to understand it, how to intervene, how to manage these cases? For those who don't know me, I'm Nicolas Rosa, a psychologist, founder, and coordinator here at BRAPS.

[00:00:28]Today I was accompanied by Sebastião Ferreira, a psychologist. Sebastião, have a great evening, feel free to introduce yourself.

[00:00:36]Good evening, Nicolas, good evening to the BRAPCI coordinators, and good evening to those who are watching us here or who will see this video later, okay? I'm Sebastião Ferreira, I'm a psychologist, okay? I specialize in systemic therapy, logotherapy, and I'm currently finishing a specialization in psychodrama.

[00:00:57]And I decided, you know, to create this group to support people with suicidal thoughts and their families in 2014. And since then, no one who attends the group has taken their own life, okay? It's there, everyone's alive and well over there. But four of my private patients who declined the invitation to join this group have already died by suicide. So, when you brought up that topic, the risk of suicide during grief, I think it's very applicable, because I'm currently treating a patient who, after the death of her son, had very strong thoughts for at least six months that she wanted to kill herself, that she wanted to be with her son, you know?

[00:01:44]So, many things that aren't revealed, that aren't talked about during life, people want to find a way to reverse that after the absence.

[00:01:56]So, he talks about death when he speaks of grief, yes.

[00:01:59]But then the question is, how do I differentiate between longing, the desire to die, and the act of suicide? Let's think about it this way: if a mother comes to you after losing her child, and she says, "I wish I could go to sleep and never wake up again." Is she talking about missing someone, or is she showing signs of suicide? That's something to think about, okay?

[00:02:28]So, most of the professionals I know—I can't speak for those I don't know, but those I do know— feel insecure when faced with these kinds of statements. Some downplay the risk, while others interpret any reference to death as a psychiatric emergency.

[00:02:48]However, both extremes can have serious consequences. A key distinction we need to make here is the following. When is a person facing suicidal thoughts or are they just talking about thoughts of death? For example, wow, it's hot today. Wow, what if we had died, right? That doesn't express a genuine desire to truly be there. It's a dissatisfaction with her current existential situation, okay? So, what's the goal here to fulfill what Nicolas asked me for, okay? The goal is for you to learn to listen to the language of grief without trivializing or pathologizing suffering.

[00:03:36]How do I distinguish between longing and suicidal thoughts? First, we need to understand the following: someone who is grieving is completely reorganizing their life.

[00:03:51]For example, that was the case with the mother. No mother thinks about burying her child. She's thinking about the opposite process. Therefore, when we talk about dying, it doesn't automatically mean wishing for our own death.

[00:04:05]So, there's a kind of diagram that I'm going to leave here for you, okay? What would that be? What comes first?

[00:04:14]The mother lost a son to suicide. The first thing that hits me is homesickness.

[00:04:20]As I said, this woman's case involves a desire for reunion, followed by a passive, not active, desire to die.

[00:04:31]By participating in these three stages, suicidal thoughts can then arise. Why? The intention is there, the planning is done, the preparation is in place, and the act itself has already taken place. So, in these three stages— planning, preparation, and action—I say that's what QPF is. What do I want? I'm planning it, okay? Here, look.

[00:04:56]P stands for preparation. Yes, I can do that.

[00:05:02]Now, the act is action, it is doing.

[00:05:06]So, remember that, okay? From QPF. I want to, I can, and I will, okay?

[00:05:13]Now let's break this down, okay?

[00:05:15]Nostalgia, it has some typical phases.

[00:05:17]What are they? Oh, how I wish I could hug him again. Oh man, I miss him so much.

[00:05:28]I would love to talk to you again.

[00:05:32]The person wants to rebuild the relationship. She does not wish to cause her own death.

[00:05:38]My desire for a reunion would be like this: I would like to be where he is.

[00:05:45]Who knows, maybe one day I'll find him?

[00:05:49]Here, the fantasy of reunion emerges. There is no intention to die yet.

[00:05:56]The focus remains on the connection. Rebuild the connection.

[00:06:02]A passive wish to die would be like this: If I didn't wake up tomorrow, everything would be alright. I'm tired. I don't want to live like this anymore.

[00:06:17]Here the focus has shifted. It's no longer about longing; death is beginning to be perceived as a relief. And it is this change that deserves clinical evaluation. Why? That's when suicidal thoughts can arise. When the person starts talking, I seriously think about ending my life.

[00:06:39]I've already imagined how I'm going to do it, because I think dying will solve everything in my life.

[00:06:49]In this context, it's no longer just about suffering.

[00:06:54]There is a tendency towards suicidal thoughts. And this difference completely changes the approach in the clinic. And here's a question for you to think about. When does death cease to represent reunion and begin to represent a solution? That's the question I leave you with. Think about it.

[00:07:20]Now Nick has given me another request. What transforms suffering into a warning sign? Okay? First, consider that not all pain represents risk, but some elements significantly increase what? The probability of suicidal behavior, okay? So, what is hopelessness? It 's not sadness, it 's the loss of the expectation of change.

[00:07:59]A person might say: "Nothing will get better, there's no way out, life is over."

[00:08:08]Therefore, hopelessness is one of the best deterrents to suicidal behavior. And we work a lot with nootherapy, which is when a person presents with hopelessness.

[00:08:21]Franco illustrates this very well in his book Man's Search for Meaning, when he experienced this in the concentration camp, where people would go to the wire, put their hand on the fence, and get electrocuted.

[00:08:35]Many did this because they had lost all hope. And that's precisely what kept him alive. When he practiced self-transcendence, he imagined himself doing things outside of that environment. So his body was there, but his soul and mind were no longer trapped, okay?

[00:08:53]And when I go looking for intensity, what am I going to look for, I want to know? It's about how long these thoughts remain.

[00:09:02]Are these thoughts fleeting, or do they occupy the person's mind most of the day?

[00:09:11]What is the frequency?

[00:09:13]Are these thoughts occasional? Are they daily? Are they constant? Therefore, the higher the frequency, the greater the need for clinical monitoring.

[00:09:24]If I'm going to look at the persistence of this thought, how long has it been going on? days, weeks, months, and especially if there was some prior act against life.

[00:09:41]Therefore, the best isolated variable for an alternative is always to ask. They can't be afraid to ask.

[00:09:51]I, you know, I tell myself that I don't work with prevention, I work with compensation, with contingency, because the public I serve has already committed acts against life, so prevention didn't work.

[00:10:11]So, everyone I treat has already committed acts against life, okay? They are different from whom. Because I have a question, Nicolas, whenever I come here and see a lecture, people say things like, "Oh, approximately 1 million people commit suicide in the world."

[00:10:29]I keep thinking: "Wow, there are over 1 million psychiatrists and psychologists in the world.

[00:10:39]Why aren't these people being accessed?

[00:10:44]If I have over 1 million professionals in psychiatry and psychology, I already have over 400 in my account. If everyone had one, that number could be different. And when you study the epidemiology of suicidal ideation, you read, read, read, but nobody reaches any conclusion.

[00:11:08]So there are some characteristics that are analyzed, it's debated that this can happen, but it's not always possible to predict. Suicide already happens because of this, because it's multifactorial.

[00:11:20]So what do I have? If I'm experiencing impulsivity, what do I need to be aware of? The behavior can occur without prolonged planning.

[00:11:34]The person may commit the act impulsively, especially in situations of intense emotional activation.

[00:11:45]This act of a person who is struggling can be motivated or fueled by the use of alcohol and drugs. Why? Because it reduces control, inhibitory control, and increases..." Impulsivity facilitates the transition from thought to action. I treated a patient who jumped from the fifth floor, but there's a video of a girl who jumped from the 15th floor.

[00:12:13]So, going back to the planning phase, what questions can I ask a person to know if they are in the planning phase? Have you thought about killing yourself, how? Have you thought about taking your life? How much? Where do you plan to do it? Have you already organized anything?

[00:12:31]The more specific the questioning, the better you will know if the risk is higher or not. And then I have to know the following: the person says, "Nicolas."

[00:12:45]It's also interesting that some patients deny suicidal ideation, thoughts, or planning, but if you ask them in a somewhat indirect way, "But what if you were going to do it, how would it be?" Has it ever crossed your mind? They describe the way, they describe the method, and that's how you get to know a little bit about how this patient's suicide planning works, right? Yes. And here I make a critique of what everyone... The world says we shouldn't talk about suicide.

[00:13:16]Then comes the study of the vert effect. But then I ask myself, if I talk about suicide, am I encouraging people to do it? And if I talk about homicide, if I talk about pedophilia, if I talk about femicide, am I not encouraging them to do that either?

[00:13:35]So I think we should reconsider this position of some of our colleagues. Yes, we should. And if the patient doesn't talk about it—I work a lot with sexual behavior, right? A topic I address a lot in courses and lectures.

[00:13:48]If we don't talk about it in the clinic, where will the patient talk about it?

[00:13:53]Yes.

[00:13:56]So, if the professional who studies and qualifies to be able to talk about it, to welcome this demand, to manage this demand, has a limitation in listening to this demand and addressing this demand in the clinic, the patient will really be totally unassisted.

[00:14:10]Yes. In a meeting I had with the last patient who died by suicide, I was with the family, right? And people were like: "Ah, but "I think I could have done more, I could have been more present." I asked a question like that, tell me something.

[00:14:25]Uh, I think nobody here wanted this ending, but answer me one question. Since you wanted to do more, would you be willing to give up your life and stay by his side 24 hours a day? Like, impossible to do that.

[00:14:42]So, you can't have that thought.

[00:14:45]We do what is possible. What is impossible is impossible, because there are people who take their own lives by suicide within psychiatric institutions.

[00:14:54]And what about there? They should be protected from that act, but it happens, okay? Why?

[00:15:02]Uh, today I said, there is no safe place for a person who has suicidal tendencies, why? Everywhere there is access, there are weapons, there is medication, there is anything that can be used as a rope, there are toxic products.

[00:15:23]You will find all of that in a house, an institution. So availability completely changes the assessment, right? For example, if we take the case of a person with severe anorexia, they don't have freedom, they are with the nurse. 24 hours a day, even in the shower, in the bathroom, during meals, it's 24 hours.

[00:15:45]Why? They could die at any moment.

[00:15:48]Now, a person who has suicidal tendencies, would it be possible for us to have such a person?

[00:15:56]And what happens a lot today, Nas, is this: Most people who die by suicide don't have access to psychiatric care, they don't have access to medication, they don't have access to hospitalization. So, what do we do now? How do I do an initial assessment of someone going through this situation?

[00:16:19]The first thing, as I said, is to dispel the myth. Talking about suicide doesn't induce anyone to commit suicide. On the contrary, it often produces relief. Finally, I can talk to someone about what I'm thinking and what I'm feeling. Which most people reject. No, no, no, for God's sake, don't talk about that. No, no, no, no, no, no. What is that?

[00:16:42]That's nonsense. You can't do that.

[00:16:45]Yes. Even if the psychologist shows some discomfort, it's normal, right? It's common to think that The patient is becoming a burden, someone feels like they're bothering you, and often this thought also arises in relation to the psychologist. So if the psychologist shows any resistance, it's a topic they might avoid so as not to overburden the professional.

[00:17:07]Perfect.

[00:17:09]You talked about how to dialogue with the person, right?

[00:17:15]So, if you notice how the person is, for example, I'll tell you this, I don't know if you'll have the courage to do this. If you want to work with prevention, whenever you meet someone for the first time, " Nice to meet you, my name is Sebastião," have you ever thought about taking your own life without me knowing the person?

[00:17:33]What they do with their hand already gives me an answer as to whether they've thought about it or not. "No, I've never thought about it." And they shake my hand calmly. If they pull their hand away, if their hand trembles, it's crossed their mind.

[00:17:46]Yes, it's so evident that they've noticed it. They've noticed it. So, the first thing is to say: "I realize you're suffering a lot."

[00:18:00]Then, at some point, have you thought about death? Would this be an option for you?

[00:18:08]If he answers yes, go ahead. He's got the line open, he's opening up space to interact with you.

[00:18:15]And then, right? There are five fundamental questions that I'll leave for you here. This, look, comes from this group I've had since 2014. First thing, do you think about dying? Do you think about causing your own death? Do you think about how you're going to do it? Do you have access to the means to carry out what you're planning?

[00:18:44]When do you plan to do it?

[00:18:47]Now I have to explain this process logically, right?

[00:18:55]So, I don't like the word investigation, okay?

[00:18:58]Okay. So, but we need to look for data about what still makes sense for this person to be alive.

[00:19:09]Who knows about their suffering? Does anyone know what's happening to them? Who could help you today?

[00:19:18]Is there someone available that we can contact in an emergency?

[00:19:25]So, these are questions that will give us guidance on protective factors.

[00:19:30]And then I come to work with the clinical formulation to determine the following: this person, are they at low risk, medium risk? Or high?

[00:19:41]Because without that, I won't understand the suffering, what the psychological state is like, what the attachment relationship is like, what the risk factors are, what the protective factors are, what the context of grief is after the death of a significant person, and what the availability of that support network is, and most importantly, what is the person's current situation? Because if it's hopelessness, there needs to be immediate intervention. Now, ladies and gentlemen, let's think about the following.

[00:20:20]If I have a minor, I have someone who decides for them. That's it. If I have a person who is having a psychotic episode, I have someone who decides for them.

[00:20:33]Now, when the person is conscious, the following: I don't want to be treated, I don't want to be hospitalized, I don't want to take medication. What do you do if the person is lucid and conscious? I can't force a person to be hospitalized if they don't want to.

[00:20:53]I can't put a straitjacket on a person who isn't having a psychotic episode.

[00:20:58]So, how do we act in a situation like that? There's no solution. So, the first thing you need to know is this: these people, the first thing you have to do is build a bond with them.

[00:21:14]So, the way I'm talking about here is not to be practiced. Oh, there's a person on the bridge, I'll go there, you don't have a bond with them.

[00:21:25]All the patients I treat sign a document, right, a document outlining the care they need to take, okay? Take medication, call their support network, be with someone if necessary, call emergency services, if they've been through all that and still want to end their life, call me and wait for me to arrive. 27 people have already called me and all 27 are alive. Why? They had a bond with me, they waited for me to arrive, and they got through the crisis.

[00:22:01]So, a well-done assessment produces a clinical formulation and not just a classification of low, medium, and high risk.

[00:22:12]But for that, I have to know the person.

[00:22:16]Now, how do we define protection, support, and what to do to refer them? The first step is to provide support.

[00:22:25]To provide support, I don't... I'm discussing this. I'm not going to convince the person, I'm not going to minimize it.

[00:22:32]I have to validate what they want. I understand that you're taking control of your life.

[00:22:38]Now, I also understand that this pain seems unbearable. Have you talked to anyone about this?

[00:22:44]Can we talk a little about it?

[00:22:46]I've already changed the focus. I'm not invalidating what they want to do, but I'm changing the focus. So, the second step, after welcoming them, would be what?

[00:22:58]Protection.

[00:23:01]But for that, you have to know: is there immediate protection? Can I reduce access to lethal means? Does this person have someone who can stay by their side so they're not alone? Can I organize supervision for this person because I have to plan for the next few hours? And here, this protection enters into something internal, which is home hospitalization.

[00:23:31]This person doesn't... they have support at home, as if they were in a hospital where they're not alone, everything is limited. They have to be accompanied 24 hours a day. Yes. And when they go out with friends, the friends have to be... Briefed on what needs to be done, okay?

[00:23:50]And the third point is, it 's interesting, right, thinking about this thing of home hospitalization, because I've been asked a lot about it in a course I taught on suicidal behavior, and it's different, right, even from the other scenario you brought up, where sometimes it's not possible to be with the patient 24 hours a day.

[00:24:07]It's also about differentiating the type of ideation that person is presenting, whether it's something isolated, right, or if it's chronic, that person who will have recurrent suicide attempts.

[00:24:19]Because in the chronic case, home hospitalization often ceases to be viable, right?

[00:24:24]Yes. But the main thing is not to leave the person alone. If you know the story of Corte Cobé, no.

[00:24:33]He convinced, he arranged an event for the family outside. The family left, took him alone, to take his own life.

[00:24:42]Jenny Jobin did a show, and in the open public show I feel like I'm making love with a million people. He went home and took his own life. There's no way to define this myth that the person warns when they're going to do it. I discard it. Because Generally, people who do this are surprised when it happens.

[00:25:09]Most people are surprised. Wow, he was so affectionate, so involved in everything.

[00:25:16]Now, one thing I've learned, because I'm a photographer, right? So, I spent 26 years as a professional photographer. I learned to know people through their eyes. So people already communicated with me through their eyes, and I can identify in a look whether that person is prone to taking their own life or not. All the people I looked at and said, "Commit them now," admitted that they were really thinking about life that day. And what I call " looking while looking" isn't just glancing, it's looking while looking. I have to look at that person as they are at that moment, okay? So, for referral, what do I need? A support network, family, friends, professionals, community.

[00:26:02]The risk should never remain restricted to the professional alone. Don't do that.

[00:26:08]There has to be a support network, okay? And the fourth step would be what?

[00:26:14]Referral when possible, because as I said, there is no voluntary hospitalization. Many cases I've followed were brought in from an emergency room. "Pinel, he got there, oh, okay, take some medication here and sent me home alone.

[00:26:35]So, we have to look at many things if we really want to work preventively so that a death by suicide doesn't happen.

[00:26:47]So we have to know if there are available means where the person is, or if there is an inability to guarantee safety. As I said, some people called me in these moments, I remember a case, right, where the person called me, 'Sebastião, today I'm leaving, it's over, I don't want to anymore.' But the voice was kind of groggy, 'Sir, something's wrong, but where are you?' 'Oh, are you at home?' 'No, no, no, I'm on the street. Where are you?' And by chance I was on the island, right? The person was on the island too. 'Describe the location to me.' She was describing the location and I was orienting myself, right?

[00:27:23]And I ended up finding the person. And when I found them, I got close, let me get closer, the person fainted in my arms. I picked them up in my arms and..." I carried her in my arms into the emergency room at Evand Freire Hospital. When we got there, the patient, this happened, and she woke up around 2 AM. I said, "Look, I'm going to have to talk to your mother." No, no, no, no, no, no, not with my mother. " Ah, but I have to talk to your mother."

[00:27:53]And then when I called the mother, she said, "Look, your daughter is with me here in my room. No, your daughter is with me in the emergency room.

[00:28:03]So, I'm here waiting for you to come and be with her. Look, I already told your mother, she's here, okay?" And then, right? After I said that the mother was coming, she extended her hand to me like this, said this, waved her hand, right?

[00:28:18]Like this, what is it? She waved her hand, right?

[00:28:21]Then I put my hand underneath, she opened her hand. When she opened her hand, I saw in my hand the shard of glass with which she was thinking of ending her life. I still have that shard of glass to this day, it's a trophy for me, okay? And this girl is alive today, okay? So, there also needs to be humanitarian action, okay? So, for this immediate intervention, okay? We have to include an urgent psychiatric evaluation when hospitalization is clinically indicated.

[00:28:56]If the If the person is conscious, it's complicated, okay? If they commit an act against life, then someone will decide for them. But if they are of sound mind, they wo n't. They can say they don't want to.

[00:29:10]So we have to go back to a question, that initial question, right? Does wanting to be with the deceased always mean a risk? I tell you that the answer is no, but it can never be ignored, because the professional is not a mind reader; they have to seek information, deepen this dialogue, because the difference between suffering that is acknowledged and suffering that is silent can begin with a simple question asked respectfully.

[00:29:45]When you say you don't want to live like this anymore, are you wishing for this pain to end or are you thinking about causing your own death?

[00:29:57]It's different.

[00:29:59]A question like that doesn't produce suicide; it produces clinical information.

[00:30:06]Clinical information allows for the construction of protection.

[00:30:11]So, in grief, talking about death can be an expression of love, longing, or despair.

[00:30:19]The professional task is not to presume which one is present, but to listen, ask, understand, because clinical assessment transforms uncertainty into knowledge.

[00:30:34]And knowledge guides decisions and care that can preserve lives.

[00:30:42]Okay? Why might this person die?

[00:30:49]That's a very small question.

[00:30:54]The difference would be if I could ask them: "What is still keeping you alive?" What is still keeping you alive?

[00:31:04]Because this question completely changes the focus of the conversation, because protective factors don't eliminate the risk, but they can decrease the likelihood of suicidal thoughts, because they can evolve into suicidal behavior.

[00:31:26]So, if I reduce that, I am, in a way, minimizing the risk. If I want to know if this person has reasons to live, what can I ask?

[00:31:38]What still makes sense to you? Is there something that still sparks the desire to continue?

[00:31:48]What brought you to where you are today? You might receive common answers that I've heard before: a child, a grandchild, a pet, a responsibility, an unfinished project, faith, the desire not to cause suffering to others. And here I'll digress for a moment to talk about faith, because there are many religious people killing themselves.

[00:32:16]And where is the faith?

[00:32:20]These elements I just mentioned don't eliminate the pain, but they can help us understand where there's still a possibility for investment in that person's life.

[00:32:31]I talked about support networks, but it's not enough to just ask this person if they have family; it's about shifting the focus of the question, of the support.

[00:32:42]Who knows when you're suffering, when you need to talk to someone, who answers your calls?

[00:32:50]If you needed someone here, who would be by your side right now?

[00:32:55]Who can you be completely honest with?

[00:33:01]And to make it perfectly clear here, I maintain professional confidentiality with my patients.

[00:33:07]The only exception is if the person tells me, or gives me to understand, that they are committing, or intend to commit, an act against life or the life of others; in that case, they can only leave accompanied, as stated in my contract.

[00:33:23]This rule has no exceptions.

[00:33:28]I realized that. As she revealed during the session, she has to go out accompanied.

[00:33:34]So, many people have dozens of contacts, but no relationship is secure enough to ask for help. Therefore, the existence of people does not mean the existence of support. If I have 1 million friends, how many will show up here? How many will show up here? And I also have to check the following. This person has the capacity to ask for help.

[00:34:04]This is an important factor that I need to investigate.

[00:34:07]If your thoughts worsen tonight, do you have someone you can call who can be with you?

[00:34:19]If necessary, you could seek help today before doing something harmful to yourself. I was once called one night by someone who was trying to jump out of the car and get run over.

[00:34:37]I went there, I spent about two to three hours sitting and talking with this person until she agreed to provide services in the group. I do n't know if you can see it, but here, look, I have a little cord here, okay? There is a sun and a moon.

[00:34:59]For my patients, I am available 24 hours a day.

[00:35:08]You can call. Whoever has this picture, if you call me, I'll answer.

[00:35:18]Why?

[00:35:20]When a person manages to make contact with someone significant, it shows that there is a possibility of interrupting this act and the isolation in which they find themselves.

[00:35:35]So, there are patients who have support networks, but are unable to access them. Others have practically no one, but spontaneously seek out health services. That's what I need to evaluate.

[00:35:52]And I said, you know, that I'm available 24 hours a day. In the beginning, I would sometimes speak with two, three, or four patients during a single night.

[00:36:01]But then, Nicolas, I did something, a friend of mine called me, Sebastião, uh, you have to come see some work I do here. What?

[00:36:11]It's a paintball team. Oh man, paintball. No, that's not cool. To keep shooting at other people.

[00:36:19]Sebastião, go check out my work, there's something there that will interest you. He insisted so much that I went, Nicolas. Upon arriving there, he gathered his team and said, "Do you know that 80% of the people here have already committed acts against life?" like this: "Wow, that really interests me."

[00:36:41]He said, "And most of them have been here for more than 3 years and don't think about taking any more lives."

[00:36:49]So, there's one here who didn't come today, but he says he has metastasis, and he's the one who joined this group here; he's been here regularly, he's been with us for four years. So, there's something interesting about that. I started talking to the staff, right?

[00:37:05]Okay, then? I'm going to conduct an experiment. Then I arrived at the group, right? That's what I told you.

[00:37:11]You all talk so much about killing yourselves. Now who's going to kill you? I'm going to shoot a lot of you guys. People went into it like this. Relax, I'll take you guys to play paintball with me. It was a party, man. It was a party. Oh yeah, I've always wanted that. I always wanted that, but I couldn't afford it.

[00:37:26]So I made arrangements with the team and took it there, right? He got there, the team captain did the training, I paid the rent, rented the weapons, rented the paintballs, and the vest. So, when it comes down to it, here's the thing: since you guys don't know how to play, let's mix up the team, right? No way, we're going to play on our team. So the patients still don't want to play on our team, we don't want to be mixed up with them, no. And then I understood something, Nicolas, nobody wanted to die, man.

[00:38:01]They were worried, "Be careful, be careful not to get shot." One was worried about not letting the other die, man. And there I discovered something like this, look. Despite my own pain, the pain of others is important.

[00:38:16]That's the end of the 4 hours, folks, let's go home. No, we don't want to leave here. No, I don't want to leave here.

[00:38:21]Nicas, we need the space for another 3 hours, until 3 PM, so people can stay there. And when someone got shot, right, with the little ball, I don't want to vote, no, no, no, man, you were only hit when it starts again. No, but I can't, man, you're only hit here when you start again. I could see that the guys didn't want to be dead.

[00:38:40]And after that, you know, going back to the session, it was a party. When are we going back? When are we going back?

[00:38:47]I said, "Look, you guys are giving me an idea here."

[00:38:51]Until now, I was the only one who stayed in contact with you during times of crisis. But what you've shown is that you want to take care of each other, right? AND. Then I created my own online group with these patients. These days, when someone goes into crisis, they go to the group and ask, "Is anyone awake?" Some days I wake up and there are 300 messages in the group chat; they support each other.

[00:39:13]And so, they became useful to each other. So now it has a deeper meaning; a new support network has been created between them, right?

[00:39:21]That's it, and they manage to talk to people who understand what they're feeling, what they want to do.

[00:39:28]So this group today is a support network. I've got another project that I'm not going to talk about, I've got another project to create a more national network like this, okay? That's working well here.

[00:39:42]And this issue of support is very interesting. Ah, some time ago, before I even started college, I think I was in my first semester or so, I found an online community of teenagers, mainly, but you could find people of all ages, ah, it was, well, I can't remember the name, my memory is really bad, but it was something like "Angels". Angels something.

[00:40:09]And this community had a large concentration of teenagers and adults suffering from depression and suicidal tendencies. And there they would make posts, comment on how they were planning, they would publish in the same way, the whole plan, suicide notes, and one supporting the other, every now and then we would see behavior there of people encouraging each other, giving ideas and everything else, but the community administration tried to limit that a little, right?

[00:40:40]To control the interactions, there was no psychological structure, no technical perspective happening there, but they came together, and some of the interactions there were very healthy.

[00:40:59]Not all parts. I had some groups, some conversations that ended up being more encouraging. Sharing letters was also something that wasn't seen as very healthy. No, at least I didn't perceive anything healthy in the interactions between the people sharing letters, but in some posts they talked about personal experiences and sometimes chatted, sometimes I would just go in and listen to them talking, we could see that when someone was guiding the conversation in a way that offered direction, the rest would talk in support of that topic and I was building a network there, a real support system.

[00:41:43]So this group functionality brings this aspect of identification and support.

[00:41:50]If it's well guided, as is the case with you, it should be a really productive thing, because what I saw happening there 400 years ago, before I even stopped to study suicide, grief, before I understood what psychology was in practice, was already showing itself to be something that is structured socially.

[00:42:13]OK. You mentioned a book, or letters, and there 's a book in English called Suicide Letters, letters from doctors who committed suicide, okay? Very good. Okay? Now, speaking of books, most of the books I have that are published abroad aren't in English, okay? Now, Paulos publishing house has invited me to give a talk on September 8th about this book, okay?

[00:42:41]Young people and suicide. So, this one is by an Italian author, and I'm reading it here on September 8th. I 'll be at 111 Mexico Street giving a talk about it in the morning and afternoon. But anyway, I don't want to criticize, okay? Now I've found much more support in the books I have from abroad, because there people really get their hands dirty.

[00:43:06]Much of what I find here comes from people who conduct research and serve clients through institutions. I, I, I say this: the work I do, I haven't found anywhere else here in Brazil, why? I work with people providing group therapy services to individuals who have this type of thinking, along with their families.

[00:43:27]No one comes here against their will; they are obligated to participate in the group.

[00:43:30]No, he'll come if he wants to.

[00:43:33]So the person comes here and they say, "Here I feel like I'm at home because here I can be who I am." Okay? And that's interesting because Vittor Franco, he has a book like that, right? In his youthful writings, he recounts the situation of being called the ugly girl. So at school she was called an ugly girl, an ugly girl. So at school she endured bullying. There was a family lunch that an uncle invited, but you're an ugly girl.

[00:44:02]She left lunch and took her own life.

[00:44:04]So, we have to consider the following: families also contribute significantly to acts against life.

[00:44:12]And that's where we need to work on that therapeutic bond, okay?

[00:44:17]The patient can now, as a professional, can the patient talk to me about suicide? He's hiding information from me; he demonstrates confidence that when someone is able to share suicidal thoughts, what does that usually represent? A protective factor.

[00:44:38]Silence is the opposite; it increases the risk. So what do I need to have?

[00:44:43]Psychological flexibility.

[00:44:46]Can the person imagine that their situation could change, or are they constantly saying, "Nothing will ever change in my life"?

[00:44:56]And that's where I see the stark hopelessness that protective factors won't minimize.

[00:45:04]Therefore, the ability to imagine different futures expands the possibility of care. So the important clinical question I have to ask is this: why do you want to die?

[00:45:16]directly. Does that question scare you? That's frightening. So let's think of another one here.

[00:45:25]What has kept you alive until today despite all the pain you feel?

[00:45:31]I'm asking essentially the same question, but in a gentler, more welcoming tone.

[00:45:37]Sometimes I have to be more forceful so the person can give you a thermal shock and then interact with you.

[00:45:45]So this question usually reveals resources that even the person in the situation wasn't aware of.

[00:45:54]And that's where, in this assessment, this specific questioning that the professional has to do is the following: what is this patient doing?

[00:46:06]I 'll just keep thinking about whether he's in the low-risk, medium-risk, or high- risk category.

[00:46:13]But these categories are not accurate.

[00:46:18]Let's think about it this way: two high-risk patients may present with different realities. A patient, for example, who lost his wife three weeks ago, reports frequent thoughts of furniture, does not have a plan, has children present, accepts help, and spontaneously seeks care.

[00:46:42]Patient B lost his job, has a history of suicide, has already prepared his medication, has already written a farewell letter, is intoxicated, and refuses treatment. In one assessment, both could receive that high-risk label, but the clinical understanding is completely different, because a classification provides information about psychological functioning, motivation, precipitating factors, and available resources. And that is why many authors and professionals argue that this assessment should be understood as a clinical formulation process.

[00:47:32]But what exactly is a clinical formulation that we're talking about here? It's a hypothesis developed by the professional to answer questions like: "What happened? Why did this happen now?

[00:47:45]What maintains this suffering? What increases the risk? What reduces the risk?

[00:47:51]What resources are still available?

[00:47:53]What role does the idea of ​​death play in this person's life experience? What needs to be done immediately?"

[00:48:03]So, you have to understand the difference. The classification answers how much risk exists. The clinical formulation answers how this risk is organized in this specific person.

[00:48:17]So, the logic of the formulation is this: it 's the history of the loss, how this person functions, the meanings attributed to the death that occurred, the intensity of the suffering, what the risk factors are, protective factors, available resources, immediate needs, and the care plan.

[00:48:42]This sequence will show what?

[00:48:45]A process of clinical understanding and not just filling out a form with checkmarks.

[00:48:54]If you imagine two patients with a fever of 39º, the temperature is the same. One has pneumonia and the other has dengue fever. The classification of high fever doesn't explain the disease, nor does it define the treatment on its own.

[00:49:08]But the assessment of suicidal behavior is similar; saying that someone presents a high risk... What does it describe? The perceived severity at that moment, but it doesn't explain how the suffering was constituted, what factors sustain it, or which interventions are most likely to be effective.

[00:49:35]Risk assessment, to conclude here, is part of a broader clinical formulation.

[00:49:42]Risk estimation may be necessary for immediate protective decisions, but in isolation it is insufficient to guide what? Care. So this clinical formulation contextualizes what?

[00:49:56]This estimate to understand the history of the loss that occurred in that person's life. The grief they suffer must consider the meaning of the suffering, what the risk and protective factors are, and the available resources and specific needs that person can count on, and the support that the professional can provide. Okay, Nas, as you asked, I stopped at 50.

[00:50:26]Perfect. I'll just ask you one more question, and the people following the chat here, okay? You can send your questions, OK? We'll answer them here. I 'll pass them on to him. If it doesn't work, send them to me and I'll answer later. You can put it in the chat if it's perfect.

[00:50:44]Well, in the case of grief, right, going back to the main topic, in grief leading to suicidal ideation, the cases you've followed, that you've seen, many involve planning, suicidal ideation, or a lot of behavior related to the act of grief. So, the person lost something, they don't process it very well, they go straight to the act, the suicide attempt, there's everything, okay? There are people who woke up, wanted to end their lives and committed an act against life, it didn't work, they went to therapy. Oh, I ended a relationship. Oh, I broke up, I was fired, no, I'm not able to. Oh, I ca n't find a job. Oh, I failed a test.

[00:51:28]So, the factors are multifactorial, there is n't one. The only thing that is common in all of them is this: "I don't see the point in continuing to live." And that's where I come in with logotherapy.

[00:51:42]This is common. I don't see the point in continuing to live. This is common. Now, why do this, to this day, with more than 400 patients, still... I haven't found one that matches another.

[00:51:59]Sometimes it's like, oh, the person passed me on the street, the person humiliated me, I felt very bad, so I go there, I want to get up there, I want to end my life.

[00:52:08]Oh, my mother prefers my brother and I feel alone. Everyone always has a reason. In these four hundred people who have passed through my life, I still have n't found one like the other, but this is constant and I don't see the point in continuing to live.

[00:52:29]This is common.

[00:52:31]Perfect.

[00:52:34]Oh, Leila, she brought up a question here.

[00:52:39]The question, right, in the case of why you want to die, is very different from why you don't want to live.

[00:52:47]If the person says they want to die, if you ask why they don't want to live, you're denying what they're saying.

[00:52:58]I understand that you're saying that I know here. If you ask why you don't want to live, you're denying what they're saying.

[00:53:05]So I have to broaden the question. I understand that you're talking about, thinking about giving up on life. Now Yes. So I can ask your question here, changing what I already said. But what has kept you alive until today?

[00:53:19]I'm asking your question in a different way. I'm not denying what he's saying. So I have subtle things that can make the person understand that you want to prevent them from doing what they want to do.

[00:53:33]And in fact, I have to change my dialogue to prolong the conversation.

[00:53:38]Why? A person who is in crisis, the crisis will pass soon. So the more time I spend talking to them, the better. But then I have to have the shrewdness to be attentive and not ask questions that deny what the person feels, nor what they want to do. That's all.

[00:54:00]Perfect, perfect. Leila commented here that she hadn't asked, she had repeated what you had said because she thought the intervention you mentioned earlier was fantastic.

[00:54:09]The explanation is very interesting, this point of not denying and especially of the professional not backing down in the face of the patient's discourse, right?

[00:54:17]If the patient is talking about dying, then that's the conversation, it's about asking how. How do you plan it?

[00:54:23]Because there can't be any fear in the clinic, right? If the professional is afraid to intervene, they won't be able to.

[00:54:33]Can I stray a little from the subject to give an example?

[00:54:36]Huh?

[00:54:37]Can I stray from the subject to give an example of what you just said?

[00:54:40]Yes, perfectly.

[00:54:42]Once, a patient came in with this question: "Today I want to kill a lot of people, what am I going to do?" He deposited it in the session, so he doesn't want to kill many people, right? Me neither. Yeah, you too.

[00:54:56]Okay. Do you know how to kill a person?

[00:55:02]No. But I'll research it. I'll tell you something. I know how to kill a person, okay? He never spoke to me again.

[00:55:11]I didn't show fear of what he was saying to me.

[00:55:16]So, it's interesting.

[00:55:17]I went through a situation, I went through a situation like that when I was attending to patients in the clinic, right, for the health plan, the patient came in, I was taking notes on the previous patient before calling the next one, right? He saw that the previous patient had left, he just went into the room, sat in the main armchair right next to me. I was startled when he slammed the door.

[00:55:38]He arrived, "I'm going to kill my wife."

[00:55:43]I looked to the side, I was taking notes, I kept taking notes to buy time. He said, "Did you hear what I said?" Yes, I heard. I'm just thinking about whether I should fill out your form completely, because if you kill her, you'll be arrested tomorrow. I'm just wasting time with your form here.

[00:55:59]So you intend to kill her. What are we doing here?

[00:56:03][laughs] You didn't deny what he said.

[00:56:08]It's over. The speech calmed down.

[00:56:12]From then on, the sessions flowed. He didn't continue, "Form, I want to be seen." We finished with the notes I was taking and we went to the appointment.

[00:56:21]Yes. Uh, going back to the chat, right, to the questions, to the comments.

[00:56:29]Oh, wait, the name is stuck, okay, I'll fix it here. He brought up the question, he asked to talk about mandatory reporting. Is that all he said?

[00:56:46]Yes. Mandatory notification. I asked to talk about mandatory notification. He brought it up earlier. Yes. Hmm.

[00:57:01]What did he bring up earlier?

[00:57:12]It's this comment, he asked to talk about mandatory notification of patients.

[00:57:18]I understand notification means you have to report a suicide case when it happens, right? Now, let me believe that's the notification itself.

[00:57:28]Now I'm going to ask you a question, right?

[00:57:31]How many death certificates have you found that say the person died by suicide?

[00:57:42]And I haven't found any yet, okay?

[00:57:45]What will be there is the cause of death. Now, what they did to make it happen isn't there. And we have two situations that must be respected. The family doesn't want others, or society, to know that someone in their family died by suicide.

[00:58:07]Second, it's a financial issue.

[00:58:12]If the person has life insurance and it says it was an act against life, the insurance doesn't pay.

[00:58:20]So there are data showing that there are underreported cases because many suicides that happen are not reported.

[00:58:29]Registered as such, okay? Now, the one who determines the cause of death has to be the doctor. So you have to know the following: what is the doctor doing with this data? He saw the cause of death, but he is informed of why that person died, but he has to perform an autopsy and fill out his document there.

[00:58:54]So this mandatory notification is a complicated situation. There's a term like, autopsy of a suicide.

[00:59:01]Have you heard of it, Nicolas? Yes, I have. So, when someone dies by suicide, you're going to evaluate how it happened and, to know the causes, what points should have been strengthened, what didn't work correctly. So that gives you data. Now, if the family doesn't want to report this, you're going to override the family. It's an issue, okay? So this mandatory notification still goes through that process.

[00:59:38]Gislane Azevedo also brought up a question here. In cases where children assume the role of caregivers for their parents, it's common That after the death, they feel guilty for believing they could have done more, even when they dedicated everything they could. How to understand this feeling within the grieving process? And then, more than understanding, I would also talk about how intervention works in this specific situation, okay? Let me tell you. This last patient of mine, when I had the meeting with the family, everyone was feeling guilty. Everyone. Oh, it could have been the same thing. Did anyone here contribute to this outcome? No, during life everything you did was with the intention of this happening. No, no. I told them not to let it happen, I was available.

[01:00:33]Oh, but I could have been more present. That's what I said. Are you going to give up your life and spend 24 hours a day with this person? There will come a time when neither they nor you will be able to bear it.

[01:00:47]What I need to know is this: Everything I did was the best I could do. But as I said, nobody is perfect.

[01:00:58]Nobody is, I'll affirm this here, nobody is capable of preventing a person from taking their own life forever.

[01:01:08]I can stop it. Just a moment, right? Research says that 30 to 40% of people who have attempted suicide will commit suicide within the next year.

[01:01:25]The data is there. I don't like statistics, but the data is there.

[01:01:29]Whoever has attempted suicide will actually carry out what they're saying next year.

[01:01:35]And then, what do I do? Do I put them in a lanyard, do the same with a baby, carry them around everywhere? There's no other way. I put them in a hospital, they can give you life in there. And then you 'll feel guilty anyway. We do what we can, our role is to do what's possible. What's impossible is impossible. So if this guilt exists, it's for the impossible.

[01:02:08]Not for the possible, which I'm sure the people around them do their best, okay?

[01:02:16]Perfect, Sebastião, I really appreciate your participation today. Your contribution today was fantastic. I think everyone really enjoyed it, everyone. It seemed like... ah, I lost the word, [laughs] but it seemed like you managed to keep up. Okay. They were following along, making comments throughout. I don't know if you were able to follow what they were commenting on during the lecture, but I can follow it here in the chat. They were really engrossed, from what I saw, people liked it. Oh, when they fill out the form there, you 'll also be able to receive some feedback.

[01:02:54]All the comments you leave about the professional on the certification form are sent to the professional. Our system sends them. So you'll receive the comments, okay? Also with feedback. They're already commenting here too. Excellent, I loved it. Wonderful lecture.

[01:03:08]Thank you very much for the clarification. I also just want to thank you.

[01:03:13]I'd like to know if you have any final thoughts you'd like to leave. My final thought is this, right?

[01:03:19]My slogan is: Life is the journey, be human, but be human with yourself. Don't demand more of yourself than you can possibly do, okay? And this month, I'm only going back to in- person appointments from September onwards, okay? But anyone who wants to talk to me, watch one of my sessions, can... No problem at all, you just have to be a psychologist, someone who likes psychology, okay? Or a medical doctor, get in touch with me, schedule a day to talk with me, participate in a session with me to listen to these people talk.

[01:03:52]This can help much more than me talking here, okay?

[01:03:56]Very interesting, everyone. For those in Rio, right? This group's work is on Ilha do Governador, right?

[01:04:01]Yes, yes. For those in Rio, it's a great opportunity to see a little more of the practice itself, to see the reality of how this discourse works, the construction of the speeches, to be able to analyze this up close is very different from any theoretical class you'll see, very different. The practice, we were talking about this even before going live, professional practice is very different from training and it's important that you have this contact. So, for those who can, it's an incredible opportunity.

[01:04:34]Sebastião, again, thank you very much.

[01:04:37]As we already discussed there, we will have other meetings, we have other moments already being planned.

[01:04:44]It will be a great pleasure to have you here with us more often.

[01:04:47]Hello. And let's schedule a coffee for... In person after I'm cleared by the doctor, okay?

[01:04:52]Cris already mentioned she's from the island, so it's even closer. In September you can contact me, you can even contact me now, then we can schedule it in September, okay?

[01:05:05]Perfect. They're asking for your Instagram, uh, Sebastião Ferreira Pil.

[01:05:11]Sebastião Ferreira Pil. I'll ask them to share it with you in the group too, OK?

[01:05:15]Perfect.

[01:05:16]Hello, master, a hug and thank you for the opportunity to be here sharing this space with you.

[01:05:22]Thank you. I'll finish up here now with more information for him. Bye.

[01:05:26]OK. A hug.

[01:05:31]Let's go then, everyone. I hope you enjoyed it, that you took advantage of it.

[01:05:37]Yay. And then? [laughs] And then? I'm going to answer your questions now about the certification, because the BRAPS systems are changing a little, they're becoming different.

[01:05:49]So, I'll show you how things will work. Well, first we continue with the two registration methods, social And it's special, okay? Social and special. Registration continues on the BRAPS website.

[01:06:05]So, you can register at braps.com.br, okay?

[01:06:11]On the registration page, there's a special registration, which is a paid registration that entitles you to a booklet that will be developed based on this material, okay?

[01:06:20]Special certification with 5 certified hours, everything very practical, a special group for you, okay? And the social registration, which can also be done through the website, takes you to the Braps channel on WhatsApp. So, Braps has its channel on WhatsApp. Let me show you our nice little channel, our channel on WhatsApp, okay? Where we share with you all the events that are happening, all the events that will happen, all the news, updates, links to access the event, okay? Links to access the event, links for certification are also sent there on that WhatsApp channel. Maria, it's not difficult, just go to our channel on WhatsApp, on the page. I'll show you the page because we do live streams, who You know how to do it live. If something freezes or crashes, just pretend it did n't happen. Thank you very much for your cooperation, right?

[01:07:25]If it freezes, just pretend it didn't happen because I'm setting up this site recently, so some unforeseen things happen, okay?

[01:07:35]Let's go. This is the Braps website, okay everyone? Our website is all nice and pretty.

[01:07:40]Down here you'll find the events, the upcoming events. For example, tomorrow is Naruto Saved the World. There's also Jung, which I'll be moderating tomorrow. Hello. There's Palank, okay? The clinic isn't Palank, it wasn't a joke when I talked about bullying, about violence masked as a joke. There's this lecture here that I'll be giving on psychology, sexuality, and crime on Thursday. And let's talk about the risk of suicide in grief, which is our event today.

[01:08:12]Opening your page, opening the page on the website, there's guaranteed access, which is special access, okay? And further down we have social access. When you... Click here to access the WhatsApp channel, okay? And besides the WhatsApp channel you'll access, it also registers your enrollment, which will be available to you in the student area. I think the button here isn't working. Yes, that button isn't working, but I'll fix it later. Ignore that detail, but on your student page, look at this nice page in the student center, see how beautiful this page is at Braps. There are certificates here, okay? And here's the suicide risk form, fill it out and issue it, which will be available for the next 24 hours. You'll fill in your information and the certificate will be issued immediately, okay?

[01:09:15]Special process, the same thing for those who registered on the student portal, which is basically brav.com.br/alunos, br/alunos, you 'll find the information for your certification with the certificate issued immediately, okay? Take advantage of this special registration, it's really worth it.

[01:09:32]Okay. Participate, register now, register for the upcoming events and I'll send you the link here on the page.

[01:09:40]Calm down, calm down, calm down, calm down. Let me make your lives even easier.

[01:09:45]Look, this is the registration link for the event. I don't know if it's clickable on YouTube.

[01:09:55]I hope it is.

[01:09:57]And here's the student portal I sent you, quebrap.com.br/los, right? I hope it's clickable for you on YouTube. Now, for the social certificate, it requires a verification word. And I'm going to tell you the verification word now, okay?

[01:10:15]Pay attention and write it down.

[01:10:19]The verification word for the lecture " Risk of suicide in grief, longing, suicidal ideation and risk assessment" is "risk". Our verification word for today's lecture is "risk". And for the third time, the verification word for today's lecture is "risk". Well, everyone, I hope you fill out your certification carefully. You can't send the verification word in the comments. Elias, let me Delete the comment. Do not share the verification word.

[01:10:55]I appreciate everyone's collaboration and everything you fill out in your form, everyone, I have access to it. I will then read the event reviews, the professional reviews, my reviews, the event suggestions, the feedback you left; they will be analyzed, they will be read, and they will be worked on. s.

[01:11:15]All the topics you submit are reviewed by the team and developed into presentations. This, for example, was one of the titles, one of the events that was suggested in the system, and we developed it and brought it to you, right? You can message me on the Braps Instagram page or on my personal Instagram profile if you have any questions. Make yourselves at home. Have a great night! Have a good rest, have a good end to your day, anything you need is at your disposal, okay? And I'll see you all there during the week at more events. I will be moderating tomorrow, giving a talk on Thursday, and also speaking on Friday and Saturday at events and conferences.

[01:11:54]See you later.

[01:12:01]Hello, you are at an official Brapice Mais event.

[01:12:07]If you tried to attend all of Brapsi's events throughout the year, the investment could exceed R$ 11,000. Braps Mais was created to change that logic and make things much easier for you.

[01:12:18]A subscription that gives you continuous access to Brapsi events. Brapsi holds dozens of events every month, and with Braps+ you can follow what really matters to you. Brapse+ is for those who understand that learning doesn't happen in a single moment, but throughout the journey. With a single subscription, you gain access to hundreds of events throughout the year and are guaranteed certification for each participation. Now take advantage of this event and, if it makes sense to you, sign up for Braps Mais.

[01:12:50]Continuous training, without missing a beat along the way.

[01:12:52]No.