“I love that it gets dark at 3 pm, that it’s pouring rain constantly, and that I haven’t seen the sun in 4 months!” said no one ever. Although some people may prefer the cold winter weather, there are a lot of us who are counting down the hours until patio season starts up again (okay, maybe that’s just me). So, until then, we are binge-watching TV, sleeping in, indulging in comfort foods, and pretty much avoiding the outdoors unless we absolutely have to go outside. The different seasons and the weather impact what we do and how we feel, which is why many of us prefer indoor activities during this time of year and for the next few months to come. However, on a rare day that the sunlight does shine through or when summer finally rolls around, we are quick to get outside and enjoy the sun. We may notice that our mood improves when the sun comes out and it can be a bit easier to get things done. Other times, we notice that when it’s dark and rainy, it’s a little harder to get out of bed, be alert, or even feel happy.
If you’re relating to this post right now, you’re not alone! Approximately, 17% of Canadians are also feeling pretty low during the winter months (CMHA, 2013). You can thank Seasonal Affective Disorder (SAD) for these mood changes, which is a form of depression that occurs at certain times of the year, specifically between September/October and April/May. It affects anyone and everyone but is more common amongst women, individuals between 15-55, people who live further up north or farther down south away from the equator, or individuals with a family history of SAD or other types of depression (HealthLinkBC, 2017).
How Do I Know If Seasonal Affective Disorder is affecting me?
You may be experiencing Seasonal Affective Disorder if you identify with these statements:
- I feel sad, moody, or anxious
- I feel tired or slowed down all the time
- I’ve lost of interest in work, friends, or interests
- I’m gaining weight
- I’m craving carbohydrates such as “comfort foods” like bread or pasta
- I’m having trouble concentrating
- I’ve been experiencing changes in my sleep, such as sleeping too much or not enough
(CMHA, 2013; HealthLinkBC, 2017)
Why Do We Struggle With SAD?
But why is SAD even an issue to begin with? It is thought that the lack of sunlight creates a change in the chemicals in our brain, specifically serotonin, which is responsible for regulating our mood. Additionally, because it is darker, it can signal to our brain that it’s time to sleep which can cause an increase of melatonin in our brain, which is responsible for regulating our sleep/wake rhythm. The truth is that we’re not completely sure why it happens, just that it does, and to many people in our community.
What Can I Do About SAD?
It’s great to identify if we have SAD. One of the main ways to help yourself if you’re struggling with SAD is to increase your exposure to the right wavelength of light. This can include:
- Spending more time outside during daylight hours
- Opening the curtains or blinds during the day
- Rearranging the space that you are in to allow more sunlight to enter
- Arranging office/household furniture so you can sit close to a window
- Adding lamps into your space
- Using a SAD Lamp
Counselling can help with the symptoms of Seasonal Affective Disorder by giving us a better understanding of how SAD affects us as individuals and helping us to cope with the effects that come about during this time of year. It can also be useful in helping us to look at our thoughts, feelings, and behaviours and how they influence our mood and can aid us in creating strategies for making changes in these areas. In addition to this, being able to talk to someone who is able to empathize and listen to us can be very beneficial.
If you’re struggling with Seasonal Affective Disorder, you’re not alone and you don’t have to go it alone. Seeing a Registered Clinical Counsellor or one of us counselling interns can be a great help!
If you’re not sure if what you’re struggling with is Seasonal Affective Disorder (SAD), please go to your family doctor who can help you determine if this is what you’re dealing with, and can refer you to a specialist if needed.
In the meantime, we’re here and we’d love to support you until the sun comes back! Feel free to contact us!
Find Help Now. (2013). Retrieved from https://cmha.bc.ca/documents/seasonal-affective-disorder-2
Seasonal Affective Disorder (SAD). (2017, May). Retrieved from https://www.healthlinkbc.ca/health-topics/hw169553
We were talking around the office this week about how there seems to be a week for everything. Admittedly, when we plan our calendar it’s sometimes difficult to keep up. Sometimes I wonder why we need a week for everything – and even, why we need a mental health week. To help us understand why we need a mental health week, I want to tell you a story.
I have a courageous young friend who has battled mental health for many years. This has involved many different treatments, counsellors, psychiatrists, medications, trips to the hospital, and more. This friend has an incredible family, many supportive friends, and others in the community who have been there to help and encourage. When things first began at a very young age, it was tough. For many years things were not stable, and treatments didn’t seem to help. Then, things changed. Life got better, treatments started helping, and things became stable for a number of years. Lately, things have been more difficult again, and life has come to a bit of a standstill. It’s discouraging. It’s disconcerting. It’s heartbreaking. On the upside, the family, friends, and community are still here, but it’s back to square one with treatment planning.
As I reflect on this, it occurs to me that this is exactly why we need a Mental Health Week. It further occurs to me that the things I feel my friend may need to hear right now may also be what others struggling with the mental health need to hear. This may also be true in terms of what we all need to hear about mental health.
Mental health issues are physiological issues that are no less physiological than cancer, diabetes, heart disease, or any other physical illness.
Often, we hear that mental health is “just in our heads.” This is neither biologically accurate, nor helpful. Mental health is in our head, in our bodies, and in our spirits. Mental health difficulties may involve imbalances in neurotransmitters, physical changes in the structures in the brain, changes in our central and autonomic nervous system, and even changes in function in just about every organ in our body; in addition, it may involve changes in our view of ourselves, our identity, our spirituality, and our belief systems.
What mental health is not, is a result of an individual being a categorical failure as a human being, because they’re not strong enough, because they aren’t trying hard enough, or because they don’t measure up. We don’t say these things of someone with heart disease, cancer, diabetes, or otherwise; we need to stop saying these things to ourselves, and others who struggle with mental health.
We are not defined by our illness.
There is a strange phenomenon, it seems, that when someone struggles with mental illness they become defined by it, both in their own minds and especially in the minds of the public. It’s not uncommon to hear someone say in conversation, “Oh, they’re a schizophrenic,” or, “he’s just an addict,” or similar. Sometimes, however, it’s us saying the same things about ourselves. The problem is that in both cases, it can become a self-fulfilling prophecy, and the struggle becomes perpetuated.
See, if we’re reduced to being a schizophrenic, an addict, or simply someone who is mentally ill, we lose our true identity. We are no longer a brother, a mother, a father, a sister, a CEO, a firefighter, or an accountant. We are no longer the beloved child of our parents, the one who wears his or her heart on their sleeve, or the one who uses art to enliven the lives of ourselves and others.
If we’re reduced to our illness, we have no identity other than that – the illness. This causes us to lose our perspective on ourselves, our loved ones, and those around us who are in the midst of some of the most difficult times in our lives. If we are reduced to our illness, then there is no hope, we are simply sick, or weak, or worse.
There is always hope.
I don’t believe in hopeless cases. There, I said it. If I did, quite frankly, I’d have the worst job in the world. Now, this doesn’t mean that everyone will recover fully and not have to deal with whatever mental health issue it is that plagues them; it doesn’t mean that we’re going to have the grand life that we see everyone around us having on Instagram (which isn’t true anyway, but that’s another article); and it doesn’t mean we’re going to be happy all the time.
What it means, is that although we struggle with mental health, we have not lost our identity; rather, both we and those around us may have lost sight of who it is that we are, and now our job is to get back to our core. It is time to get back to having lived a life worth living and to get back to the essence of what makes us unique.
We are born with natural gifts and abilities, and usually, they are the first things to go when we struggle with mental health or other issues. A little-known fact about me is that I’m a classically trained pianist. I played piano for many years, training with the Royal Conservatory of Music and then training in jazz and blues. Now I play a number of different instruments when I make the time. I love music, it’s one of the few things that no matter what place I’m in, brings me joy. This is true whether I’m playing it myself or listening to one of the greats on a recording.
Music is what has kept me balanced throughout my life when I’ve let it. When I was at my worst, struggling with depression and anxiety, I didn’t pay nearly enough attention to music. It was too much effort, it didn’t seem worth it, I just couldn’t. See, music is a double-edged sword for me – I also have had very high expectations of myself, and historically, I expected to be the best, to never make mistakes, etc., etc., etc. My identity at times became my ability to perform. I’d lost my way.
The truth, however, is that music is part of the core of who I am. When I was trained in The Birkman Method, this came out in spades – right at the top of my interests and passions. I knew this already, however, because when I was able to play music in my recovery, for the joy of it, and the emotional processing of it, and not for the expectation to perform, it helped my recovery more than anything else.
“Music gives me hope.”
Sometimes I work with clients who have lost hope, and I can understand why they have. Their depression is unrelenting, they’ve just discovered their partner has had an affair for the past 10 years, their teenage son is addicted to heroin, or otherwise. Life can be incredibly painful.
Sometimes my job as a counsellor is to hold hope for my clients and to hold hope for those who are struggling until they can hold it themselves.
One thing that I have learned in over a decade of doing this work is that there are no hopeless cases – there is always hope. If you’re reading this and you’re the one struggling, hold on. If you don’t have hope, find someone who can hold it for you. If you’re the one who cares for someone in the struggle, hold hope for them. Encourage them daily. Don’t give up, life can get better for them, and for you.
This is why we need a Mental Health Week. We need a reminder that mental illness is real, and it is physiological, and it is not because we’re weak. We need a reminder that we are no more defined by our illness than we are the size of our shoes. We need a reminder that there is always hope for us and always hope for those we love.
We need a reminder that life can be worth living once again if we keep going.
Anxiety and Depression account for the majority of mental health diagnoses in Canada. At any given time, at least 11.6% of Canadians aged 18 and over are dealing with a mood or anxiety disorder based on a survey in 2013. My experience suggests that this number is low, both because the statistics are now 5 years old, and because it’s based on self-report and we know that many people don’t report their struggles even when asked on anonymous surveys. One of the common questions we get here at Alongside You is how to support a friend or family member who is struggling with depression. In fact, we were asked again yesterday and that’s what instigated this article.
If you run a Google search on the subject, there are many articles on this topic, such as this one from the Mayo Clinic, or this one from HereToHelp. There are many great resources out there with many suggestions around educating yourself on depression, helping friends get exercise and eat healthy food, and similar tactics. These are all great suggestions and ideas and I encourage you to spend some time looking through the articles that are available.
In this piece, I want to take a slightly different road and look at how we can help a friend, family member, or other loved one who is struggling with depression in terms of how we need to be with them. This might sound a little strange because many of us (myself included) are practical, hands-on types who like practical strategies. The thing is, being who we need to be with people is a practical strategy, and it is very effective.
The Importance of Not Knowing
When we’re struggling with something, and certainly when that something is depression, we often feel misunderstood. We say things like, “They just don’t get it,” or, “Nobody understands how I feel,” and quite frankly, it’s usually true. Even for those of us who have struggled with depression in our lifetime, the experience of someone else may be very different. How it felt for us and how we responded may not line up with this person’s experience. If we assume we know how the other person is feeling, we run the risk of alienating them and making them feel even less understood than they already do.
So, our first job then is to listen and to listen to understand versus listening to respond. Often, especially when we’re under stress, we do the latter; we listen and feel the need to respond in the hope that it will help someone feel better or feel connected. Often, we’ll respond with something along the lines of, “Oh yeah, I totally know how you feel, I went through the exact same thing!” No, we didn’t. We may have been depressed, we even may have been through similar circumstances and reacted similarly, but we don’t know how they are feeling unless we ask and listen, and we most certainly didn’t go through the exact same thing. If we want to be helpful and fight against the alienation and isolation our loved one is likely experiencing, we need to listen to understand.
The Importance of Empathy
One of the greatest challenges we face in trying to support a loved one with depression is the fact that we don’t understand. In fact, this very thing often places a great deal of stress on us because we want to understand, we feel we need to understand. The fact of the matter is, we don’t need to understand to be helpful. If we build on this stance of not knowing, we can work toward understanding on a deeper level, understanding the emotional level, and by strengthening the connection between us. This, in a nutshell, is empathy.
Empathy is not our naturally occurring, number one go to strategy – our go-to natural strategy is usually sympathy. If you haven’t seen it already, I would encourage you to watch this short video of Brené Brown talking about the difference. When people are depressed, one of the most significant things that help is the connection with others. This is why empathy is so important – we can show empathy without understanding yet. It can be as simple as saying, “Wow, I don’t even know what to say right now but I’m glad you told me, and I’m here.” And yes, I totally stole that line from Brené Brown. I stole it because it’s that good. See, if we can admit our limitations and be vulnerable with our loved one that is struggling, not only do we encourage connection, but we model the vulnerability that they need in order to connect with us. If they can do this in return, it will directly combat those voices in their heads telling them that nobody cares, nobody listens, nobody understands, and they are not good enough.
If we can do the two things above, we stand a greater chance of success in this third thing I’m going to talk about: getting help. Most of us are proud people – we think we can do it all on our own and further, we think we should. I remember when I was dealing with major depression I thought it was because I was doing something wrong, that I just wasn’t working hard enough, and that I was a failure. Part of the reason that I believed this is because to my knowledge at the time, nobody I knew, and none of my family had ever struggled with depression, and certainly not the suicidal thoughts that were commonplace for me. This is where vulnerability and even some self-disclosure on our part can be helpful, particularly if we’ve struggled with depression ourselves. Some careful self-disclosure can normalize the struggle, and fight against the negative self-beliefs.
If we can listen to understand, and show empathy, we send the message to the one struggling that it’s ok that they’re struggling, it’s ok that they don’t have it all figured out, and it’s okay to ask for help. Now, when I say it’s ok I don’t mean it’s pleasant, or that we should like being depressed, or anything along these lines. What I mean is that it’s not because of some inherent flaw in who they are that they are struggling, and it certainly isn’t because they’re not worth it.
See, by spending time listening and understanding, spending time in empathy and connection, we are sending a strong message. That message is, “You’re worth it.” In my opinion, this is the single most important message for anyone to receive when they are dealing with depression because if their belief about themselves is that they aren’t worth it, then why would they tell anyone how they feel? Why would they open up to someone? Finally, why would they bother asking for help, because they don’t deserve it?
If we can help our loved ones come to a place of even beginning to understand that they are worth it, they are loved, and they are valuable then we stand a much better chance of succeeding at getting them the help they need. This is where we can again show vulnerability and explain that we love them, but we don’t possess the skills necessary to help them recover fully, the skills that a mental health professional does. This is also where we can reinforce that we’d like to help them get the help they need and that we will be there alongside them as they go through this. In fact, we can emphasize that we will go through this together with them.
How We Are With People Is Most Important
The reality is that helping a loved one who is struggling with depression is usually a start and stop, back and forth, messy process. Most of the time, emphasizing the practical strategies doesn’t work very well. Why is this? Because we don’t have the connection needed where the person will believe they are worth it, that they are loveable, and that recovery is possible. If we can be with the person on a deeper, empathic level, we give them the best chance possible to buy into the recovery process and we show them that they’re not alone.
If you’re reading this because you have a loved one struggling, or because you are that loved one struggling, I encourage you to take the first step toward recovery. If we can be of help to you, please don’t hesitate to ask. This is why Alongside You exists – because we believe that everyone is worth it. Feel free to contact us!
One of the most common questions I get from people when I give talks on Borderline Personality Disorder (BPD) and Dialectical Behaviour Therapy (DBT) is the question of how to support someone with BPD? So many individuals, couples, and families are struggling with how to love, care for, and support someone in the midst of what often feels like total chaos and painful experiences.
Shari Y. Manning, former President and CEO of Behavioral Tech and Behavioral Tech Research, the research organizations founded by Marsha Linehan to provide training in BPD, wrote a book on just this, titled “Loving Someone with Borderline Personality Disorder” and in it she focuses on how to keep the out of control emotions from destroying relationships between individuals with BPD and their families and other supports. She highlights the difficulty of balancing compassion for the person, while still wanting to help them find ways to change their behaviour and managing their emotions.
I’ll admit that it’s not easy to help someone struggling with BPD. It may seem that they are manipulative, egocentric, and focused on their own needs exclusively. The reality is that it’s not actually too far from the truth. The key to supporting someone with BPD without losing our own sanity, in my mind, is in our approach and how we frame what we’re observing. This is where Dialectical Behaviour Therapy (DBT) skills come in handy for us as well.
Interpersonal Effectiveness and Manipulation
Let’s talk for a minute about the idea that people with BPD are manipulative. It’s common to hear, both amongst clients with BPD, support systems, and yes, even professionals. I remember years ago that I used to get very angry when I heard this because I felt very compassionate toward clients with the borderline personality disorder and their need for help. Then it dawned on me – that is, they are being manipulative. And so are we.
See, manipulation is nothing new in relationships. We do it all the time – in fact, as I said to my intern John this week in supervision, we’re all in relationships to get what we need from the other person. None of us would be in relationships if this weren’t true. The difference is, we do it in a mutually beneficial way that serves everyone involved. The fact remains, however, that we’re all trying to get what we need from others, we just have more ability to do so effectively. This is what interpersonal effectiveness skills in DBT do for clients and for members of support systems; they teach us how to get what we need from others in an effective way.
Why Individuals with BPD Behave the Way That They Do
I remember back many years ago when I began working with individuals with developmental disabilities, we often repeated the phrase with staff and caregivers, “All behaviour is communication.” This is a very important concept and applies just as much to kids and adults alike, as well as individuals with BPD. When we can’t use words to communicate, we use actions. Further, when we see the often extreme behaviours of individuals with BPD, it’s important we remember what is happening to them at that moment, and how it got that way.
We’ve learned from research that individuals with BPD have reasons for interacting with the world in the way they do, just as we all do! Linehan’s theory from 1993 is the most substantiated, and it suggests that BPD can be the result of the interaction between biological and psychosocial factors, including adverse childhood experiences. One of the predominant factors is invalidating developmental contexts where emotional expression is invalidated in childhood. Further research suggests that between 30%-90% of individuals have experienced abuse and neglect in their lifetime. This has a significant impact on the developing brain.
What we also know from brain science, and certainly I’ve observed this in my clinical work, is that individuals who have histories of abuse, neglect, invalidating emotional environments, and other traumas, have brains that are more sensitive to danger. The limbic system is designed to keep us safe and also regulate our emotions. At its’ best, it keeps us safe when we’re in danger, and regulates our emotions to keep us at an even keel. At its’ worst, it’s being triggered in situations that aren’t dangerous and causing us to react in ways that would make sense if we’re in danger but make no sense when we’re not. It’s also important to remember that when this system is acutely active, it shuts down our frontal cortex, which is where our rational thought mechanisms are housed. So, when we’re in danger, as I often say to clients, we can’t think to save our lives. This is the brain state that individuals with BPD are in when they react in extreme ways. Their brains are in full-blown fight or flight mode and simply reacting, trying to do anything they can to be safe. Most often, they turn to their closest relationships.
Relationships as Safety
Ever heard the idea that we hurt the ones we love the most? This is often the case with individuals with BPD when they react in extreme ways. But why is this? Many people with BPD have a very externalized locus of control, meaning, they don’t believe they can contain their own emotions, especially when they’re overwhelmed. You know what? They’re right. When they’re in fight or flight the mechanisms in their brain responsible for regulating emotions and behaviour are not rational, and are just reacting and they can’t contain it. This is simply a more extreme version of what happens to all of us. So then, what’s the difference?
I believe the difference is the level of fear experienced in these moments. The idea of not being able to contain extreme emotions would be, I imagine, quite terrifying. Coupled with the fear of being left by the people they are closest to, the proverbial pot boils over and they have to do something extreme to get attention. I often hear, “Oh they’re just attention-seeking,” to which I reply with an emphatic, “Yes, of course, they are!”
Remember the idea that all behaviour is communication? When people with BPD are at this heightened state they are unable to communicate effectively and are doing their darndest to communicate their pain and fear to us, asking us to help them contain it. What may look to us like someone simply showing out of control behaviour, I believe, is a desperate attempt at seeking safety and containment.
Can you imagine what it would be like to be in this position? Having BPD, feeling so unsafe and so in pain that you have to go to such extreme lengths to try to get help? I can’t. The idea of being there is far too terrifying to me. Quite frankly, I don’t want to know what it feels like to be in that place, but it gives me a great deal of compassion for those who are.
What Do We Do To Help?
One of the best ways to be supportive is to help those struggling with BPD to get the help they need. Dialectical Behaviour Therapy (DBT), on an individual basis as well as in skills groups, is very effective in helping those with BPD manage their symptoms. With the right help, individuals with BPD can learn the skills they need to manage their emotions and relationships and ultimately, have a life worth living! This was Marsha Linehan’s goal in developing DBT, to help those struggling with suicidal thoughts have a life worth living. We’re proud to say that our DBT programs have been effective at doing just that for our clients, and we’d love to help even more people this way.
We have often been asked if we run groups for family members and other supports who are trying to help someone with BPD. Unfortunately, we don’t at the moment but it’s on our radar. We are looking into doing exactly this in the future. What we can do, however, is teach DBT skills on an individual or family basis for those supporting someone with BPD. We have a number of counsellors available for this, and you can talk to Doug, Share, or Kelly about this if it would be helpful.
Education is also very important as once we understand what is happening, it gets less scary. There are many books that can be very helpful. Here are a few ideas to get you started:
Stop Walking on Eggshells by Paul Mason
Loving Someone with Borderline Personality Disorder by Shari Y. Manning
DBT Made Simple: A Step-by-Step Guide to Dialectical Behavior Therapy by Sheri Van Dijk
Finally, self-care is absolutely paramount to your survival for yourself and the person struggling with BPD. As the airlines often remind us, we need to put our mask on before we can help anyone else! If we don’t take care of ourselves, we will flip our lids and react in much the same way as those we’re trying to help.
I hope this has been helpful – if our team can be of any help to you as you support someone with BPD please feel free to give us a shout. Our Dialectical Behaviour Therapy program is comprehensive, and we would love to teach you the skills needed to be a solid support, for yourself and your loved ones with BPD!
Suicide. To most this can be a feared word, much like, “He Who Must Not Be Named,” but as Hermione Granger would say, “fear of a name only increases fear of the thing itself.” 1 While a helpful illustration, we shouldn’t let the Harry Potter quote take away from the gravity of the subject of suicide. With knowledge comes power and although there are things in life that may ultimately be outside of our control, it is important for us to be informed.
One author writes, “stigmatization of…mental health disorders is alive and well,” and perpetuated by misinformation, miscommunication, and media sensationalization, despite the best efforts of good intentioned campaigners. 2 Those with mental health disorders are often painted as “crazy,” “violent,” or “untrustworthy,” but could these descriptors not also be attributed to those without mental health disorders? I am certain that most of us could think of someone in our life that we have a colourful moniker for, much like those aforementioned, that does not have a mental health disorder. The truth of the matter is that research shows that individuals living with mental illness are more likely to harm themselves than others.2 Stigma can produce profound impacts, including social disgrace and shame, which then serve as obstacles to identifying and acting on warning signs of suicide.3 Individuals may recognize warning signs for suicide as easily as they do those for physical ailments (e.g. heart attack or stroke) but tend to respond less urgently.3 All this to say, if we want to do something to reduce suicides, we need to reduce stigma, and be aware of the warning signs.
Determining the risk of suicide for an individual with one hundred percent accuracy is impossible. Suicide assessments consider a complex interplay of variables encompassing risk factors, protective factors, and warning signs. Due to these complexities, it takes much training, supervision, and experience to thoroughly conduct suicide risk assessments and should only be done by an experienced professional.
So if suicide risk assessments can only be completed by trained professionals what can you do? If you are concerned about a family member, friend, or colleague there are ten common warning signs to be aware of6 :
- Ideation or communication about suicide
- Substance abuse
- Anxiety or panic
- Trapped feelings
- Withdrawal from social groups
- Agitation or irritability
- Reckless behaviour
- Mood changes
An important thing to remember is that nothing is certain. Warning signs are just that, signs. The presence of a warning sign does not automatically mean that an individual is suicidal, just as the lack of warning signs does not automatically mean that an individual is not suicidal. The purpose is to recognize the signs and start the conversation, get more information, or seek the help of a professional. Let’s start treating mental health like physical health and take preventative measures to ensure the health and safety of our loved ones.
Crisis Intervention and Suicide Prevention Centre of BC
Anywhere in BC 1-800-SUICIDE: 1-800-784-2433
Mental Health Support Line: 310-6789
Sunshine Coast/Sea to Sky: 1-866-661-3311
Seniors Distress Line: 604-872-1234
Online Chat Service for Youth: www.YouthInBC.com (Noon to 1 am)
Online Chat Service for Adults: www.CrisisCentreChat.ca (Noon to 1 am)
S.A.F.E.R (Suicide Attempt Follow-up Education & Research)
8:30 am to 4:30 pm Monday to Friday Call: 604-875-4794
Aboriginal Wellness Program (AWP) Vancouver
In an emergency call 9-1-1.
 Rowling, J. K. Harry Potter and the Philosopher’s Stone. (1997). London, England: Bloomsbury Publishing Plc.
 The Lancet. (2013). Truth versus myth on mental illness, suicide, and crime. The Lancet, 382(9901), 1309. doi:10.1016/S0140-6736%2813%2962125-X
 Rudd, M. D., Goulding, J. M, & Carlisle, C. J. (2013). Stigma and suicide warning signs. Archives of Suicide Research, 17(3), 313-318. doi:10.1080/13811118.2013.777000
 Fowler, J. C. (2011). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy, 49(1), 81-90. doi:10.1037/a0026148
 Granello, D. H. (2010). The process of suicide risk assessment: Twelve core principles. Journal of Counseling & Development, 88(3), 363-371. doi:10.1002/j.1556-6678.2010.tb00034.x
 Wu, R. (2017). Individual Appraisal for Counsellors in Practice. Suicide risk Ax. [PowerPoint slides]. Retrieved from https://adler.hotchalkember.com/courses/15984/files/743942?module_item_id=36008