Suicide & Violence in Mental Health & Addiction Cultures

1. Suicide & Violence in Mental Health & Addiction Cultures By Jill S. Perry, MS, NCC, LPC, CAADC, SAP April 12, 2019 JP Counseling & Associates, LLC701 Sharon Road, Suite 2 Beaver, PA 15009 724-494-6750 www.jpcounselingcenter.org

2. What does COD Look Like? JP CounselingHealing for Adults, Youth and Families

3. 5 Rules to Eliminate Stigma Who remembers????? JP Counseling & Associates, LLCHealing for Adults, Youth and Families

4. Rules to Eliminate Stigma • DON’T: • Label people who have a mental illness or addiction • Be afraid of people with mental illness or addiction • Use disrespectful terms for people with mental illness or addiction • Be insensitive or blame people with mental illness or addiction JP Counseling & Associates, LLCHealing for Adults, Youth and Families

5. Rules to Eliminate Stigma • DO: • Be a role model

6. Definitions JP CounselingHealing for Adults, Youth and Families

7. Attitude A state of mind or feeling with regard to something Refers to a lasting group of feelings, beliefs and behavior tendencies directed towards specific people, groups, ideas or objects. Attitudes develop over time and not only reflect where we have come from but also how we will proceed with our life in the future. Attitudes are a powerful element in our life, are long enduring and hard to change—but not impossible!

8. One of the problems with our attitudes is we often ignore any information which is not consistent with them—we become selective in the way we perceive and respond to events and issues—and lose our ‘objectivity’ about the world. JP CounselingHealing for Adults, Youth and Families

9. Beliefs Assumptions/convictions you hold as true about something Beliefs come from real experiences but often we forget that the original experience is not the same as what is happening in life now. The beliefs that we hold are an important part of our identity. Beliefs are precious because they reflect who we are and how we live our lives.

10. Values Ideas about the worth or importance of people, concepts or things Values are usually fairly stable, yet they don't have strict limits or boundaries. As you move through life, your values may change.  JP CounselingHealing for Adults, Youth and Families

11. JP CounselingHealing for Adults, Youth and Families

12. Violence Acts of battery that resulted in physical injury; sexual assaults; assaultive acts that involved the use of a weapon; or threats made with a weapon in hand JP CounselingHealing for Adults, Youth and Families

13. Suicide Death caused by self-directed injurious behavior with an intent to die as a result of the behavior.

14. Suicidal ideation Thinking about, considering, or planning suicide.

15. Suicide attempt A non-fatal, self-directed, potentially injurious behavior with an intent to die as a result of the behavior; might not result in injury.

16. Non-Suicidal Self-Directed Violence Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is no evidence, whether implicit or explicit, of suicidal intent.

17. Undetermined Self-Directed Violence Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. Suicidal intent is unclear based on the available evidence.

18. Screening • The screening process seeks to answer a “yes” or “no” question: • Does the substance abuse client being screened show signs of a possible mental health problem? • Does the mental health client being screened show signs of a possible substance abuse issue? • Does the client being screened show signs of suicidality? • Does the client being screened show signs he/she could become violent?

19. Assessment A process for defining the nature of the problem(s) and developing specific treatment recommendations for addressing the problem(s).

21. Questions to Explore Today Are people with mental health disorders, substance abuse disorders, COD at a higher risk for suicide? Are people with mental health disorders, substance abuse disorders, COD at a higher risk to be violent? Are the public at risk? How do we help?

22. History First known suicide note was written in Egypt somewhere between 2181 and 2040 BC It was translated into German in 1896 by Adolph Erman who called it "The Dispute With His Soul Of One Who Is Tired Of Life” or “A Dispute Over Suicide.”

23. Suicide 10th leading cause of death in US 2017 reported 47,173 Americans died by suicide 2017 reported an estimated 1,4 million suicide attempts For every one suicide, there are 25 attempts 2015 reported that suicide and self-injury cost the US $69 billion

24. Suicide Rate of suicide is highest in middle-age white men (79%) 2017 reported men died by suicide 3.54X more often than women On average, there are 129 suicides/day Firearms accounted for about half of all suicide deaths (51%)

25. Suicide Police officers are twice as likely to die from suicide than in the line of duty. An average of 20 Veterans each day die of suicide. Women Veterans are more likely to die by suicide than non-Veteran women. Women Veterans are more likely than non-Veteran women to use firearms as a method of suicide.

26. Suicidality Not a mental health disorder High-risk behavior associated with COD, especially (but not limited to) serious mood disorders Most people who commit suicide have a mental health disorder or a substance abuse disorder or both Majority have depressive disorder

27. Suicide Abuse of alcohol and/or drugs is a major risk factor in suicide for those with COD and for the general public Alcohol is associated with up to 50% of all suicides Up to 27% of all deaths of people who abuse alcohol are caused by suicide Lifetime risk for suicide among people who abuse alcohol is 15%

28. Suicide The association between alcohol and suicide may also be related to the capacity of alcohol to decrease inhibitions leading to mood instability, poor judgment and impulsivity Substance intoxication is associated with increased violence toward self and others.

29. Suicide People who inject drugs have a 14X greater risk for suicide JP CounselingHealing for Adults, Youth and Families

30. People with SUD who are in treatment have an even higher risk of suicidal behavior because: They enter treatment at a point when their SU is out of control They enter treatment when a number of co-occurring life crises may be occurring (ie—marital, legal, job) They enter treatment at peaks in depressive symptoms Crises that are known to increase suicide risk sometimes occur during treatment (ie—relapse & treatment transitions)

31. Safety screening should be done early and on-going. • The clinician can specifically ask the client if he or she has any immediate impulse to engage in self-injurious behavior • These questions should be asked directly of the client and of anyone else who is providing information

32. Once this information is gathered, if it appears that the client is at some immediate risk, the clinician should arrange for a more in-depth risk assessment by a mental-health–trained clinician, and the client should not be left alone or unsupervised. JP CounselingHealing for Adults, Youth and Families

33. Things to Remember about Suicide Attitudes, beliefs and values to help guide you when screening, assessing or dealing with someone who is suicidal JP CounselingHealing for Adults, Youth and Families

34. Almost all people who are suicidal are ambivalent about living or not living. Hesitation wounds are often seen on those who have died of suicide The struggle between wanting to die and wanting to live is at the core of a suicidal crisis Do everything you can to support the side of the client that wants to live, but do not trivialize or ignore signs of wanting to die.

35. Suicidal crises can be overcome Acute suicidality is a transient state Important interventions include addressing substance use, depression, financial and marital issues CBT has shown positive results in reducing repeated suicide attempts

36. Suicide prevention actions should extend beyond the immediate crisis Identifying and addressing core issues that contribute (ie—depression, sexual abuse history, marital problems, relapses)

37. Suicide contracts are not recommended and are never sufficient Should never be used as a stand-alone intervention Studies have never shown these contracts to be effective at preventing suicide Effective contracts can help to focus on the key elements that are most likely to keep clients safe, such as agreeing to remove the means a client is most likely to use to commit suicide.

38. Some clients will be at risk of suicide, even after getting clean and sober People with an independent psychiatric disorder, particularly depression People who have unresolved difficulties that promote suicidality (ie-deteriorating partner relationship, ongoing domestic violence, victimization, impending legal sentencing Those who have a marked personality disturbance Those with trauma histories

39. Suicide attempts always must be taken seriously Often a mismatch between the intent of the suicidal act and the lethality of the method chosen Regardless any suicide attempt must be taken seriously, including those that involve little risk of death Any suicidal thoughts must be carefully considered in relation to the client’s history and current perspective

40. Suicidal individuals generally show warning signs Expressions of hopelessness Suicidal communication Seeking access to a method Making preparations

41. It is best to ask clients about suicide directly Research does not support that asking about suicide will put that idea in their mind

42. The outcome does not tell the whole story A client at significant risk maybe survive despite never being screened, assessed or offered intervention A clinical team may do a thorough job of screening, assessing and intervening and the client may not survive Approximately 45% of people who die by suicide consult a PCP within 1 month of death, yet rarely is there any documentation by the physician of questions regarding SI during that visit A tragic outcome does not, by itself, equate to improper treatment of suicidality.

43. IS PATH WARM I = Ideation S = Substance abuse P = Purposelessness A = Anxiety T = Trapped H = Hopelessness W = Withdrawal A = Anger R = Recklessness M = Mood changes JP CounselingHealing for Adults, Youth and Families

45. At-Risk Populations • Older Adults: • Plan more carefully and use more deadly methods • Are less likely to be discovered and rescued • Physical frailty means they are less likely to recover from an attempt

46. At-Risk Populations • LGBTQ • 40% of high school students who identified with these orientations stated they were seriously considering suicide • 24% had attempted suicide in the past year • Those identifying as bisexual had the highest rates for suicide

47. At-Risk Populations • LGBTQ • Those who experienced rejection of family and friends, discrimination, victimization or violence had elevated prevalence of suicide attempts, including: • Harassment of bullying at school: 50% • Doctor or health-care provider refusal to treat: 60% • Physical or sexual violence: up to 78% • Disrespected or harassed by law enforcement: 61% • Homelessness: 69%

48. Risk Factors • Age • Adolescents & young adults are more likely to make nonfatal suicide attempts • Older individuals are more likely to die by suicide

49. Risk Factors • Gender • Women are more likely to attempt (not as high as before) • Men are more likely to die from suicide (higher intent to die, more lethal means)…in all racial groups

50. Risk Factors • Race & Ethnicity • White and Native Americans have higher rates of suicide than African-Americans • Anxiety D/O is important risk factor for suicide among Blacks • Low prevalence of deaths by suicide among African American females • Hispanics/Latinos have similar rates to White Americans • Increased prevalence of suicidal thoughts and behaviors among Hispanics/Latinos who are more acculturated to mainstream American culture