Crisis Intervention and Suicide

1. LECTURE NO.8 Crisis Intervention and Suicide

2. Learning Objectives • Define crisis • Name the types of crisis • Describe the various phases of crisis • Describe various steps in the nursing process in relation to crisis • Name the various psychiatric and medical disorders coexisting with suicidal acts • Describe the various risks and protective factors for suicide • Discuss the principles of suicide precautions and hazard-free environment in the hospital • Describe basic level interventions implemented in the management of a suicidal patient

3. Definitions • Crisis is an acute, short-lived and overwhelming emotional reaction to a situation or an event. • A sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem.

4. Types of Crisis • Maturational • Situational • Adventitious

5. Maturational Crisis • This relates to the process of maturation and passing through various stages of the life cycle. • Coping skills used earlier may no longer be helpful and appropriate. This leads to anxiety or crisis. • Adolescence, marriage, becoming a parent and retirement are some of the examples of maturational crises.

6. Situational Crisis • Is precipitated by various life events and is not anticipated • Change of job, loss of job, divorce, financial loss, death of a loved one and major physical illnesses are some of the life events that can lead to situational crisis.

7. Adventitious Crisis • Also known as crisis of disaster, adventitious crisis is a situation that is not a part of everyday life • It is unplanned and accidental. • Various examples of adventitious crisis include earthquake, flood, airplane crashes, rape, murder, war, riots and terrorism.

8. Phases of Crisis Caplan (1964) described four phases of crisis: i. When faced with a problem that seems to be unsolvable, ‘tension’ starts and anxiety mounts. The person attempts more and more to solve the situation.

9. Phases of Crisis (cont.) ii. Anxiety increases further with impairment of function and results in disorganization and distress. If anxiety and arousal are in excess, it hinders coping behaviour. iii. Emergency measures are taken and new coping skills are tried. iv. Failure to resolve the crisis leads to further deterioration, disorganization and decompensation.

10. Application of the Nursing Process • Nursing Assessment • Determine the severity of the crisis • Assess the risk for suicide/homicide • Assess patient’s perception of the precipitating events • Assess the patient’s coping skills • Assess the available support system

11. Application of the Nursing Process (cont.) 2. Nursing Diagnosis • Various nursing diagnosis in a patient with crisis include: • Anxiety • Ineffective coping • Inability to meet role expectations • Inability to carry out routine activities

12. Application of the Nursing Process (cont.) • Decreased socialization • Low self-esteem • Risk to self

13. Application of the Nursing Process (cont.) 3. Nursing Outcome • Set short-term and long-term goals with patient and the family • Goals should be realistic, culturally relevant and meet the patient’s level of functioning • Nursing Outcome Classification (NOC) can be used to help set the outcome goals.

14. Short Term Refrains from harming self or attempting suicide Level of anxiety goes down Sleeps better Becomes more coherent and organized Interacts better with others Able to see some hope in life Long Term Feels safe even when alone Sleep and appetite patterns are back to pre-crisis level Learns new coping skills Able to carry out roles at home and at the workplace Has confidence in self to handle life and problems effectively Possible Outcome Criteria in Crisis Intervention

15. Application of the Nursing Process (cont.) 4. Nursing Intervention • Crisis intervention is a brief psychiatric treatment to forestall the process of mental decompensation in severe emotional stress. • Two basic aims of crisis intervention are safety and anxiety reduction. • Nursing interventions in a crisis can be carried out at three levels.

16. Levels of Crisis Intervention • Primary level: promotes mental well-being and reduces the incidence of crisis • Secondary level: works towards preventing prolonged anxiety, diminished efficacy and personality disorganization. • Tertiary level: aims at providing support to patients recovering from a crisis

17. Application of the Nursing Process (cont.) 5. Evaluation • To judge the effectiveness of the crisis intervention strategies used • Usually carried out 4–8 weeks after the initial assessment • Nurse may decide to follow up with patient or refer to other agencies

18. Crisis Stabilization • People with mental illness are more prone to crisis. • The nurse can adapt the crisis model by taking the following steps: • Clarify the reality of the situation • Make the patients aware of own capabilities and social support available

19. Crisis Stabilization (cont.) • Set realistic goals according to level of functioning • Take up responsibility and help the patient for the initial period

20. Suicide is the third leading cause of death among 14–25 years olds, after accidents and homicides. • The majority of people with suicidal ideations have a treatable psychiatric disorder. • Only 1% of the people with suicidal ideations commit suicide. • Suicide does not always mean presence of a psychiatric disorder.

21. Psychiatric Conditions Major depressive disorder Bipolar disorder Schizophrenia Substance use disorder Panic disorder Borderline and antisocial personality disorder Medical Conditions AIDS Myocardial infarction Cardiac failure Cirrhosis Stroke Epilepsy Huntington’s disease Multiple sclerosis Peptic ulcer Comorbidity Clinical Conditions Associated with High Suicide Risk

22. Aetiology • i. Psychosocial factors • Freud described suicide as aggression turned inward, towards an internalized love object. • Menninger expanded on Freudian theory and described suicidal hostility as the wish to kill, the wish to be killed and the wish to die. • Aaron Beck identified hopelessness as a central factor underlying the act of suicide.

23. Aetiology (cont.) • Durkheim divided suicides into 3 categories: • Egoistic suicide, which occurred in persons who have lost their sense of integration within their social group. • Anomic suicides are seen in times of major social changes or political crisis when the society lacks order. • Altruistic suicide means sacrificing one’s life for the welfare of the social group.

24. Aetiology (cont.) • ii. Biological factors • Evidence of the role of genetic factors in suicide comes from the findings that suicide runs in families. • Low levels of serotonin or its metabolites in the cerebrospinal fluid have been associated with the suicidal act.

25. Aetiology (cont.) iii. Cultural factor • Cultural factors including family values, religious beliefs and attitudes towards life and death have a bearing on the suicide rates.

26. Protective factors Risk factors • Good coping skills • Good social support • Family cohesiveness • Sense of responsibility to family • Religious beliefs • Pregnancy • Intact reality testing • Clear suicidal intent • Lethal suicidal plan • Previous suicidal attempt • Comorbid psychiatric/ medical conditions • Unemployment • Being single (especially in males) • Old age • Family history of suicide • Recent stressful life event • Poor social support • Poor impulse control Risk and Protective Factors for Suicide

27. Nursing Process • Assessment • Assessment of suicide risk involves: • taking detailed psychological and medical history • identifying risk and protective factors. • If there is no clear desire to die, suicidal feelings can be managed at the outpatient level with frequent follow-ups. • The presence of clear intent with a lethal plan or a history of parasuicide would warrant emergency hospitalization.

28. Nursing Process (cont.) • Almost all suicidal patients give clues and hintsabout their suicidal ideas and plans (intent). • These clues can be: • verbal—overt ones like ‘I wish I were dead’ or covert ones (e.g. ‘Soon I would not be a burden on anyone’). • non-verbal (behavioural)—sudden improvement in mood and energy levels, giving away personal belongings or organizing finances.

29. Nursing Assessment (cont.) • It is important to evaluate the lethality of suicidal plans. Lethality can be judged by the proposed method and the accessibility to the planned method. • High risk (‘hard’) methods include: • jumping off a high building • jumping in front a running train • hanging

30. Nursing Assessment(cont.) • using a gun • staging a car crash. • poisoning with organophosphorus chemicals (pesticides) • Low-risk (‘soft’) methods include • overdosing on pills • slashing wrists

31. Nursing Diagnosis • Risk for suicide is the diagnosis with the highest priority and should be handled immediately. • Nursing Diagnoses for a Suicidal Patient: • Risk for suicide • Ineffective coping • Hopelessness • Powerlessness • Social isolation • Loneliness • Low self-esteem • Deficient knowledge

32. Nursing Outcome Criteria NOC and NIC labels for a suicidal patient Nursing Outcome CriteriaNursing Intervention Criteria Suicide self-restraint Suicide prevention Hope Hope installation Self-esteem Self-esteem enhancement Coping Coping enhancement Social support Family mobilization Spiritual health Support system enhancement

33. Nursing Planningand Implementation • During the acute suicidal crisis, the following interventions will help in the recovery process. • Specialized milieu therapy • Appropriate psychobiological interventions • Counselling • Case management and • Health education

34. Specialized Milieu Therapy • Suicide Precautions • Continuous nursing observation on one-to-one basis • Restrain, if warranted • Continuous assessment of risk • Ensure hazard-free environment • Recording of mood, thoughts and behaviour every 15–30 minutes

35. Specialized Milieu Therapy (cont.) • Supervise medication intake to ensure that patient swallows tablets • Maintain the physical distance • Explain all these to the patient and the reason for doing so

36. Psychobiological Interventions • Electroconvulsive therapy (ECT) • Antidepressants (SSRIs are preferred to tricyclic antidepressants considering their safety profile even when overdosed) • Antipsychotics (atypical antipsychotics are preferred to the typical ones because these have fewer adverse effects) • Anti-anxiety agents to control anxiety and insomnia.

37. Counselling • Establishing a working relationship with the patient encourages him to solve the problems in a realistic manner. • A No-Suicide contract is written by the patient where he agrees not to harm himself but to use alternative methods to control suicidal ideas (e.g. use help-line, talking to the staff). • The patient should come for regular follow-up after discharge from the hospital.

38. Case Management • The patient is helped to recognize the support system available to him. • Re-establishing the contacts with family and friends is the major focus of case management. • The patient should be given information on aftercare referral, crisis hotlines, support groups and recreational groups. • Depending upon the religious beliefs, the patient may be encouraged to join a spiritual support group.

39. Health Education • The nurse should provide information about the psychiatric diagnosis, if any, the need for treatment, maturational crisis, coping and communication skills and various community resources available. • Family and friends should also be included in the health teaching sessions.

40. Nursing Evaluation • Evaluation is an ongoing process. The evaluation should include short-term goals and establish long-term ones as the suicidal ideas resolve. • The patient is observed to see whether he is able to talk about his thoughts and feelings freely and readily, is able to use problem-solving methods and is using the social support system. • The patient is constantly monitored for any sudden change in the mood and behaviour as it may indicate a suicidal intent.