Suicide Prevention

1. Suicide Prevention Yanisse Scott, MSW, LISW-CP

2. Objectives At the end of this program you will be able to: • Define Suicide as it relates to violence. • Identify suicide rates in the United States and South Carolina (general population and the population with Spinal Cord Injuries (SCI). • Identify what are the most at risk populations for suicide. • Identify risk and protective factors of suicide. • Identify the signs of a person who may be suicidal. • Identify best evidenced-based treatment practices for overall prevention. • Understand what to include when developing a crisis plan. • Understand what to do if you believe someone is at risk of suicide. • Start a conversation if someone may be at risk of suicide. • Identify the continuum model of suicide exposure and what you can do to assist a survivor of suicide.

3. Statistics about Suicide • The World Health Organization estimates that approximately 1 million people die each year from suicide. • According to the CDC, suicide rates have increased nearly 30 percent in half of the states between 1999 and 2016. • Suicide rates in South Carolina increased 38.3 percent from 1999-2016. • Nearly 45,000 death can be attributed to suicide in the year 2016 only. • Highest increased (58 percent) occurred in North Dakota. • Rates increased in all states including the District of Columbia. • Nevada was the only state where the rate decreased.

5. Statistics about Suicide • In 2015 (the most recent year of available death data), suicide was responsible for 44,193 deaths in the U.S. • 1suicide every 12 minutes. • Suicide ranked as the 10th leading cause of death in 2015 and has been among the top 12 leading causes of death since 1975 in the U.S. • Suicide mortality is (3) times higher in people with Spinal Cord Injuries than in the general population • Third leading cause of death in people ages 10-14 • Second leading cause of death among people ages 15-34 • Fourth leading cause of death among people 35-44 • Fifth leading cause of death among people 45-54 • Eight leading cause of death among people 55-64

6. Let’s talk about Terms: Suicide • The Centers for Disease Control and Prevention (CDC), define suicide as part of a broader class of behavior called self-directedviolence. • Suicideis a death caused by self-directed injurious behavior with any intent to die as a result of the behavior. • Suicide attempt is a non-fatal self-directed and potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury.

7. Let’s Talk About Terms: Suicide • “Suicide is a desperate attempt to escape suffering that has become unbearable. Blinded by feelings of self-loathing, hopelessness, and isolation, a suicidal person can’t see any way of finding relief except through death. But despite their desire for the pain to stop, most suicidal people are deeply conflicted about ending their own lives. They wish there was an alternative to suicide, but they just can’t see one.”

8. Why is Suicide so Prevalent? It contributes to: • Premature death, • Morbidity, • Lost productivity, • Health care costs. Many people think about suicide or attempt suicide. • 9.8 million seriously thought about suicide • 2.8 million made a plan for suicide • 1.3 million attempted suicide

9. Who is at Risk? • American Indian and Alaskan Natives; • Non-Hispanic Whites; • Rural populations; • Older adults (especially white males); • Active or retired military personnel; • Individuals with mental and/or substance use disorders; • Individuals bereaved by suicide; • Individuals in justice and child welfare settings; • Individuals who engage in non-suicidal self-injury; • Individuals who have attempted suicide; • Individuals with medical conditions; • Individuals who are lesbian, gay, bisexual, or transgender (LGBT); • Men in midlife.

10. People with Spinal Cord Injuries and Suicide are at Risk Too • Individuals with SCIs are at an increased high risk of suicide compared to the general population. • 3 times higher. • In a study, it was concluded that the suicide accounts for between 4 and 11% of deaths following SCI. • Paralysis from a spinal cord injury (SCI) increases risk of psychological problems including not only suicide attempts, but also substance use disorder, negative emotions (e.g., anger), depression, anxiety, ASD/PTSD.

11. Risk Factors in the general population and People with SCI • History of mental illness • Substance abuse • Traumatic experiences • Previous suicide attempts • Excessive threat perceptions • Limited social support • Family fragmentation • Easy access to means • Sleep disturbances • Poor access to psychological support in the community

12. Is having a mental health condition necessary to be at risk of Suicide? • In studies conducted as early as 2014, researchers found that death by suicide was related to mental health conditions such as depression. • In recent years, studies demonstrate that people with no known mental health conditions are not exempted.

13. Is having a mental health condition necessary to be at risk? • 54 percent of the people who killed themselves in 27 states didn’t have a mental health disorder. Rather: • Relationship problems, • Substance misuse, • Physical health problems, • Job or financial problems, • Recent crises or things that were coming up in their lives that they were anticipating.

14. Risk Factors

15. SOURCE: CDC’s National Vital Statistics System

16. Implications • Because people who die by suicide not necessarily have a mental health illness, efforts have to be made to prevent suicide even without going to a mental health or medical provider.

17. Quote • “People with disabilities are more concerned about their relationships and social inclusion, financial security, difficulties while at work.” (Weiss)

18. Some Signs that may be related to a person feeling suicidal • Talking about wanting to die or to kill oneself • Looking for a way to kill oneself • Talking about feeling hopeless or having no reason to live • Talking about feeling trapped or in unbearable pain • Talking about being a burden to others • Dropping out on daily routines • Increasing the use of alcohol or drugs • Acting anxious or agitated; behaving recklessly • Sleeping too little or too much • Changes in eating patterns • Withdrawing or feeling isolated • Showing rage or talking about seeking revenge • Displaying extreme mood swings

19. Protective Factors • Effective clinical care for mental, physical, and substance abuse disorders • Sense of control • Acceptance and hope • Easy access to a variety of clinical interventions and support for help seeking • Family and community support (connectedness) • Engagement and social participation and access to responsive support systems • Relational commitments • Quality social support • Support from ongoing medical and mental health care relationships

20. Protective Factors cont. • Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes • Ability to perceive injury as a challenge, rather than a threat • Cultural and religious beliefs that discourage suicide and support instincts for self-preservation • Purpose in Life • Personal resilience “When you feel like giving up, just remember the reason why you held on for so long.” ~ Unknown

21. Prevention Strategies • Suicide is not caused by a single factor • Research suggests that reductions in suicide will not be prevented by any single strategy or approach. • Suicide prevention is best achieved by a focus across the individual, relationship, family, community, and societal levels and across all sectors, private and public. • States can use a comprehensive evidence-based public health approach to prevent suicide risk before it occurs, identify and support persons at risk, prevent reattempts, and help friends and family members in the aftermath of a suicide.

23. Importance of Connectedness • Connectedness is the degree to which a person or group is socially close, interrelated, or shares resources with other persons or groups. The nature and quality of connections both within and between multiple levels of the social ecology, including: • Connectedness between individuals • Connectedness of individuals and their families to community organizations • Connectedness among community organizations and social institutions

24. Importance of connectedness in people with SCI • Their circle of friends, significant others, family, and co-workers typically gets smaller, after someone becomes paralyzed. Spinal injury patients often have psychological problems such as low total self-concept, acute stress disorder (ASD)/Post Traumatic Stress Disorder (PTSD) symptoms, and/or suicidal thoughts and behavior.

25. Lethal Means: Firearms Reduce access to lethal means (i.e. weapons, hanging, suffocation, poisoning and the like.) • Approximately 50% of all American suicide deaths result from firearms • 85%-95% of all suicide attempts involving a firearm result in death • Firearm access is not associated with developing suicidal thoughts • Firearm access is associated with death by suicide • Firearms may facilitate the rare transition from suicidal thoughts to death by suicide

26. Best Treatment Practices for Suicide Prevention and Intervention • Gatekeeper Training- training programs to assist hotline counselors, crisis workers and other gatekeepers to assess and provide guidance and ancillary services. • Crisis intervention- National Hotlines, Crisis Center • Dialectical Behavioral Therapy (DBT)- a multicomponent therapy for individuals at high risk for suicide and who may struggle with impulsivity and emotional regulation issues. It includes individual therapy, group therapy, phone consultation and therapist consultation team approach. It is used to treat not only high risk for suicide individual but also individuals depression, high intensity emotions, and anxiety,

27. Mindfulness can Help • Mindfulness is a psychological technique that helps people learn how to “be in the present moment, without judgement” and helps patients gain more control over their own pathological thought patterns (e.g., to become less critical of themselves and others), emotions and maladaptive behaviors. • Its benefits include: physical health, relieve stress, lower blood pressure, reduce chronic pain, improve sleep, and alleviate gastrointestinal difficulties. • A recent case study suggested that VR mindfulness helped a patient newly injured with an SCI feel less depressed, less nervous, less emotionally upset, and reduced patient’s emotions of sadness, fear, anger, guilt, shame, and disgust.

28. Best Treatment Practices for Suicide Prevention cont. • Attachment-Based Family Therapy (ABFT)-is a program for adolescents aged 12–18 and is designed to treat clinically diagnosed major depressive disorder, eliminate suicidal ideation, and reduce dispositional anxiety. • Emergency Department Brief Intervention with Follow-up Visits- is a program that involves a one-hour discharge information session that addresses suicidal ideation and attempts, distress, risk and protective factors, alternatives to self-harm, and referral options, combined with nine follow-up contacts over 18 months (at 1, 2, 4, 7, 11 weeks and 4, 6, 12,18 months). • Cognitive Behavior Therapy for Suicide Prevention (CBT-SP)-is an example of a therapeutic approach to prevent re-attempts.

29. Develop a Crisis Plan • Phone numbers for your loved one’s therapist, psychiatrist and other healthcare providers • Family members and friends who would be helpful, and local crisis line number • Phone numbers of family members or friends who would be helpful in a crisis • Local crisis line number (you can usually find this by contacting your NAMI Affiliate, or by doing an internet search for “mental health crisis services” and the name of your county) • Mobile Crisis Unit phone number in the area (if there is one) • Determine if police officers in the community have Crisis Intervention Training (CIT)

30. Develop a Crisis Plan • Addresses of walk-in crisis centers or emergency rooms • The National Suicide Prevention Lifeline: 1-800-273-TALK (8255) • Your address and phone number(s) • Your loved one’s diagnosis and medications • Previous psychosis or suicide attempts • History of drug use • Triggers • Things that have helped in the past

31. What YOU Can Do If you believe someone is at risk of suicide: • Ask them if they are thinking about killing themselves. (This will not put the idea into their heads, or make it more likely that they will attempt suicide.); • Call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255); • Take the person to an emergency room or seek help from a medical or mental health professional; • Remove any objects that could be used in a suicide attempt; and • If possible, do not leave the person alone.

32. What YOU Can Do cont. • Take the threat seriously • Remember: Suicidal Behavior is a cry for help • Be willing to give and get help rather sooner than later • Listen • No secrets • Get Involved: World Suicide Prevention Day is an awareness day observed on 10 September every year, in order to provide worldwide commitment and action to prevent suicides, with various activities around the world since 2003.

33. Have you been exposed? Are you a survivor?

34. Surviving a Loved One’s Suicide • Survivor of suicide is a family member or friend of a person who died by suicide. • It is estimated that for every suicide there are at least 6 survivors. • Based on this estimate, approximately 6 million Americans became survivors of suicide in the last 25 years.

35. Postvention • Postvention is an organized response in the aftermath of a suicide to accomplish any one or more of the following: • To facilitate the healing of individuals from the grief and distress of suicide loss • To mitigate other negative effects of exposure to suicide • To prevent suicide among people who are at high risk after exposure to suicide

37. Suicide Exposure: The Continuum Model • Exposed- anyone whose life or activities in any way intersect with a particular suicide fatality. • Affected- a subset of those exposed and includes everyone who has a reaction to the suicide that might require some type of assistance, whether the reaction is due to grief or some other issue, such as posttraumatic stress disorder (PTSD).

38. Suicide Exposure: The Continuum Model • Suicide bereaved short-term-a subset of those affected and includes everyone who has a reaction that is clearly related to grief, meaning that it stems from some type of personal or close relationship between the bereaved person and the deceased. • Suicide bereaved long-term- a subset of those bereaved short-term and includes all bereaved people who encounter extraordinary difficulties in the course of their grief—with their intensive bereavement likely to endure for at least a year or longer.

39. After Suicide, it is important to know: • Grief work is an extremely individual and unique process. • Each person will experience it in their own way and at their own pace. • Grief does not follow a linear path. • There is no time frame for grief. • They do not expect that their lives will return to their prior state. • Survivors aim to adjust to life without their loved one.

40. What YOU can Do for a Suicide Survivor • Listen without, judgment criticism or prejudice. Leave your preconceptions “outside the door” • Ask how you can help. • Let them talk at their own pace. • Be patient. Repetition is part of healing. • Use the decedent’s name. • Be present even when you don’t know what to say. • Do not tell them how they should act and or feel. • Avoid statements such as “I know how you feel.”

41. From a Survivor’s Perspective • Communicating the idea that suicide is preventable is essential to public health in their approach to reduce suicide. • Have you considered that if every suicide is preventable then: “My loved one’s suicide could and should have been prevented?” This could add to the survivor’s grief. • A survivors view of whether a suicide was preventable or not can propel the survivor’s experience in multiple directions. • Preventable? why didn’t I prevent it?, why didn’t someone prevent it? or God prevent it? What “role” should I have in preventing it? • Not preventable? “My loved one is not suffering,” “I feel relief his/her pain is gone” or “helpless about not being able to do anything about it.”

42. Survivors Support Groups in SCVisit: https://afsp.org/find-support/ive-lost-someone/find-a-support-group • 1. Survivors of Suicide • Greenville South Carolina • 2. Survivors of Suicide Loss • Myrtle Beach South Carolina • 3. Survivors of Suicide • Greenville South Carolina • 4. Survivors of Suicide • Hilton Head Island South Carolina • 5. Survivors of Suicide/Charleston • Charleston South Carolina • 6. Survivors of Suicide Bereavement Support Group • Aiken South Carolina • 7. Columbia Survivors of Suicide • Columbia South Carolina

43. Resources • Alliance of Hope • American Association of Suicidology • American Foundation for Suicide Prevention • Centers for Disease Control and Prevention • Center for Mental Health Services • Division of Violence Prevention • National Alliance of Mental Illnesses • National Center for Injury Prevention and Control • Substance Abuse and Mental Health Services Administration (SAMHSA) • Suicide Prevention Lifeline (1-800-273-TALK (8255) • Suicide Prevention Resource Center • Survivors of Suicide • U.S. Department of Health and Human Services • Veterans Crisis Line (1-800-273-8255 Press 1)

44. Thank You! “Suicide is a permanent solution to a temporary problem.” ~Unknown

45. Questions?

46. References • American Association of Suicidology. (2014) Helping Survivors of Suicide: What Can You Do? Retrieved from URL on February 19, 2019. • Cao Y, Massaro J, Krause J, Chen Y, Devivo M. (2014) Suicide Mortality After Spinal Cord Injury in the United States: Injury Cohorts Analysis. Retrieved from URL www.archives-pmr.org on February 16, 2019. • Carlson T. (2017, August 22) Suicide and SCI: Moving Past the Darkness. Retrieved from URL on February 16, 2019. • Flores A, Linehan M, Todd S R, Hoffman H. (2018, April 23) The Use of Virtual Reality to Facilitate Mindfulness Skills Training in Dialectical Behavioral Therapy for Spinal Cord Injury: A Case Study. Retrieved from URL on February 16, 2019. • Foster M. (2018) Preventing Suicide in People with Disabilities. Retrieved from URL on February 3, 2019.

47. References 6. https://metanoia.org/suicide/. (2019, January 4) What can I do to help somebody who may be suicidal. Retrieved from URL on February 3, 2019. 7. Kennedy, P & Garmon-Jones, L. (2017, September 27). Self-harm and suicide before and after spinal cord injury: a systematic review. Retrieved from URL on February, 14, 2019. 8. National Center for Injury Prevention and Control (2017) Preventing Suicide: A Technical Package of Policy, Programs, and Practices. 9. Savic, G; DeVivo, M J; Frankle H A; Jamous M A; Soni B M & Chalifue, S. (2017, September 26). Suicide and traumatic spinal cord injury—a cohort study. Retrieved from URL on February 3, 2019.

48. References 10. Substance Abuse and Mental Health Services Administration. (2017) Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from URL on February 19, 2019. 11. Survivors of Suicide Loss Task Force (2015 April) Responding to Grief, Trauma, and Distress After a Suicide: U.S. National Guidelines. Retrieved from URL on February 19, 2019. 12. U.S. Surgeon General and of the National Action Alliance for Suicide Prevention (2019) National Strategy for Suicide Prevention: Goals and Objectives for Action, 2012: A Report. Retrieved from URL on February 8, 2019.

49. References 13. Vital Signs: Trends in Suicide Rates and Circumstances Contributing to Suicide — United States, 1999–2016 and 27 States, 2015. MMWR Morb Mortal Wkly Rep 2018;67(22):617-624. Retrieved from URL on February 8, 2019. 14. Weiss T. (2015, June, 14; Revised 2017, February, 13) People with Disabilities and Suicide Awareness. Retrieved from URL on February 3, 2019.