Suicide and Other Risk Assessment

1. Suicide and Other Risk Assessment Finding the best solution while staying least restrictive focused

2. Mental Health Crisis • Too often, public systems respond as if a mental health crisis and danger to self or others were one and the same. A narrow focus on dangerousness is not a valid approach to addressing a mental health crisis.

3. Mental Health Crisis • Assessing crises accurately requires thoughtful consideration of various presenting circumstances and a perspective that looks beyond whether an individual is dangerous or immediate psychiatric hospitalization is indicated.

4. Risk Taking There are risks when working with someone who is having unsafe thoughts and/or are experiencing a mental health crisis Having a clear and consistent assessment process assists with managing risk and shows best faith through thought process and collaboration

5. Risk Management • Shared risk- collaboration assists in sharing risk and liability between crisis staff, law enforcement and others. • Documentation- comprehensive assessment documentation • Creative thinking- remember that not everyone is thinks like you and/ or has the same values as you. Get the client involved in this process. Crisis work is not black and white- be creative and open regarding your ideas and thoughts to keep someone safe • Problem solving- be open that you may not have all of the answers. It is imperative that you reach out to the client, collateral parties and people you work with • Best Faith Effort-Basing decisions on information provided by person in crisis, collaborative parties, state regulations, and assessment of need

6. Mental and Physical Status

7. Assessing Mental and Physical Status • Is the person intoxicated? • Is there any apparent physical injury? • Is the person coherent? • Is the person oriented to person, place and time? • Is there any other type of physical distress? (i.e. profuse perspiration, complaints of respiratory problems, complaints of cardiac problems, complaints of abdominal pain) If the person is ascertained to be in acute physical distress, he/she should be seen at the nearest emergency room ASAP. The crisis worker should make arrangements for emergency medical transportation if needed.

8. Assessing Mental and Physical Status • General appearance- i.e.: clothes, grooming • Behavior - cooperative, agitated… • Speech –normal, pressured, rapid… • Affect – sad, angry, appropriate… • Thought content – goal directed, delusional… • Memory (if deficits in recent, remote or intermediate memory)

9. Assessing Mental Status- Orientation Possible Questions • “What is your full name?” • “What is your date of birth?” • “Do you know where we are?” • “Can you tell me what month/year it is?”

10. Assessment considerations - Mood • Sleep pattern- sleeping a lot, not sleeping • Has client’s mood changed significantly? • If in a positive manner assess increase motivation to implement at plan. • Always assess suicidality! • Is this behavior different than the client’s “typical” or “baseline” behavior? Ask the client and collateral parties!

11. Assessment considerations - Mood Possible Questions: • “How are you feeling?” • “Have you been discouraged/depressed/low/blue lately?” • “Have you felt energized/elated/out of control lately?” • “Have you been angry/irritable/edgy lately?”

12. Assessment considerations - Psychosis • Atypical behaviors and speech • Detachment of reality- including person, place, and time. • A client who is not aware of who they are, where they are, or the date is described as “not oriented times three (x3)” • Is the delusion and/ or hallucination dominating the person’s ability to be safe? Ability to care for self? • Is this behavior different than the client’s “typical” or “baseline” behavior? Ask the client and collateral parties!

13. Assessment considerations - Psychosis • Acknowledge the validity of the person’s sensory experience, • Get enough information to determine how the person is feeling about the experience (frightened, angry, okay) • Is the delusion and/ or hallucination dominating the person’s ability to be safe? Ability to care for self? • Is this behavior different than the client’s “typical” or “baseline” behavior? Ask the client and collateral parties!

14. CONSIDER MEDICAL ISSUES • If you do not look for it you will not find it! • The need for “medical clearance”

15. Medical Illness that Can Present as Psychosis • Drug intoxications • Drug withdrawals • Medical emergencies

16. Medical Illness that Can Present as Psychosis Symptoms of some medical problem can present as psychiatric illness • Hypoglycemia (low blood sugar) • DT's (delirium tremens) • Acute thiamine (vitamin B6) deficiency: can cause rapid brain damage -- usually found in alcoholics.

17. Medical Illness that Can Present as Psychosis • Drug withdrawal from alcohol or other sedative hypnotics • Urinary Tract Infection (especially in the elderly) • Dehydration • Low potassium

18. Suicide Risk Assessment

19. Suicide –Wisconsin Statistics Wisconsin- 2014 state publication • Highest suicide rate per age is adults ages 45-54 • Nearly four out of five people who die by suicide are male • By race, Caucasians have the highest suicide rate followed by Native Americans

20. Suicide –Wisconsin Statistics Wisconsin- 2014 state publication • By gender, males over the age of 84 have the highest suicide rate • Rates of emergency department and hospitalizations due to self injury were highest among teens and young adults ages 15-24 • Veterans who died by suicide account for 19% of all suicides for those 18 and older. However, only 9.7% of WI residents over age 18 were veterans

21. Suicide –Wisconsin Statistics • The three primary means for suicide in Wisconsin are • firearms • hanging/strangulation/suffocation • poisoning (medication overdoses, carbon monoxide)

22. Suicide Risk Assessment Risk Factors and Warning Signs • Risk factors are statistically derived, usually unchangeable and may not be significant independently. i.e.: age, gender, previous attempts, mental illness • Warning signs are observable behaviors, current circumstances for an individual. • Warning signs + risk factors= elevated concern

23. Suicide Risk Factor - Firearms • The presence of a firearm in the home has been found to be an independent, additional risk factor for suicide. • 45% of suicides in Wisconsin are by firearms • Nearly 80% of all firearm suicides are committed by white males • Suicide by firearms is the fastest growing method

24. Additional Suicide Risk Factors • LGBTQ • Teens when another suicide has occurred in their community • Mental Illness • Substance Abuse • Cultural &/or religious beliefs that support suicide as a resolution • Easy access to lethal methods • History of previous acts • History of suicide in the family • Veteran • Never married/divorced • Caucasian male • Adult age 45-54

25. Additional Suicide Risk Factors • Feeling like a burden to others, socially isolated • Physical health problem • Intimate partner problems • Loss of employment/financial problems

26. Suicide -Warning Signs • Suicidal ideation – thinking or talking about suicide/death • Suicidal intention – behavior related to suicide plan or intent • Securing means to commit suicide (i.e.: stockpiling medications) • Preparing/updating will • Giving away personal possessions • Hopelessness • Withdrawing from friends, family

27. Wisconsin Suicides

28. Suicide Risk Assessment

29. Suicidal Desire • Feeling trapped • Severe health changes • Recent criminal charges • Recent losses/ relationships • Survivor of abuse/ trauma • Medical issues . Desire signals a crisis • Ideation- thoughts/desire to kill self or others • Feeling alone/disconnected • Helplessness -feels situation is out of control • Hopelessness-no other solutions • Perceived burden on others .

30. Suicidal Capability Noting these risk factors equals an increase in risk than desire alone. • History of suicide attempts • History of or current violence/aggression • Substance use/abuse • Availability of means to carry out threat - lethality • Exposure to someone else’s death by suicide • Acute symptoms of mental illness .

31. Suicidal Capability • Self injurious behavior • Extreme agitation/ rage • Sleep disruption • Increased anxiety • Discrepancies in report Capability indicates fearlessness and competence to make an attempt.

32. Suicidal Intent • Attempt in already occurred • Expressed intent to die • Mentally rehearsing plan • Preparatory behaviors • Giving away pets/ belongings • Suicide note • Creating or changing will Intent-a thing intended; an aim or plan

33. Columbia – Suicide Severity Rating Scale (C-SSRS) • Offers a full version and a screener. • The Screener is a 6 question suicide screening tool that evaluates suicidal ideation of increasing severity from a wish to die to an active thought of killing oneself with a plan and intent. • Uses a 1-5 rating scale that measures both suicidal ideation and suicidal behavior • Evaluates suicidal ideation by: • Wish to die • Active thoughts • Associated thoughts of methods • Some intent • Plan and intent • Examines suicide attempt and other suicidal behaviors (interrupted, aborted, and preparatory). • Distinguishes from non-suicidal self-injurious behaviors. • Gives operationalized criteria for next steps to help streamline interventions and resources. .

34. Columbia – Suicide Severity Rating Scale (C-SSRS) -History • Developed by leading experts from the National Adolescent Attempters’ Study who identified a gap in then existing scales and tools to address suicide risk and assessment. • C-SSRS was created to: • Assess both suicidal behavior and ideation together • Look at intensity/severity • Track change • Designed to give the most critical, evidence-based items needed to complete a thorough assessment .

35. Columbia – Suicide Severity Rating Scale (C-SSRS) -Benefits • Only screening tool that captures both suicidal ideation and behaviors which is shown to be best predictor of suicidality • Enables quicker crisis response and improves linkage to interventions and services • Reduces burden both in unnecessary interventions, costs, resources, and time. • Evidence-based and supported – Joint Commission “The Gold Standard” • Appropriate for use across the lifespan and with specialized populations • Applicable across environmental settings • Easy to administer • Can used with multiple sources or collateral contacts • High consumer/patient satisfaction • No specific mental health training or certification needed to administer • Correctly identifies those in need of interventions and resources .

36. COLUMBIA-SUICIDE SEVERITY RATING SCALE – Screen • Interview with the creator: • https://www.youtube.com/watch?v=tWuUR-LaVaI&index=1&list=PLZ6DpvOfzN1l81qtX3lvdMtBNypX0rpUJ • Screener Training: • https://www.youtube.com/watch?v=Ted_gl-UXi8

38. C-SSRS Screen • Have you wished you were dead or wished you could go to sleep and not wake up? • Have you actually had any thoughts of killing yourself? No matter the situation we ask these questions

39. If YES to 2 ask 3-6If NO to 2 go directly to 6 • Have you been thinking about how you might kill yourself? • Have you had these thoughts and had some intention of acting on them? • Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? • Have you ever done anything, started to do anything, or prepared to do anything to end your life?

40. Homicide Risk Assessment

41. Homicidal Risk Assessment • Assess Homicidal Ideation. Ask: • (Normalize): When someone feels as upset as you do, they may have thoughts about hurting the person who has upset or hurt them. What thoughts have you had like this? • Assess Plan/Means  • If you decided to try to hurt ____, how would you do it? Tell me about the plans you’ve made. • Access to Means   • You mentioned that if you were to hurt __, you’d probably do it by (describe method). How easy would it be for you to do this? • Assess Intent • People often have very mixed feelings about harming other people. What are some reasons that would prevent you from trying to hurt ________?

42. Mandated Reporting- Duty to Warn • Expectation-A professional is negligent if he/she does not warn, when harm to a third person is foreseeable by a professional exercising due care • Threat-a serious specific threat of harm against a specific, clearly identified victim • Duty to Warn- if a person makes a threat to harm someone else you are mandated to report this to the person the threat was directed and to law enforcement. • Consult with your supervisor before making any report • Most situations of duty to warn will be addressed by law enforcement

43. Mandated Reporting- Duty to Warn Tarasoff v. Regents of the University of California, (Cal. 1976), was a case in which the Supreme Court of California held that mental health professionals have a duty to protect individuals who are being threatened with bodily harm by a patient. The original 1974 decision mandated warning the threatened individual, but a 1976 rehearing of the case by the California Supreme Court called for a "duty to protect" the intended victim. The professional may discharge the duty in several ways, including notifying police, warning the intended victim, and/or taking other reasonable steps to protect the threatened individual.

44. Additional Assessment Considerations

45. Assessment Considerations - Substance Use • Signs or disclosure of recent use • Amount and frequency of use; including history • Minimizing use- demonstrated by testing or collateral informants • History of treatment and withdrawal • Incapacitation • Always inquire if a person has used something- do not assume!!

46. Assessment considerations – Substance Use Ask client the following: 1- Have you been concerned about your drug and/ or alcohol use? 2- Have others been concerned about your drug and/ or alcohol use? 3- Have you noticed being unable to remember things while using drug and/ or alcohol? • Inquire about hangover/ discomfort after using.

47. Assessment considerations - Psychopharmacology • Always inquire about current medications • Any recent change in dose? • Any recent addition or discontinuation of a medication? • Issues related to potential side-effects from medication take medical priority to a mental health assessment or hold.

48. Jail Assessment Considerations • It is important to keep work in the jail in the context of crisis • Each county is a bit different in each jail-see county specific directives regarding this

49. Inmate Risk • Inmates are particularly at risk during their first 24 hours under custody as they face the reality of incarceration. • The risk further increases for offenders and detainees whom have no way to post bail - particularly if this is their first incarceration for felony offenses.

50. Inmate Risk • The jail environment embodies fear, distrust, lack of control, isolation, and shame and is often dehumanizing. Coping with entering this environment, inmates often feel overwhelmed and hopeless, leading some to choose suicide as a way to escape. • Offenders are likely to have several risk factors that predispose them to suicidal behavior.