Suicide & Crisis Prevention

Suicide & Crisis Prevention Bruce Michael Cappo, Ph.D. Clinical Associates, P.A.

Premise • Nearly all suicidal people do not want to die

Premise • They are in a suggestible state & likely to respond to your demands • Tell them what they must do

Premise • When suicidal - people are acutely suicidal • Imminent danger lasts only seconds, minutes • Intervene prior to this critical stage

Premise • They have mixed emotions • (That is why they called you) • They want to be talked out of hurting themselves

Three H’s • Hopelessness • Helplessness • Haplessness

Hopelessness • Strongest predictor of suicide • Stronger than depression • Only people who have lost all hope kill themselves • Do whatever you can to build hope - however small • The want to have hope in the future

Helplessness • Person views himself as unable to make any changes to the situation • Person views himself as unable to make any changes in life • High risk situation

Haplessness • These folks have sad lives • 25% have history of successful suicides in family • History of mental illness, divorce, abuse, unemployment, etc. • Multiple problems at the same time • Overwhelmed

Hardcore Suicide • Serious about killing themselves • Nothing you can do to stop them • <5% of suicidal population • They do NOT leave notes, call help lines or even talk about their ideation • You only have contact with them after they have completed the act

Guns DO kill people • 64% of men use guns • 41% of women use guns • Dramatic increase for women over drug use since 1970

NOT a spontaneous activity • Gradual wearing down away time • Usually no single precipitating event • Series of events • Seeds perhaps sown in childhood • If child under 5 kills himself then sibling is 9x more likely to attempt

A Form of Communication • Understand attempts as a form of communication • Do not treat in a punitive manner • Ask: • what are they tryin gto say • what needs are unsatisfied • how can this be expressed differently • what can I do to generate hope

Ambivalence • Live & die at the same time • Confusion seeks resolution & they call • Feelings peak prior to taking action • When they pull the trigger they have resolved the ambivalence and are satisfied with the decision • Use ambivalence to help them • You do not want them to reach the resolution stage

The Significant Other • Usually another person is involved • Find out who would be most effected by their action • May seek a short term solution to a problem involving this person • e.g. had a fight & walked out - you help restore communication without manipulations the underlying motivator

Motivations for Attempters • Escape intolerable situations • Join a deceased loved one • Manipulate others • Gain attention • Punish survivors • Revenge • Control when death occurs • Become a martyr • Not want to be a burden to others • Terminal disease

Early Signals • 75% of attempters give notice • behavioral, written, verbal • Do not ignore these signs • Do not panic at first sign - • Inquire, attend & look for a clustering of symptoms

Types of Signals • High risk situation • Depressive symptoms • Verbal warnings • Behavioral warnings

High Risk Situations • Sudden, unexpected trauma that strikes at heart of our existence • One spouse dies in a situation where they are highly dependent on one another • Great athlete becomes paralyzed • Diagnosis of traumatic illness

Depressive Symptoms • Loss of appetite or eat constantly • Anhedonia • Lethargy • Apathy • Withdrawal • Not care about appearance • Substance use

Verbal Warnings • They come right out and tell you that this is an option for them and that they are considering it

Behavioral Warnings • Strongest behavioral warnign is an unsuccessful attempt • Over 40% of completers have at least one prior attempt

DIRT • Dangerousness • Impression of degree of risk • Rescue • Timing

Dangerousness • How dangerous was attempt • 3 pills or whole bottle

Impression of Degree of Risk • Did they think they would die • They may have thought 3 pills would kill them

Rescue • Chances that they would be found and rescued • Did it happen right after everyone left in morning or right before they were to return home

Timing • The more recent the attempt the more dangerous

DON’Ts • NEVER say “why would you do that - you have so much to live for” • Focus on HOW they would do it to asses lethality & imminence of situation • Do not be afraid to ask straight out - you will not give ideas

Assessing Seriousness - SLAP • Specific • More specifc = greater risk • Lethality • Gun to head more lethal than cutting wrists • Availability • Can they get what they need easily • Proximity • The farther from the greater the lethality

Okay, Okay, all that is fine and good… • BUT …What do I do if someone actually calls when I am on the phones?

Establish Relationship with the Person • Reinforce for them having called • Be non-judgemental • Exude confidence & concern • Reassure them that you will be there to help • Get info (phone #, location, etc.)

Assess Risk • SLAP

Identify the Problem • Keep in mind that they may have been dwelling on this for years & you will not have a magic answer for them

Assess their Resources • Ask about significant others, etc.

Mobilize Their Resources • Have them involve others

DOs • Sound calm & understanding • Take a positive approach • Try to remove accessibility to the means

DON’Ts • Be shocked by what they say • Stress the embarassment they would put others through • Engage in debate or argue

75% of those who attempt or complete will threaten • 35% of completers have a prior attempt • 10% of attempters successfully complete

Teens • 80-90% of adolescent attempts are via drugs • Most completers involve firearms

Completers - 14 and Older • Most often Male 3.7 : 1 • Most often by firearm in home • Males tend to act out prior to completion with conduct disorders • Females tend to act out prior to completion with prior suicidal attempts

Attempters 14 and Older • Most often female 3 : 1

Significant Events in 12 Months Prior to Death • Death of grandparent • Hospitalization of parent • Separation of parent • Divorce of parent • Remarriage of parent • Serious psychological trauma • watch spousal homicide, etc.

Alerting Signs - History of ... • Family Hx positive for suicide, depression • Exposure to peer, sibling suicide • Prior attempt • Significant change (anticipated or real) • Parental conflict • Parental pathology

Alerting Signs - Current ... • Antisocial acting out behaviors • Depressed or withdrawn • Hoplessness • Substance abuse • Rigid perfectionism • Idetifies with peer who attempted/completed • Feels trapped

Assessing Imminence • Compulsion to act • Inability to stop self from doing it • Available & readily accessible method • Note already written

Contraindications to Imminent Action • Resources / Supports / Alliances • through therapist, crisis line, etc • Ability to form short term ‘no harm’ contract • Ability to engage in cognitive rehearsal • Ability to engage in self assessment • Can see positives and gray areas • Situation specificity of suicidal urge

Children 5-14 y/o • Completions rare • Some completions may be disguised as accisdents • running into traffic, etc. • 12,000 inpatient admits for attempts each year

Adolescents 15-24 y/o 1 of 2 • 5000 completions each year • 2nd leading cause of death for white males • 75% of all completions are by white males • 80% of all attempts are by white females • Increased use of firearms by both genders

Adolescents 15-24 y/o 2 of 2 • Attempts estimated at 110 for every completion • Only one in eight may be treated • Topeka survey estimates that 2,000,000 high school students under age 19 have at some time in their lives made an attempt

Older Adults • Fastest growing group • Highest for divorced or widowed • Higher prevalence of alcohol abuse • Higher prevalence of depression • Use highly lethal methods • Fewer attempts per suicide • Have more illness • Have increased social isolation

Suicide & Crisis Prevention