An Introduction to Suicide Assessment and Intervention

An Introduction to Suicide Assessment and Intervention James D. Raper, PhD, LPCS Associate Director Wake Forest University Counseling Center October 14, 2013

Getting Started • Impact of workingwithsuicidal and potentiallysuicidal clients • Increasedanxiety • Ethical implications • What are your goals for today? • What do you want to know? • What questions do you have? • …fears? • Other?

Three Pillars of Competent Practice(Jobes & Berman, 1993) • Foreseeability - Assessment and documentation of risk • Treatment Planning - Documentation of plan based on determined risk • Follow-up/Follow Through - Documentation of executing and following plan

U.S. Suicide: 2010 Official Final Data • Deaths by suicide • Nation: 38,364 (12.4/100,000) • Males: 30,277 (20.0/100,000) • White Males: 27, 422 (22.6/100,000) • Non-White Males: 2,855 (9.4/100,000) • Black Males: 1,755 (8.7/100,000) • Females: 8,087 (5.2/100,000) • White Females: 7,268 (5.9/100,000) • Non-White Females: 819 (2.5/100,000)

U.S. Suicide Attempts2010 Estimates • Approximately 922,725 suicide attempts annually • ~25 attempts for every death by suicide • 100-200:1 for young • 4:1 elderly • 3:1 Female to Male attempt ratio

U.S. Suicide Means2010 Final Data • Firearms: 50.8% • All Other: 49.2% • Suffocation/Hanging: 24.4% • Poisoning: 17.3% • Cut/pierce: 1.8% • Drowning: 1.1%

ClinicianBeliefs Beliefs Continuum • Suicide is wrong, does violence to the dignity of life • Sometimes permissible, when alt. is unbearable • Neutral: not a moral/ethical issue • A positive response to certain conditions: person has the innate right to make any decision, provided it is based on rational and logical thinking, including suicide. • Has intrinsic positive value: way in which one can be immediately reunited with valued ancestors.

Risk Factors vs. Warning Signs Warning Signs • Current substance abuse • Agitation • Anxiety/panic attacks • Social withdrawal • Insomnia • Purposelessness • Plans/preparations • Desperation • Flight into health Risk Factors • Sex • Age • Race • Marital status • Diagnosis • Prior suicide attempts • Family history • Unemployment • Firearms

Assessment of Suicidal Thoughts • Normalize a certain level of ideation • Gentle assumption: “When did you last think about suicide/killing yourself/ending your life?” • Frequency • Duration • Intensity/Severity

Assessment of Suicidal Plans • Specificity • Lethality – How dangerous are their means? • Availability • Proximityof Social Support

Interviewing for Suicidal Intent • History of previous attempts? Severity? *History of attempt is greatest predictor of a completed suicide* • What are clt’s reasons for living? (children, religion, etc) • Clt’s reasons for dying? (list and rank both) • “What has stopped your thus far?” • What does intuition tell you? (This is why addressing your own anxiety is important, so that you can clearly listen to your intuition.)

Clinical Interventions • “No Suicide Contracts” (Hmmmmm) • Siding with life • Solution-focused approach: • “When there have been times when you weren’t thinking about killing yourself – what was different?”

Clinical Interventions (cont.) • Decrease clt’s sense of isolation • Externalize suicidality from clt: “this is something that you’re really wrestling with.” • Align yourself with client/teamwork: “Lets try and figure this out together.” • Speak slowly and clearly, repeating the key, important messages

Clinical Interventions (cont.) Widen clt’s “blinders” • Identify all options, including suicide. • Clts can feel relieved to talk about suicide • Validate that suicide is one option available to them (just not a healthy one) • Reasons for dying vs. reasons for living • Consider other possibilities • Who is clt committing suicide at? • Have clt rate where suicide is on the new list • Still #1, then seriously consider hospitalization

Evaluating Protective Factors • What internal coping skills and external supports does client have available to her/him that will help them stay alive? • Desire to live • Connection with family and/or friends; pets • Connection with faith • Engagement in therapy • Awareness of how a completed suicide would affect others, and desire to not have that happen.

Crisis Response/Safety Plan • Brainstorm list of healthy coping responses • Explore process of contacting appropriate resources, “what would that be like for you to ask for help if you were feeling unsafe?” • Role play with clt. (Imagine how hard it may be for many clt’s to disclose this info) • 3x5 note card of ways in which clt will respond to SI. • Be wary of “no-suicide contracts”.

Consultation and Supervision • Do I need to seek consultation before the client leaves? • Do I need/want to seek supervision after the session and/or before the next session with this client? • How am I feeling about this? • What are my specific concerns for my client? • What are my concerns about myself? • Am I ready/able to see my next client? • What can I do to help re-center myself?

Documentation • Discussed limits of confidentiality • Relevant client history • Previous records • Asked directly about suicidal thoughts/impulses • Specifics of thoughts (FDI); Plans (SLAP)

Documentation (cont.) • Consulted (as needed) • Staged Client (see below), naming relevant risk and protective factors • Implemented appropriate suicide interventions • Provided resources • What is the plan for clt for next 24/12/1 hour?

Documentation: Suicide Staging Criteria

Stage I: Low Risk • No thought pattern of suicide or self-harm • Fleeting/existential thoughts about death may be present with no significant risk factors.

Stage II (Mild) • No verbal expressions of intent for suicide or self-harm unless asked • May vigorously deny suicidal thoughts or admits to intermittent/passing thoughts of death with spontaneous assurance to the evaluator that no attempt will be made • Feeling overwhelmed with crisis, feels hopeless for change • May exhibit somatic complaints

Stage II (Mild) (cont.) • Feeling depressed, “the blues” • Feelings of rejection or disappointment • Support system is available • Expresses options (other than suicide) to solve problems • Will make a Safety Plan, usually does so spontaneously

Stage III (Moderate) • Hesitates when asked if suicidal ideation is present • Makes joking or off-hand statements about suicide • May have a diagnosis of a chronic or terminal illness, including chronic emotional illness • Thoughts of suicide but nonspecific plan

Stage III (Moderate) (cont.) • Suicidal ideation is present and includes: • Listlessness, tiredness, depression, neurovegetative signs • Thoughts of wanting to go to sleep and never waking up, being a burden to others • Accident proneness • Alcohol/Drug abuse • Support system not utilized, significant others/family not aware of depression

Stage III (Moderate) (cont.) • Spiritual thoughts a deterrent to self-harm • Can think of options other than suicide to solve problems but sees “not being here” as an option • Agrees to Safety Plan, which includes going to emergency center/calling support if the impulse for self harm becomes strong

Stage IV (Advanced/Severe) • Admits to thoughts of death • Plans a suicide attempt and selects a method/weapon (lethality of method: Advanced → Severe) • May actually attempt suicide or self-harm • Suicidal ideation is present and includes: • Feelings of hopelessness, depression

Stage IV (Advanced/Severe) (cont.) • “It will never get better”; “the pain of living is too much to bear” • Thoughts of wanting to “get it over with” • Gives needed things away, makes a will, checks insurance policy • Writes letters of goodbye • May have history of unsuccessful attempt(s) • May disclose suicide plan to therapist

Stage IV (Advanced/Severe) (cont.) • No support system, perceives self as a great burden to others • Has rationalized spiritual ideology to encompass a justification of planned actions • Can think of no other option other than suicide • Hesitant to make a Safety Plan

An Introduction to Suicide Assessment and Intervention