CRC Suicide Protocol Training

1. CRC Suicide Protocol Training February 22, 2007 10 a.m. – 11:30 a.m. Presented by: Patrick Arbore, Ed.D.

2. Definition of Suicide • Currently in the Western World, suicide is best defined as a conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual who defines an issue for which the suicide is perceived as the best solution. ─ Edwin Shneidman (1985)

3. US Suicide: 2003 Official Final Data • US Rate of Suicide – 10.8 per 100,000 • Males – 17.6 per 100,000 • Females – 4.3 per 100,000 • Whites – 12.1 per 100,000 • Nonwhites – 5.5 per 100,000 • Elderly (65+) – 14.6 per 100,000 • Young (15-24) – 9.7 per 100,000

4. California Suicide Deaths 2004 • Males – 2,543 actual #’s – 14.0 rate • Females – 821 actual #’s – 4.5 rate • Firearms – Males – 1,185 actual #’s (46.6% of total male suicides) • Firearms – Females – 178 actual #’s (21.7% of total female suicides) • Jumping – Males – 89 actual #’s • Jumping – Females – 31 actual #’s

5. California Suicide Deaths by Age 2004 • Age 55-64 – 439 Deaths – 13.3 rate • Age 65-74 – 256 Deaths – 12.6 rate • Age 75-84 – 250 Deaths – 17.6 rate • Age 85 + – 126 Deaths – 23.0 rate

6. Suicide & Homicides • Suicide ranks as the 11th cause of death • Homicide ranks as the 15th cause of death • That is, more Americans kill themselves than are killed by others.

7. What Causes Suicide? According to Dr. Edwin Shneidman: • Suicide is caused by psychache – intolerable mental (and/or physical) pain. • Suicide occurs when the psychache is deemed to be unbearable • Involves each person’s own threshold for enduring psychological pain • When a person reaches their maximum threshold of pain, they consider suicide

8. Examples of Psychache • Shame • Guilt • Humiliation • Loneliness • Fear • Angst • Dread of growing old • Dying badly • Helplessness • Watching a loved one die

9. Common Single Predictors of Suicide According to Maris • Depressive illness • Alcoholism, drug abuse • Suicide ideation • Prior suicide attempts • Lethal methods • Isolation, loss of support • Hopelessness • Being an older white male

10. Caregiving and Depression • Caregiving does not cause depression • People experience depression in different ways • Symptoms of depression include: any change in behavior (e.g. eating habits, sleep patterns); fatigue; loss of interest in people or activities that once were pleasurable; thoughts of death and/or suicide; feelings of worthlessness.

11. Depression and Suicide • According to Clark (1999) – For approximately 60% of all cases of suicide and 83% of elderly suicides – major depression plays a pivotal role in facilitating suicide.

12. Suicide & Guns • Most gun deaths are suicides not homicides • Among both men and women, firearms are the most common method of suicidal death • The presence of a firearm in the home increases the risk of suicide more than fourfold even after controlling for variables such as living alone or the use of medications or alcohol

13. Suicide Risk Factors in Late Life • Suicidal behavior is difficult to predict • Even in high-risk groups, it is infrequent • Many different variables contribute in some degree to the probability of suicidal behavior • The onset of significant illness strongly increases the risk of suicide • Depression represents an important risk factor for suicide among the elderly

14. Risk Factors for Suicide • Severe physical illness • Marked change of body image in self or loved one • Loss of significant emotional ties • Decrease in level of socialization • Lack of religious faith • Cognitive impairment • Isolation • Chronic pain • Loss of functional capacities

15. Culture & Suicide • The prevalence of suicide in elderly immigrants is largely determined by their country of origin • Asian Nations – greater rates of suicide among older rather than younger age groups; women exhibit significantly higher rates of suicide in older age compared to women of other countries

16. Implications According to Conwell • Depressed adults who took their own lives escaped adequate diagnosis and treatment • Suicide risk is associated with physical illness and functional limitations • Reductions in older adult suicide hinge on the understanding of the interplay of depression, physical illness, and functional impairment

17. What You Can Do: • Refer to the CRC Suicide Protocol and familiarize yourself with the content 2. While most of your contacts are going to be with clients who are not exhibiting suicidal behavior, all members of the team need to be informed about how to manage a suicidal person 3. Examples of real life situations will be discussed.

18. Risk Assessment • The CRC assessment tools (A-/R-tool) ask in three ways about a caregiver’s feelings of depression and stress. • As written in the suicide protocol, whether a client is on the phone or in person, any indirect or direct reference to ending life must be taken seriously.

19. Risk Assessment • Questions to ask to assess high or low risk are provided for you. • Remember, most of your contacts with clients will be of a low risk nature. • Knowledge of local resources will be helpful in order to offer a caregiver an appropriate referral if they are in need of assistance.

20. Mood or Affect • The amount of stress or depression a person is experiencing in threatening or difficult situations depends largely on how well they think they can cope in that situation. • Affect involves a generic sense of arousal or activation that can be either emotional or physiological. • Different cultures have different rules around the expression of mood or affect – do not assume that everyone expresses emotion in the same way.

21. Emotional Insight • Is associated with better individual and interpersonal functioning. • If people understand their emotional experience, they are in a better position to know how they need to respond to environmental demands. • Understanding one’s own emotional experience makes it possible to regulate one’s behavior.

22. The Experience of Crying • Can be a starting point in a process of distress resolution. • Crying is a sign that individuals are actively experiencing their emotions. • Crying indicates an opportunity for people to understand and process their feelings. • A crying client on the phone or in person may benefit from a referral to a counselor in their area who can help them make sense of their experience.

23. Flooded Expression • Occurs when people have such intense levels of emotional experience and arousal that their feelings seem to burst out of them. • At high levels of emotional arousal, people can’t think straight. • Some people may feel frightened by what they perceive as their uncontrollable waves of expression; they may see this as a sign that something is wrong. • This person may benefit from a mental health referral

24. What Helps the Caregiver • Show empathy with the caregiver • Listen attentively • Reflect feelings • Create rapport • Offer appropriate resources/referral

25. Some Key Word Definitions • Plan • Means • Affect • Speech: speed, volume • Thoughts: paranoid, delusional, psychotic

26. Case Examples Using the CRC Suicide Protocol as a Guide to managing “at risk” caregivers

27. What Helps You? • Be aware of the stress and personal toll talking with a person of high or low risk of suicide can take on you. • Talk to your supervisors or colleagues about your feelings. • Take good care of yourself – self-care and service to others are linked. The best way to care for others is to care for yourself.

28. Questions? If you have questions for Patrick or Dorothy, please e-mail them to bethlogan@comcast.net