Suicide Prevention, Intervention & Postvention

1. The Suicidal Client:Prevention, Intervention, & Postvention Ellen Behrens, Ph.D. Westminster College Master’s Program in Mental Health Counseling Associate Professor ebehrens@westminstercollege.edu

2. Who is in the room?What are your learning needs?

3. OUTLINE Presentation is clinically-oriented, evidence-informed and risk-management informed Will not address NSSI and chronic suicidality associated with clients who have personality disorders This is a sensitive topic - Please self-monitor today and commit to address issues that arise for you • Part 1: PREVENTION • Risk factors • Risk assessment • Part 2: INTERVENTION • Treating your suicidal client

4. This is the world in which our clients live. • LinkinPark singer Chester Bennington committed suicide in 2017, after releasing “One more light", which was dedicated to his friend, Chris Cornell, of Soundgarden, who himself committed suicide a couple of months before. Bennington died on would have been Cornell's 53rd birthday. • https://www.youtube.com/watch?v=Tm8LGxTLtQk

5. https://www.youtube.com/watch?v=JebwYGn5Z3E

6. Salt Lake Tribune, June 2018

8. Secondary/Tertiary PREVENTION: ASSESSMENT OF SUICIDE RISK “…is one of the most complex, difficult, and challenging evaluate procedures” in mental health practice (Simon, 2002)

9. RISK ASSESSMENT: Legal Issues • My wish for you: be aware and informed about legal issues, but do not be driven to a “defensive practice” (e.g., interventions more restrictive than warranted, terminating suicidal clients, overreliance on forms/contracts, practice of fear) • Experts conclude the best way to avoid lawsuits is via quality care & documentation. Do your good work and forge on.

10. RISK ASSESSMENT: Legal Issues • Malpractice claim of negligence occurs when there is a “failure to exercise the standard of care that a reasonably prudent counselor would have exercised in a similar situation” (Bongar & Sullivan, p.59) • Negligence does not require intent, nor is it excused by ignorance • Determined by expert testimony by a mental health professional who has expertise on what another reasonably qualified counselor would have done • Courts have held that therapists cannot be held liable for an error in judgment provided that standard of care was followed • Make a reasonable attempt to detect risk and, when elevated, employ reasonable clinical intervention

11. RISK ASSESSMENT:State of Knowledge • After > 40 years of systematic research… • there is no consensus on the specific weight and significance to be given to various risk factors, and • there is consensus that suicidality is a highly complex biopsychosocial phenomenon with multiple pathways and determinants.

12. RISK ASSESSMENT:State of Knowledge • …we do not possess any single item of information or any combination of items to permit us to predict to a reliable degree the person who will commit suicide. • ….we do not possess the tools to predict particular suicides before the fact.” • (conclusion of Podorny’s,1983, landmark study of 4,800 veterans followed x 5 years and supported in subsequent research since)

13. RISK ASSESSMENT:So, why assess? • The purpose of assessment is not to predict which client might die by suicidor when but, rather, to do the best job we can to increase safety, reduce risk, and promote wellness and recovery. • It is necessary to assess and intervene, but it will not always prevent suicide.

14. RISK ASSESSMENT: WHEN • Every intake session • Each session during a period of suicidal ideation • At all important treatment junctures (i.e., changes in treatment) • With perceived changes in client functioning

15. RISK ASSESSMENT: General approach • Express an understanding of desire to cope with intolerable pain and hopelessness. It is a sign of distress, not deviance. As counselors, we “lean into” our clients distress. • Engender confidence that there’s an alternative to alleviating that pain and that you believe the client can be empowered to use tx and services to do so …without minimizing the pain • Treat the interview as collaborative, empathic exploration of the client’s experience and history, not as checklist. • ALWAYS make the therapeutic alliance primary. Don’t shift into defensive mode, check-lists, or try to shut down affect.

16. RISK ASSESSMENT: COMPONENTS • ASSESS MOOD • ASSESS RISK • IDEATION, INTENT, PLAN, RISK FACTORS, PROTECTIVE FACTORS • DETERMINE LEVEL OF RISK • CONSULT • INTERVENE WITH CLIENT • DOCUMENT

17. Sommers-Flanagan Approach: Assess Mood • Is it ok If I ask you about your mood? • I would like you to rate your mood using a 0 -10 scale. 0=the worst possible mood; you are so depressed that you are going to kill yourself. 10- you are as happy as you could be. • What would you rate your mood now? • What’s happening that makes you give your mood that rating? • What is the lowest mood rating you’ve ever had? • What was happening then? • What is the highest mood rating you’ve ever had? • What was happening then? • For you what would a normal mood rating be on a normal day?

18. RISK ASSESSMENT: Ascending/Normalizing approach to assessing suicide risk(Bryan & Rudd, 2006) Builds rapport, reduces anxiety, normalizes feelings/thoughts, promotes disclosure • Symptomatic presentation “From what you have shared, it sounds like you have been feeling depressed and carrying much pain.” 2. Assess hopelessness “It’s common that people who feel like this also feel like things won’t improve – do you ever feel that way?” 3. Transition to suicidal thinking “People feeling this pain and hopelessness sometimes think about death and dying… do you ever have thoughts about killing yourself?”

19. RISK ASSESSMENT: Assess Risk(Sommers-Flanagan & Shaw, 2017) • Ideation: Frequency, intensity, duration • Intent: Expectation, ego-strength • Plan: • When?, Where?, How? • Preparatory acts such as aborted attempts, rehearsals, settling “affairs” • Access to means • Risk Factors: • Prior attempts, Active DSM Dx, Family Attempts, Stressors, Change in Treatment, Key sx (hopelessness, perturbation, pain, etc.) • Protective Factors: • Internal: Religion, Coping Skills, Mental Health status • External: Children/pets, Social Support, Engagement in Therapy, Relationships

20. RISK ASSESSMENT: Some sample questions Ideation: Have you ever wished you were dead or wished your life was over? Have you had thoughts of killing yourself? When?....How often?....How long do they last?....How intense are the thoughts?....Can you stop thinking about this if you want to? Intent: Have you had any intention or desire to act on these thoughts? How likely would you be able you stop yourself if you wanted to? Plan: Have you been thinking about how you might do this? (timing, location, lethality, means, access). Have you begun to prepare or rehearse? Protective factors: Are there things or people that have stopped you or might stop you from wanting to die by suicide?

21. RISK FACTORS: Strongest EmpiricalSupport Treat each client’s risk profile as a unique set of factors • Previous attempt • Lethality of planned method • Psychiatric diagnosis • Key signs/sx • hopelessness, perturbation (discomfort, agitation), pain, anhedonia, impulsivity, insomnia, command hallucinations • Suicide ideation and/or plan (1/3 and ¾ rule = 1/3% ideators transition to planning; 3/4 of planners transition to attempt) • Impoverished roles: social, family, work/school • Family hx of suicidality or “Axis 1” • Precipitants/stressors • Change in treatment provider or level of care

22. Risk Factors: Using theory to conceptualize risk (as per Sommers-Flanagan & Shaw, 2017) • Merged 3 theories: Schniedman, Joiner, and Klonsky & May, into 8 Pre-suicide Dimensions (aka Risk Factors) of which 6 are NOT in most Risk Factor lists • Psych-ache • Agitation/Perturbation • Problem-Solving Impairment/Mental Constriction (See either Pain or Relief by death) • Thwarted Belonging & Perceived Burdensomeness • Hopelessness • Suicide Desensitization

23. RISK ASSESSMENT: Consultation • Consult with a senior clinician when risk is >moderate • even if you are a senior clinician • Drift? • Desensitization? • Documentation of the consultation or supervision is necessary for legal recognition. Include: • Name, credentials, date, duration • Options discussed • Recommendations of consultant • If recommendations not followed, document rationale

24. RISK ASSESSMENT: Determine Risk Level and Intervention • The prevailing method is to assign low, medium, or high risk designations. • Despite many efforts to define these terms, definitions are difficult to apply and lack predictive validity and cross-clinician consistency. • But, use because it is a standard of care. SAMHSA SAFE-T Guide

25. RISK ASSESSMENT: Intervene • If risk remains after your assessment and discussion during the session: • High: Hospitalize (involuntary or voluntary) • Moderate: Evaluate hospitalization. Evaluate a reasonable increase in level of care/services; Consult/SU; Establish detailed Crisis plan; Involve loved ones/family; Med referral; secure means. • Low: Consider reasonable increase in level of care/services; Establish crisis plan; Evaluate med referral.

26. Intervention Scenarios • 1. Ideation + Plan + Means+ Access + No intent + Weak ego strength/hopeless • 2. Ideation + Plan + Means+ Access + No intent + Adequate egostrenth +Not willing to surrender means • 3. Ideation + Plan + No means + Intent • 4. Ideation + Plan + Means+ Access + Intent + Resists Hospitalization (shame/bad experience) • 5. Ideation + Plan + Means+ Access +No intent + Weak ego strength + cancels apt via text • 6. Ideation + Plan + Refuses to answer all other questions

27. Other issues:Standardized measures and Documentation

28. RISK ASSESSMENT: Add a standardized measure • Assessments provide clarifying information and a supplemental source of information • Generally considered “standard of care” • Caveat: • Overreliance on forms and checklists are sx of anxiety in the clinician and can interfere with tx • The core of the assessment is a face-to-face interview, in the context of clinical rapport

29. RISK ASSESSMENT: >35 Evidence-Supported Suicide Assessment Measures (Interviews, Forms) • There is no “gold standard” (Ghasemi, Shaghaghi, & Allehverdipour, 2015). • Suggestions for selecting a measure: http://zerosuicide.sprc.org/webinar/screening-and-assessment-suicide-health-care-settings • Commonly used measures • Beck Depression Inventorywith Beck Hopelessness Scale http://www.pearsonclinical.com/psychology/products/100000776/beck-family-of-assessments.html#tab-details • Beck Scale for Suicide Ideation http://www.pearsonclinical.com/psychology/products/100000776/beck-family-of-assessments.html#tab-details • Columbia Suicide Severity Rating Scaleversions for EDs, inpatient, primary care • Patient Health Questionnaire for primary care setting • Cultural Assessment of Risk for Suicide for ethnic and sexual minorities • Assessment of Suicidal Behaviors and Risk among Children and Adolescents D. http://www.sprc.org/sites/sprc.org/files/library/GoldstonAssessmentSuicidalBehaviorsRiskChildrenAdolescents.pdf • SAFE-T for outpatient setting

30. RISK ASSESSMENT:A form for repeated measurement.C-SSRS “Self ReportSince Last Contact”

31. RISK ASSESSMENT: Documentation Shifting to another painful reality….risk of negligence Absence of notes is a breach of duty Good risk-management Remember: If you follow the standard of care of reasonable, qualified counselors and you document that well, the risk of negligence is low Focuses counselor on sound judgment bc it promotes an ethos of meticulousness (“think aloud” approach)

32. RISK ASSESSMENT: Documentation Goal • Delineate clinical decision-making process that specifies what led you to take certain actions and reject others. Ensure you have outlined a risk/benefit analysis of the particular action chosen.

33. RISK ASSESSMENT: Documentation Template • X participated in a counselor-led safety assessment. During the assessment X appeared…. 2. The counselor inquired about suicidal ideation, intent, plan, risk & protective factors (e.g., substance use, diagnostic sx, social support). 3. During the assessment, she reported the following acute risk factors for suicide… 4. The following acute risk factors were observed during the session 5. The following chronic risk factors were present, based on knowledge of her history…

34. RISK ASSESSMENT: Documentation Template 6. The following protective factors were noted… 7. Based on the foregoing, her suicide risk level was assessed as (low, mod, high) 8. The action taken was…. because… The benefit of this action, which included …, was determined to outweigh the risk, which was… 9. The action was taken in the following manner….(mention consultation, which can be expanded on in a separate note) 10. An possible action considered, but not taken was….. because. 11. The next steps in the treatment plan are…..

35. RISK ASSESSMENT: Documentation Sample 1. X participated in a counselor-led safety assessment. Though appearing initially reluctant, she disclosed information in detail and with increasing forthrightness. 2. The counselor inquired about ideation, intent, intensity, means, plan, rehearsal, risk & protective factors (e.g., substance use, diagnostic sx, social support) 3. During the assessment, she reported the following acute risk factors for suicide: daily, intense, long-lasting (>30 minutes) suicidal ideation, which she feels increasingly unable to resist (She said, “I wonder if I might lose control when this happens.”). Though she denied suicidal intent (She said, “I don’t want to die..I just can’t stand the pain.”), she reported having a suicide plan involving a gun to which she has access in her home. She reported engaging in suicide preparation events (e.g., purchasing bullets, watching YouTube instructional video). She indicated she has been using cannabis and alcohol in increasing amounts (i.e., daily x 1 week). 4. The following acute risk factors were observed during the session: Relative to the prior session, I observed her to have increased and high levels of hopelessness, perturbality (agitation, anxiety, self-directed anger), as well as emotional pain. Her thought content appeared to be rigidly focused on her perceived inadequacies and thought process was somewhat circumstantial. Her ego strength appeared diminished, relative to the prior session.

36. RISK ASSESSMENT: Documentation Sample 5. The previous information was integrated with my knowledge of her chronic risk factors which include 2 prior suicide attempts, of which one was 1 month ago, and a recent relationship loss combined with a near complete lack of social support. 6. The following protective factors were noted: She appears to rely on the therapeutic alliance as a source of strength. She has a family member who is a positive source of support with whom she is willing to initiative a supportive connection. 7. Based on the foregoing, her suicide risk level was assessed as high because of her loss of ego-strength, substance use, plans with means/access, lack of social support, and recent mental status changes. 8. . The action under consideration was intensive outpatient treatment combined with increased outpatient sessions (3 x/week).The benefit of this action, which included autonomy in a least restrictive environment, medication was determined to outweigh the risk, which was self-harm. This plan became a reasonable choice because, during the assessment, she phoned her mother who removed the gun from her premises and locked it in a safe box for which the client does not have access.

37. RISK ASSESSMENT: Documentation Sample 9. The action was taken in the following manner…. 10. An action considered, but not taken was hospitalization because the client did not meet commitment criteria after the intervention and did not want to admit herself to the hospital. She had a negative reaction to her prior placement and internalized it as “failure” (risk of hospitalization); she was willing to renew her Commitment to Therapy contract under the plan (benefit of IOP). With the suicide means removed from her possession and her willingness to engage in a higher level of care, the risk was determined to be lower. 11. The next steps in the treatment plan are to consult with her IOP providers prn and at least 1/time per week, to see her on … for our next session at which time I will re-evaluate her risk.

38. RISK ASSESSMENT: Documentation Guidelines • Use client or family quotes when possible. • Provide a detailed rationale with “evidence”. • Describe suicidal ideation • E.g., fleeting, vague, persistent, specific, frequent, intense, uncontrollable, % of time • Describe suicidal intent • vague, minimal, conflicted, ambivalent, compelling, firm • Describe Plan’s • Is it vague, unclear or specific, detailed • And actually describe the plan • Describe Means and access • E.g., “a gun, which she has in her home”, “overdose of prescription drugs, which she has stockpiled for 3 months”,

39. References • Bongar, B., & Sullivan, G. (2013). The suicidal patient: Clinical and legal standards of care. Washington DC: American Psychological Association. • Bryan, C.J. & Rudd, M.D. (2006). Advances in the assessment of suicide risk. Journal of Clinical Psychology, 62, 185-200. • Ghasemi, P., Shaghaghi, A., Allahverdipour, H. (2015). Measurement scales of suicidal ideation and attitudes: A systematic review article. Health Promotion Perspective, 5, 156-168. • Gutheil, T.G. (1999). Liability issues and liability prevention in suicide. In D.G. Jacoms (Ed.). The Harvard Medical School Guide to Suicide Assessment and Intervention (pp. 561-578). San Francisco_ Jossey-Bass. • Jordan, J.R., & McIntosh, J.L. (2011). Grief after suicide. New York: Routeldge. • Juhnke, G.A., & Granello, P.F. (2007). Shattered Dreams of professional competence: The impact of client suicices on mental health practitioners and how to prepare for it. Journal of Creativity in Mental Health, 1, 205-223. • Neal, S.B. (2017) The impact of a client’s suicide. Transactional Analysis Journal, 47, 173-185. • Rudd, M.D., Joiner, T., Rajab, M.H. (2001). Treating suicidal behavior: An effective, time-limited approach. New York: Guilford. • Rudd, M.D., Joiner, T., Trotter, D, Williams, B., & Cordero, L. (2009). The psychosocial treatment of suicidal behavior. In P.E. Kleespies (Ed.)., Behavioral Emergencies: An evidence-based resource for evaluating and managing risk of suicide, violence and victimizations. Washing DC: AAPA • Simon, R.I (2004). Assessing and managing suicide risk: Guidelines for clinically-based risk management. Wash DC: American Psychiatric Assn. • Sommers-Flanagan, J., & Shaw, S.L. (2017). Suicide risk assessment: What psychologists should know. Professional Psychology: Research and Practice, 48, 98-106 • Websites: • http://zerosuicide.sprc.org/ • http://mypage.iu.edu/~jmcintos/therapists_mainpg.htm

41. Part 2: Intervention:Treating your suicidal client Ellen Behrens, Ph.D. Westminster College Master’s Program in Mental Health Counseling Associate Professor

42. Who is in the room?What are your learning needs?

43. SUICIDE INTERVENTION: Monitor yourself • Audit your case load 1-2 moderately-severely suicidal and 2-3 mild-moderately suicidal clients on a case load. If exceeds seek additional professional support/consultation and explore ways to decrease long-term. • Monitor countertransference/burn-out • Defensive-orientation as self-protection (risk-management and over-reactive stance) • Denial as self-protection • Able to connect/ empathize? • Establish regular professional consultation with senior counselors

44. SUICIDE INTERVENTION :Do active and ongoing assessment • Use of interview protocols and/or assessment tools • Obtain prior records and/or consult with prior providers • Involve family in assessment results and care plans (with all minors and if possible with adults with consent)

45. SUICIDE INTERVENTION :Continually evaluate treatment plan • Evaluate an increase in Level of care • PHP, IOP, RTC, Inpatient hospital • Services • Increase frequency of sessions • Scheduled phone “check-ins” with “no show” agreement • Medication referral/consult

46. Suicide Interventions:Crisis Management • Means removal asap • Enlist allies (with client consent) and specify duration/conditions • Crisis Response Plan • “Commitment to treatment” contract c c

47. SUICIDE INTERVENTION: Crisis Management, Cont., A note about “SAFETY CONTRACTS”= The client agrees not to harm themselves. Widely used but have little empirical support. Case law suggests suicide/safety contracts do not decrease liability for malpractice and may even increase it (Rudd et al., 2000) • Create a false sense of security? • Instead Practice Guidelines recommend a Safety/Crisis Plan and an “alliance for safety” via a commitment to treatment

48. SUICIDE INTERVENTION: Crisis Management, Cont., CRISIS REPONSE PLANS • Convert into Safety Cards • Complete with client. (Not “homework”; not prescribed) • Caveat: Plans/Cards are NEVER sufficient for treatment: the Plan/Card is just one part of treating suicide risk. To that, you add increasing level of care &/or amount of therapy, Med referral, family support, secure the environment, etc.

49. Safety/Crisis Response Plan • 1. My warning signs that a crisis may be starting are: • 2. Some internal coping skills I will try when a crisis is coming on: • 3. Some people I can reach out to, especially to distract me from suicidal thoughts are: • 4. Trustworthy and safe family and friends I will call to help me when my own coping strategies and/or social distractions are not sufficient: ____________________________________________________ (Continue to next slide)

50. SUICIDE INTERVENTION: Crisis Management, Cont., 5. When in crisis I will contact the following emergency resources: • 1. This agency’s crisis services, available _____, at __________ and/or a Crisis Counselor at University Neuropsychiatric Institute, available 24/7, at 801.587.3000 OR SafeUT app, which I have installed on my phone. • and • 2. Contact a loved one, ____________,at _____________ or ___________ at ____________ and ask them to stay with me until I am with a professional and am safe. • I understand that suicidal risk is to be taken very seriously. In some cases, inpatient hospitalization may be necessary.