Suicide Prevention

1. Suicide Prevention Robert Tell, LCSW Amy Guffey, LCSW, Joe Bertagnolli, MSW, Victoria Neindow

2. Today Continued • Nomenclature. • What do we know about suicide? • How can we understand the problem of Veteran suicide? • What can we do about it.

3. What do we know about suicide? • It’s a big problem • 11th leading cause of death • 33,000 suicides occur each year in the U.S. • 91 suicides occur each day • One suicide occurs every 16 minutes • More Suicides than Murders • In Oregon more likely to die by suicide than in a car accident.

4. But it’s confusing… • The warning signs: rage, feeling trapped, increased alcohol use, withdrawing, trouble sleeping, relationship problems, etc apply to lots of people • Yet a tiny tiny fraction will ever attempt suicide.

5. What about Veterans? • Deployments are a risk factor, yet half the Army’s suicides never deployed. • There are record numbers of Active Duty suicides, but • No evidence for increased rates in OEF/OIF Veterans relative to sex, age, and race matched people in the population as a whole.

6. 1950-2005: Four wars; seven recessions; unprecedented advancement in diagnosis & treatment of mental illness and the overall American suicide rate hasn’t changed WHAT’S THE PROBLEM? Haloperidol, 1962 Clozapine 1989 Chlorpromazine1952 Aripiprazole 2001 Amitriptyline 1961 Fluoxetine 1987 Lithium 1949 MAOIs 1957 Korean War, 1950-53 Vietnam War, 1961-1975 First Gulf War, 1990-91 OEF / OIF, 2001-present

7. We aren’t even speaking the same language • Self-harm • Self-injury • Suicide attempt • Aborted suicide attempt • Accidental death • Unintentional suicide • Successful attempt • Completed suicide • Life-threatening behavior • Suicide-related behavior • Suicide • Suicidal ideation • Death wish • Suicidal threat • Cry for help • Self-mutilation • Parasuicidal gesture • Suicidal gesture • Risk-taking behavior

9. Standard Approach to Suicide Risk • Differentiate between Acute and Chronic risk

10. Chronic Risk Factors • Psychiatric diagnosis • Substance abuse • Previous attempts • Poor self-control/ impulsivity • Family History of suicide • History of abuse (physical, sexual, emotional) • Co-morbid health problems • Age, gender, race (elderly or young white male) • Same-sex orientation

11. Acute Risk Factors • Hopelessness/ desperation/ sense of ‘no way out’ • Current depression • Recent discharge from a psych unit • Current substance abuse or impulsive overuse • Anxiety, panic, insomnia • Pain and physical discomfort (nausea) • Extreme humiliation/disgrace; narcissistic mortification • Newly diagnosed co-morbid health problem or worsening symptoms • Break-down in communication/loss of contact with significant other (including therapist)

12. Protective (Mitigating) Factors • Responsibility to children, elder parents, beloved pets • Religious Faith • Connections to family and community support • Social Role • Purpose and meaning in life • Problem Solving ability • Resilience • Persistence • Positive Coping Skills • Attitudes towards Suicide • “Psychic Toughness” • Positive professional relationship

13. Suicide Inquiry • SI-Frequency, duration, and intensity • Plan • Preparatory Acts or behaviors and Rehearsals • Level of Intent • Reasons for living, lying and dying

14. Sum it all up • Assign a level of risk and a treatment plan based off of that risk. • Document

15. Thomas Joiner’s Theory

16. Perceived burdensomeness • The view that ones existence burdens family, friends, and/or society • “My death will be worth more than my life to family, friends, society, etc.” Assessing for Burdensomeness • Would the people you care about be better of with out you? • Do you feel like you have failed the people in your life?

17. Failed belongingness • The experience that one is alienated from others, not an integral part of family, circle of friends, or other valued group • February 22, 1980-lowest # of recorded suicides in US history • Annual Sunday with lowest # of suicides in US Assessing for Belongingness • Are you connected to other people? • Do you feel like an outsider in social situations? • Do you interact with people who care about you

18. Assessing acquired ability to enact lethal self injury • Do the things that scare most people scare you? • Do you avoid certain situations because of the possibility of injury or pain? • Can you tolerate a lot more pain than most people?

19. How do we make sense of it? • We can identify a large group of people who may be at risk. • What’s harder to do is identify which of that group will actually commit suicide.

20. Preventing Veteran Suicides • What’s a framework that can help us understand Veteran Suicide • And try and make a difference?

21. The Background Marsha Linehan, Ph.D.

22. Military Training • Stay in Reasonable Mind • If you’re in emotion mind – Act!

23. The problem • Veterans are too darn capable • Able to cope with too much which leaves you vulnerable to being swamped.

24. Units of Distress

25. Evidence Based interventions for suicide prevention • Continuity of Care – Mail Programs • Safety Planning? • Treatment – if there’s a mental health problem it reduces risk, but if there isn’t a mental health problem does it help? • CAMS, Cognitive therapy for Suicide, DBT

26. Similarities in evidence based approaches • Address Suicide Directly • Overt persistent connecting and collaborative stance • Work as a team

27. Mail Program • Dr. Motto identified patients who had made an attempt and then didn’t show for outpatient care. • Letters were sent for two years without expectation. The group that received the letters had fewer suicides than the control. • Recreated in two other studies using cards and postcards. Being tested now with texts.

28. Safety Planning • 6 step guide for getting through an emotional crisis.

29. STEP 1: RECOGNIZING WARNING SIGNS • -Depressed thoughts and feelings, crying. • -Thinking of loss of best friends and financial issues. • -Experiencing stress, e.g. in traffic. • -Coping with hearing of troubling news regarding wars in the Mideast. • -Panic feelings including shortness of breath and sweating • STEP 2: USING INTERNAL COPING STRATEGIES • -Reading positive materials. • -Taking long, relaxing walks. • -Prayer. • -Walking my dog. • -Listening to music. • STEP 3: SOCIAL CONTACTS WHO MAY DISTRACT FROM THE CRISIS • -My brother Rob and sister-in-law Sue. • -The gym. • -Drag races. • -Church and Church activities. • -Attending AA meetings.

30. STEP 4: FAMILY OR FRIENDS WHO MAY OFFER HELP • These are people that I would be willing to talk to about my thoughts of • suicide in order to help me stay safe: • -My Pastor Rex Smith 503-987-6543. • -My dad Thomas Doe 503-234-5678. • -My brother Rob Doe 541 123-456-789. • -My AA sponsor John Greene 503-321-7654. • STEP 5: PROFESSIONALS AND AGENCIES TO CONTACT FOR HELP • -1-800-273-TALK(8255)press #1 for vets -The Veterans Crisis Line • -Call 911 or come to the Emergency Department (or go to a local ED at own expense) • Your Therapist • -Portland VA Suicide Prevention Team 503-402-2857 during business hours • STEP 6: MAKING THE ENVIRONMENT SAFE • - Discuss means restriction • - Guns, guns, guns

31. A shift in focus… • Instead of focusing on getting help during the crisis…

33. A shift in focus… • Get help before it becomes a crisis.

35. Veteran’s Crisis Line PSA

36. NY Times Hotline Video

37. Portland VA Medical Center Suicide Prevention • Robert Tell, LCSW • Robert.tell@va.gov • 503-402-2857 or 503-220-8262 x56198 • Amy Guffey, LCSW • Amy.guffey@va.gov • 503-402-2857 or 503-220-8262 x56493 • Joe Bertagnolli, MSW • Joe.bertagnolli@va.gov • 503-402-2857 or 503-220-8262 x59423