Forest View Hospital

1. SUICIDAL CLIENTS: Assessing and Managing Risk2011 SUD CONFERENCELansing, MI September 12, 2011 Forest View Hospital Jim Bottenhorn, MA, LLP

2. TRAINING OUTLINE • Understanding Suicide • Terms & Statistics • Attitudes and Emotions that Affect Outcomes • Common emotions • Risk and Protective Factors • Interviewing Skills for Eliciting Accurate Information • Formulating a Risk Assessment • Developing a Safety Plan • Policy, Procedures, Practices • Documentation

3. Suicide Prevention SUICIDE PREVENTION • 50% of persons who die by suicide never receive any form of help • Persons may not spontaneously report suicide ideation but 70% communicate their intentions to family/friends • 50% of persons who die from suicide, die as a result of their first try One only finds what one looks for, One looks for what one knows. ~ Goethe ~

4. Terms and Usage SUICIDE TERMS AND USAGE Completed Death or Death by Suicide: Self-inflicted death where there is evidence that the act was intentional and led to the person’s death Suicidal Ideation: Thoughts of causing one’s death. Ideation may vary in seriousness depending the specificity of suicide plans and the intent. Non-suicidal self-injury: Self-inflicted injury with no intention to die.

5. Terms and Usage SUICIDE TERMS AND USAGE Suicide Attempt: Self-injurious behavior with a non-fatal outcome with evidence that the person intended to die. It is considered an attempt even if the person had some ambivalence about wanting to die (Hine’s slide) Suicide Attempt Survivors: Individuals who have survived a prior suicide attempt Suicide Survivors: Family members, significant others, or friends and acquaintances who have lost a loved one due to suicide. It is estimated that there are at least six survivors who are directly affected by each suicide.

6. NATIONAL SUICIDE DATA National Suicide Data • In 2007 there were 34,598 suicides in the U.S. That’s about 95 suicides per day, (of which 80% or 76 were men), or one suicide every 15.2 minutes. • Suicide attempts account for 670,000 ER visits per year. • Suicide is the 3rd leading cause of death for persons aged 15 to 24 and the second leading cause of death among college students.

7. National Suicide Data NATIONAL SUICIDE DATA • Approximately one fourth of all suicide deaths in the U.S. are individuals with a chemical dependency. (Murphy & Wetzel, 1990) • Lifetime prevalence of completed suicide in alcoholics is 7%-15%. (Inskip et al., 1998, Murphy et al., 1992, 1979) • Alcohol intoxication is indicated in as many as 64% of all suicide attempts. • Childhood sexual abuse is the strongest and most independent risk factor for suicide attempts, accounting for 9 to 20% of suicide attempts.

8. ATTITUDES AND EMOTIONS • Our attitudes can and do leak out and affect outcomes • Identify, monitor and manage our emotions • Common emotions associated with suicide • Fear, Hopelessness, Anger, Frustration

9. ATTITUDES AND EMOTIONS • Clinical anxiety can disrupt judgment • Denial, avoidance • Relying solely on “gut” reactions • Power struggles • Minimizing attempts • Hospitalization biases; a panacea or a failure

10. ATTITUDES AND EMOTIONS Negative emotional reactions may lead to: • Feelings of aversion, rejection, abandonment • Failure to disclose true feelings • Withdrawal from the therapeutic relationship

11. KEY RISK FACTORS • Prior Suicide Attempt • Major depression • Substance use disorders Other Risk Factors: • Other mental health disorders • Chronic pain • Insomnia • PTSD, • TBI • Recent losses or events leading to shame

12. SUICIDE RISK FACTORS- Know what to look for - • Current and Past Psychiatric Diagnoses: • While 90% of suicides are associated with mental illness, over 95% of those diagnosed with a mental disorder never attempt suicide. • Mood disorders, depressed or mixed (bipolar) phase), psychotic disorder, alcohol/substance use disorders, personality disorders or traits, eating disorders and anxiety disorders. • Warning Signs: • Loss of interest or pleasure (anhedonia), impulsivity or recklessness, anger, hopelessness or despair, social withdrawal, insomnia, substance use, giving away possessions, making final preparations/getting one’s affairs in order; recent onset of illness. • .

13. Suicide Risk Factors- Know what to look for - SUICIDE RISK FACTORS- Know what to look for - • Suicidality: Current suicide ideation, intent, plan. Recent, or history of, attempts, aborted or rehearsed attempts, or non-suicidal self injury. • Family History: Suicide, attempts (first-degree relatives 2.6 times greater risk) or a psychiatric diagnosis requiring hospitalization (1.3 times greater risk). • Precipitants/Stressors: Triggering events leading to humiliation, shame or despair, e.g., relapse, loss of relationship, disciplinary action, financial, or health status, contagion (esp. youth), ongoing medical illness, chronic pain, and/or intoxication.

14. SUICIDE RISK FACTORS- Know what to look for - • Access to firearms: Availability of guns to the individual • Physical Illnesses: Certain medical diagnoses and conditions are associated with higher risk of suicide including: • cancer, HIV/ AIDS, kidney failure requiring dialysis, pain syndromes, functional impairment including brain injuries (TBI), diseases of nervous system, especially multiple sclerosis, and epilepsy

15. SUICIDE RISK FACTORS- Know what to look for - • Childhood Trauma: Sexual/physical abuse, neglect, parental loss • Demographic: Male; elderly group; gay/lesbian/bi-sexual; widowed, divorced or single, particularly for men • Other High Risk Markers: perceived burdensome, alienation/loneliness, routine exposure to death (veterans,physicians/police) T. Joiner

16. SUICIDE RISK FACTORS • Hendin, et all, (2006) reviewed case narratives of 36 therapists who had patients die by suicide; 6 recurrent problems were identified: • Poor communication among treaters • Permitting patients and/or relatives to control treatment • Avoidance of sexuality issues • Ineffective or coercive measure taken due to therapist’s anxieties re. patient’s potential suicide • Not interpreting patient’s communications • Untreated or undertreated symptoms

17. Predictors of Suicide Attempts in Alcoholics (n=1,237) over 5 years? Rate = 4.5% attempted suicide • Prior attempts • Earlier onset and more severe dependence. • Other drug dependence • Separated or divorced • More likely to have had treatment (more severe) • More Panic • More Substance Induced Psych Disorder Preuss/Schuckit et al Am J Psych03

18. SUICIDE PROTECTIVE FACTORS • Identify protective factors – enhance whenever possible. (The presence of protective factors does not counteract significant acute suicide risk) • Internal factors: Ability to cope with stress, religious beliefs, frustration tolerance, absence of psychosis. (“How have you made it through all this?”) • External factors: Responsibility to children or beloved pets, positive therapeutic relationships, social supports, AA/NA, sponsor, etc.

19. ELICITING INFORMATION • It is a myth that talking about suicide with a person who may be thinking about suicide will cause the person to attempt to kill themselves. • Research has repeatedly shown that in fact the reverse is true - once a person has been asked if they are thinking of suicide, they feel relief, not distress; anxiety decreases, hope increases, and hopefulness reduces the risk of suicide.

20. ELICITING INFORMATION • Indirect questions, should always be followed by direct ones • Question collateral sources whenever possible • Utilize self-report tools and review answers • Normalization“Others in similar positions have reported…” • Shame Attenuation(Shea, 1998) “With all that you have been through, I wouldn’t be surprised if …”

21. ELICITING INFORMATION • Gentle Assumption(Pomeroy, Flax & Wheeler, 1982) • Not “Do you use other drugs”, rather “What other drugs…” “Tell me about …” • Symptom Amplification (Shea, 1998) Counters the impulse to minimize • Behavioral Incident (Pascal, 1983) “How many pills did you take (not take)?, Did you load the gun?, What did you do then”? • Denial of the Specific (Shea, 1998) • More accurate responses when asked specific vs. general questions

22. RISK FORMULATION Never rely solely on one piece of information Risk assessment deals with probabilities, not predictions Consider the following when formulating risk: • Risk and protective factors • Diagnoses • Mental status • Suicidality • Intention of client

23. S.L.A.P. A Suicide Assessment Tool (SLAP) Suicide Assessment Tool SLAP, is an acronym for a quick and easy way to assist in assessing suicide risk. However, no objective screening or assessment tool is 100% effective in assigning accurate risk, and is there is no substitute for a professional clinical assessment • Specificity. How specific is the plan to complete suicide? • Lethality. What is the perceived lethality of the planned attempt? • Availability. How available are the means? • Proximity. What is the proximity of rescue?

24. THE SAFETY PLAN The plan should be collaborative, using the client’s words, and be concise. Assess barriers to each step and person’s willingness and capacity to comply. Develop a support plan for SO’s. 1. Identify triggers to avoid; people, places, etc. 2. List warning signs: how will you know when you need to use the plan, what will you notice? 3. Suggested coping skills; what helps, including activities that are distractions?

25. THE SAFETY PLAN 4. Identify supportive contacts with phone numbers. 5. Identify agencies or support groups that can help: AA/NA, etc. 6. Making a plan to remove lethal means; firearms, stockpile of meds, etc. Review and update the plan periodically, especially if there are any major changes Discuss where copies of the plan should be placed

26. DOCUMENTATION • If it is not written down, it didn’t happen • Document risk formulation and your rationale • Remember that protective factors do not counteract acute high risk • When in doubt, always consult • Different clinicians can have different high risk thresholds • Clinicians get sued for not following usual practice, not for poor clinical judgment

27. POLICY, PROCEDURE, PRACTICES Develop a crisis plan to manage suicide risk Staff should view suicide risk as an expectation • Client self-assessment tool; symptom checklist • Suicide assessment guide, SAFE-T card • Safety plan template • Protocols to manage crises; who calls police, etc. • Involuntary process, current petitions & certs on hand, identify physician/FLP to complete certifications • Relationship with local police and CMH

28. SUMMARY • “Suicide is the most preventable death” and risk should be expected with MH/SA clients • There are almost always warning signs that someone is thinking about suicide. • Look for warnings signs and risk factors • Always take talk of suicide seriously, even if it is said in a joking manner. • Design practices to better screen, assess and manage suicide risk

29. RESOURCES • Suicide Prevention Resource Center, SPRC, and the AMSR Core Competencies for Mental Health Professionals. • The American Association of Suicidology • Thomas Joiner, PhD, Florida State Univ. • Survivors of Suicide • QPR Institute, Paul Quinnett, Ph.D. • Screening for Mental Health, Douglas G. Jacobs, M.D.

30. RESOURCES American Psychiatric Association Practice Guidelines Richard Ries, MDHarborview Medical Center and the University of Washington,Seattle, Washington www.samhsa.gov Substance Abuse and Mental Health Services Administration: • www.sprc.org – Suicide Prevention Resource Center (for suicide prevention basics and training resources) Publications: (877) 726-4727 • www.suicideology.org – The American Association of Suicidology (an education and resource organization)