suicide and what can make a difference kim kane, mpa program director, idaho lives project former...
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Suicide Prevention for the Justice System
Suicide and What Can Make a Difference
Kim Kane, MPA Program Director, Idaho Lives Project Former Executive Director, SPAN Idaho Member, Idaho Governor’s Council on Suicide Prevention Certified QPR Suicide Prevention Trainer
Agenda
STATS WHY? SPAN
IDAHO
?
?
?
??
SAVE A
LIFE
SURVIVOR SUPPORT
CLINICAL PREVENTION
FACILITIES
Suicide Prevention Action Network of Idaho
A 501(c)(3) non-profit
Vision : Idahoans choose to live
A Resource
www.spanidaho.org
208-860-1703
Who is SPAN Idaho?
BOARD OF DIRECTORS 13 Volunteers
STAFF Executive Director Resource SpecialistREGIONAL CHAPTERS 8 Chapters Volunteer chairperson(s) Volunteer participants
www.spanidaho.org
8 Driggs (new)
Stats
Suicide Statistics
US 2011 ID 2011 ID 2012 ID 2013
Total Deaths 39,518 24 299 308
Deaths/week 760 5.5 6 6
Suicide Rate 12.7 17.9 18.7 19.1
Average Suicide Deaths per Month in Idaho 2013
Sun. Mon. Tues. Wed. Thurs. Fri. Sat.
1
X2 3
X4
X5
X6
X7
X8
X9
X10
X11 12
X13
X14
X15
X16 17
X18
X19
X20
X21
X22
X23
X24 25
X26
27
X28
X29
X30
X31
X
Where Does Idaho Rank?US Suicide Death Rate Rankings (CDC 2010)
17.9
Wyoming Idaho U.S. D.C.
6.0
12.7
23.3
9 24 15
Idaho and It’s Neighbors
1. Wyoming1. Montana3. New Mexico4. Alaska5. Vermont6. Nevada
7. Oklahoma8. Arizona9. Colorado9. Utah11. Idaho
We are not unlike our neighbors
Top Eleven States, 2011
Why Does Idaho Rank So High?
1. Wyoming2. Alaska3. Montana4. Nevada5. New Mexico6. Idaho
7. Oregon8. Colorado9. South Dakota10.Utah11.Arizona
We are not unlike our neighbors
Top Eleven States:
Why Does Idaho Rank So High?
Lack of Access
Easy Access
Stigma/Rugged individualist culture
Boot straps
Youth Suicide Facts 2nd leading cause of death among Idaho’s youth.
29%
48%
29%
5%
3%
3%3%
2%8%
Idaho Teen (age 14-19) MortalityIdaho Bureau of Vitial Records and
Health Statistics, 2010
Accidents
Suicide
Cerebrovacular
Malignancies
Heart diseases
Congenative Malform
Pneumonitis
Other
Youth Suicide Facts Idaho high school students, 2013 YRBS shows
1 in 13 have attempted
suicide
1 in 8 actually have a
suicide plan
1 in 7 have considered
suicide
School-Age Children Idaho has lost 83 school-aged children to suicide in the last 5 years.
(2008-20012)
16 of those children were age 14 or younger
Suicide in Jail
Suicide is the leading cause of death in American jails.
Suicide rates in prison are higher than the general population, but higher still
are rate in smaller facilities
Suicide rates in local jails are 4 - 9x than the national rate.
The Suicidal Mind
Shooters and Suicidality
Those who enact murder-suicide, including school shooters are first suicidal.
Suicide is primary; murder is secondary.
“To understand the primary source code of violence – the suicidal mind – we must first understand that persistent suicidal thoughts and feelings are markers of unremitting, unendurable psychological pain and suffering.”
~ Paul Quinnett, PhD
Thomas Joiner, PhD Distinguished Research Professor and The
Bright-Burton Professor in the Department of Psychology at Florida State University
Author of over 400 peer-reviewed publications Editor-in-Chief of the journal Suicide & Life-Threatening Behavior Author of “Why People Die by Suicide,” “Myths About Suicide” and “Lonely at the Top.”
Sketch of a TheoryThomas Joiner, PhD
PerceivedBurdensomeness
ThwartedBelongingness
Those Who Are Capable of Suicide
Fearlessness about Pain, Injury & Death
Acquired Ability for Self-Harm
Serious Attempt or Death by Suicide
Those Who Desire Suicide
Derived from Sketch of a TheoryPower Point presentation, 2013Thomas Joiner, PhD
Di s t a l Fac t or s
Why People Die by Suicide
Suicide: Fact vs. Fiction
True or False?
1.Asking someone about suicide might “plant the seed” or increase risk.
2.More females attempt suicide than males.
3.Suicides increase over the winter holidays.
4.Very young children complete suicide.
5.Most suicidal people are ambivalent about it.
6.Suicide is often done on whim, especially among youth.
7.Restricting access to lethal means is a critical prevention method.
Suicide is Preventable People routinely survive deep depression and
suicidal thoughts and behaviors. The basic instinct to survive is
ever-present. Suicidal people survive because someone
identifies what’s happening and gets help. 90% of those who complete suicide had a
mental health or substance about disorder. THESE DISORDERS ARE TREATABLE!
Suicide is Never About Only One Thing
SUICIDE IS COMPLEX
Substance Abuse
Lack of Support
Hopelessness
Previous Attempt
Abuse
Mental Illness
Family History
Suicide is Complex Suicide is multi-facetted There is never just one thing that leads to
suicide There can, however, be a triggering event:
• Arrest itself• Fear of transfer to more secure facility or undesirable
placement• Failure in the program• Suicide of a peer/contagion• Threat of/failure to visit• Death in the family• Loss of relationship• Ridicule from peers
Mental Health 90% of those who die by suicide had a mental
health and/or substance use disorder. 55%-75% of those in jail or prison have a
mental health disorder, including depression. Three quarters of those have a co-occurring
substance use disorder.
What does this tell us about the potential for prevention?
Attitudes and Knowledge Unhelpful HelpfulSuicide is inevitable Suicide is preventable
Suicide is selfish Suicidal youth irrationally believe they are a burden
S/He only wants attention Threats and attempts are two of the most significant
precipitating factors for suicide
Labeling suicidal thoughts Such labels increase stigma or behavior as irrational or and can cause youth to shut“crazy” down/not seek out or accept
help
What to Look For
Important Notes about Warning Signs
The more signs, the greater the risk.
Warning signs are especially important if the person has attempted suicide in the past.
One sign alone may not indicate suicidality
but all signs are reason for concern
and several signs may indicate suicidality,
and any one of three signs alone is cause for immediate action.
1. 2. 3.
4. 5. 6.
R I SK
Warning Signs
Previous suicide attempts Talking about, making a plan or threatening to
complete suicide Isolation, withdrawal from friends, family or
society Agitation, especially when combined with
sleeplessness Nightmares
Direct Statements “I’ve decided to kill myself.”
“I wish I were dead.”
“I’m going to commit suicide.”
“I’m going to end it all.”
“If _______ doesn’t happen, I’ll kill myself.”
QPR Institute
Indirect Statements “I’m tired of life; I just can’t go on.”
“My family would be better off without me”
“Who cares if I’m dead anyway.”
“I just want out.”
“Pretty soon you won’t have to worry about me.”
QPR Institute
Warning Signs
Changed eating habits or sleeping patterns Giving away prized possessions,
making final arrangements, putting affairs in order
Themes of death or depression in conversation, writing, reading or art
Recent loss of a friend or family member through death, suicide or divorce
Sudden dramatic decline or improvement in the program
Warning Signs Feeling hopeless or trapped Use or increased use of drugs and/or alcohol Chronic headaches and stomach
aches, fatigue Major mood swings or abrupt
personality changes Neglect of personal appearance Taking unnecessary risks or acting reckless No longer interested in favorite activities or
hobbies.
High Risk Times in Facilities
Room Confinement Withdrawal from Alcohol or Drugs Court or other Legal Hearing Significant Date to the Offender Receipt of Bad News Impending Release/Transfer Family Threat of/Failure to Visit Failure/Lack of Progress in the Program Ridicule from Peers Severe Guilt or Shame about Offense Sexual/Physical Assault
Signs of Immediate Risk = Take Immediate Action
Talking about wanting to die or to kill oneself
Looking for a way to kill oneself
Talking about feeling hopeless or having no reason to live
What to Do
Responding to Warning Signs
Any suspicion that the person may be suicidal must be acted upon.
Any report of such suspicions by the person’s family or other inmates (if incarcerated) should also be taken seriously.
Faking It? Yes, some may use the threat of suicide or a
feigned suicide attempt to manipulate the system or get attention.
Attention-getting tells us something.
Challenging to tell the difference
Attempt habituation can lead to underestimation of lethality.
TAKE ALL THREATS SERIOUSLY
Emotional Safety Connect with the person Avoid discussing personal info that may
be embarrassing in front of others Reduce stress of the unknown Monitor emotions before and after
visitation or calls Assist the person in managing
conflict Encourage discussion and
role play re: court or PO visit, etc.
Listening Can be challenging – be persistent Talk in semi-private location if possible Avoid trying to identify with the
person Avoid trying to argue him/her
out of it Understand, listen and refer Try to understand how the person may see
him/herself: Rigid thinking, overgeneralizing, catastrophizing, attachment, trauma
Listening Listening is Powerful!
• Explore suicidality – level of intent• Listen non-judgmentally • Use reflective listening• Reasons for dying• Refrain from offering advice/solutions or
interrupting with your experience • Reasons for living• Offer hope, support, willingness to help/get
help
Getting Help Get a commitment to accept help and make
arrangements and contact family/friends Ensure person is not left alone Notify family If person is deemed to be at high risk,
also contact mental health agency where the person can go for further help.
1-800-273-TALK (8255) Call police if person is in possession of a weapon Follow up with person/family and mental health
agency Debrief staff involved – self care Document everything!
Exercise
Clinical Prevention
Primary Target: Reduce Stigma and Build Hope
Not about curing mental illness Reduce stigma associated with mental health
problems Reduce stigma associated with help-seeking
• Being in treatment and using crisis services Remove barriers to getting help Building Hope
• Symptom reduction• Identity change
Resolving hopelessness• Relationships that last• Finding a life worth living
From M. David Rudd, PhD
Why is suicide difficult to predict?
Suicidality is fluid
Tad Friend. Jumpers. The New Yorker (2003)
On the bridge, Baldwin counted to ten and stayed frozen. He counted to ten again, then vaulted over. “I still see my hands coming off the railing,” he said. As he crossed the chord in flight, Baldwin recalls, “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable—except for having just jumped.”
Elements of Intent Gives Clues to Suicide Risk
Willingness to act (motivation to die)• People talk about reasons for dying
Preparation to act (preparation and rehearsal behaviors)• People prepare for their death
Will, letters, finances, research Capability to act
• Builds over time with exposure• Ordinarily people engage in the behavior for some time prior
to death High Risk Behavior Self-mutilation Suicide Attempts
Barriers to act (reasons for living)• People will discuss their ambivalence about death• Relationships critical
From M. David Rudd
Points to Remember about Hope The role of shame and guilt
• Influence on the assessment dynamic Recognize the fluid nature of intent Identify and reinforce individual
ambivalence• Reasons for dying are readily accessible to
those in crisis• Reasons for living are often unrecognized
and inaccessibleFrom M. David Rudd, PhD
CRISIS | % same day by age
6
13
2021
33
0-17 18-24 25-44 45-64 65+
Age group
%
N=1,671 CT, ME, UT, WI, Allegheny County, San Francisco County
2001 Data
Impulsivity
Warning Signs in Clinical Practice• Hospital Discharge – THE warning sign
• Capability• Loss of connectedness• Burdensomeness• Shame/Embarrassment
• Non-Compliance with treatment• ~37% of suicides are by those in
treatment• Represents persistence of hopelessness
and intent• Issue of personal responsibility for care• Potential implicit messages
• Treatment doesn’t work• Treatment is hopeless
From M. David Rudd, PhD
5 Things that Save Lives1. Easy to understand treatment model
• Identify early skill development/deficiencies related to current functioning
• Target Thoughts (core beliefs) – motivation for dying Feelings (physiological/emotional) Behavior (increasing adaptive)
2. A Focus on Treatment Compliance• Specific interventions to target poor adherence• Clear directions about what to do in non-adherence
emerges
From M. David Rudd, PhD
5 Things, cont.3. Focus on Skills-Building
• Identify skill deficits with opportunity for skills building practice Emotion regulation Interpersonal
• Clear understanding of “what is wrong” and “what to do about it”
• Separate from identity
4. Taking personal responsibility• Emphasis on self-reliance and self-management (commitment
to treatment statement, safety plan - PRACTICE)• Patients assume high level of responsibility for their care,
including crisis management
5. Easy access to treatment and crisis services
From M. David Rudd, PhD
Survival Kit (Hope Box) Items that generate productive,
hopeful thoughts and feelings Always review items individually Practice use (review; describe; ask
what are you thinking & feeling? Are you more hopeful?)
From M. David Rudd, PhD
Survivor Support
Survivor Support Simply be there
Be a friend, family, neighbor, church community
After 2 weeks – Reach out
Anniversaries
Survivor Support Suicide Survivor Packets: contact SPAN Support groups
• Boise Area Facilitators: Kirby and Susan Orme Where: First United Methodist Church Cathedral of the Rockies 11th and Hays Streets, Boise Olivet Room, enter through glass doors on 11th Street When: Second Friday of each month from 7:00 to 9:00 p.m.
• Meridian Area Facilitator: Cynthia Mauzerall Where: Holy Apostles Church, 6300 N Meridian Rd., Meridian When: Fourth Monday of each month from 7:00 to 8:30 p.m.
• www.spanidaho.org, click Survivor Support Books
• No Time to Say Goodbye, Carla Fine• Night Falls Fast, Kay Redfield Jameson
Facilities
For Facilities
Written policies for prevention, intervention, responding to attempts and postvention
All staff trained on when and how to implement these policies/plans
Protocols Protocols must include:
• Assessing suicide risk and imminent suicide risk Beyond intake because suicidality is fluid
• Effective communication about suicide risk Risk status and history can get lost in the shuffle Staff must be vigilant Information that must follow the inmate: suicide
threat made, behavior indicating depression, history of psychiatric care and meds, status of protective custody
Assessing Should be part of admission process Should NOT be a one-time occurrence Mental health staff: formal
assessment Non-mental health staff may need to
do an informal assessment• Ask the question --- more than once if
necessary• How to ask, how not to ask• If they keep denying, is everything okay?AGAIN AGAIN AGAIN
Protocols Use of isolation cells
• Increases risk of suicide• If an inmate at risk requires isolation ensure cell is suicide-
resistant Consider all anchors and ligatures
Training for staff • Recognizing and responding to suicide risk• CRP and first aid• Rescue tools
Availability of first aid safety equipment• Latex gloves• Resuscitation breathing masks• Defibrillators• Tools to open jammed cell doors• Cutting tools for ligatures
Methods Anchors: Any tie-off point
Ligature: Anything used to hang oneself; any material which can be tied around the neck and withstand body weight or strangle (clothing hooks, shower knobs, cell doors, sinks, toilets, ventilation grates, windows, smoke detectors)
WHY? Majority of inmate death are by hanging Result in death in 5-6 min.; brain death in 4 min.
Postvention Reporting:
• Notify all appropriate staff, family, appropriate outside authorities• All staff in contact with the deceased prior to incident should submit a
statement as to their full knowledge of the youth and incident Mortality Review Minimize Contagion
• Share facts to prevent rumors• Do not simplify, glamorize or romanticize the person or his/her death• Emphasize that suicide is rare and is not a common response to problems
with which other young adults may identify• Monitor young adults and most vulnerable and refer those struggling with
the death SPAN Idaho Postvention Guidelines Liability - “Deliberate indifference” & Not intervening does
not equal protection from liability Self Care
Resources
Suicide Prevention Resource Centerwww.sprc.org
SPAN [email protected]
National Center on Institutions and Alternativeswww.ncianet.org
