suicide prevention and intervention revisited focus on adults

Suicide Prevention and Intervention Revisited

Focus on Adults

National TASC Workshop/Plenary National TASC Workshop/Plenary

May 8, 2014May 8, 2014

Judith Harrington, Ph.D.Judith Harrington, Ph.D.

University of MontevalloUniversity of Montevallo

Alabama Suicide Prevention & Resources Coalition Alabama Suicide Prevention & Resources Coalition (501c3)(501c3)

Nationally, 38,364 persons died from suicide,

now the 10th cause of death (AAS, 2010).

• Alabama Suicide Prevention and Resources Alabama Suicide Prevention and Resources Coalition (ASPARC) A 501c3 Non-Profit Coalition (ASPARC) A 501c3 Non-Profit AgencyAgency

• This presentation is partly funded by a This presentation is partly funded by a Garrett Lee Smith Suicide Prevention grant Garrett Lee Smith Suicide Prevention grant from SAMHSA in partnership with the from SAMHSA in partnership with the Alabama Department of Public Health and Alabama Department of Public Health and the ASPARC, your tax dollars brought home the ASPARC, your tax dollars brought home to prevent suicide.to prevent suicide.

PREFERRED TERMS

• Died from suicide• Completed suicide• AVOID: committed suicide, took his own life,

chose to end her life, “successful suicide” (no such thing as a successful suicide, only successful prevention)

• Survivor of suicide loss• Attempt survivor, the lived experience

Definitions - suicide

• Death by suicide, (died by suicide) or completed Death by suicide, (died by suicide) or completed suicide: suicide: Death from self-inflicted injury, poisoning, or Death from self-inflicted injury, poisoning, or suffocation where there is evidence that the act was suffocation where there is evidence that the act was intentionalintentional (purposed, aim, or goal)and led to death (purposed, aim, or goal)and led to death

• Suicide intent: Suicide intent: Self-injurious behavior with non-fatal Self-injurious behavior with non-fatal outcome, with evidence of intent to die (was rescued, outcome, with evidence of intent to die (was rescued, thwarted, or changed mind).thwarted, or changed mind).

• Suicide ideation: Suicide ideation: Thoughts of suicide related Thoughts of suicide related behavior, do not make an explicit attemptbehavior, do not make an explicit attempt

• Suicide attempt survivorsSuicide attempt survivors

• Suicide survivors (of loss) Suicide survivors (of loss) (often confused with attempt (often confused with attempt survivors) survivors)

Examples of suicidal behavior

• Suicide ideationSuicide ideation

• Suicide rehearsalSuicide rehearsal

• Suicide “gesture”Suicide “gesture”

• Suicide attemptSuicide attempt

• Completed suicide or death from suicideCompleted suicide or death from suicide

• Days of limited survival from attempt Days of limited survival from attempt before deathbefore death

• Permanent disability from suicide attempt Permanent disability from suicide attempt

Incidence of Suicide

From a 2008 CDC StudyFrom a 2008 CDC Study• 2.9 million in U.S. ages 18-29 had suicidal 2.9 million in U.S. ages 18-29 had suicidal

thoughtsthoughts• 2.2 million in U.S. considered adults in 2.2 million in U.S. considered adults in

U.S. hadU.S. had suicide plans suicide plans• 1.0 million adults in U.S. 1.0 million adults in U.S. made a suicide made a suicide

attempt attempt in the 2007in the 2007

• Source: Crosby, A. E., Han, B., Ortega, L. A. G. Parks, S. E., Gfroerer, J. Source: Crosby, A. E., Han, B., Ortega, L. A. G. Parks, S. E., Gfroerer, J. (2011). Suicidal thoughts and behaviors among adults aged ≥ 18 (2011). Suicidal thoughts and behaviors among adults aged ≥ 18 years---United States 2008-2009. Retrieved http://www.cdc.govyears---United States 2008-2009. Retrieved http://www.cdc.gov

AT RISK GROUPS BASED ON INTENT TO DIE AND SURVIVALCampbell (2005)

Survival: Die

Survival: Live

Intent:Die

SUICIDE “died by suicide”[formerly “completed” suicide or chose to end life]

SUICIDE ATTEMPTAmbivalence is present and help reaches them. Intervention is successful.

Intent:Live

ACCIDENTAL SUICIDE An attempt gone awry.

PARASUICIDESo-called "attention-seeking" or "cry for help" (euphemisms)40 times more likely to die by suicide.

FALSE POSITIVE AND FALSE NEGATIVE SUICIDE ASSESSMENTAdapted from Granello & Granello (2007)

Client IS suicidal

Client IS NOT suicidal

Counselor assesses

that client IS

suicidal

Accurate Assessment

False positive

Counselor assesses

that client IS NOT suicidal

False negative

Accurate

Assessment

COUNSELOR LIABILITYHarrington (2008)

Client lives

Client Dies

Counselor is effective

Assessment, intervention works.

"The operation was a success but the patient died."

Counselor is ineffective

Luck. Something else prevails, other resources, hardiness not attributable to counselor.

Potential malpractice. Scope of competence issues.

Is suicide a choice?

Andrew Slaby, M.D., Ph.D., M.P.H., New York University and New York Medical College:

•People who die by suicide do not want to die; they simply want to end the pain often caused by depression. If there were another way to end the pain, they would seek it. Failing to find a source of reprieve, they become hopeless. More than depression, hopelessness predicts who will die by suicide… (p. 11).


Mark J. Goldblatt, M.D., Harvard University Department of Psychiatry, in Case Discussion:

…that his [the case under discussion] cognitive function was impaired by his physical illnesses or by his depression…he was never really competent to make his own treatment decisions, because he was impaired by his mental illness (p. 336).


Kay Redfield Jamison, Johns Hopkins University, author of, An Unquiet Mind and Night Falls Fast, has bipolar disorder and attempted suicide, stated

•In short, when people are suicidal, their thinking is paralyzed, their options appear spare or nonexistent, their mood is despairing, and hopelessness permeates their entire mental domain. The future cannot be separated from the present, and the present is painful beyond solace. (p. 93).

OLD VS. NEW PARADIGM FOR UNDERSTANDING SUICIDE

OLDOLD• a. Suicide: Killing of

oneself • b. Goal: End life• c. It is seen as an

event or a behavior.• d. Viewed as a decision

and a personal choice.• e. Viewed as a means

of control or manipulation.

NEWNEW• a. Penacide: Killing the

pain. • b. Goal: End pain and

suffering.• c. It is seen as a process of

debilitation.• d. Viewed as a disease

outcome; no choice involved beyond crisis point in the process of debilitation.

• e. Viewed as the result of severe stress and psychological pain.

OLD VS. NEW PARADIGM FOR UNDERSTANDING SUICIDE

OLDOLD• f. Seen as a voluntary

action and individual responsibility.

• g. The individual is seen as a decision-maker.

• h. Thought to be a phenomenon involving the mind.

• i. Etiology: Emotional disorder, personality disorder, poor coping skills

NEWNEW• f. Seen as an involuntary

response. • g. The individual is seen as

a victim. • h. Thought to be a

physiological or neurobiological phenomenon involving the brain.

• i. Etiology: A biochemical deficiency created or aggravated by pain.

CORE COMPETENCIES FOR ASSESSING & MANAGING SUICIDE RISK

A. Working with Individuals at Risk for Suicide: Attitudes and Approach1. Manage one’s own reactions to suicide2. Reconcile the difference (and potential conflict)

between the clinician’s goal to prevent suicide and the client’s goal to eliminate psychological pain via suicidal behavior

3. Maintain a collaborative, non-adversarial stance

4. Make a realistic assessment of one’s ability and time to assess and care for a suicidal client as well as for what role one is best suited


B. Understanding Suicide

• 5. Define basic terms related to suicidality

• 6. Be familiar with suicide-related statistics

• 7. Describe the phenomenology of suicide

• 8. Demonstrate understanding of risk and protective factors


C. C. Collecting Accurate Assessment Information

9. Integrate a risk assessment for suicidality early in a clinical interview, regardless of the setting in which the interview occurs and continue to collect assessment information on an ongoing basis

10. Elicit risk and protective factors

11. Elicit suicide ideation, behavior, and plans

12. Elicit warning signs of imminent risk of suicide

13. Obtain records and information from collateral sources as appropriate


D. Formulating RiskD. Formulating Risk

14. 14. Make a clinical judgment of the risk that a client will attempt or complete suicide in the short and long term

15. 15. Write the judgment and the rationale in the client’s record

16. 16. Collaboratively develop an emergency plan that assures safety and conveys the message that the client’s safety is not negotiable

17. Develop a written treatment and services plan that addresses the client’s immediate, acute, and continuing suicide ideation and risk for suicide behavior

18. Coordinate and work collaboratively with other treatment and service providers in an inter-disciplinary team approach


E. Developing a Treatment and Services PlanE. Developing a Treatment and Services Plan

16. Collaboratively develop an emergency plan that assures safety and conveys the message that the client’s safety is not negotiable 17. Develop a written treatment and services plan that addresses the client’s immediate, acute, and continuing suicide ideation and risk for suicide behavior 18. Coordinate and work collaboratively with other treatment and service providers in an inter-disciplinary team approach


F. Managing CareF. Managing Care

19. 19. Develop policies and procedures for following clients closely including taking reasonable steps to be proactive

• Motivate and support clients in getting them to a referral source or to their next treatment/intervention session

• Engage in collaborative problem-solving with the client to address barriers in adhering to the plan and to revise the plan as necessary…session by session

• Assure that the client, family, significant others, and other care providers are following through on actions as agreed

• Assess the outcome of each referral• Develop and implement follow-up procedures for all missed appointments• Be available between appointments• Arrange for clinical coverage when therapist is unavailable• Assure continuity of care and follow-up contact with all suicidal clients who

have ended treatment20. Follow principles of crisis management


G. DocumentingG. Documenting

21. 21. Document the following items related to suicidality

• Informed consent• Information that was collected from a bio-psycho-social

perspective • Formulation of risk and rationale• Treatment and services plan• Management • Interaction with professional colleagues• Progress and outcomes


H. Understanding legal and regulatory issues related to suicidality

22. Understand state laws pertaining to suicide

23. Understand that poor or incomplete documentation make it difficult to defend against legal challenges

24. Protect client records and rights to privacy and confidentiality following the Health Insurance Portability and Accountability Act of 1996 that went into effect April 15, 2003

Continuum of Suicide Risk

Think of risk as a status on a Think of risk as a status on a continuumcontinuum

High Emergency Risk

Harm in 24 hrs +/-

Recent loss/distress

Lethal Means

Intent

Plan

Rehearsals

Warning Signs

Vince Foster type suicide

Doing well

Life stress

Existential reflection

Crisis, Pile up

Build up over weeks, months

Chronic

Demographic markers more important

Relationship problems

Marilyn Monroe type suicide

Assessment of suicidal risk

• IS PATH WARMIS PATH WARM• IdeationIdeation• Substance abuseSubstance abuse• PurposelessnessPurposelessness• AnxietyAnxiety• TrappedTrapped• HopelessnessHopelessness• WithdrawalWithdrawal• RecklessnessRecklessness• Mood ChangeMood Change

• SIMPLE STEPSSIMPLE STEPS• SuicidalSuicidal• IdeationIdeation• Means to completeMeans to complete• PerturbationPerturbation• LossLoss• Earlier attemptsEarlier attempts• Substance useSubstance use• Trouble-solving Trouble-solving

abilityability• EmotionEmotion

• Hopelessness, Hopelessness, worthlessness, worthlessness, depressiondepression

• Parent, family historyParent, family history• Stress and life eventsStress and life events

There are a plethora of paper & pencil, authenticated instruments to assess suicide, such as the PANSI and many more.

Assessment of suicidal risk

• F.A.C.T.F.A.C.T.• Feelings: Feelings:

Hopelessness, Fear Hopelessness, Fear of loss of control, of loss of control, helplessness, helplessness, sadnesssadness

• Actions or events:Actions or events:• Loss, agitation, Sub Loss, agitation, Sub

Abuse, recklessAbuse, reckless• Change in Change in

personality, personality,

behavior, sleep, behavior, sleep, etc.etc.

• ThreatsThreats• Statements, plans Statements, plans

gesturesgestures

• Acute vs. ChronicAcute vs. Chronic• Emergent vs. long Emergent vs. long

termterm• Warning signs vs. Warning signs vs.

risk factorsrisk factors• Event vs. relationalEvent vs. relational

• Demographics or Risk Demographics or Risk FactorsFactors

• ChronicChronic• Over many weeks, Over many weeks,

months, yearsmonths, years• ““marker” for suicide, marker” for suicide,

not a predictornot a predictor• Prior attemptsPrior attempts• Hx of abuseHx of abuse• Poor support syst.Poor support syst.

• Warning SignsWarning Signs• recent loss or defeatrecent loss or defeat• Changes in mood, Changes in mood,

actions, ADL’sactions, ADL’s• HopelessHopeless• Intent, plan, means, Intent, plan, means,

timetabletimetable• rehearsalsrehearsals• Substance abuseSubstance abuse

Distinguishing risk from warning

Chronic vs. Acute Risk

• ChronicChronic

• Ongoing suicidality due to past hx and the presence Ongoing suicidality due to past hx and the presence of certain risk factors (alcohol or Axis II), of certain risk factors (alcohol or Axis II),

• has no current suicidal intent, no organized plan, has no current suicidal intent, no organized plan,

• has reasons for living has reasons for living

• Not considered immediate risk, but under certain Not considered immediate risk, but under certain conditions (recurrence of depression, actual or conditions (recurrence of depression, actual or anticipated relationship loss, financial setbacks, anticipated relationship loss, financial setbacks, legal problems, or serious medical dx…could legal problems, or serious medical dx…could develop into acute riskdevelop into acute risk

Chronic vs. Acute Risk

• AcuteAcute• Serious recent suicidal behavior, current Serious recent suicidal behavior, current

psychotic processes, and/or serious suicidal psychotic processes, and/or serious suicidal planning or intent. Can be considered at planning or intent. Can be considered at near-term risk for suicide within hours, days, near-term risk for suicide within hours, days, or weeks from the time of assessment. or weeks from the time of assessment.

• Paramount for MHP to intervene immediatelyParamount for MHP to intervene immediately

Low, Moderate, High risk

• LowLow: no hx of past suicidal behavior, no current : no hx of past suicidal behavior, no current suicidal ideation, some chronic risk and anticipated suicidal ideation, some chronic risk and anticipated losses, and protective factors are presentlosses, and protective factors are present

• ModerateModerate: elevated level of risk based on factors : elevated level of risk based on factors such as suicidal ideation or desire, chronic drug or such as suicidal ideation or desire, chronic drug or alcohol use, problematic relationships or some alcohol use, problematic relationships or some other current stressor.other current stressor.

• HighHigh: hx of multiple suicide attempts, the : hx of multiple suicide attempts, the presence of recent suicidal ideation and planning, presence of recent suicidal ideation and planning, and an anticipated triggering eventand an anticipated triggering event

“Purpose” of suicide

• To end the painTo end the pain• To stop being a burden or disappointment To stop being a burden or disappointment

to familyto family• To overcome psychacheTo overcome psychache• To overcome shame or dishonorTo overcome shame or dishonor• To escape feeling trappedTo escape feeling trapped• To go be with loved ones (or friend or To go be with loved ones (or friend or

significant other) in heavensignificant other) in heaven• Other….?Other….?

Essential Features of Risk Assessment

• Each person is uniqueEach person is unique

• It is complex and challengingIt is complex and challenging

• It is an ongoing processIt is an ongoing process

• It uses multiple perspectivesIt uses multiple perspectives

• Tries to uncover foreseeable riskTries to uncover foreseeable risk

• Relies on clinical judgmentRelies on clinical judgment

• Assessment is considered to be Assessment is considered to be “treatment”“treatment”

Coping skills for suicidal risk

• Safety planning in concert with a clinicianSafety planning in concert with a clinician• Means restrictionMeans restriction• SoothingSoothing• Self-careSelf-care• Family supportFamily support• Crisis planningCrisis planning• Community resourcesCommunity resources

• Life skills, problem-solvingLife skills, problem-solving

• Social supportSocial support

• Cognitive behavioral approachCognitive behavioral approach

• See Rudd (2006)See Rudd (2006)

Good Resources

• Rudd, M. D. (2006). The assessment and management of Rudd, M. D. (2006). The assessment and management of suicidality (practitioner's resource).suicidality (practitioner's resource). Sarasota, FL: The Sarasota, FL: The Professional Resource Exchange. Professional Resource Exchange.

• American Association of Suicidology American Association of Suicidology www.suicidology.org

• American Foundation for Suicide Prevention American Foundation for Suicide Prevention www.afsp.org

• SAMHSA TIP 50 Addressing Suicidality in Substance Abuse SAMHSA TIP 50 Addressing Suicidality in Substance Abuse Treatment Settings Treatment Settings www.samhsa.gov

• National Suicide Prevention Lifeline (NSPL): National Suicide Prevention Lifeline (NSPL): •1-800-273-TALK (8255)1-800-273-TALK (8255)

• National Suicide Prevention Lifeline (NSPL)National Suicide Prevention Lifeline (NSPL)•1-800-SUICIDE1-800-SUICIDE

Thank you for attending!

Comments, questions, Comments, questions,

Thoughts, or feelings?Thoughts, or feelings?

Judith HarringtonJudith Harrington

[email protected]

About your presenter

• Facilitator of the Birmingham Crisis Center Suicide Survivors Facilitator of the Birmingham Crisis Center Suicide Survivors support group for 14 yearssupport group for 14 years

• 5 year Member of the National Suicide Prevention Lifeline 5 year Member of the National Suicide Prevention Lifeline Training, Standards and Practices CommitteeTraining, Standards and Practices Committee

• Approved Trainer for the American Association of Suicidology and Approved Trainer for the American Association of Suicidology and the Suicide Prevention Resource Centerthe Suicide Prevention Resource Center

• President, 2010-2013, two terms, Alabama Suicide Prevention & President, 2010-2013, two terms, Alabama Suicide Prevention & Resource Coalition (ASPARC)Resource Coalition (ASPARC)

• Former Coordinator of the Alabama Suicide Prevention Task Force Former Coordinator of the Alabama Suicide Prevention Task Force (2007-2008), member since 2004(2007-2008), member since 2004

• Professor, developed Suicide Prevention, Intervention, & Professor, developed Suicide Prevention, Intervention, & Postvention courses, 3 credit hour graduate Counseling Class, Postvention courses, 3 credit hour graduate Counseling Class, UAB, University of Montevallo suicidology courseUAB, University of Montevallo suicidology course

• Full time faculty member, University of Montevallo Counselor Full time faculty member, University of Montevallo Counselor Education and part time private practice after 27 years in full time Education and part time private practice after 27 years in full time practice. practice.

suicide prevention and intervention revisited focus on adults

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