SUICIDAL CLIENTS: Assessing and Managing Risk

2011 SUD CONFERENCE Lansing, MI September 12, 2011

Forest View Hospital

Jim Bottenhorn, MA, LLP

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

TRAINING OUTLINE

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 ~

SUICIDE PREVENTION

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.

SUICIDE TERMS AND USAGE

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.

SUICIDE TERMS AND USAGE

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.

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.

NATIONAL SUICIDE DATA

Our attitudes can and do leak out and affect outcomes

Identify, monitor and manage our emotions

Common emotions associated with suicideFear, Hopelessness, Anger,

Frustration

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

ATTITUDES AND EMOTIONS

Negative emotional reactions may lead to:

Feelings of aversion, rejection, abandonment

Failure to disclose true feelings Withdrawal from the therapeutic

relationship

ATTITUDES AND EMOTIONS

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

KEY RISK FACTORS

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.

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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.

Suicide Risk Factors - Know what to look for -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

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

SUICIDE RISK FACTORS - Know what to look for -

Hendin, et all, (2006) reviewed case narratives of 36 therapists who had patients die by suicide; 6 recurrent problems were identified:

1. Poor communication among treaters2. Permitting patients and/or relatives to control

treatment3. Avoidance of sexuality issues4. Ineffective or coercive measure taken due to

therapist’s anxieties re. patient’s potential suicide5. Not interpreting patient’s communications6. Untreated or undertreated symptoms

SUICIDE RISK FACTORS

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

Predictors of Suicide Attempts in Alcoholics (n=1,237) over 5 years?

• 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.

SUICIDE PROTECTIVE FACTORS

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.

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 …”

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

ELICITING INFORMATION

Never rely solely on one piece of informationRisk assessment deals with probabilities, not

predictionsConsider the following when formulating risk:1. Risk and protective factors2. Diagnoses3. Mental status4. Suicidality5. Intention of client

RISK FORMULATION

(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?

S.L.A.P. A Suicide Assessment Tool

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?

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

THE SAFETY PLAN

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

DOCUMENTATION

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

POLICY, PROCEDURE, PRACTICES

• “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

SUMMARY

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.

RESOURCES

American Psychiatric Association Practice Guidelines

Richard Ries, MD Harborview 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)

RESOURCES