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9/12/17
1
SuicidePreventionWebinarSeanConvoy,DNP,PMHNP-BC
CDR,USN,Retired
PresentationDisclaimer
•TheviewsexpressedinthispresentationarethoseoftheauthoranddonotreflecttheofficialpolicyorpositionoftheDepartmentofDefense,DepartmentoftheNavy, ortheUnitedStatesGovernment.• Ihavenoconflictsofinteresttoreport.
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LearningObjectives
• Thistrainingwillintroducestrategiesabouthowtoassess,communicatewithandengageatriskmilitaryservicemembers,veteransandfamilymemberswhoarepotentiallyatriskforharmtoselforothers.• Explorehowtoassessforrisktoself-harmandothersamongmilitaryservicemembersandveterans.
• Discussstrategiesfordeescalatingatriskmilitaryservicemembersandveterans.
• Identifyanticipatorytactics,techniquesandproceduresthatcanbeusedtostreamlinecrisisinterventionwork.
• Developastandardizedapproachabouthowtodiscussgunandweaponownershipwithatriskmilitaryservicemembersandveterans.
Wheremymotivationcomesfrom…
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Perspective…
• Everythingwedo(anddon’tdo)matters.
SuicidePreventionAnalogoustotheRedZone…
• Suicideisthedistalprojectionoftheproblem• Unidentified,untreatedorundertreatedmentalillnessistheproximaletiologyoftheproblem• Mentalhealthcaredeliverysystemcommonlyhyperfocusonthedistalprojection.• Publichealthsectorcommonlyhyperfocusontheproximaletiology.• Today’spresentationisaboutthe“redzone”ofsuicidebutpleasedon’tforgetabouttheother98yards!
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Johari’sWindow
Known Thingsthatweknowthatweknow
Thingsthatweknowthatwedon’tknow
Unknown Thingsthatweknowthatwedon’tactuallyknow
Thingsthatwedon’tknowThatwedon’tknow
Knowns Unknowns
Jody’sCase
• 28yearoldveteranwithunreportedMSThistorywhois9monthspostservicerelease(noVA/DoDfiling)withdualdiagnosishistory(PTSDandAUD)presentlyadversetoDoD/Veterancare(allegedassaulteraffiliatedwithmilitarymedicine).• Traumasymptomsareprofoundlyfunctionallyimpairingmakingschool,workandintimaterelationshipsinconceivable.
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ViewingJody’sCaseThroughJohari’sWindow
Known
• PopulationRiskFactors• SubjectiveHistory• MentalStatusExamination• SafetyAssessment
• IntentionalWithholdingofRelevantClinicalData
• IncidentalWithholdingofRelevantClinicalData
Unknown • ClinicalDeficiencies/Myopias• CounterTransference • Literally EverythingElse
Knowns Unknowns
ViewingJody’sCaseThroughJohari’sWindow
Known
• PopulationRiskFactors• SubjectiveHistory• MentalStatusExamination• SafetyAssessment
• IntentionalWithholdingofRelevantClinicalData
• IncidentalWithholdingofRelevantClinicalData
Unknown • ClinicalDeficiencies/Myopias• CounterTransference • Literally EverythingElse
Knowns Unknowns
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ViewingJody’sCaseThroughJohari’sWindow
Known
• PopulationRiskFactors• SubjectiveHistory• MentalStatusExamination• SafetyAssessment
• IntentionalWithholdingofRelevantClinicalData
• IncidentalWithholdingofRelevantClinicalData
Unknown • ClinicalDeficiencies/Myopias• CounterTransference
• Literally EverythingElse
Knowns Unknowns
ViewingJody’sCaseThroughJohari’sWindow
Known
• PopulationRiskFactors• SubjectiveHistory• MentalStatusExamination• SafetyAssessment
• IntentionalWithholdingofRelevantClinicalData
• IncidentalWithholdingofRelevantClinicalData
Unknown • ClinicalDeficiencies/Myopias• CounterTransference • Literally EverythingElse
Knowns Unknowns
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Jody’sCase
Known
• PopulationRiskFactors• SubjectiveHistory• MentalStatusExamination• SafetyAssessment
• IntentionalWithholdingofRelevantClinicalData
• IncidentalWithholdingofRelevantClinicalData
Unknown • ClinicalDeficiencies/Myopias• CounterTransference • Literally EverythingElse
Knowns Unknowns
Risk AssessmentPopulationScreening
• Patientpopulationidentification• Developinggranularknowledgeofhighvolumepopulation• FeederService/Commands• MilitaryOccupationalSpecialties• CriticalService/CommandHistory
• ReachingouttoareaMilitaryTreatmentandVeteransAffairsFacilitiesforpopulationhealthdata
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Risk AssessmentSiloEffect
• Lackofinformationflowingbetweengroupsorpartsofasystem• Reinforcedbyequaldosesofprivacyconcernsandstigma• Canoccuratmanydifferentlevels
Risk AssessmentPatientScreening
• Milieumessaging• Familyfriendlymessaging• Patienthealthhistory• Twofactorscreening• Serialassessment• Risk&protectivefactors• HIPPAcompliantpatientportals• Ancillarystaffutilization• Establishedcrisisinterventionplan
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Risk AssessmentScreeningInstruments• OutcomeQuestionnaire45.2(OQ®-45.2)https://www.oqmeasures.com/measures/adult-measures/oq-45/
• SuicideAssessmentFive-stepEvaluationandTriage(SAFE-T)https://store.samhsa.gov/product/Suicide-Assessment-Five-Step-Evaluation-and-Triage-SAFE-T-/SMA09-4432
• AskSuicideScreeningQuestions(ASQ)https://www.nimh.nih.gov/news/science-news/2013/file_143902.pdf
• Columbia– SuicideSeverityRatingScale(C-SSRS)http://www.cssrs.columbia.edu/documents/C-SSRSClinicalPracticeScreeners.docx
Risk AssessmentBottomLineUpFront(BLUF)
• Reticencetoaskthequestion(s)isunintentionallystigmatizing• Distinguishingsuicidalityasasymptomtotreat,ratherthanastateofbeing• Reframingsuicidalityinnonabsoluteterms• Clinicallyactingonintent,ratherthanpresence
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De-escalation StrategiesSuicideContracts
De-escalation StrategiesKayR.Jamison’sLocusofControl
• Suicideastheultimatemanifestationofcontrol• Resistingtheurgetotakecontrolfromthepatient• Alternativelyshiftingtherisktotherightand“reshufflingthedeck.”• Employingastrategytorealigneffortsinpursuitoflivingratherthandying
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De-escalation Strategies
•CognitiveRestructuring• EmotionalRegulation•CollaborativeAssessmentandManagementofSuicide(CAMS)• SafetyPlanning
WarriorEthos
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Mental Illness StigmaSussman’s MentalIllnessStigmaQuiz1. There’snorealdifferencebetweentheterms“mentallyill”and“hasamentalillness.”2. Peoplewithmentalillnesstendtobedangerousandunpredictable.3. Iwouldworryaboutmysonordaughtermarryingsomeonewithamentalillness.4. I’vemadefunofpeoplewithmentalillnessinthepast5. Idon’tknowifIcouldtrustaco-workerwhohasamentalillness.6. I’mscaredoforstayawayfrompeoplewhoappeartohaveamentalillness.7. Peoplewithamentalillnessarelazyorweakandneedtojust“getoverit.”8. Oncesomeonehasamentalillness,theywillneverrecover.9. Iwouldhesitatetohiresomeonewithahistoryofmentalillness.10. I’veusedtermslike“crazy,”“psycho,”“nutjob,”or“retarded”inreferencetosomeone
withamentalillness.
http://davidsusman.com/2015/04/30/5-simple-steps-to-reduce-stigma-about-mental-illness/
Risk Assessment VignetteJody’sAssessment
• Purposefuluseofpatientcenteredspace• Onlinepatienthealthhistorygaveinsightintosymptomspriortopatient’sevaluation• Ancillarystaffscreening(byalgorithm)sensitizedprovidertopresentfocusedriskspriortoevaluation• Jodywasactivelysuicidalwithintent,meansandplan.
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Risk AssessmentGun&WeaponSafety
Risk AssessmentGun&WeaponSafety
ThatWhichWeCanPotentiallyControl• Thoroughnessofassessment• Abilitytoaskdifficultquestions• Understandingourroles,responsibilitiesandlimitations• Collaborativelymanagingrisk• Documentation• Stayinguptodatewithlaw
ThatWhichWeCantNecessarilyControl• State&federalgunlaws• Thepatient
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ClinicalPearls
• Rememberthepatient’sremotecontrolandmutebutton• Johari’sWindowcanhelpyougrowthegreenofyourknownknowns• Acommunityhealthassessmentrepresentsaninvestmentintoyourpatient’shealthandwellbeingaswellasyourqualityoflife• Betterutilizingancillarystaffimprovesoutcomesandsavestime• Whenitcomestosuicidecontracts,justsayno• Resisttheurgetotrytocontrolsuicide,rathershifttherisktotheright
De-escalation StrategiesWarriorEthos
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References
• AmericanPsychiatricAssociation(2014)."PositionStatementonFirearmAccess,ActsofViolenceandtheRelationshiptoMentalIllnessandMentalHealthServices."
• Bartlett,M.(2006).TheEfficacyofNo-SuicideContractswithClientsinCounselingonanOutpatientBasis.DoctoralDissertation.A.University.AuburnUniversity.
• Beach,E.K.(1982)."Johari'sWindowasaframeworkforneedsassessment."JContin Educ Nurs13(3):28-32.
• Benner,P.E.(1984).Fromnovicetoexpert:excellenceandpowerinclinicalnursingpractice.MenloPark,Calif.,Addison-WesleyPub.Co.,NursingDivision.
• ConsortiumforRisk-BasedFirearmPolicy(2013)."Guns,PublicHealth,andMentalIllness:AnEvidenceBasedApproachforStatePolicy."
• deVries,P.,etal.(2008)."[Theno-suicidecontract:ariskyritual]."Tijdschr Psychiatr 50(10):667-671.
References
• Gold,L.H.(2013)."Gunviolence:psychiatry,riskassessment,andsocialpolicy."JAmAcadPsychiatryLaw 41(3):337-343.
• Jamison,K.R.(1995).Anunquietmind.NewYork,A.A.Knopf.
• Jamison,K.R.(1999).Nightfallsfast:understandingsuicide.NewYork,Knopf.• Lee,J.B.andM.L.Bartlett(2005)."Suicideprevention:criticalelementsformanagingsuicidalclientsandcounselorliabilitywithouttheuseofano-suicidecontract."DeathStud 29(9):847-865.
• Meade,B.J.,etal.(2013)."MissionCritical:GettingVetswithPTSDBacktoWork."News&Perspectives.fromhttp://www.medscape.com/viewarticle/781380_3.
• Melamed,Y.,etal.(2011)."Assessingtheriskofviolentbehaviorbeforeissuingalicensetocarryahandgun."JAmAcad PsychiatryLaw 39(4):543-548.
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References
• Pirelli,G.,etal.(2015)."PsychologicalEvaluationsforFirearmOwnership:LegalFoundations,PracticeConsiderations,andaConceptualFramework."ProfessionalPsychology:ResearchandPractice.
• Robert,C.andD.Camus(2006)."[A"non-suicidecontract"undertheguiseofprevention]."Krankenpfl Soins Infirm 99(9):46-49.
• Simon,R.I.(1999)."Thesuicidepreventioncontract:clinical,legal,andriskmanagementissues."JAmAcad PsychiatryLaw 27(3):445-450.
• Slovak,K.,etal.(2008)."Clientfirearmassessmentandsafetycounseling:theroleofsocialworkers."Soc Work 53(4):358-366.
• Sutherland,J.A.(1995)."TheJohariWindow:astrategyforteachingtherapeuticconfrontation."NurseEduc 20(3):22-24.
• Verklan,M.T.(2007)."Johariwindow:amodelforcommunicatingtoeachother."JPerinatNeonatalNurs 21(2):173-174.
• Weiss,A.(2001)."Theno-suicidecontract:possibilitiesandpitfalls."AmJPsychother 55(3):414-419.