Embed Size (px)
Citation preview
Suicide Prevention for First Suicide Prevention for First RespondersResponders
Abby LandmeierAbby LandmeierSheila Linwood, MBASheila Linwood, MBA
Western Colorado Suicide Prevention Western Colorado Suicide Prevention FoundationFoundation
(970) 683-6626(970) 683-6626
Course ContentCourse ContentRationale (CPR, Heimlich, etc)Crisis interventionAssessment and initial actions
Situational factors (What is happening?)
Behavioral factors (Why is it happening?)Response choices (What is the safest and
most effective response?)Communication TechniquesUse of Active Listening SkillsAbnormal Behavior
High Risk Factors for Homicide – SuicideSuicide Risk & Assessment
Make yourself Make yourself ApproachableApproachableApplied Suicide Intervention Skills Training- 2 day Applied Suicide Intervention Skills Training- 2 day
workshop workshop
Jan 20-21 Feb 24-25 Apr 7-8Jan 20-21 Feb 24-25 Apr 7-8
Question, Persuade, Refer - 90 minutesQuestion, Persuade, Refer - 90 minutes
LINK for Life- any time frameLINK for Life- any time frame
Sheila (970) 683-6626Sheila (970) 683-6626
Schedule a workshop now, your bottom line will Schedule a workshop now, your bottom line will improve by 10%improve by 10%
Ask us howAsk us how
HotlinesHotlinesSuicide calls- 16% increase in the past yearSuicide calls- 16% increase in the past year
10% increase each month10% increase each month
Housing counseling- significant increaseHousing counseling- significant increase
Money relatedMoney related
Economic situation- reminiscent of 9/11Economic situation- reminiscent of 9/11
Domestic violence shelters fullDomestic violence shelters full
Suicides generally increase during economic Suicides generally increase during economic downturnsdownturns
““By the time you foreclose on my house, I By the time you foreclose on my house, I will be dead.”will be dead.”
BeliefsBeliefs
YOUREALITY
BeliefFilters
You see the world not as it is, but as you are
First Responder Risk AssessmentFirst Responder Risk Assessment•The first 15 to 45 minutes of an escalated emotional incident is a critical time period.
•The average Crisis Negotiation/SWAT team response time is 45 minutes to 1 hour.
•The first responder should use communication skills to reduce the level of emotion in the incident.
•Reduce the likelihood of further violence through "verbal containment.“
Possible CircumstancesPossible Circumstances
• Domestic disturbanceDomestic disturbance• Violence in the workplaceViolence in the workplace• Mentally Disturbed IndividualMentally Disturbed Individual• Depression/SuicideDepression/Suicide• School crisisSchool crisis• Road rageRoad rage• Drug or alcohol involvementDrug or alcohol involvement• Any call for serviceAny call for service
Serious Attempt or Serious Attempt or Death by SuicideDeath by Suicide
Joiner, 2008Joiner, 2008
Those Who Desire Suicide
Those Who Are Capable of Suicide
PerceivedBurdensomeness
ThwartedBelongingness
Distal
Factors
Identify the CrisisIdentify the CrisisIf the subject feels he is in crisis, he is.
Crisis comes when normal coping mechanisms do not work.
What precipitating event has usually occurred within the last 24-48 hours, and the subject's normal coping mechanisms have failed to resolve the situation?
Behavior is irrational / poor decision making level in response to a highly stressful situation.
What a Crisis looks likeWhat a Crisis looks likeThe situation is perceived to be a threat to the emotional, psychological and physical needs of the subject.
Emotions, not reason, are controlling the subject's actions.
People will generally turn inward, away from usual support systems and feel more isolated.
In many instances the subject has experienced a real or perceived loss.
Attempt to identify the loss. Usually the loss of: - Loved one - Job - Health - Money - Self-esteem
Identify the lossIdentify the loss
250 points = Reactive DepressionDeath of a spouse: 100 + Death of another family member: 63 Personal wounds or illness: 53 Loss of a job or income: 47 Family member wounded or ill: 44 Personal possessions or financial losses: 38Death of a close and personal friend: 37 Changing jobs or a new position: 36 Overwhelming debt: 31 A change in lifestyle or relocating: 25 A change in personal habits or routines: 24 A new school or a change in recreational activities: 20 A change in social activities: 18 Christmas, Anniversaries, and Birthdays: 12
Rates of StressorsRates of Stressors
Holmes and Rahe 1968
On Scene AssessmentOn Scene Assessment
First few minutes are critical; anticipate confusion and high emotion.
Anger, anxiety and/or fear are the predominant emotions.Expect extreme responses from the subject. (Verbal abuse ....................Silence)
•Ego will drive a situation- don’t let it be yours
The Purpose of Crisis The Purpose of Crisis InterventionIntervention
Defuse intense emotions
Gain information/Assess situation
Gain time
Establish rapport/communicate empathy
Ideally return subject to his/her normal
functioning level
What’s going on?What’s going on?
What's happening now? (Yelling, threats, carrying weapon, breaking things, all quiet, not activity noted)
Where is it happening? (Home, office, public place, isolated area)
What is driving this incident? (fear, anger, regret, guilt, depression, suicide)
What is important to the suspect? (family, work, neighbors, image, revenge)
Postvention: Warning Postvention: Warning SignsSigns
IS PATH WARM?IS PATH WARM? I IdeationI Ideation
S Substance Abuse S Substance Abuse P Purposelessness P Purposelessness A Anxiety A Anxiety T Trapped T Trapped H Hopelessness H Hopelessness W Withdrawal W Withdrawal A Anger A Anger R Recklessness R Recklessness M Mood Changes M Mood Changes
Primary Emotional DriversPrimary Emotional Drivers
• FearFear• ElationElation• DepressionDepression• ConfusionConfusion• PsychosisPsychosis• Hopelessness, Hopelessness,
DemoralizationDemoralization
•Hostility and evasion
•Risk taking behaviors
•Self-destructive behavior
•Odd, dangerous behavior
•Very odd behavior
•Attempts at self-treatment with alcohol, drugs, behaviors
The person may be feeling this:
While showing this:
Source: Gordon Neligh, M.D.
Initial ActionsInitial Actions
Begin to clear the area of uninvolved personsBegin to clear the area of uninvolved persons
Gather immediate intelligence, you are an expert Gather immediate intelligence, you are an expert witness. Attempt to respond based on your witness. Attempt to respond based on your assessment of information obtained thus far.assessment of information obtained thus far.
Develop a Crisis Action Plan- Plan B (What to do if Develop a Crisis Action Plan- Plan B (What to do if things go bad)things go bad)
Keep the subject from harming othersKeep the subject from harming others
Verbal ContainmentVerbal ContainmentReduce the likelihood he will attack the police.
If something is keeping the subject in an escalated state, distract them to other topics.
Project calm professional demeanor to provide subject with a sense of order.
Develop additional intelligence - In order to begin to answer the question, what
is driving this incident?
Communication TechniquesCommunication Techniques
The first few statements will set the tone for the incident.
INTRODUCTION (Example)
"Hello, my name is (_________) withthe (Law enforcement agency).
"I would like to help. Are you okay? Could you help me understand what's going on?"
Communication TechniquesCommunication TechniquesTell them you would like their help to resolve this peacefully
Reassure the person that you have things under control.
Advise the person he is responsible for keeping things calm and under control inside (“We can do this the easy way, or the hard way- the choice is theirs).
Communication TechniquesCommunication TechniquesLower emotions by providing a non-threatening environment in which the subject may be able to think more rationally (step away from the immediate crisis location).
Acknowledge that you are listening
Allowing him to tell "his story" will help him vent and will lower his anxiety.
Communication TechniquesCommunication TechniquesIf he's talking . . . you are buying TIME.
It's more important to be a good listener.
Listening will provide you with valuable intelligence; everything he says will tell you something about what is happening, and why.
Try to see the problem through the "eyes of the subject." (People want to be understood)
-Understanding his behavior does not mean you agree with his actions.
Communication TechniquesCommunication Techniques
Take your time; speak slowly and calmly (law enforcement is generally bad at this)
Your tone indicates your attitude; it speakslouder than your words.
How you say something is as important aswhat you say. Be honest, genuine and sincere. They will
give it back- Avoid tricks
Communication TechniquesCommunication Techniques
ASSUME NOTHING - If you are not sure what he means by something he has said . . . ASK HIM!
"I'm not sure I understand what you mean, could you explain that further?”
Could you help me to understand how this started?
AvoidAvoid
NEVER ask them to clarify a threat.Giving orders that may escalate the confrontation.ArguingBargaining with or making concessions to theperson.Trying to “solve his problems.” e.g. “Why don’t you just ….?”
Don’t tell people what to do (“Just sit down”, “Just calm down”), help them make better decisions.
Listening for EmotionsListening for Emotions
People communicate on two levels
CONTENT-The simple facts (the story)
EMOTIONS-The emotional reaction to the facts (feelings about circumstances)
Listening for EmotionsListening for EmotionsTrain yourself to listen for the emotions surrounding what happened.Emotional reaction and subsequent behavior make the situation a crisis, not the facts of the situation.How a person feels about a situation will strongly influence their behavior.Controlling the subject's emotions will help control the subject's behavior.
Non-Judgmental ApproachNon-Judgmental Approach
The subject's feelings, values, life style and opinions are what counts.
Be accepting.
Do not inject your values into the situation.
TIMETIME
Emotions vs. Time
NORMAL FUNCTIONING LEVEL
EMOTIONAL- COGNATIVE
RATIONALITY
ACTIVE LISTENING CONCEPTS ACTIVE LISTENING CONCEPTS
EMPATHY versus SYMPATHY
• Empathy implies understanding of another's feelings and thereby builds rapport and trust.
•Sympathy implies pity.
The Seven Active Listening Skills
Emotion – Labeling Identify the feeling ... "You sound...","You seem... ", "I hear…”
Paraphrasing Put meaning into your own words
Reflecting / Mirroring The "gist", last couple of words
The Seven Active Listening Skills (continued)
Effective Pauses (silence)Immediately before or after saying something
meaningful
Minimal Encouragers Indicate your presence... "Uh-huh...OK, etc.“
"I" Messages "When you ...", "I feel ...", "Because ..."
The Seven Active Listening Skills (continued)
Open - Ended Questions
"What?", "When?", "How?", --- OR ---
"Tell me more about ...",
"I'd like to hear more about ..."
Building Rapport
Let the person know which emotion you think you hear
•"This situation seems to have really made you mad.“
• "It sounds like this is very frustrating to you.“
• “You seem to be confused about what to do."
Behavioral Change Stairway
BEHAVIORAL CHANGE
INFLUENCE
RAPPORT
EMPATHY
ACTIVE LISTENINGSKILLS
Trust
TimeFBI
Is not just a bad mood or feeling “blue”
Is a depressed mood, of at least two weeks duration, with symptoms such as sleep disturbance, weight loss or gain, and difficulty concentrating
Depression
Depression Depression CharacteristicsCharacteristics
• Profound sadness• Hopelessness• Helplessness• Unworthy• Blames self – guilt• Brooding over past events – tearfulness• Sleep / appetite disorders / disturbances• Recent loss• Psychomotor reactions slowed / meds• Thoughts of suicide ASK?
WHY SUICIDE WHY SUICIDE INTERVENTION?INTERVENTION?
There is the potential for suicide in virtually all crisis situations.
SUICIDE CLUESSUICIDE CLUES
Expressions of hopelessness and helplessness
"No one cares" "I can't go on“ “I wish I were dead.” “I wish I could go to sleep and never wake up.”
TIME CLUESTIME CLUES
"It won't matter after today.“
"Tomorrow? There won't be a tomorrow."
INDICATORSINDICATORS
TBI / PTSD Giving personal items away Writing a note Test firing of weapon Withdrawal from family / friends Sudden cessation of previously enjoyable activities Preoccupation with talk of death
The FrameworkThe Framework
Multiple Attempter?Yes No
Any Other Significant Finding = AT LEASTModerate Risk
Elevated on Resolved Plans & Preparation?
Yes No
Elevated on SuicidalDesire & IdeationYes
No
Low Risk
Any Other Significant Finding = AT LEASTModerate Risk
Two or More Other Significant Findings = AT LEAST
Moderate Risk
Joiner ,2008
Suicidal Risk Assessment Suicidal Risk Assessment LINK for LifeLINK for Life
LLook ook LListen for warning signsisten for warning signs
IInquire- Ask “Are you thinking about nquire- Ask “Are you thinking about suicide.”suicide.”
NNote the level of riskote the level of risk Do they have a plan?Do they have a plan?
Previous suicide attempts?Previous suicide attempts? Ask if they have access to weapons – knives, Ask if they have access to weapons – knives,
firearms, etc. (ASSUME they do- 62% of homes firearms, etc. (ASSUME they do- 62% of homes in Colorado have guns in them)in Colorado have guns in them)
KKnow your resourcesnow your resources
1 800 273-TALK1 800 273-TALK
Postvention: What to DoPostvention: What to Do• Here are some ways to be helpful to someone Here are some ways to be helpful to someone
who is threatening suicide:who is threatening suicide: • Be direct. Talk openly and matter-of-factly Be direct. Talk openly and matter-of-factly
about suicide. about suicide. • Be willing to listen. Allow expressions of Be willing to listen. Allow expressions of
feelings. Accept the feelings. feelings. Accept the feelings. • Be non-judgmental. Don’t debate whether Be non-judgmental. Don’t debate whether
suicide is right or wrong, or whether feelings suicide is right or wrong, or whether feelings are good or bad. Don’t lecture on the value of are good or bad. Don’t lecture on the value of life. life.
• Get involved. Become available. Show interest Get involved. Become available. Show interest and support. and support.
Postvention: What to DoPostvention: What to Do
• Don’t dare him or her to do it. Don’t dare him or her to do it. • Don’t act shocked. This will put distance Don’t act shocked. This will put distance
between you. between you. • Don’t be sworn to secrecy. Seek support. Don’t be sworn to secrecy. Seek support. • Offer hope that alternatives are available but Offer hope that alternatives are available but
do not offer glib reassurance. do not offer glib reassurance. • Take action. Remove means, such as guns Take action. Remove means, such as guns
or stockpiled pills. or stockpiled pills. • Get help from persons or agencies Get help from persons or agencies
specializing in crisis intervention and specializing in crisis intervention and suicide prevention. suicide prevention.
Suicide Statistics / Suicide Statistics / 100,000 100,000
• National Suicide RateNational Suicide Rate 10.710.7• Colorado RateColorado Rate 16.716.7• Western SlopeWestern Slope 21 – 2421 – 24• Attempt numbers 25-100 times Attempt numbers 25-100 times
thesethese
• 50-75% of suicides on the Western 50-75% of suicides on the Western Slope are from the Construction Slope are from the Construction industryindustry
• 95% have Alcohol / Drugs on board95% have Alcohol / Drugs on board
SUICIDE BY COPSUICIDE BY COPPossible indicators
May demand to be killed by police
May set a deadline for his/her death
May have just killed a significant other
May have stated a verbal willMay have expressed and/or established an elaborate death plan
Expected sentencing
SUICIDE BY COP SUICIDE BY COP STATISTICSSTATISTICS
Incident began as a call other than Incident began as a call other than suicide (73%)suicide (73%)
Occurred during:Occurred during: Domestic disturbance (46.3%)Domestic disturbance (46.3%) Mental Illness (24.7%)Mental Illness (24.7%) Criminal offense (20.4%)Criminal offense (20.4%)
Source: Vivian Lord, Ph.D
Homicide followed by Homicide followed by Suicide:Suicide:
An Analysis of Chicago DataAn Analysis of Chicago Data
• Ex-spouse/loverEx-spouse/lover
• ChildChild
• Girlfriend/boyfriendGirlfriend/boyfriend
• FriendFriend
• 12.6812.68
• 10.2810.28
• 6.116.11
• 1.881.88
Relationship of victim Increase in likelihood of suicide
Steven Stack, Criminology, 1997, Volume 35, No. 3, pp. 435 – 445.
If someone chooses If someone chooses death?death?
• Know that you did the best you can doKnow that you did the best you can do– Seek out a debriefing- Crisis Support TeamsSeek out a debriefing- Crisis Support Teams– Trust your decisions- You are a good personTrust your decisions- You are a good person– You are not responsible for others actionsYou are not responsible for others actions– Let go of any and all guilt immediatelyLet go of any and all guilt immediately– Have faith that next time you will be better Have faith that next time you will be better
because of what you have learnedbecause of what you have learned– Practice SELF CAREPractice SELF CARE– Be aware of PTSD symptoms - seek helpBe aware of PTSD symptoms - seek help
earlyearly
Death NotificationDeath Notification• This moment will shape the recipient’s life forever. This moment will shape the recipient’s life forever.
– Use the “D” words (Death, Died, Deceased)Use the “D” words (Death, Died, Deceased)– This begins the healing without misinterpretation, This begins the healing without misinterpretation,
denial, false hope.denial, false hope.– Let them vent (anger, hysterics, silence- all normal)Let them vent (anger, hysterics, silence- all normal)
• Watch for strange behavior- walking in trafficWatch for strange behavior- walking in traffic• Two years out- lowered immune system- CancerTwo years out- lowered immune system- Cancer• Respectful of last moments, belongingsRespectful of last moments, belongings• If you are uncomfortable with the topic, ask someone If you are uncomfortable with the topic, ask someone
else to do it.else to do it.• I know this was not your fault, touch themI know this was not your fault, touch them• If they want the note- give them the note.If they want the note- give them the note.
Suggested ReadingSuggested Reading
• ““Verbal Judo”- ThompsonVerbal Judo”- Thompson• ““The Rock Warrior ‘s Way” – IlgnerThe Rock Warrior ‘s Way” – Ilgner• ““Goodbye to Guilt” - JampolskyGoodbye to Guilt” - Jampolsky• ““The Speed of Trust”- CoveyThe Speed of Trust”- Covey• ““Seven Habits of Highly Effective People”- Seven Habits of Highly Effective People”-
CoveyCovey• ““The Fifth Element”- SengeThe Fifth Element”- Senge• ““Why People Die by Suicide”- JoinerWhy People Die by Suicide”- Joiner• The Assessment and Management of The Assessment and Management of
Suicidality - RuddSuicidality - Rudd
It’s the little thingsIt’s the little things
• ““Never doubt that a small Never doubt that a small group of thoughtful citizens group of thoughtful citizens can change the world. can change the world. Indeed, it is the only thing Indeed, it is the only thing that ever has.” Margaret that ever has.” Margaret MeadMead
