Crisis Intervention: Addressing Suicidal Thoughts and Behaviors

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Crisis Intervention Addressing Suicidal
Thoughts and Behaviors

• Presented by
• Amanda Myatt, LCSW
• Director of Emergency Psychiatric Services
• Mental Health Cooperative, In.

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Crisis Defined

• A crisis represents both danger and opportunity
• Dangerthreatens to overwhelm the person and/or
  their support system. May result in suicide,
  homicide, and/or psychotic break.
• Opportunityduring time of crisis, the individual
  may be more receptive to therapeutic influence
  and intervention.
• Intervention may lead to new and/or improved
  coping skills

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Facts about Suicide

• In 2006, suicide was the 11th leading cause of
  death in the U.S., claiming 33,300 lives per
  year. Suicide rates among youth (ages 15-24)
  have increased more than 200 in the last 50
  years.

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Facts and Stats Continued

• Four times more men than women kill themselves
  but three times more women attempt than men
  attempt.
• Suicide occurs across ethnic, economic, social
  and age boundaries.

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Facts and Stats Continued

• Suicide Methods
• Firearm 50.2
• Suffocation
• Poisoning
• Drowning

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What do you do when a client is in crisis???

• DONT panic
• Stay calm and gather information
• Seek assistance from others

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Elements of Crisis Assessments

• Determine nature of the crisis situation and its
  impact on the individual.
• What factors precipitated the crisis?
• Adaptive capacities of the individual (How do
  they usually cope with stress?)
• Resources that can be tapped to alleviate the
  crisis situation
• Extent to which the individual is receptive to
  intervention

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Goal of suicide risk assessment

• The goal of a suicide risk assessment is to
  identify factors that may increase or decrease
  the persons level of risk, to estimate an
  overall level of suicide risk, and to develop a
  treatment plan that addresses patient safety.

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Beck Suicide Intent Scale

• Aaron Beck has developed and validated several
  scales that are used in both research and
  clinical settings.
• Beck Anxiety Inventory (BAI)
• Beck Depression Inventory (BDI-II)
• Beck Cognitive Insight Scale (BCIS)
• Beck Hopelessness Scale (BHS)

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Beck Suicide Scales

• Beck Scale for Suicide Ideation (BSI)
• The BSI is a 21-item self report questionnaire
  that may be used to identify the presence and
  severity of suicidal ideation. Items on this
  measure assess the respondents suicidal plans,
  deterrents to suicide, and the level of openness
  to discussing suicidal ideations and openness to
  interventions.

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Beck Scale for Suicide Ideation (SSI)

• The SSI measures characteristics of an
  individuals plans and wishes to commit suicide.
  The 19 item clinician administered scale is based
  on a semi-structured interview with the client.

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Common Elements of all Crisis Risk Assessments

• Suicidality
• Current suicidal ideations
• Current plan?
• Access to means to act on plan?
• Does the individual understand risk involved and
  lethality of their plan?
• Time/place to execute plan?
• Has the individual recently given away any of
  their possessions? Recently made a will?

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Crisis Risk Assessment Continued

• History of gestures/attempts (seriousness of
  prior attempts outcome of attempt and treatment
  received)?
• Suicide modeling (attempts/gestures by
  significant otherswhen and whom?)
• All these questions need to be explored fully.

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Crisis Risk Assessments Continued

• Current Impulse Control Ability
• History of impulsive actions?
• Current Stressors
• Recent relapse
• Financial
• Residential
• Domestic Violence
• Legal
• Grief Issues
• Separation from significant other
• Recent loss of a partner
• Extreme community violence/trauma

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Crisis Risk Assessment Continued

• History of Physical and/or Sexual Abuse
• Are they the victim or perpetrator?
• How recent?
• Police involvement?
• Mandatory reporting?

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Crisis Risk Assessment Continued

• Medical issues
• Chronic medical condition?
• New diagnosis?
• History of head injury?
• History of seizures?
• Complicated withdrawal issues?

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Crisis Risk Assessment Continued

• Mental Health Diagnosis?
• The presence of a psychiatric disorder is
  probably the most significant risk factor for
  suicide. Psychological autopsy studies have
  consistently shown that more than 90 of person
  who die from suicide satisfy the criteria for one
  or more psychiatric disorders.

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Crisis Oriented Risk Assessment Continued

• Mood Disorders (Depression Bi-polar)
• Schizophrenia
• Anxiety Disorders
• Eating Disorders

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Crisis Risk Assessment and Substance Use

• Use of alcohol and/or illegal drug abuse
  increases risk with period of intoxication being
  one of the highest risk times for individuals.

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Crisis Risk Assessment Continued

• Current Consumer Resources
• Perceived resources
• Actual resources
• Involvement of patients family/social support
• Current family/social support concern regarding
  dangerous thoughts or behaviors?
• Is support system sufficient?

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Gender Specific Issues

• In virtually all countries that report suicide
  statistics to the World Health Organization,
  suicide risk increases with age in both sexes,
  and rates for men in older adulthood are
  generally higher than those for women.

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Gender Specific Continued

• Suicide rates in males is approximately 4 times
  higher than rates for women in the US.
• A number of factors may contribute to these
  gender differences in suicide risk. Men who are
  depressed are more likely to have comorbid
  alcohol and/or substance abuse problems than
  women, which places the men at higher risk.

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Gender specific issues continued

• Men are also less likely to seek and accept help
  or treatment.
• Women, meanwhile, have factors that protect them
  against suicide. In addition to lower rates of
  alcohol and substance abuse, women are less
  impulsive, more socially embedded, and more
  willing to seek help.
• However these differences are changing.

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Gender specific issues continued

• Women have higher rates of depression and respond
  to unemployment with greater and long-lasting
  increases in suicide rates than do men.
• Other gender specific issues to consider
• Pregnant women
• Post partum complications
• Women with children in the home

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Services to assist individuals in crisis

• When do you call 911 and request an ambulance or
  law enforcement vs when do you call a mobile
  crisis team?
• If the person is trying to leave or is
  aggressive, call law enforcement.
• If the person has attempted or you suspect an
  attempt (ieoverdose) call 911 and request an
  ambulance.

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Services to assist Consumers in crisis

• If the person is highly intoxicated, medical
  clearance will be required.
• If the person is not threatening to leave or has
  no means to leave---call your local mobile crisis
  team. Be prepared to give demographic
  information and explain what is going on at this
  time.

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Crisis Continuum Services

• 24/7 Mobile Crisis Response Services
• Police walk-in centers
• Crisis Resolution Centers
• Crisis Respite Programs
• Crisis Stabilization Units

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Crisis Resolution Center (CRC)

• 24/7 Crisis assessment and Resolution
• Staffed by nurses and Bachelor Level Mental
  Health Professionals
• Daily rounds and evaluations performed by
  Psychiatrist and/or psychiatric nurse
  practitioner
• Offers quick, solution focused assistance for
  individuals in crisis

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Crisis Resolution Center Continued

• Length of StayUp to 12 hours (sometimes this
  stay may be extended but cannot exceed 23 hours)

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Crisis Respite

• Can be helpful in de-escalating a situational
  crisis, providing stabilization in a mental
  health emergency, and giving he person time to
  make positive decisions that they may not be able
  to make during the initial crisis phase.
• Staffed with 24/7 awake staff nurse makes visits
  5 days a week access to psychiatric consult
  daily.

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Crisis Respite Continued

• Length of stay up to 3 days
• While in respite, individuals are encouraged to
  attend house groups and work with staff on
  development of comprehensive discharge plan.
• Crisis respite is for individuals who do not
  require hospitalization but need 24 hour
  monitoring in a community based setting.

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Crisis Respite Admission Criteria

• An individual is appropriate for Crisis Respite
  if they
• Are experiencing a mental health crisis,
• Have insight into their need for intervention
• Agreeable to the placement

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Crisis Stabilization Unit

• Intensive level of care
• 24/7 staff that includes RN LPN Bachelors
  level mental health staff Peer support
  specialist
• Daily rounds by psychiatric provider
• 24/7 on-call psychiatric provider
• Unit must maintain a 15 ratio at all times

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Crisis Stabilization Unit

• 15 bed capacity
• Groups conducted daily (at least 5 groups offered
  throughout a typical day)
• Individual sessions as needed
• Highest level of care that an individual can
  receive in a community based setting.

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Crisis Stabilization Unit Continued

• Length of stay is up to maximum of 96 hours with
  average length of stay approximately 2.5 days.
• CSU is a voluntary unit
• Individuals appropriate for CSU are experiencing
  an acute crisis episode but have insight and
  agree to intervention.

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Crisis Stabilization Unit Continued

• Individuals may be actively suicidal and/or
  psychotic but have enough insight to know that
  they need treatment.
• Once on the CSU unit, if a higher level of care
  is needed to maintain the individuals safety,
  then the staff will facilitate transfer to an
  inpatient psychiatric hospital.

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Involuntary Hospitalization Criteria

• Involuntary Commitment Process State of Tennessee
• Title 33, Chapter 6, Part 4, Tennessee Code
  Annotated (commonly known as 6-404)
• Latest revision of the mental health law of
  Tennessee became effective July 1, 2002 (last
  major revision was over 20 years ago)

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Involuntary Commitment Criteria in TN

• Criteria
• To Detain for Examination (TCA Section 33-6-401)
• 1. A person has a mental illness or serious
  emotional disturbance (SED), AND
• 2. Poses an immediate substantial likelihood of
  serious harm because of the mental illness or
  serious emotional disturbance.
• Admission to Hospital (TCA Section 33-6-403)
• 1. A person has a mental illness or serious
  emotional disturbance, AND
• 2. Poses an immediate substantial likelihood of
  serious harm because of the mental illness or
  serious emotional disturbance.
• 3. Needs care, training, or treatment because
  of the mental illness or serious emotional
  disturbance, AND
• 4. All available less drastic alternatives to
  placement in a hospital or treatment resource are
  unsuitable to meet the needs of the person

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Substantial Likelihood of Serious Harm

• TCA Section 33-6-501
• If and Only If
• (1)(A) A person has threatened or attempted
  suicide or to inflict serious bodily harm on
  himself, OR
• (B) The person has threatened or attempted
  homicide or other violent behavior, OR
• (C) The person has placed others in reasonable
  fear of violent behavior and serious physical
  hart to them, OR
• (D) The person is unable to avoid severe
  impairment or injury from specific risks, AND
• (2) There is a substantial likelihood that such
  harm will occur unless the person is placed under
  involuntary treatment.
• Then
• (3) The person poses a substantial likelihood of
  serious harm for purposes of Title 33.

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Examples of Key Indicators for Certificate of
Need Completion

• 1. Is mentally ill as shown by the following
  facts and reasoning
• - active symptoms of psychiatric disorder
• - previous psychiatric diagnosis
• - previous psychiatric hospitalizations
• - previous prescription of psychotropic
  medications
• - reported or clinically suspected substance
  dependence
• - reported history of behaviors clinically
  indicative of a psychiatric disorder

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Examples of Key Indicators for Certificate of
Need Completion Cont.

• Poses an immediate substantial likelihood of
  serious harm because of the mental illness as
  shown by the following facts and reasoning
• - clinical depression with suicidal attempt by
  overdose
• - threatening to kill wife due to paranoid
  delusions that she was poisoning food
• - entered neighborhood grocery threatening
  revenge on former co-workers
• - walking in interstate traffic drinking toxic
  substances etc.
• Plus, clinical opinion/indicators that such harm
  will occur or re-occur unless the individual is
  placed under involuntary treatment.

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Examples of Key Indicators for Certificate of
Need Completion Cont.

• Needs care, training or treatment because of the
  mental illness
• - treatment likely to prove beneficial in
  symptom reduction
• - medication likely to prove beneficial in
  behavior control
• - condition is likely to further deteriorate
  without treatment

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Examples of Key Indicators for Certificate of
Need Completion Cont

• All available less drastic alternatives to
  hospital or treatment resources are unsuitable
  due to
• - adequate evaluation requires secure setting
• - inability to contract for safety
• - unable to resist impulses or control behavior
• - will not agree to respite suitable respite
  not available failed respite, etc.
• - unable to provide safe environment no support
  persons to provide or assist with supervision
• - present condition places self/others at too
  high a risk for injury

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Involuntary Commitment Process State of Tennessee
Continued

• Role of Mandatory Pre-screening Agent (MPA)
• Intersecting RoadsThe Law and TennCare

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Contracting for Safety

• Dont rely on the suicidal client to tell you
  that they will not harm themselves.
• Decision about intervention strategies should be
  based on thorough clinical evaluation.

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Taking Care of yourself and your Staff

• Critical Incident De-briefing
• De-briefing needs to occur quickly and in an
  environment that the individual feels safe to
  express their emotion.

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Presentation Sources

• Aguilera, D., 1998. Crisis Intervention Theory
  and Methodology, Eighth Edition
• American Psychiatric Association, 1994.
  Diagnostic and Statistical Manual of Mental
  Disorders, Fourth Edition
• Bureau of Justice Statistics Special Report.
  Washington, DC U.S. Department of Justice,
  Office of Justice Programs
• Harris, R., Vanderbilt School of Nursing, 9/01.
  Diagnostic Interview Assessment of Thought
  Disorders
• Hersen, M. Turner, S., 1994. Diagnostic
  Interviewing, Second Edition
• Hoff, L., 1995. People in Crisis Understanding
  and Helping, Fourth Edition
• American Psychiatric Assoction, 2009, Practice
  Guidelines for the Assessment and Treatment of
  Patients with Suicidal Behaviors
• American Association of Suicidology, May 2010

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Questions/Comments
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For more information

• Contact
• Amanda Myatt, LCSW
• Director of Emergency Psychiatric Services
• Mental Health Cooperative
• Direct office number 744-7442
• E-mail amyatt_at_mhc-tn.org
• 24/7 crisis line 726-0125