Suicide Training

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Suicide Training

• COMMUNITY BIBLE CHURCH
• APRIL 3, 2009

• CENTER FOR HEALTH CARE SERVCIES
• AARON V. DIAZ, LCSW-ACP, Director of Jail
  Diversion and Crisis Services adiaz_at_chcsbc.org
• JEANIE PARADISE, LPC, Clinical Director of Crisis
  Services jparadise_at_chcsbc.org

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Definition of Crisis

• Short-term state, self-limiting 
• State of disequilibrium - loss of balance in
  life, psychological immobility 

• The event or situation is seen as intolerable or
  unsolvable because it exceeds the customary
  coping or problem-solving strategies

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Coping

• Coping involves adjusting one's thoughts,
  feelings and behaviors in response to events,
  including changing the environment if necessary.

• Coping can be adaptive or maladaptive leading to
  healthy or unhealthy side-effects.

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Questions

• What would influence a persons susceptibility to
  crisis?

• What leads to one outcome of crisis instead of
  another?

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Communication Skills

• Helper Characteristics Explain?
• Genuine
• Empathetic
• Non-judgmental
• Empowering
• Am I being GENE?

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Communication Skills

• Normalizations
• Assists in expression of emotions
• Decreases feelings of isolation
• Pre-normalization

• Examples
• Its normal to feel angry sometimes
• Its not uncommon to feel angry

A lot of the people who struggle with _________
report feeling a sense of shame. Has that been
going on for you?
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Communication Skills

• Validations
• Gives person permission to experience feelings

Examples
Its okay to be angry Thats a valid
feeling Theres nothing wrong with being upset
sometimes
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Conditions that may lead to Depression

• Recent loss
• Intense stress causing chronic fatigue
• Loneliness and rejection
• Hopelessness
• Alcohol and drugs
• Post Partum depression following childbirth

• Aging
• Glandular disorders
• Physical injury
• Post operative
• Retirement
• Divorce
• Displacement

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LISTEN FOR DEPRESSION

• Voice Quality, flat, without expression or manic
  and agitated
• You will hear statements such as

I cant control my life. Im no good. I
cant deal with. I just want to be alone.
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Crisis Callers ? Suicidal at Follow Up
BASELINE SUICIDAL THOUGHTS
TOLD COUNSELOR
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Suicide in Texas, by County, 1989-1998 (CDC)
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Rate of Suicide, Texas vs. US, 2004
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Texas Suicides, 2004
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Suicide Risk Assessment Guidelines

• When?
• Early in the call this is your most important
  task once initial engagement is established
• At mention of suicide ideation
• If the caller has initiated self-harm behavior
  recently
• At indication of acute psychiatric symptoms or
  warning signs, increased environmental stress, or
  worsening
• At mention of an anticipated event that is
  similar to a one that triggered earlier
  suicidality
• At times of social context transition or
  significant stress (impending or recent loss,
  threat of public humiliation or shame, )

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Suicide Risk Assessment Guidelines

• A caveat
• Verbalized suicidal ideation, while a cardinal
  indicator heightening risk for potential, overt
  suicidal behavior, is neither a necessary nor a
  sufficient condition for the assessment of risk
  for that behavior. Asking about suicidal
  thoughts, however, is absolutely necessary.

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Eliciting Suicide Ideation and Plans
Normalization

• When people are feeling as extremely upset as you
  are, it is not unusual for them to have thoughts
  of killing themselves

• Wanting to hurt themselves
• Wanting to end their pain
• Of suicide
• Of Id rather be dead

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Unfounded Belief

• Introducing the idea of suicide by asking a
  caller if they are thinking about suicide will
  give them the idea to kill themselves and
  increases the chance that they might act in a
  suicidal way

• Avoiding the topic says that you are not really
  listening, you are not very empathic, you dont
  want me to open up to you

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Dealing with Denied Ideation
Youve told me that you arent thinking of
suicide and that you really dont want to die,
but all that youve told me about your behavior
over the last several weeks suggests otherwise
(describe what has been reported and what you
pick up nonverbally)It almost seems like youre
telling me two different things. I need for you
to help me make some sense of this
contradiction
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Tips to Decrease Callers Reluctance to Discuss
Suicide

• Be direct
• Notice hesitancy
• Do not accept first no
• Appear unhurried and comfortable talking about
  suicide
• Peel the onion to understand

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Eliciting Suicide Ideation and Plans Behavioral
Incident

• Ask for specific facts, details, trains of
  thought
• Recreate actions taken, step by step, so that
  they can be visualized

• How Many pills did you take?
• What did you do next?
• Where did you point the gun?
• How and where did you cut yourself?

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Suicidal Behaviors

• A caveat
• We can neither predict that suicidal behavior
  will occur nor differentiate which outcome
  behavior may result even if we assess risk for
  that behavior.

• Completed Suicide
• Non-fatal suicidal behaviors
• Repetitive or single episode
• Low lethality (gestures) to high lethality
• Suicide ideation

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Verbalized Ideation

• Im thinking of ending it all
• No one can help me. Whats the use?
• I wish I were dead
• If I wasnt around, no one would miss me
• I wont be needing these things any more
• Im a loser. I cant do anything right
• Life is not worth living
• I just want to go to sleep forever
• If I killed myself, then people will be sorry
• My family will be better off without me

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Suicide Ideation Cues

• I think Im going to have to eat my gun
• Ive decided to take the spirit trail
• If someone dies by suicide, do they still go to
  heaven?
• I gave my cats to my neighborI cant take them
  where Im going
• I need to tell Dr. Jones that he was a wonderful
  doctor, but that I wont need any more
  appointments.

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Red Flags

• I Ideation/threatened or communicated
• S Substance Abuse/excessive or increased
• P Purposeless/no reasons for living
• A Anxiety, Agitation/Insomnia
• T Trapped/feeling no way out
• H Hopelessness
• W Withdrawal from friends, family, society
• A Anger (uncontrolled) /rage/seeking revenge
• R Recklessness/risky acts - unthinking
• M Mood changes (dramatic)

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Mental Status Affective System

• Anger/rage
• Dysphoria
• Guilt
• Anxiety, tension, panic states
• Fearfulness
• Loneliness
• Shame ( perfectionism)
• Humiliation
• Suspiciousness
• Psychic pain
• Burdensomeness

• Risk increases if following affect states are
  poorly controlled, intense or severe, and/or not
  tolerated

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Mental Status Cognitions

• Hopelessness about self, future, others
• SI with intent to die
• SI with plan
• With specific, accessible and lethal means
• e.g. firearm at home
• With low likelihood of rescue
• With preparations or rehearsal

• SI with evidence of impulsivity, acute
  intoxication
• SI that is intense, vivid, persistent,
  uncontrollable
• Suspiciousness, paranoia

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Mental Status Behavioral Activation/Arousal

• Agitation, intense restlessness
• Insomnia
• Panic, impaired attention/concentration
• Unconstrained aggressive behavior, rage
• Binge drinking or excessive intoxication
• Impulsivity

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Suicide Methods

• The most important variable to consider when
  assessing the possibility that suicide risk might
  turn into suicide action is the availability and
  accessibility of a lethal method.

• Approximately one in four nearly-lethal suicide
  attempts occurred on impulse

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Lethality

• Medical/biological danger to life, i.e. the
  potential for death associated with the means
  used to attempt suicide
• The more lethal the method, the less likely is
  survival

• Case fatality rates
• High Lethality firearms, jumping from heights or
  in front of train, hanging, suffocation, CO,
  drowning
• Low lethality wrist cutting, ingestion of other
  gases, some drug ODs and poisonings

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Lethality

• Context or circumstances mitigate outcome
• Low rescuability, e.g., DO NOT DISTURB vs.
• Expectations of intervention, e.g., OD in front
  of others
• Communicated warnings

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Lethality Drug ODs

• Lag time between oral ingestion and death varies
• Change of mind (intent)
• Rescue
• Knowledge varies
• Teens grossly misunderstand lethality of
  acetaminophen
• Toxicity varies by body weight and dosage

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Triggers (Precipitants)

• Acute stressors (in the context of vulnerability)
• Real/threatened losses of valued/desired
  attachments
• Acute disappointments
• Threat of legal action/incarceration

• Embarrassments, humiliations, threat to
  status/ego
• Threat of/actual loss of job/financial loss
• Chronic health problems with pain, deterioration,
  stigmatization, cognitive impairment, dependency
  (males), debilitation

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Precipitating risk factors

• Loss of social support (friends, family)
• Loss of identity/meaning (job, career)
• Acute psychiatric symptoms (psychosis,
  depression, panic)
• Loss of hope/Sense of failure
• Availability of means
• Anniversary reaction

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Risk Factors for Suicidal Behavior

• Perpetuating risk factors
• Family history (violence, suicide, mental
  disorder (requiring hospitalization)
• History of psychiatric hospitalization
• Early history of abuse
• Skill deficits (social, cognitive)
• Multiple/chronic personal losses
• Prior suicide attempt

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Risk Factors for Suicidal Behavior

• Predisposing risk factors
• Poor self-esteem/Self-concept
• Current psychiatric illness
• Chemical dependency
• Significant medical illness
• Exposure to suicidal behavior
• Impulsivity/aggressivity
• Social isolation or marginalization

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Risk Factors for Suicidal Behavior

• Mental Disorders
• Impair resilience
• Amplify distress
• Impair coping
• Decrease protections
• Retrospectively diagnosed in 90 of completed
  suicides

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Prior History of Suicidal Behavior

• The Aftermath of Suicide Attempts
• No further attempt 66
• Further attempt(s) 33
• New attempt within 1 year 10-20
• Completed suicide within 1 year 1-2
• Completed suicide (lifetime) 10-15
• Fremouw, dePerczel, Ellis (1990)

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Prior History of Suicidal Behavior

• Risk increases if,
• Past attempt is recent
• Multiple past attempts, especially if one was of
  high lethality
• Outcome of past attempt was not a positive , e.
  g, positive therapeutic experience

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Risk Increases in Cases of

• Recent inpatient psychiatric hospitalization and
  discharge
• History of developmental trauma, e.g., abuse,
  neglect, family violence, early bullying

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Protective Factors

• Self-esteem positive attitudes toward self
• Personal control confidence in cope-ability
• Internal (e.g., religiosity) and external
  constraints (e.g., family, children)

• Coping strategies cognitive/behavioral
  repertoires problem-solving skills
• Support availability/
• accessibility
• Support Usability help receptivity
  communication, feelings of integration.

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Lethality Assessment

• Suicidal Desire
• Ideation hurting self and/or others
• Psychological pain
• Hopelessness
• Helplessness
• Perceived burden on others
• Feeling trapped

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Lethality Assessment

• Suicidal Capability
• History of suicide attempts
• History of/current violence to others
• Available means of hurting self/other
• Currently intoxicated
• Acute symptoms of mental illness
• Recent dramatic mood change
• Out of touch with reality
• Extreme agitation/Rage
• Increased anxiety
• Decreased sleep
• Recent acts and/or threats of aggression

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Lethality Assessment

• Suicidal Intent
• Plan or attempt in progress
• Plan to hurt self/other (e.g., method known)
• Preparatory behaviors
• ideation with intent to be dead as we know it
  (includes concepts of afterlife, rebirth...) 

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Rules of Thumb

• An attempt in progress is an emergency
• Assess for lethality and need for active
  intervention
• Acute suicide risk may require an active
  intervention or emergency referral
• Some degree of acute risk in the context of
  chronic risk translates into at least a need for
  more in depth evaluation

• Anticipated or actual loss of attachment of
  significance in context of acute risk should be
  referred for evaluation
• Protective factors do not counteract acute risk
• Ideation alone does not translate into acute risk
• The absence of ideation in the context of other
  acute risk factors still means that there is
  moderate or greater risk

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Lethality Assessment

• Absence of Buffers, Disconnectedness
• Perceived lack of immediate supports
• Perceived lack of social supports
• Lack of plans for the future
• Lack of engagement with crisis telephone worker
• Lack of ambivalence for living
• Lack of core values or beliefs
• Lack of a sense of purpose

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How to Follow Up

• Assess how they are doing now. 
• Review the time that has passed since the crisis
  contact.
• Define the Crisis', but this time in order to
  understand their post-crisis state. 

• Evaluate the action plan developed during the
  crisis contact.
• For example Did they follow the plan?
• How did it work? 
• Did the client have to adapt the plan?