Suicide Lethality Assessment for I&R

Suicide Lethality Assessment for I&R
Suicide Risk Assessment and Intervention for I&R Specialists AIRS 31st Annual I&R Training and Education Conference “Mining for I&R Excellence” Reno, NV Monday June 1, 2009 Part 1 – 1:00 – 2:30 PM Part 2 – 3:15 – 3:45 PM Suicide Lethality Assessment for I&R John Plonski Database/Training Coordinator Covenant House International President NYS AIRS Janice M. Harris MA, CIRS 2-1-1 Service Coordinator Community Service Council of Greater Tulsa

Your Presenters Janice M. Harris MA, CIRS 2-1-1 Service Coordinator Community Service Council of Greater Tulsa John Plonski Database/Training Coordinator Covenant House International President NYS AIRS At this point if the group is manageable we can ask them to identify themselves…briefly…I like to do this because it gets them used to talking.

What are we going to do today?
Suicide Lethality Assessment for I&R What are we going to do today? This workshop intends to provide I&R workers a basic understanding of crisis intervention that will enable them to assess immediacy of danger to the person at risk of suicide: Identify the person at risk of suicide Enable the caller to talk about and work through their feelings to facilitate assessment, problem-solving, and appropriate coping and referral De-escalate and stabilize suicidal callers Maintain contact with the caller pending referral or rescue and to follow through with any referrals given

Kevin In September 2000, Kevin Hines took a leap off the Golden Gate Bridge. A few minutes before that he got off the bus, went onto the span, and stood there crying.

Kevin He encountered several people on his way to the rail.
Bridge Workers Bikers Joggers Policemen on Bikes

Kevin He said to himself, “If just one person, just one, comes up to me and asks me if I need help, I’ll tell them everything.” One woman asked him to take her picture.

Kevin Not one person asked him what was wrong so he took a running leap over the rail into the water. As soon as he left the bridge, Kevin thought, “I don’t want to die.”

Your thoughts about…. Kevin The people Kevin met on the bridge Any other people who may have been in Kevin’s life Suicide facts and myths

USA, 2005 Pop. 295,895,897 Reported suicides: 32,657 Unreported suicides: 5% to 25% more suicides Non-fatal suicidal behaviors: 40 to 100 times greater than number of suicides Number of people affected: Each suicidal behavior may affect a few or a very large number People with thoughts of suicide: 5% of the population: 14,794,794

Ok. If you say so. Where do we start?
Suicide Lethality Assessment for I&R Ok. If you say so. Where do we start? Let’s begin by talking about assumptions we can make about the person who is not in “Crisis”. They are relatively “normal”. They have basic coping skills. They have ways to cope with day to day problems. Remember normal has several contexts. As it relates to Crisis Intervention people are a product of three affects. Their: Thoughts Feelings Behaviors

You said something about “coping skills”. What’s that about?
Suicide Lethality Assessment for I&R You said something about “coping skills”. What’s that about? As individuals, when things go wrong, we each have our own ways of problem-solving or coping. While we may not actually think about it, we have three levels of resources we use to respond to stress and fix stuff. They are: Primary Resources Secondary Resources Tertiary (AKA Adaptive/Maladaptive Resources) Actually, problem-solving devices and coping strategies are two ways to say pretty much the same thing. As individuals, when things go wrong, we each have our own ways of problem-solving or coping. While we may not actually think about it, we have three levels of resources we use to fix stuff. They are: Primary Resources Secondary Resources Adaptive/Maladaptive Resources (AKA. Tertiary)

Adaptive/Maladaptive Resources Secondary Resources Primary Resources

Based on what you now know about coping we would like to ask you a question… Is suicide a crisis?

A suicidal person like any person in crisis is faced with an intolerable life issue for which they are seeking a solution. The suicidal activity is not, in itself, a crisis. In essence it is a maladaptive coping response. Suicidal activity is both a means for resolving a situation and a method of communicating the intense feelings of hopelessness and helplessness surrounding it as well as emotional pain. A suicidal person like any person in crisis is, by definition, a person faced with an intolerable life issue for which they are seeking a solution. In working with the Suicidal Caller we must remember that the suicidal activity is not, in itself, a crisis. In essence suicidal activity is a maladaptive coping response. Suicidal activity is both a means for resolving a situation and a method of communicating the intense feelings of hopelessness and helplessness surrounding it.

However, it can be difficult to identify the person at risk of suicide. As a society we are generally suicide denying. Suicide is something we see as something a person shouldn’t do. Some may see the act as a weakness. Some may cite religious reasons forbidding the act. In any case there exists a societal taboo making it difficult for the person at risk to state their intention openly.

This means the I&R worker will need to be aware of clues a person may be at risk. Nearly everyone at some time in their lives thinks about suicide. Most decide to live because they come to realize that the situation is temporary but death isn’t. Some will openly state their wish to die. However, most offer invitations (clues) as to their intent hoping the listener will interpret those clues and listen.

Clues to look for include:
Direct hints: “I just can’t take it anymore”, “ I want to escape”, “I want to go to sleep forever”, “They’ll be sorry when I’m gone.” “I can’t stand this pain anymore.” “Nothing will ever get better,” “My family would be better off if I were not around” Important losses include death, job, divorce or possessions. Behaviors changes such as withdrawal, not sleeping, excess drugs or alcohol. Changes in sexual behavior.

More clues to look for: Tone of voice very soft or loud, weak,
long pauses, sighs, depressed agitated Important losses include death, job, divorce or possessions. Behaviors changes such as withdrawal, not sleeping, excess drugs or alcohol. Changes in sexual behavior.

More clues to look for: Losses – actual, perceived, or threatened
Death of a significant other (this can include an idol, role model, or a pet), Breakup of a relationship, divorce or separation, Loss of a job or housing. Onset of illness for either the person or a significant other Anniversary of a loss Move to a new area Situation where a guardian is absent Onset of physical or emotional disabilities Important losses include death, job, divorce or possessions. Behaviors changes such as withdrawal, not sleeping, excess drugs or alcohol. Changes in sexual behavior.

More clues to look for: Behaviors – Extreme changes.
Have trouble eating or sleeping Withdraw from friends and/or social activities Lose interest in hobbies, work, school, etc. Write a will and making final arrangements Give away prized possessions Take unnecessary risks Be preoccupied with death and dying Lose interest in personal appearance Increase use of alcohol or drugs Important losses include death, job, divorce or possessions. Behaviors changes such as withdrawal, not sleeping, excess drugs or alcohol. Changes in sexual behavior.

Just a few more clues Feelings
Intense or long lasting painful ones: depressed, alone, hopeless, scared, confused, helpless, angry. The person at risk of suicide feels they can’t : Stop the pain Think clearly Make decisions See any way out Sleep eat or work Get out of the depression Make the sadness go away See a future without pain See themselves as worthwhile Seem to get control

Additional Factors in Assessing Suicidal Intent There many factors to consider when assessing whether a person is at risk of suicide. These factors are as follows: Changes Related to Loss or Threat of Loss Symptomatic Patterns Statistical Patterns Cultural Influences Physiological Changes Psycho-Sexual Changes 1. Any recent loss, illness, or an outbreak of symptoms makes a person a higher risk. 2. The anniversary of a loss may also trigger suicidal thoughts. Suicidal behavior can occur in many different psychological states. Many people who have completed suicide exhibited signs of severe long-term depression. Some of these signs are: Sleep disorders, Loss of appetite, Major weight change, Panic attacks, Changes in sexual activity (promiscuity or abstinence), Social withdrawal, Apathy, Despondency, and/or Physical and psychological exhaustion. The depressed individual may present themselves as feeling sad experiencing crying spells when alone or in the company of others. When we talk to the depressed person on the phone the person will sound lethargic, speaking in a slow labored manner. Conversely, the depressed person can sound agitated and restless citing their inability to contain the pressure of their feelings and anxieties. The presence of any or all of the symptoms in their severe form would indicate high lethality. Psychotic states when combined with suicidal ideation represent a highly lethal situation. Substance abuse is also connected to high suicidal risk. Note: If a person is considering consuming, or has consumed, any amount of drugs in an effort to suicide, that dosage is should be considered lethal. Statistical patterns can be a window into the level of risk. The elderly represent the highest suicide rate, followed by the age group. More females attempt suicide than males-males complete more suicides. Young people attempt suicide in the morning and late afternoon when there is a chance for them to be found and "rescued". Adult attempts happen in the very late night or early morning hours when there is little risk of discovery. Cultural influences: People can feel crushed by the effects and demands of society on their lives. Physiological changes from adolescence (puberty) to old age(menopause). Psycho-sexual changes: relationships, dating, first sexual experience, and own sexuality. Psycho-sexual changes are not limited to adolescents and can represent a suicide risk for adults. The aging process does produce psychosexual changes in persons over the age of 18.

Once the caller makes mention of ending their life, a basic suicide risk assessment should be done. (see handout) The worker should interact with the person at risk in a way to help the individual understand their ambivalence about their decision It is important to remember that the assessment process is fluid.

Immediacy/Lethality Assessment Protocols
Suicide Lethality Assessment for I&R Immediacy/Lethality Assessment Protocols An immediacy/lethality assessment is an evaluation based on determining how dangerous a situation is and addressing issues such as the person’s intent, method, timing and state of mind. Such an assessment is directly related, but not limited to assisting individuals who are: threatening suicide, homicide or assault; victims of domestic abuse or other forms of violence, child, adult or elder/dependent victims of abuse or neglect; people experiencing a psychiatric emergency; chemically dependent people in crisis;

A few general observations regarding Immediacy/Lethality assessment: Recognize that the person at risk may not directly announce their intent … they may use phrases or exhibit actions intended to invite you to ask them about their suicidal intent. If you suspect a person is considering suicide, ask them in a direct manner. If you think your caller may be considering suicide, don’t go it alone. Consult with supervision, support staff, and your peers. When Calling emergency services have another worker make the initial contact if possible.

An Important Point!!! If an individual tells you they are in the process of dying by suicide or the have taken any direct action to end their lives This is not an intervention this is an emergency – You should do whatever you can to get immediate emergency assistance to the individual as quickly as possible.

Our goal in working with the suicidal caller is twofold: 1. To assist the caller in focusing on the issue thus enabling them to communicate their feelings verbally instead of behaviorally; 2. To explore more adaptive resolutions to the precipitating issue presented.

In interacting with the suicidal caller we operate under the assumption that the Caller is ambivalent about their decision to suicide otherwise they would not be contacting us. This bestows upon us the moral right and responsibility to attempt to intervene. To effectively intervene with the Suicidal Caller we need to accomplish three tasks: 1. Establish a relationship (Connecting) Evaluate the suicidal potential (Understanding) 3. Formulate a plan and mobilize Resources (Assisting) Address use of Caller ambivalence in facilitating the interaction with the Caller.

Establishing a Relationship (Connecting)
Suicide Lethality Assessment for I&R Establishing a Relationship (Connecting) To establish a relationship with the person at risk: Present yourself as being patient, interested, self-assured, and knowledgeable. Be accepting, respectful, and empathic. Use your active listening skills Listen for suicidal clues If you hear clues address the issue of suicide

Establishing A Relationship
Suicide Lethality Assessment for I&R Establishing A Relationship Bring the issue of suicide up for open discussion. If the Caller shares anything that gives you the impression they are suicidal ask them, “Are you feeling suicidal?” Listen for, indicate, and support any messages from the Caller that reflect a reluctance to die (ambivalence). Stay calm and sound confident Avoid moralistic pronouncements about suicide. Shye01: I would like to share some more about what might give someone the impression that a caller is suicidal. That is the thing people fail at the most - picking up on cues from the caller and asking.… WARNING SIGNS FEELINGS EXPERIENCED BY A SUICIDAL PERSON Nearly everyone at some time in his or her life thinks about committing suicide. Most people decide to live because they come to realize that the crisis is temporary but death isn’t. On the other hand, people in the midst of a crisis often perceive their dilemma as inescapable and feel an utter loss of control. These are some of the feelings and things they experience: Can’t stop the pain Can’t think clearly Can’t make decisions Can’t see any way out Can’t sleep, eat, or work Can’t get out of the depression Can’t make the sadness go away Can’t see a future without pain Can’t see themselves as worthwhile Can’t get someone’s attention Can’t seem to get control

Evaluating the Suicidal Potential (Understanding)
Suicide Lethality Assessment for I&R Evaluating the Suicidal Potential (Understanding) This step of the assessment serves two purposes: It helps us to understand the danger the person at risk is in and the appropriate intervention we need to initiate or referral to make It helps the person at risk to understand the danger they are in as well as their ambivalence about dying

Evaluating the Suicidal Potential (Understanding)
Suicide Lethality Assessment for I&R Evaluating the Suicidal Potential (Understanding) You have two tasks in this step. To listen for, acknowledge, and point out the person at risk’s reasons for Living and for Dying. You will then use these reasons to point out the ambivalence indicated by the contradictory messages. The introduction of ambivalence will, often, push the individual towards a life affirming decision. To assess the actual risk the person is in

Evaluation of Suicide Potential The Worker needs to make an evaluation of the seriousness of the Caller’s suicidal intent. This evaluation will determine the best plan of intervention: Calling an ambulance; Engaging significant others; A referral to a mental health agency, etc. A Callers' degree of risk can be accurately determined using exploring the Caller’s: Current Plan Pain Resources + Prior Suicidal Behavior + Mental Health

Current Suicide Plan The inherent lethality of the proposed method; “How do you plan to kill yourself?” The availability of the means; “Where is the weapon, drugs or other implement that you plan to use?” The specificity of the plan; “What have you done to prepare to die?” The time frame of the plan; “When do you plan to die?” 1. Does the person have a specific detailed plan in mind? When will they carry out the plan? The more detailed the plan, the higher the danger. 2. Lethality of method. How lethal and irreversible is the proposed method? Pills, wrist cutting and gas take time, and their effects can be reversed. They are less lethal than gunshots, car crashes, or hanging. 3. How available are the means? The person who has a bottle of barbiturates is more lethal than the person who plans to shoot himself but has no gun available.

Assessing Pain Suicide is a maladaptive coping mechanism intended to relieve the pain of the hopelessness and helplessness precipitated by crisis. To assess that pain we need to ask, “ Do you have pain that at time feels unbearable?”

Assessing the Caller’s Resources Internal Resources; “What have you done to change things before you decided to attempt suicide? Do you think any of those things may work now?” External Resources; “Who have you talked to about what is going on for you? Is there anybody else you might consider?” Communication with their external resources; “Have you been able to talk with people who have helped you in the past? Or “How do you get along with people who have helped you in the past?” 1. Internal. How does the person see themselves? The person who sees themself as worthless or no good has fewer resources than the person who is reacting out of fear or panic. 2. External. Family, friends, work, clergy, social agencies, and so on. The person who is isolated from others has fewer resources to work with than the person who has some type of support system. 3. Communication. What links the person to her resources? This may prove useful in seeking short-term goals. The person who has been rejected by family, friends, and others, has fewer alternatives than the person who has isolated herself by choice.

+ Assessing Prior Suicidal Behavior Have there been previous attempts; “Have you attempted suicide before?” The previous method; “What were your previous attempts?” History of attempts by significant others; “Has anybody you know attempted suicide?” Response and treatment; “Following your previous attempts did you get help? How did that work out for you?” A person with previous attempts is a higher risk. 1. Method: Lethal or gesture. Did they actually try or did they talk about it and plan it? Has there been a tendency of escalation? 2. Response and treatment. What happens to a person after trying to commit suicide will often influence future behavior. (a) How did family, friends, and others treat them? (b) Did they get any relief through counseling, therapy, or other means?

+ Assessing Mental Health A mental health history can be a contributing factor in a person at risks suicidal ideation. “Are you receiving or have you received mental health care?”

Formulating a Safeplan and Mobilizing Resources
All Safeplans include: Keep Safe Safety Contacts Addressing limited use of alcohol or drugs Link to resources

Risk Specific Safeplans and Mobilizing Resources
Current Suicide Plan: Disable the plan Pain: Ease the pain Resources: Link to resources + Prior Suicidal behavior: Protect against the current danger and support past survival skills + Mental Health: Link to mental health worker

I&R and Suicide: General thoughts
Suicide Lethality Assessment for I&R I&R and Suicide: General thoughts Make contact at a feeling level. Be patient and listen carefully. Identify and reflect the Caller's feelings. Let the Caller tell their story in their own words and time. Be patient. Simply note any factual information about possible resources that the Caller may share (names, addresses, telephone numbers, etc.). You can clarify the particulars once openness and trust are established. Control your personal feelings of stress and anxiety by reflecting them to the Caller (Parallel Process). Avoid any sermons about suicide or policy.

Things To Avoid Don’t debate whether suicide is right or wrong.
Don’t moralize or judge the person’s feeling or situation. Don’t allow yourself to be sworn to secrecy. Don’t give advice.

Don’t minimize the caller’s pain or situation.
Avoid statements such as , “It could be worse”, “Don’t worry, things will get better.” Don’t avoid talking about suicide. Don’t take responsibility for “saving” the caller.

CRISIS DEFUSED Once the crisis has been defused, you can go to the next level: Explore existing supports: Does the caller have support from family or friends available? Assess coping skills: Has the inquirer faced similar situation in the past? How did they manage to cope before?

Prioritize: Work with the caller to identify the different aspects of their situation. Help them decide which issues need to be addressed immediately and/or are easiest to solve. For example, “You seem most concerned with ….so let’s start with that. Collaborate with the caller on finding resources. Help them be responsible for their decisions.

Referral searching: Explore all possible options
Referral searching: Explore all possible options. Re-explore options tried. Look for the most relevant resources and try to give the individual a number of options. Review sources and offer to transfer him/her to appropriate agencies.

Try to end call on a positive but realistic note.
Remind caller that they have started in the right direction by asking for help and that there will always be people trying to help. Review safe plan and check for understanding of the plan.

Formulating A Plan and Mobilizing Resources There are three possible scenarios in working with the suicidal individual: Suicide in progress Suicide attempt has not been initiated but high lethality is indicated Suicide attempt has not been initiated but low lethality is indicated The plan we formulate and the resources we mobilize is different in each instance

Suicide in Progress In reality the suicide in progress is an emergency situation as the Caller may not be able to, or may become unable to, participate in situational resolution. An immediate offer to dispatch assistance will be made. If the Caller declines assistance and their location is known assistance will be sent regardless of their desire. If they decline and their location is not known, work to build a trusting relationship focusing on their ambivalence as indicted by their call. Although we accept a strong stance against interfering in the lives of our Caller’s the suicide in progress call presents us with a unique set of circumstances that require deviation from this rule. We will not make a judgment against a person for deciding to take their own life. However, if an individual calls the hotline to discuss their intent to suicide we then become involved in their decision making process. Being involved in that process confers on us the moral and ethical obligation to prevent death. It is always our hope that though sensitive crisis intervention and support the Caller will make their own choice to live. However, if that is not the case, we will take what steps we can to prevent their death. In this matter the Caller has no choice. . .as an agency we will always opt for life in a suicidal situation. In reality the suicide in progress is an emergency situation as the Caller may not be able to, or may become unable to, participate in situational resolution. An immediate offer to dispatch assistance will be made. A refusal of assistance is not acceptable. If the Caller’s location can be determined help is to be sent with or without their permission. If the Caller declines such assistance, focus should be placed on establishing a trusting relationship with the Caller in the hope that the offer of help will be eventually accepted. If they decline and location not known do the focus on relationship focusing on the ambivalence indicted by their call

Suicide in Progress Do’s and Don’ts Do offer to call emergency services immediately Don’t instruct the Caller to call 911 unless you are instructed to do so by emergency services once you call them. Do get the Caller’s complete address, including apartment number and telephone number. Do conference the Caller with emergency services if they are unsure of their exact location. Do explain how the emergency process will work. Basically, both police and an ambulance will be dispatched to the Caller’s location. Explain that the purpose for the police presence (the need for their presence is usually frightening to the Caller) is to ensure the safety of the Caller and the emergency personnel as well as getting aid to the location as quickly as possible. The emergency services people will evaluate the situation and if warranted will transport the Caller to the hospital.

Suicide in Progress Do’s and Don’ts Do instruct the Caller to collect the containers of any substance they may have consumed to help those responding accurately assess what steps need to be taken. Do inform the emergency services people of any weapons the Caller may be planning to use in their suicide attempt. Do ask the emergency services people how they wish the issue of weapons handled. Do stay on the phone until the emergency services arrive. Do let the emergency services worker you contact talk to the caller. Many of these workers have training similar to yours and will work with the Caller until help arrives. To avoid confusion just listen to what is going on unless asked by the worker to join in. However, if something is said that confuses the situation you should interrupt to clarify.

Suicide Attempt Has Not Been Initiated but High Lethality Is Indicated In cases of high suicidal potential, efforts should be made to: Help the Caller engage resources in their own environment. Involve as many individuals as possible with the suicidal person. Offer to talk to or contact immediate family members. Encourage and facilitate contact with mental health professionals. Make efforts to guarantee that a person seriously contemplating suicide is not left alone or permitted an opportunity to act upon their plan. Before closing the call attempt to have the Caller eliminate the lethal means by encouraging them to flush pills down the toilet, give the gun to another, responsible person, etc. Enlist the aid of a responsible person in the Caller’s environment to carry this out.

Suicide Attempt Has Not Been Initiated but High Lethality Is Indicated In the case of very high lethality where the Caller doubts their ability to control their suicidal impulses and wishes help arrange for immediate professional intervention. Explain that the Caller can voluntarily present themselves at the emergency room of any hospital with a psychiatric component or at the admissions office of the state psychiatric hospital and ask to be evaluated. To alleviate apprehension call the nearest appropriate facility and ask for an explanation of their admission procedure. Engage the Caller in an exploration of what family members or friends might be available to help them negotiate this process.

Suicide Attempt Has Not Been Initiated but High Lethality Is Indicated Do’s and Don’ts Do listen for any input from the Caller that would indicate they have decided to initiate the suicide process. Do explore what significant others or caregiving professionals are most able to assist the Caller. Explain to the Caller we can contact immediate family members and professionals on their behalf. Do ask the Caller if there are responsible people at the location they are calling from and ask the Caller if you can talk to them about the situation you have been discussing. Do be candid with any person you talk to on behalf of the Caller. Explain the situation as the Caller has explained it to you, your concern about the situation, and invite the person to add any input they may have regarding the Caller.

Suicide Attempt Has Not Been Initiated but High Lethality Is Indicated Do’s and Don’ts Do contact the local hospital or mental health facility to find out what their emergency admission procedure is. Don’t promise that emergency services will transport the Caller. Generally, emergency services will only transport in cases of immediate life or death. Do have the Caller repeat to you, in their own words, the plan the two of you have developed. If there are any discrepancies point them out and then have the Caller repeat the plan again. Don’t insist the Caller dispose of or remove the means of their suicide until the end of the call. Doing so prematurely can interfere with the establishment of the openness and trust necessary in such situations.

Suicide Attempt Has Not Been Initiated and Low Lethality Is Indicated In a situation of less immediate danger, assistance of an outpatient nature can be offered. Make conference calls to appropriate agencies or treatment centers to make arrangements. Be candid with the resource about the suicidal element so the Caller can be seen without undue delay. Where suicide is an issue, many agencies will circumvent waiting lists. Refer to community resources that will allow the Caller to address the issue(s) that led them to consider suicide a problem-solving tool.

Suicide Attempt Has Not Been Initiated and Low Lethality Is Indicated Do’s and Don’ts Do listen for any escalation in lethality during the call and address any change with the Caller. Do make conference calls to agencies and advocate for the caller if there is any indication they do not have the ability or resources to do so. Do remind the Caller they can involve significant others in helping resolve their problems. Do have the Caller repeat to you, in their own words, the plan that the two of you have developed. If there are any discrepancies point them out and then have the Caller repeat the plan again.

Suicide Lethality Assessment for I&R

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