Presentation on theme: "Crisis Management: Suicide Risk Assessment A Guide for Mental Health Professionals By: Jesus Quiroga."— Presentation transcript:
1 Crisis Management: Suicide Risk Assessment A Guide for Mental Health Professionals By: Jesus Quiroga
2 Presentation Overview Overview of Suicide PrevalencePurpose of Crisis ManagementDefinition of a CrisisCrisis PreventionIdentifying a Crisis /Symptoms of a CrisisCrisis InterventionSafety ContractsProper Utilization of ResourcesCrisis ResolutionCrisis Follow-upCrisis Assessment & DocumentationInterviewing SkillsMental Status ExaminationLevel of Risk
3 Age-adjusted suicide rates among all persons by state -- United States, 2001 Rates per 100,000 population0.0 to 9.09.1 to 10.610.7 to 13.213.3 to 21.7Source: Centers for Disease Control and Prevention (CDC) mortality data
4 Suicide in Texas, by County, 1989-1998 (CDC) El Paso
11 Purpose of Crisis Management The goal of Crisis Management is to recognize early warning signs and symptoms in a person and prevent the situation from deteriorating into a crisis or worsening into an emergency situation.Safeguard yourself and provide a blanket of security for the consumer and others involved.Utilize effective Crisis Prevention strategies that encourage a collaborative partnership with the consumer and available community resources.Use de-escalation techniques and other reactive measures to ensure safetyTo bring the consumer to pre-crisis level of functioning.
12 What is a Crisis ? Self-Limiting, State of Disequilibrium A crisis is not the precipitating event but the individual’s inability to cope with a situationA person's thoughts and feelings are beyond their control.A sudden deterioration in emotional or mental stateExpression of suicidal thoughts or actionsPotential of a serious risk to themselves or othersExpression of irrational and bizarre thoughts and behaviors that indicate they have completely lost touch with reality, i.e. hallucinations and/or delusions that potentially lead to dangerous situations
13 Crisis Prevention Knowing yourself Knowing your consumer Proper and timely assessmentsProviding medically appropriate services as per UM Guidelines (what is authorized in PIP)ConsistencyAppropriate & gentle confrontationReferrals to community outreach programs/resourcesCrisis planningAttention to needsIf you can anticipate it you can intervene and prevent the crisis from exacerbating
14 Impending Crisis Subtle Attitude and Behavioral Changes (non-specific) Complaining about having to take medicationsSaying medication is not working or is not neededSkipping or forgetting to take doses of medicationMissing scheduled appointments with mental health professionals, non-adherenceDoing less than usual during the day / low energy levelsMaking too many changes at once (i.e., moving, changing jobs frequently, etc.)Subtle changes in eating and sleepingTrouble concentrating / focusingIncrease in smoking/ drinkingPacing uncontrollablyChange in affectPrevention of Deterioration to More Severe SymptomsMental Health Professional should encourage the consumer’s family/friends to track these changes daily (in writing)These changes in attitude and behavior should be discussed with the consumer’s treating physicianThe Mental Health Professional should work with the consumer and his/her family or friends on developing a crisis plan.
15 Symptoms of a Mental Health Crisis These more severe and persistent symptoms can include (but not limited to):Talk or plans of suicide/homicideAbuse of alcohol or drugsDramatic mood swingsStaying awake/asleep for periods exceeding 24 hoursComplete withdrawal from activities / loved onesBizarre behaviorUncontrollable anger / fits of rageParanoia/suspiciousObvious change in affectInternally stimulatedChanges in attitude apparentRefuses treatment / medicationsImpaired Judgment / Poor insightWhen the symptoms of mental illnesses become so severe that the individual is unable to manage basic self-care such as eating, bathing or dressing selfJudge the severity of the consumer’s reactions, not the “seriousness” of the event
16 More Severe SymptomsSignificant impairment in judgment that results in dangerous behaviorWalking the streets alone late at nightGetting into cars with strangersAggression / ViolenceSexually acting outGets verbally agitatedYelling or cursing at people / ridicules peopleOverreacts to frustrations that are usually handled calmlyExpresses paranoia directed at family, friends, or othersAccuses a family member or other person of poisoning their foodAccuses a family member of controlling their mindAccuses a family member of putting thoughts into their headStates that a neighbor is breaking in at night and stealing thingsAccuses a friend of being a spy or working with the CIAStates that a person is planning to kill them
17 The Continuum A crisis can be seen as a process Not an isolated event but a process that has a build-up, peak, de-escalation phase, and resolutionA crisis may take a few hours or encompass several days even weeks
18 Why Does a Mental Health Crisis Occur? A mental health crisis can occur for a variety of reasons and can be connected with life events which have become overwhelming:Bereavement / Death of a loved oneNon-adherence to medications or treatment (consumers)Prolonged periods of stress and anxietySevere DepressionAiling health or chronic illnessDivorce / Marital conflictFamilial problems / Discord with a friendTrauma (past and/or present)Alcohol/Drug abuse (dependency)A mental health crisis can still arise despite full adherence to medications or treatment.
19 Comorbidity and Suicide Risk In general, the more diagnoses present, the higherthe risk of suicide.Psychological Autopsy of 229 Suicides44% had 2 or more Axis I diagnoses31% had Axis I and Axis II diagnoses50% had Axis I and at least one Axis III diagnosisOnly 12 % had an Axis I diagnosis with no comorbidity
20 RISK FACTORS Demographic male; widowed, divorced, single; increases with age; whitePsychosociallack of social support; unemployment; drop in socio-economic status; firearm accessPsychiatricpsychiatric diagnosis; comorbidityPhysical Illnessmalignant neoplasms; HIV/AIDS; peptic ulcer disease; hemodialysis; systemic lupus erthematosis; pain syndromes; functional impairment; diseases of nervous systemPsychological Dimensionshopelessness; psychic pain/anxiety; psychological turmoil; decreased self-esteem; fragile narcissism & perfectionismBehavioral Dimensionsimpulsivity; aggression; severe anxiety; panic attacks; agitation; intoxication; prior suicide attemptCognitive Dimensionsthought constriction; polarized thinkingChildhood Traumasexual/physical abuse; neglect; parental lossGenetic & Familialfamily history of suicide, mental illness, or abuse
21 Areas to Evaluate in Suicide Assessment PsychiatricIllnessesComorbidity, Affective Disorders, Alcohol / Substance Abuse, Schizophrenia, Cluster B Personality disorders.HistoryPrior suicide attempts, aborted attempts or self harm; Medical diagnoses, Family history of suicide / attempts / mental illnessIndividual strengths /vulnerabilitiesCoping skills; personality traits; past responses to stress; capacity for reality testing; tolerance of psychological painPsychosocial situationAcute and chronic stressors; changes in status; quality of support; religious beliefsSuicidality and SymptomsPast and present suicidal ideation, plans, behaviors, intent; methods; hopelessness, anhedonia, anxiety symptoms; reasons for living; associated substance use; homicidal ideationAdapted from APA guidelines, part A, p. 4
22 Psychiatric Examination DETERMINATION OF RISKPsychiatric ExaminationRiskFactorsProtectiveFactorsSpecific SuicideInquiryModifiable RiskFactorsRisk Level:Low, Med., High
23 Family History/Genetics Relatives of suicidal subjects have a four-fold increased risk compared to relatives of non-suicidal subjects.Twin studies indicate a higher concordance of suicidal behavior between identical rather than fraternal twins.Adoption studies: a greater risk of suicide among biologic rather than adoptive relatives.Suicide appears to be an independent, inheritable risk factor.
24 Psychosocial: Life Stressors Recent severe, stressful life events associated with suicide in vulnerable individualsStressors include interpersonal loss or conflict, economic problems, legal problems, and movingHigh risk stressor: humiliating events, e.g., financial ruin associated with scandal, being arrested or being fired can lead to impulsive suicide.Identify stressor in context of personality strength, vulnerabilities, illness, and support system.
25 Family Psychopathology Family history of abuse, violence, or other self-destructive behaviors place individuals at increased risk for suicidal behaviorsHistory of childhood physical abuse and sexual abuse, as well as parental neglect and separations, may be correlated with a variety of self-destructive behaviors in adulthood
26 Components of Suicidal Ideation Intent:Subjective expectation and desire for a self-destructive act to end in death.Lethality:Objective danger to life associated with a suicide method or action. Lethality is distinct from and may not always coincide with an individual’s expectation of what is medically dangerous.Degree of ambivalence - wish to live, wish to dieIntensity, frequencyRehearsal/availability of methodPresence/absence of suicide noteDeterrents (e.g. family, religion, positive therapeutic relationship, positive support system - including work)Remember to read the suicide note and document that you read it.Beck et al. (1979)
27 Components of a Suicidal Plan Risk / Rescue Issues:MethodTimePlaceAvailable Means and AccessArranging Sequence of EventsJacobs (1998)
28 Protective FactorsChildren in the home, except among those with postpartum psychosisPregnancyDeterrent religious beliefsLife satisfactionReality testing abilityPositive coping skillsPositive social supportPositive therapeutic relationship
29 Suicide SUICIDE: A MULTI-FACTORIAL EVENT Psychiatric Illness Co-morbidityPersonality Disorder/TraitsNeurobiologyImpulsivenessSubstance Use/AbuseHopelessnessSevere MedicalIllnessSuicideFamily HistoryAccess To WeaponsPsychodynamics/Psychological VulnerabilityLife StressorsSuicidalBehavior
30 Validate the Crisis VALIDATE feelings, not INSTRUCT on how to feel Remember that you are ignorant of another person’s experienceShow understanding of the current situation / eventAcknowledge their reactionsAssist in reviewing their optionsProvide emotional supportProvide empathy / compassion
31 Approach: Establish Rapport Sometimes in our business: You begin to see clients as “different” than yourself:Consider the person’s experience age, educational level, developmental stage, and cultureUse language appropriate / contextualWatch body language / facial gesturesEncourage discussionBe objectiveKeep composureSet Limits / gently confrontBe genuine—If you’re being fake, a consumer will knowBe patient—watch the momentum of your assessment and the pace of your questionsOtherwise resolution will not be long term / efficacious
32 Crisis Intervention: Cautionary Probing Gauge the severity of the behavior and amount of insight into realityIf the consumer’s sense of reality allows, ask ample but not an overwhelming amount of open-ended questionsGet as much collateral information as possible (weigh possible ulterior motives from family members or possible exploitation)Be careful about the established relationship (do not rely on rapport)Balance information from the past and the current situationAssess the direction of your questions (do not ask leading questions)Do not aggravate open wounds (deviate as you see visual cues of agitation)
33 Communication Skills Normalizations Assists in expression of emotions Decreases feelings of isolationPre-normalizationA lot of the people who struggle with _________ report feeling a sense of shame. Has that been going on for you?ExamplesIt’s normal to feel angry sometimesIt’s not uncommon to feel angry
34 Interviewing Skills Open Questions Generates dialogue and discussion Assists in gathering information important to the person you are speaking withExamplesTell me more about your situationWho in you life can you turn to for support?How has this affected your life?
35 Interviewing Skills Closed Questions Helps gather specific information Used to clarifyExamplesDo you want to talk about it?Have you told anyone about this?
36 Interviewing Skills Paraphrases Summarizes and clarifies Contains feelings and contentExamplesSo what I’m hearing you say is that you didn’t get the response you wanted from social services.Am I correct in saying that you’re sad because ex-partner is moving?
37 Interviewing Skills Questions to Avoid “Why” Questions Leading QuestionsMultiple Questions
38 There are many listening models this is just a basic outline of the stages. What models do you use?Ask how they would establish rapport?What does a helper focus on concern?How do you support a caller or client?How do manage the end of the call?How can you prevent circular calls?
39 Crisis Intervention: Safety Ensure the safety of yourself, the consumer, and othersClear the area of other non-essential people and ensure privacy if you canLocate / remove potential hazards in the roomNote exits, phones, and where others are locatedApproach the person in a non-threatening and calm manner – they are likely to be very confused and frightenedAttempt to reassure the individual
40 Crisis Intervention: Prevent Escalation De-escalate:Prevent escalation –emotion turns into adrenalineYOU must be calm under very trying circumstancesAllow time to pass (cool off)Sometimes de-escalation is not an optionAuthorities (911) must be involved for safety reasonsIf you are uncertain that this is the correct course of action, then call a supervisorMost Importantly: LISTEN
41 Intervention: Control Emotions Stay calmYou must be aware of your own thoughts, reactions, feelings, and behaviorsAvoid directives with upset consumers such as:“calm down”, “you shouldn’t feel so angry”, “relax”Modeling is more effective:Demonstrate a calm even tone, even breathing, and sympathetic voice, keeping calm at all timesAvoid non-verbal behaviors that suggest frustration, condescension, or agitation on your part
42 Crisis Intervention: Reality Orientation Your role is to assist consumers in gaining a more realistic perspective on emotional state and the precipitating event.While listening to a consumer, clarify feelings and relate them to specific causative factors.If the consumer is still feeling incapable of coping, point out how reactions / negative thinking are exacerbating the problem.
43 Crisis Intervention: Course of Action Clarify ProblemsDevelop AlternativesAgree on a Course of ActionUtilize Family members / friends if appropriateEncourage linkages with otherIndividuals / FamilyAgencies / ProfessionalsEvaluate severity of risk
44 Crisis Intervention: Evaluate Severity of Risk Ask questions that relate to risk factors for lethality:Asking questions that can determine if hospitalization is a medically necessary alternative or if a lesser restrictive option is the most suitable and clinically appropriate course of actionFIDO:FrequencyIntensityDurationObjective PlanGo with your clinical gut
45 Crisis Intervention: Safety Contract Safety plans and no-harm contractsFirst order of business:How will your consumer stay safe?Who will help the consumer in a crisis?Who will they call once a crisis begins?What will they do if crisis erupts?Where will they go in a crisis?These plans are not for us they are for the consumerThe consumer needs to show ownership by collaborating, signing, and keeping a copy of the contractConsistent review of the plan is necessary to ensure progress
46 Crisis Intervention: Safety Contract Part of the plan should include follow-up phone calls and sessions with the primary professionalIf the plan was successful, encourage the consumer during other sessions to keep up with strategiesEnsure accountability
47 Suicide or Safety Contract Problems:Commonly used, but no studies demonstrating ability to reduce suicide.Not a legal document, whether signed or not.Used pro-forma, without evaluation by psychiatrist.Possibilities:Useful when there is positive therapeutic relationship (do not use when covering for colleague).If employed, outline terms in patient’s record.Useful when they emphasize availability of clinician.Rejection of contracts have significance.Bottom line – still considered within standard of care
48 Crisis Intervention: Final Analysis You’ve assessed risk and you have discovered:The consumer is in danger and not able to stay in the community. Follow Crisis/ Intake procedures, follow-up with supervisor.OrThe consumer has de-escalated within a clinically reasonable amount of time and able to return home.
49 Crisis Unresolved Hospitalization is necessary: Imminent danger to self / othersHas a plan to execute threats to self / otherSeveral courses of actionHave consumer assessed further by an M.D. or Licensed CounselorCall 911 if an individual is in immediate danger or If medical emergency arises prior / during crisisRefer Police to EPMHMR Intake for determination / appropriateness for admission to inpatient treatmentCall EPMHMR Crisis Line (915) (24hours,365 day) for Mobile Outreach to assess consumer ( as appropriate)Staff must provide on-going crisis interventionComplete an Emergency Detention form by any AdultCoordination between, Police, EMS (if involved) EPMHMR Crisis/Intake, El Paso Psychiatric Center (or identified hospital)
50 Crisis ResolutionConsumer has demonstrated without question that they are not a threat to self or another personDe-escalation has lasted for an appropriate length of time, to be determined by the severity of the event crisis and the consumer’s ability to gain control of emotions and actionsMedication has been administered and the above has been demonstratedAn M.D. or licensed professional has deemed consumer safe to go home and does not recommend inpatient treatmentConsumer is sent home (if available with family) or to a temporary respite where safety is assured
51 Crisis Resolution: Follow-Up Establish open communication to Prevent Future Incidents:All treatment team providers should be notified of incident or crisis situationSupervisorCase ManagerRehab WorkerDoctor (if appropriate)Family member (if appropriate)Document all actions and interventions
52 Crisis Resolution: Preventing Recidivism Follow-Up session within 24 working hoursTrag Assessment and Provider Implementation Plan (PIP) or treatment planShould be revised and amended as appropriate as consumer’s needs have possibly changedFrequency of sessions and treatment objectives may need to be reviewedFamily members and all treatment team members should be involved in any revisionsModifications to medication can be adjusted as clinically deemed by a medical professional
53 What to Document in a Crisis Assessment The risk levelThe basis for the risk levelThe treatment plan for reducing the riskExample:This 62 y.o., recently separated man is experiencing his first episode of major depressive disorder. In spite of his denial of current suicidal ideation, he is at moderate to high risk for suicide, because of his serious suicide attempt and his continued anxiety and hopelessness. The plan is to hospitalize with suicide precautions and medications
54 Mental Status Exam, What is it? The mental status examination (MSE) is based on your observation of the client.It is not related to the facts of the client’s situation but to the way the person acts, talks, and looks while in your presence.This can be an abbreviated process or one that takes place over several interviews..The MSE always has the same content, and you write your observations in roughly the same order each time.Use descriptions and whenever possible use direct quotes.
55 What to Observe: General appearance Behavior Thought process and contentAffectImpulse controlInsightCognitive functioningIntelligenceReality testingSuicidal or homicidal ideationjudgment
56 Orientation and Level of Consciousness Lethargy: trouble remaining alert and appears to want to drift of to sleepOriented x3: knows who they are, where they are, and when it isAsk for the current date: reasonably accurate dates are acceptableAsk where the person isAsk who the person is and or DOB
57 Insight and JudgmentInsight is having a realistic understanding of a situation. For example, a person with poor insight into their drinking problem may genuinely believe that there is no problem and their behavior is appropriate.Judgment is the ability to critically evaluate the situation and make good decisions about a course of action.
58 AppearanceAlways indicate when you this is present. It involves such things as body odor, looking disheveled, or an unkempt appearance. Would include dirty, stained, or rumpled clothing.
59 Attitude and Interpersonal Style Always note hostility, aggressiveness, rudeness, uncooperativeness, sarcasmAlways note if a person is uncooperative.Always note boundary violations. This occurs if the person is too friendly, touches you, or attempts to draw you out personally
60 Behavior and Psychomotor Activity Always indicate any mannerisms you see and any posturing.Always indicate tension, particularly if the person seems tense and the interview does nothing to relax the person. This can include tensed fist, or an otherwise stiff posture.Always note severe akathisia (restlessness). It can be part of an illness, a sign of withdrawal, or a medication side effect. Try to establish when it started, how long it has gone on, and if it has gotten worse.
61 Behaviors and Psychomotor Activities Always note:PacingFidgetingNail bitingtrembling or tremulousnessRockingBouncingGrimacing (particular strange facial movements)
62 Tardive Dyskinesia:Occurs when psychiatric patients have been on antipsychotic medications over a long period of time.The term literally means “late appearing abnormal movements”Involves the muscles of the face, mouth, and tongue. Sometimes the trunk and limbs are also affectedMovements can be quick or slow.All the movements are brief, involuntary, and purposeless.A person may twist the tongue and lips, make odd faces, bounce or tap the feet, or actually writhe and squirm in the seat.
63 Catatonic BehaviorA sign of severe depression or schizophrenia, catatonic type.Generally appears as a rigidity of posture where attempts to reposition the person are rigidly resisted.The person may pose in bizarre and inappropriate ways.One form, waxy flexibility, is when the limbs of the person will remain in the position in which they are placed.
64 Speech and LanguagePressured: often rapid but constantly talking; cannot be interrupted. Thoughts appear to be racing.Monotonous: no variation in toneEmotional: very expressiveAccented: note a native accent and also if the patient seems to accent certain words or syllablesImpoverished: may say very little either because of depression or because they are being interviewed in a language other than the native tongue. May indicate some lack of facility with language.Neologisms: Made up words with idiosyncratic meanings. This can happen with because of brain injury due to accident or stroke.
65 AphasiaLoss of ability to understand and produce language; damage usually to left hemisphere of the brain (left-handed people often have this in the right hemisphere).Global: can neither speak nor understandBroca’s aphasia: can understand written and spoken language, but has trouble expressing own thoughts verballyWernicke’s aphasia: inability to understand language and uses fluent, bizarre, nonsensical speech. The person may also act strange and appear euphoric, paranoid, or agitated. Note: In schizophrenia the person is usually able to write and speak, repeat words, and name objects.Perservation: repeating a verbal or motor response to a prior stimulus even when confronted with something new. May give the same answer to different questions, stay on the same topic, or repeatedly return to the same subject
66 Mood Euthymic: normal mood Expansive: feels very good and is getting betterEuphoric: giddy and happyAnxious: worried and distressed
67 Sleep Disturbance Initial insomnia: trouble falling asleep Middle insomnia: waking up in the middle of the nightTerminal insomnia: early morning wakening. Depressed individuals will often wake several hours earlier than usual and feel most depressed in the mornings.Hypersomnia: sleeping too much.
68 MemoryShort term memory: immediate recall limited to about seven items and generally lasts for about one minute.Long-term memoryAmnesia: inability to rememberAnterograde amnesia: cannot learn NEW materialRetrograde amnesia: cannot recall recent past events
69 Memory Testing As if they have had problems with memory. Test immediate recall using a random list of digits asking the person to repeat them. Start with two and keep adding digits until two consecutive failures.Test recent memory by asking them what happened in the last few hours or days before coming to see you.Test remote memory by asking the client to recall events in their lives and commonly known public events that happened in years past.
70 Thought ContentDistortions: a person distorts a part of reality. A woman with anorexia believes she is fat when she is thin.Delusions: an inappropriate idea from which a person cannot be dissuaded using the normal means of argument or evidence. Delusions indicate psychosis.Paranoid delusions: being singled out for harassment or are being controlled by forces outside of themselves.
71 Disordered Perceptions Illusions: the person either misperceives or misinterprets a sensory stimulus. A tree branch brushing the side of the house in the winds sounds like people entering the house or a fan sounds like people talking in another room.Hallucinations: in the absence of external stimuli, the person perceives something. The most common hallucination is hearing voices but there can be visual or hallucinations that are smells. If the person hears voices try to determine who is talking, what they are saying, how the person feels about it, and is there a command to do something.Depersonalizations: the person feels estranged or detached from self.Derealization: the person feels detached from what is going on around them. A person who dissociates cannot always be sure that what is happening is real.
72 Delusions Common to Schizophrenia Thought withdrawal: one’s thoughts are being taken out of one’s mind by an outside forceThought insertion: thoughts are being placed into the mindThought broadcast: thoughts are being taken and broadcast so that others knowSuspiciousness: always describe this and report the object of the suspicionGrandiose delusions: false belief that one is extremely important or imbued with special powers.Somatic delusions: false beliefs about healthMagical thinking: thinks they have magical powers with words, thoughts, or actions. This thinking is found in children who have not developed reality testing.
73 ReliabilityBriefly state you impression of the clients’ reliability and accuracy in giving you the details of their situation.If a person is psychotic, the material presented is likely to be extremely unreliable.
74 Debriefing Utilization of Peers for Debriefing Prevention of Secondary Trauma
75 Intake & Crisis Emergency Services 24 Hours, 7 Days a week, 365 a Year 1600 MontanaEl Paso, TX 79902(915) Crisis HotlineArray of Services:Crisis HotlineMobile Crisis Outreach (E.R. Based)Mobile Crisis Outreach (Community Based)Walk-In Crisis Services (Site Based)Walk-In Outpatient Services (Site Based)Remote Walk-In Services (RV) (Tele-Psychiatry)Crisis Follow-Up
76 Open Forum for Questions Thank YouOpen Forum for Questions