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Assessment and Management of Suicide Risk May 24, 2007 Melissa J. Pence, Psy.D. Licensed Clinical Psychologist Hampton Roads Neuropsychology and Behavioral.

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Presentation on theme: "Assessment and Management of Suicide Risk May 24, 2007 Melissa J. Pence, Psy.D. Licensed Clinical Psychologist Hampton Roads Neuropsychology and Behavioral."— Presentation transcript:

1 Assessment and Management of Suicide Risk May 24, 2007 Melissa J. Pence, Psy.D. Licensed Clinical Psychologist Hampton Roads Neuropsychology and Behavioral Medicine

2 Outline 1.Impact 2.Demographics and epidemiology 3.Etiology 4.Risk assessment 5.Psychological Testing 6.Treatment and prevention 7.Medical-legal concerns

3 A personal account of the impact of suicide " His light, through me, will grow as a beacon for others." John C. Gibbs

4 Survivors of Suicide (Schneidman, 1969) Suicide Victim Survivor

5 Suicide Definition of suicide: “Suicide is the death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows will produce this result.” Emile Durkheim Requires: 1.Death/lethal outcome 2.Self-inflicted 3.Intentionally inflicted 4.Awareness or consciousness of outcome

6 Problems in studying suicide Low base rate No test (biological or psychological) or clinical marker that predicts suicide Requires clinical judgment Numerous false positives in prediction paradigms High risk suicidal patients excluded from most clinical studies

7 Demographics and Epidemiology A MAJOR Public Health Problem!

8 How is this data gathered? Death certificate information reported by each state to the National Center for Health Statistics Most recent national data available is 2003 Numbers are generally understood to be a modest underestimation of actual suicide deaths due to difficulties in conclusively determining cause of death

9 U.S. National Statistics (2003) (CDC) 31,484 deaths by suicide 86 deaths per day 1 every 17 minutes 11 th leading cause of death Approximately 787,000 attempts, ratio 25:1 Twice as many people die by suicide than by homicide


11 Statistics (2003) (CDC) Number Per Day* Rate% of DeathsGroup (Number of Suicides)Rate Nation31,48486.310.81.3White Male (22,830)19.5 Males25,20369.017.62.1White Female (5,655)4.7 Females6,28117.24.30.5Nonwhite Male (2,373)9.1 Whites28,48578.012.11.4Nonwhite Female (626)2.2 Nonwhites2,9998.25.50.9Black Male (1,597)8.8 Blacks1,9555.45.10.7Black Female (358)1.8 Elderly (65+ yrs.) 5,24814.414.60.3Hispanic (2,007)5.0 Young (15-24 yrs.) 3,98810.99.711.9Native American (322)10.4 Asian/Pacific Islander (722)5.5


13 State by State Rate Comparisons

14 Firearms are the Leading Method of Suicide (2003) Suicide Methods: NumberRate Percent of Total NumberRatePercent of Total Firearm suicides16,9075.853.7% All but Firearms 14,5775.046.3% Suffocation/Hanging6,6352.321.1%Poisoning5,4621.917.3% Cut/Pierce5710.21.8%Drowning3390.11.2%

15 Data on Means of Suicide (2001)

16 Youth Suicide Rates 3 rd leading cause of death in those aged 15-24, behind only accidents and homicide. 2 nd leading cause of death in college students. 6 th leading cause of death in 5-14 year olds. Ratios of attempts to completions estimated to range between 100:1 to 200:1 In 2001, firearms were used in 54% of youth suicides.

17 Youth Suicide In 1999, 20% of HS students reported seriously considering suicide and 8% attempted. Frequent drug and alcohol abuse was found to be the most common characteristic in young people who attempted suicide (Department of Education)

18 Youth Statistics (2003) Age Group Number of Suicides Suicide Rate 10-14 yrs244 1.2 15-19 yrs 1,4877.3 20-24 yrs2,501 12.1

19 Suicide in the Elderly –Higher Completion rates (1:4) over age 65. –Medical illness a significant factor in 70% of suicides over age 70. –Most saw a physician within a few months of their death and 1/3 within the previous week. –Rate of suicide is 14.8 per 100,000 when compared to 10.8 per 100,000 in general population.

20 Male Suicide Rates 8 th leading cause of death (2003) 4 times more likely to die by suicide than females 60% of suicides involve the use of a firearm Rates are relatively constant between ages 20-64, but increase sharply after age 65.

21 Female Suicide Rates Women attempt suicide twice as often as men. Some studies suggest the rate is closer to 3:1. One woman attempts suicide every 78 seconds in the U.S. Rates peak between the ages of 45-54 (around time of menopause) and again after age 75.


23 Breakdown by Race Caucasians are over 2x more likely to complete suicide than African Americans (AA). AA males comprised 84% of suicide deaths in that racial group. Firearms predominant method among AAs, regardless of gender. American Indian and Alaskan native men have the 2 nd highest rate of suicide after Caucasians.


25 Etiology Cognitive Psychology Diathesis- Stress Model Neurobiology


27 Familial and Genetic Factors There is a transmission of familial and genetic factors that contribute to risk for suicidal behavior. Major psychiatric illnesses, such as MDD, schizophrenia, and alcoholism have genetic component in etiology.

28 Familial and Genetic Factors Several studies have found genetic and familial transmission risk is independent of transmission of psychiatric illness. First degree relatives of individuals (including dizygotic twins) who have completed suicide have more than 2x the risk of the general population. –For monozygotic twins, risk increases to 11x. (Quin, Agenbo, & Mortensen, 2002) Recent study could not find genetic effect on suicidal ideation. (Farmer et al, 2001)

29 Studies on the Serotonergic System Difficult area to study, numerous methodological problems. There is evidence of modest reductions in in brain stem/prefrontal cortex serotonin or its marker 5-HIAA (metabolite). Lower CSF (cerebral spinal fluid) 5-HIAA levels has been reported by most studies in patients with a history of suicide attempt and a diagnosis of MDD, Schizophrenia, or PD compared to control groups of patients with these diagnoses.

30 Serotonergic system, continued Low CSF 5-HIAA level predicts higher rate of past and future suicidal acts as well as seriousness of suicidal acts over the lifetime. PET scans can map serotonin-induced changes in brain activity. –Size of abnormality in anterior cingulate and prefrontal cortex is proportional to lethality. (Oquendo et al., 2003)

31 Noradrenergic System Reduced noradrenergic functioning is suggested, however the evidence is not as strong as in the serotonergic system. The conclusion: there is a period of noradrenergic over-activity (which may be a stress response and state dependent) prior to suicide which contributes to NE depletion.

32 The Diathesis- Stress Model Proposed by Zubin and Spring (1977) An individual has unique biological, psychological and social elements. These elements include strengths and vulnerabilities for dealing with stress.

33 The Diathesis-Stress Model

34 Beck’s Cognitive Model (1967) Schema: tacit beliefs and memory structures that serve to organize the encoding, retrieving, and processing of information –Latent much of the time –May be activated by specific life events –Develop from an early age –Reinforced and consolidated by life events Schema of depressed individuals thought to be rigid, negativistic toward self and others, future is bleak, lack control over outcomes.

35 Beck’s Cognitive Model, Continued Cognitive distortions most frequently associated with suicidal ideation: –Cognitive constriction or tunnel vision –Polarized or all or nothing thinking –Selective recall of past failure and overlooking past success These are believed to play a role in development and maintenance of dysfunctional attitudes and irrational beliefs.


37 What is a Suicide Risk Assessment? “Refers to the establishment of a clinical judgment of risk in the very near future, based on the weighing of a very large mass of available clinical detail.” “More than a guess or intuition- it is a reasoned, inductive proceess.” “A necessary exercise in estimating probability over short periods.” From Jacobs, 2003

38 Who should receive a suicide assessment? ANY patient who meets criteria for DSM-IV mental or substance use disorder(s). Should initially occur at the point of entry into treatment (i.e. initial visit or intake) and periodically as clinically indicated. If the patient meets criteria for a depressive disorder and/or manifests any degree of suicide lethality, they should be assessed each session.

39 Two Components of Assessment PART 1: The elicitation and elaboration of suicidal ideation PART 2: The identification and qualification of risk factors for completed suicide

40 Part 1: Assessing Suicidal Ideation Begin with general questions about self-harm, such as asking whether the patient has had thoughts of death or suicide. Ask them to elaborate in their own words and describe what these thoughts are like. Use open ended questions. Thoughts should be characterized as active (“When I am walking, I get the impulse to jump out into traffic”) or passive (“Everyone would be better of if I was dead”).

41 Assessing Suicidal Ideation, Continued If suicidal thoughts are present, assess how often and in what context they occur. Are they fleeting, periodic, or persistent? Are the situation specific? Are they increasing or decreasing in intensity?

42 Assessing Suicidal Ideation, Continued The patient should be asked if they have a plan, or if they have thought of a means in which they would use to carry out suicide. –Method (availability, lethality) –Suicide notes, final acts in preparation for death (i.e. will preparation) –Has mental rehearsal taken place? Is there a plan for a time or place? –Have any attempts been made thus far?

43 Assessing Suicidal Ideation, Continued History of similar thoughts, impulses, plans, aborted attempts and/or attempts should be obtained. Corroborating report from family or providers should be obtained (if possible).

44 Assessing Suicidal Ideation, Continued –Confidentiality can legally be broken to obtain appropriate care if you have evidence to suggest the patient is acutely a danger to himself or others. Usually necessary information can be obtained by simply listening to the family members and it may not be necessary to reveal private or confidential information to the family. However, in some situations you may be obligated to break confidentiality to protect the patient. Remain sensitive to family issues and disclose necessary information to protect the patient. Helps to discuss this during informed consent at the beginning of the process.

45 Assessing Suicidal Ideation, Continued Determine if there are any barriers to suicide. –What are the patient’s reasons for living and reasons for dying? –How has the patient managed to evade the act of suicide thus far? Assess level of current supports (family, significant other, friends, employer, therapist, etc.)

46 Part 2: Assessing Risk Factors

47 “Risk Factor” Defined Leading to or being associated with suicide Individuals possessing the risk factor are at greater potential for suicidal behavior Some risk factors can be changed or reduced (i.e. providing Lithium treatment for Bipolar Disorder), others are static (The patient’s father completed suicide) From Suicide Prevention Resource Center,

48 Presence of a mental disorder Present in over 90% of completed suicides. High risk diagnoses are: –Depression (unipolar and bipolar) –Alcohol/substance abuse or dependence –Schizophrenia –Borderline Personality Disorder

49 Co-morbidity increases risk! Psychological autopsy studies of 229 suicides: –44% had 2 or more Axis I diagnoses –31% had Axis I and Axis II diagnoses –50% had Axis I and at least one Axis III diagnosis –12% had an Axis I diagnosis with no co-morbidity From Henriksson et al, 1993

50 Recent psychiatric hospitalization Within the last year Acute exacerbation of illness

51 The presence of depression Including hopelessness, guilt, loss Global insomnia Note: Hopelessness has been found to be co-occurring with depression as well as a predictor of suicidal ideation and behavior.

52 Recent or impending loss –Loss of job –Loss of relationship –Loss of loved one, grief –Recent move (CDC, 2002) –Humiliating events, such as financial ruin due to a scandal, being arrested or being fired, can lead to impulsive suicide (Hirschfeld and Davidson, 1998)

53 Substance or alcohol use Up to 50% of those completing suicide drinking alcohol at time of death. Drinking within three hours of the attempt was the most important alcohol-related risk factor for nearly lethal suicide attempts, more important than alcoholism and binge drinking. (CDC, 2002) –CNS depressants increase risk. (Wines et al, 2004)

54 History History of impulsive or dangerous behavior, and/or history of suicide attempts –Severe self-mutilation –A history of serious suicide attempts may be the best single predictor of completed suicide; the greatest risk occurs within 3 months of the first attempt. –HOWEVER, the majority of suicides are in individuals with no prior attempts.

55 Access to firearms 92% of suicide attempts by firearm are successful Keeping firearms in the home increases the risk of suicide for both genders even after other factors, such as depression and alcohol use, are controlled for.

56 Family history of suicide First degree relatives = more than 2x the risk of the general population –For monozygotic twins, risk = 11x.

57 Social isolation or withdrawal Having a strong preference for being alone (change from previous behavior) Withdrawing from family, social, or volunteer activities Not keeping appointments

58 Concurrent medical disorder Characterized by: chronicity, poor prognosis, disfigurement and/or persistent pain.

59 Medical illness, continued Diagnoses most associated with completed suicide: –Huntington’s Chorea –Malignant Neoplasms –Multiple Sclerosis –Renal disease –Peptic Ulcers –Spinal Cord injuries –Lupus –HIV/AIDS –Epilepsy (only medical diagnosis documented to increase risk in children and adolescents)

60 Severe agitation/anxiety Panic attacks, severe psychic anxiety, and global insomnia all significantly associated with suicide at one year follow up. (NIMH) Behavioral signs: pacing, wringing hands, rocking, severe restlessness, etc. Assess for treatment responsive acute risk factors, such as askathsia.

61 From Jacobs (2003), Harvard Medical School

62 Depression: Unipolar and Bipolar The lifetime risk for suicide in patients with mood disorders (major depressive disorder and bipolar disorder) is approximately 15-19%, and the risk is highest in the early stages of the illness.

63 Major Depression Factors to consider: –The concurrent presence of anxiety –Substance abuse or dependence –Command hallucinations –Irritability or anger associated with impulsivity –Severe insomnia, especially global insomnia –Presence of or access to a gun (Jones et al, 2000)

64 Bipolar Disorder (Goodwin & Jamison, 1990) Risks: –Severe depression with anxiety, agitation –Global insomnia –Substance abuse –Transition periods/early recovery phase –Impulsive or violent behavior

65 Bipolar Disorder, continued –Assess current mood: Typically rates < 2% during psychotic mania (Dilsaver, 1997) 11% directly after remission from mania (Goodwin, 2002) Approximately 79% during major depressive episode (Goodwin, 2002) 11% during mixed state (Goodwin, 2002)

66 Alcohol/Substance Abuse or Dependence The suicide risk among patients suffering from alcoholism is similar to that in patients with mood disorders, but they tend to commit suicide late in the course of alcoholism and are frequently depressed at the time of death. Two factors affecting risk (Weiss & Hufford, 1999) 1.Effects of acute intoxication 2.Co-morbid psychopathology such as MDD Risk with recent or anticipated interpersonal loss

67 Schizophrenia (Tsuang, Fleming, & Simpson, 1999) Risk Factors for suicide in psychotic patients: –Young age (<30) #1 cause of death for young people Dx with Schizophrenia –Good intellectual functioning –Disillusion with treatment –Good premorbid functioning –Early stage of illness –Communication of intent –Frequent exacerbations and remissions –Painful awareness of the likely degree of chronic disability in the future –Periods of clinical improvement following relapse –Supervention of a depressive episode and increased hopelessness

68 Timeline of Risk

69 Borderline Personality Disorder Most likely associated with parasuicidal rather than suicidal acts: –HOWEVER approximately 8.5% of patients eventually commit suicide, usually after multiple attempts or gestures. –Nearly 75% of patients make one attempt in lifetime. –With alcohol problems=19% –Per Stone (1993) with alcohol + major affective D/O=38% –Usually qualify for a co-morbid Axis I diagnosis at the time of death. Hx of childhood sexual abuse increases the amount and lethality of parasuicidal behaviors.

70 Identify Chronic vs. Acute Risk Acute: –New, acute presentation –Presence of significant stressor –Emergent response to acute crisis of mood and despair –Possible co-morbid Axis I disorder Chronic: –Recurrent and persistent suicidal thoughts that provide an ongoing psychological mechanism for coping with distress –Frequent, usual response to life stresses and disappointments –Patient may be aware of chronicity

71 Protective Factors Protective factors are believed to enhance resilience and serve to counterbalance risk factors. –An individual's genetic/neurobiological make-up –Attitudinal/behavioral characteristics –Family/community support –Effective and appropriate clinical care for mental, physical and substance abuse disorders –Pregnancy or children in the home, except for post-partum illness

72 Protective Factors, continued –Easy access to effective clinical interventions and support –Restricted access to highly lethal methods of suicide –Cultural and religious beliefs that discourage suicide and support self- preservation instincts –Support from ongoing medical/mental health care, positive therapeutic relationship –Acquisition of learned skills for problem solving, conflict resolution and non-violent management of disputes.

73 Prevention and Treatment Strategies Therapeutic Treatment Strategies No Suicide Contracts Pharmcotherapy Hospitalization

74 Prevention/Treatment Strategies ASSESS, ASSESS, ASSESS –Assess acute vs. chronic risk 24 hour access to crisis care Strong therapeutic alliance is ESSENTIAL! Work with family and other support systems Use multiple resources, multidisciplinary approach

75 Access to Services Crisis services by phone –National Hotline 1(800) 273-TALK Emergency Department

76 Prevention/Treatment Strategies Short term coping strategies, behavioral treatments –Deep breathing –Relaxation training –Imagery training –Grounding Specific, concrete, written safety plan in place and frequently renewed and reviewed –Access to means removed immediately

77 Dialectical Behavioral Therapy (Linehan, 1993) Developed by Linehan for patients Dx w/ BPD and engaging in self-harm behaviors Philosophical orientation focuses on dialectics –Move from dichotomous thinking to balance Patients learn to observe and describe, be non-judgmental and focus on the present, and focus on current activity

78 What is a no-suicide contract? Also known as no-harm contract or safety contract. Involves an agreement in which a patient makes a verbal or written promise not to harm or kill themselves. Commonly used by mental health practitioners, including: psychiatrists, psychologists, nurses, social workers, and therapists.

79 No-Suicide Contracts Usually Contain An explicit statement not to harm or kill oneself. A specific duration of time. Contingency plans if contract conditions cannot be kept.


81 No Suicide Contracts When the patient doesn’t agree…. If the patient can not or will not agree to the terms of the negotiated contract or if non-verbal/historical cues contradict the agreement, he/she is usually considered to be at- risk. In the presence of a strong therapeutic alliance when manipulative behavior is suspected, this should be further explored.

82 History of NSCs First documentation in 1973 in study by Drye, Goulding, & Goulding. Surveyed 31 counselors reporting on 609 patients, 266 of whom were judged “seriously suicidal”. 24 suicides or serious attempts were reported where their method for assessment was NOT used and 4 deaths occurred where their method was used. Method= When counselor became aware of SI, asked client to repeat, “No matter what happens, I will not kill myself, accidentally or on purpose, at any time” (p.172) Then client discussed his/her reaction to the statement. Objections or alterations were deemed at risk.

83 No Suicide Contracts: Potential Pitfalls

84 Pitfall #1 BELIEVING THAT A SIGNED SUICIDE CONTRACT ELIMINATES SUICIDE RISK –Suicide cannot be absolutely predicted- False sense of security. –There is no data demonstrating its effectiveness or its acceptance in the professional community. (Drew, 2001) –In one study, 41 percent of psychiatrists had patients who committed suicide or made serious attempts after entering into a NSC. (Kroll, 2000)

85 Pitfall #2 CONTRACT: THE LEGAL TERM –Clinicians may wish to consider avoiding the word “contract” in their medical documentation. –The term may also appear to attempt to free the clinician from blame for suicide attempts/completions. –Appropriate clinical assessment and intervention, rather than liability prevention, should be the focus of care. Outcomes of legal cases and judgments about clinician’s care are improved by demonstration of comprehensive assessment and treatment.

86 Pitfall #3 INFORMED CONSENT??? –Informed consent is a legal and ethical doctrine involving the disclosure of risks, alternatives, and facts that allow a patient to make informed and unpressured decisions about treatment options. –The competency of a patient to understand what they are signing or to give informed consent to such an agreement during a time of crisis is in question.

87 Who may or may not be capable of giving informed consent? DiagnosisCited in… Cerebral ImpairmentDrye et al (1973) PsychosisGoulding (1979) Egan (1997) Under the influence of drugs/alcohol Goulding (1979) Egan (1997) Impulse control deficiencies Davidson et al (1995) Motto (1979) Severe DepressionEgan (1997) Simon (1999)

88 Informed Consent: Farrow & O’Brien (2003) VERY limited data in this area Their study concluded that most patients interviewed were not able to participate in informed consent for a NSC at the time of suicidal crisis. In retrospect, most subjects doubted their competence to enter a NSC at the time of crisis. “My thinking was so confused. I did not understand what they were suggesting.” Participants reported a strong sense of being coerced by clinician.

89 Pitfall #4 A safeguard against liability??? –A NSC may be used as a means to reduce the evaluator or therapist’s anxiety regarding litigation. –Frequently charted phrases or shorthand such as “contracted for safety” should be avoided without appropriate ancillary documentation (suicide risk assessment, basis for clinical judgment, plan for managing risk.) –Providers may believe that securing a NSC completes an assessment of suicidality, this is short sighted and legally precarious. Range et al, 2000, Stanford et al, 1994, Weiss, 2001, Miller, 1999, Miller et al, 1998, Lee & Bartlett, 2005

90 No Suicide Contracts: Potential Benefits

91 Benefits 1.A means of evaluating current suicidality –One part of a comprehensive suicide risk evaluation. –Opportunity to discuss suicidal feelings directly. 2.Provision of specific behavioral alternatives to suicidal acts. –Written behavioral plan for patient in a crisis situation 3.An adjunct to comprehensive evaluation and treatment –In the context of a sound and positive therapeutic relationship –The more concrete, the better! (i.e. written vs. oral, specific behavioral strategies tailored to the patient’s needs)

92 Bottom line about NSCs –Use NSCs with caution, understanding that they are one part of a comprehensive suicide risk assessment and treatment plan and have not been demonstrated in the literature to reduce suicide risk.

93 Pharmcotherapy There are reasons to believe that selective serotonin reuptake inhibitors (SSRIs) might reduce suicidality. SSRIs remain the preferred psychopharmacological treatment for depression. Lithium has a strong, and possibly unique protective effect against suicidal acts in patients with bipolar disorder. ( Baldessarini & Tondo, 1999)

94 Pharmcotherapy Patients being treated with psychotropic medication should be closely observed for clinical worsening: –Agitation, irritability, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases.

95 From Jacobs (2003) Harvard Medical School

96 Medical-legal Concerns

97 Litigation Bereaved survivors have a unique grief, often feeling hurt, angry, and possibly guilty. May seek compensation for their loss through a claim of negligence. Number of lawsuits continues to rise. Hospitals are the primary target, however there has been an increase in number of claims against outpatient providers.

98 A Shift in the Law (Gutheil, 2000) Before 1940: Suicide was considered an independent intervening cause of death After 1940: But for the provider or physician’s negligence, the patient would not have committed suicide (negligence as a proximate cause)

99 Medical-legal Concerns The law recognizes that there are no standards for the prediction of suicide and that suicide results from a complicated array of factors. The standard of care for patients with suicidality is based on the concept of "foreseeability" Courts assume that a suicide is preventable if it is foreseeable.

100 Medical- Legal Concerns (Lee & Bartlett, 2005) Forseeability is defined as “A comprehensive and reasonable assessment of risk” Reasonable care involves “Developing a comprehensive treatment plan and timely implementation based on the assessment of risk, or forseeability” Failure to assess risk and make sound judgments makes the provider a possible target of litigation.

101 Risk Management Realistically, a clinician is not always able to prevent a suicide in a determined patient. Common themes identified in liability suits include: –lack of an ongoing, documented assessment of suicide risk, especially prior to hospital discharge, a change in privileges, or a change in clinical status, –lack of documentation to reflect a clinical rationale regarding treatment decisions, and –inadequate patient supervision.

102 Documentation In the case of a lawsuit, the chart will be examined. Although most lawsuits arise over inpatients who commit suicide, documentation of encounters with all suicidal patients should include: –Risk assessment –Contacts with family members –Contacts with other treatment providers –Phone calls, letters –Responses to failed appointments –Non-compliance with treatment

103 Risk Management: Key Points (Lee & Bartlett, 2005) Keep abreast of current legal and ethical standards Develop and implement a policy for handling crisis situations –24 hour availability of services –Increasing frequency or duration of sessions –Bring in supportive family/friends –Refer where appropriate for multidisciplinary Tx –Follow up for compliance and disposition –Monitor medication allocation, access, and use –Establish check-in system with the client

104 Risk Management: Key Points (Lee & Bartlett, 2005) Maintain clinical competency (continuing education, supervision, consultation) Ensure accurate and thorough documentation Develop relevant resources, such as a network to consult with, community programs, etc.

105 Postvention Immediately provide support to the family Consider attending funeral or writing letter of condolence –Serves both humanitarian and risk management goals Care for yourself –Understand your feelings (guilt, grief, anger, fear, etc.) –Discuss/consult/debrief with trusted colleague or supervisor

106 Provider self-care Caring for suicidal patients can be very taxing- emotionally and physically! Remember to care for yourself: –Eat a balanced nutritional diet, get adequate sleep, exercise –Seek personal counseling formally or informally –Consult appropriately with colleagues and supervisors May wish to share personal emotional reactions, burnout, and counter-transference issues (Shea, 2002)

107 Questions or comments….

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