1. ZERO SUICIDE QUEST ASSESSMENT AND TREATMENT PROTOCOL

2. Suicide Risk Factors Mental disorders, mood disorders, schizo, anxiety disorders and certain personality disorders Alcohol/other substance use disorders Hopelessness Impulsive and/or aggressive tendencies Major physical illnesses Previous suicide attempts/Family Hx/Comm Hx Job, financial, relationship loss Access to lethal means Local clusters of suicide Lack of social support and sense of isolation Stigma associated with asking for help Lack of healthcare, especially MH and SA treatment Cultural and religious beliefs, that suicide is a noble resolution of a personal dilemma Exposure to others who have died by suicide (in real life or via media/internet)

3. Protective Factors Effective Clinical Care-MH, Medical, & SA Access to Clinical Interventions Restricted Access to Lethal Means Connections to Family/Community Support Support thru ongoing Medical, MH, & SA Rxs Non-Violent Problem Solving/Conflict Resolution Skills Cultural and Religious beliefs that discourage suicide and support self- preservation

4. *This chart is intended to represent a range of risk levels and interventions, not actual determinations. Risk Level Risk/Protective Factor SuicidalityInterventions HIGH Psychiatric Dxs w/severe symptoms or acute precipitating event: protective factors not relevant. Potentially lethal suicide attempt or persistent ideation w/strong intent or suicide rehearsal. Admission generally indicated unless a significant change reduces risk. Suicide precautions. MODERATE Multiple risk factors, few protective factors. Suicidal ideation w/plan, but no intent or behavior. Admission may be necessary depending on risk factors. Develop crisis plan. Give emergency/crisis numbers. LOW Modifiable risk factors, strong protective factors. Thoughts of death, no plan, intent, or behavior. Outpatient referral, symptom reduction. Give emergency/crisis numbers. SAMHSA’s Risk Level/Intervention Model

5. ZERO SUICIDE CULTURE Quest is creating a leadership driven, safety- oriented culture that is committed to dramatically reducing suicide. A vital part of the leadership and planning will be to seek input from those who have attempted suicide as well as input from loss survivors to guide policy and procedure. Organizational culture will focus on: safety of staff as well as persons served, opportunity for dialogue and improvement without blame, and deference to expertise instead of rank.

6. Reporting and Safety Plan Protocols CHILD: Threat of suicide or attempted suicide by a consumer under the age of 18 shall be reported to a guardian and a safety plan will be developed to ensure the safety of the child. If guardian does not appear responsive to instruction, a report of potential neglect shall be made promptly to the Department of Human Services. ADULT: If an adult, then Quest employee/contractor will notify consumer’s family, friends, authorities (sheriff/police/APS) as part of the client’s safety plan that is developed with the consumer. HOSPITAL ADMISSION DENIED CASES: In cases where a consumer was denied admission to an inpatient psychiatric facility, employees/contractors are expected to complete the Quest Critical Incident form and follow the Zero Suicide Assessment and Treatment Protocol.

7. Reporting Protocols Cont’d QUEST employees/contractors must notify a Clinical Director along with making a report to the DHS (or other authorities) and complete the Quest Critical Incident Form. No QUEST employee or agent may prevent a threat or attempt from being reported. Any employee so doing, whether by originally overlooking reportable conditions or causing another employee's suspicion not to be reported, is subject to disciplinary action.

8. ZERO SUICIDE ASSESSMENT AND TREATMENT PROTOCOL When a Quest employee/contractor, upon screening for suicidality within the biopsychosocial, CAR Update, or regular discussions as part of your interactions with a consumer, finds that a consumer is potentially suicidal utilize the following steps: Complete the Columbia Suicide Severity Rating Scale with the consumer to assess their current level of suicidality. Complete a Quest Safety Plan collaboratively with the consumer, and provide the consumer with a copy prior to leaving. Safety Plan may include sending the consumer for inpatient psychiatric care and/or the notification of consumer’s family, friends, authorities, etc. as partners in restriction of lethal means and maintaining the safety of the consumer.

9. ZSAT PROTOCOL Continued Update the treatment plan accordingly to include the prevention of suicide as a priority goal/objective. Utilize Evidenced Based Practices from the National Registry of Evidence Based Programs and Practices (www.nrepp.samhsa.gov) like DBT, CBT-SP, and CAMS to treat the consumer appropriately and effectively. Perform ongoing continuity of care by re-assessing, contacting, engaging, and supporting the client (and caregivers) to ensure the consumer’s safety. Quest Case Managers must actively and aggressively provide inpatient to outpatient transition support prior to the consumer leaving the hospital, provide follow up contacts, and ensure the consumer makes their follow up appointments with therapist, physician, resources, etc. This statistically reduces the consumer’s chances of re-attempting suicide and being readmitted to the hospital. Quest will apply a data-driven quality improvement approach to inform system changes that will lead to improved patient outcomes and better care for those at risk.

10. BPS/CAR & Depression CAR Domains give a measure on depressed mood, cognitive and suicidal thinking, familial/interpersonal relationships, SA issues, financial/legal issues, etc. that all provide indicators of depression and suicidality levels. The indicators imbedded in these forms assist you in determining when to utilize the C-SSRS and Safety Plan.

11. Columbia-Suicide Severity Rating Scale (C-SSRS) SUICIDAL IDEATION Ask questions 1 and 2. If both are negative, proceed to “Suicidal Behavior” section. If the answer to question 2 is “yes”, ask questions 3, 4 and 5. If the answer to question 1 and/or 2 is “yes”, complete “Intensity of Ideation” section below. Since Last Visit: 1. Wish to be Dead - Subject endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up. Have you wished you were dead or wished you could go to sleep and not wake up? If yes, describe:Yes No □□ 2. Non-Specific Active Suicidal Thoughts - General, non-specific thoughts of wanting to end one’s life/commit suicide (e.g., “I’ve thought about killing myself”) without thoughts of ways to kill oneself/associated methods, intent, or plan during the assessment period. Have you actually had any thoughts of killing yourself? If yes, describe:Yes No □□ 3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act - Subject endorses thoughts of suicide and has thought of at least one method during the assessment period. This is different than a specific plan with time, place or method details worked out (e.g., thought of method to kill self but not a specific plan). Includes person who would say, “I thought about taking an overdose but I never made a specific plan as to when, where or how I would actually do it...and I would never go through with it.” Have you been thinking about how you might do this? If yes, describe:Yes No □□ 4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan - Active suicidal thoughts of killing oneself and subject reports having some intent to act on such thoughts, as opposed to “I have the thoughts but I definitely will not do anything about them.” Have you had these thoughts and had some intention of acting on them? If yes, describe:Yes No □□ 5. Active Suicidal Ideation with Specific Plan and Intent - Thoughts of killing oneself with details of plan fully or partially worked out and subject has some intent to carry it out. Have you started to work out or worked out the details of how to kill yourself? Have you started to work out or worked out the details of how to kill yourself? Yes No Do you intend to carry out this plan? If yes, describe: Yes No □□

12. INTENSITY OF IDEATION - The following features should be rated with respect to the most severe type of ideation (i.e., 1-5 from above, with 1 being the least severe and 5 being the most severe). FREQUENCY - How many times have you had these thoughts? (1) Less than 1 a week (2) 1 a wk (3) 2-5 times in wk (4) Daily/almost daily (5) Many txs ea day DURATION - When you have the thoughts, how long do they last? (1) Fleeting - few seconds or minutes (2) Less than 1 hour/some of the time (3) 1-4 hours/a lot of time (4) 4-8 hours/most of day (5) More than 8 hours/persistent or continuous CONTROLLABILITY - Could/can you stop thinking about killing yourself or wanting to die if you want to? (1) Easily able to control thoughts (2) Can control thoughts with little difficulty (3) Can control thoughts with some difficulty (4) Can control thoughts with a lot of difficulty (5) Unable to control thoughts (0) Does not attempt to control thoughts DETERRENTS - Are there things - anyone or anything (e.g., family, religion, pain of death) - that stopped you from wanting to die or acting on thoughts of committing suicide? (1) Deterrents definitely stopped you from attempting suicide (2) Deterrents probably stopped you (3) Uncertain that deterrents stopped you (4) Deterrents most likely did not stop you (5) Deterrents definitely did not stop you (0) Does not apply REASONS FOR IDEATION - What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain or stop the way you were feeling (in other words you couldn’t go on living with this pain or how you were feeling) or was it to get attention, revenge or a reaction from others? Or both? (1) Completely to get attention, revenge or a reaction from others (2) Mostly to get attention, revenge/reaction from others (3) Equally to get attention, revenge or a reaction from others and to end/stop the pain (4) Mostly to end /stop the pain (you couldn’t go on living with the pain/how you were feeling) (5) Completely to end/stop the pain (you couldn’t go on living with the pain/how you were feeling) (0) Does not apply

13. SUICIDAL BEHAVIOR (Check all that apply, so long as these are separate events; must ask about all types)Since Last Visit Actual Attempt: A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part thought of as method to kill oneself. Intent does not have to be 100%. If there is any intent/desire to die associated with the act, then it can be considered an actual suicide attempt. There does not have to be any injury or harm, just the potential for injury or harm. If person pulls trigger while gun is in mouth but gun is broken so no injury results, this is considered an attempt. Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or circumstances. For example, a highly lethal act that is clearly not an accident so no other intent but suicide can be inferred (e.g., gunshot to head, jumping from window of a high floor/story). Also, if someone denies intent to die, but they thought that what they did could be lethal, intent may be inferred. Have you made a suicide attempt?Total # of Attempts______Yes No □□ Have you done anything to harm yourself? Have you done anything dangerous where you could have died? What did you do? Did you______ as a way to end your life? Did you want to die (even a little) when you_____? Were you trying to end your life when you _____? Or did you think it was possible you could have died from_____? Or did you do it purely for other reasons / without ANY intention of killing yourself (like to relieve stress, feel better, get sympathy, or get something else to happen)? (Self-Injurious Behavior without suicidal intent) If yes, describe: Has subject engaged in Non-Suicidal Self-Injurious Behavior?Yes No □□ Interrupted Attempt: When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if not for that, actual attempt would have occurred). Overdose: Person has pills in hand but is stopped from ingesting. Once they ingest any pills, this becomes an attempt rather than an interrupted attempt. Shooting: Person has gun pointed toward self, gun is taken away by someone else, or is somehow prevented from pulling trigger. Once they pull the trigger, even if the gun fails to fire, it is an attempt. Jumping: Person is poised to jump, is grabbed and taken down from ledge. Hanging: Person has noose around neck but has not yet started to hang - is stopped from doing so. Has there been a time when you started to do something to end your life but someone or something stopped you before you actually did anything? If yes, describe: Total # of interrupted______ Yes No □□ Aborted Attempt: When person begins to take steps toward making a suicide attempt, but stops themselves before they actually have engaged in any self-destructive behavior. Examples are similar to interrupted attempts, except that the individual stops him/herself, instead of being stopped by something else. Has there been a time when you started to do something to try to end your life but you stopped yourself before you actually did anything? If yes, describe:Total # of aborted______ Yes No □□

14. Preparatory Acts or Behavior: Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a verbalization or thought, such as assembling a specific method (e.g., buying pills, purchasing a gun) or preparing for one’s death by suicide (e.g., giving things away, writing a suicide note). Have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting pills, getting a gun, giving valuables away or writing a suicide note)? If yes, describe:Yes No □□ Suicidal Behavior: Suicidal behavior present during the assessment period?Yes No □□ Completed Suicide:Yes No □□ Answer for Actual Attempts OnlyMost Lethal Attempt Date: ____________ Actual Lethality/Medical Damage: (0) No physical damage or very minor physical damage (e.g., surface scratches). (1) Minor physical damage (e.g., lethargic speech; first-degree burns; mild bleeding; sprains) (2) Moderate physical damage; medical attention needed (e.g., conscious but sleepy, somewhat responsive; second-degree burns; bleeding of major vessel). (3) Moderately severe physical damage; medical hospitalization and likely intensive care required (e.g., comatose with reflexes intact; third-degree burns less than 20% of body; extensive blood loss but can recover; major fractures). (4) Severe physical damage; medical hospitalization with intensive care required (e.g., comatose without reflexes; third-degree burns over 20% of body; extensive blood loss with unstable vital signs; major damage to a vital area). (5) Death Enter Code______ Potential Lethality: Only Answer if Actual Lethality=0. Likely lethality of actual attempt if no medical damage (the following examples, while having no actual medical damage, had potential for very serious lethality: put gun in mouth and pulled the trigger but gun fails to fire so no medical damage; laying on train tracks with oncoming train but pulled away before run over). (0) Behavior not likely to result in injury (1) Behavior likely to result in injury but not likely to cause death (2) Behavior likely to result in death despite available medical care.Enter Code______

15. Quest Safety Plan Section 1: Consumer lists warning signs that they are going into crisis/suicidality. Section 2: Consumer lists coping strategies that can distract and de- escalate them. Section 3: Consumer lists those people and things worth living for. Section 4: Consumer lists people/places that can distract and de- escalate them. Section 5: Consumer lists people who they can talk to when under stress. Section 6: List local emergency and suicide hotline numbers along with your name/phone number to contact in crisis. Section 7: Consumer makes a plan for restricting lethality means in their access. Section 8: Consumer and clinician signatures and dates.

16. Resources Safety Plan Treatment Manual to Reduce Suicide Risk (Stanley & Brown, 2008) Safety Plan by Padraic Doyle Managing Suicidal Risk: A Collaborative Approach by David Jobes, PhD Suicidal Care in System Framework by Stephen O’Connor, PhD (Oklahoma) VA Models Those Who Desire Suicide by Thomas Joiner, 2005 https://implicit.harvard.edu/implicit/user/pimh/linkinfo.html Phone apps: VirtualHope Safety Plan Future Treatment Methods - Implicit Association Test - Measuring the Suicidal Mind: Implicit Cognition Predicts Suicidal Behavior by Nock, Park, Finn, Deliberto, Dour & Banaji, 2010 www.cnsresponse.comwww.cnsresponse.com - Measures pore openings/CNS response to predict reactivity levels Affective Startle Response (in Veterans w/Suicidal Behavior) and Suicide Risk by Goodman & Hazlett

17. Treatment and the Tx Plan When a consumer scores positive on the C-SSRS, then their Treatment Plan must be created/updated to show that the primary goal is decreasing the risk for suicide. Research supports highly structured, problem solving treatment approaches. Example Goals - Increase reasons for living; increase the number of people/things I feel are worth living for, increase the number or people/things/activities that distract me from my feelings of hopelessness; decrease the number of people/things/activities that have a negative effect on me; increase hope for the future; increase my knowledge of supportive resources available to me. Example Objectives - Decreased Depression scores; completion of Tx Program (DBT, CBT-SP, CAMS, etc.)

18. Dialectical Behavior Therapy DBT is a form of psychotherapy that was originally developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat people with borderline personality disorder (BPD) and chronically suicidal individuals.psychotherapyMarsha M. LinehanUniversity of Washingtonborderline personality disorder DBT combines standard cognitive-behavioral techniques for emotion regulation and reality- testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice.cognitive-behavioralemotion regulationmindful awarenessBuddhist DBT is a therapy designed to help people change patterns of behavior that are not effective, such as self-harm, suicidal thinking and substance abuse. This approach works towards helping people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings and behaviors that lead to the undesired behavior. DBT assumes that people are doing the best that they can, but either are lacking the skills or are influenced by positive or negative reinforcement that interfere with one’s functioning. *The most thoroughly studied and efficacious psychotherapy for suicidal behavior, http://behavioraltech.orghttp://behavioraltech.org

19. CBT for Suicide Prevention

20. Phased Approach Tx Phase Therapeutic Goals Phase I: Engagement *Build Therapeutic Alliance *Provide Psychoeducation *Develop Collaborative Safety Plan *Construct Suidcide Attempt Story Phase II: Self-Management *Instill Hope - Increase Reasons for Living *Teach Adaptive Coping Strategies *Target Deficits in Problem Solving Phase III: Skill Development *Promote Linkage to Outpatient Aftercare *Teach Relapse Prevention Strategies *Refine Safety Plan before Discharge/other treatments Phase IV: Relapse Prevention *Follow-Up Contacts *Tune-Up Sessions as needed

21. CBT-SP Resources Cognitive Behavior Therapy for Suicide Prevention (CBT-SP): Treatment Model, Feasibility and Acceptability by Stanley, Brown, etc., 2009 Cognitive Therapy for Suicidal Patients: Scientific and Clinical Applications by Wentzel, Brown, & Beck, 2009 http://www.intechopen.com/books/mental-disorders-theoretical- and-empirical-perspectives/cognitive-behavioral-therapy-approach- for-suicidal-thinking-and-behaviors-in-depression http://www.ct-cbt.com/pdf/Depression_Chapter.pdf CBT with Adults: A Guide to Empirically-Informed Assessment and Intervention, Edited by Hoffman & Reinecke

22. Collaboration Assessment and Management of Suicidality (CAMS) by Dr. Jobes, PhD Identifies and targets Suicide as the primary focus of assessment and intervention. Uses the Suicide Status Form (SSF) as a means of deconstructing the “functional” utility of suicidality. CAMS as an intervention emphasizes a problem-focused intensive outpatient approach that is suicide-specific and “co-authored” with the consumer. Empirical research (15-20 yrs of study)

23. SSF (Jobes & Mann 1999/2000) Reasons for Living FamilyFamily FriendsFriends Responsibility to OthersResponsibility to Others Burdening Others w/SuicideBurdening Others w/Suicide Unrealized Plans & GoalsUnrealized Plans & Goals Hope for the FutureHope for the Future Enjoyable ThingsEnjoyable Things Beliefs (Religion)Beliefs (Religion) Preservation of SelfPreservation of Self Reasons for Dying Others (Retribution) Unburdening Others Loneliness Hopelessness Issues about Self General Escape Escape the Past Escape the Pain Escape Responsibility To increase reasons for living: Construct a Hope Box/Survivor Kit w/pictures, letters, poetry, prayer card, coping cards, use guided imagery; use the free iTunes app VirtualHope.

24. CAMS-5 Core components of collaborative clinical care (over 10-12 sessions/3 months) Component I-Collaborative Assessment of Suicidal Risk Comp II: Collaborative Tx Planning Attend Tx reliably as scheduled over 3 months Reduce access to lethal means Develop and use a Coping Card as part of Crisis Response Plan Create Interpersonal Supports Comp III-Collaborative Understanding of the Patient’s Suicidal Drivers Relationship issues (especially family) Vocational issues (what do they do?) Self-related issues (self-worth/self-esteem) Pain and suffering—general and specific Comp IV-Collaborative Problem-Focused Interventions(based on Comp III) Comp V-Collaborative Development of Reasons for Living Develop plans, goals, and hope for the future Develop Guiding beliefs—a post-suicidal life (e.g. lessons in living)

25. CAMS Format Consumer shows a positive Suicide Score Initial Session-Complete the CAMS Suicide Status Form-SSF IV (Initial Session) Sessions 8-10 - Complete the CAMS On-Going Care Form Consumer has 3 consecutive “resolution” sessions Final CAMS Session - Complete the CAMS Outcome (Final Session) Form

26. Malpractice Liability Reduction Forseeability Treatment Planning Follow-Up/Follow-Through *Malpractice Liability, Competent Practice, and Cases of Suicide (Jobes & Berman 1993)

27. Forseeabilty Risk assessment was conducted Risk assessment was thorough Possible use of assessment instruments Possible use of psychological testing Make overall clinical judgment of suicide risk Seek consultation and adequately document assessment and consultation

28. Treatment Planning Use overall risk to inform and shape Tx Plan Identify both short/long-term Tx Goals Consider full range of treatments-what will be used and why Consider various safety contingencies Routinely revise and update the Tx Plan Overhaul Tx Plan when necessary Seek consultation and adequately document Tx information

29. Follow-up and Follow- Through Make sure Treatments are being implemented Coordinate care with others as needed Always insure clinical coverage when unavailable Carefully make referrals and follow-up (issues w/clinical abandonment) Seek consultation and adequately document follow- up/follow-through

31. Every Life is Precious Debbie Spaeth, LMFT, LPC, LADC dspaeth@questmhsa.com