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Telephonic Assessment of Suicidal Ideation Paradigm Brent L. Halderman, Ph.D. James R. Eyman, Ph.D. Sheryl Feutz-Harter, J.D., MSN, CHC Nashville, TN October.

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Presentation on theme: "Telephonic Assessment of Suicidal Ideation Paradigm Brent L. Halderman, Ph.D. James R. Eyman, Ph.D. Sheryl Feutz-Harter, J.D., MSN, CHC Nashville, TN October."— Presentation transcript:

1 Telephonic Assessment of Suicidal Ideation Paradigm Brent L. Halderman, Ph.D. James R. Eyman, Ph.D. Sheryl Feutz-Harter, J.D., MSN, CHC Nashville, TN October 7, 2006 This presentation is proprietary and cannot be duplicated, used, or adapted without NDBH permission. For permission, contact:

2 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 2 Telephonic Assessment of Suicide Paradigm Stage 1 Suicide Potential Stage 2 Working Relationship Stage 3 Recommendations

3 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 3 Stage 1 Evaluation of Suicide Risk General Risk Factors  Sex  Age  Marital Status  Losses  Social Support  Medical Illness  Alcoholism  Affective Disorder  Anxiety Disorder  Schizophrenia  Eating Disorder  Borderline Personality Disorder

4 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 4 Stage 1 Specific Risk Factors for Suicide  Anxiety  Ruminations  Depression with Delusions  Hopelessness  Global Insomnia  Recent Alcohol Use

5 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 5 Stage 1 Assessing Suicidal Ideation  How do you feel now?  Ever feel so bad that you wish you were dead?  Ask directly about suicidal ideation Why suicidal? What precipitating event?  Suicidal ideation is on a continuum

6 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 6 Stage 1 Preparation to End Life  Usually have more than one plan  Note how the person talks about suicidal ideation and plan  Well thought out and developed plans will more likely succeed Perception of the lethality of the method Availability of the method Efforts to thwart rescue Suicidal behavior is on a continuum.

7 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 7 Stage 1 Past Suicide Attempts  How close have you come to killing yourself?  Suicide risk increases with escalating seriousness of past attempts  History External circumstances Internal circumstances

8 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 8 Stage 1 Available Support  Degree of attachment Family crisis Psychological resources  Family  Friends  Self

9 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 9 Stage 1 Meaning of Life and Death  Gain from suicide What will happen after you die?  Protective Factors What has kept you alive?  Responsibility to family  Fear of act of suicide  Fear of social disapproval  Religious beliefs

10 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 10 Stage 1 Obtain Information from Other Sources  Family  Friends  Co-workers

11 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 11 Stage 1 Contracts to Prevent Suicide  Used by 50 percent of all clinicians  All three stages involve a form of no suicide contract  No research evidence  1973 American Journal of Psychiatry

12 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 12 Stage 1 Shifting from Higher to Lower Suicide Risk  Convincing?  Will it stand up under scrutiny?  Consultation

13 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 13 Stage 1- Desktop Procedure Assessment of Mental Status & Psychological State of Suicidal Ideation  Minimum criteria for safety to move to Stage 2 Plan – Yes Intent – No Contract – Yes  Meets criteria? Go to Stage 2  If above criteria not met, can caller shift to criteria during the call?  If criteria cannot be met, implement appropriate recommendations from Stage 3

14 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 14 Stage 2 Considerations  Therapeutic alliance  Ambivalence  Evaluate from all gathered information  Impact of understanding dangers of misleading

15 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 15 Stage 2 Factors Interfering with Alliance  Cognitive Psychosis Delusions Alcohol – Drugs Intelligence, brain impairment Decision to die  Emotional Difficulty containing feelings Impulsivity Paranoia If unable to form an alliance reevaluate information from Stage 1.

16 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 16 Stage 2 – Desktop Procedure Does Caller Understand Danger of Misleading the Clinician?  Ask directly  Glean from what has been said  Using drugs/alcohol?  Cognitive functioning (limited, age)  Psychological functioning (e.g., Personality Disorder) If caller does not understand danger of misleading clinician, re-assess Stage 1 and make appropriate recommendations from Stage 3.

17 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 17 Stage 3 Caller’s Role in the Recommendation Process  Callers must agree to clinically appropriate recommendations  Plan to negotiate to find a recommendation that caller will follow If caller does not follow recommendations, reassess Stages 1 and 2 and make appropriate recommendations.

18 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 18 Stage 3 The Clinician’s Responsibility  Plan that is appropriate for risk  Patient safety Moderate to severe suicide risk, take appropriate action Make appointment and involve family or friends to promote follow-through Follow-up with referral source  The clinician’s goals Create a reasonable and justifiable referral/intervention plan Transfer to treating clinician Close the loop.

19 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 19 Stage 3 – Desktop Procedure Recommendations  Can caller follow recommendations?  If not, how can plan be modified? Partial hospital/IOP Warm transfer to therapist, PCP, psychiatrist, insurance Advise parents of safety precautions Prevention call Talk with Family/supervisor Remove dangers (guns, pills) Follow-up allowed Someone accompany to appointment Someone stay with caller or go to friend/family NDBH & ER 24/7 availability and number Emergency room Inpatient Emergency appointment

20 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 20 Stage 3 – Desktop Procedure Recommendations continued  Ascertain follow-through Provide clinical to ER and/or providers Ask for confirmation patient was seen  Provide concrete help Offer to call ambulance/transportation Inquire whether family member/friend/supervisor feels safe transporting patient to facility  Wellness check Advise caller of the need to call police for wellness check Communicate clinical information/urgency to authorities Advise authorities of need for clinical assessment Duty to warn Other

21 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 21 Resist Seduction Of Going Along With Callers Plan When Not Appropriate  Why we get seduced Don’t want to make caller/company mad Hope it will turn out OK Want to help We can fix anything Lack of information (shift change) Second hand knowledge You are the Clinician. Callers need to follow your plan.

22 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 22 When Stage 3 Cannot be Met  Reassess responses in Stages 1 and 2  Clinical consultation  Supervisory consultation  Legal consultation

23 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 23 Legal Risks  ELEMENTS OF LIABILITY Duty Breach of Duty/Malpractice Causation of Injury Damages

24 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 24 How to Establish Standards of Care  Legal definition: “The level of conduct expect of a similar healthcare professional acting under the same or similar circumstances.”  Laws and court decisions  Professional association standards  Professional journals and research studies  Facility policies/guidelines

25 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 25 Standards of Care Issues  Assessment Performance of Documentation  Referral/Intervention Plan Rationale Time Frames Modifications

26 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 26 Standards of Care Issues  Informed decision making By Client/Caller Capacity to consent  Actions taken Review prior health information Communications Wellness Checks

27 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 27 Lessons Learned Development of this Paradigm  Right decision – wrong result  Don’t wait and hope caller will make good choices  Increase our direction earlier in process  Help caller make good decisions  Help caller to “walk the walk”  All three stages of paradigm must be achieved

28 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 28 Evaluation of Paradigm Effectiveness  Vast majority of callers are grateful for direction No complaints Positive satisfaction surveys  Most important – no adverse outcomes

29 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 29 EAP Data Evaluation of Paradigm Effectiveness

30 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 30 Evaluation of Paradigm Effectiveness  Overall reduction in wellness checks 92.48% (p≤.001)  62.3% increase in calls voicing suicidal ideation from 2002 to 2004  2005 – 2 wellness checks for the same 6 month period

31 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 31 MMH Emergent Data Evaluation of Paradigm Effectiveness

32 Copyright 2006 New Directions Behavioral Health LLC. All rights reserved. 32 Evaluation - Continued  Recent application of paradigm for MMH Call Center  Reduction in emergent wellness checks of 59% comparing 2004 with 2006TD

33 Telephonic Assessment of Suicidal Ideation Paradigm Brent L. Halderman, Ph.D. James R. Eyman, Ph.D. Sheryl Feutz-Harter, J.D., MSN, CHC Nashville, TN October 7, 2006 This presentation is proprietary and cannot be duplicated, used, or adapted without NDBH permission. For permission, contact:


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