Presentation on theme: "Juli McNeil, MSSW, LCSW Program Manager, Suicide Prevention"— Presentation transcript:
1 Self-Directed Violence (SDV) Classification System-What is it and Why it Matters Juli McNeil, MSSW, LCSWProgram Manager, Suicide PreventionJack C. Montgomery VA Medical Center
2 Objectives Suicide Prevention Program The Self-Directed Violence Classification System (SDVCS): What is it and why it mattersVA Resources
3 Jack C. Montgomery VAMC and Clinics Suicide Prevention Team Juli McNeil, LCSWProgram Mgr, SuicidePrevention/3699Tina Bevans, LCSWTulsa VA Clinics (41st and 11th)Suicide PreventionCoordinatorAlexa Youngblood, LCSWSuicide Prevention Case Mgr/3699Tawnya WilsonSuicide Prevention Program &SUD Intensive Outpt ProgAdministrative Assistant/3439
4 Oklahoma City VA Suicide Prevention Team Juanita Celie, LCSW, BCD Team Coordinator (405) Sherry Oliver, LCSW, BCD Case Manager (405)Bryan Stice, Ph.D Case Manager (405) Alicia Oddi, LPN Program Assistant (405)
5 Oklahoma is 12th in the Nation. Suicide Statistics37,793 US deaths from suicide/yearOne Suicide every 15 minutesSuicide is the 10th leading cause of death in the USSuicide is the 2nd leading cause of death among year oldsSuicide is the 3rd leading cause of death among year olds4 times as many men kill themselves compared to women, yet 3 times as many women attempt suicide as compared to men.Oklahoma is 12th in the Nation.
6 Suicide Statistics Continued ~20% are Veterans~18 deaths from suicide per day are Veterans~About 5 deaths from suicide per day among Veterans receiving care in VHAData shows since 2006 : decreased suicide rates in Veterans aged who use VA health care relative to Veterans in the same age group who do not. This decrease in rates translates to about 250 lives per year.
7 National Level Suicide Prevention Suicide Prevention efforts, such as the Suicide Hotline and hiring of Suicide Prevention Coordinators began in FY2007 with full implementation in FY08A 24/7 Veterans Crisis Line , Press 1Over 600,000 callers, since 2007Online Chat ServiceOver 50,000 chatters, since 2009Text toOver 1,600 texts since November 2011Over 21,000 rescues since 2007
8 Nomenclature: Self-Directed Violence Classification System (SDVCS) In 2008, former Secretary of Veterans Affairs,Dr. James B. Peake, recommended a standard nomenclature for “suicide” and “suicide attempts” to improve Veterans Affairs’ (VA):Suicide prevention programsSuicide prevention researchSuicide prevention education
9 SDVCS OverviewTo learn and begin to using the new nomenclature for self-directed violence.Review of the language of suicidologyRationale for a self-directed violence classification systemImplementation of a new classification system
10 Case ExampleA healthy 24-year-old female Veteran is brought by her boyfriend to the Emergency Department after she ingested all remaining pills in a bottle of regular strength Tylenol. She estimates there were 4 to 6 pills total in the bottle ( mg total dose), and she reports no ill effects. Lab tests done at the time of admission to the ED reported her acetaminophen level within the therapeutic range. During triage, she states that before she took the pills she was upset from arguing with her boyfriend and just wanted to die. She feels better now and requests to go home.
11 Behavior? Criteria? What is her behavior? Gesture?Threat?Acting Out/Manipulation?Attempt?Other?What criteria did you use to decide?Lethality of method?Expressed intent?Number of pills ingested?Lab results?
12 The Language of Self-Directed Violence Identification of the Problem Suicidal ideationDeath wishSuicidal threatCry for helpSelf-mutilationParasuicidal gestureSuicidal gestureRisk-taking behaviorDeliberate Self-HarmNon-Suicidal Self InjurySuicidal GestureSelf-harmSelf-injurySuicide attemptAborted suicide attemptAccidental deathUnintentional suicideSuccessful attemptCompleted suicideLife-threatening behaviorSuicide-related behaviorSuicide
13 The Language of Self-Directed Violence Why does it matter? “ A rose is a rose is a rose” “Sacred emily,” by Gertrude Stein, 1913 EXCEPT IN THE FIELD OF SUICIDOLOGY Where a Suicide Attempt (by one person’s assessment) is NOT Always a Suicide Attempt (by another’s).
14 The Problem…The field of suicidology is challenged by the lack of conceptual clarity about suicidal behaviors and a corresponding lack of well-defined terminology- In both research and clinical descriptions of suicidal actsThere is a great variability of terms referring to the same behaviors (e.g., threat, gesture). Terms are often pejorative and based on incorrect notions about seriousness and lethality of methods (e.g., manipulative, non-serious, etc
15 Hence…. It becomes very difficult to: Accurately count the number of suicides and suicide attempts that occur annuallyAccurately differentiate suicide attempts from non-suicidal self-injuriesConduct longitudinal studies of suicide attemptersCommunicate between and among clinicians, researchers, patients, and patients’ familiesEstablish suicide and suicide attempts as a major public health problem that warrants investment of resources
16 The Language of Self-Directed Violence Implications of the Problem ClinicalResearchPublic Health (e.g., surveillance)Public Policy
17 The Problem…..The field of suicidology is challenged by the lack of conceptual clarity about suicidal behaviors and a corresponding lack of well-defined terminology- In both research and clinical descriptions of suicidal actsThere is a great variability of terms referring to the same behaviors (e.g., threat, gesture). Terms are often pejorative and based on incorrect notions about seriousness and lethality of methods (e.g., manipulative, non-serious, etc
18 Current Terminology Research Implications of the Problem
19 Consequences of Ill-Defined Terms Makes interpreting the meaning of self-injurious acts more difficult and hampers precise communication on individual or population basisSome Self-injurious acts that should be classified as suicidal may be mislabeledOther types of Self-injurious acts may be inappropriately classified as suicidal
20 The Need for Consistent Definitions & Data Elements “Research on suicide is plagued by many methodological problems… Definitions lack uniformity … reporting of suicide is inaccurate…”(Reducing Suicide: A National Imperative, Institute of Medicine, 2002)
21 Definitions 15 Definitions for Suicide 9 Definitions for Non-Fatal Self-Harm
25 What is the Purpose of a Nomenclature? Commonly understood, widely acceptable, comprehensive.Solution to the Problemenhance clarity of communicationhave applicability across clinical settingsbe theory neutralbe culturally neutraluse mutually exclusive terms that encompass the spectrum of thoughts and actions
26 Why “Self-Directed Violence” ? Blue Ribbon Task Force recommendation was to work with CDC and other federal agencies on the development of a nomenclature and classification systemCDC was already developing a Self-Directed Violence Surveillance System that included Uniform Definitions and Recommended Data ElementsThe opportunity presented itself for the VHA, DoD, and CDC to adopt the same nomenclature and classification system
27 Research Team Members Lisa A. Brenner, Ph.D. Ryan E. Breshears, Ph.D. Lisa M. Betthauser, M.B.A.Katherine K. Bellon, Ph.D. Elizabeth Holman, Ph.D.Jeri E.F. Harwood, Ph.D. Morton M. Silverman, M.D.Joe Huggins, M.S.W./M.S.C.I.S. Herbert T. Nagamoto, M.D.VISN 19 Mental Illness Research Education and Clinical CenterDenver VA Medical CenterUniversity of Colorado, Denver, School of MedicineWellStar Health System, GeorgiaUniversity of Georgia, AthensDepartment of Biostatistics and Informatics, Colorado School of Public Health
28 REMEMBERWhen both THOUGHTS and BEHAVIOR are present BEHAVIORS Trump THOUGHTS For the purposes of classification
29 When both are present SELF-DIRECTED VIOLENT BEHAVIORS Trump PREPATORY REMEMBERWhen both are present SELF-DIRECTED VIOLENT BEHAVIORS Trump PREPATORY
30 Suicidal Intent:There is past or present evidence (implicit or explicit) thatan individual wishes to die, means to kill him/herselfand understands the probable consequences of his/heractions or potential actions. Suicidal intent can bedetermined retrospectively and in the absence of suicidalbehavior.The individual:Component 1: Wishes to dieComponent 2: Means to kill him/herselfComponent 3: Understands the probable consequences (i.e. death).
31 Get Out Clipboard When both Thoughts and Behaviors are present Behaviors trump Thoughtsfor purposes of classificationWhen both are SDV Behaviors and Preparatory are presentSelf-Directed Violent Behaviors trump Preparatory
33 CASE EXAMPLE 1: A Veteran comes in for an initial mental health intake CASE EXAMPLE 1: A Veteran comes in for an initial mental health intake. During the intake, the therapist and the Vet have the following dialogue:Therapist: “Have you had thoughts of suicide?”Veteran: “There have been times when I’ve thought about it.”Therapist: “Times? Like recently?”Veteran: “Yeah, well sometimes those thoughts enter my mind.”Therapist: “Can you say more about that?”Veteran: “Well … if you had the pain I have, you might understand.”Therapist: “You’re telling me that your pain feels unbearable at times?”Veteran: “Yeah, like yesterday … I thought it would be better if I just went tosleep and never woke up. “Therapist: “So you wanted to die?”Veteran: “Yeah, you could say that.”Therapist: “Did you take any actions to make that happen?”Veteran: “You mean, like, did I try to kill myself?”Therapist: “Yes.”Veteran: “Oh no. I mean I thought about it, but I didn’t do anything. I just tookmy medication like I always do.”Therapist: “Your medication?”Veteran: “Yeah, my pain meds. They usually help the pain pretty well.”
34 SUICIDE IDEATION WITH SUICIDE INTENT ANSWER:SUICIDE IDEATION WITH SUICIDE INTENT
35 Case Example 2A wife finds her husband tearful and holding knife to his wrist. He has already made a few small cuts. On his bed is a note stating, “I can’t go on like this. You’ll be better off without me.”
36 SUICIDE ATTEMPT, WITH INJURY, INTERRUPTED BY SELF/OTHER ANSWER:SUICIDE ATTEMPT, WITH INJURY, INTERRUPTED BY SELF/OTHER
37 Case Example 3 A 75-year-old veteran loses his wife to cancer. Within hours, he purchases ammunition for ahandgun he has had for years and contactshis attorney asking to revise his will. His sonasks him about these behaviors, and herefuses to answer, changing the subject.
38 Key Concept Preparatory Behavior Acts or preparation towards engaging in Self-Directed Violence, but before potential for injury has begun. This can include anything beyond a verbalization or thought, such as assembling a method (e.g., buying a gun, collecting pills) or preparing for one’s death by suicide (e.g., writing a suicide note, giving things away).Preparatory Self-harm/suicidal beh4pm pm 6pm pm pmAmmo Attny Son
39 Resources Refer to VA Resource Guide Safety Planning Guide Suicide Risk Assessment GuidePTSD COACH APP