1. Building Hope with At Risk Clients: Connection & Means Restriction Aimee Johnson, LCSW Suicide Prevention Coordinator Portland, Oregon VA Medical Center Friday July, 2014 Bend, Oregon

2. VETERANS HEALTH ADMINISTRATION Today What do we know about suicide? What are warning signs & risk factors? What are resources and how do we prevent it?

3. VETERANS HEALTH ADMINISTRATION Background In 2007, the Department of Veterans Affairs began an intensive effort to reduce suicide among Veterans. In 2008, VA’s Mental Health Services established a suicide surveillance and clinical support system based on reports of suicide and suicide events (i.e. non-fatal attempts, serious suicide ideation, suicide plan) submitted by Suicide Prevention Coordinators located at each VA Medical Center and large outpatient facility. In 2010, the VA also began an intensive effort to shorten delays associated with access to National Death Index (NDI) data and increase understanding of suicide among all Veterans by developing data sharing agreements with all 50 U.S. states. The integration of information collected through the NDI, state mortality records, Suicide Behavior Reports, VA’s Veterans Crisis Line, and the VA’s universal electronic medical records contribute to an increased understanding of suicide and risk management by identifying gaps in existing knowledge, opportunities for intervention and the impact of VA-sponsored suicide prevention programs. All of these data collection systems have matured to the point where VA can now glean information to better determine if the current suicide prevention program is having an effect, where gaps may occur, and where there may be potential improvements for the future. 3

4. VETERANS HEALTH ADMINISTRATION What We Know About Veteran suicide 2012 Suicide Date Report VHA Response and Executive Summary 18-22 is the estimated number of Veterans who die from suicide each day (which has remained relatively stable over the past 12 years). The overall number of suicides nationally has increased although those suicides reported as Veterans has decreased. A majority of Veteran suicides are among those age 50 years and older. Male Veterans who die by suicide are older than non-Veteran males who die by suicide. The majority of Veterans who have a suicide event were last seen in an outpatient setting. A high prevalence of non-fatal suicide events result from overdose or other intentional poisoning. The most common means of male Veteran suicide is firearms and overdose is the most common means of female Veteran suicide. 4

5. VETERANS HEALTH ADMINISTRATION What do we know about suicide? (AAS 2010) It’s a big problem – 10 th leading cause of death – 38,364 suicides occur each year in the U.S. – 105.1 suicides occur each day – One suicide occurs every 13.7 minutes – 6 new survivors of suicide every 13.7 minutes – More Suicides (#10) than Murders (#16) (national – In Oregon more likely to die by suicide than in a car accident. – 7 th leading cause of death for Men and 11 th leading cause of death for Women in Oregon (Oregon Vital Statistics Annual report 2012)

6. VETERANS HEALTH ADMINISTRATION The Face of Suicide in the U.S.(AAS 2010) Gender – Men complete suicide at nearly four times the rate of women. – Women attempt suicide three times more than men. Age – – Suicide is the third leading cause of death among 25-34 year olds and the third leading cause among 15-24 year olds – Persons aged 45-54 years have the highest suicide rate – One older adult commits suicide every 90 minutes Veteran Status -Veterans may be at even greater risk than those in the general population 6

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11. VETERANS HEALTH ADMINISTRATION Suicidal Behavior =Provider Anxiety Those At Risk Struggle to Follow-up with Care 11

12. VETERANS HEALTH ADMINISTRATION Suicide is Everyone’s Business, Not just mental health providers 12

13. VETERANS HEALTH ADMINISTRATION Standard Approach to Suicide Risk Differentiate between Acute and Chronic risk 13

14. VETERANS HEALTH ADMINISTRATION Chronic Risk Factors Psychiatric diagnosis Substance abuse Previous attempts Poor self-control/ impulsivity Family History of suicide History of abuse (physical, sexual, emotional) Co-morbid health problems Age, gender, race (elderly or young white male) Same-sex orientation 14

15. VETERANS HEALTH ADMINISTRATION Acute Risk Factors Hopelessness/ desperation/ sense of ‘no way out’ Current depression Recent discharge from a psych unit Current substance abuse or impulsive overuse Anxiety, panic, insomnia Pain and physical discomfort (nausea) Extreme humiliation/disgrace; narcissistic mortification Newly diagnosed co-morbid health problem or worsening symptoms Break-down in communication/loss of contact with significant other (including therapist) 15

16. VETERANS HEALTH ADMINISTRATION Protective (Mitigating) Factors Responsibility to children, elder parents, beloved pets Religious Faith Connections to family and community support Social Role Purpose and meaning in life Problem Solving ability Resilience Persistence Positive Coping Skills Attitudes towards Suicide “Psychic Toughness” Positive professional relationship

17. VETERANS HEALTH ADMINISTRATION it’s confusing… The warning signs: rage, feeling trapped, increased alcohol use, withdrawing, trouble sleeping, relationship problems, etc apply to lots of people  Yet a tiny, tiny fraction will ever attempt suicide. 17

18. VETERANS HEALTH ADMINISTRATION Thomas Joiner’s Theory 18

19. VETERANS HEALTH ADMINISTRATION Perceived Burdensomeness The view that ones existence burdens family, friends, and/or society “My death will be worth more than my life to family, friends, society, etc.” Assessing for Burdensomeness Would the people you care about be better of with out you? Do you feel like you have failed the people in your life? 19

20. VETERANS HEALTH ADMINISTRATION Failed Belongingness The experience that one is alienated from others, not an integral part of family, circle of friends, or other valued group February 22, 1980-lowest # of recorded suicides in US history Annual Sunday with lowest # of suicides in US Assessing for Belongingness Are you connected to other people? Do you feel like an outsider in social situations? Do you interact with people who care about you? 20

21. VETERANS HEALTH ADMINISTRATION Assessing acquired ability to enact lethal self injury Do the things that scare most people scare you? Do you avoid certain situations because of the possibility of injury or pain? Can you tolerate a lot more pain than most people? 21

22. VETERANS HEALTH ADMINISTRATION Preventing Veteran Suicides What’s a framework that can help us understand Veteran Suicide to try and make a difference? 22

23. VETERANS HEALTH ADMINISTRATION The Background 23

24. VETERANS HEALTH ADMINISTRATION Military Training Stay in Reasonable Mind If you’re in emotion mind – Act! 24

25. VETERANS HEALTH ADMINISTRATION Means Restriction: Dispelling MYTHS If you stop someone from hurting themselves they’ll just go somewhere else… Seiden, R. 1978 515 People restrained from jumping off the Golden Gate Bridge compared to a group of 184 people who attempted suicide and were taken to San Francisco Emergency Room http://www.kevinhinesstory.com/ Interview on CNN 25

26. VETERANS HEALTH ADMINISTRATION Portland Vista Bridge Barrier 26 Summer 2013 barrier was placed on Vista Bridge "Before the barriers were up, we did not hear of instances of people being talked down from jumping, because people just went and jumped," Novick tells WW. "People have to work to a place where they can jump, and it gives them time to think about it. When they stop and they think about it, the police get out there to talk to them.“ Commissioner Steve Novick Estimated 174 suicides since 1924 off the Vista Bridge

27. VETERANS HEALTH ADMINISTRATION Guns, Guns, Pills and Guns Provide Trigger locks and limit access to pills, discuss means restriction as a routine practice with clients. Because… Gun deaths: Firearms were one of the top five leading causes of injury-related deaths nationwide in 2010. Veterans and guns: Data collected between 2003 and 2006 show that Veterans use firearms more frequently than the general population in acts of suicide. Veterans are, respectively, 1.3 and 1.6 times more likely to use firearms compared with non-Veterans. Guns in homes: Research conducted in 2012 showed that firearms could be found in roughly 34 percent of homes nationwide. Weekly dispensing of medications, securing excess medication, getting rid of old ones. Using a pill box that has the Veterans Crisis Line, adding crisis line information to pill bottle caps 27

28. VETERANS HEALTH ADMINISTRATION Safety Planning Provides a prioritized list of coping strategies that are pre- planned Bolsters Wise Mind during times we may be stuck in emotion mind or reasonable mind. 6 steps that are easy to follow, collaborative, Veteran own words Can be kept on a cell phone app or written in purse, wallet, home, car Break in to small groups and come up with some examples of coping strategies for the safety plan in the next 5 minutes

29. VETERANS HEALTH ADMINISTRATION STEP 1: RECOGNIZING WARNING SIGNS -Thinking that I am worthless. STEP 2: USING INTERNAL COPING STRATEGIES -Listen to music. STEP 3: SOCIAL CONTACTS WHO MAY DISTRACT FROM THE CRISIS -Talking to people at the gym. Safety Planning

30. VETERANS HEALTH ADMINISTRATION STEP 4: FAMILY OR FRIENDS WHO MAY OFFER HELP These are people that I would be willing to talk to about my thoughts of suicide in order to help me stay safe: -My Pastor Rex Smith 503-987-6543. STEP 5: PROFESSIONALS AND AGENCIES TO CONTACT FOR HELP -Veterans Crisis Line 1-800-273-TALK(8255) press #1, or chat veteranscrisisline.netveteranscrisisline.net -Call 911 or come to the Emergency Department - STEP 6: MAKING THE ENVIRONMENT SAFE - Discuss means restriction - Safety Planning

31. VETERANS HEALTH ADMINISTRATION CPRS Documentation associated with Suicide Prevention Positive clinical reminder for depression and PTSD Veteran seen first time in ED or MH outpatient setting Part of admission H&P to inpatient psychiatric unit Within 48 hours d/c from inpatient psychiatric unit When Veteran reports or clinician determines a change in their status Note Title: Suicide Risk Assessment Complete for ALL reported suicidal behavior, attempts or deaths by suicide The first person to receive information about the behavior should complete the SBR One report per behavior, only behavior reported in the last 12 months Note Title: Suicide Behavior Report Veteran made a suicide attempt Reports suicidal ideation Otherwise been determined to be at moderate or high risk for suicide Has a high risk for suicide flag Note Title: Suicide Safety Planning 31

32. VETERANS HEALTH ADMINISTRATION Suicide Data Report Update January 2014, Janet E. Kemp, RN, PhD Suicide rates among the overall population of VHA users have remained more or less constant over the past several years Nevertheless, there are indicators that VHA’s program for suicide prevention has led to positive outcomes: –Decreased rates of suicide among VHA users with mental health conditions –Decreased mortality in the 12 months following a survived suicide attempt –Decreased rates of suicide among VHA male users aged 35-64 years –Decreased rates of non-fatal suicide events* –Decreased percentage of calls to the Veterans Crisis Line resulting in a rescue**Recent findings regarding suicide rates in young male Veterans and in female Veterans call for increased efforts * See also, page 31 of VA Suicide Data Report, 2012 ** See also, page 43 of VA Suicide Data Report, 2012 32

33. VETERANS HEALTH ADMINISTRATION Veteranscrisisline.net