Crisis Management: Suicide Risk Assessment A Guide for Mental Health Professionals By: Jesus Quiroga

Presentation Overview Overview of Suicide Prevalence Purpose of Crisis Management Definition of a Crisis Crisis Prevention Identifying a Crisis /Symptoms of a Crisis Crisis Intervention Safety Contracts Proper Utilization of Resources Crisis Resolution Crisis Follow-up Crisis Assessment & Documentation Interviewing Skills Mental Status Examination Level of Risk

Age-adjusted suicide rates among all persons by state -- United States, 2001 Rates per 100,000 population 0.0 to 9.0 9.1 to 10.6 10.7 to 13.2 13.3 to 21.7 Source: Centers for Disease Control and Prevention (CDC) mortality data

Suicide in Texas, by County, 1989-1998 (CDC) El Paso

Suicide by Age, Texas, 2004

Texas Suicides, 2004 TX US Total White Male WM BM Rate (%) 10.57 11.1 11.59 (92.5%) 12.3 (90.2%) Male 17.33 (78.4%) 17.7 (78.8%) WM 18.78 (72.3%) 19.6 (71.2%) BM 9.66 (5.1%) 9.0

Suicide rates among males 15-19 years: 1980-2004 Suff rate is approaching the firearm death rate; poisoning decling

Suicide rates among males 10-14 years: 1980-2004 Note here that the sui by suff rate now exceeds the rate by firearms

Death Rates for Suicide by Age and Sex, 2003

Male Rates for Suicide by Race & Age, 2003

Purpose of Crisis Management The goal of Crisis Management is to recognize early warning signs and symptoms in a person and prevent the situation from deteriorating into a crisis or worsening into an emergency situation. Safeguard yourself and provide a blanket of security for the consumer and others involved. Utilize effective Crisis Prevention strategies that encourage a collaborative partnership with the consumer and available community resources. Use de-escalation techniques and other reactive measures to ensure safety To bring the consumer to pre-crisis level of functioning.

What is a Crisis ? Self-Limiting, State of Disequilibrium A crisis is not the precipitating event but the individual’s inability to cope with a situation A person's thoughts and feelings are beyond their control. A sudden deterioration in emotional or mental state Expression of suicidal thoughts or actions Potential of a serious risk to themselves or others Expression of irrational and bizarre thoughts and behaviors that indicate they have completely lost touch with reality, i.e. hallucinations and/or delusions that potentially lead to dangerous situations

Crisis Prevention Knowing yourself Knowing your consumer Proper and timely assessments Providing medically appropriate services as per UM Guidelines (what is authorized in PIP) Consistency Appropriate & gentle confrontation Referrals to community outreach programs/resources Crisis planning Attention to needs If you can anticipate it you can intervene and prevent the crisis from exacerbating

Impending Crisis Subtle Attitude and Behavioral Changes (non-specific) Complaining about having to take medications Saying medication is not working or is not needed Skipping or forgetting to take doses of medication Missing scheduled appointments with mental health professionals, non-adherence Doing less than usual during the day / low energy levels Making too many changes at once (i.e., moving, changing jobs frequently, etc.) Subtle changes in eating and sleeping Trouble concentrating / focusing Increase in smoking/ drinking Pacing uncontrollably Change in affect Prevention of Deterioration to More Severe Symptoms Mental Health Professional should encourage the consumer’s family/friends to track these changes daily (in writing) These changes in attitude and behavior should be discussed with the consumer’s treating physician The Mental Health Professional should work with the consumer and his/her family or friends on developing a crisis plan.

Symptoms of a Mental Health Crisis These more severe and persistent symptoms can include (but not limited to): Talk or plans of suicide/homicide Abuse of alcohol or drugs Dramatic  mood swings Staying awake/asleep for periods exceeding 24 hours Complete withdrawal from activities / loved ones Bizarre behavior Uncontrollable anger / fits of rage Paranoia/suspicious Obvious change in affect Internally stimulated Changes in attitude apparent Refuses treatment / medications Impaired Judgment / Poor insight When the symptoms of mental illnesses become so severe that the individual is unable to manage basic self-care such as eating, bathing or dressing self Judge the severity of the consumer’s reactions, not the “seriousness” of the event

More Severe Symptoms Significant impairment in judgment that results in dangerous behavior Walking the streets alone late at night Getting into cars with strangers Aggression / Violence Sexually acting out Gets verbally agitated Yelling or cursing at people / ridicules people Overreacts to frustrations that are usually handled calmly Expresses paranoia directed at family, friends, or others Accuses a family member or other person of poisoning their food Accuses a family member of controlling their mind Accuses a family member of putting thoughts into their head States that a neighbor is breaking in at night and stealing things Accuses a friend of being a spy or working with the CIA States that a person is planning to kill them

The Continuum A crisis can be seen as a process Not an isolated event but a process that has a build-up, peak, de-escalation phase, and resolution A crisis may take a few hours or encompass several days even weeks

Why Does a Mental Health Crisis Occur? A mental health crisis can occur for a variety of reasons and can be connected with life events which have become overwhelming: Bereavement / Death of a loved one Non-adherence to medications or treatment (consumers) Prolonged periods of stress and anxiety Severe Depression Ailing health or chronic illness Divorce / Marital conflict Familial problems / Discord with a friend Trauma (past and/or present) Alcohol/Drug abuse (dependency) A mental health crisis can still arise despite full adherence to medications or treatment.

Comorbidity and Suicide Risk In general, the more diagnoses present, the higher the risk of suicide. Psychological Autopsy 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 Only 12 % had an Axis I diagnosis with no comorbidity

RISK FACTORS Demographic male; widowed, divorced, single; increases with age; white Psychosocial lack of social support; unemployment; drop in socio-economic status; firearm access Psychiatric psychiatric diagnosis; comorbidity Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease; hemodialysis; systemic lupus erthematosis; pain syndromes; functional impairment; diseases of nervous system Psychological Dimensions hopelessness; psychic pain/anxiety; psychological turmoil; decreased self-esteem; fragile narcissism & perfectionism Behavioral Dimensions impulsivity; aggression; severe anxiety; panic attacks; agitation; intoxication; prior suicide attempt Cognitive Dimensions thought constriction; polarized thinking Childhood Trauma sexual/physical abuse; neglect; parental loss Genetic & Familial family history of suicide, mental illness, or abuse

Areas to Evaluate in Suicide Assessment Psychiatric Illnesses Comorbidity, Affective Disorders, Alcohol / Substance Abuse, Schizophrenia, Cluster B Personality disorders. History Prior suicide attempts, aborted attempts or self harm; Medical diagnoses, Family history of suicide / attempts / mental illness Individual strengths / vulnerabilities Coping skills; personality traits; past responses to stress; capacity for reality testing; tolerance of psychological pain Psychosocial situation Acute and chronic stressors; changes in status; quality of support; religious beliefs Suicidality and Symptoms Past and present suicidal ideation, plans, behaviors, intent; methods; hopelessness, anhedonia, anxiety symptoms; reasons for living; associated substance use; homicidal ideation Adapted from APA guidelines, part A, p. 4

Psychiatric Examination DETERMINATION OF RISK Psychiatric Examination Risk Factors Protective Factors Specific Suicide Inquiry Modifiable Risk Factors Risk Level: Low, Med., High

Family History/Genetics Relatives of suicidal subjects have a four-fold increased risk compared to relatives of non-suicidal subjects. Twin studies indicate a higher concordance of suicidal behavior between identical rather than fraternal twins. Adoption studies: a greater risk of suicide among biologic rather than adoptive relatives. Suicide appears to be an independent, inheritable risk factor.

Psychosocial: Life Stressors Recent severe, stressful life events associated with suicide in vulnerable individuals Stressors include interpersonal loss or conflict, economic problems, legal problems, and moving High risk stressor: humiliating events, e.g., financial ruin associated with scandal, being arrested or being fired can lead to impulsive suicide. Identify stressor in context of personality strength, vulnerabilities, illness, and support system.

Family Psychopathology Family history of abuse, violence, or other self-destructive behaviors place individuals at increased risk for suicidal behaviors History of childhood physical abuse and sexual abuse, as well as parental neglect and separations, may be correlated with a variety of self-destructive behaviors in adulthood

Components of Suicidal Ideation Intent: Subjective expectation and desire for a self-destructive act to end in death. Lethality: Objective danger to life associated with a suicide method or action. Lethality is distinct from and may not always coincide with an individual’s expectation of what is medically dangerous. Degree of ambivalence - wish to live, wish to die Intensity, frequency Rehearsal/availability of method Presence/absence of suicide note Deterrents (e.g. family, religion, positive therapeutic relationship, positive support system - including work) Remember to read the suicide note and document that you read it. Beck et al. (1979)

Components of a Suicidal Plan Risk / Rescue Issues: Method Time Place Available Means and Access Arranging Sequence of Events Jacobs (1998)

Protective Factors Children in the home, except among those with postpartum psychosis Pregnancy Deterrent religious beliefs Life satisfaction Reality testing ability Positive coping skills Positive social support Positive therapeutic relationship

Suicide SUICIDE: A MULTI-FACTORIAL EVENT Psychiatric Illness Co-morbidity Personality Disorder/Traits Neurobiology Impulsiveness Substance Use/Abuse Hopelessness Severe Medical Illness Suicide Family History Access To Weapons Psychodynamics/ Psychological Vulnerability Life Stressors Suicidal Behavior

Validate the Crisis VALIDATE feelings, not INSTRUCT on how to feel Remember that you are ignorant of another person’s experience Show understanding of the current situation / event Acknowledge their reactions Assist in reviewing their options Provide emotional support Provide empathy / compassion

Approach: Establish Rapport Sometimes in our business: You begin to see clients as “different” than yourself: Consider the person’s experience age, educational level, developmental stage, and culture Use language appropriate / contextual Watch body language / facial gestures Encourage discussion Be objective Keep composure Set Limits / gently confront Be genuine—If you’re being fake, a consumer will know Be patient—watch the momentum of your assessment and the pace of your questions Otherwise resolution will not be long term / efficacious

Crisis Intervention: Cautionary Probing Gauge the severity of the behavior and amount of insight into reality If the consumer’s sense of reality allows, ask ample but not an overwhelming amount of open-ended questions Get as much collateral information as possible (weigh possible ulterior motives from family members or possible exploitation) Be careful about the established relationship (do not rely on rapport) Balance information from the past and the current situation Assess the direction of your questions (do not ask leading questions) Do not aggravate open wounds (deviate as you see visual cues of agitation)

Communication Skills Normalizations Assists in expression of emotions Decreases feelings of isolation Pre-normalization A lot of the people who struggle with _________ report feeling a sense of shame. Has that been going on for you? Examples It’s normal to feel angry sometimes It’s not uncommon to feel angry

Interviewing Skills Open Questions Generates dialogue and discussion Assists in gathering information important to the person you are speaking with Examples Tell me more about your situation Who in you life can you turn to for support? How has this affected your life?

Interviewing Skills Closed Questions Helps gather specific information Used to clarify Examples Do you want to talk about it? Have you told anyone about this?

Interviewing Skills Paraphrases Summarizes and clarifies Contains feelings and content Examples So what I’m hearing you say is that you didn’t get the response you wanted from social services. Am I correct in saying that you’re sad because ex-partner is moving?

Interviewing Skills Questions to Avoid “Why” Questions Leading Questions Multiple Questions

There are many listening models this is just a basic outline of the stages. What models do you use? Ask how they would establish rapport? What does a helper focus on concern? How do you support a caller or client? How do manage the end of the call? How can you prevent circular calls?

Crisis Intervention: Safety Ensure the safety of yourself, the consumer, and others Clear the area of other non-essential people and ensure privacy if you can Locate / remove potential hazards in the room Note exits, phones, and where others are located Approach the person in a non-threatening and calm manner – they are likely to be very confused and frightened Attempt to reassure the individual

Crisis Intervention: Prevent Escalation De-escalate: Prevent escalation –emotion turns into adrenaline YOU must be calm under very trying circumstances Allow time to pass (cool off) Sometimes de-escalation is not an option Authorities (911) must be involved for safety reasons If you are uncertain that this is the correct course of action, then call a supervisor Most Importantly: LISTEN

Intervention: Control Emotions Stay calm You must be aware of your own thoughts, reactions, feelings, and behaviors Avoid directives with upset consumers such as: “calm down”, “you shouldn’t feel so angry”, “relax” Modeling is more effective: Demonstrate a calm even tone, even breathing, and sympathetic voice, keeping calm at all times Avoid non-verbal behaviors that suggest frustration, condescension, or agitation on your part

Crisis Intervention: Reality Orientation Your role is to assist consumers in gaining a more realistic perspective on emotional state and the precipitating event. While listening to a consumer, clarify feelings and relate them to specific causative factors. If the consumer is still feeling incapable of coping, point out how reactions / negative thinking are exacerbating the problem.

Crisis Intervention: Course of Action Clarify Problems Develop Alternatives Agree on a Course of Action Utilize Family members / friends if appropriate Encourage linkages with other Individuals / Family Agencies / Professionals Evaluate severity of risk

Crisis Intervention: Evaluate Severity of Risk Ask questions that relate to risk factors for lethality: Asking questions that can determine if hospitalization is a medically necessary alternative or if a lesser restrictive option is the most suitable and clinically appropriate course of action FIDO: Frequency Intensity Duration Objective Plan Go with your clinical gut

Crisis Intervention: Safety Contract Safety plans and no-harm contracts First order of business: How will your consumer stay safe? Who will help the consumer in a crisis? Who will they call once a crisis begins? What will they do if crisis erupts? Where will they go in a crisis? These plans are not for us they are for the consumer The consumer needs to show ownership by collaborating, signing, and keeping a copy of the contract Consistent review of the plan is necessary to ensure progress

Crisis Intervention: Safety Contract Part of the plan should include follow-up phone calls and sessions with the primary professional If the plan was successful, encourage the consumer during other sessions to keep up with strategies Ensure accountability

Suicide or Safety Contract Problems: Commonly used, but no studies demonstrating ability to reduce suicide. Not a legal document, whether signed or not. Used pro-forma, without evaluation by psychiatrist. Possibilities: Useful when there is positive therapeutic relationship (do not use when covering for colleague). If employed, outline terms in patient’s record. Useful when they emphasize availability of clinician. Rejection of contracts have significance. Bottom line – still considered within standard of care

Crisis Intervention: Final Analysis You’ve assessed risk and you have discovered: The consumer is in danger and not able to stay in the community. Follow Crisis/ Intake procedures, follow-up with supervisor. Or The consumer has de-escalated within a clinically reasonable amount of time and able to return home.

Crisis Unresolved Hospitalization is necessary: Imminent danger to self / others Has a plan to execute threats to self / other Several courses of action Have consumer assessed further by an M.D. or Licensed Counselor Call 911 if an individual is in immediate danger or If medical emergency arises prior / during crisis Refer Police to EPMHMR Intake for determination / appropriateness for admission to inpatient treatment Call EPMHMR Crisis Line (915) 779-1800 (24hours,365 day) for Mobile Outreach to assess consumer ( as appropriate) Staff must provide on-going crisis intervention Complete an Emergency Detention form by any Adult Coordination between, Police, EMS (if involved) EPMHMR Crisis/Intake, El Paso Psychiatric Center (or identified hospital)

Crisis Resolution Consumer has demonstrated without question that they are not a threat to self or another person De-escalation has lasted for an appropriate length of time, to be determined by the severity of the event crisis and the consumer’s ability to gain control of emotions and actions Medication has been administered and the above has been demonstrated An M.D. or licensed professional has deemed consumer safe to go home and does not recommend inpatient treatment Consumer is sent home (if available with family) or to a temporary respite where safety is assured

Crisis Resolution: Follow-Up Establish open communication to Prevent Future Incidents: All treatment team providers should be notified of incident or crisis situation Supervisor Case Manager Rehab Worker Doctor (if appropriate) Family member (if appropriate) Document all actions and interventions

Crisis Resolution: Preventing Recidivism Follow-Up session within 24 working hours Trag Assessment and Provider Implementation Plan (PIP) or treatment plan Should be revised and amended as appropriate as consumer’s needs have possibly changed Frequency of sessions and treatment objectives may need to be reviewed Family members and all treatment team members should be involved in any revisions Modifications to medication can be adjusted as clinically deemed by a medical professional

What to Document in a Crisis Assessment The risk level The basis for the risk level The treatment plan for reducing the risk Example: This 62 y.o., recently separated man is experiencing his first episode of major depressive disorder. In spite of his denial of current suicidal ideation, he is at moderate to high risk for suicide, because of his serious suicide attempt and his continued anxiety and hopelessness. The plan is to hospitalize with suicide precautions and medications

Mental Status Exam, What is it? The mental status examination (MSE) is based on your observation of the client. It is not related to the facts of the client’s situation but to the way the person acts, talks, and looks while in your presence. This can be an abbreviated process or one that takes place over several interviews.. The MSE always has the same content, and you write your observations in roughly the same order each time. Use descriptions and whenever possible use direct quotes.

What to Observe: General appearance Behavior Thought process and content Affect Impulse control Insight Cognitive functioning Intelligence Reality testing Suicidal or homicidal ideation judgment

Orientation and Level of Consciousness Lethargy: trouble remaining alert and appears to want to drift of to sleep Oriented x3: knows who they are, where they are, and when it is Ask for the current date: reasonably accurate dates are acceptable Ask where the person is Ask who the person is and or DOB

Insight and Judgment Insight is having a realistic understanding of a situation. For example, a person with poor insight into their drinking problem may genuinely believe that there is no problem and their behavior is appropriate. Judgment is the ability to critically evaluate the situation and make good decisions about a course of action.

Appearance Always indicate when you this is present. It involves such things as body odor, looking disheveled, or an unkempt appearance. Would include dirty, stained, or rumpled clothing.

Attitude and Interpersonal Style Always note hostility, aggressiveness, rudeness, uncooperativeness, sarcasm Always note if a person is uncooperative. Always note boundary violations. This occurs if the person is too friendly, touches you, or attempts to draw you out personally

Behavior and Psychomotor Activity Always indicate any mannerisms you see and any posturing. Always indicate tension, particularly if the person seems tense and the interview does nothing to relax the person. This can include tensed fist, or an otherwise stiff posture. Always note severe akathisia (restlessness). It can be part of an illness, a sign of withdrawal, or a medication side effect. Try to establish when it started, how long it has gone on, and if it has gotten worse.

Behaviors and Psychomotor Activities Always note: Pacing Fidgeting Nail biting trembling or tremulousness Rocking Bouncing Grimacing (particular strange facial movements)

Tardive Dyskinesia: Occurs when psychiatric patients have been on antipsychotic medications over a long period of time. The term literally means “late appearing abnormal movements” Involves the muscles of the face, mouth, and tongue. Sometimes the trunk and limbs are also affected Movements can be quick or slow. All the movements are brief, involuntary, and purposeless. A person may twist the tongue and lips, make odd faces, bounce or tap the feet, or actually writhe and squirm in the seat.

Catatonic Behavior A sign of severe depression or schizophrenia, catatonic type. Generally appears as a rigidity of posture where attempts to reposition the person are rigidly resisted. The person may pose in bizarre and inappropriate ways. One form, waxy flexibility, is when the limbs of the person will remain in the position in which they are placed.

Speech and Language Pressured: often rapid but constantly talking; cannot be interrupted. Thoughts appear to be racing. Monotonous: no variation in tone Emotional: very expressive Accented: note a native accent and also if the patient seems to accent certain words or syllables Impoverished: may say very little either because of depression or because they are being interviewed in a language other than the native tongue. May indicate some lack of facility with language. Neologisms: Made up words with idiosyncratic meanings. This can happen with because of brain injury due to accident or stroke.

Aphasia Loss of ability to understand and produce language; damage usually to left hemisphere of the brain (left-handed people often have this in the right hemisphere). Global: can neither speak nor understand Broca’s aphasia: can understand written and spoken language, but has trouble expressing own thoughts verbally Wernicke’s aphasia: inability to understand language and uses fluent, bizarre, nonsensical speech. The person may also act strange and appear euphoric, paranoid, or agitated. Note: In schizophrenia the person is usually able to write and speak, repeat words, and name objects. Perservation: repeating a verbal or motor response to a prior stimulus even when confronted with something new. May give the same answer to different questions, stay on the same topic, or repeatedly return to the same subject

Mood Euthymic: normal mood Expansive: feels very good and is getting better Euphoric: giddy and happy Anxious: worried and distressed

Sleep Disturbance Initial insomnia: trouble falling asleep Middle insomnia: waking up in the middle of the night Terminal insomnia: early morning wakening. Depressed individuals will often wake several hours earlier than usual and feel most depressed in the mornings. Hypersomnia: sleeping too much.

Memory Short term memory: immediate recall limited to about seven items and generally lasts for about one minute. Long-term memory Amnesia: inability to remember Anterograde amnesia: cannot learn NEW material Retrograde amnesia: cannot recall recent past events

Memory Testing As if they have had problems with memory. Test immediate recall using a random list of digits asking the person to repeat them. Start with two and keep adding digits until two consecutive failures. Test recent memory by asking them what happened in the last few hours or days before coming to see you. Test remote memory by asking the client to recall events in their lives and commonly known public events that happened in years past.

Thought Content Distortions: a person distorts a part of reality. A woman with anorexia believes she is fat when she is thin. Delusions: an inappropriate idea from which a person cannot be dissuaded using the normal means of argument or evidence. Delusions indicate psychosis. Paranoid delusions: being singled out for harassment or are being controlled by forces outside of themselves.

Disordered Perceptions Illusions: the person either misperceives or misinterprets a sensory stimulus. A tree branch brushing the side of the house in the winds sounds like people entering the house or a fan sounds like people talking in another room. Hallucinations: in the absence of external stimuli, the person perceives something. The most common hallucination is hearing voices but there can be visual or hallucinations that are smells. If the person hears voices try to determine who is talking, what they are saying, how the person feels about it, and is there a command to do something. Depersonalizations: the person feels estranged or detached from self. Derealization: the person feels detached from what is going on around them. A person who dissociates cannot always be sure that what is happening is real.

Delusions Common to Schizophrenia Thought withdrawal: one’s thoughts are being taken out of one’s mind by an outside force Thought insertion: thoughts are being placed into the mind Thought broadcast: thoughts are being taken and broadcast so that others know Suspiciousness: always describe this and report the object of the suspicion Grandiose delusions: false belief that one is extremely important or imbued with special powers. Somatic delusions: false beliefs about health Magical thinking: thinks they have magical powers with words, thoughts, or actions. This thinking is found in children who have not developed reality testing.

Reliability Briefly state you impression of the clients’ reliability and accuracy in giving you the details of their situation. If a person is psychotic, the material presented is likely to be extremely unreliable.

Debriefing Utilization of Peers for Debriefing Prevention of Secondary Trauma

Intake & Crisis Emergency Services 24 Hours, 7 Days a week, 365 a Year 1600 Montana El Paso, TX 79902 (915) 779-1800 Crisis Hotline Array of Services: Crisis Hotline Mobile Crisis Outreach (E.R. Based) Mobile Crisis Outreach (Community Based) Walk-In Crisis Services (Site Based) Walk-In Outpatient Services (Site Based) Remote Walk-In Services (RV) (Tele-Psychiatry) Crisis Follow-Up

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