Kathy D. Robinson, PhD, LPC, CPCS, NCC

Mercer University

Penfield College – Department of Counseling

Prevention Raise awareness and empower individuals to seek assistance.

Intervention During a crisis when an individual is imminently suicidal.

During a longer period of time when a individual has an ongoing, lower-level risk but still may be monitored; and

After a suicidal crisis, when the individual is stabilized.

Postvention Interventions that occur AFTER a suicide for spouses, partners, parents, family,

friends and the community.

Defining the Problem

Understanding the Suicidal Mind

Risk and Protective Factors

Warning Signs

Prevention Question Persuade and Refer (QPR)

Mental Health First Aid (MHFA)

Crisis Intervention Team (CIT)

Intervention and Treatment Considerations

Columbia Suicide Severity Rating Scale (CSSRS)

Lethal Means

Brown and Stanley Safety Plan

Georgia Crisis Access Line (GCAL)

1013 Involuntary Transport

Collaborative Assessment and Management of Suicidality CAM)

Postvention Debriefing

Support Groups

Psychological Autopsy

Resources

Suicides and Suicide Attempts Are Significantly Affected by Substance Use.

Individuals with substance use disorders (SUDs) are particularly susceptible to suicide and suicide attempts. Indeed, suicide is a leading cause of death among people who misuse alcohol and drugs.

Substance misuse significantly increases the risk of suicide:

Approximately 22 percent of deaths by suicide involved alcohol intoxication, with a blood-alcohol content at or above the legal limit (CDC, 2014b);

Opiates (including heroin and prescription painkillers) were present in 20 percent of suicide deaths, marijuana in 10.2 percent, cocaine in 4.6 percent, and amphetamines in 3.4 percent (CDC, 2014b).

(SAMHSA, 2008; HHS, 2012; Wilcox, Conner, & Caine, 2004; Pompili et al., 2010).

Who is your client?

Few counselor education, psychology, or psychiatry programs train clinicians to deal with suicidal clients. Most mental health professionals receive only two hours of formal suicide training.

No other patient behavior generates more stress and fear among mental health professionals than suicidal behavior.

There have been exponential increases in suicide-related malpractice liability lawsuits against mental health clinicians.

Suicidal behavior is the most frequently encountered mental health emergency.

50% of practitioners fail to detect suicidal ideation.

One in five mental health counselors will lose a client to suicide.

71% of mental health counselors have at least one client attempt.

(Berman, 2007; Beutler, Clarkin, & Bonger, 2000; Foster & McAdams, 1999; Peterson, Luoma, & Dunne, 2002; Rogers, et al., 2001)

Why do people die by suicide?

What are my beliefs about suicide?

Who do I know that has died by suicide?

Suicide typically does not have a simple cause; it has a complex developmental history.

Mental pain or “psychache” may lead one to seek death through suicide as an escape.

Suicide is not a specific disorder, but a painful process accompanied by biological, psychological, social, and existential factors.

Psychological studies indicate that more than 90% of individuals who died by suicide had a diagnosable psychiatric disorder.

Suicide attempts are not attention-seeking; they are help-seeking.

(Foster & McAdams, 1999; Peterson, Luoma, & Dunne 2002; Shneidman, 1999)

Can’t See Way Out

Can’t Live With Burden

Can’t See a Future

Can’t Live “Like This”

Can’t Get Control

Can’t Cope With Feelings

(AAS & SPRC, 2008)

Can’t Stop the Pain

Can’t See Self as Worthy

Can’t Feel Anything

Can’t Sleep, Eat, or Work

Can’t Think Clearly

Can’t Get Help

Why People Die by Suicide

Dr. Thomas Joiner

Mental Illness

Substance Abuse

Physical Illness

Loss

Relationship Instability

Childhood Trauma

Family History

Inadequate Coping Skills

Perceptions of Suicide

Previous Attempts

Poor Support System

Suicide Rehearsal

Access to Weapons

Disconnect from Peers

Financial Debt

Barriers to Care

(AAS & SPRC, 2008)

Problem-Solving Skills

Good Coping Skills

Conflict Resolution Skills

Community Connection

Restricting Means

Increased Resiliency

Family Cohesion

Extended Supports

Religion/Spirituality

Pets

Optimistic Outlook

Access to Care

Quiet & Withdrawn Behavior

Changes in Behavior & Personality

Recent Family Changes

Recent Loss or Losses

Symptomatic Statements & Acts

Difficulty Concentrating

Preoccupation With Death

Burdensomeness, Lack of Belongingness, & Capacity to Complete Suicide Act

(AAS & SPRC, 2008; Joiner, 2010)

Any previous suicide attempt

Acquiring a gun or stockpiling pills

Co-occurring depression, moodiness, hopelessness

Putting personal affairs in order

Giving away prized possessions

Sudden interest or disinterest in religion

Drug or alcohol abuse, or relapse after a period of recovery

Unexplained anger, aggression and irritability

DIRECT VERBAL CLUES

“I’ve decided to kill myself.”

“I wish I were dead.”

“I’m going to commit suicide.”

“I’m going to end it all.”

“If (such and such) doesn’t happen, I’ll kill myself.”

INDIRECT VERBAL CLUES

“I’m tired of life, I just can’t go on.”

“My family would be better off without me.”

“Who cares if I’m dead anyway.”

“I just want out.”

“I won’t be around much longer.”

“Pretty soon you won’t have to worry about me.”

While some suicides are deliberative and involve careful planning, many appear to have been hastily decided-upon and to involve little or no planning.

Chronic, underlying risk factors such as substance abuse and depression are also often present, but the acute period of heightened risk for suicidal behavior is often only minutes or hours long. (Hawton 2007).

Three steps anyone can learn to help prevent suicide.

Identify, understand and respond to signs of mental illness and substance use disorders

Helps to recognize a suicidal person and create a plan that supports their safety.

Assess lethality

Establish rapport

Identify major problems

Deal with feelings

Explore alternatives develop action plan

Follow up

Connection Stability Safety

END GOALS

Assess for and rule out emergency risk

Plan to conduct multiple assessments

Integrate risk assessment early & often

Elicit risk and protective factors

Elicit suicide ideation, behavior, and plans

Elicit warning signs

Elicit lethal means

Obtain records from collateral sources

Formulate a clinical judgment of risk

Be able to justify your decision (AAS & SPRC, 2008)

Is a subjective clinical judgment

Based on clinical and collaborative evidence

Gauge coping skills and resources

Gauge intent and lethality

Consider psychopathology

Assess compliance with the clinician

Be able to justify your decision

Document your rational (Jobes, 2007)

Just ask. Because you can save a life. Columbia University Medical Center

Three versions of the Columbia Suicide Severity Rating Scale are available for use in clinical practice.

The Lifetime/Recent version allows practitioners to gather lifetime history of suicidality as well as any recent suicidal ideation and/or behavior.

The Since Last Visit version of the scale assesses suicidality since the patient’s last visit.

The Screener version of the C-SSRS is a truncated form of the full version.

• Answers on the C‐SSRS provide the

information needed in order to

classify someone’s suicidal ideation

and behavior, and when combined

with clinical judgment, can help

determine levels of risk and aid in

making clinical decisions about care.

Training

P.I.M.P.

P- PLAN

I – INTENT

M – MEANS

P – PRIOR ATTEMPT

P.L.A.I.D.

P – PREVIOUS ATTEMPTS

L – LETHALITY

A – ACCESS

I – INTENT

D – DRUGS ALCOHOL

This course explains why means restriction is an important part of a comprehensive approach to suicide prevention. It will teach you how to ask suicidal patients/clients/students about their access to lethal means, and work with them and their families to reduce their access.

http://training.sprc.org/enrol/index.php?id=3

WHAT WE KNOW...

• Access to lethal means can determine whether a person who is

suicidal lives or dies.

• Research has shown time and again that reducing access to

lethal means or “means restriction" can saves lives.

• By reducing or restricting access to firearms and other highly

lethal methods the decline in suicide rates by that method and

overall suicide rates begin to decline.

• The majority of suicidal individuals, if prevented from accessing

their planned means, will not substitute one means of death for

another.

A safety plan IS NOT a “NO SUICIDE CONTRACT” which is not recommended by experts in the field of suicide prevention. As they are generally used, no-suicide contracts ask patients to promise to stay alive WITHOUT telling them HOW TO STAY ALIVE.

A brief intervention for individuals at increased risk but not requiring immediate rescue. They are not in danger of ACTING.

Use with clients who have...

Made an attempt

Suicide ideation

Psychiatric disorders that increase suicide risk

Otherwise been determined to be at risk for suicide

Fills a gap for in-between settings

Not a substitution for treatment

It IS NOT A FORM, it is a CLINICAL INTERVENTION.

Reduces access to lethal means

Teaching brief problem-solving and coping skills

Enhancing social support and identifying emergency contacts

Using motivational enhancement to increase likelihood of engagement in further treatment

Explain purpose of the safety plan

Encourage active participation

Let them do the work

Let them verbalize their “own picture”

Teach them how to progress through each step

After completion, role play with them

Safety Plan

Training

Intended to de-escalate crisis situations

Relieve the immediate distress of individuals experiencing a crisis situation

Reduce the risk of individuals in a crisis situation doing harm to themselves or others

Promote timely access to appropriate services for those who require ongoing metal health or co-occurring mental health and substance abuse services

A 1013 is a legal certificate governed by State law.

Once it is signed by the appropriate professional, it requires the individual to be TRANSPORTED to an EMERGENCY RECEIVING HOSPITAL.

Only certain hospitals are ERF’s

List is on DBHDD website

An Emergency Room is not necessarily an ERF

It is recommended we do everything possible to avoid writing a 1013/2013

Helping an individual access care voluntarily is powerful.

(Schneider, W., BHL, CEO)

A therapeutic framework for suicide-specific assessment and treatment of a patient’s suicidal risk.

Structured, problem solving therapies Dialectical Behavior Therapy

Cognitive Behavior Therapy

Post-traumatic loss debriefing is a structured group process approach to help survivors manage their physical, cognitive and emotional responses to a traumatic loss.

It creates a supportive environment to process blocked communication which often interferes with the expression of grief or feelings of guilt.

It also serves to correct distorted attitudes toward the deceased, as well as discuss ways of coping with the loss.

The purpose of the debriefing is to reduce the trauma associated with the sudden loss, initiate an adaptive grief process and prevent further self-destructive or self-defeating behavior.

Survivors of Suicide (SOS) Support Groups – AFSP and AAS provides a directory for suicide loss survivors.

Psychological autopsy is one of the most valuable tools of research on completed suicide.

The method involves collecting all available information on the deceased via structured interviews of family members, relatives or friends as well as attending health care personnel.

The psychological autopsy helps promote understandings to the often-asked "why?" question raised by survivors regarding the suicide of their loved one.

AMERICAN ASSOCIATION OF SUICIDOLOGY (AAS) http://www.suicidology.org/

AMERICAN FOUNDATION FOR SUICIDE PREVENTION (AFSP) https://afsp.org/

SUICIDE PREVENTION RESOURCE CENTER (SPRC) https://www.sprc.org/

DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL DISABILITIES