The Assessment, Management, and Treatment of Suicidal PatientsEthics and Psychology PodcastEpisode #25

Hosted by Dr. John Gavazzi, PsychologistBoard Certified in Clinical PsychologyDr_Gavazzi www.ethicalpsychology.com

This podcast fulfills Act 74 requirements for Pennsylvania licensed psychologists, social workers, marriage and family therapists, and professional counselors.

The Assessment, Management, and Treatment of Suicidal Patients

An Introductory Podcast

Special Guest: Samuel J. Knapp, EdD, ABPP

Disclaimer

This podcast/video can only provide a basic introduction to the assessment, management, and treatment of patients at risk to die from suicide. As an educational program, it does not purport to provide clinical or legal advice on any particular patient.

Participants with concerns about the assessment, management, or treatment of any particular patient are urged to seek clinical or legal advice. Also, individual psychotherapists need to use their clinical judgment with particular patients and incorporate procedures or techniques not covered in this podcast/video or modify or omit certain recommendations herein because of the unique needs of their patients.  

A Note on CompetenceA brief program of this nature can only highlight some important facts about suicide assessment, management, and intervention. It may serve as an update or refresher for experienced clinicians. However, competence in assessing, managing, or treating suicidal patients can only come with more extensive education and supervised experience.

Learning Objectives

At the end of this program the participants will learn basic information that will help them to

1. Assess patients who are at risk to die from suicide;

2. Manage the risks of suicide; and

3. Treat patients who are at risk to die from suicide.

General OutlineSuicide is the 10th leading cause of death in the United States and the most frequent crisis experienced by mental health professionals.

This podcast/video reviews basic information about the assessment, management, and treatment of patients at risk to die from suicide.

It fulfills Act 74 requirements for Pennsylvania licensed psychologists, social workers, marriage and family therapists, and professional counselors.

Outline•Assessment of Suicide

•Screening Instruments

•Suicide Management (4 M’s)

•Interventions

•Quality Enhancement Strategies

Assessment – Step 1•Asking about suicidal thoughts, plans, and

intentions; does not increase risk.

•Needs to be part of an initial assessment

•If the patient denies current suicidal ideation, plan, and intent, then can revisit later if needed.

•Important to ask about a history of suicidal ideation, plans, and attempts.

Assessment – Step 1

•If a patient reports a low level of suicidal ideation or history, then it may be appropriate to continue with assessment.

•Passive versus active suicidal ideation

•About 4% of Americans will report SI in the past year and about 1/3 of those with suicidal plan.

Assessment - Step 1

•Often, people with SI will deny it.

•Fear of hospitalization, negative appraisal of psychologist, or actual desire to complete.

•If a patient denies suicidal ideation with other risk factors, such as a history of attempts, significant depressive symptoms, co-morbid substance abuse, impulsivity, etc., move to the second step.

Assessment - Step 2•Effective helpers will interview in a

respectful, nonjudgmental and caring manner.

•Baseline Factors

•Acute Features

•Dynamic Variables

•Protective Factors

Baseline (static) Factors

•Age

•Race

•Gender

•Sexual Orientation

•Unemployment

•Lack of Access to Healthcare

•Substance Abuse

Acute Factors

•Suicidal ideation

•Prior attempts

•Psychiatric History

•Recent stressors

•Medical Conditions

•Lack of Support

•Access to means to attempt suicide

Dynamic Variables

• Thwarted belongingness

• Perceived burdensomeness

• Emotional pain (mental illness)

• Physical illness (disability or pain)

• Guilt and/or moral challenges

Protective Factors

•Religious beliefs or affiliations

•Marriage

•Children

•Other support networks

Step Three: Screenings

• Columbia Suicide Screening Rating Scale

• Suicide Behavior Questionnaire – Revised

• Beck Hopelessness Scale

• Beck Suicide Ideation Scale (Pearson)

Balancing Factors•Very difficult to predict which individuals

will act upon suicidal ideation

•Previous attempts single best predictor

•Detailed plans are at higher risk

•May want to quantify: low, medium, high risk

The Four M’s of Management

Motivate

Means

Medicate

Monitor

Motivation Tools• Commitment to Life (Treatment) Agreement

• Reasons for living

• Avoid people, places, and things

• Symbols of hope

• How to manage distress

• Crisis numbers if needed

Means Restriction

•Details of suicide plan and remove guns, medications, etc. away from patient

•Patients seldom substitute one means of suicide for another

Medication

•A management strategy for schizophrenia or bipolar disorder

•Its effectiveness in reducing short-term suicide risk in other patients is unclear

•Increased risk when starting or getting off medication

Monitoring•Continue to measure suicidal ideation and plans

•Day-to-day check ins or monitoring with patients consent may be indicated for some patients

•Hospitalization in extreme cases

Quality Enhancement Strategies

The positive reframe on Risk Management Strategies

Quality Enhancing Strategies

As the legal risks, the possibility of treatment failure, or patient

complexity increases,the greater the level of attention

should be given to quality enhancing strategies.

Quality Enhancing Strategies

Consultation

Empowered Collaboration

Documentation

Redundant Protections

Consultation

Technique oriented information

Emotional reactions

Reduction of emotional turmoil

Thinking through solution together

Consultation

Write down issues in advance

Need to be open and honest

Be willing to admit mistakes or clinical errors

Empowered Collaboration

Empowering psychologists respect a patient’s autonomy and decision making skills about the goals of treatment, process of treatment, and life choices.

Examples of tough decisions and ambivalent patients

Documentation: Legal Purposes

Required by insurers, State Board of Psychology, APA Ethics Code, etc.

A record of treatment for future providers

Useful risk management tool

Write out evaluation, decision-making steps, consultations, and final decision

Redundant Protections

Multiple layers of information in order to provide the highest level of care

Another health care provider Psychological testing or screening device Family member or significant other Consultation

Why Redundant Protections?

Avoid errors in judgment

Obtain essential information

Promote greater chance of success

(Obtain prior records)

Suggested Checklist for Ongoing Treatment

Patient Collaboration Self-Reflection

1. Does the patient think you have a good working relationship?

2. Do my patient and me share the same treatment goals?

3. Does the patient report any progress in therapy?

4. Does the patient want to continue in treatment?

1. Do I believe I have a positive working relationship with my patient?

2. Is my assessment of the patient sufficiently comprehensive?

3. Do unresolved clinical issues impede the course of treatment?

4. Have I documented appropriately?

The EndPlease complete course evaluation if you are looking for CE credit.

www.papsy.orgPennsylvania Psychological Association