 Hey there everybody. We're getting ready to get started. Let me find my correct clickers. Alrighty. I hope everybody is having an amazing, what day is today? Thursday. It's kind of nasty outside here in Tennessee today so I'm rather glad to be working. Good afternoon everybody and welcome to today's presentation on crisis intervention and preventing suicide. This is based in part on the APA practice guidelines and in your additional resources section of your class, there's the full text to it if you really want to look at it, but we're just going to obviously in a little over an hour hit the highlights. So we're going to talk about how to estimate suicide risk. We spent quite a bit of time yesterday in legal issues talking about involuntary commitment and one of the reasons people very often get involuntarily committed is because they are a suicide risk. So we're going to talk about how to estimate that and you know we really have not found a foolproof way of doing so which is why it is so important when you have a client who is suicidal or you think may be suicidal to consult to make sure that you can document that you know another reasonable person with your levels of education and training would have made a similar decision. So if you consult you can document that and you know the decision was made to not involuntarily commit and the person does attempt suicide you've got a little bit more legal recourse to protect yourself saying you know none of us saw it coming. Factors altering the risk of suicide and attempted suicide so we're going to look at things that we can do to prevent suicidal ideation and suicide as well as you know if somebody is in crisis what we can do to try to intervene. Additional considerations and specific treatment settings so if somebody becomes suicidal or goes into crisis in residential or outpatient what do we need to do. Strategies for enhancing motivation and promoting treatment engagement. When somebody is clinically depressed and they're to the point where they just don't feel like they can go on living having them have motivation to do worksheets and journaling is it's tough so we're going to talk about ways to increase that motivation. We'll talk about education points for the client and family and risk management and documentation issues. So it's important to remember that all clients perceive events uniquely based on their history you know what is traumatizing for one person may not be a big deal for another person. So you don't want to assume as we talked about in trauma informed care that you know how a client is interpreting or reacting to an event. All clients participate in care that is respectful and non-judgmental in crisis intervention because you know now's not the time for them to be feeling like they're judged or they're looked down upon because they're already feeling vulnerable and threatened. Reflection and empathy is most effective you know let's just hear what the person has to say because right now they're feeling out of control they feel like they're spinning so if they can bounce some things off of us if we can empathize with how out of control they may be feeling right now that gives them a sense that okay somebody kind of gets it there might be some hope. Ego strength is a variable among individuals and it's influenced by past experiences and social support so who they are what they want you know if they're a good person all those beliefs that they may have you know depends on the person some people have very little ego strength and they're always chameleoning trying to be what everybody else wants them to be in order to get approval their self-esteem is really low etc. It's important that clients and families are actively involved in collaboration and decision-making because they want to feel you know in crisis it feels like everything's out of control hopeless helpless when they start making progress it's important for them to feel like they're in control of the process they're developing that self-efficacy again. We want to remember that stress is a normal part of existence and can foster self-development and growth and crisis I mean I have never met someone who hasn't at some point in their life gone through a crisis or 12 you know things happen and it can you know throw you into sort of a proverbial tailspin for a few minutes but it doesn't mean that you're broken it means that you've you know hit a barrier where you've never had to do something like this before or you've overwhelmed the skills that you do have so you're gonna have to be creative and grow and develop from it you know people can go through hardships that they never knew they could handle you know you ask them later you know how did you get through that and they're like I never thought that I could manage something like that and lo and behold I did and so we start talking about that growth that came out of it and we need to remember that all clients are capable of assuming personal responsibility and you know you may say well if somebody's in crisis they may need to be involuntarily committed okay maybe but at some point you know when they're in a frame of mind where they're thinking clearly and everything they're capable of assuming personal responsibility 99% of the time or you know much greater actually because 99 is one out of every 100 but much greater than that 99.99% of the time even when clients are in crisis they're thinking clearly enough to assume personal responsibility and say yes this is something I need or no this is not all clients grow and change in an environment of acceptance trust and empathic understanding so there's that humanistic thing coming out but it's true if we accept them and we trust that they know what's best for them and we understand where they're coming from you know we try to get into their head and you're not going to understand exactly where they're coming from because you haven't been there but we can accept that their point of view may be right you know that whole dialectics thing we both can have very valid points so we want to accept that they have valid points they have valid opinions that we want them to feel validated. Sustain change occurs when clients feel ready and supported and people have a need for self mastery and control which is why we need to bring them in and get them involved and say all right I'm sure you've gone through you know tough times before or what do you think could help you at this moment instead of doing things to and for the person asking them all right I need you to help me here because you're the expert on you help me see what it is I can do what you need. Crises can be screwed as danger or opportunities for growth so if we can help change the paradigm instead of feeling hopeless helpless out of control as one of a challenge that is the opportunity to grow then it can be you know a little bit more liberating and motivating to the person. Think about you know when you want to take your GREs your SATs or any of those tests that you really can't study for I mean you can prep but you can't study it feels overwhelming at least it did to me because I was one of those people who likes to study likes to know the answers and going into those I could have approached it like oh my gosh you know I have no idea what's going to be on this test and I'm going to be completely overwhelmed and yada da da da but instead I said you know I've done the test prep class I've done everything I can do until now you know with the skills and tools I have let's go see you know I looked at it as a challenge to see how well I could do on something that wasn't the normal way I prepared for things and you have to learn to take tests differently when you do the GRE and SAT and aptitude type tests so you know it's kind of the same thing on a much more impactful scale when we're talking about crises encouraging clients to look at what they have you know not you know let's take a gratitude inventory right now that wouldn't be sensitive or appropriate but we can say all right you know your life is very chaotic right now your husband left you lost your job and you've got three kids and you have no idea how you're going to pay the bills and yada yada so the person's in crisis okay who can you rely on what social supports do you have what financial stuff do you have you know savings accounts and stuff what community resources are there to help you start making a list of all the strengths and resources that this person has so they can go okay I'm not feeling quite as out of control there are options crisis intervention is an active process that focuses on the immediate problem we're not talking about dealing with how she feels about how her spouse you know walked out on her we're talking about dealing with the immediate problem she's concerned about providing for her children crisis intervention is time limited you know generally crises don't last more than a few days or a week or so before the person you know either starts to feel better or become suicidal because you know when they're really intense crises some crises can go on a little bit longer but crisis intervention you're really looking at you know a month or less for crisis intervention services now the person may still need counseling services after that to deal with some of their other stuff but the presenting problem should be able to be on its way to being resolved in a month advocacy is essential you know when somebody's in crisis it's up up to us to advocate for them with their family with their you know obviously with appropriate releases of information yada yada but to help them in whatever way they need so if we're seeing a client who's in crisis and you know maybe they would benefit or they think they would benefit from increasing their dose of antidepressants or something um and they want us to advocate for them with their position in order to make that happen you know obviously it's going to be a clinical decision if they're trying to get you to get the uh prescribing doctor to prescribe them you know a whole bunch of medications for you know that are addictive and stuff and and you your spidey senses are going off going i'm not sure that's really going to help the problem but we can still advocate with the physician and provide him a written summary of kind of what's going on and how the client is right now and what the client thinks he or she needs and then let the physician decide from there but we can help serve as an interim intermediary we can also help the client identify um what what it is that they need because sometimes they don't even know so we can just sit down and we can say all right let's just make a list here of the things that have helped in the past and what we might be able to do because that stops all the spinning that's going on in their head and it puts it down on paper even if they're not visual learners just putting it down on paper can very often help because then it feels like they're getting grounded and it can as as you pointed out um help the client feel validated when we advocate for them to say you know you're not broken um you're you're struggling right now but there are things that we can do so let's work together because they feel i don't want to say like we're on their side but they feel like what they're asking for is not unreasonable at that point um the focus is always on increasing the client's level of social occupational cognitive and behavioral functioning so socially we want to increase their social support you know wherever that is if it's support groups or people they already have in their network we'll talk about that because in a crisis people need more support and it can be assistance with their kids because sometimes you know when if you have a a child that's in the hospital and you have other children at home you're going to be stressed out about that child that's sick but then you're going to need help with the kids that are at home if you know something happens and you know the caregiver is just clinically depressed and and in crisis they may not have the energy and and ability to think through the process of cooking meals and stuff for a little while i mean we see this when people are grieving in that initial grief process what do we do for wakes and stuff we bring over casseroles we say you know what we know that you don't have the energy to cook right now so we're going to help them focus on what their social supports are but also what resources are in the community that can help them um occupationally help them with figuring out how to take time off from work if they need to how to get through work if they can't take time off how can you just kind of get through the process or whatever they need cognitively we're going to help them look at the situation maybe from a broader perspective you know open up that tunnel vision and behavioral functioning looking at what can you do that's going to help you feel better what can you do that or what do you want to avoid that might make you feel worse such as drinking or not sleeping or whatever 10 step trauma management protocol wouldn't it be great if it were that easy just 10 steps bing bang boom they're done but it's not so the first thing we want to do is assess for danger to safety for self and others this means the victim us the counselors and anybody else who may have been affected by the trauma so if there's a trauma that happens um you know you want to see where this person is and and we'll use the uh school shootings as an example because you know it's a trauma everybody's talking about right now for each client that we're talking to uh each person that was in that in that school or related to someone in that school we want to assess for danger for self and others are they feeling hopeless helpless out of control defeated um what about you know obviously if there were the victims of a trauma you know any of them who were actually in there um we want to assess how they're doing we also want to assess the counselors that are talking to the the victims for vicarious trauma and you know we want to look at all aspects you know anybody who's touched by this trauma how are they doing consider the physical emotional and perceptual mechanisms of the injury physical mechanisms obviously if the person was punched raped shot whatever emotional how did it make them feel unsafe out of control angry you know any of those dysphoric emotions um and even remember in trauma you can have some some people who come out of it and feel elated because they kind of got through it's that rush of adrenaline like oh my gosh I survived and then they may feel guilty because they felt elated so we got to look at all that stuff and perceptual mechanisms how did it change how they perceive the world their safety the goodness of other people the environment you know all that kind of stuff so cognitive emotional and physical the victim's level of responsiveness should be evaluated or the person in crisis their level of responsiveness should be evaluated to see you know are they here or are they in you know denial and I'm not talking about Egypt because sometimes right after a trauma people just kind of shut down and they're physically there but they're in such a state of shock that they're not respond really responsive right now address any medical needs if the person's in crisis or if there was a trauma you know make sure that they are medically stable and that can include if you know anybody you know if it's a trauma situation like like the shooting any of the the survivors that came out making sure that they have enough food and water and anybody who's diabetic is getting their insulin tested and making sure that stays stable and they're staying medically stable I mean they're not going to be great after a trauma but we want to make sure they stay stable and we don't have other things because stress makes blood sugar go all over the place high blood pressure can also be elevated so check the teachers for high blood pressure identify signs of traumatic stress after a trauma or if you're dealing with someone in crisis again look for signs of traumatic stress maybe a trauma that happened that is now prompting this current crisis connect with the individual by developing rapport go figure build rapport by allowing the client or person to tell their story help me understand what's going on here you know instead of going in and going all right I need you to I need you to you've got to that's taking all their power away if you can start out with help me understand what's going on here now sometimes you need to set some limits ahead of time to make everybody you know a little bit safer if there's you know when there were fights on the day room in the day room I would have to say all right I need everybody to go to their rooms right now or sit down or whatever the case was and then I would say you know this person you need to go with that therapist you why don't you come with me let's go take a walk and let me understand what's going on you know because I wasn't there fill me in and so we're not taking their power away we're not trying to fix the situation but it's you know getting everybody safe and into a place where we can start as interveners can start understanding what's going on if a client's in your office obviously you just have to say all right help me understand provide support through active and empathic listening you know no judgment here it was a crappy situation or or whatever let me let me just hear normalize validate and educate individuals emotions stress and adaptive coping styles so I can't imagine what it's like to be going through this like you are you know normalize the emotions they're feeling from anger to guilt to relief to whatever it is help them understand what normal stress reactions are going to look like or traditional stress reactions are going to look like after a crisis or a trauma so they can go okay you know this is not unexpected when people are in crisis the worst thing that can happen or one of the worst things that can happen is for the unexpected to happen so if we can say you know you may not experience any of these symptoms but let me tell you what might happen just so you're not caught off guard it helps them feel more in control and we'll talk about adaptive coping styles what you're doing right now you know crying asking for help is not a sign of weakness it's a sign that you're trying to survive you know after your after the trauma you know maybe the trauma happened a year ago or something and the person started drinking or you know we'll just use that because that's a really common example and and instead of pathologizing it we can say you know you had to figure out how did it make the pain stop somehow and nothing else was working now you're trying to look for other options or now the alcohol is not working either and you're feeling just out of at the end of the road and then go from there bring the person to the present describe future events and provide referrals as needed so we want to talk about what is it that you need right now you know I understand all this stuff that happened yesterday or last week or over the past six months you know they've told us that story and that's a lot to deal with so you know what is it that at this very moment you're needing you know in the next 24 hours what is it that you might need what you know do you have kids that need to be tended a dog that needs to be walked plants that need to be watered you know have them talk about some of that stuff that's normal for their daily life you know tell me what your normal day looks like so we can figure out you know if they're going well I don't know what I need okay what is your average day look like you get up in the morning what do you do walk them through that so you can figure out if there are dogs kids significant others a job that needs to be alerted etc and then you can start saying alright now how are we going to handle all this which means you're talking about about making future plans if somebody's willing to make future plans that is always a good sign it isn't a be all end all but it's a good sign the safer or model and I've added the extra are stabilize obviously you know if somebody's in crisis they're not thinking as clearly they feel like you know they're spinning a fish out of water they can use different metaphors but we want to help them feel like they're stable like they can stand like their legs aren't going to fall out from under them acknowledge what's going on no judgment just let me understand what's going on and acknowledge how tough that is facilitate understanding of you know you need to understand what's going on with them but they may also need some understanding of what's going on with them so they understand why they're having these reactions and they understand what to expect encourage adaptive coping so we're going to look at what are the problems you're identifying and what are the logical steps you can take restore functioning help them see you know we were talking about that daily routine how can you start getting back into that daily routine you may not be a hundred percent so what are the minimum things you need to do I know when I was recovering from surgery it felt like it took forever and I wasn't a hundred percent and it drove me nuts but I had to figure out okay now you know given the amount of energy I have right now what needs to be done and help them you know I restored functioning a little bit as I got more energy I added more things back to my daily routine and then refer you know once you have them stabilized you know what's going on most people in crisis are going to need some assistance and you know most people period need some assistance you're not most of us don't do everything all by ourselves all the time so make sure they know what resources are out there if they need to tap into them prevention is always the best and primary prevention keeps the problem from ever happening so we would avoid trauma you know nobody'd ever be traumatized and we'd avoid anything that would precipitate a crisis well that doesn't happen but we can do things to prevent as much trauma as possible we can do things for example to make schools safer we can do things to make it so people feel safe going to the store and you know other things we can do it do things to make people safe in their neighborhood so that's primary prevention secondary prevention prevents the problem from causing other problems you know okay there's a trauma let's keep it from let's help the person deal with it so they don't also start developing you know generalized anxiety with agoraphobia and substance abuse issues so secondary prevention says all right we've got this let's keep it from getting any worse it's like when you get a cut a cut is one thing if you let it fester if you don't address it then it could turn septic and then it starts affecting all of your organs so and obviously that's way down the line but you want to prevent it from causing other issues tertiary prevention is preventing the problem from getting any worse you know just all right we've got this problem the person has was just diagnosed with hiv or the person you know has clinical depression or is in crisis all right well they're in crisis right now let's prevent it from becoming a suicidal a situation where they may be be feeling suicidal in a suicide assessment obtain information about the patient's psychiatric and other medical history and current mental state now this is when you know ideally you've already done the rapport building and everything and you're actually doing a formal assessment for treatment at this point you're going to identify specific psychiatric signs and symptoms go through your depression and your anxiety checklists look for signs of bipolar disorder psychotic features assess past suicidal behavior including intent of self-injurious acts intent some people injure themselves for reasons other than trying to die and so it's important to understand what was the intent when you did that some people accidentally overdose on on drugs and they weren't intending to die they just you know accidentally overdosed review past treatment history and treatment relationships to figure out what have you done what's worked what hasn't are there any treatment relationships or people we can hook you back up with and identify the family history of suicide mental illness and dysfunction because then you're going to be able to identify some of the contributing factors potentially to the current crisis but also some of the restorative factors if you have a apparent who has a mental illness you know how did they deal with it you know what things helped them so that may give us some clues address the patient's immediate safety and determine the most appropriate setting for treatment so this is a suicide assessment this isn't crisis intervention now we're up to you know the patient is has some suicidal ideation we just don't know where they are on the spectrum at this point develop a biopsychosocial differential diagnosis to further guide the planning of treatment remember suicide assessment scales lack the predictive validity necessary for use in routine clinical practice so that is the long disclaimer that's in there that says you can use these scales to see how suicidal somebody potentially is but their their reliability and ability to accurately predict who's going to attempt suicide and who's not pretty low because you can have two people who have similar levels of suicidal ideation and one may attempt and the other one may not and we just don't know how to figure out identify specific factors and features that may generally increase or decrease risk for suicide or other suicidal behaviors and that may serve as modifiable targets so social support network is it good if it's good it can mitigate the suicidal ideation you know we might be able to pull that in and you know who can help you if the social support network is you know one of the main causes of the distress at this point then we're going to try to figure out other workarounds where we can help them get social support but it may not be from their primary network right now cultural religious beliefs particularly as they relate to death or suicide some religions and cultures see suicide as an honorable thing to do when to prevent shame from coming to the family other cultures see suicide as a unforgivable sin so so looking at cultural religious beliefs now you've got to remember culturally responsive approach helps us understand that just because I happen to be a white female Catholic doesn't necessarily mean I embrace white female Catholic principles you know you know I am from I have certain I have certain ethnicities and cultures that I associate with but it doesn't mean that you know I have embraced those values so you don't want to assume that because someone is a certain ethnicity or religion or whatever that they necessarily embrace the values of that culture nature frequency depth timing and persistence of suicidal ideation so if their suicidal ideation you know happens once a year you know not very often it comes it's a person feels suicidal for a day or two and then it goes that's different than someone who feels suicidal you know seven times a month and it's really intense the depth of the suicidality is also important you know are they have an ideas about it or do they have a plan and they have the means and everything's kind of good to go so we want to figure out where they are the timing you know sometimes the timing corresponds to certain holidays sometimes it is you know maybe when somebody is alone you know at night they get suicidal during the day they're doing fine they're they're busy they're at work whatever at night they go home they start to think they get kind of trapped in their own head and they become suicidal so all these things are things we're going to think about and if for that person we're going to say how can we help you in the evening you know first thing I would think of is is there somebody you can stay with for a little while so you're not alone at night and you have somebody you can rely on if not let's look for hotlines let's look for people that you can call who are willing to pick up the phone anything that can help help you kind of get out of your own head if ideations present you want to know more detail about the plans how are you going to do it do you have the means yada yada and remember if they plan on doing it one way and they don't have the means and something exacerbates their their suicidality and they decide I'm going to do it they may choose a different method so don't assume that just because they said they were going to commit suicide this way and they don't have access to that means right now don't assume that means you're you're free and clear identify the current psychosocial situation and the nature of the crisis you know get a broad picture of what's going on and appreciate the psychological strengths and vulnerabilities of the individual patient so you know maybe one of their vulnerabilities is they worry about everything and they're they're stressed out and tend to go from zero to 220 and 2.3 seconds okay that's a vulnerability but one of their strengths is they persevere one of their strengths is they're really smart one of their strengths you know you can build on those strengths too so we're recognizing that nobody's perfect but let's look at their strengths and how can we use these strengths to deal with or mitigate the vulnerabilities so if somebody's really smart sometimes they can use cognitive behavioral interventions to deal and you know I don't want to say just people who are really smart but if somebody's intelligent they can use cognitive behavioral interventions to deal with you know persistent anxiety they can use thought stopping there techniques that that they can use so we want to help people see let's use this strength and we're helping them see that they're pulling from stuff they already have within themselves to deal with this other issue begin with questions that address the patient's feelings about living such as how does life seem to you at this point now I probably wouldn't choose that one necessarily at the beginning you know for me I tend to start out with you know more rapport building and then move into things like have you ever felt like life wasn't worth living or do you ever wish you could go to sleep and not just wake up I've never been comfortable starting out with those kinds of questions though because I feel like people would be going no because that catches them off guard and they may be afraid that they're going to be involuntarily committed so you know I try to establish rapport and then we start talking about some of these questions focus on the nature frequency extent and timing of the suicidal thoughts and the interpersonal situational and symptomatic context in which they are occurring interpersonal we've kind of talked about you know are they alone are they with friends are their friends making it worse yada yada what's the situation you know is it some did something recently change in their life that's precipitating this crisis a diagnosis of a terminal illness or who knows so there could be a situation that's precipitating it it could be the situation of a holiday anniversary that is reminding them of a trauma and precipitating it and what is the symptomatic context you know what are their symptoms what's going on are they feeling agitated restless insomnia wanting to sleep all the time is it occurring in concert with you know maybe a persistent depressive disorder or generalized anxiety because that's really gonna impact the types of interventions that you might be looking for inquire about suicidal thoughts elicit the presence or absence of a plan if the patient doesn't report a plan ask whether there are certain conditions under which they would consider suicide which you know that's something that I typically haven't done that I was reminded of when I did this this presentation you know okay you don't have a plan but could that change basically so we want to have them think about it and no we're not pressing them and that's not going to trigger them to get there that's us saying you know let's plan you know ahead of time so we can put safeguards in place so if what might push you to the point where you would consider suicide all right let's make sure that doesn't happen whether or not a plan is present if the patient has acknowledged suicidal ideation there should be a specific inquiry about the presence or absence of a firearm men typically use firearms more than women but it doesn't mean that women won't use them and you know firearms are probably one of the most common methods you know there's also hanging but some people avoid hanging because that sounds painful and they just want it to be over with quickly but firearms and and I also ask about pills in the house especially opiate type pills if the patient has access to a firearm recommend to him that a significant other restricts access to this so they they get rid of it somehow they either put it in a safe and have you know their their spouse changed the lock so they can't get into the safe they give it to a friend same thing for medications that could be used to overdose I encourage patients if they've got benzos or opiates in the house that they're not taking you know or even if they have them in the house I encourage them to have somebody else kind of in charge of them if they think that that might be a risk factor and then if they're supposed to be taking them then that person gives them you know a certain number each day so they have enough to get them through the day and that's actually how we deal with a lot of people when they first get out of substance abuse treatment too if they're prescribed certain medications like benzos you know who can help you monitor your medication and then we wean off to where you know we're just doing pill counting every week when they come in and yada yada but anyway getting somebody involved that's going to help protect the person from the most lethal means document in the medical record being sure to include any instructions that have been given to the patient and significant others about firearms other weapons that can include you know knives machetes you know whatever they use to hunt with and I also include medications in there for myself when I do it assess the degree of suicidality including intent and lethality of the plan that'll give you a general idea now remember some people can they can have thought about it they can have actually created the whole plan in their head you know and but they may not have that intent you know they see it as this out that's kind of out there but their intent is low but you also have other people who when they get to the point of thinking it out have 100% intent and remember if their mood changes if they're depressed you know really depressed really upset one week and then they come in and they seem to be doing a little bit better don't take that to mean necessarily that they're doing better that could be they've just made the decision that they're going to commit suicide so you still want to keep you know paying attention intervening you know being alert to what's going on sometimes when people are in crisis or really depressed they don't have the energy and when they start getting that energy back is when you know they they decide to take the steps to kill themselves so be cognizant of that between age 20 10 and 24 doesn't that break your heart between the ages of 10 and 24 and over 70 years are the critical periods these are the highest you know I've told you yesterday that the risk of suicide was bimodal so young people and older adults tend to be at higher risk thoughts of death are more common and older adults but as people age they're less likely to endure suicide so you know a lot of times they're just like they come to peace with whatever it is and decide when it's their time it's their time self-destructive acts by older people do tend to be more lethal though the greater the lethality is the function of several factors reduced physical resilience and this is in older adults reduced physical resilience greater social isolation and greater determination to die so if they're starting to have a lot of physical health problems and if they maybe their spouse just died or what have you they may have a stronger determination to die so we want to look at all those things in in older adults what's changing suicidal elders give fewer warnings a lot of times you know there are very few warnings there are warnings but there are very few most of the time gender death by suicide is more more than four times as frequent in men and women men are less likely to seek and accept help for treatment we've kind of we still have that stigma going on and a lot of men perceive treatment to be you know warm and fuzzy and crying and tissues and talking about feelings and some men are not comfortable with that and one of the things that I emphasize when I work with some of my clients especially when I do presentations to first responder units is that there is cognitive behavioral you know we can talk about very practical very active things we don't have to get down into you know that emotionally charged stuff necessarily and that seeking help is not a sign of weakness it's a sign that you know you don't know how to do something you know you had to have somebody teach you how to fill in the blank drive a car shoot a gun whatever it is and so sometimes you need somebody to help teach you how to deal with things that are overwhelming that overwhelm those skills that you currently have women have several protective factors tend to have lower rates of alcohol and substance abuse although that's starting to change less impulsivity I was surprised by that more socially embedded and as women typically and this isn't true of all women by any means but a lot of times women have more friends they have you know friends in the community and they have people they can rely on not everybody so you know you want to not assume that just because it's a female that she's got five girlfriends she can call because that may not be the case women do tend to be more willing to seek help though women have higher rates of depression and respond to unemployment with greater and longer lasting increases in suicide rates than men so I thought that was another interesting fact so when women become unemployed their suicide risk goes up women who are pregnant or have young children are less likely to kill themselves so yes we have those bad media played up incidents of postpartum depression but in general women who are pregnant or who have children don't want to leave leave those children rates of suicidal ideation and attempts are also increased in individuals with borderline personality disorder and those with a history of domestic violence and physical and or sexual abuse talking to the client getting to know you know what their abuse history is what their trauma history is if they've got borderline characteristics or you know substance abuse is not listed here but a lot of people when they are in active addiction have characteristics that are very similar to borderline personality disorder and so if you've got those characteristics going on they they tend to be at more risk suicide in whites and non-Hispanics are approximately twice those observed in Hispanics non-Hispanic African-Americans and Asian Pacific Islanders so white non-Hispanics tend to be the ones that are at higher risk for immigrant groups in general suicide rates tend to mirror the rates in the country of origin but converge toward the rate in the host country over time so if there were high suicide rates in the country of origin and there are lower suicide rates here the longer they're in the country theoretically the lower their risk of suicide racial and ethnic differences in culture religious beliefs and societal position may influence the rates and values about suicide in some cultures like I said earlier shame can be considered a traditionally accepted way of dealing with shame distress or physical illness so knowledge of insensitivity to common contributors to suicide in different racial and ethnic groups as well as cultural differences in beliefs about death and suicide are really important for every mental health counselor because you've got people who come in who may be biracial who may you know be of a certain racer or culture and you need to have that knowledge ahead of time the suicide rate of single people is twice that of those who are married despite what the memes on facebook would tell you divorced separated or widowed individuals have rates four to five times higher than married individuals so considering you know what does being divorced separated or widowed mean to this person and you can see where their suicide risk might go up the presence of another person in the household also may serve as a protective factor by decreasing social isolation engendering a sense of responsibility towards others and increasing the likelihood of discovery after a suicide attempt so if somebody slips their wrists or overdoses they may be found in time to be rescued and revived so encouraging people not to be alone when it all possible the presence of a high conflict or violent marriage can be a precipitant rather than a protective factor of suicide that's not a shock major psychiatric symptoms more than 90 percent of people who die from suicide satisfy the criteria for one or more psychiatric disorders so you know the statistic kind of can be used against the people with mental health issues are not dangerous but you've got to remember it's not either or whatever you want to say there are millions of people that have diagnosable mental illnesses there are not millions of people that commit suicide but of the people who do try to commit suicide 90 of them qualify for one or more psychiatric disorders so of the you know 100 000 people that try to commit suicide each year they also will likely have a psychiatric disorder but the proportion of people with mental health issues that commit violent acts is really very small patients with mood disorders who died by suicide were more likely to have panic attacks severe anxiety diminished concentration global insomnia so they just can't sleep moderate alcohol abuse severe loss of pleasure or interest in activities let me say something about global insomnia though because I have read some studies that have indicated that people who have insomnia that that are able to get to sleep but they wake up at 12 or 1 in the morning and they're alone with their thoughts may be at greater risk than somebody who you know has difficulty falling asleep so if they can't sleep at all or if they can't stay asleep they're at risk suicidal ideation and a history of suicide attempts also augments risk if you've already crossed that line you're going to be a little bit more likely I guess if you will to cross that line again comorbid and if somebody's attempted suicide before then you have an idea that their their culture and spiritual principles or whatever don't necessarily admonish it we don't know if it advocates for it or not but so you know you can't that there are some of the things that might prevent other people from committing suicide aren't necessarily going to prevent this person comorbid anxiety alcohol use and substance abuse are common in patients with mood disorders suicide in patients with schizophrenia is about 8.5 fold higher than those without schizophrenia in schizophrenia or schizoaffective disorder psychotic symptoms are often present during a suicide attempt it doesn't mean necessarily that they're having command hallucinations um but they can be psychotic um command hallucinations account for a relatively small percentage of suicides patients with schizoaffective disorder appear to be a greater risk for suicide than those with schizophrenia i'm going to let that sink in for a second patients with schizoaffective disorder are at a greater risk than those with schizophrenia and suicide risk is increased in those who recognize a loss of previous abilities and are pessimistic about treatment so if they you know we know that schizophrenia typically doesn't happen until later in life you know in the in the 20s late 20s um so they may have had a great college career and be you know on their current career and now they're going oh my gosh you know i don't know that this will help i don't want to be you know i don't want to be schizophrenic if they don't have a lot of hope that treatment's going to help sub abusive substances including alcohol may be the second most frequent psychiatric precursor to suicide and i don't know the answer to that question about whether paranoid schizophrenics tend to commit suicide more or less than others but i will look it up for you alcohol abuse or dependence is present in 25 to 50 of those who die by suicide impending interpersonal losses and comorbid psychiatric disorders have been specifically linked to suicide in alcoholic individuals so you've got somebody who is struggling you know with interpersonal losses and comorbid psychiatric issues then they drink alcohol which is a disinhibitor it takes down the takes down those inhibitions and they're just like well you know i can do this um the normal filter that would say no we're not going there may not be quite as prevalent full-time employment is a protective factor in alcoholics and the majority of people who are alcoholic or sub alcohol dependent um actually are employed so you know that's not a surprising statement individuals with personality disorders have an estimated seven time increased risk for suicide especially borderline antisocial avoidant and schizoid personality disorders personality disorders exist in approximately 30 to 40 percent of those who attempt to or die by suicide so not only are we looking at mood issues we're also looking at personality disorder symptoms at least so risk factors factors that increase suicide risk include communications of suicidal intent all right if they they said they're going to do it let's take them seriously even if they have said it before prior suicide attempts um so if they had prior suicide attempts we need to be on guard a little bit more um for future suicide attempts continued or heavier drinking recent unemployment and living alone poor social support legal and financial difficulties serious medical or mental illness personality disturbance or other substance use I don't think any of these criteria are going to surprise you if you have someone who's struggling they're going to be at a greater suicide risk than somebody who's not um and so we've got to look biopsychosocially you know is there pain is there physical are there physical conditions that are contributing to it etc suicides multiple motivations you know we don't know why people do it there are some theories it's anger turned inward or a wish of death toward others that's redirected toward the self um you know that's obviously more psychoanalytic in nature and re revenge reunion or rebirth some people when they kill themselves are trying to get back at someone else some people when they kill themselves they can't take it anymore some people when they kill themselves are doing it because they don't want to be a burden to others and there's some probably a million other reasons but those are three big categories suicide is rooted in a triad of motivations the wish to die you know I can't take it anymore the wish to kill I can't take you anymore and the wish to be killed you know I wish somebody would make it go away suicidal behavior has been associated with poor object relations and the inability to maintain stable accurate and emotionally balanced memories of the people in one's life so thinking about the person for example with borderline personality disorder where it's all or nothing they either love you or they hate you it's very unstable um concepts of different people other important psychodynamic concepts are shame worthlessness and impaired self-esteem so in patient settings um you know we talked about how to handle it in different settings patients may be in the midst of an acute suicidal crisis or display the symptoms and disorders that typically lead to psychiatric hospitalization or increased suicide risk um so if they're in inpatient settings we need to know that they're already obviously struggling for some reason and just because they're an inpatient don't think that they're safe don't think that that says all right the pressure's off they're not going to become suicidal they can still decompensate there do not appear to be specific risk risk factors unique to the inpatient setting more than half of the patients who die by suicide in the hospital were admitted without suicidal ideation so more than half of them came in they weren't suicidal but at some point during that treatment episode they did become suicidal that's important to remember now whether they were triggered from trauma or whatever caused them to decompensate further it's important to recognize that it's a high percentage extreme agitation or anxiety or a rapidly fluctuating course is common before suicide and each suicidal crisis must be treated as new with each admission and assessed accordingly um let's see and in inpatient settings we're talking about both psychiatric inpatient where they're involuntarily committed or voluntarily committed um generally when that happens they're already espousing some suicidal ideation or homicidal ideation if they're involuntarily committed um or they're on a crisis stabilization unit but what we're talking about specifically here is a normal admit for a residential unit for something uh more than 50 percent of patients become suicidal after they've been admitted in outpatient settings suicidality may wax and wane in the course of treatment sudden changes in clinical status may include worsening or unexpected improvements in reported symptoms and that requires that suicidality be reconsidered so remember i said people may start acting like they're feeling better and they may actually start feeling like the fog is lifting but when that fog lifts they may see what they think is the forest for the trees which is hopelessness and decide you know what no no and become suicidal and make that decision and then they're at peace with it and they start tidying up affairs and saying they're goodbyes and doing that stuff risk may also be increased by a lack of a reliable therapeutic alliance a patient's unwillingness to engage in psychotherapy or adhere to medication treatment an inadequate family or social supports and remember it's family as the client defines it not necessarily family as you define it so we want to just talk about social supports in jail and correctional facilities suicide is one of the leading causes of death persons who die by suicide in jails tend to be young white single and intoxicated suicide in correctional facilities generally occurs by hanging and isolation may increase suicide in these places so if somebody is in jail and their family is not coming to visit them and they feel like you know nobody understands them especially if they've never been in jail before the fear the anxiety the dread of you know what they're facing and everything can contribute suicidal behaviors increase if you're in a correctional facility this is one of those things to pay attention to immediately upon entry the oh crap what did i just do i ruined my life after new legal complications with the inmates case like a denial of parole a sense of hopelessness and helplessness may set in after inmates receive bad news about loved ones you know that could happen to anybody and after sexual assault or another trauma suicidal patients can activate our own latent emotions about death and suicide so we need to know how we feel about it counter transference we may have some feelings of hate and anger at suicidal patients and avoid patients who bring up anxieties around suicide we may see patients who seem to be somewhat suicidal and go no i'm not dealing with that person or that's going to be too difficult or we could have you know more guttural emotional reactions to it that we need to pay attention to because we're probably reacting to the suicidality not the patient and get that in check seek consultation seek supervision overestimating the patient's capabilities creates unrealistic and overwhelming expectations for the patient be aware of becoming enveloped by the patient's sense of hopelessness and despair then responding by becoming discouraged about the progress of treatment and the patient's capacity to improve there's going to be you know very very small steps and it can be two steps forward and one and a half back but we want to see you know what we're looking for is the patient still surviving and you know a little bit better and it's can be very very incremental but we want to focus on that and and yes guards need to be cognizant of suicidality and mental health issues in jails and families um you know they may have very good reasons for not visiting their loved ones in in jail or in prison or whatever um however when we see someone who never has visitors um you know that's a risk factor so ideally it should send up the warning flags for the for the jail staff choice of specific treatment setting depends on the estimate of the patient's current risk to self or others their medical and psychiatric comorbidity so psychiatric you know that's we know that if they're clinically depressed we're gonna probably put them in a higher level of care um then if the suicidality is brought on by some sort of proximal precipitating event but you know it may not be any less lethal so we want to pay attention to that but we got to remember medical you know if they're dealing with fibromyalgia for example i've worked with patients with fibromyalgia that just i mean they wake up in the morning and they don't want to get out of bed they're just like it hurts too much i don't i hurt all the time i i don't want to go on like this and that's not necessarily a mood issue as much as a pain issue or if somebody's diagnosed with a terminal illness or a chronic illness um that can contribute to uh suicidality we want to look at the strength and the availability of the psychosocial support network the one that have and are they willing to reach out are they willing to go to support groups are they willing to you know connect with other people who could be helpful to them um and their ability to provide adequate self-care give reliable feedback and cooperate with treatment so you know can they do what they need to do on a daily basis if not then we need to consider residential benefits of intensive interventions must be weighed against their possible negative effects such as having the person feel like they've lost their independence the stigma associated with going into residential the issue of you know i've got kids that you know i need somebody to take care of the impact it will have on their finances the impact it may have on their job you know there are a lot of impacts that are going to happen if jim bob is suddenly not there for 30 60 days suicide prevention contracts or the no harm contracts are not a substitute for clinical assessment the patient's willingness or reluctance to enter into an oral or written suicide prevention contract shouldn't be viewed as an absolute indicator of suitability for discharge so if they say that yeah i'll sign that no problem that doesn't mean that they believe it you know not recommended for use with patients who are agitated psychotic impulsive or under the influence of any substance if they're dependent on established they need to be dependent on established position patient relationship so if you don't have a good relationship with that person you're not going to be able to judge their truthfulness in signing it but you know if you know i'm working with somebody that i've never met before and they say you know will you sign this okay fine if it'll get me out of here i'll sign it but if i'm working with you know my primary or something i might go you know what let's be honest here and suicide prevention contracts are not recommended for use in emergency settings or with newly admitted or unknown patients because again they'll sign anything if they really want to get out of that situation somatic interventions benzos treat symptoms such as insomnia agitation panic attacks or anxiety long acting agents are often preferred over short acting agents now when people take benzos some people have the effect that as it starts to get out of the system they may have rebound panic which they may feel is even worse than just not taking it at all so monitor the benefits of benzo should be weighed against the occasional tendency to produce disinhibition you know taking off those inhibitions to hurt themselves their potential for interactions with other sedatives and their potential for abuse and addiction benzos being discontinued after prolonged use should be reduced gradually and the patient monitored for increased symptoms of anxiety agitation depression or suicidality benzo diazepine withdrawal is one of those that needs to be monitored medically monitored it's not safe for people to just quit cold turkey and they can have significant anxiety as well as changes in blood pressure and heart rate and stuff if they are discontinued too quick antidepressants there is an evidence for a lowering of suicide rates with antidepressants but it's inconclusive so there's some studies that say yes some studies that say no some studies that say it increases suicidal ideation antidepressant effects may not be observed for days or weeks we say 30 30 days to six weeks to really get in the system patient should be monitored closely early in treatment and educated about this probable delay in symptom relief some docs will prescribe something that's a little shorter acting while the ssri's are kicking in i've seen clonopin prescribed a lot not so much volume and xanax more more clonopin than than those two and i've seen boost boron prescribed a fair amount as well so other calming medications include trasodone low doses of some second generation antipsychotics and some anticonvulsants such as gabapentin lithium is you know there's a lot of side effects to lithium but in some cases it may be the only option the long-term maintenance treatment is associated with major reductions in the suicide risk in patients with bipolar and recurrent major depressive disorder um so you have to weigh the benefits versus the side effects still requires frequent blood testing and um there are certain foods people can't eat etc ec t is effective in patients with severe depressive illnesses with or without psychotic features and is often associated with a rapid and robust antidepressant response a lot of people think about the old ec t and it terrifies the snot out of them so they don't want to go anywhere near it so educating them about what it looks like what it feels like what it will do um is important and then they can make an educated decision it may be recommended as a treatment for severe episodes of major depression that are accompanied by suicidal ideation and ec t may also be indicated for suicidal individuals during pregnancy and for those who have already failed to tolerate or respond to oral medications um clausapine is associated with a significant decrease in rates of suicide attempts for individuals with schizophrenia or schizoaffective disorder it should be given serious consideration for psychotic patients with frequent suicide suicidal ideation um so there are a lot of different things that you might see the doc prescribe and if you're not if the patient doesn't seem to be improving they're having multiple episodes you know remembering these things and advocating for the client as needed in order to promote treatment compliance you know we need to remember that while they're symptomatic while they're in crisis right after a trauma they may be poorly motivated to do the stuff that you're asking them to do because they're just like i can't i can't handle life right now let alone one more thing you're asking me to do what are you thinking about they may be less able to care for themselves so making sure that they're remembering to eat you know it's not like they're you know incapacitated but sometimes they need to be prompted to eat they need they may need somebody to you know help them remember to take their medication some people with really bad depression really severe clinical depression may just not have the energy to get up and take a bath so they may need somebody to encourage them to do it they may be unduly pessimistic about their chances of recovery so we want to educate cheerlead keep baseline data so we can show them those incremental improvements they may suffer from memory deficits or psychosis especially the memory deficits have them write things down so they remember when they took their medication they remember you know when they ate last etc and you can just do check sheets it doesn't have to be this big long thing if they're experiencing psychotic features obviously you're going to be working with a psychiatrist to try to get that under control and they may have reductions in insight about having an illness or needing treatment so they may not see you know they may just see this as a bad environmental social situation and not recognize kind of their part in it how they're interpreting it how they're dealing with it or see that there are other outs so they may not recognize that treatment can help so we want to educate them about what treatment can do for them during maintenance patients undervalue the benefits of treatment and focus on its burdens it's expensive it's time consuming i got to take time off from work so if we can make it convenient that's helpful um and and try to work with the person you know maybe every every two weeks and you have a face to face session and in the in the middle on the off weeks or whatever you have a brief phone call you know i don't know how you would bill for that but try to think about ways to increase their compliance when you're talking with their family encourage educate that psychiatric disorders are real illnesses and effective treatments are both necessary and available people aren't just going to snap out of it you know whether it's cognitive or biochemical or whatever's causing it there's something that's causing this neurochemical imbalance so we need to and it could be behavioral um so we need to address that or that neurochemical imbalance is probably going to persist so we need to help them figure out what it is the role of stressors and other disruptions in precipitating and exacerbating suicidality or other symptoms so you know how can we minimize stressors and let's educate about what stress does and how it increases anxiety and the hpa axis and imp imp impid sleep and all that stuff the course of improvement is probably going to be uneven there's going to be jumps and then plateaus and maybe even a little backsliding but that's okay you know we kind of expect that and that helps us learn more effectively what the person needs in order to avoid this in the future family history of suicide may increase suicide risk but it doesn't make suicide inevitable so it's you know not a hopeless situation families need to know how to identify symptoms that may indicate the patient is decompensating that are specific to that patient when gym bob starts to become suicidal what does he do not everybody acts the same way they need to know methods for involving the police for involuntary evaluation or as one of you pointed out earlier having them do a well-being check and i've had that done on on many occasions not a ton but enough um where a patient wasn't answering the phone and i was concerned and so we sent law enforcement body to a well-being check so know what the laws and regulations are in your area talk with your attorney and your supervisor about you know the limits of hpa and confidentiality and stuff but most of the time if you have a genuine concern for this individual you can do a well-being check and educate about how to react to suicidal behaviors in persons with borderline personality disorder because sometimes um suicidal or self-injury behaviors self-injurious behaviors are not uncommon in people with borderline personality disorder we don't want the family to assume that oh that sally she's just acting out again we want them to take it seriously and know how to act in order to diffuse the situation instead of spiral it out of control self-injurious behaviors may or may not be associated with suicidal intent sometimes it can be a means of releasing endorphins numbing the pain the interpsychic pain getting control getting getting back at somebody by trying to make them feel guilty there are a lot of motivations um without having any desire for death individuals may intentionally injure themselves to express anger relieve anxiety generate a feeling of normality or self-control terminate a state of depersonalization so if they feel like they're detached from themselves that may let them feel something and to distract or punish themselves self-injurious behaviors are sometimes characterized as gestures aimed at achieving secondary gains which may lead to behaviors being downplayed when associated with minimal self-harm let's not just knock that out of your brain right now take everything seriously in assessing chronic self-injurious behaviors determine whether suicidal intent is present um and obviously if you're working with somebody who's chronically self-injurious there's going to be a whole clinical plan around that so you know how not to reinforce that behavior but how to also give it you know due consideration there's an absence of suicidal intent or a minimal degree of self-injury should not lead the clinician to overlook other evidence of increased suicide risk so if they're tidying up affairs and saying their goodbyes even if they're not really hurting themselves significantly right now doesn't mean they won't every act needs to be assessed in the context of the current situation biopsychosocial the most frequent lawsuit settlements and verdicts against psychiatrists are for suicides failure to document suicide risk assessment and interventions may give the court reason to conclude they were not done so document it and document your consultations when you call up you know your your fellow colleague and say hey you know i'm wondering if you would involuntarily commit on this for patients who are hospitalized it's also important to document the aspects of the risk assessment that justify inpatient treatment particularly when it's occurring on an involuntary basis so what justifies keeping this person on a 72 hour or however long hold in documentation you need to have reference to the reason for the assessment in order to set the context for the evaluation so why is this person here why do we think they're suicidal the documentation reviews the factors that may contribute to increased shorter term or longer term suicide risk so you know the person had ideation but what made you think that they were really at risk what risk factors were there reasoning processes that went into the assessment clinical conclusions and again consultation please put that in there changes in the treatment plan should also be noted along with the rationale for such actions so if they've been in once a week outpatient going along and then all of a sudden they are involuntarily committed or voluntarily committed their treatment plans probably going to change so we need to know why you know not just have a sudden treatment plan change but know why it changed interventions or actions that were considered but rejected should be recorded as well so if you considered hospitalization but decided against it defend why you did that suicide contracts are overvalued it's not a legal document it cannot and should not take the place of a thorough suicide risk assessment um an undue reliance on suicide prevention contracts falsely lowers clinical vigilance without altering the patient's suicidal state and I've seen this when we've had a client when we've had clients on the unit who have been suicidal and we've put them we've had them sign a no harm contract and we also have them checking in every hour with their moods but if they willingly sign that contract I've seen the intensity that's not the word I'm looking for but of staff supervising that client go down so they're like okay the person's fine we'll just check in with them every hour if the person resists signing that contract um and it seems to be you know more resistant to it um then I see staff being more vigilant about watching that person so it's important not to take a piece of paper and assume it really means much of anything crisis intervention is a client-centered and comprehensive it uses patients strengths and resources when people are in suicide have suicidal ideation they are in crisis empathy and genuineness are key factors to developing that rapport and resolving the situation treatment modalities and settings are based on the client's level of functioning their dangerousness to self and the availability of supports and resources so family supports but also community resources and you know also consider when we talk about supports and we talked about this a little bit if they're alone if they live alone that's a higher risk setting than if they don't documentation is essential throughout the process not just an assessment but when you're reassessing before discharge when you change a treatment plan because we want to make sure that we're kind of keeping our finger on the pulse of what's going on here pharmacological interventions are used to provide acute symptom relief and enable the patient to focus on psychosocial interventions it may help them get enough energy to focus on the interventions or reduce their anxiety enough where they can think clearly all clients have the ability to help themselves though and that's what we really want to take away from this all ready everybody thank you for sticking with me do you have any questions and yes Andrea points out a good thing that a lot of times when people are in crisis they may have gotten to the point where they have exhausted their family resources and the family's just like I don't have any more to give and sometimes when people are in jail that's another reason they don't visit because the family's just like well maybe they need some tough love for a while because everything I've done hasn't seen the help so we don't want to condemn families for not visiting or not being as present as social supports as we would like because we probably don't know what's lit up to that okay okay everybody have an amazing weekend and I will see you next week and yeah we still have a couple more days in the month so I'm not going to say see you in March quite yet