Suicide Risk Management Clinical Strategies

Transcription

1 Suicide Risk Management Clinical Strategies March 12, 2015 Steven Vannoy, PhD, MPH Department of Counseling and School Psychology University of Massachusetts Boston

2 Review: What Explains Suicide? Vast majority of people don t Men do it more often Risk goes down for women with age but up for men Rural and urban rates are similar Rates around the world are similar

3 Review: Barriers to Prevention Suicide is difficult to predict Topic is stigmatized Limited training for suicide prevention Limited system support for managing high risk 3

4 Review: What Do We Know ALL mental health disorders increase risk Warning signs increase risk Psychiatric hospitalization is a strong predictor of future suicide Suicide Cognitions Increase Risk Safety Plans, not No-Harm Contracts 4

5 Suicide Risk Management Identify Pt s at Risk Assess Risk Level Formulate Treatment Plan Initiate Treatment Plan Document Follow up 5

6 Asking the Questions Be very attentive Remain calm and non-threatened Give the patient time to talk Stress a collaborative approach Be willing to say suicide without flinching 6

7 Current Mental Status Passive Suicide Ideation Better off dead Life is not worth living Wish I could just disappear Imagining funeral, or post-funeral world Intent is non-existent or weak 7

8 Current Mental Status Active Suicide Ideation Wish to harm self Imagining killing self Planning methods How detailed How lethal How available Intent (wish to die) is present 8

9 Current Mental Status Describing Ideation How strong Intensity, Impulsiveness, distressing How frequent How detailed How long do ideas last Intent to die 9

10 Current Mental Status Preparatory Behavior Accumulating means Putting affairs in order Saying goodbyes/visiting Updating wills Checking on insurance status Rehearsing Intent is strong 10

11 Current Mental Status Suicide Related Cognitions Suicide Ideation Hopelessness Being a burden Social isolation Being unlovable Unable to coping Entrapment

12 Current Behavioral Warning Signs Loss of interest in being around others Agitation (crawl out of my skin) Increased Anger/Irritability Sleep disruption & Nightmares (specifically) Substance Abuse

13 Suicide Related Behavior History Any past attempts When, how, why Lethality Why are you still alive Past ideation How did this resolve 13

14 Current Environmental Factors Why Now? Stressors Financial Relationship Legal Work Social Support 14

15 Protective Factors Reasons for Living Feels strongly connected to loved/ones Has interest in future (job, children, etc) Feels a purpose in life and wants to fulfill it Strong religious reasons/involvement Suicide is inconsistent with self-view Optimistic that the situation will improve Religious involvement Document reasons 15

16 Static Risk Factors Past attempts History of Mental Illness PSYCHIATRIC HOSPITALIZATION Family history of suicide Who, When, Impact History of substance abuse Age Gender 16

17 Review: Involving Significant Others Confirm Patient Reports Provide Additional Information Provide Surveillance Enact Social Support 17

18 Establishing a Risk Level Putting It All Together Ideation (behavior, active, passive) Related cognitions, behaviors History of attempts and/or ideation Co-morbid psychiatric conditions Psychosocial Stressors/Warning Signs Psychosocial Protective Factors Involvement of Others 18

19 Establishing a Risk Level Acute immediate concern about safety; immediate intervention High active ideation/prep; treatment engagement required; strong surveillance Moderate active/passive ideation with other RF s, treatment engagement required without or other mitigating factors; routine surveillance Low passive ideation, substantial protective factors; treatment engagement recommended; surveillance recommended 19

20 Review: Elements of a Treatment Target of treatment Plan Suicide related behavior/risk Other mental disorder Who is on the treatment team How is coordination of care conducted Observation (maintaining contact and assessing status)? 20

21 Suicide as Target of Treatment Dialectic Behavioral Therapy Collaborative Assessment & Management of Suicide Cognitive Behavioral Therapy for Suicide Safety Planning My3 & Other Apps

22 DBT Core Skills Development Linehan Distress Tolerance Emotion Regulation Interpersonal Effectiveness Mindfulness

23 CAMS (Jobes) Collaboration Development and Review of Suicide Status Form Risk Assessment Crisis Response Plan (Safety Plan) Planning Clinical Contact Removing Access To Means Between Session Access The Coping Card Hope Kit Increasing Social Supports Increasing Behavioral Activation

24 Cognitive Therapy for Suicidal Patients Wenzel, Brown, Beck Risk Assessment Safety Plan Cognitive Conceptualization and Treatment Plan Application of Cognitive and Behavioral Strategies Relapse Prevention Protocol Continued Treatment for Secondary Condition

25 The Safety Plan (Stanley & Brown, 2008) Warning Signs Internal Coping Strategies People and Social Settings That Are Distracting People Whom I Can Ask For Help Professionals or Agencies I Can Contact During Crisis Making the Environment Safe

26 After The Plan Is Developed Adapted from Stanley & Brown 2008 ASSESS the likelihood that the overall safety plan will be used and problem solve with the patient to identify barriers or obstacles to using the plan DISCUSS where the patient will keep the safety plan and how it will be located during a crisis EVALUATE if the format is appropriate for the patient s capacity and circumstances REVIEW the plan periodically when patient s circumstances or needs change

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29 Resources Suicide Prevention Resource Center (SPRC.org) American Foundation for Suicide Prevention (AFSP.org)