Safety Planning and Lethal Means Reduction to Prevent Suicide Fall Substance Use Conference 2015 Doug Thomas, LCSW Director

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1 Safety Planning and Lethal Means Reduction to Prevent Suicide Fall Substance Use Conference 2015 Doug Thomas, LCSW Director Division of Substance Abuse and Mental Health

2 Overview Suicide Data Where does Utah rank and what impact do SUD s have? Risk/Protective Factors What are they and why are they important? Warning Signs What do I need to look for (some things are obvious, others are subtle)? Safety Planning How can I help the people I serve be SAFE? Reducing Access to Lethal Means How can I help reduce access to lethal means and how does that help? 2

3 Quiz How many Utahns died by suicide last year?

4 Utah and U.S. Suicide Trend

5 Youth Suicides

6 Suicide Belt Source: WISQARS 2012 Ageadjusted rates

7 Utah Data

8 Rate of suicides by age group, Utah,

9 Rate of suicides by age group and sex, Utah,

10 Suicide and Substance Use Those who die by suicide: 32% tested positive alcohol 19% positive for opiates 9% positive for cocaine 8% positive for marijuana 5% positive for amphetamines 49% positive for other drug McKeon, 2013

11 Substance Use Disorder Risk of suicide attempts 6.2 x greater 132,500 emergency room visits for alcohol or drug related attempts 85% admitted Suicide a leading cause of death for people with SUD Those treatment for SUD 10 x greater risk 14 x for those who inject drugs Molnar, et al., 2001 SAMHSA, 2007 Wilcox, et al., 2004

12 Acute Substance Use Present in 40% of attempts Increased disinhibition/impulsivity Increased focus on current situation Promotes depression and hopelessness Impairs problem solving Facilitates aggression

13 Compared to the general population, individuals with a history of Have a suicide risk that is Prior Suicide Attempt Major Depression Mixed Drug Abuse Bipolar Disorder Opioid Abuse Obsessive-Compulsive Disorder Panic Disorder Schizophrenia Almost 40 times greater than the expected rate 20 times greater than the expected rate 19 times greater than the expected rate 15 times greater than the expected rate 14 times greater than the expected rate Almost 12 times greater than the expected rate 10 times greater than the expected rate Almost 9 times greater than the expected rate Alcohol Abuse Almost 6 times greater than the expected rate Cannabis Abuse Almost 4 times greater than the expected rate Data Source: Simon, R. (2003). Guidelines for clinically based risk management. American Psychiatric Publishing, Inc.

14 Tip of the Iceberg

15 Causes of Death and Injury Firearm closely followed by suffocation Poisoning

16 Firearm Related Death 16

17 Firearm Related Death 17

18 Risk Factors Mental Illness Substance Abuse Previous Suicide Attempts History of Trauma Exposure to friend/family suicidal behavior- family history of suicide Stressful life event or loss Incarceration- loss of freedom Access to means- firearms in the home

19 Protective Factors Effective clinical care for mental, physical and substance use disorders Family connectedness, school, & community connectedness Reduced access to firearms (other means) Safe schools Academic achievement Self-esteem

20 Signs That Immediate Help is Needed Talking about wanting to die or to kill themselves. Looking for a way to kill themselves, such as searching online or buying a gun Talking about feeling hopeless or having no reason to live. Talking about feeling trapped or in unbearable pain. Talking about being a burden to others. Increasing the use of alcohol or drugs. Acting anxious or agitated; behaving recklessly. Sleeping too little or too much. Withdrawing or isolating themselves. Showing rage or talking about seeking revenge. Displaying extreme mood swings.

21 Now what??? 21

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23 Key Strategies Community Awareness Training and Education/Clinical Care Improvement Access to Services Reducing Access to Lethal Means Postvention: Support to Survivors; Individuals, Families and Communities Who have Lost someone to Suicide 23

24 Reducing Access to Lethal Means Firearms Medication/ Poisoning 24

25 Training: Zero Suicide Utah 25

26 TIP 50: Consensus Panel Recommendations Screen all clients at intake and at specific points in the course of treatment- regularly screen clients with significant risk factors Be prepared to develop and implement treatment plans that explicitly address suicidality Confirm that referral appointments are kept. Monitor collaboratively with other providers Acquire basic knowledge about suicide prevention and risk

27 TIP 50: Consensus Panel Recommendations Be empathic and nonjudgemental with people experiencing suicidal thoughts and behaviors Be aware of the own impact of your own attitudes toward and experiences with suicidality Understand ethical and legal principles that exist in working with clients with suicidal thoughts

28 Suicide Prevention depends upon appropriate identification and screening

29 Screening Version As few as 3 questions Find training at onallianceforsuicidepr evention.org/

30 Brief Intervention to Mitigate Risk Comprehensive and Collaborative Safety Planning 30

31 TIP 50 No Contracts Suicide contracts are not recommended and NEVER sufficient So what do I do?

32 Safety Planning For training on the Safety Plan visit Effective safety planning is collaborative

33 Step 1: Warning Signs (thoughts, images, mood, situation, behavior) that a crisis may be developing 1. Suicidal thoughts, feeling hopeless _. 2. Desire to drink 3. Escalated fighting with partner _ 4. Imagining what others life would be like without me

34 Step 2: Internal Coping Strategies- Things I can do to take my mind off my problems without contacting another person (relaxation, physical activity, etc ) 1. Go for a run 2. Play the guitar 3. Write in my journal

35 Step 3: People and social settings that provide distractions 1.Name: Sally (sister) Phone: Name: Gerry (cousin) Phone: Place: Fountain at City Creek 4.Place: Salt Lake City Library

36 Step 4: People whom I can ask for help 1.Name: Anne (mother) Phone: Name: Jessie (Faith leader) Phone: Name: Joe (friend) Phone:

37 Step 5: Professionals or agencies I can contact during a crisis 1. Clinician Name Dr. Leo Marvin Phone Clinician Pager or Emergency Contact # Clinician Name Jennifer Dodge Phone Clinician Pager or Emergency Contact # Local Urgent Care Services Urgent Care Services- ER Address Phone 4. Suicide Prevention Lifeline Phone: TALK (8255)

38 Step 6: Making the environment safe 1. _Only keep a small amount of pills in the home 2. _Don t keep alcohol in the home 3. Give my gun to my sister when I start noticing triggers

39 Final Step The one thing that is most important to me and worth living for is:

40 Circle back Follow up with people! It Reduces Risk It Adds Protection It Increases Engagement and Likelihood of Follow-up 40

41 Making the environment safe TIPS For Talking About a Safe Environment Openly discuss thoughts of suicide Openly discuss method Openly discuss the possibly of things escalating quickly Understand why reducing access to lethal means is a key suicide prevention strategy 41

42 Reducing a Suicidal Person s Access to Firearms and other lethal means Access to lethal means is a key risk factor for suicide death in youth Seeking access to lethal means is a key warning sign for suicide Reducing access is a key prevention strategy 42

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45 Sri Lanka & United Kingdom Pesticides are the leading suicide method in Sri Lanka. Restrictions were placed on sales of the most highly humantoxic pesticides in the mid to late 1990s. Suicide rates dropped 50% from 1996 to Nonfatal poisonings and suicide by other methods did not drop. Before 1960, domestic gas was the leading method of suicide in the United Kingdom. By 1970, almost all domestic gas in the UK was non-toxic. Suicide rates dropped by nearly a third. The drop was driven by a drop in gas suicides; non-gas suicides increased slightly. Gunnell Int l J of Epidemiology Source: Kreitman 1976,. Brit J Prev Soc Med.

46 Why Does Reducing Access to Lethal Means Prevent Some Suicides?

47 Reducing Access to Lethal Means- Why Means Matter Why? Suicide acts are often impulsive Crises are often temporary Suicide attempts are often undertaken quickly with little planning. Most people who attempt suicide and survive do not go on to die from suicide- 90% of those who survive even nearly-lethal attempts do not go on to later die by suicide. Some suicide methods are far more deadly than others ( case fatality ranges from 1% for some methods to 85-90% for the most deadly, like firearms). Where lethal means are less available, fewer people die- it works. The common cognitive state of suicide is ambivalence (Shneidman, 1996)

48 Assessing Risk If a person has a plan, ask about method to guide the conversation and see what methods require particular attention Even if the person does not have a specific plan, ask about access to firearms About 40% of attempts are made without prior specific plans (Borges et al., 2006) You have told me that you have had thoughts of suicide, have you thought about how you would do it? 48

49 Ask about firearms Ask about firearms in the home A crisis can escalate quickly Reducing access is like taking keys from someone who is drinking alcohol- doing it prior to a crisis/intoxication is far more effective Discuss storage options 49

50 Openly discuss storage options Best Option: Temporary storage outside of the home Trusted friend or relative Firearm storage facility Gun shops/ranges Police Department When working on a plan to store outside of the home- get specific! 50

51 Openly discuss storage options Storing inside the home Another member of the home: Unload all guns Lock up guns (multiple layers of locks preferred, change passwords) Store ammunition separately 51

52 Assess Plan & Address Barriers Discuss realistically how likely the individual is to implement the plan Be realistic and don t minimize emotions/reactions regarding firearms Discuss timetable Ongoing conversation Engage support system 52

53 Making a Difference Family and friends can protect a suicidal person by temporarily storing all firearms away from home. Have a trusted person outside the home hold onto them until the situation improves. Some storage facilities, police departments, gun clubs, and gun shops will store guns. If off-site storage isn t an option: Lock the guns at home with new locks or combinations. Keep ammunition out of the home or locked separately. Or, remove a key component of the guns, e.g., the bolt.

54 Ask About Medication Use lower toxicity medication when possible Limit quantities (i.e. require weekly refills) Take into account OTC, other medication and alcohol use. Engage support network Remove unnecessary medication from home Consider use of a medication lockbox 54

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56 Use Only As Directed

57 Firearm Safety 57

58 For more information Means Matter website: Take CALM-Online free, online course on Counseling on Access to Lethal Means Request technical assistance from Means Matter Request an in-person CALM training

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60 For more information, please visit: or Doug Thomas Director Kim Myers Suicide Prevention Coordinator Division of Substance Abuse and Mental Health