Suicide Prevention & The Art of Asking: Bridging Clinical Assessment and Community Conversations to Promote Awareness and Prevention

Transcription

1 Suicide Prevention & The Art of Asking: Bridging Clinical Assessment and Community Conversations to Promote Awareness and Prevention Introductions Daniel Schwarz, Ph.D. Daniel Schwarz, Ph.D. Anna Trout, MSW Montgomery County Suicide Prevention Task Force Introductions My Step Brother Boaz Anna Trout, MSW, CPRP Prevention Specialist, Montgomery County Office of Mental Health Coordinator of the Montgomery County Suicide Prevention Taskforce Objectives Points of discussion critical to this training: The scope and pervasiveness of suicide Suicide as a preventable Public Health Crisis The role of psychologists as liaisons to the community at large in spreading information about suicide awareness and prevention Participants will learn: Use of the Columbia Suicide Severity Rating Scale (CSSR S) as an effective Assessment Strategy for Suicide Risk along with some options for the treatment of Suicidal Patients, Attempt Survivors and Family Members Tenants of QPR Prevention training as both a component of clinical training and practice, as well as a tool for communicating with individuals, families, and the community Strategies for bridging clinical expertise with community engagement to promote awareness, intervention, and connections Reported Suicide Deaths in 2015 World wide: more than 800,000 (more than all the wars and homicides combined) United States: 44,193 (Rate: 13.8) Pennsylvania: 1,894 (Rate: 14.8) *Drapeau, C.W., & McIntoch, J.,L. (for the American Association of Suicidology). (2016). U.S.S. suicide 2015: Official Final Data. Washingotn, DC: American Association of Suicidology, dated December 23, 2016, downloaded form 1

2 U.S.A. Data Specifics Fatal Outcomes The United States has slowly but steadily seen an increase in suicide rates since 2001, following long term trends of decline from This trend upward becomes more pronounced from 2007 onward. U.S.A. Data Specifics Fatal Outcomes Suicide is the 10 th ranking cause of death in the U.S. across all ages (note: homicide ranks 16 th ) 2 nd leading cause of death for year olds Means Matter Firearms (22,018, 49.8% of total deaths) Suffocation/Hanging (11,855, 26.8% of total deaths) Poisoning (6,816, 15.4% of total deaths) Training recommendation: Counseling on Access to Lethal Means (CALM) U.S.A. Data Specifics Who is most at risk? Middle aged folks, particularly white men, are most at risk for death by suicide. U.S.A. Data Specifics Who is most at risk? In 2015, middle age people were 26.2% of the population, but were 37.3% of the suicides Men are 3.3 times as likely to die by suicide than women White men made up 30,658 of the 44,193 suicides (rate of 24.6, with the next highest rate being Native Americans at 12.6) Pennsylvania Pennsylvania falls slightly above the national average for overall suicide rate. PA rate in 2015 was 14.8 (Northeast Region Rate: 10.8, National Rate: 13.8) Men died by a rate of 23.4 (National Rate: 21.5) Women died by a rate of 6.5 (National Rate 6.3) PA rates for elderly (15.4) and youth (12.2) suicides are slightly below the national rates middle age deaths are the primary drivers of the suicide rate in Pennsylvania Montgomery County Pennsylvania A local partnership: Montgomery County Suicide Prevention Taskforce, Department of Health & Human Services, and Coroner s Office. Benefits of local data Faster turnaround of information (vs waiting for national data to filter up and then back down) Building relationships and communication between systems Montgomery County loses approx. 100 people a year to suicide. Trends match closely with what s happening on a national level (men die 3x more often, middle age deaths are increasing, women are most likely to die from an overdose, March is the most common time of year, firearms are most common method at 36%). 2

3 Montgomery County Pennsylvania (Youth) 66% of all youth suicides in Montgomery County happen in September, October, or January. What do you notice? 65% of public school districts in MontCo have experienced a suicide in the last 7 years Most common method for young people is hanging With the scope of the problem defined. How can Psychologists be champions of suicide prevention in Pennsylvania? *Clinical Practice & Intervention* *Community Awareness & Empowerment* Three (3) out of every ten (10) high school students report feeling depressed or sad most days of the year. Clinical Practice & Intervention: Examples of Tools for Assessment PHQ 2 PHQ 9 National Prevention Lifeline Suicide Risk Assessment Standards Colombia Suicide Rating Scale (C SSRS) 3

4 Columbia Suicide Severity Rating Scale (C SSRS) A giant THANK YOU to Dr. Kelly Posner, Columbia University, and The Lighthouse Project for their generosity, time, and commitment to making this information free, accessible, and practical for use far and wide, all for the purpose of preventing suicide. Additional, full, and free toolkits, guides, PDFs, FAQ, videos, and more can be found at: cssrs.columbia.edu Columbia Suicide Severity Rating Scale (C SSRS) Columbia Suicide Severity Rating Scale (C SSRS) Developed in response to a need for Common Language Suicide Prevention as a mentality C SSRS training indicated universally (screening and full version) Strong research base indicating tool appropriateness and effectiveness Columbia Suicide Severity Rating Scale (C SSRS) Screening Version Who can use it? 4

5 C SSRS: Screening Version Columbia Suicide Severity Rating Scale (C SSRS) Full Version Who should use it? Focus: Intensity of Ideation & Suicidal Behavior C SSRS: Full Version (Page 1 of 2) C SSRS: Full Version (Page 2 of 2) C SSRS: Demonstration (Screener Demo Video with Police Officer) Administration of C SSRS: Suicidal Ideation Question 1: Have you wished you were dead or wished you could go to sleep and not wake up? Question 2: Have you actually had any thoughts of killing yourself? If answer is NO to Question 2: Move on to Suicidal Behaviors If answer is YES to Question 2: Ask Questions 3, 4, & 5 5

6 Administration of C SSRS: Increasing Suicidal Ideation Administration of C SSRS: Increasing Suicidal Ideation Question 3: Have you been thinking about how you might do this? Question 4: Have you had these thoughts and had some intention of acting on them? Question 5: Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Administration of C SSRS: Intensity of Ideation (Full Version Only) Frequency: How many times have you had these thoughts? 1. Less than once a week 2. Once a week times in a week 4. Daily or almost daily 5. Many times each day Administration of C SSRS: Intensity of Ideation (Full Version Only) Duration: When you have the thoughts, how long do they last? 1. Fleeting 2. Less than 1 hour/some of the time hours/a lot of the time hours/most of the day 5. More than 8 hours/persistent or continuous Administration of C SSRS: Intensity of Ideation (Full Version Only) Controllability: Could/Can you stop thinking about killing yourself or wanting to die if you want to? 1. Easily able to control thoughts 2. Can control thoughts with little difficulty 3. Can control thoughts with some difficulty 4. Can control thoughts with a lot of difficulty 5. Unable to control thoughts 6. Does not attempt to control thoughts Administration of C SSRS: Intensity of Ideation (Full Version Only) Deterrents: Are there things- anyone or anything (e.g. family, religion, pain of death)- that stopped you from wanting to die or act on thoughts of suicide? 1. Deterrents definitely stopped you from attempting suicide 2. Deterrents probably stopped you 3. Uncertain that deterrents stopped you 4. Deterrents most likely did not stop you 5. Deterrents definitely did not stop you 0. Does not apply 6

7 Administration of C SSRS: Intensity of Ideation (Full Version Only) Reasons for Ideation: What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain or stop the way you were feeling (in other words you couldn t go on living with this pain or how you were feeling) or was it to get attention, revenge or reaction from others? Or both? Administration of C SSRS (Ideation Demo Video) 1. Completely to get attention, revenge, or reaction from others 2. Mostly to get attention, revenge, or reaction from others 3. Equally to get attention, revenge, or reaction from others and to end/stop the pain 4. Mostly to end or stop the pain (you couldn t go on living with the pain or how you were feeling) 5. Completely to end or stop the pain (you couldn t go on living with the pain or how you were feeling) 0. Does not apply Suicidal Behavior Section of C SSRS Definition of a Suicide Attempt: A self-injurious act committed with at least some intent to die as a result of the act. At least some intent to die Connection between behavior and intent to die Suicidal Behavior Section of C SSRS Actual Attempt: Have you made a suicide attempt? Have you done anything to harm yourself? Did you as a way to end your life? Did you want to die (even a little) when you? Were you trying to end your life when you? Or did you think it was possible that you could have died from? Or did you do it purely for other reasons/without ANY intention of killing yourself (like to relieve stress, feel better, get sympathy, or to get something else to happen? Infer Intent (if a person denies intent, you can infer) C SSRS: Non Suicidal Self Injurious Behavior Accidental death with no intent Getting sympathy from others C SSRS: Other Suicidal Behaviors Interrupted Attempt Has there been a time when you started to do something to end your life but someone or something stopped you before you actually did anything? Aborted or Self-Interrupted Attempt Has there been a time when you started to do something to try to end your life but you stopped yourself before you actually did anything? Preparatory Acts or Behavior Have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting pills, getting a gun, giving valuables away or writing a suicide note)? 7

8 C SSRS: Lethality = Medical Damage C SSRS: Suicide Attempt or Not? (Behavior Demo Video) Non-psychiatric Scale from 0-5 8

9 Timeframes for Using C SSRS Initial Visit Use the Lifetime/Recent Ideation Lifetime Recent- Last Month Behavior Lifetime Recent- Last 3 Months Timeframes for Using C SSRS Subsequent Visits Version Every visit Significant Stressors Whenever appropriate in Day, Residential, and other programs Next Steps: Parameters for Triage and Referral Ideation: 4 or 5 in past month Any of the 4 behaviors in the last 3 months Integration of C SSRS into Electronic Medical Records C SSRS: Interactive Skills Practice 9

10 Question, Persuade, Refer (QPR): Ask a Question, Save a Life ANYONE can be trained as a Gatekeeper and learn to: Recognize warning signs, Ask someone about suicidal thoughts, Offer hope, and Connect to help Developed by Paul Quinnett Ph.D., in partnership with Spokane Mental Health Washington Institute for Mental Illness Research and Training State of Washington Dept. of Health Spokane County Health Dept Sacred Heart Medical Center Eastern Washington University School of Social Work Suicide Awareness\Voices of Education (SA\VE) Suicide Prevention Advocacy Network (SPAN USA) American Association of Suicidology In person and online training options ( Question, Persuade, Refer (QPR): Montgomery County Suicide Prevention Taskforce s Local QPR Initiative Research and comparison of other training options (ASIST, SAFETalk, MHFA) Yearly train the trainer (25 trainers w/diverse backgrounds and experiences) Approx. 2,000 people trained in QPR by taskforce sponsored trainers since 2015 Teachers Religious groups Social service workers (serving: mental health, criminal justice, youth, and the elderly) Health dept. College students (Psychology 101 partnership, RA s, Orientation leaders) NAMI Local politicians as hosts Teenagers/students Open community trainings Question, Persuade, Refer (QPR): QPR as a Community Driven Prevention Initiative Can be delivered BY and TO community members Discuss: training relevance for clinically trained professionals Low material costs (books and materials are able to be covered by minimal donations) Fidelity to training model is basic, room for adaptability is high Next Steps: Add bilingual trainers to bureau Add more (attempt) survivor trainers Create training packages for specific groups (Veterans, Elderly, Youth, Law Enforcement, Communities of Faith, Clinical Professionals) Question, Persuade, Refer (QPR): MontCo Training Flow Video: Brene Brown on Empathy Introductions Self Care Expectations Video: The Dille Family (HOPE 4 Tomorrow) Video: About QPR/Global Stats & Data Myths & Facts Why would someone take their own life? (Owl Brain, Lizard Brain) Local Data & Trends Warning Signs (What People Say, What People Do, What s Happening in Someone s Life) Interactive Review Q: QUESTION How to Ask Interactive Practice/Scripted Role Play Video: A Survivor s Perspective on the Importance of Asking (Kevin Hines/Buzzfeed) P: PERSUADE How to Persuade someone to stay alive and seek help Interactive Practice/Scripted Role Play R: REFER Review of national and local resources Interactive Practice/Scripted Role Play Peyton Heart Project What we ve learned: immense benefit of strategic use of videos and interactive practice, open trainings always attract folks with some type of lived experience, co-trainers tend to be more powerful than single trainers (especially if one of the trainers is a survivor or a person with lived experience), attendees are experts in humanity and inform future trainings. QPR: Suicide Myths and Facts Myth Noone can stopa suicide, it is inevitable. Fact If people in a crisis get the help they need, they will probably never be suicidal again. Myth Confronting a person about suicide will only make them angry and increase the risk of suicide. Fact Asking someone directly about suicidal intent lowers anxiety, opens up communication and lowers the risk of an impulsive act. Myth Only experts canprevent suicide. Fact Suicide prevention is everybody s business, and anyone can help prevent the tragedy of suicide Myth Suicidal people keep their plans to themselves. Fact Most suicidal people communicate their intent sometime during the week preceding their attempt. Myth Those who talkabout suicide don t do it. Fact People who talk about suicide may try, or even complete, an act of self destruction. Myth Once a person decides to complete suicide, there is nothing anyone can do to stop them. Fact Suicide is the most preventable kind of death, and almost any positive action may save a life. Myth If a suicidal young person tells a friend, the friend will access help. Fact Most young people do not tell an adult. 10

11 Direct Verbal Clues: I ve decided to kill myself. I wish I were dead. I m going to commit suicide. I m going to end it all. If doesn t happen, I ll kill myself. QPR: Verbal Clues Indirect Verbal Clues I m tired of life, I just can t go on. My family would be better off without me. Who cares if I m dead anyway. I just want out. I won t be around much longer. Pretty soon you won t have to worry about me. QPR: Behavioral Clues Any previous suicide attempt Acquiring a gun or stockpiling pills Co occurring depression, moodiness, hopelessness Putting personal affairs in order Giving away prized possessions Sudden interest or disinterest in religion Drug or alcohol abuse, or relapse after a period of recovery Unexplained anger, aggression and irritability MontCo Trainers Add: Changes in sleeping patterns, Sudden upswing after a period of depression QPR: Situational Clues Being fired or being expelled from school A recent unwanted move Loss of any major relationship Death of a spouse, child, or best friend, especially if by suicide Diagnosis of a serious or terminal illness Sudden unexpected loss of freedom/fear of punishment Anticipated loss of financial security Loss of a cherished therapist, counselor or teacher Fear of becoming a burden to others MontCo Trainers Highlight Themes: Shame, Isolation, Loss of Control over a situation QPR: Tips for Asking the Suicide Question If in doubt, don t wait, ask the question If the person is reluctant, be persistent Talk to the person alone in a private setting Allow the person to talk freely Give yourself plenty of time Have your resources handy; QPR Card, phone numbers, counselor s name and any other information that might help Remember: How you ask the question is less important than that you ask it Less Direct Approach: Have you been unhappy lately? Have you been very unhappy lately? Have you been so very unhappy lately that you ve been thinking about ending your life? Do you ever wish you could go to sleep and never wake up? QPR: Asking the Question Direct Approach: You know, when people are as upset as you seem to be, they sometimes wish they were dead. I m wondering if you re feeling that way, too? You look pretty miserable, I wonder if you re thinking about suicide? Are you thinking about killing yourself? If you cannot ask the question, find someone who can. QPR: How NOT to ask the suicide question: You re not thinking of killing yourself, are you? You wouldn t do anything stupid would you? Suicide is a dumb idea. Surely you re not thinking about suicide? In MontCo, we add Are you thinking of hurting yourself?. 11

12 QPR: Persuade How to Persuade someone to stay alive Listen to the problem and give them your full attention Remember, suicide is not the problem, only the solution to a perceived insoluble problem Do not rush to judgment Offer hope in any form Then Ask: Will you go with me to get help? Will you let me help you get help? Will you promise me not to kill yourself until we ve found some help? This is the extent of the QPR Core Persuade slides, in Montco we add: What does listening look like, what to do if someone is stuck, the value of curiosity over advising. QPR: Refer Suicidal people often believe they cannot be helped, so you may have to do more. The best referral involves taking the person directly to someone who can help. The next best referral is getting a commitment from them to accept help, then making the arrangements to get that help. The third best referral is to give referral information and try to get a good faith commitment not to complete or attempt suicide. Any willingness to accept help at some time, even if in the future, is a good outcome. Say: I want you to live, or I m on your side...we ll get through this. Get Others Involved. Ask the person who else might help. Family? Friends? Brothers? Sisters? Pastors? Priest? Rabbi? Bishop? Physician? Join a Team. Offer to work with clergy, therapists, psychiatrists or whomever is going to provide the counseling or treatment. Follow up with a visit, a phone call or a card, and in whatever way feels comfortable to you, let the person know you care about what happens to them. Caring may save a life. QPR: Refer MontCo Additions to Refer: What do we mean by help? Why is it hard to ask for help? What to expect if you call or go for help National and local resources and contact numbers A nod to professional obligations QPR: MontCo Enhancements Always tailor to group attending (ex. Include information about the oncampus counseling center if presenting at a college) Local data Local resources Social media discussion Peyton Heart Project Videos (available on YouTube) Brene Brown On Empathy HOPE 4 Tomorrow The Dille Family Kevin Hines/Buzzfeed I Jumped Off the Golden Gate Bridge Visuals/Anecdotes/Metaphors Trainers stories and experiences The gift of going second Wait, what? Owl Brain, Lizard Brain QPR Interactive Skills Practice Asking the Question Don t Make Promises You Can t Keep Persuade Refer 12

13 Beyond Training & Intervention: Advocacy and Community Empowerment Where is your circle of influence? Developing (attempt) survivors as leaders, trainers, and advocates New Hampshire: The Gun Shop Project Montgomery County community taskforce Strategic use of subcommittees Community trainings as skill AND awareness building Free Gun Lock Tracking Project School/college outreach New Hampshire Gun Shop Project Partnership Post Suicidal Options for Care/Treatment: Individuals and Families Questions, Answers, & Ideas Attempt Survivors Chronically Suicidal Patients Suicide Loss Survivors 13

14 Scholarly References & Resources Bono, V., & Amendola, A. (2015, December). Primary care assessment of patients at risk for suicide. Journal of the American Academy of Physicians Assistants, 28 (12), Cerel, J (2015, April 18), We are all connected in suicidology: The continuum of survivorship Plenary presentation at the 48 th annual conference of the American Association for Suicidology: Atlanta, GA. Cerel, J., McIntosh, J.L., Neimeyer, R.A., Maple., &Marshall, D. (2014) The continuum of survivorship : Definitional issues in the aftermath of suicide. Suicide & Life-Threatening Behavior, 44(6), Doi: /sltb Drapeau, C.W., & McIntosh, J.L. (for the American Association of Suicidology). (2016). U.S.A. suicide 2015: Official final data. Washington D.C.: American Association of Suicidology, dated December 23, 2016, downloaded from Ferris,S.(2016, June 14).Top doctor s group declares gun deaths a public health crisis. The Hill. Kroenke K., Spitzer R.L., & Williams J.B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine, 16, McDaniel, S.H. & Belar, C.D. (2016, June20). Re: APA s ongoing response to the Orlando tragedy and what you can do now [ sent to APA members]. Oquendo, M.A., Halberstam, B.& Mann J.J., Risk factors for suicidal behavior: utility and limitations of research instruments. In M.B. First [Ed.] Standardized Evaluation in Clinical Practice, pp , 2003). Scholarly References & Resources Posner, K. et.al., Columbia-Suicide Severity Rating Scale (C-SSRS) Lifetime/Recent version 1/14/2009 The Research Foundation for Mental Hygiene, Inc. Posner, K., et al. Posner, K., et. al., (2011). The Columbia-Suicide Severity Rating Scale: Initial Validity and Internal Consistency Findings from Three Multisite Studies with Adolescents and Adults. American Journal of Psychiatry (AiA:1-12.) Posner, K. et al., (Revised ) The Columbia Suicide Severity Rating Scale (C-SSRS): Supporting Evidence, The Columbia Lighthouse Project/Center for Suicide Risk Assessment, (1-18). Quinnett, P., Question, Persuade, Refer (QPR Training) SAMHSA, (2009) Suicide Assessment Five-step Evaluation and Triage (SAFE-T) Schwarz, D. (September, 2016) Suicide Awareness, Assessment, and Prevention: Suicide Can Be Prevented. The Pennsylvania Psychologist, 76, (8), Schwarz, D. (2016, March), Gun violence prevention and gun safety initiatives: What can psychologists do? The Pennsylvania Psychologist, 76 (3), Sorenson, s. (2016), June 17). Gun violence through the life span: A view from 5,00 feet. Presented at the Pennsylvania Psychological Association convention, Harrisburg, Pennsylvania. Shute, N. (2016, June). A plan to prevent gun suicides: Firearm sellers have become unlikely allies of public health authoritiesin the effort to block people from killing themselves. Scientific American. Retrieved from Additional References & Resources National Suicide Prevention Lifeline: (Veterans Press 1) National Crisis Text Line: National Trans Lifeline: For free gun locks: Montgomery County Data & Statistics Presentation: Professional Assessment Products, April )Reynolds, W.M. Suicidal Ideation Questionnaire 2)Reynolds, W.M. Adult Suicidal Ideation Questionnaire Rocky Mountain MIRECC, U.S. Department of Veterans Affairs 1)How to Talk to a Preschool Child about a Suicide Attempt in Your Family 2)How to Talk to a School Age Child about a Suicide Attempt in Your Family 3)How to Talk to a Teenager about a Suicide Attempt in Your Family Survivors of Suicide Loss Task Force, (April2015), Action Alliance for Suicide Prevention, Responding to Grief, Trauma, and Distress After a Suicide: U.S. National Guidelines: pdf. References & Resources: Videos Suicide prevention Resource Center, Counseling on Access to Lethal Means (CALM): The Peyton Heart Project, Brene Brown, On Empathy, Youtube Video: Kevin Hines, Attempt Survivor Video: HOPE4Tomorrow, The Dille Family, Youtube Video: New Hampshire: The Gun Shop Project, Youtube Video: Suicide Prevention Trainings for Gun Shop and Range Owners: Thank You for Coming! Please Complete and Hand in Your Evaluations 14