4. It s OK to Ask about suicide (youth/gatekeepers) - itsok2ask.com. 6. American Foundation for Suicide Prevention (education / tools) - afsp.

Transcription

1 TALK Connects a person to the nearest crisis call center Crisis Text Line: and Text Start Survivors of Suicide Loss Support groups (SOS) Find information for your local area at afsp.org, under surviving suicide loss. Survivor Online Support Groups Parents of Suicide POS angelfire.com/mi2/parentsofsuicide Friends and Family of Suicide FFOS angelfire.com/ga4/ffos/support Alliance of Hope allianceofhope.org Online Prevention Resources / Suicide Chatlines: 1. Reachout (teens and tweens) - reachout.com 2. The Trevor Project (LGBT teens) - thetrevorproject.org 3. Go Ask Alice (teens) goaskalice.columbia.edu 4. It s OK to Ask about suicide (youth/gatekeepers) - itsok2ask.com 5. Zero Suicide (professional resources/training) sprc.org 6. American Foundation for Suicide Prevention (education / tools) - afsp.org 7. Suicide Awareness Voices of Education (education / resources) - save.org 8. American Association of Suicidology (professionals) suicidology.org Suggested Reading for Family and Friend Survivors Archibald, R. Finding Peace Without All the Pieces Smolin, A. & Guinan, J. Healing after the Suicide of a Loved One. NY: Fireside, Fine, C. No Time to Say Goodbye: Surviving the suicide of a Loved One Myers, M and Fine, C. Touched by Suicide. Gotham Books, Wrobleski, A. Suicide Survivors: A guide for those left behind. MN: Afterwords Pub, 1991 Carr, G., Carr, G. Fierce Goodbye: Living in the shadow of suicide. Herald Press, 2004 Bolton, I. My Son, My Son. Atlanta: Bolton Press, The 29th Annual Festival of Legal Learning 1 February 9, 2019

2 Preventing and Responding to Attorney Suicide Jodi Flick, ACSW, LCSW Family and Children s Resource Program Jordan Institute for Families UNC-Chapel Hill School of Social Work joflick@ .unc.edu Dispelling the myths Rate highest: late spring / early summer Suicide more than twice rate of murder 12.5 per 100,000 vs. 4.8 per 100,000 Rates rise with age, with highest rates among white men in their 70s and 80s More rural than urban More people use guns than drugs Kids 57% Teens 74% NC higher than U.S. rate Availability = increased risk NCVDRS, 2012; CDC, 2014; US DoJ, 2010; Stallones, 2005 The 29th Annual Festival of Legal Learning 2 February 9, 2019

3 Attorneys and suicide Fourth among occupations in rate of suicide 6 times rate of depression of general pop. Rates same before law school, but increase by third year and never go down 1 in 4 estimated to suffer from depression; anxiety and hostility far higher than civilians Enough concern that NC State Bar added mental health component to mandatory CLE Beliefs that are common, but aren t true Talking about it will give them the idea. Suicide occurs with little or no warning. If attempt was not fatal, it means it was only attention-seeking behavior. Suicide occurs because of a stressful event. If they want to die, they will just keep trying until they succeed. Intervening takes away a person s right to individual choice. If you recognize some of those beliefs are part of your thinking it will likely impair your ability to help a person at risk of suicide. The 29th Annual Festival of Legal Learning 3 February 9, 2019

4 Efforts in Prevention Limit access to methods Limit mass media coverage Religious proscriptions Desecration of corpse Crime against the state Telephone / internet crisis lines Primary medical care assessment School prevention programs Gatekeeper programs: MHFA, QPR, ASIST, Kognito Mostly know what does not work; few EBTs Suicide: Causes Most explanations are too simplistic: Never the result of single factor or event. No single CAUSE of suicide; only CAUSES. Highly complex interaction of biological, psychological, cultural, sociological factors Mental disorders Substance abuse History of trauma Modeled by others Pain sensitivity Relationship loss Economic Hardship Isolation Head injury / brain illness The 29th Annual Festival of Legal Learning 4 February 9, 2019

5 Suicide Prevention Stress model Normalizes the behavior Overemphasizes frequency Ignores contagion effect Could happen to anybody model Biological model 90-95% of suicides have identifiable brain illness Depression Bipolar disorder Schizophrenia Substance abuse (Anxiety disorder; Borderline Personality, Anorexia) Depression and Bipolar Depression Substance abuse Just like heart disease or cancer, some people die as a consequence of mental illness / brain illness. Cavanagh et al 2003; NIMH, 2010 The 29th Annual Festival of Legal Learning 5 February 9, 2019

6 Risk potential is cumulative prior attempt family history depression I m so depressed! Trivializes the suffering of people with depression; makes it difficult to understand the depth of pain. The 29th Annual Festival of Legal Learning 6 February 9, 2019

7 Why do people kill themselves? Don t want to die; want to end intolerable pain. Internal struggle between will to live and wish to die; something tips the balance It is confluence of pain and hopelessness, alienation and burdensomeness that matters. Although act may appear impulsive, person going downhill a long time: months, years, decades 70% give some warning Klonsky, 2015; Anestis, 2014; Joiner, 2010 Depression and unhappiness are not the same. Unhappiness: normal grief, bereavement, situational depression, reactive depression exogenous originating from outside Depression: biochemical, clinical, biological endogenous originating from inside The 29th Annual Festival of Legal Learning 7 February 9, 2019

8 1. Grief or bereavement 2. Depression 3. Grief leading to Depression Trigger onset Trigger relapse Make episode worse Make episode last longer Marano, 1999 Recurrent illness 1 episode: 60% chance will have second 2 episodes: 70% chance will have third 3 or more: 90% chance will have another Subsequent episodes more severe and shorter time between episodes Time APA, 2013; Marano, 1999; Marsh, 2002 The 29th Annual Festival of Legal Learning 8 February 9, 2019

9 People look for an explanation When person depressed, attempts or dies by suicide, people look for explanation Failing or girlfriend left him Failing because depression affected concentration, attendance Girlfriend left because depressed: irritable, apathetic, no fun Jamison, 1999 Cause or consequence? People think that problems were the cause, but more likely, problems were the consequences. Many people still don t recognize that depression is a biological illness. People don t see it like flu or diabetes. Symptoms not something person has control over. The 29th Annual Festival of Legal Learning 9 February 9, 2019

10 People with depression: think more slowly tire more quickly have problems with short term memory are easily distracted (pulled off track) are less able to problem solve or make decisions Depression: Causes Biology: changes in brain structure and chemistry hereditary vulnerability Environment: stresses can trigger and/or worsen episodes Cognition: thoughts / beliefs The 29th Annual Festival of Legal Learning 10 February 9, 2019

11 Continuum of Severity + _ = Biology / Heredity Events / Stressors Outcomes Serotonin Central in regulating: mood sleep appetite neurotransmission addictive behaviors impulsivity / aggression / risk taking perception of physical pain Low serotonin levels associated with depression and with higher suicide risk. Jamison, 1999; Nolen-Hoeksema & Hilt, 2009 The 29th Annual Festival of Legal Learning 11 February 9, 2019

12 Depression: Changes in the brain Low levels of neurotransmitters Inflammation of brain tissue Loss of brain cells (glia) Lack of nerve growth factor (BDNF) EEG abnormalities (changes in REM sleep) B-vitamin deficiency (B6, B12) D-vitamin deficiency (D3) Over-activity of limbic system; area 25 Decreased blood flow / metabolism High levels of cortisol NAS, 2013; Dobbs, 2006; Jamison,1999; Stone,1999 ; Nolen-Hoeksema, 2009; Marano,1999 Hereditary Risk In general population: one in 10 Close relative: 2-3 times greater Both parents: 7 times greater Gene for decreased serotonergic functioning Family, twin and adoption studies show influence beyond heredity The 29th Annual Festival of Legal Learning 12 February 9, 2019

13 Society and Culture Influences: stigma vs. acceptability for suicide & asking for help modeling: family member suicide = 2-3x more likely Risk factors / stressors: available, easy, lethal methods (3x increase among gun owners) excessive use of alcohol prevalence of negative life events economic hardship: 1.3% per 1% increase in unemployment long periods disrupted sleep Protective factors: support / proximity, religious faith, access to care Access to easy lethal methods Method at hand makes life / death difference Cutting / poisoning: 1-2% fatal Firearm: 8-9 out of 10 fatal Suicidality waxes / wanes: it s not sustained Many people start attempt and stop Low lethality methods give window of opportunity for person to change mind May say no to plan now, but might be suicidal in a week, and now still have access CALM: Counseling About Lethal Means 5 minutes can save a life: The 29th Annual Festival of Legal Learning 13 February 9, 2019

14 Environmental Influence: Childhood trauma Affects developing brain with potentially lifelong abnormalities / deformities Changes in biochemical functioning Stress response dysregulation Pain response exaggerated Vulnerable to subsequent traumas Greater number / severity = greater risk Sexual abuse - highest risk of suicide (over a lifetime) of all child maltreatment 25x higher independent of psychopathology CDC, 2015; DeBellis, 2002; Fairbanks, 2002; Teicher, 2000 Adverse Childhood Experiences: ACE Studies 47,000 people ACEs = increasingly higher incidence of: Smoking, alcoholism, drug abuse, obesity, HIV Heart disease, stroke, diabetes, emphysema Bronchitis, hepatitis, liver/kidney disease Cancers, STDs, arrests, irritable bowel syndrome Depression, suicide, attempted suicide Suicide attempt ACE % The 29th Annual Festival of Legal Learning 14 February 9, 2019

15 People work up to the act Selfpreservation Time Acquired ability to enact lethal self-injury: Get used to pain and fear Gradually lose inhibition against it Build knowledge needed to accomplish Not fearlessness losing fear in face of true threat Courage approaching threat even with fear Stable Fluctuates Capable of suicide Desire suicide: Perceived burdensomeness + Failed sense of belonging Serious attempt / death by suicide The 29th Annual Festival of Legal Learning 15 February 9, 2019

16 Feeling like you Belong Frequent interaction plus consistent caring More satisfying in stable relationships Only partly met if feels loved but not face-to-face (proximity important) or stable but unpleasant Feeling like a Burden Ineffectual, especially so ineffective that loved ones are threatened or burdened Feel let others down Worse when not remediable; permanent Feel out of control, causes negative self-image Think about risk factors in light of this model: How are they explained by these 3 concepts? Relationship loss (death / divorce / breakup) Previous suicide attempts Job loss / economic hardship Childhood trauma, especially abuse Medical conditions, especially chronic illness with poor prognosis / constant pain Military service Being male Advanced age The 29th Annual Festival of Legal Learning 16 February 9, 2019

17 Fire prevention vs. suicide prevention Fire requires three things: Fuel Oxygen Heat Take away just one and fire goes out. Suicide requires three things: Capability Feeling like you don t belong Feeling like you are a burden Thoughts and Beliefs Beck, Ellis The 29th Annual Festival of Legal Learning 17 February 9, 2019

18 Cognitive Distortions Many brain illnesses severely impair judgment; cause people to believe things that are not true I m no good. I m worthless. People will be better off without me. No one loves me. No one will ever like me. Nothing will ever change. My life is ruined. I can t live without this person. We must begin to see suicide as symptom of serious illness, like coughing and sneezing are symptoms of a cold, not as something selfish, hostile, irresponsible, or weak Attorney Characteristics What puts attorneys at higher risk of depression / suicide? Perfectionism Over developed sense of control Profession is magnet for workaholics; can lead to isolation High stress profession with conflict/adversity built in Stigma re: asking for help; you re supposed to be a problem solver, not have problems Public s issue with lawyers: seen as rich and powerful, so don t want to hear about it not reality for most Fear reporting depression before taking bar: worry about character and fitness requirements The 29th Annual Festival of Legal Learning 18 February 9, 2019

19 Feedback Loop Chemistry interacts with thinking Thinking interacts with stress Stress interacts with chemistry Riley, 2000 Treatment / Intervention Medication / Treatment Improve brain function/chemical imbalance Electroconvulsive Therapy (ECT) Vagus nerve stimulation (VNS) Transcranial Magnetic Stimulation (TMS) Neurofeedback (NFB) Eye Movement Desensitization/Reprocessing (EMDR) Cognitive Behavioral Therapy (CBT + DBT) Changes the negative thought patterns that reinforce and worsen feelings Environmental changes Reduce stress: conflict, sleep, exercise, meditation Increase protective factors: social skills, managing emotions, optimism The 29th Annual Festival of Legal Learning 19 February 9, 2019

20 Vagus Nerve Stimulation (VNS) Pacemaker-like device that provides small amount of electrical stimulation on continuous basis to part of brain that regulates mood. Transcranial Magnetic Stimulation (TMS): Electromagnetic coil held against scalp creates magnetic field that stimulates targeted brain cells and affects nerve cell communication Neurofeedback (NFB) Brainwave patterns recorded and shown to you on computer; your brain learns to alter its patterns: EEG biofeedback EMDR: Eye Movement Desensitization / Reprocessing Bilateral stimulation of brain hemispheres. Significant improvement in a few sessions. Prolonged Exposure Therapy - Desensitization through imagining and live exposure. Repeated exposures reduce distress/avoidance of trauma cues. Improvement in 80% of those with PTSD Yoga: Observing / feeling yourself: mindfulness, body control, gentle self-awareness. Being quiet and still is too hard, can t tolerate. Focus in yoga on doing something while becoming more mindful 8 sessions decreased hyperarousal / increased mood Book: Healing Trauma Through Yoga The 29th Annual Festival of Legal Learning 20 February 9, 2019

21 Environmental Changes Reduce stress in any way. Intervene in: child abuse / neglect / sexual abuse conflict: family, bully, teacher, work inadequate sleep / exercise / nutrition / sunlight social concerns / hygiene unmet spiritual needs Environmental Changes Increase protective factors: Improve social skills making friends assertiveness empathy reading social situations negotiating / setting limits Foster connections / support Increase optimism / hope Coping skills: managing stress / emotions Klonsky, 2015; (Goldsmith, 2002; Hockey, 2003; Seligman, 2011) The 29th Annual Festival of Legal Learning 21 February 9, 2019

22 Environmental Changes Increase protective factors: Find purpose / meaning Altruism isn t just altruistic Volunteer Do small acts of kindness Positivity skills - lots of activities at: authentichappiness.org nowmattersnow.org (Goldsmith, 2002; Hockey, 2003; Seligman, 2011) Intervention ASK question directly: Have things gotten so bad that you ve thought about killing yourself? If yes, actively listen Reflect person s concerns Gently reinforce what holds them back Ask, Have you decided how? Have you collected things you would need? Don t judge or use guilt to threaten Set goal no matter how small Don t leave person alone if actively suicidal The 29th Annual Festival of Legal Learning 22 February 9, 2019

23 Getting Help National Suicide Prevention Hotline HELP (8255) Crisis Textline text to Online resources: AFSP.org SAVE.org Your family physician BARCares NC Lawyers Assistance Program Since every man is part of a community, he injures that community by killing himself. St. Thomas Aquinas ( ) Postvention is prevention. Schneidman, 1972 The 29th Annual Festival of Legal Learning 23 February 9, 2019

24 Aftermath: family / community Don t say committed suicide: Use died by suicide lost to suicide died of brain illness Educate about brain illness; suicide prevention Attend to contagion effect / limit public memorials Focus on living memorials Survivors of Suicide Loss Support Groups: Chapel Hill, Charlotte, Gastonia, Greenville, Raleigh, Wake Forest, Hillsborough, Wilmington, Shelby, Winston Salem, Statesville, Mount Airy, King Online support groups Parents of Suicides Family and Friends of Suicides Spouses of Suicides Living Through the Suicide of a Loved One Suicidegrief.com The 29th Annual Festival of Legal Learning 24 February 9, 2019

25 Suicide Prevention in North Carolina Law Enforcement Crisis Intervention Training AARP Preventing Suicide Is Everyone s Business To those who have lost their lives by suicide, To those who struggle with thoughts of suicide, To those who have made an attempt on their lives, To those caring for someone who struggles, To those left behind after a death by suicide, To those in recovery, and To all those who work tirelessly to prevent suicide and suicide attempts in our nation. We believe that we can and we will make a difference. Dedication from the 2012 National Strategy for Suicide Prevention The 29th Annual Festival of Legal Learning 25 February 9, 2019