Crisis Intervention and Suicide

Transcription

1 Crisis Intervention and Suicide DR. ARNEL BANAGA SALGADO, D.Sc., Ed.D., RN, MA, B.Sc, Cert.Ed, MAT (Psychology) H/P No.: URL: Personal URL: Doctor of Science (D.Sc.) Doctor of Education (Ed.D.) Master of Arts in Nursing (RP) Master of Arts in Teaching - Psychology (PNU) Registered Nurse (RP, Mal, UAE) Licensed Teacher (RP) Certificate in Teaching, Bachelor of Science in Nursing (BSN) Author of McGraw-Hill

2 Chapters 13 & 17 of the required textbook

3 Learning Objectives 1. Define crisis 2. Name the types of crisis 3. Describe the various phases of crisis 4. Describe various steps in the nursing process in relation to crisis 5. Name the various psychiatric and medical disorders coexisting with suicidal acts 6. Describe the various risks and protective factors for suicide 7. Discuss the principles of suicide precautions and hazard-free environment in the hospital 8. Describe basic level interventions implemented in the management of a suicidal patient 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 3

4 Definitions Crisis is an acute, short-lived and overwhelming emotional reaction to a situation or an event. A sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 4

5 Types of Crisis Maturational Situational Adventitious 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 5

6 Maturational Crisis This relates to the process of maturation and passing through various stages of the life cycle. Coping skills used earlier may no longer be helpful and appropriate. This leads to anxiety or crisis. Adolescence, marriage, becoming a parent and retirement are some of the examples of maturational crises. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 6

7 Situational Crisis Is precipitated by various life events and is not anticipated Change of job, loss of job, divorce, financial loss, death of a loved one and major physical illnesses are some of the life events that can lead to situational crisis. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 7

8 Adventitious Crisis Also known as crisis of disaster, adventitious crisis is a situation that is not a part of everyday life It is unplanned and accidental. Various examples of adventitious crisis include earthquake, flood, airplane crashes, rape, murder, war, riots and terrorism. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 8

9 Phases of Crisis Caplan (1964) described four phases of crisis: i. When faced with a problem that seems to be unsolvable, tension starts and anxiety mounts. The person attempts more and more to solve the situation. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 9

10 Phases of Crisis (cont.) ii. Anxiety increases further with impairment of function and results in disorganization and distress. If anxiety and arousal are in excess, it hinders coping behaviour. iii. Emergency measures are taken and new coping skills are tried. iv. Failure to resolve the crisis leads to further deterioration, disorganization and decompensation. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 10

11 Application of the Nursing Process 1. Nursing Assessment Determine the severity of the crisis Assess the risk for suicide/homicide Assess patient s perception of the precipitating events Assess the patient s coping skills Assess the available support system 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 11

12 Application of the Nursing Process (cont.) 2. Nursing Diagnosis Various nursing diagnosis in a patient with crisis include: Anxiety Ineffective coping Inability to meet role expectations Inability to carry out routine activities 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 12

13 Application of the Nursing Process (cont.) Decreased socialization Low self-esteem Risk to self 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 13

14 Application of the Nursing Process (cont.) 3. Nursing Outcome Set short-term and long-term goals with patient and the family Goals should be realistic, culturally relevant and meet the patient s level of functioning Nursing Outcome Classification (NOC) can be used to help set the outcome goals. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 14

15 Possible Outcome Criteria in Crisis Intervention Short Term Refrains from harming self or attempting suicide Level of anxiety goes down Sleeps better Becomes more coherent and organized Interacts better with others Able to see some hope in life Long Term Feels safe even when alone Sleep and appetite patterns are back to pre-crisis level Learns new coping skills Able to carry out roles at home and at the workplace Has confidence in self to handle life and problems effectively 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 15

16 Application of the Nursing Process (cont.) 4. Nursing Intervention Crisis intervention is a brief psychiatric treatment to forestall the process of mental decompensation in severe emotional stress. Two basic aims of crisis intervention are safety and anxiety reduction. Nursing interventions in a crisis can be carried out at three levels. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 16

17 Levels of Crisis Intervention Primary level: promotes mental well-being and reduces the incidence of crisis Secondary level: works towards preventing prolonged anxiety, diminished efficacy and personality disorganization. Tertiary level: aims at providing support to patients recovering from a crisis 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 17

18 Application of the Nursing Process (cont.) 5. Evaluation To judge the effectiveness of the crisis intervention strategies used Usually carried out 4 8 weeks after the initial assessment Nurse may decide to follow up with patient or refer to other agencies 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 18

19 Crisis Stabilization People with mental illness are more prone to crisis. The nurse can adapt the crisis model by taking the following steps: Clarify the reality of the situation Make the patients aware of own capabilities and social support available 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 19

20 Crisis Stabilization (cont.) Set realistic goals according to level of functioning Take up responsibility and help the patient for the initial period 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 20

21 Suicide is the third leading cause of death among years olds, after accidents and homicides. The majority of people with suicidal ideations have a treatable psychiatric disorder. Only 1% of the people with suicidal ideations commit suicide. Suicide does not always mean presence of a psychiatric disorder. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 21

22 Comorbidity Clinical Conditions Associated with High Suicide Risk Psychiatric Conditions Major depressive disorder Bipolar disorder Schizophrenia Substance use disorder Panic disorder Borderline and antisocial personality disorder Medical Conditions AIDS Myocardial infarction Cardiac failure Cirrhosis Stroke Epilepsy Huntington s disease Multiple sclerosis Peptic ulcer 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 22

23 Aetiology i. Psychosocial factors Freud described suicide as aggression turned inward, towards an internalized love object. Menninger expanded on Freudian theory and described suicidal hostility as the wish to kill, the wish to be killed and the wish to die. Aaron Beck identified hopelessness as a central factor underlying the act of suicide. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 23

24 Aetiology (cont.) Durkheim divided suicides into 3 categories: Egoistic suicide, which occurred in persons who have lost their sense of integration within their social group. Anomic suicides are seen in times of major social changes or political crisis when the society lacks order. Altruistic suicide means sacrificing one s life for the welfare of the social group. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 24

25 Aetiology (cont.) ii. Biological factors Evidence of the role of genetic factors in suicide comes from the findings that suicide runs in families. Low levels of serotonin or its metabolites in the cerebrospinal fluid have been associated with the suicidal act. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 25

26 Aetiology (cont.) iii. Cultural factor Cultural factors including family values, religious beliefs and attitudes towards life and death have a bearing on the suicide rates. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 26

27 Risk and Protective Factors for Suicide Risk factors Clear suicidal intent Lethal suicidal plan Previous suicidal attempt Comorbid psychiatric/ medical conditions Unemployment Being single (especially in males) Old age Family history of suicide Recent stressful life event Poor social support Poor impulse control Protective factors Good coping skills Good social support Family cohesiveness Sense of responsibility to family Religious beliefs Pregnancy Intact reality testing

28 Nursing Process Assessment Assessment of suicide risk involves: taking detailed psychological and medical history identifying risk and protective factors. If there is no clear desire to die, suicidal feelings can be managed at the outpatient level with frequent follow-ups. The presence of clear intent with a lethal plan or a history of parasuicide would warrant emergency hospitalization. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 28

29 Nursing Process (cont.) Almost all suicidal patients give clues and hints about their suicidal ideas and plans (intent). These clues can be: verbal overt ones like I wish I were dead or covert ones (e.g. Soon I would not be a burden on anyone ). non-verbal (behavioural) sudden improvement in mood and energy levels, giving away personal belongings or organizing finances. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 29

30 Nursing Assessment (cont.) It is important to evaluate the lethality of suicidal plans. Lethality can be judged by the proposed method and the accessibility to the planned method. High risk ( hard ) methods include: jumping off a high building jumping in front a running train hanging 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 30

31 Nursing Assessment (cont.) using a gun staging a car crash. poisoning with organophosphorus chemicals (pesticides) Low-risk ( soft ) methods include overdosing on pills slashing wrists 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 31

32 Nursing Diagnosis Risk for suicide is the diagnosis with the highest priority and should be handled immediately. Nursing Diagnoses for a Suicidal Patient: Risk for suicide Social isolation Ineffective coping Loneliness Hopelessness Low self-esteem Powerlessness Deficient knowledge 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 32

33 Nursing Outcome Criteria NOC and NIC labels for a suicidal patient Nursing Outcome Criteria Suicide self-restraint Hope Self-esteem Coping Social support Spiritual health Nursing Intervention Criteria Suicide prevention Hope installation Self-esteem enhancement Coping enhancement Family mobilization Support system enhancement 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 33

34 Nursing Planning and Implementation During the acute suicidal crisis, the following interventions will help in the recovery process. Specialized milieu therapy Appropriate psychobiological interventions Counselling Case management and Health education 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 34

35 Specialized Milieu Therapy Suicide Precautions 1. Continuous nursing observation on one-to-one basis 2. Restrain, if warranted 3. Continuous assessment of risk 4. Ensure hazard-free environment 5. Recording of mood, thoughts and behaviour every minutes 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 35

36 Specialized Milieu Therapy (cont.) Supervise medication intake to ensure that patient swallows tablets Maintain the physical distance Explain all these to the patient and the reason for doing so 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 36

37 Psychobiological Interventions Electroconvulsive therapy (ECT) Antidepressants (SSRIs are preferred to tricyclic antidepressants considering their safety profile even when overdosed) Antipsychotics (atypical antipsychotics are preferred to the typical ones because these have fewer adverse effects) Anti-anxiety agents to control anxiety and insomnia. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 37

38 Counselling Establishing a working relationship with the patient encourages him to solve the problems in a realistic manner. A No-Suicide contract is written by the patient where he agrees not to harm himself but to use alternative methods to control suicidal ideas (e.g. use help-line, talking to the staff). The patient should come for regular follow-up after discharge from the hospital. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 38

39 Case Management The patient is helped to recognize the support system available to him. Re-establishing the contacts with family and friends is the major focus of case management. The patient should be given information on aftercare referral, crisis hotlines, support groups and recreational groups. Depending upon the religious beliefs, the patient may be encouraged to join a spiritual support group. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 39

40 Health Education The nurse should provide information about the psychiatric diagnosis, if any, the need for treatment, maturational crisis, coping and communication skills and various community resources available. Family and friends should also be included in the health teaching sessions. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 40

41 Nursing Evaluation Evaluation is an ongoing process. The evaluation should include short-term goals and establish long-term ones as the suicidal ideas resolve. The patient is observed to see whether he is able to talk about his thoughts and feelings freely and readily, is able to use problem-solving methods and is using the social support system. The patient is constantly monitored for any sudden change in the mood and behaviour as it may indicate a suicidal intent. 16/Sep/2015 Dr. Arnel - Crisis Intervention & Suicide 41