Workshop Description. The Essentials of Screening and Assessing Suicidal Patients. Act 74 of Act 74 (continued) 6/6/2018

Transcription

1 Workshop Description The Essentials of Screening and Assessing Suicidal Patients Samuel Knapp, Ed.D., ABPP Summer 2018 This program introduces psychologists to practical and evidence informed steps to screen for and assess suicidal patients. Emphasis will be placed on using the assessment to inform the management and treatment of suicide. The presenter will view suicide through the perspective of the Interpersonal Theory of Suicide. Learning Objective At the end of this program the participants will learn basic information that will help them to assess patients who are at risk to die from a suicide attempt. Conflict of Interest Samuel Knapp is under contract with the American Psychological Association for a book on suicide prevention with expected publication in Act 74 of 2016 Act 74 of 2016 requires all psychologists, social workers, marriage and family therapists, and licensed professional counselors to have one (1) hour of continuing education each renewal period in the assessment, management, and treatment of suicidal persons. Act 74 (continued) The State Board of Psychology has opined that the CE would be handled the same way the ethics CE mandate is handled: Complete the CE, like other CEs; No monitoring EXCEPT the routine audits of all CE 1

2 Competence and Suicide The brief CE program is just an introduction, perhaps a refresher or update for experienced clinicians. For others who have not acquired expertise in working with suicidal patients and wish to do so, a more comprehensive program is needed. Richard Cory by E. A. Robinson Whenever Richard Cory went downtown, We people on the pavement looked at him; He was a gentleman from sole to crown, Clean favored and imperially slim. So on we worked, and waited for the light And went without the meat, and cursed the bread; And Richard Cory, one calm summer night, Went home and put a bullet through his head. Psychologists and Suicide 1 in 5 psychologists will have a patient die from suicide in their career (Chemtob et al., 1989) probably much higher today Within one year, 4% of psychologists had at least one patient die from suicide (Knapp & Letizel, 2017). Psychologists and Suicide in PA 87% had a patient with suicidal ideation in % gad a patient with a suicide plan 23% had a patient who had attempted suicide 28% of psychologist in PA reported that treating suicidal patients was distressing or very distressing Data on Suicide 45,000 Americans died from suicide in th or 11 th leading cause of death in USA Rate of suicide increased 20% since 1999 Demographics of Suicide Women attempt suicide more often than men Men complete suicide more often then women European and Native Americans die from suicide more often than Black or Asian Americans 2

3 Ideation, Plans, Attempts, Completions One 1999 study found that, over a lifetime, Key Concepts The interpersonal theory of suicide 15% have ideation 5% have a plan 2 3% attempt >1% complete a suicide (but more recent studies find higher rates) Acute suicidal affective disturbance (suicidal mode) Fluid vulnerability theory of suicide The Interpersonal Theory of Suicide Suicide involves 1. Acquired capacity to kill oneself 2. The desire to die Developed by Thomas Joiner and colleagues The Interpersonal Theory of Suicide 2 Acquired capacity: lose fear of death and habituation to pain and suffering Desire to die: Thwarted Belongingness and Perceived Burdensomeness Thwarted Belongingness The person does not feel close connections with others, or does not identify with any valued group of people. May be a recent loss of a valued relationship through divorce, family conflict, or death Perceived Burdensomeness The world is better off without me. People may perceive themselves as an emotional, physical, or financial burden (may have illness or functional limitations) Implicit: self disgust and hopelessness 3

4 Acute Suicidal Affective Disturbance (ASAD) Akin to the concept of a suicidal mode which is a mixture of thoughts, feelings, behaviors, and motivations linked to a suicide attempt. The ASAD is an empirically driven model that specifies what to look for in the suicidal mode Acquired Capability AND ASAD Features Thwarted Belongingness OR Perceived Burdensomeness (hopelessness and self disgust) COMBINED WITH (at least two of): insomnia, irritability, agitation, anxiety, social withdrawal, or nightmares Applying the Theory So we look to the Interpersonal Theory and the ASAD to help us identify Who is likely to enter the suicidal mode (ASAD) and what will their suicidal model look like? What to focus on in the assessment that will help us to craft suicide management and treatment Usefulness of Theory The theory will be used to help 1. Focus the assessment 2. Formulate suicide management plans 3. Guide treatment Fluid Vulnerability Theory Patients have a baseline of risk May move up or down the baseline depending on intervening events Those with a high baseline will find it easier to get into the suicidal mode (e.g., ASAD); and harder to get back to baseline. Screening and Assessment Screening: does this person have suicidal thoughts? Assessing: gathering information to a. Predict risk of suicide b. Inform management and treatment c. Establish baseline of functioning d. Build a relationship 4

5 Assessment Thorough, extensive, and multifaceted David Jobes, 2008, p. 406 Three Steps of Assessment 1. Specific questions about ideation, plans, attempts 2. Static (baseline), acute (dynamic), and protective factors 3. Brief tests if needed Step One: Screening Questions 1. Written question on initial patient form? 2. Direct question Are you having suicidal thoughts? Results of Screening Most do not have suicidal thoughts proceed with regular intake Those who have suicidal thoughts need a more thorough assessment But do some have suicidal thoughts that they are not revealing? Accuracy of Screening? True Deniers: deny suicidal thoughts and low on risk factors 70% 80% Possible False Deniers: (1) Inconsistent responses OR (2) deny and high on risk factors 10% 15%. Acknowledge suicidal thoughts: 5% 10% False Deniers Yes on written form and no in verbal response (or vice versa) Deny, but have high risk factors Try to reconcile apparently conflicting data Ask about passive ideation 5

6 Reasons for Withholding Self negation I do not deserve to be helped Self stigma suicidal people are weak and cowardly Shame, self disgust there is something terribly wrong with me because I have these thoughts Fear of punitive responses they will put me in a hospital, they will tell my family, etc. Demoralized treatment does not work Anticipate Witholding Calm, nonjudgmental Normalize many people that have gone through so much think of suicide. Have you ever thought of suicide? Transparency about nature of treatment and treatment philosophy Ideation Start with open ended questions to give patients a chance to tell their story Frequency, intensity, and duration of ideation Do certain events trigger ideation? What is the psychological experience occurring during ideation? Past Attempts The single best predictor of suicide is a past attempt Start with open ended questions Do certain events trigger ideation? What is the psychological experience occurring during ideation? Past Attempts 2 Precipitants what led to the attempt Motivations why (e.g. to end pain, to punish myself, etc.) Outcomes what happened? Reactions of others If multiple attempts ask about most recent and worst Plans Start with open ended questions More detail suggests a greater degree of risk Access to means, preparation, rehearsals? Secondary or tertiary plans? 6

7 Unplanned Attempts 10 to 25% of suicides occur among patients who denied any plan for a suicide Implications of Ideation, Attempts and Plans Ask patients the likelihood that they will die from suicide on a scale of 1 to 5. Impulsivity perhaps in some Alcohol/drug induced perhaps in some Also, dormant plans or secondary plans not assessed The psychological experiences associated with ideation, plans, or past attempts give us a clue into the suicidal mode of the confluence of thoughts, feelings, etc. that precede suicide attempts Common Features of the Suicidal Mode Look at the ASAD: Perceived burdensomeness Thwarted belongingness, Hopelessness and self disgust Insomnia, nightmares, irritability, agitation, social withdrawal AND other emotions Past Attempts and Acquired Capability Past attempts habituate an individual to suffering and suggest a gradual diminishing of the healthy fear of death The psychological threshold for a suicide attempt appears to decrease with every incomplete suicide attempt Relationships and Assessment The assessment is also the first part of building a relationship with the patient Calm, nonjudgmental, sympathetic, interested At the End of the Assessment Patients should have a sense that you care about them AND they had a chance to tell their stories Neither alarmist nor uninterested 7

8 Psychotherapist Feelings Often psychotherapists feel fear: Step Two: A More Thorough Evaluation 1. Static/fixed factors having a patient die from suicide OR of litigation in case something goes wrong Those with a good background in assessment, management, and treatment of suicide will have confidence which will keep their fear in check. 2. Dynamic/changing factors 3. Protective factors Static Factors Age, race, gender, sexual orientation Developmental history: child abuse, trauma, exposure to violence, history of mental illness Nothing about these factors inevitably leads to suicide they are only valuable to the extent that they suggest an individual has been exposed to risk factors Old White Males There is no white male suicide gene that inevitably manifests itself as the man grows old The demographic merely represents the likelihood that the individual has had experiences that will increase the acquired capacity for suicide and the desire to die. Implications of Static Factors Look for situations that lead to the acquired capability for self harm. This includes exposure to violence or suffering as a witness, victim, or perpetrator Recent life events Social Networks Physical Health Mental Illness Religion/Values Dynamic Changing 8

9 Themes in Dynamic Factors Look for Themes related to suicide Thwarted belongingness Perceived burdensomeness (harsh self criticism) Emotional pain (mental illness) Physical illness (disability or pain) Guilt moral challenges Mental Illness Suicide cuts across diagnoses Even in high risk diagnoses, such as Bipolar, most patients do not have suicidal thoughts Comorbid diagnoses increase risk substantially Protective Factors Identifies with a social group Intimate, caring relationships Religious beliefs life protecting, i.e., suicide is a sin life promoting, e.g., self forgiveness Protective Factors Make it harder for patient to move into the ASAD OR Make it easier for patient to interrupt the ASAD Brief Instruments Never in isolation only supplement interview No instrument is high in both sensitivity (identifying suicidal persons) and specificity (excluding non suicidal persons) Step Three: Instruments Beck Depression Inventory Beck Hopelessness Scale Suicide Intent Scale, and others May be especially useful when patients deny suicidal behavior, but have high risk factors OR As baseline to measure progress 9

10 Levels of Risk For short term predictions only Imminent hospitalize High closely monitor outpatient Moderate monitor outpatient Low regular outpatient Imminent High Imminent acquired capacity access to means high baseline easy to move into suicidal mode High acquired capacity but limited access moderate to high baseline harder to move into suicidal mode Moderate and Low Cautions with Levels of Risk Moderate Low perhaps acquired capacity no access low to moderate baseline harder to move into suicidal mode no acquired capacity, no access lower baseline and harder to go to suicidal mode Put continuous variables into dichotomous forms Consider mixing levels, such as moderate/high Factors are ever changing Any rating system has a high rate of false positives One factor may, with some patients, warrant greater weight than a predetermined algorithm could capture Other Goals of Assessment Establish baseline of functioning self report data OR instrument data Inform Treatment use data to develop suicide monitoring plan and treatment plan Tips on Improving Quality Use both written and verbal question Be sensitive to the possibility of false deniers Ask about secondary or tertiary suicide plans Ask about the likelihood that they will die from suicide Identify warning signs using ASAD as a guide Sensitive to cultural issues Ensure that patients feel they had a chance to tell their story and that you care about them. 10

11 Thank You!! Questions? 11