Workshop Description Assessment, Management, and Treatment of Suicide: Abbreviated Course Samuel Knapp, Ed.D., ABPP Fall 2017 Suicide is the 10 th leading cause of death in the United States and the most frequent crisis encountered by mental health professionals. This home study reviews basic information about the assessment, management, and treatment of patients at risk to die from suicide. It fulfills Act 74 requirements for Pennsylvania licensed psychologists, social workers, marriage and family therapists, and professional counselors Learning Objectives Act 74 of 2016 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, manage the risks of suicide, and treat patients who are at risk to die from a suicide attempt. 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 Competence and Suicide The brief CE program is just a basic 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. 1
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, 14% of psychologists had at least one patient die from suicide (Knapp & Keller, 2004). 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. Data on Suicide 43,000 Americans died from suicide in 2014 Demographics of Suicide Women attempt suicide more often than men 10 th or 11 th leading cause of death in USA Rate of suicide increased 20% since 1999 Men complete suicide more often then women European and Native Americans die from suicide more often than Black or Asian Americans Ideation, Plans, Attempts, Completions One 1999 study found that, over a lifetime, 15% have ideation 5% have a plan 2 3% attempt >1% complete a suicide (but more recent studies find higher rates) Responses to Suicide Historically, across all health care professionals, the most common responses to suicide are: medication no suicide contracts seeking a hospitalization 2
Responses to Suicide (2) No suicide contracts no evidence Medication except for bipolar or schizophrenia, no evidence on short term risk Assessment Thorough, extensive, and multifaceted David Jobes, 2008, p. 406 Hospitalization no evidence on long term benefit Three Steps of Assessment 1. Specific questions about ideation, plans, attempts 2. Static (baseline), acute (dynamic), and protective factors Step One: Assessment Questions Written question on initial patient form? Direct question Are you having suicidal thoughts? 3. Screening or brief suicide inventories (look at charts and tables) Assessment Clarification Follow up on thoughts, ask about frequency, intensity, and duration of ideation Ask about plans, ask for details Even if no suicidal ideation: IF OTHER FACTORS SUGGEST RISK, ask about passive suicide Relationships and Assessment The assessment is also the first part of building a relationship with the patient Calm, nonjudgmental, sympathetic, interested Show that you care 3
Psychotherapist Feelings Often psychotherapists feel fear: Fear of having a patient die from suicide OR fear of litigation in case something goes wrong Ideally, those with a good background in suicide assessment, management, and treatment will have the confidence to keep their fear in check. Step Two Assessment: Static Baseline/Stable Age, race, gender, sexual orientation History: child abuse, trauma, exposure to violence, history of mental illness Step Two Assessment: Acute Dynamic/Changeable Thwarted belongingness Perceived burdensomeness (harsh self criticism) Emotional pain (mental illness) Physical illness (disability or pain) Guilt moral challenges Step Two Assessment: Protective Factors Identifies with a social group Intimate, caring relationships Religious beliefs Self forgiveness Step Three Assessment: Screenings Examples: Columbia Suicide Screening Rating Scale Suicide Behavior Questionnaire Beck Hopelessness Scale Beck Suicide Ideation Scale Putting Them All Together Serious, High, Moderate, Low? 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 4
Management Myth One Four M s Motivate Means Medicate Monitor Myth: No suicide contracts have value TRUTH: No evidence supports their use Management Motivate Commitment to Life (Treatment) Agreement Reasons for living Situations to avoid, situations or people to seek out, ways to self soothe Symbols of hope How to manage distress Crisis numbers if needed Management Motivate (2) Unlike no suicide contracts, commitment to life or treatment contracts may help. Reasons for living What to do if distressed Created cooperatively with patient Crisis numbers, etc. Management Motivate (3) If your pain were to go away, would you still want to kill yourself? No. I think I can help you with that. Means Safety Details of suicide plan; then move guns, medications away from patient Patients seldom substitute one means of suicide for another. 5
Myth Two Myth: If you take away their guns (or pills) patients will just find another way to kill themselves. Truth: Taking away guns or medications reduces the likelihood of a completed suicide. Medication A management strategy for schizophrenia or bipolar disorder Its effectiveness in reducing short term suicide risk in other patients is unclear. Increased risk when starting or getting off medication Myth Three Myth: Medications will reduce suicidal risk. Truth: Except for schizophrenia and bipolar disorder, medications do not appear to reduce suicidal risk in the short run. A pill does not remove a gun from the home. Management: Monitor Continue to measure suicidal ideation and plans. Day to day check ins or monitoring with patients consent may be indicated for some patients. Hospitalization in extreme cases Myth Four Myth: No one can stop a patient who really wants to die from suicide. Truth: Although no one an MAKE a patient refrain from suicide, almost all patients are intensely ambivalent and good management and treatment techniques will greatly increase the chance of living. Management Techniques Breaking confidentiality: Do so only as a last resort. Involuntary hospitalization: Do so only as a last resort. Emergency room: Use with discretion, only when clearly necessary. 6
Effective Treatments Evidence based Rudd et al. (2015) CBT Linehan et al. (2015) DBT Others may be effective as well. Treatment Is Similar Good treatment of suicidal patients contains the essential elements of good treatment in general: Relationship Agreement on goals Empathy Monitoring progress, etc. Treatment Is Unique Be flexible in scheduling option of more than once a week. Continue to monitor suicidal ideation and plans. Continue management strategies as long as needed. Focus of Treatment Physical illness, pain, or disability? Coordinate with health professionals. Social isolation (thwarted belongingness or perceived burdensomeness) Focus on building relationships. Focus of Treatment (2) Guilt self compassion Emotional pain relaxation, mindfulness, cognitive reappraisals Other topics as needed Quality enhancing strategies Consultation Empowered Collaboration Documentation Redundant Protections 7
Ethical Foundations of Quality Enhancement Strategies Strategy Salient Moral Principles Consultation Empowered collaboration (informed consent) Beneficence, nonmaleficence Respect for patient autonomy Evidence Base for Quality Enhancement Strategies Consultation: Look at diagnosis, treatment choice, relationship quality. Documentation Redundant protection Beneficence Beneficence Empowered collaboration: Agree on treatment goal, legitimate patient preferences. Redundant protection: Routinely monitor patient progress. Quality Enhancing Strategies As the legal risks, possibility of treatment failure, or patient complexity increases, the greater the level of attention should be given to quality enhancing strategies. Consultation Beneficence/nonmaleficence Addresses stress and isolation Competent community Consultation Technique oriented information Emotional reactions (countertransference) Reduction of emotional turmoil Empowered Collaboration Respect for patient autonomy Evidence based relationship: agree on treatment goal accommodate reasonable preferences Thinking through solution together 8
Empowered Collaboration (2) Empowered collaboration builds upon informed consent and attempts to maximize patient involvement in all essential elements of treatment. The patient becomes more actively involved in the process of psychotherapy. Greater commitment leads to better outcomes. Empowered Collaboration (3) Empowering psychologists respect a patient s autonomy and decision making skills about goals of treatment, process of treatment, and life choices. Examples of tough decisions and ambivalent patients Documentation: Legal Purposes Beneficence/ Nonmaleficence Required by insurers, State Board of Psychology, APA Ethics Code A record of treatment for future providers Useful risk management tool Documentation: Quality Enhancing Dialogue between self and patient regarding process and goals of treatment Means to identify pertinent clinical issues Procedure to document progress Monitoring Progress Beneficence/Nonmaleficence Additional source of information for a difficult patient Four Session Rule Always monitor progress Be especially vigilant if progress has not occurred by the fourth session Routine procedure with high risk patients 9
Prompt List 1. Rethink diagnosis and goals: Do you need a consultation? 2. Discuss issues with patients. 3. Are there secondary sources of data to explore? Prompt List: Additional Reflections Do YOU think you and the patient have a good working relationship? Is your assessment of the patient adequate? Are there unresolved ethical issues? Do unresolved clinical issues impede treatment? What does your System I say about the patient? System II? Thank You!! Questions? 10