Stacy Rivers, MSW, LICSW WHAT IS IMMINENT RISK? UNDERSTANDING THE FUNDAMENTALS OF SUICIDE RISK ASSESSMENT AND MANAGEMENT Journal of Dawn Renee Befano, 10/29/1995 I want to die. Today I feel even more vulnerable than usual. The pain is all consuming, overwhelming I live in hell, day in and day out. Every day. I break down a little bit more. I am eroding, bit by bit, cell by cell, pearly by pearl. I am not getting any better... I am a hopeless case. I have lost my angel. I have lost my mind Suicide is the anchor point on a continuum [it] extends through different degrees and types of suicidal thinking and ends with suicide attempts...include[ing] not only those acts where there is a clear or likely intent to die, but those where there is no intent to die (for instance, acts where the individual wishes to use the appearance of intending to kill himself or herself in order to obtain some other end). Kay Redfield Jameson 10 th leading cause of death in the US 123 suicide per day About 1,400 hospital visits per day for self injury 9 out of 10 who die by suicide have a mental illness Stats All suicidal people are depressed Fact While depression is often a factor, it is not always present. Psychosis, mania, trauma, physical illness, or psychosocial factors may play a role. 1
The psychopathology of despair The young boy scrawled a note and pinned it to his shirt. Then he walked to the far side of the family Christmas tree and hanged himself from a ceiling beam. The note was short Merry Christmas and his parents never forgot or understood it. A person who has attempted suicide will never attempt suicide again Feeling trapped Recent suicide of a friend or relative Withdrawal or isolation Preoccupation with death Depression Substance use Giving away possessions Making a will or other final arrangements Fact Past attempts including aborted or interrupted attempts are indicators and risk factors in future attempts. Warning Signs Sudden irritability or anxiety Sense of unbearable pain or shame Hopelessness Searching for a way to end their lives Sense of unworthiness or failure Visiting or calling people to say goodbye Lack of interest in the future Changes in eating habits Talking about being a burden Major changes in sleep patterns High risk behaviors Expressed suicidal thoughts All suicidal comments or gestures should be taken seriously. s People who talk about suicide are just seeking attention Facts Talking or writing about death or suicide is a warning sign. Even attempts to harm one s self for attention can still result in harm 2
Let s Talk About Suicide Most suicidal people don t want to end their lives: wish is to end the pain and suffering Most suicidal people tell others they are considering suicide as an option for coping with the pain Often, if we don t ask, people will not tell us their thoughts of suicide Most suicidal people have psychological or social problems and poor coping methods Symptom vs Focus of Care If I ask about suicide, people will be more likely to do it Facts When we ask, we open the door for people to share, communicate, and connect Use of leading questions is not the same as direct, open ended assessment questions Assessment & Management of Suicidality Understand Risk & Protective factors Complete a thorough inquiry Collaborate on interventions based on formulation of risk Assessment Tools PHQ-2 PHQ-9 SAFE-T Columbia Suicide Severity Rating Scale (C-SSRS) 3
The C SSRS provides standard, consistent language and assessment for providers in a flexible format. Screen 1. Have you wished you were dead or wished you could go to sleep and not wake up? 2. Have you actually had any thoughts of killing yourself? 3. Have you been thinking about how you might kill yourself? 4. Have you had these thoughts and some intention of acting on them? 5. Have you started to work out or worked out the details of how to kill yourself? And if so, do you intend to carry out this plan? 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? If so, how long ago? Full Assessment Most severe ideation and behavior in lifetime, and in recent 1-3 months. Description of Ideation Frequency Duration Controllability Deterrents Reasons Prior attempts, including type (aborted, interrupted) Non suicidal self injury Prepatory acts or behavior Family history of suicide Protective Factors Significant loss Mental Illness Stressful life event Reasons for living Responsibility to others Fear of dying Religious obligations/morality Risk Factors Access to lethal means Chronic illness, pain Isolation Engagement with work, school, or family system Supportive family/network Receiving and engaged with treatment Internal coping skills Trauma Prepatory behaviors TBI Access to lethal means Prior attempts Future goals and orientation; sense of hope Psychological flexibility Adaptive problem solving skills Restricted access to lethal means 4
Let s Talk Assess for Ideation & Behaviors: If no to 1 & 2, skip to 6 1. Be fully present 2. Ask questions that are direct, open, & simple 3. Go with the flow and allow the conversation 1. Have you wished you were dead or wished you could go to sleep and not wake up? 4. Have you had these thoughts and some intention of acting on them? 2. Have you actually had any thoughts of killing yourself? 5. Have you started to work out or worked out the details of how to kill yourself? And if so, do you intend to carry out this plan? 3. Have you been thinking about how you might kill yourself? 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? If so, how long ago? Suicide contracts keep people safe Fact Suicide contracts are not evidence based - collaborative approaches to risk assessment and treatment planning are found to be more efficacious Managing Risk Collaborative Approaches 5
Expand protective factors Bolster internal and external coping methods Provide community resources Reduce access to lethal means Collaborate on a safety plan Negotiate an ongoing treatment plan Interventions Reflection American Association of Suicidology. Suicidology.org American Foundation for Suicide Prevention: afsp.org Columbia Lighthouse Project: cssrs.columbia.edu Detecting and Treating Suicidal Ideation in All Settings (2006). The Joint Commission (56). REFERENCES & RESOURCES Jobes, D.A., (2006). Managing Suicidal Risk: A Collaborative Approach. New York, New York. The Gulliford Press. Pisani, A.R., Murrie, D.C., Silverman, M.M. (2015). Reformulating Suicide Risk Forumalation: From Prediction to Prevention. Academic Psychiatry. Retrieved from Springerlink.com Redfield-Jamison, K. (1999). Night Falls Fast. New York, New York. Alfred A. Knopff. SAFE-T: Suicide Assessment Five-step Evaluation and Triage for Mental Health Professionals. Originally conceived by Douglas Jacobs, MD, and developed as a collaboration between Screening for Mental Health, Inc. and the Suicide Prevention Resource Center Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256 264. Suicide Prevention Resource Center: sprc.org Veteran Affairs Mental Health: mentalhealth.va.gov/ Zero Suicide: zerosuicide.sprc.org 6