NASW Oklahoma 2012 Helping those at risk: Suicide Prevention clinical tools and resources

1. NASW Oklahoma 2012Helping those at risk: Suicide Prevention clinical tools and resources Juli McNeil, MSSW, LCSW Program Manager, Suicide Prevention Tina Bevans, MSW, LCSW Suicide Prevention Coordinator-TulsaJack C. Montgomery VA Medical Center

2. Objectives • Suicide Prevention Program and Staff • Suicide Facts and Statistics • The Self-Directed Violence Classification System (SDVCS): What is it and why it matters • Suicide Risk Assessment • Safety Planning • VA Programs and Services

3. Initiation of the Suicide Prevention Program 2007 Joshua Omvig Veterans Suicide Prevention Act

4. Jack C. Montgomery VAMC and Clinics Suicide Prevention Team Juli McNeil, LCSW Program Manager, Suicide Prevention 918-577-3087/4144 Juli.McNeil@va.gov Tina Bevans, LCSW Tulsa VA Clinics (41st and 11th) Suicide Prevention Coordinator 918-628-2659

5. Suicide Prevention Team Cont’d Alexa Youngblood, LCSW Suicide Prevention Case Manager 918-577-3672 Alexa.Youngblood@va.gov Tawnya Wilson Suicide Prevention Program & SUD Intensive Outpatient Program Administrative Assistant 918-577-4111/3439

6. Out of the Darkness Walk 10/8/2011

7. Oklahoma City VA Suicide Prevention Team Juanita Celie, LCSW, BCD Team Coordinator (405) 456-4692 Sherry Oliver, LCSW, BCD CaseManager (405) 456-5736 Bryan Stice, Ph.D Case Manager (405) 456-5206 Alicia Oddi, LPN Program Assistant (405) 456-4228

8. Suicide Statistics • 36, 909 US deaths from suicide/year • One Suicide every 15 minutes • Suicide is the 10th leading cause of death in the US • Suicide is the 2nd leading cause of death among 25-34 year olds • Suicide is the 3rd leading cause of death among 15-24 year olds • 4 times as many men kill themselves compared to women, yet 3 times as many women attempt suicide as compared to men. Oklahoma is 12th in the Nation.

9. Suicide Statistics Continued • ~20% are Veterans • ~18 deaths from suicide per day are Veterans • ~About 5 deaths from suicide per day among Veterans receiving care in VHA • Veterans are more likely to use firearms as a means for suicide • ~1000 attempts/month among Veterans receiving care in VHA as reported by suicide prevention coordinators. ~8 % repeat attempts with an average of 3 months follow-up ~0.45% deaths from suicide in attempters with an average of 3 months follow-up ~33% of recent suicides have a history of previous attempts • Preliminary data since 2006 show decreased suicide rates in Veterans aged 18-29 who use VA health care relative to Veterans in the same age group who do not. This decrease in rates translates to about 250 lives per year.

10. National Level Suicide Prevention • Suicide Prevention efforts, such as the Suicide Hotline and hiring of Suicide Prevention Coordinators began in FY2007 with full implementation in FY08 • A 24/7 Veterans Crisis Line • Over 417,000 callers have called the Crisis line • Over 259,000 of those callers have identified themselves as Veterans or family members/friends of Veterans • Over 15,000 rescues of actively suicidal Veterans • Online Chat Service • Initiated in July 2009 • Over 17,000 chatters; over 3761 mentioned suicide • VISN 16 Total Calls YTD 2010 –9742 (2nd highest) • VISN 22: 12365 (1st highest)

11. Nomenclature: Self-Directed Violence Classification System (SDVCS) • In 2008, former Secretary of Veterans Affairs, Dr. James B. Peake, recommended a standard nomenclature for “suicide” and “suicide attempts” to improve Veterans Affairs’ (VA): • Suicide prevention programs • Suicide prevention research • Suicide prevention education

12. SDVCS Overview • To learn and begin to using the new nomenclature for self-directed violence. • Review of the language of suicidology • Rationale for a self-directed violence classification system • Implementation of a new classification system

13. Case Example • A healthy 24-year-old female Veteran is brought by her boyfriend to the Emergency Department after she ingested all remaining pills in a bottle of regular strength Tylenol. She estimates there were 4 to 6 pills total in the bottle (1300-1950 mg total dose), and she reports no ill effects. Lab tests done at the time of admission to the ED reported her acetaminophen level within the therapeutic range. During triage, she states that before she took the pills she was upset from arguing with her boyfriend and just wanted to die. She feels better now and requests to go home.

14. Behavior? Criteria? • What is her behavior? • Gesture? • Threat? • Acting Out/Manipulation? • Attempt? • Other? • What criteria did you use to decide? • Lethality of method? • Expressed intent? • Number of pills ingested? • Lab results? • Other?

15. The Language of Self-Directed ViolenceIdentification of the Problem • Suicidal ideation • Death wish • Suicidal threat • Cry for help • Self-mutilation • Parasuicidal gesture • Suicidal gesture • Risk-taking behavior • Deliberate Self-Harm • Non-Suicidal Self Injury • Suicidal Gesture • Self-harm • Self-injury • Suicide attempt • Aborted suicide attempt • Accidental death • Unintentional suicide • Successful attempt • Completed suicide • Life-threatening behavior • Suicide-related behavior • Suicide

16. The Language of Self-Directed Violence Why does it matter? “ A rose is a rose is a rose” “Sacred emily,” by Gertrude Stein, 1913 EXCEPT IN THE FIELD OF SUICIDOLOGY Where a Suicide Attempt (by one person’s assessment) is NOT Always a Suicide Attempt (by another’s).

17. The Problem… • The field of suicidology is challenged by the lack of conceptual clarity about suicidal behaviors and a corresponding lack of well-defined terminology • - In both research and clinical descriptions of suicidal acts • There is a great variability of terms referring to the same behaviors (e.g., threat, gesture). Terms are often pejorative and based on incorrect notions about seriousness and lethality of methods (e.g., manipulative, non-serious, etc

18. Hence…. It becomes very difficult to: • Accurately count the number of suicides and suicide attempts that occur annually • Accurately differentiate suicide attempts from non-suicidal self-injuries • Conduct longitudinal studies of suicide attempters • Communicate between and among clinicians, researchers, patients, and patients’ families • Establish suicide and suicide attempts as a major public health problem that warrants investment of resources

19. The Language of Self-Directed ViolenceImplications of the Problem • Clinical • Research • Public Health (e.g., surveillance) • Public Policy

20. Current Terminology Research Implications of the Problem

21. Consequences of Ill-Defined Terms • Makes interpreting the meaning of self-injurious acts more difficult and hampers precise communication on individual or population basis • Some Self-injurious acts that should be classified as suicidal may be mislabeled • Other types of Self-injurious acts may be inappropriately classified as suicidal

22. The Need for Consistent Definitions & Data Elements “Research on suicide is plagued by many methodological problems… Definitions lack uniformity … reporting of suicide is inaccurate…” (Reducing Suicide: A National Imperative, Institute of Medicine, 2002)

23. Definitions • 15 Definitions for Suicide • 9 Definitions for Non-Fatal Self-Harm

24. Synonyms for Suicide • Committed Suicide • Completed Suicide • Failed Attempt • Fatal Repeater • Fatal Suicide • Fatal Suicide Attempt • Hastened Death • Intentional Self-Murder • Intentional Suicide • Lethal Suicide Attempt • Rational Suicide • Self-Inflicted Death • Self-Murder • Self-Slaughter • Sub-intentional Death • Suicide Victim • Successful Attempt • Successful Suicide • Unintentional Suicide

25. Synonyms for Suicide Attempt • Non-Fatal Suicide-Related Behavior • Non-Fatal Self-Harm Behavior • Non-Lethal Self-Injurious Act • Non-Suicidal Self-injury • Parasuicide • Risk-Taking Behavior • Self-Assaultive Behavior • Self-Destructive Behavior • Self-Harm Behavior • Self-Inflicted Behavior • Self-Injurious Behavior • Suicidal Episode • Suicidal Manipulation • Suicidal Rehearsal • Aborted Suicide Attempt • Attempted Suicide • Cry for Help • Death Rehearsals • Deliberate Self-Harm • Failed Attempts • Failed Completion • Failed Suicide • Instrumental Suicide-Related Behavior • Near Lethal Self-Harm • Near Miss Attempt

26. “Unacceptable Terms” • Attempted Suicide • Completed Suicide • Committed Suicide • Failed Attempt • Failed Completion • Fatal Suicide Attempt • Parasuicide • Nonfatal Suicide Attempt • Nonfatal Suicide • Successful Suicide • Suicidality • Suicide Threat • Suicide Victim • Suicide Gesture • Manipulative Act

27. What is the Purpose of a Nomenclature? Nomenclature: Commonly understood, widely acceptable, comprehensive. • Solution to the Problem • enhance clarity of communication • have applicability across clinical settings • be theory neutral • be culturally neutral • use mutually exclusive terms that encompass the spectrum of thoughts and actions

28. Why “Self-Directed Violence” ? • Blue Ribbon Task Force recommendation was to work with CDC and other federal agencies on the development of a nomenclature and classification system • CDC was already developing a Self-Directed Violence Surveillance System that included Uniform Definitions and Recommended Data Elements • The opportunity presented itself for the VHA, DoD, and CDC to adopt the same nomenclature and classification system

29. Research Team Members Lisa A. Brenner, Ph.D. Ryan E. Breshears, Ph.D. Lisa M. Betthauser, M.B.A. Katherine K. Bellon, Ph.D. Elizabeth Holman, Ph.D. Jeri E.F. Harwood, Ph.D. Morton M. Silverman, M.D. Joe Huggins, M.S.W./M.S.C.I.S. Herbert T. Nagamoto, M.D. VISN 19 Mental Illness Research Education and Clinical Center Denver VA Medical Center University of Colorado, Denver, School of Medicine WellStar Health System, Georgia University of Georgia, Athens Department of Biostatistics and Informatics, Colorado School of Public Health

30. Suicidal Intent: There is past or present evidence (implicit or explicit) that an individual wishes to die, means to kill him/herself and understands the probable consequences of his/her actions or potential actions. Suicidal intent can be determined retrospectively and in the absence of suicidal behavior. The individual: Component 1: Wishes to die Component 2: Means to kill him/herself Component 3: Understands the probable consequences (i.e. death).

31. Get Out Clipboard • When both Thoughts and Behaviors are present Behaviors trump Thoughts for purposes of classification • When both are SDV Behaviors and Preparatory are present Self-Directed Violent Behaviors trump Preparatory for purposes of classification

32. Case Examples

33. CASE EXAMPLE 1: A Veteran comes in for an initial mental health intake. During the intake, the therapist and the Vet have the following dialogue: • Therapist: “Have you had thoughts of suicide?” • Veteran: “There have been times when I’ve thought about it.” • Therapist: “Times? Like recently?” • Veteran: “Yeah, well sometimes those thoughts enter my mind.” • Therapist: “Can you say more about that?” • Veteran: “Well … if you had the pain I have, you might understand.” • Therapist: “You’re telling me that your pain feels unbearable at times?” • Veteran: “Yeah, like yesterday … I thought it would be better if I just went to • sleep and never woke up. “ • Therapist: “So you wanted to die?” • Veteran: “Yeah, you could say that.” • Therapist: “Did you take any actions to make that happen?” • Veteran: “You mean, like, did I try to kill myself?” • Therapist: “Yes.” • Veteran: “Oh no. I mean I thought about it, but I didn’t do anything. I just took • my medication like I always do.” • Therapist: “Your medication?” • Veteran: “Yeah, my pain meds. They usually help the pain pretty well.”

34. SDV Classification Tool Begin with these 3 Questions: 1-Is there any indication that the person engaged in self-directed violent behavior, either preparatory or potentially harmful? If NO, proceed to Question 2 If YES, proceed to Question 3 2-Is there any indication that the person had self-directed violence related thoughts? If NO, to Questions 1 and 2, there is insufficient evidence to suggest self-directed violence—no SDV Term. If YES, proceed to Decision Tree A 3-Did the behavior involve any injury? If NO, proceed to Decision Tree B If YES, proceed to Decision Tree C

35. Case Example 2 A wife finds her husband tearful and holding knife to his wrist. He has already made a few small cuts. On his bed is a note stating, “I can’t go on like this. You’ll be better off without me.”

36. SDV Classification Tool Begin with these 3 Questions: 1-Is there any indication that the person engaged in self-directed violent behavior, either preparatory or potentially harmful? If NO, proceed to Question 2 If YES, proceed to Question 3 2-Is there any indication that the person had self-directed violence related thoughts? If NO, to Questions 1 and 2, there is insufficient evidence to suggest self-directed violence—no SDV Term. If YES, proceed to Decision Tree A 3-Did the behavior involve any injury? If NO, proceed to Decision Tree B If YES, proceed to Decision Tree C

37. Case Example 3 A 75-year-old veteran loses his wife to cancer. Within hours, he purchases ammunition for a handgun he has had for years and contacts his attorney asking to revise his will. His son asks him about these behaviors, and he refuses to answer, changing the subject.

38. SDV Classification Tool Begin with these 3 Questions: 1-Is there any indication that the person engaged in self-directed violent behavior, either preparatory or potentially harmful? If NO, proceed to Question 2 If YES, proceed to Question 3 2-Is there any indication that the person had self-directed violence related thoughts? If NO, to Questions 1 and 2, there is insufficient evidence to suggest self-directed violence—no SDV Term. If YES, proceed to Decision Tree A 3-Did the behavior involve any injury? If NO, proceed to Decision Tree B If YES, proceed to Decision Tree C

39. Key ConceptPreparatory Behavior Preparatory: • Acts or preparation towards engaging in Self-Directed Violence, but before potential for injury has begun. This can include anything beyond a verbalization or thought, such as assembling a method (e.g., buying a gun, collecting pills) or preparing for one’s death by suicide (e.g., writing a suicide note, giving things away). Preparatory SDV occurs 4pm 5pm 6pm 8pm

40. VA Screenings and Suicide Risk Assessments VA Clinical Reminders: Screening for Depression, PTSD, Alcohol, etc. Suicide Risk Assessments • Completed on those who present with risk factors (depression, anxiety, etc.) • Initial MH Visit • During Inpatient Psychiatric Stay • Treatment Plan Updates • During times of significant changes/stress/crisis

41. RISK FACTORS • Thoughts about harming self that include plan & method • Previous suicide attempts • Alcohol or substance abuse • History of mental illness • Poor self-control • Hopelessness • Recent loss (e.g., loved one, job, relationship) • Family history of suicide • History of abuse • Serious health problems • Sexual identity concerns: especially among men 16-24 • Recent discharge from hospital, group home etc. • Recent diagnosis of an illness • Demographic factors: White men over 70 years of age are at increased risk • Burdensomeness, Isolation • Chronic Pain , PTSD, TBI

42. VETERAN SPECIFIC RISKS • Multiple deployments • Length of deployments • Deployments to hostile environments • Exposure to extreme stress/death/combat • Physical/sexual assault while in the service (not limited to women) • Service related injuries (TBI, PTSD, other medical and mental health diagnoses) • Familiarity with weapons

43. PROTECTIVE FACTORS • Positive social support (#1) • History of adaptive coping skills • Participating in treatment and/or good relationship w/their provider. • Veteran acknowledges hopefulness • Religious/Spirituals beliefs • Life satisfaction (e.g., rating 1 to 10) • Fear of suicide or death • Family or friends that act as barrier to self-harm

44. Safety Planning • STEP 1: Warning Signs • STEP 2: Internal Coping Strategies • STEP 3: Social Contacts Who May Distract from the Crisis • STEP 4: Family or Friends Who May Offer Help • STEP 5: Professionals and Agencies to Contact for Help • STEP 6: Making the Environment Safe

45. Resources • Refer to VA Resource Guide (handouts at booth) • www.veteranscrisisline.net • www.suicidepreventionlifeline.org • PTSD COACH APP

46. Questions…Juli.McNeil@va.gov(918) 577-3087

47. Helpful websites National Veterans Crisis Line:  www.veteranscrisisline.net VA Mental Health:  http://www.mentalhealth.va.gov/ VA VISN 19 MIRREC:  http://www.mirecc.va.gov/visn19/ American Association for Suicidology:  http://www.suicidology.org/home Suicide Prevention Resource Network:   http://www.sprc.org/ National Center for PTSD:  www.ptsd.va.va If anyone needs any other information, feel free to contact me via email or phone.