Crisis Intervention: Addressing Suicidal Thoughts and Behaviors

1. Crisis Intervention: Addressing Suicidal Thoughts and Behaviors Presented by: Amanda Myatt, LCSW Director of Emergency Psychiatric Services Mental Health Cooperative, In.

2. Crisis Defined • A crisis represents both danger and opportunity • Danger—threatens to overwhelm the person and/or their support system. May result in suicide, homicide, and/or psychotic break. • Opportunity—during time of crisis, the individual may be more receptive to therapeutic influence and intervention. • Intervention may lead to new and/or improved coping skills

3. Facts about Suicide • In 2006, suicide was the 11th leading cause of death in the U.S., claiming 33,300 lives per year. Suicide rates among youth (ages 15-24) have increased more than 200% in the last 50 years.

4. Facts and Stats Continued • Four times more men than women kill themselves; but three times more women attempt than men attempt. • Suicide occurs across ethnic, economic, social and age boundaries.

5. Facts and Stats Continued • Suicide Methods • Firearm 50.2% • Suffocation • Poisoning • Drowning

6. What do you do when a client is in crisis??? • DON’T panic • Stay calm and gather information • Seek assistance from others

7. Elements of Crisis Assessments • Determine nature of the crisis situation and it’s impact on the individual. • What factors precipitated the crisis? • Adaptive capacities of the individual (How do they usually cope with stress?) • Resources that can be tapped to alleviate the crisis situation • Extent to which the individual is receptive to intervention

8. Goal of suicide risk assessment • The goal of a suicide risk assessment is to identify factors that may increase or decrease the person’s level of risk, to estimate an overall level of suicide risk, and to develop a treatment plan that addresses patient safety.

9. Beck Suicide Intent Scale • Aaron Beck has developed and validated several scales that are used in both research and clinical settings. • Beck Anxiety Inventory (BAI) • Beck Depression Inventory (BDI-II) • Beck Cognitive Insight Scale (BCIS) • Beck Hopelessness Scale (BHS)

10. Beck Suicide Scales • Beck Scale for Suicide Ideation (BSI) • The BSI is a 21-item self report questionnaire that may be used to identify the presence and severity of suicidal ideation. Items on this measure assess the respondent’s suicidal plans, deterrents to suicide, and the level of openness to discussing suicidal ideations and openness to interventions.

11. Beck Scale for Suicide Ideation (SSI) • The SSI measures characteristics of an individual’s plans and wishes to commit suicide. The 19 item clinician administered scale is based on a semi-structured interview with the client.

12. Common Elements of all Crisis Risk Assessments • Suicidality • Current suicidal ideations • Current plan? • Access to means to act on plan? • Does the individual understand risk involved and lethality of their plan? • Time/place to execute plan? • Has the individual recently given away any of their possessions? Recently made a will?

13. Crisis Risk Assessment Continued • History of gestures/attempts (seriousness of prior attempts; outcome of attempt; and treatment received)? • Suicide modeling (attempts/gestures by significant others—when and whom?) All these questions need to be explored fully.

14. Crisis Risk Assessments Continued • Current Impulse Control Ability • History of impulsive actions? • Current Stressors • Recent relapse • Financial • Residential • Domestic Violence • Legal • Grief Issues • Separation from significant other • Recent loss of a partner • Extreme community violence/trauma

15. Crisis Risk Assessment Continued • History of Physical and/or Sexual Abuse • Are they the victim or perpetrator? • How recent? • Police involvement? • Mandatory reporting?

16. Crisis Risk Assessment Continued • Medical issues • Chronic medical condition? • New diagnosis? • History of head injury? • History of seizures? • Complicated withdrawal issues?

17. Crisis Risk Assessment Continued • Mental Health Diagnosis? • The presence of a psychiatric disorder is probably the most significant risk factor for suicide. Psychological autopsy studies have consistently shown that more than 90% of person who die from suicide satisfy the criteria for one or more psychiatric disorders.

18. Crisis Oriented Risk Assessment Continued • Mood Disorders (Depression; Bi-polar;) • Schizophrenia • Anxiety Disorders • Eating Disorders

19. Crisis Risk Assessment and Substance Use • Use of alcohol and/or illegal drug abuse increases risk with period of intoxication being one of the highest risk times for individuals.

20. Crisis Risk Assessment Continued • Current Consumer Resources • Perceived resources • Actual resources • Involvement of patient’s family/social support • Current family/social support concern regarding dangerous thoughts or behaviors? • Is support system sufficient?

21. Gender Specific Issues • In virtually all countries that report suicide statistics to the World Health Organization, suicide risk increases with age in both sexes, and rates for men in older adulthood are generally higher than those for women.

22. Gender Specific Continued • Suicide rates in males is approximately 4 times higher than rates for women in the US. • A number of factors may contribute to these gender differences in suicide risk. Men who are depressed are more likely to have comorbid alcohol and/or substance abuse problems than women, which places the men at higher risk.

23. Gender specific issues continued • Men are also less likely to seek and accept help or treatment. • Women, meanwhile, have factors that protect them against suicide. In addition to lower rates of alcohol and substance abuse, women are less impulsive, more socially embedded, and more willing to seek help. • ***However these differences are changing.

24. Gender specific issues continued • Women have higher rates of depression and respond to unemployment with greater and long-lasting increases in suicide rates than do men. • Other gender specific issues to consider • Pregnant women • Post partum complications • Women with children in the home

25. Services to assist individuals in crisis • When do you call 911 and request an ambulance or law enforcement vs when do you call a mobile crisis team? • If the person is trying to leave or is aggressive, call law enforcement. • If the person has attempted or you suspect an attempt (ie—overdose) call 911 and request an ambulance.

26. Services to assist Consumer’s in crisis • If the person is highly intoxicated, medical clearance will be required. • If the person is not threatening to leave or has no means to leave---call your local mobile crisis team. Be prepared to give demographic information and explain what is going on at this time.

27. Crisis Continuum Services • 24/7 Mobile Crisis Response Services • Police walk-in centers • Crisis Resolution Centers • Crisis Respite Programs • Crisis Stabilization Units

28. Crisis Resolution Center (CRC) • 24/7 Crisis assessment and Resolution • Staffed by nurses and Bachelor Level Mental Health Professionals • Daily rounds and evaluations performed by Psychiatrist and/or psychiatric nurse practitioner • Offers quick, solution focused assistance for individuals in crisis

29. Crisis Resolution Center Continued • Length of Stay—Up to 12 hours (sometimes this stay may be extended but cannot exceed 23 hours)

30. Crisis Respite • Can be helpful in de-escalating a situational crisis, providing stabilization in a mental health emergency, and giving he person time to make positive decisions that they may not be able to make during the initial crisis phase. • Staffed with 24/7 awake staff; nurse makes visits 5 days a week; access to psychiatric consult daily.

31. Crisis Respite Continued • Length of stay up to 3 days • While in respite, individuals are encouraged to attend house groups and work with staff on development of comprehensive discharge plan. • Crisis respite is for individuals who do not require hospitalization but need 24 hour monitoring in a community based setting.

32. Crisis Respite Admission Criteria • An individual is appropriate for Crisis Respite if they: • Are experiencing a mental health crisis, • Have insight into their need for intervention • Agreeable to the placement

33. Crisis Stabilization Unit • Intensive level of care • 24/7 staff that includes RN; LPN; Bachelor’s level mental health staff; Peer support specialist • Daily rounds by psychiatric provider • 24/7 on-call psychiatric provider • Unit must maintain a 1:5 ratio at all times

34. Crisis Stabilization Unit • 15 bed capacity • Groups conducted daily (at least 5 groups offered throughout a typical day) • Individual sessions as needed • Highest level of care that an individual can receive in a “community based setting.”

35. Crisis Stabilization Unit Continued • Length of stay is up to maximum of 96 hours with average length of stay approximately 2.5 days. • CSU is a voluntary unit • Individuals appropriate for CSU are experiencing an “acute crisis episode” but have insight and agree to intervention.

36. Crisis Stabilization Unit Continued • Individuals may be actively suicidal and/or psychotic but have enough insight to know that they need treatment. • Once on the CSU unit, if a higher level of care is needed to maintain the individual’s safety, then the staff will facilitate transfer to an inpatient psychiatric hospital.

37. Involuntary Hospitalization Criteria • Involuntary Commitment Process State of Tennessee • Title 33, Chapter 6, Part 4, Tennessee Code Annotated (commonly known as 6-404) • Latest revision of the mental health law of Tennessee became effective July 1, 2002 (last major revision was over 20 years ago)

38. Involuntary Commitment Criteria in TN • Criteria: To Detain for Examination (TCA Section 33-6-401) 1. A person has a mental illness or serious emotional disturbance (SED), AND 2. Poses an immediate substantial likelihood of serious harm because of the mental illness or serious emotional disturbance. Admission to Hospital (TCA Section 33-6-403) 1. A person has a mental illness or serious emotional disturbance, AND 2. Poses an immediate substantial likelihood of serious harm because of the mental illness or serious emotional disturbance. 3. Needs care, training, or treatment because of the mental illness or serious emotional disturbance, AND 4. All available less drastic alternatives to placement in a hospital or treatment resource are unsuitable to meet the needs of the person

39. Substantial Likelihood of Serious Harm • TCA Section 33-6-501 If and Only If: (1)(A) A person has threatened or attempted suicide or to inflict serious bodily harm on himself, OR (B) The person has threatened or attempted homicide or other violent behavior, OR (C) The person has placed others in reasonable fear of violent behavior and serious physical hart to them, OR (D) The person is unable to avoid severe impairment or injury from specific risks, AND (2) There is a substantial likelihood that such harm will occur unless the person is placed under involuntary treatment. Then (3) The person poses a “substantial likelihood of serious harm” for purposes of Title 33.

40. Examples of Key Indicators for Certificate of Need Completion 1. Is mentally ill as shown by the following facts and reasoning: - active symptoms of psychiatric disorder - previous psychiatric diagnosis - previous psychiatric hospitalizations - previous prescription of psychotropic medications - reported or clinically suspected substance dependence - reported history of behaviors clinically indicative of a psychiatric disorder

41. Examples of Key Indicators for Certificate of Need Completion Cont. • Poses an immediate substantial likelihood of serious harm because of the mental illness as shown by the following facts and reasoning: - clinical depression with suicidal attempt by overdose - threatening to kill wife due to paranoid delusions that she was poisoning food - entered neighborhood grocery threatening revenge on former co-workers - walking in interstate traffic; drinking toxic substances; etc. Plus, clinical opinion/indicators that such harm will occur or re-occur unless the individual is placed under involuntary treatment.

42. Examples of Key Indicators for Certificate of Need Completion Cont. • Needs care, training or treatment because of the mental illness: - treatment likely to prove beneficial in symptom reduction - medication likely to prove beneficial in behavior control - condition is likely to further deteriorate without treatment

43. Examples of Key Indicators for Certificate of Need Completion Cont • All available less drastic alternatives to hospital or treatment resources are unsuitable due to: - adequate evaluation requires secure setting - inability to contract for safety - unable to resist impulses or control behavior - will not agree to respite; suitable respite not available; failed respite, etc. - unable to provide safe environment; no support persons to provide or assist with supervision - present condition places self/others at too high a risk for injury

44. Involuntary Commitment Process State of Tennessee Continued • Role of Mandatory Pre-screening Agent (MPA) • Intersecting Roads…The Law and TennCare

45. “Contracting for Safety” • Don’t rely on the suicidal client to tell you that they will not harm themselves. • Decision about intervention strategies should be based on thorough clinical evaluation.

46. Taking Care of yourself and your Staff • Critical Incident De-briefing • De-briefing needs to occur quickly and in an environment that the individual feels safe to express their emotion.

47. Presentation Sources • Aguilera, D., 1998. Crisis Intervention Theory and Methodology, Eighth Edition • American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition • Bureau of Justice Statistics – Special Report. Washington, DC: U.S. Department of Justice, Office of Justice Programs • Harris, R., Vanderbilt School of Nursing, 9/01. Diagnostic Interview: Assessment of Thought Disorders • Hersen, M. & Turner, S., 1994. Diagnostic Interviewing, Second Edition • Hoff, L., 1995. People in Crisis: Understanding and Helping, Fourth Edition • American Psychiatric Assoction, 2009, Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors • American Association of Suicidology, May 2010

48. Questions/Comments

49. For more information • Contact Amanda Myatt, LCSW Director of Emergency Psychiatric Services Mental Health Cooperative Direct office number 744-7442 E-mail: amyatt@mhc-tn.org 24/7 crisis line: 726-0125