Suicide and Risk Assessment

1. Suicide and Risk Assessment Behavioral Health Training Partnership University of Wisconsin - Green Bay Revised: April 2015

2. Agenda • Introduction to Training • Taking Care of Yourself • Trauma Informed Crisis Response • Suicide Statistics • Suicide Risk Assessment • Assessment/Intervention with Violent Persons • Legal Implications

3. Objectives • Define secondary traumatic stress and ways to take care of yourself • Understand trauma informed crisis response • Understand the role of validation and active listening in crisis response • Describe suicide statistics in the general and specific populations • Understand suicide risk factors and protective factors

4. Objectives (cont’d) • Conduct an assessment for suicide • Understand factors involved in assessing a potentially violent person • Understand the legal implications and responsibilities

5. Introductions activity • Introduce yourself to the group • Name, agency, position

6. Occupational Hazard • Working with potentially suicidal people is very stressful • Crisis workers are at risk to develop secondary traumatic stress (or compassion fatigue) • Secondary Traumatic Stress (STS) is the result of exposure to trauma experienced by others, generally within a workplace context • Symptoms are similar to those who have actually experienced the traumatic event directly • Listening to stories or reading documents describing trauma can have an impact

7. Small Group Activity on Self Care • Think about what you do or can do to take care of yourself when you get stressed out • Share what you do to take care of yourself in your small group.

8. Stress Management • Exercise (walking, biking, swimming, etc) • Take breaks, including lunch, away from your work • Artistic pursuits—music, art, crafts, etc. • Take a real vacation—at least a week off • Meditation, mindfulness, prayer • Journaling • Talking with support persons (peers at work, friends, family, etc) • Breathe!!!

9. Stress Management (con’t) • If your own strategies aren’t working for you, talk to your supervisor • For more info about STS, plan to attend: Secondary Traumatic Stress and the Behavioral Health Professional offered by the Behavioral Health Training Partnership

10. Crisis Response is Trauma Informed • We assume that all people with whom we work have experienced and survived trauma, to avoid inadvertently or unnecessarily re-traumatizing them. • We acknowledge that trauma comes in many forms. • We recognize that the experience of trauma can impact how people think about and respond to themselves, events, people, and circumstances.

11. Signs & Symptoms of Trauma • The world is an unsafe place in which to live. • Other people are unsafe and cannot be trusted. • Own thoughts and feelings are unsafe. • Anticipation of continued crises, danger and loss. • Lack of belief in self-worth and capabilities.

12. Think of Symptoms as Survival Skills • A trauma-informed model frames survivors symptoms as adaptations, rather than as pathology. • Every symptom helped a survivor in the past and continues to help in the present — in some way. • Emphasizes resilience in human response to stress. • Reduces shame. • Engenders hope for clients and providers alike.

13. Trauma Informed Approach--RICH • Respect: Validate, reduce shame, give choices, encourage safety, normalize behaviors in a non-judgmental way, focus on strengths • Information: Provide resources, support, teach skills (only after empathy and trust are established) • Connection: Acknowledge healing power of relationships, connect them to others, be open & collaborative • Hope: For the people we serve and workers alike

14. Validation • Most important support to give is validation • It is ok for the client to feel however he/she does • Normalize feelings • Affirm their worth and their efforts to cope • Reassure them you are there to help them get through the crisis and they deserve help Crisis Training Manual, Tennessee Department of Mental Health, 425 Fifth Avenue North, Nashville, TN, January, 2011

15. Active Listening Skills • Active listening really helps to validate the person • Most people in crisis want to know that someone is listening to them—someone cares • Video—It’s Not About The Nail • Group practice session—listening skills and observations (HO #4) and observation sheets

16. How do we tell when someone is escalating? • There are clear symptoms • Important to pay attention to these

17. Symptom Behavior • Anxiety or agitation • Low self-esteem • Depression, frustration, loneliness, feelings of guilt • Hallucinations, delusions • Disorganized or illogical thinking • Slow response time • Loss of contact with reality/personal boundaries • Difficulty with establishing self-initiated goal directed activity

18. Symptom Behavior • Difficulty making decisions • Bizarre behavior • Withdrawn behavior • Exaggerated response to stimuli • Aggressive behavior • Lethargy, loss of interest • Sleep disturbances

19. Team Activity • Work in table groups or small groups of three or four • Using Symptom Behavior Sheet, brainstorm and document specific actions for approaching consumers presenting with the symptoms/behaviors assigned to your group “How can a crisis responder assist a person who is experiencing specific symptoms or behaviors?” • Return to the large group for sharing and discussion

20. Person-Centered Crisis Planning • What does the person believe is the most important issue? • What is the person hoping for? • What does the person think he/she needs? • What had he/she already tried? • What has worked in the past? • What personal strengths and community resources does this person have to draw on? Tennessee Crisis Manual

21. Working with a Team • Try to include other significant people in the crisis response (both gathering information and developing a response) • Use family/other supports if appropriate • Use law enforcement when necessary • Be the facilitator of communication between those involved

22. Using the Team to Assist in Crisis Response • Allows for more information about the consumer and crisis • More options and resources in resolving the crisis • Supports the consumer in stabilization • May give you less liability in decision making

23. Team Activity • Read the crisis scenario (HO #4) • Large group discussion about how you would respond to the situation • How might better collaboration helped this situation?

24. Burden of suicide in Wisconsin (2007-2011) • Average of 724 suicides per year in Wisconsin • Higher rates in Northern and Western regions • Highest rates among the 45-54 age group • Teen and young adults more likely to be seen in ER for self-inflicted injuries • 4 out of 5 persons who died of suicide were male • Veterans accounted for 1 out of 5 suicides • Firearms most frequently utilized means of suicide 45%, followed by Hanging or suffocation 24.9%, poisoning 19.5%

25. Burden of suicide in Wisconsin (con’t) • Suicide rates by race/ethnicity

26. Burden of Suicide in Wisconsin (con’t) • Among suicides with known circumstances: • 51% had a current mental health diagnosis and 43% were receiving treatment • 26% had an alcohol problem, 13% had another substance abuse problem • 24% had a history of suicide attempts • 34% disclosed their intent to die by suicide to at least one person • 35% involved intimate partner problems • 23% had physical health problems • 21% involved job problems • https://www.dhs.wisconsin.gov/publications/p0/p00648-2014.pdf

27. Wisconsin Youth risk behavior survey (2013) • 49% LGB youth seriously considered suicide vs. 11% of heterosexual students • 28% LGB youth attempted suicide vs. 4% of heterosexual youth • 19% of all suicides were veterans, but veterans make up only 9.7% of the population • Divorced people were over-represented while married people were under-represented in the statistics • People with less than a high school degree were also over-represented

28. Suicide is a Complex Behavior • There is often some identifiable event that precedes the act of suicide (the why) • But suicide is more complicated than simply being the result of one event in a person’s life • History, concurrent stressors, and coping ability are all part of the equation. • There are many facts of the circumstances that add up to the whole story. The most promising way to prevent suicide and suicidal behavior is through early recognition and treatment of depression and other psychiatric disorders. (Tennessee Curriculum)

29. Risk Factors • Previous suicide attempt • Mental disorders (particularly mood disorders such as depression or bipolar) • Co-occurring mental and alcohol and substance abuse disorders • Family history of suicide • Hopelessness • Impulsive and/or aggressive tendencies • Barriers to accessing mental health treatment • Relational, social, work, or financial loss • Physical illness

30. Risk Factors (cont’d) • Easy access to lethal methods, especially guns • Unwillingness to seek help • Influence of significant people who have died by suicide • Cultural and religious beliefs (i.e. suicide means you are going to hell vs suicide is a noble act) • Local epidemics of suicide that have a contagious influence • Isolation, a feeling of being cut off from other people (U. S. Public Health Service, DHHS, The Surgeon Generals Call to Action on Suicide)

31. Doing a Risk Assessment • Identification of risk factors, warning signs and protective factors. • Do a Skillful interview, asking directly about suicide but with tact. • Assess lethality—the plan, the means, the intent • Assess Protective factors (coping resources)-- environmental supports, ethical beliefs, future thinking, sense of purpose, etc. • Gather collateral information from others such as family, friends, other providers

32. Formulation of RiskAMsr-Training Manual Long-term risk factors Impulsivity/Self Control (include substance use) RISK STATUS Past suicidal behavior Potential Triggers COPING RESOURCES Recent/present suicidal ideation, behavior Identifiable stressors Precipitants RISK STATE Clinical presentation (dynamic factors and Dx) Engagement and reliability

33. Formulation of Risk- Historical/Clinical DataAMsr-Training Manual Past historical information that may contribute to current risk i.e. past hospitalizations, family history of suicide, history of abuse/neglect, long standing diagnosis of mental illness, etc. Long-term risk factors History of binge drinking during which he becomes suicidal, lacks ability to control impulses, history of inability to manage anger, Impulsivity/Self Control (include substance use) History of repeated crisis contacts due to risk to self or others, past hospitalizations for suicidal, past suicidal ideations, attempts, or threat of harm to self or others Past suicidal behavior

34. Formulation of Risk- Historical/Clinical DataAMsr-Training Manual current intent/behaviors, ideations, attempt, or dangerous behaviors leading to harm of self or others Recent/present suicidal ideation, behavior current stressors i.e. relationship issues, loss of loved ones, job loss, health issues, legal issues, etc. Identifiable stressors Precipitants Depressed mood, loss of interest, intoxication, irritability, hopeless/helpless, command hallucinations, lack of orientation Clinical presentation (dynamic factors and Dx) Is consumer collaborative/cooperative, good reporter of information? Engagement and reliability

35. Formulation of Risk-Risk AssessmentAMRS-Training Manual Historical/Clinical data compared to others with similar demographics i.e. race, sex, age, diagnosis, gender identity, Risk Status Historical/Clinical data compared to individuals own prior history/baseline Risk State Identified protective factors i.e. future thinking, treatment alliances, natural supports available, insight, willingness to develop new coping skills, willingness to engage Coping Resources Identified stressors that can potentially increase current risk state i.e. break up with significant other, death of family or friends, job loss, arrest, conflict with family Potential Triggers

36. Also need to consider Protective Factors • Easy access to a variety of clinical interventions and support for help seeking • Restricted access to highly lethal methods of suicide • Family and community support • Support from ongoing medical and mental health care relationships • Learned skills in problem solving, conflict resolution and non violent handling of disputes • Cultural and religious beliefs that discourage suicide and support self preservation instincts

37. Team Activity • Work in your table groups • Complete the Suicide Protective Factors sheet, brainstorming protective factors for special population/s assigned to your group (Handout #6) • Be ready to share in the large group

38. Columbia Suicide Severity Rating Scale (C-SSRS) • In addition to formulation or risk and protective factors, do the Columbia Suicide Severity Rating Scale (C-SSRS) • Review HO#7 Full Version • Review HO#8 Screener Version

39. Video Demonstration • Watch the interview process with the Columbia Suicide Severity Rating Scale • Be prepared to discuss and practice the interview yourself http://zerosuicide.actionallianceforsuicideprevention.org/sites/zerosuicide.actionallianceforsuicideprevention.org/files/cssrs_web/course.htm

40. Columbia-Suicide Severity Rating Scale(C-SSRS) Yes No Ideation Question 1 Ideation Question 2 Intensity Questions 3-5 AND Behavior Questions 6 Yes No Ideation Question 2 Behavior Questions 6 Yes Intensity Questions 3-5 AND Behavior Questions 6

41. Team Activity • Pair off in groups of 3 • Choose a scenario from the 2 provided, as a group do a formulation of risk provided in HO #5 on your scenario • When that is complete, use the C-SSRS (HO #7), 1 person ask the questions, 1 person answer the questions and 1 person observe and give feedback • When trainer tells you, switch and pick up where the last person left off until everyone has taken a turn • Large group discussion about the process

42. Assessment/Intervention with Violent Persons • Assessing is similar to assessing for suicide—Do they have intent? Means? • Risk assessment for dangerousness is a very in-exact science • Even the most trained professionals can accurately predict only 1 of 3 episodes of violent behavior

43. Basic Guidelines for Interacting with a Person who is Potentially Violent • Get as much information as possible before going into any crisis situation • Do not intervene alone • Do not go anywhere there may be weapons • Approach in a calm manner • Be aware of dangerous articles that could be used as weapons • Be assertive, not aggressive • Remove any bystanders from the area if possible

44. Basic Guidelines for Interacting with a Person who is Potentially Violent • Do not interview in cramped rooms and know your exit routes • Give an agitated or angry consumer space to calm down • Encourage the consumer to use more appropriate behavior to get what they want • Pay attention to the person’s speech and behavior (cues that they may be escalating) • Don’t argue about the reality of hallucinations or delusions

45. Basic Guidelines for Interacting with a Person who is Potentially Violent DO NOT STAY IN A DANGEROUS SITUATION!!

46. Factors in Assessing a Person for Potential Harm to Others • Previous episodes of violent behavior • Under what circumstances was the person violent in the past • What is the frequency of violence? • Clarity of the plan for violence • Has the person identified a victim? • Do they have means or access to a means to harm the potential victim? • The level of isolation, agitation, paranoia, or belief that another is planning to or is hurting or harming them in some way. • Command hallucinations

47. Factors in Assessing a Person for Potential Harm to Others • The level of external support or external constraints available to the individual • Does the person wish to control him/herself? Can she/he? • Does the person have a brain injury or other cognitive impairment that makes control difficult? • Is the person intoxicated? • If the mental state of the person is so agitated that a full evaluation cannot be completed the crisis worker should consider the person as potentially violent. • Collateral information from family, friends and medical records is very important in intervening with potentially violent individuals Minnesota Department of Human Services – Crisis Curriculum, A Mental Health Manual, 2002

48. Putting it all together • Develop a response plan • Work with consumer and their supports • Collaborate with other professionals • Weigh the risks against the protective factors and coping skills • Consult with Supervisor if needed

49. Supervision and Consultation with Others • Never attempt to manage risk alone • Use supervision or consultation with other team members • It is a collective responsibility to formulate an impression of the seriousness of the risk and to determine the action/s to be taken • Will provide invaluable input to promote safety, give you needed support and reduce your personal liability

50. Circumstances Requiring Supervision/Consultation • Direct warning signs are evident • Screening questions suggest there is current risk • Follow-up questions to indirect warning signs suggest that there is a current risk • Additional information from others (referral source, family members etc.) suggests that there is a current risk.