Transcript Youth Suicide

Youth Suicide
Lorna Martin
[email protected]
Common Warning Signs of
Youth Suicide
 Suicide threats (written, direct, indirect)
 Preoccupation with death (making final arrangements,
giving away prized possessions, talking, reading, writing, drawing about
death or a dead person)
 Changes in behaviour, physical condition,
thoughts, or feelings
(withdrawal, isolation, increased risktaking, decreased performance, frequent lateness, unexplained absence,
crying jags, heavy use of alcohol or drugs, abrupt changes in appearance,
appetite, sleep patterns, exaggerated fears, irrationality/anxiety,
hopelessness, increased irritability, moodiness, lethargy)
 Stress (intolerable loss)
Four Indicators of Risk Levels
• Stress
– Critical situational events, personal loss
– Disruptive life events
• Symptoms
– Changes in behaviour, physical condition,
thoughts/feelings
• Thoughts of Suicide
– Direct/indirect
• Loss/Lack of Social Network/Support
– Healthy connections to others missing or lost
Assessment of Risk
• Current Suicide Plan
– Method, preparation, means, time frame
– The more detailed the plan, the greater the risk
• Prior Suicidal Behaviour
– Prior attempt(s) reveal(s) acceptance of suicide as an
alternative
• Resources
– Risk decreases with personal support resources such
as a place to live, caring family, friends or teachers,
access to help
Spectrum of Suicidality
• Not all youths follow the same trajectory
towards suicide
• Self-harm is not necessarily a precursor to
suicide
• Not all suicidal youths are depressed
• Not all youths indicate their feelings of
suicide prior to an attempt or completion
Sample 1 Trajectory
IDEATION
-thoughts of death
-wishes never born
-life not worth living
-thoughts of killing self
(general moving
towards specific)
-sees suicide as
retribution
INTENTION
-writing notes/will
-giving away
possessions
-subtle/overt threats
-minor self-harm and
self-destructive risktaking
Sample 1 Trajectory (cont’d)
ATTEMPT
-pseudo-suicide attempt
(in a place and time
when interveners will
be present)
-minor attempt (failure
is distinct possibility)
-major attempt (failure
remote)
COMPLETION
Sample 2 Trajectory
IDEATION
- Thoughts of killing
self (specific)
INTENT
- Expresses threat in
angry outburst
- Threatens to harm
others simultaneously
ATTEMPT
- Major attempt
(selects time and
method with little
chance of failure)
COMPLETION
Sample 3 Trajectory
IDEATION
- None expressed
INTENT
- None observed
ATTEMPT
- None observed
COMPLETION
Sample 4 Trajectory
IDEATION
-Morbid ideation
-Preoccupation with
death and dying
INTENT
-Writes songs
-Self-harms
ATTEMPT
- None observed
COMPLETION
-None to date
Early Family Influences on
Suicidal Behaviour
ATTACHMENT
HISTORY
Insecure attachment
PSYCHOLOGICAL
RESPONSE
Separation anxiety
Failure
Alternative
attachments
Persistent anxiety
Depression
Impaired capacity
to form attachments
Loneliness
Low self-esteem
Depression
Threatened
attachments
Abandonment anxiety
Suicidal ideation
Recurrent
attachment failure
Chronic anxiety
Severe depression
Persistent suicidal
ideation
Hopelessness
Depair
Social isolation
Adam, K.S., Early family influences on suicidal behaviour
ATTACHMENT
BEHAVIOUR
Protest
Despair
Detachment
Object hunger
Anxious
attachment
Emotional
detachment
Relationship
difficulties
Marital
dysfunction
Suicidal threats
Suicide attempts
Repeated
suicide attempts
Suicide
ASSOCIATED
BEHAVIOUR
Antisocial
behaviour
Behaviour disorder
School phobia
Illness behaviour
Personality disorder
Alcohol & drug
abuse
Alcoholic binge
Promiscuity
Phobic stages
Major affective
disorder
Chronic alcoholism
Assessing Risk Levels
Ensure you are qualified to make risk decisions. If you have
not been trained through a program such as ASIST or
LivingWorks, seek assistance immediately. If you are
trained, it is still important to debrief with a qualifed
colleague.
• Risk levels increase as resiliency factors decrease
• Risk levels increase with
– Current suicide plan
– Prior suicidal behaviour
– Lack of available resources to act as a safety net
• Risk levels further escalate if suicide plan has method,
means and established timeframe
If you are a trained intervener:
• The next slides are reminders
If you are likely to be a trusted
professional:
• The next slides are for your information, to
assist you providing details to a trained
intervener
Seeking Assistance and Support
• Use the school threat assessment and/or crisis
•
•
•
•
intervention protocol to assist you
Access the school psychologist, social worker,
AFM worker or other qualified intervener within
your system
Access medical, RCMP, or mobile crisis unit if
there are no qualifed interveners within your
system.
Contact parent(s)/guardian(s).
Document your actions.
Acronyms to Aid in Assessing Risk
To respond efficiently to a suicidal youth, it
is important to be calm, patient, and
direction.
To determine the degree of risk, you need
to learn answers to specific questions. Ask
them. It may be a life-saving decision.
Miller (1984) Acronym 1
S how specific is the plan of attack? The more
specific the details related the higher the degree of
present risk
L how lethal is the proposed method? How quickly
could the person die if the plan is implemented? The
greater the level of lethality, the greater the risk.
A How available is the proposed method? If the
implement to be used is readily available, the level of
suicidal risk is greater.
P What is the proximity of helping resources?
Generally, the greater the distance the youth would be
from helping or supporting resources if the plan were
implemented, the greater the degree of risk.
Miller (1984) Acronym 2
Four additional factors to aid in assessing the level of suicidal risk when
the youth has made a previous suicidal attempt:
D – Dangerous – How dangerous was the prior attempt and
current plan? The greater the danger, the higher the current risk.
I – Impression – Even if the danger in the attempt or plan is not
significantly high, if the impression is that the danger is high and
will surely cause death, the present risk is high.
R – Rescue – If the opportunity for rescue was great in the prior
attempt or present plan, the risk is lower than if the opportunity for
rescue was remote. If the chances were or are poor that rescue will
occur, the present risk is high.
T – Timing – If the previous attempt was recent, the present risk is
higher than if the previous attempt was long ago.
If a youth may be at immediate risk, you must immediately
implement any process necessary to protect that youth or to
provide life-saving supports.
Safety Contracts
• Many low to moderate risk youths respond
positively and reliably to a safety contract.
• The contract should include
– A specific plan that prevents immediate risk
– A commitment to not engage in self-harm for
an agreed-upon timeframe
– Crisis support, including names and telephone
numbers
• Ensure you have a ‘back-up’ plan in
addition to a safety contract
Sample Safety Contract
PERSONAL SAFETY CONTRACT
Date:________________________ Time: ________________
I, (name), promise to keep myself safe until (date and time) when I see my
counsellor. I will not harm myself or others in any way. If I feel like I cannot
control myself or start to feel worried, or anxious, or that I might not keep
this promise, I will call:
(insert youth’s choice of trusted friend or family member and telephone
number) or
(insert youth’s alternative choice and telephone number) or
(insert name of hospital/RCMP/nursing station and telephone number)
_______________________
Signature of Youth
_______________________
Signature of Counsellor
Ensure you have a ‘back-up’ plan in addition to a personal safety contract.
Contact resources.
Assisting Low Risk Youths
• Listening empathically
• Obtaining a specific, written promise to
seek help when needed
• Providing a promise of continued support
“Will you be safe until Tuesday?”
“I’ll stay with you while you tell your parent how you’re
feeling.”
“Can you promise me that you will follow the instructions
we have agreed to in this contract?”
“Will you keep your appointment with me tomorrow?”
Assisting Moderate Risk Youths
without a specific plan
•
•
•
•
Require more intervention and direction
Written and verbal commitment required
Refer to school psychologist
Contact parent(s)
“I’m not positive you’re going to be okay after you leave here.”
“Will you keep the promises you made in our contract?”
“Here’s a telephone number where I can be reached, the suicide crisis
line and the clinic number. Promise me now that you will call me or
any of these other numbers for help before you decide to take any
action that might harm you. Even when the idea enters your head
and you’re not sure….phone. Can you promise?”
“Can I telephone you this evening to make sure you’re all right? I’m
very concerned and I want us to talk again to make things better for
you.”
“Will you be safe if you leave here now? Are you positive?”
Assisting High Risk Youths
•
•
•
•
Youth is in crisis
Do not leave the youth unsupervised.
Support cannot be withdrawn for any reason
Be assertive and directive.
“I can’t leave you here alone. I want you to come with me now so we
can get you more help than I can give you here.”
“You can’t promise that you won’t kill yourself and that concerns me.
Let’s go together to the hospital where we can get more support.”
• Do not take ‘no’ for an answer. Follow school
•
protocol for threat assessment/crisis
intervention.
Contact parent(s). Dial 911 if necessary.
Summary of Typical Risk Factors
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Recent attempts
Recent losses
Critical incidents
Prior traumas
Isolation/withdrawal
Substance abuse
• Destructive coping
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styles
Poor problem solving
skills
Disorientation
Inadequate support
Hopelessness/
helplessness
Summary of Protective Factors
• Support from family and
•
•
•
•
•
•
friends
Perceived connection to
family and friends
Strong cultural ties
Good physical and mental
health
Strong spiritual ties
Positive self-esteem
Early identification and
treatment of psychiatric
illness
• Good school performance
• Positive attitude towards
•
•
•
school
Skills in stress
management,
communication, problemsolving
Fear of suicide and
objections to suicide
Sense of belongingness
Risk vs Imminent Danger
PHASE ONE
Is there a plan and means?
Risk factors – five of the following (1-4=risk,
5 or more=danger):
a)
b)
c)
d)
e)
f)
g)
h)
Male
Past attempt
More than one attempt
Antisocial behaviour
Friend or family who has committed suicide
Drug and/or alcohol abuse
Depression
Difficulty socially, especially family problems
Risk vs Imminent Danger
(cont’d)
PHASE TWO
Can the youth complete tasks incompatible with suicidal
states?
1. Written promise to abstain from suicidal behaviour for
specified time
2. Ability to compliment self and others
3. Ability to assess their own emotional state (e.g,
develop hierarchy of situations that would raise
suicidal thoughts)
4. Capacity to plan ahead (e.g., being prepared for
stressors, positive imagery, relaxation, develop social
support system
(Inability to accomplish these four tasks indicates possible
imminent danger)
Referrals
• Report suicidality and refer to a trained
•
•
•
•
professional (e.g., psychologist, medical doctor,
Salvation Army Mobile Crisis Unit). While
awaiting the professional,
Remove access to means of suicide
Use protocols for threat assessments/crisis
intervention
Inform parent that referral has been made
Maintain supervision of youth
Formal Assessments
There are several instruments available to
trained professionals to detect suicidality.
Some of the most commonly used are:
• Suicide Probability Scale (SPS)
• Suicidal Ideation Questionnaire (SIQ)
• ISO-30
• Children’s Depression Rating Scale
• Beck Hopelessness Scale (BHS)
• Index of Potential Suicide
Making the Connection
• You’ve recognized the signs and symptoms.
• You’ve asked the questions directly.
• You’ve documented the interview and your
•
•
•
actions.
You’ve made a connection with the youth.
You may be the difference between recovery
and imminent death.
The youth is trusting you to be a reliable,
responsible adult.
Keeping the Connection
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Stay focused.
Stay calm.
Stay with the youth.
Err on the side of caution.
Trust your ‘gut’.
Get help. Create a helping network with the
youth.
Document events.
Debrief with a trusted colleague following the
initial resolution of the event.
This presentation has been an
overview of commonly held
principles and practices when
dealing with suicidal clients.
It is intended as an information
session only.
This presentation does not provide
training for suicide intervention.
For information on training in intervention
and postvention, please contact:
Centre for Suicide Prevention
Suite 320, 1202 Centre Street S.E.
Calgary, Alberta Canada T2G 5A5
Phone: 403 245-3900 Fax: 403 245-0299
[email protected]
or
Lorna Martin
Manitoba Education, Citizenship and Youth
Phone: 204 945-7964 Fax: 204 948-2291
[email protected]