Transcript Suicide Risk Assessment and Intervention for I&R Specialists

Suicide Risk Assessment and
Intervention for I&R Specialists
AIRS 31st Annual I&R Training and Education Conference
“Mining for I&R Excellence”
Reno, NV
Monday June 1, 2009
Part 1 – 1:00 – 2:30 PM
Part 2 – 3:15 – 3:45 PM
Janice M. Harris MA, CIRS
2-1-1 Service Coordinator
Community Service Council of Greater
Tulsa
918.295.1244
John Plonski
Database/Training Coordinator
Covenant House International
President NYS AIRS
[email protected]
212.727.4040
Your Presenters
Janice M. Harris MA, CIRS
2-1-1 Service Coordinator
Community Service Council of
Greater Tulsa
918.295.1244
John Plonski
Database/Training Coordinator
Covenant House International
President NYS AIRS
[email protected]
212.727.4040
What are we going to do today?
This workshop intends to provide I&R
workers a basic understanding of crisis
intervention that will enable them to assess immediacy of
danger to the person at risk of suicide:
• Identify the person at risk of suicide
• Enable the caller to talk about and work through their
feelings to facilitate assessment, problem-solving, and
appropriate coping and referral
• De-escalate and stabilize suicidal callers
• Maintain contact with the caller pending referral or
rescue and to follow through with any referrals given
Kevin
In September 2000, Kevin Hines took a
leap off the Golden Gate Bridge.
A few minutes before that he got off the
bus, went onto the span, and stood there
crying.
Kevin
He encountered several people on his way
to the rail.
1.
2.
3.
4.
Bridge Workers
Bikers
Joggers
Policemen on Bikes
Kevin
He said to himself, “If just one person,
just one, comes up to me and asks me if I
need help, I’ll tell them everything.”
One woman asked him to take her
picture.
Kevin
Not one person asked him what was
wrong so he took a running leap over the
rail into the water. As soon as he left the
bridge, Kevin thought, “I don’t want to die.”
Your thoughts about….
Kevin
The people Kevin met on the bridge
Any other people who may have been in
Kevin’s life
Suicide facts and myths
USA, 2005
Pop. 295,895,897
Reported suicides: 32,657
Unreported suicides:
5% to 25% more suicides
Non-fatal suicidal behaviors: 40 to 100 times greater than
number of suicides
Number of people affected:
Each suicidal behavior may affect
a few or a very large number
People with thoughts of
suicide:
5% of the population:
14,794,794
Ok. If you say so.
Where do we start?
Let’s begin by talking about assumptions we can
make about the person who is not in “Crisis”.
• They are relatively “normal”.
• They have basic coping skills.
• They have ways to cope with day to day problems.
As it relates to Crisis Intervention people are a
product of three affects. Their:
• Thoughts
• Feelings
• Behaviors
You said something about
“coping skills”. What’s that
about?
As individuals, when things go wrong, we
each have our own ways of problem-solving or coping.
While we may not actually think about it, we have three
levels of resources we use to respond to stress and fix
stuff. They are:
• Primary Resources
• Secondary Resources
• Tertiary (AKA Adaptive/Maladaptive Resources)
Secondary
Primary
Resources
Resources
Adaptive/Maladaptive
Resources
Based on what you now
know about coping we
would like to ask you a
question…
Is suicide a crisis?
• A suicidal person like any person in crisis is
faced with an intolerable life issue for which
they are seeking a solution.
• The suicidal activity is not, in itself, a crisis.
In essence it is a maladaptive coping
response.
• Suicidal activity is both a means for
resolving a situation and a method of
communicating the intense feelings of
hopelessness and helplessness
surrounding it as well as emotional pain.
However, it can be difficult to
identify the person at risk of
suicide.
As a society we are generally suicide denying.
• Suicide is something we see as something a
person shouldn’t do.
• Some may see the act as a weakness.
• Some may cite religious reasons
forbidding the act.
In any case there exists a societal taboo
making it difficult for the person at risk to
state their intention openly.
This means the I&R
worker will need to be
aware of clues a person
may be at risk.
Nearly everyone at some time in their lives thinks
about suicide.
• Most decide to live because they come to realize
that the situation is temporary but death isn’t.
• Some will openly state their wish to die. However,
most offer invitations (clues) as to their intent hoping
the listener will interpret those clues and listen.
Clues to look for include:
Direct hints:
– “I just can’t take it anymore”,
– “ I want to escape”,
– “I want to go to sleep forever”,
– “They’ll be sorry when I’m gone.”
– “I can’t stand this pain anymore.”
– “Nothing will ever get better,”
– “My family would be better off if I were
not around”
More clues to look for:
Tone of voice
– very soft or loud,
– weak,
– long pauses,
– sighs,
– depressed
– agitated
More clues to look for:
Losses – actual, perceived, or threatened
– Death of a significant other (this can include an
idol, role model, or a pet),
– Breakup of a relationship, divorce or separation,
– Loss of a job or housing.
– Onset of illness for either the person or a
significant other
– Anniversary of a loss
– Move to a new area
– Situation where a guardian is absent
– Onset of physical or emotional disabilities
More clues to look for:
Behaviors – Extreme changes.
– Have trouble eating or sleeping
– Withdraw from friends and/or social activities
– Lose interest in hobbies, work, school, etc.
– Write a will and making final arrangements
– Give away prized possessions
– Take unnecessary risks
– Be preoccupied with death and dying
– Lose interest in personal appearance
– Increase use of alcohol or drugs
Just a few more clues
Feelings
– Intense or long lasting painful ones: depressed,
alone, hopeless, scared, confused, helpless,
angry.
The person at risk of suicide feels they can’t :
– Stop the pain
– Think clearly
– Make decisions
– See any way out
– Sleep eat or work
– Get out of the depression
– Make the sadness go away
– See a future without pain
– See themselves as
worthwhile
– Seem to get control
Additional Factors in Assessing Suicidal
Intent
There many factors to consider when assessing
whether a person is at risk of suicide. These factors
are as follows:
• Changes Related to Loss or Threat of Loss
• Symptomatic Patterns
• Statistical Patterns
• Cultural Influences
• Physiological Changes
• Psycho-Sexual Changes
Once the caller makes mention of ending
their life, a basic suicide risk assessment
should be done. (see handout)
The worker should interact with the person
at risk in a way to help the individual
understand their ambivalence about their
decision
It is important to remember that the
assessment process is fluid.
Immediacy/Lethality Assessment
Protocols
An immediacy/lethality assessment is an evaluation
based on determining how dangerous a situation is and
addressing issues such as the person’s intent, method,
timing and state of mind. Such an assessment is directly
related, but not limited to assisting individuals who are:
• threatening suicide, homicide or assault;
• victims of domestic abuse or other forms of violence,
• child, adult or elder/dependent victims of abuse or
neglect;
• people experiencing a psychiatric emergency;
• chemically dependent people in crisis;
A few general observations regarding
Immediacy/Lethality assessment:
• Recognize that the person at risk may not directly
announce their intent … they may use phrases or
exhibit actions intended to invite you to ask them
about their suicidal intent.
• If you suspect a person is considering suicide, ask
them in a direct manner.
• If you think your caller may be considering suicide,
don’t go it alone. Consult with supervision, support
staff, and your peers.
An Important Point!!!
If an individual tells you they are in
the process of dying by suicide or
the have taken any direct action to
end their lives
-This is not an intervention this is
an emergency –
You should do whatever you can to
get immediate emergency
assistance to the individual as
quickly as possible.
Our goal in working with the
suicidal caller is twofold:
1. To assist the caller in focusing
on the issue thus enabling them
to communicate their feelings
verbally instead of behaviorally;
2. To explore more adaptive
resolutions to the precipitating
issue presented.
In interacting with the suicidal caller we operate under the
assumption that the Caller is ambivalent about their
decision to suicide otherwise they would not be
contacting us. This bestows upon us the moral right and
responsibility to attempt to intervene.
To effectively intervene with the Suicidal Caller we need
to accomplish three tasks:
1. Establish a relationship (Connecting)
2. Evaluate the suicidal potential
(Understanding)
3. Formulate a plan and mobilize
Resources (Assisting)
Establishing a Relationship
(Connecting)
To establish a relationship with the
person at risk:
• Present yourself as being
patient, interested, self-assured,
and knowledgeable.
• Be accepting, respectful, and empathic.
•Use your active listening skills
•Listen for suicidal clues
•If you hear clues address the issue of suicide
Establishing A Relationship
• Bring the issue of suicide up for open
discussion. If the Caller shares anything
that gives you the impression they are
suicidal ask them,
“Are you feeling suicidal?”
• Listen for, indicate, and support any messages
from the Caller that reflect a reluctance to die
(ambivalence).
• Stay calm and sound confident
• Avoid moralistic pronouncements about suicide.
Evaluating the Suicidal
Potential
(Understanding)
This step of the assessment serves
two purposes:
• It helps us to understand the
danger the person at risk is in and
the appropriate intervention we
need to initiate or referral to make
• It helps the person at risk to understand the danger
they are in as well as their ambivalence about dying
Evaluating the Suicidal
Potential (Understanding)
You have two tasks in this step.
• To listen for, acknowledge, and point out
the person at risk’s reasons for Living and
for Dying. You will then use these reasons to point
out the ambivalence indicated by the contradictory
messages. The introduction of ambivalence will,
often, push the individual towards a life affirming
decision.
•To assess the actual risk the person is in
Evaluation of Suicide Potential
• The Worker needs to make an evaluation of the
seriousness of the Caller’s suicidal intent.
• This evaluation will determine the best plan of
intervention: Calling an ambulance; Engaging significant
others; A referral to a mental health agency, etc.
• A Callers' degree of risk can be accurately determined
using exploring the Caller’s:
• Current Plan
• Pain
• Resources
• + Prior Suicidal Behavior
• + Mental Health
Current Suicide Plan
• The inherent lethality of the proposed
method; “How do you plan to kill
yourself?”
• The availability of the means; “Where is the weapon,
drugs or other implement that you plan to use?”
• The specificity of the plan; “What have you done to
prepare to die?”
• The time frame of the plan; “When do you plan to
die?”
Assessing Pain
Suicide is a maladaptive coping
mechanism intended to relieve the
pain of the hopelessness and
helplessness precipitated by crisis.
To assess that pain we need to ask,
“ Do you have pain that at time feels
unbearable?”
Assessing the Caller’s Resources
• Internal Resources; “What have you done to change
things before you decided to attempt suicide? Do you
think any of those things may work now?”
• External Resources; “Who have you talked to about
what is going on for you? Is there anybody else you
might consider?”
• Communication with their external
resources; “Have you been able to talk
with people who have helped you in the
past? Or “How do you get along with
people who have helped you in the past?”
+ Assessing Prior Suicidal Behavior
• Have there been previous attempts; “Have you
attempted suicide before?”
• The previous method; “What were your previous
attempts?”
• History of attempts by significant others; “Has
anybody you know attempted suicide?”
• Response and treatment; “Following your
previous attempts did you get help? How
did that work out for you?”
+ Assessing Mental Health
A mental health history can be a
contributing factor in a person at
risks suicidal ideation.
“Are you receiving or have you
received mental health care?”
Formulating a Safeplan and Mobilizing
Resources
All Safeplans include:
• Keep Safe
• Safety Contacts
• Addressing limited use of
alcohol or drugs
• Link to resources
Risk Specific Safeplans and Mobilizing Resources
• Current Suicide Plan:
Disable the plan
• Pain:
Ease the pain
• Resources:
Link to resources
• + Prior Suicidal behavior:
Protect against the current danger and support past
survival skills
• + Mental Health:
Link to mental health worker
I&R and Suicide: General thoughts
• Make contact at a feeling level.
• Be patient and listen carefully.
• Identify and reflect the Caller's feelings.
• Let the Caller tell their story in their own words and
time. Be patient.
• Simply note any factual information about possible
resources that the Caller may share (names, addresses,
telephone numbers, etc.). You can clarify the particulars
once openness and trust are established.
• Control your personal feelings of stress and anxiety by
reflecting them to the Caller (Parallel Process).
• Avoid any sermons about suicide or policy.
Things To Avoid
Don’t debate whether suicide is right or
wrong.
Don’t moralize or judge the person’s
feeling or situation.
Don’t allow yourself to be sworn to
secrecy.
Don’t give advice.
Don’t minimize the caller’s pain or
situation.
Avoid statements such as , “It could be
worse”, “Don’t worry, things will get better.”
Don’t avoid talking about suicide.
Don’t take responsibility for “saving” the
caller.
CRISIS DEFUSED
Once the crisis has been defused,
you can go to the next level:
Explore existing supports: Does the caller
have support from family or friends
available?
Assess coping skills: Has the inquirer
faced similar situation in the past? How
did they manage to cope before?
Prioritize: Work with the caller to identify
the different aspects of their situation.
Help them decide which issues need to be
addressed immediately and/or are easiest
to solve. For example, “You seem most
concerned with ….so let’s start with that.
Collaborate with the caller on finding
resources. Help them be responsible for
their decisions.
Referral searching: Explore all possible
options. Re-explore options tried.
Look for the most relevant resources and
try to give the individual a number of
options.
Review sources and offer to transfer
him/her to appropriate agencies.
Try to end call on a positive but realistic
note.
Remind caller that they have started in
the right direction by asking for help and
that there will always be people trying to
help.
Review safe plan and check for
understanding of the plan.
Formulating A Plan and Mobilizing Resources
There are three possible scenarios in
working with the suicidal individual:
• Suicide in progress
• Suicide attempt has not been initiated
but high lethality is indicated
• Suicide attempt has not been
initiated but low lethality is indicated
The plan we formulate and the
resources we mobilize is different in
each instance
Suicide in Progress
• In reality the suicide in progress is an emergency
situation as the Caller may not be able to, or may
become unable to, participate in situational
resolution.
• An immediate offer to dispatch assistance will be
made.
• If the Caller declines assistance and their location
is known assistance will be sent regardless of their
desire.
• If they decline and their location is not known, work
to build a trusting relationship focusing on their
ambivalence as indicted by their call.
Suicide in Progress Do’s and Don’ts
• Do offer to call emergency services immediately
• Don’t instruct the Caller to call 911 unless you are
instructed to do so by emergency services once you
call them.
• Do get the Caller’s complete address, including
apartment number and telephone number.
• Do conference the Caller with emergency services
if they are unsure of their exact location.
• Do explain how the emergency process will work.
Suicide in Progress Do’s and Don’ts
• Do instruct the Caller to collect the containers of
any substance they may have consumed to help
those responding accurately assess what steps
need to be taken.
• Do inform the emergency services people of any
weapons the Caller may be planning to use in their
suicide attempt.
• Do ask the emergency services people how they
wish the issue of weapons handled.
• Do stay on the phone until the emergency
services arrive.
• Do let the emergency services worker you contact
talk to the caller.
Suicide Attempt Has Not Been Initiated but
High Lethality Is Indicated
In cases of high suicidal potential, efforts should be made to:
• Help the Caller engage resources in their own environment.
• Involve as many individuals as possible with the suicidal person.
• Offer to talk to or contact immediate family members.
• Encourage and facilitate contact with mental health
professionals.
• Make efforts to guarantee that a person seriously contemplating
suicide is not left alone or permitted an opportunity to act upon
their plan.
• Before closing the call attempt to have the Caller eliminate the
lethal means by encouraging them to flush pills down the toilet,
give the gun to another, responsible person, etc. Enlist the aid of
a responsible person in the Caller’s environment to carry this out.
Suicide Attempt Has Not Been Initiated but
High Lethality Is Indicated
In the case of very high lethality where the Caller doubts their
ability to control their suicidal impulses and wishes help
arrange for immediate professional intervention.
• Explain that the Caller can voluntarily present themselves
at the emergency room of any hospital with a psychiatric
component or at the admissions office of the state psychiatric
hospital and ask to be evaluated.
• To alleviate apprehension call the nearest appropriate
facility and ask for an explanation of their admission
procedure.
• Engage the Caller in an exploration of what family members
or friends might be available to help them negotiate this
process.
Suicide Attempt Has Not Been Initiated but
High Lethality Is Indicated Do’s and Don’ts
• Do listen for any input from the Caller that would indicate
they have decided to initiate the suicide process.
• Do explore what significant others or caregiving
professionals are most able to assist the Caller. Explain to the
Caller we can contact immediate family members and
professionals on their behalf.
• Do ask the Caller if there are responsible people at the
location they are calling from and ask the Caller if you can talk
to them about the situation you have been discussing.
• Do be candid with any person you talk to on behalf of the
Caller. Explain the situation as the Caller has explained it to
you, your concern about the situation, and invite the person to
add any input they may have regarding the Caller.
Suicide Attempt Has Not Been Initiated but
High Lethality Is Indicated Do’s and Don’ts
• Do contact the local hospital or mental health facility to find
out what their emergency admission procedure is.
• Don’t promise that emergency services will transport the
Caller. Generally, emergency services will only transport in
cases of immediate life or death.
• Do have the Caller repeat to you, in their own words, the
plan the two of you have developed. If there are any
discrepancies point them out and then have the Caller repeat
the plan again.
• Don’t insist the Caller dispose of or remove the means of
their suicide until the end of the call. Doing so prematurely can
interfere with the establishment of the openness and trust
necessary in such situations.
Suicide Attempt Has Not Been Initiated and
Low Lethality Is Indicated
In a situation of less immediate danger, assistance of an
outpatient nature can be offered.
• Make conference calls to appropriate agencies or
treatment centers to make arrangements.
• Be candid with the resource about the suicidal element
so the Caller can be seen without undue delay. Where
suicide is an issue, many agencies will circumvent
waiting lists.
• Refer to community resources that will allow the Caller
to address the issue(s) that led them to consider suicide
a problem-solving tool.
Suicide Attempt Has Not Been Initiated and
Low Lethality Is Indicated Do’s and Don’ts
• Do listen for any escalation in lethality during the call and
address any change with the Caller.
• Do make conference calls to agencies and advocate for the
caller if there is any indication they do not have the ability or
resources to do so.
• Do remind the Caller they can involve significant others in
helping resolve their problems.
• Do have the Caller repeat to you, in their own words, the
plan that the two of you have developed. If there are any
discrepancies point them out and then have the Caller repeat
the plan again.