![Page 1: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/1.jpg)
David D Nowell PhDwww.DrNowell.com
![Page 2: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/2.jpg)
A challenge….
![Page 3: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/3.jpg)
Risk Assessment & Clients in Crisis
An overview of the day:• Assessment of risk•Mental status examination• Intervention planning• Documentation
![Page 4: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/4.jpg)
Patient at risk?
male
personality
divorce pain
guns
alcohol
![Page 5: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/5.jpg)
David D Nowell PhD
DavidNowell
DavidNowellSeminars
www.DrNowell.com
![Page 6: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/6.jpg)
Psychodynamic Issues
Anxiety mastery
Depression mastery
Capacity to feel real and continuous across time
![Page 7: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/7.jpg)
Edwin Schneidman
• Psychache• Press• Perturbation
![Page 8: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/8.jpg)
Edwin Schneidman
• Psychache (pain)• Press• Perturbation
![Page 9: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/9.jpg)
And so I leave this world, where the heart must either break or turn to lead. Nicolas-Sebastien Chamfort, French writer, d. 1794
![Page 10: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/10.jpg)
I haven’t felt the excitement of listening to as well as creating music…for too many years now. I feel guilty beyond words about these things.
Kurt Cobain, musician, d. 1994
![Page 11: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/11.jpg)
I must end it. There's no hope left. I'll be at peace. No one had anything to do with this. My decision totally.
Freddie Prinze, comedian, d. 1977
![Page 12: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/12.jpg)
I feel certain that I'm going mad again. I feel we can't go thru another of those terrible times. And I shan't recover this time. I begin to hear voices.
Virginia Woolf, author, d. 1941
![Page 13: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/13.jpg)
![Page 14: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/14.jpg)
Edwin Schneidman• Psychache (pain)• Press (stress)• Perturbation (agitation)
![Page 15: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/15.jpg)
![Page 16: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/16.jpg)
Edwin Schneidman• Psychache (pain)• Press (stress)• Perturbation (agitation)
![Page 17: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/17.jpg)
When to assess risk?
![Page 18: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/18.jpg)
When to assess risk?
![Page 19: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/19.jpg)
When to assess risk?
![Page 20: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/20.jpg)
When to assess risk?
• At first contact• At any time of loss or uptick in stress • At any follow-up contact with “high
risk” client
![Page 21: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/21.jpg)
SUICIDE PREDICTION vs. SUICIDE RISK ASSESSMENT
![Page 22: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/22.jpg)
300.4, rule out 296.25
![Page 23: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/23.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 24: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/24.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 25: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/25.jpg)
Risk Assessment & Management
Predisposing factors
• Older• White• Male• Personality disorder• Substance abuse• Access to guns• Recent stress or public humiliation
![Page 26: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/26.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 27: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/27.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 28: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/28.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 29: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/29.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 30: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/30.jpg)
DSM-IV 5-Axis System
• Axis I• Axis II• Axis III• Axis IV• Axis V
![Page 31: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/31.jpg)
DSM-IV 5-Axis System
• Axis I• Axis II• Axis III• Axis IV• Axis V
![Page 32: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/32.jpg)
• Axis I• Axis II• Axis III• Axis IV• Axis V
![Page 33: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/33.jpg)
Predisposing Clinical Risk Factors
• Mood disorders–15% lifetime risk–50 – 70% of all suicides
![Page 34: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/34.jpg)
Predisposing Clinical Risk Factors
• Depression
![Page 35: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/35.jpg)
![Page 36: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/36.jpg)
Predisposing Clinical Risk Factors
• Bipolar Disorder
![Page 37: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/37.jpg)
Predisposing Clinical Risk Factors
• Substance Abuse / Dependence
![Page 38: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/38.jpg)
Predisposing Clinical Risk Factors
• Substance Abuse / Dependence–Lifestyle Issues
![Page 39: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/39.jpg)
Predisposing Clinical Risk Factors
• Anxiety Disorders
![Page 40: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/40.jpg)
Predisposing Clinical Risk Factors
• Schizophrenia
![Page 41: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/41.jpg)
Predisposing Clinical Risk Factors
• Personality disorders–5 – 10% lifetime risk–15 – 25% of all suicides
![Page 42: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/42.jpg)
Borderline Personality and Risk Lifetime rate of suicide - 8.5% With alcohol problems -19% With alcohol problems and major affective disorder -38%
![Page 43: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/43.jpg)
Borderline features which increase risk
• Impulsivity• Hopelessness-despair• Antisocial features • Aloofness• Self-mutilating tendencies• Psychosis
![Page 44: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/44.jpg)
Borderline features which ameliorate risk
• Clinging• Dependency• Use of suicidal behavior to maintain
connections
![Page 45: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/45.jpg)
Antisocial Personality Disorder
• Concurrent Axis I disorder• Over age 40• Recent narcissistic injury / impulsivity
![Page 46: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/46.jpg)
Narcissistic Personality Disorder
• Failure• Humiliation• Criticism
![Page 47: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/47.jpg)
SUICIDE RISKS IN SPECIFIC DISORDERS
Prior suicide attempt 38.4 0.549 27.5Bipolar disorder 21.7 0.310 15.5Major depression 20.4 0.292 14.6Mixed drug abuse 19.2 0.275 14.7Dysthymia 12.1 0.173 8.6Obsessive-compulsive 11.5 0.143 8.2Panic disorder 10.0 0.160 7.2Schizophrenia 8.45 0.121 6.0Personality disorders 7.08 0.101 5.1Alcohol abuse 5.86 0.084 4.2Cancer 1.80 0.026 1.3
General population 1.0 0.014 0.72
Condition RR %-yr %-Lifetime
Adapted from A.P.A. Guidelines, part A, p. 16
![Page 48: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/48.jpg)
SUICIDE RISKS IN SPECIFIC DISORDERS
General population 1.0 0.014 0.72
Adapted from A.P.A. Guidelines, part A, p. 16
Condition RR %-yr %-Lifetime
![Page 49: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/49.jpg)
SUICIDE RISKS IN SPECIFIC DISORDERS
Prior suicide attempt 38.4 0.549 27.5Bipolar disorder 21.7 0.310 15.5Major depression 20.4 0.292 14.6
Adapted from A.P.A. Guidelines, part A, p. 16
Condition RR %-yr %-Lifetime
![Page 50: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/50.jpg)
SUICIDE RISKS IN SPECIFIC DISORDERS
Dysthymia 12.1 0.17 8.6Panic disorder 10.0 0.16 7.2
Adapted from A.P.A. Guidelines, part A, p. 16
Condition RR %-yr %-Lifetime
![Page 51: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/51.jpg)
COMORBIDITY
In general, the more diagnoses present, the higher the risk of suicide.
![Page 52: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/52.jpg)
COMORBIDITY
In general, the more diagnoses present, the higher the risk of suicide.
Psychological Autopsy of 229 Suicides• 44% had 2 or more Axis I diagnoses• 31% had Axis I and Axis II diagnoses• 50% had Axis I and at least one Axis III
diagnosis• Only 12 % had an Axis I diagnosis with no
comorbidity Henriksson et al, 1993
![Page 53: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/53.jpg)
Predisposing Medical Risk Factors
• Chronic Pain• Chronic illness
![Page 54: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/54.jpg)
Predisposing Family History Risk Factors
Relatives of suicidal subjects have a two-fold increased risk compared to relatives of non-suicidal subjects.
Twin studies indicate a higher concordance of suicidal behavior between identical rather than fraternal twins.
Adoption studies: a greater risk of suicide among biologic rather than adoptive relatives.
![Page 55: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/55.jpg)
Predisposing Demographic Risk Factors
• Male • Older• Lives alone • Widowed / separated • White, or Native American• Access to weapons• Sexual minority (GLBT)
![Page 56: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/56.jpg)
![Page 57: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/57.jpg)
![Page 58: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/58.jpg)
![Page 59: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/59.jpg)
• Mexico 4.0
• Dominican 2.3
• Puerto Rico 7.4
• Colombia 4.9
![Page 60: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/60.jpg)
• S. Korea 31.7
• China 22.3
• India 10.5
![Page 61: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/61.jpg)
![Page 62: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/62.jpg)
![Page 63: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/63.jpg)
![Page 64: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/64.jpg)
![Page 65: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/65.jpg)
![Page 66: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/66.jpg)
![Page 67: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/67.jpg)
![Page 68: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/68.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 69: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/69.jpg)
Potentiating Risk Factors
• Recent stressor• Contagion• Recent diagnosis of major illness • Recent relapse of major illness• Hepatitis C treatment
![Page 70: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/70.jpg)
Potentiating Risk Factors
• Recent stressor–Legal Problems–Loss of Job–Relationship issues–Homeless–Finances
![Page 71: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/71.jpg)
Potentiating Risk Factors
• Recent stressor• Contagion• Recent diagnosis of major illness • Recent relapse of major illness• Hepatitis C treatment
![Page 72: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/72.jpg)
Admiral Jeremy Boorda
![Page 73: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/73.jpg)
Choi Jin-sil
![Page 74: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/74.jpg)
![Page 75: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/75.jpg)
Patient at risk?
male
personality
divorce pain
guns
alcohol
![Page 76: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/76.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 77: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/77.jpg)
1 – Item Suicidality Assessment
![Page 78: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/78.jpg)
Specific Suicide Inquiry
• (Current) Ideation• (History of ) Threats• (History of) Attempts
![Page 79: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/79.jpg)
Ideation
• Passive thoughts• Active thoughts
Duration: Frequency: Persistent? Obsessive?
![Page 80: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/80.jpg)
Suicidal ideation
• Able to control suicidal thoughts?• Has made preparations for death?• Has rehearsed?• Command hallucinations?
![Page 81: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/81.jpg)
Suicidal plan:
• No concrete plan but has intent• Plan without means• Plan with means:• Lethality
![Page 82: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/82.jpg)
Suicidal intent:
• No intent but does not feel capable of maintaining safety plan
• Intent related to:–Wish to die–Desire to hurt someone else–Need to escape–Need to punish self
![Page 83: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/83.jpg)
History of threats• Seek collateral information• Determine context of threats
![Page 84: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/84.jpg)
History of attempts• Actions imply gestures vs. intent?• Dangerous/not believed to be lethal?• Dangerous/potentially lethal?• History of self-injurious behavior?
![Page 85: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/85.jpg)
Competency / Capacity
• Psychosis• Impaired judgment• Decompensated• Overwhelmed
![Page 86: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/86.jpg)
Impulsivity
• History of money management?• Impulsive relapses?• Domestic violence?• Abrupt firings from jobs?• How have relationships ended?• History of impulsive suicidality?
![Page 87: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/87.jpg)
Deterrents to suicide
• Religious faith • Hopefulness re: resolution• Ambivalence• Reasons for living• Loved ones• Relationship with therapist
![Page 88: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/88.jpg)
![Page 89: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/89.jpg)
“signs” and “symptoms”
![Page 90: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/90.jpg)
Current risk factors, reported (symptoms)
• Self-report• Collateral data–Records–Significant others, family, friends
![Page 91: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/91.jpg)
Current risk factors, observed (signs)
• mental status examination
![Page 92: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/92.jpg)
Current risk factors, observed
• mental status examination–Behavior–Emotional–Cognitive
![Page 93: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/93.jpg)
90791
![Page 94: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/94.jpg)
ABC STAMPLICKER
![Page 95: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/95.jpg)
ABC STAMPLICKER• appearance
![Page 96: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/96.jpg)
“client appears his stated age…”
![Page 97: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/97.jpg)
![Page 98: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/98.jpg)
![Page 99: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/99.jpg)
![Page 100: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/100.jpg)
ABC STAMPLICKER• behavior
![Page 101: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/101.jpg)
ABC STAMPLICKER• cooperation
![Page 102: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/102.jpg)
ABC STAMPLICKER• speech
![Page 103: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/103.jpg)
ABC STAMPLICKER• thought
![Page 104: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/104.jpg)
ABC STAMPLICKER• Thought–form–content
![Page 105: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/105.jpg)
Common abnormalities of thought form
• Loose associations• Clang• Overinclusiveness• Pressure• Tangentiality
![Page 106: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/106.jpg)
Common abnormalities of thought content
• Delusions• Obsessions• Phobias• Violent ideation.
• Hallucinations (abnormal perception)
![Page 107: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/107.jpg)
ABC STAMPLICKER• affect
![Page 108: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/108.jpg)
Euthymic:
• Calm• Comfortable• Euthymic• Friendly• Normal• Pleasant• Unremarkable
![Page 109: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/109.jpg)
Angry:
• Angry• Bellicose• Belligerent• Confrontational • Frustrated• Hostile• Sullen
• Impatient• Irascible• Irate• Irritable• Oppositional• Outrage
![Page 110: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/110.jpg)
Dysphoric:
• Despondent• Distraught• Dysphoric• Grieving• Hopeless• Overwhelmed• Remorseful• Sad
![Page 111: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/111.jpg)
Terms to describe parameters of affect:
• Appropriateness• Intensity• Range
![Page 112: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/112.jpg)
ABC STAMPLICKER•mood
![Page 113: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/113.jpg)
ABC STAMPLICKER• perception
![Page 114: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/114.jpg)
“sensorium intact…”
![Page 115: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/115.jpg)
PersonPlaceTime
Situation
“Oriented X 3”“O X3”
![Page 116: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/116.jpg)
PersonPlaceTime
Situation
“Oriented X 3”“O X3” “Oriented X 4”
“OX4”
![Page 117: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/117.jpg)
ABC STAMPLICKER• Level of arousal
![Page 118: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/118.jpg)
“Patient is an 89 year old male, A+O x 3, no AH/VH, denies SI/HI.”
![Page 119: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/119.jpg)
ABC STAMPLICKER• insight
![Page 120: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/120.jpg)
Disorders that contribute to impaired insight
• Drug and alcohol dependence• Depression• Mania• Psychosis• Personality
disorders
• Delirium• Dementia• ADHD• Conversion disorder• Factitious disorder
![Page 121: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/121.jpg)
Judgment
• The ability to weigh and compare the relative values of different aspects of an issue.
![Page 122: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/122.jpg)
ABC STAMPLICKER• cognition
![Page 123: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/123.jpg)
ABC STAMPLICKER• Cognition–Attention–Memory
![Page 124: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/124.jpg)
MMSE normsEighth Grade Education
Ages 18 to 69: Median MMSE Score 26-27 Ages 70 to 79: Median MMSE Score 25
Age over 79: Median MMSE Score 23-25 High School Education
Ages 18 to 69: Median MMSE Score 28-29 Ages 70 to 79: Median MMSE Score 27
Age over 79: Median MMSE Score 25-26 College Education
Ages 18 to 69: Median MMSE Score 29 Ages 70 to 79: Median MMSE Score 28 Age over 79: Median MMSE Score 27
Crum (1993) Journal of the American Medical Association
![Page 125: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/125.jpg)
ABC STAMPLICKER• Knowledge
![Page 126: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/126.jpg)
ABC STAMPLICKER• Endings
![Page 127: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/127.jpg)
ABC STAMPLICKER• reliability
![Page 128: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/128.jpg)
Patient at risk?
male
personality
divorce pain
guns
alcohol
![Page 129: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/129.jpg)
![Page 130: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/130.jpg)
Validity techniques in risk assessment
• Behavioral incident• Shame attenuation• Gentle assumption• Symptom amplification• Denial of the specific• Normalization
![Page 131: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/131.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 132: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/132.jpg)
Suicide Risk Classification
High risk
Moderate Risk
Low risk
![Page 133: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/133.jpg)
Suicide Risk Classification
High risk
Moderate Risk
Low risk
![Page 134: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/134.jpg)
Suicide Risk Classification
High risk
Moderate Risk
Low risk
![Page 135: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/135.jpg)
Moderate Risk
• Follow-up evaluation of risk• Increased frequency of
outpatient contact.• Involvement of family members,
if possible.• 24 hour availability of crisis
centers• Referral for consideration of
pharmacological tx• Use of telephone contacts to
monitor progress• Safety plan
![Page 136: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/136.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 137: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/137.jpg)
Determine level of intervention1. Acute versus chronic2. Evaluate competence and impulsivity3. Assess therapeutic alliance4. Plan reassessments
![Page 138: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/138.jpg)
Determine level of intervention1. Acute versus chronic2. Evaluate competence and impulsivity3. Assess therapeutic alliance4. Plan reassessments
![Page 139: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/139.jpg)
Disorder-based (acute)
Personality-based (chronic)
![Page 140: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/140.jpg)
Disorder-based (acute)
Personality-based (chronic)
![Page 141: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/141.jpg)
Determine level of intervention1. Acute versus chronic
2. Evaluate competence and impulsivity
3. Assess therapeutic alliance4. Plan reassessments
![Page 142: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/142.jpg)
Competency / Capacity
• Client able to indicate a preference?• Able to weigh the pros/cons of
various options?• Able to apply pros/cons to her own
specific situation?
![Page 143: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/143.jpg)
![Page 144: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/144.jpg)
![Page 145: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/145.jpg)
![Page 146: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/146.jpg)
Determine level of intervention1. Acute versus chronic2. Evaluate competence and impulsivity
3. Assess therapeutic alliance4. Plan reassessments
![Page 147: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/147.jpg)
Determine level of intervention1. Acute versus chronic2. Evaluate competence and impulsivity3. Assess therapeutic alliance
4. Plan reassessments
![Page 148: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/148.jpg)
![Page 149: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/149.jpg)
Consultation with others
• When appropriate involve family members in decision making.• Other professionals • Collaboration with the patient
![Page 150: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/150.jpg)
Consultation with others
• When appropriate involve family members in decision making.• Other professionals • Collaboration with the patient
![Page 151: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/151.jpg)
No Harm Contracts
![Page 152: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/152.jpg)
An Alternative Approach: Collaborative approach
![Page 153: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/153.jpg)
Elements of the collaborative approach
• Educate the patient about the uncertainty inherent in treatment.• Underscore the mutual responsibility of
sharing the burden of managing suicidal thoughts.• Directly discuss the risk of death from
suicide.• Discuss risks other than suicide such as
dependence and regression.
![Page 154: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/154.jpg)
• Discuss the patient’s competence or capacity to give informed consent.
• Warn the patient about the serious consequence of not following treatment recommendations.
• Consult with a peer when possible.• Prepare concise documentation of assessment
and treatment planning emphasizing collaboration.
![Page 155: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/155.jpg)
Elements of a safety plan
• How will I know that my risk for self-harm has become more serious?• What are the coping strategies which I
will use if I feel more distressed or sad?• Who can I contact if I need someone to
spent time with and distract me from my distress?
![Page 156: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/156.jpg)
Elements of a safety plan
• Who can I contact if I need to seek support or talk me through difficult feelings?
• Who are the helping professionals to whom I will reach out if I need support? (include contact information; include contacts available on 24 hour basis such as EMH)
• What specific steps will I take to make my home environment safer for me?
![Page 157: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/157.jpg)
Providing Feedback
![Page 158: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/158.jpg)
Feedback approach
–Collaborative–Mutuality–Curiosity
![Page 159: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/159.jpg)
Feedback approach
–Review chief complaints–Add pertinent info re: signs
![Page 160: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/160.jpg)
Feedback approach
–Offer diagnosis• Share attitude of round pegs/square
holes• Emphasize hope
–Request feedback–Offer accurate empathy
![Page 161: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/161.jpg)
Feedback approach
• Feedback provides three types of information for patient–Confirms the obvious–Gently challenges–Doesn’t fit
![Page 162: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/162.jpg)
Feedback approach
• Feedback regarding personality disorder
![Page 163: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/163.jpg)
Oldham & Morris. Personality Self-Portrait
![Page 164: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/164.jpg)
Personality Styles
• Narcissistic• Dependent• Paranoid• Anti-social• Borderline
• Self-confident• Devoted• Vigilant• Adventurous/challenger• Mercurial
![Page 165: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/165.jpg)
Adventurous/Challenger
• Nonconforming• Daring• Mutual independence• Persuasive• Charming• Free lance• No regrets
![Page 166: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/166.jpg)
Mercurial
• Romantic attachment• Intensity• Heart• Unconstraint• Activity• Open mind• Alternate states
![Page 167: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/167.jpg)
Self-Confident
• Self-regard• Red carpet• Ambition• Competition• Stature• Dreams• Poise
![Page 168: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/168.jpg)
Disposition
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention
5. Document the assessment
![Page 169: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/169.jpg)
Documentation
![Page 170: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/170.jpg)
Documentation
![Page 171: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/171.jpg)
4 Reasons to Document Carefully
• Good documentation keeps us out of court• If we must defend our decision-making,
good documentation helps our legal counsel• Good documentation drives good care• Good documentation helps treaters
communicate among ourselves
![Page 172: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/172.jpg)
300.4, rule out 296.25
![Page 173: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/173.jpg)
The Written Report
• Identifying data• HPI / background info• Med hx• Social hx
![Page 174: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/174.jpg)
The Written Report
• MSE • Review of systems–Somatic–Cognitive–Affective
![Page 175: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/175.jpg)
The Written Report
• Impression• Summary–Differential–Contributing factors– Further information needed–Prognosis–Response to referral questions
![Page 176: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/176.jpg)
The Written Report
• Risk Potential– Low/moderate/high– Safety plan (if appropriate to level of risk)
• Treatment Plan• Cost / Benefit Comments re: alternate
treatments
![Page 177: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/177.jpg)
![Page 178: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/178.jpg)
How to Use the Form Provided Today
![Page 179: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/179.jpg)
• Columbia Suicide Severity Rating Scale (CSSRS)–cssrs.columbia.edu
• Suicide Behaviors Questionnaire – Revised (SBQ-R)–www.integration.samhsa.gov/images/
res/SBQ.pdf
![Page 180: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/180.jpg)
![Page 181: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/181.jpg)
Clinical examples
![Page 182: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/182.jpg)
![Page 183: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/183.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 184: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/184.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 185: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/185.jpg)
Disposition
Determine level of intervention1. Acute versus chronic2. Evaluate competence and impulsivity3. Assess therapeutic alliance4. Plan reassessments
![Page 186: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/186.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 187: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/187.jpg)
![Page 188: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/188.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 189: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/189.jpg)
Disposition
Determine level of intervention1. Acute versus chronic2. Evaluate competence and impulsivity3. Assess therapeutic alliance4. Plan reassessments
![Page 190: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/190.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention5. Document the assessment
![Page 191: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/191.jpg)
![Page 192: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/192.jpg)
Risk Assessment & Management
Overview of risk assessment protocol1. Identify predisposing factors2. Examine potentiating factors3. Conduct a specific suicide inquiry4. Determine level of intervention
1. Acute versus chronic2. Evaluate competence and impulsivity3. Assess therapeutic alliance4. Plan reassessments
5. Document the assessment
![Page 193: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/193.jpg)
Risk Management Guidelines
![Page 194: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/194.jpg)
Documentation
• Evidence of an “assessment of risk”
![Page 195: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/195.jpg)
![Page 196: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/196.jpg)
![Page 197: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/197.jpg)
Information on Previous Treatment
• The past is the best predictor of the future. • All available sources of information
should be pursued.
![Page 198: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/198.jpg)
Involvement of the Family & Significant Others
• Good sources of collateral data and integral components of the patient’s support system.
![Page 199: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/199.jpg)
Consultation on Present Circumstances
• Two perspectives are always better than one when assessing risk.
![Page 200: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/200.jpg)
“Good care”
• Intervention appropriate to the level of risk
• Intervention in timely manner
![Page 201: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/201.jpg)
Knowledge of Community Resources
• Crisis numbers, in-patient options, substance abuse resources. • Documentation that these sources
have been discussed.
![Page 202: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/202.jpg)
The 4Ds of Malpractice
• A doctor-patient relationship creating a DUTY of care must be present.
• DEVIATION from the standard of care must have occurred
• DAMAGE to the patient must have occurred.
• The damage must have occurred DIRECTLY as result of deviation from the standard of care.
![Page 203: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/203.jpg)
Malpractice
• Failure to take adequate protective measures• Early patient release• Abandonment
![Page 204: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/204.jpg)
When a Suicide Occurs
Ensure that the patient’s records are complete
Be available to assist grieving family members
Remember the medical record is still official and confidentiality still exists
Seek support from colleagues / supervisors
Consult risk managers
![Page 205: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/205.jpg)
Assessment of Risk for Violence
![Page 206: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/206.jpg)
Clinical features associated with risk for violence
• Has threatened harm• Entertains thoughts of violence• Has access to means/weapons• Has taken steps to secure means• Reports command hallucinations
![Page 207: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/207.jpg)
Clinical features associated with risk for violence
• History of Paranoid Schizophrenia• Recent ETOH/drug abuse• Quarreling• Intense jealousy• Habitual rage response• Childhood fire setting/cruelty to animals• Violence in family of origin
![Page 208: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/208.jpg)
Legal history associated with risk for violence
• Reckless use of a weapon
• Destruction of property
• Has been stalking or harassing others
![Page 209: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/209.jpg)
Risk Potential
• Low–Denies current violent or homicidal
ideation, no indicators evident.• Moderate–Violent/homicidal ideation without
intent.• High–Strong ideation with intent.
![Page 210: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/210.jpg)
Risk Potential
• Low (Potential)
• Moderate (Urgent)
• High (Emergent)
![Page 211: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/211.jpg)
Risk Potential
• Potential– Rules– Physical indicators– Boundaries
![Page 212: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/212.jpg)
Risk Potential
• Urgent– Curious compassionate
nonjudgmental– Behind all anger is hurt– One: one– Win-win– Offer incompatible behavior
![Page 213: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/213.jpg)
Risk Potential
• Emergent– Escape– Five: one– Debrief
![Page 214: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/214.jpg)
Risk Assessment in Schools
• Targeted violence versus general aggression
![Page 215: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/215.jpg)
Risk Assessment in Schools
• Profiling• Structured clinical assessment• Automated decision making /
actuarial formulas
![Page 216: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/216.jpg)
Risk Assessment in Schools• Profiling• Structured clinical assessment• Automated decision making /
actuarial formulas
![Page 217: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/217.jpg)
Risk Assessment in Schools• Profiling• Structured clinical assessment• Automated decision making / actuarial
formulas
![Page 218: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/218.jpg)
Risk Assessment in Schools
• Threat assessment approach
![Page 219: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/219.jpg)
Risk Assessment in Schools
• Threat assessment approach–“making a threat”–“posing a threat”
![Page 220: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/220.jpg)
Risk Assessment in Schools
• Threat assessment approach–Perpetrator–Situation–Target–Setting
![Page 221: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/221.jpg)
10 Elements of Threat Assessment
1. motivation for the behavior at hand2. communication about ideas and
intentions;3. unusual interest in targeted violence; 4. evidence of attack-related behaviors
and planning;
![Page 222: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/222.jpg)
10 Elements of Threat Assessment
5. mental condition;6. level of cognitive sophistication or
organization to execute an attack plan; 7. recent losses (including losses of
status); 8. consistency between communications
and behaviors;
![Page 223: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/223.jpg)
10 Elements of Threat Assessment
9. concern by others about the individual’s potential for harm; and
10. factors in the individual’s life and/or environment that might increase or decrease the likelihood of attack.
![Page 224: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/224.jpg)
A challenge….
![Page 225: Suicide Risk Assessment Public Health Management Corporation](https://reader033.vdocuments.us/reader033/viewer/2022061206/5481ef84b4af9f32538b4620/html5/thumbnails/225.jpg)
David D Nowell PhD
Let’s stay in touch!
Join my e-newsletter list:
• Fill out a card today and drop it in the box.
• Text to join: text DNSEMINARS to 22828
• Sign up at www.DrNowell.com