Suicide Risk Assessment and Intervention for I&R SpecialistsAIRS 31st Annual I&R Training and Education Conference

“Mining for I&R Excellence”Reno, NV

Monday June 1, 2009Part 1 – 1:00 – 2:30 PMPart 2 – 3:15 – 3:45 PM

John PlonskiDatabase/Training CoordinatorCovenant House InternationalPresident NYS AIRSjplonski@covenanthouse.org212.727.4040

Janice M. Harris MA, CIRS2-1-1 Service CoordinatorCommunity Service Council of Greater Tulsa918.295.1244

Your Presenters

Janice M. Harris MA, CIRS2-1-1 Service CoordinatorCommunity Service Council of Greater Tulsa918.295.1244

John PlonskiDatabase/Training CoordinatorCovenant House InternationalPresident NYS AIRSjplonski@covenanthouse.org212.727.4040

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

KevinKevin

In September 2000, Kevin Hines took a In September 2000, Kevin Hines took a leap off the Golden Gate Bridge. leap off the Golden Gate Bridge.

A few minutes before that he got off the A few minutes before that he got off the bus, went onto the span, and stood there bus, went onto the span, and stood there crying.crying.

KevinKevin

He encountered several people on his way He encountered several people on his way to the rail. to the rail.

1.1. Bridge WorkersBridge Workers

2.2. BikersBikers

3.3. JoggersJoggers

4.4. Policemen on BikesPolicemen on Bikes

KevinKevin

He said to himself, “If just one person, He said to himself, “If just one person, just one, comes up to me and asks me if I just one, comes up to me and asks me if I need help, I’ll tell them everything.”need help, I’ll tell them everything.”

One woman asked him to take her One woman asked him to take her picture.picture.

KevinKevin

Not one person asked him what was Not one person asked him what was wrong so he took a running leap over the wrong so he took a running leap over the rail into the water. As soon as he left the rail into the water. As soon as he left the bridge, Kevin thought, “I don’t want to die.”bridge, Kevin thought, “I don’t want to die.”

Your thoughts about….Your thoughts about….

KevinKevin

The people Kevin met on the bridgeThe people Kevin met on the bridge

Any other people who may have been in Any other people who may have been in Kevin’s lifeKevin’s life

Suicide facts and mythsSuicide facts and myths

USA, 2005Pop. 295,895,897

Reported suicides: 32,657

Unreported suicides:

Non-fatal suicidal behaviors:

Number of people affected:

People with thoughts of suicide:

5% to 25% more suicides

40 to 100 times greater than number of suicides

Each suicidal behavior may affect a few or a very large number

5% of the population: 14,794,794

Ok. If you say so.Where do we start?

As it relates to Crisis Intervention people are a product of three affects. Their:

• Thoughts• Feelings• Behaviors

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.

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)

Adaptive/Maladaptive Resources

Secondary

Resources

Primary 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:Clues to look for include:

Direct hints: Direct hints:

– ““I just can’t take it anymore”, I just can’t take it anymore”,

– “ “ I want to escape”, I want to escape”,

– ““I want to go to sleep forever”, I want to go to sleep forever”,

– ““They’ll be sorry when I’m gone.” They’ll be sorry when I’m gone.”

– ““I can’t stand this pain anymore.”I can’t stand this pain anymore.”

– ““Nothing will ever get better,”Nothing will ever get better,”

– ““My family would be better off if I were My family would be better off if I were not around”not around”

More clues to look for:More clues to look for:

Tone of voice Tone of voice

– very soft or loud, very soft or loud,

– weak, weak,

– long pauses, long pauses,

– sighs, sighs,

– depresseddepressed

– agitatedagitated

More clues to look for:More clues to look for:

Losses – actual, perceived, or threatenedLosses – actual, perceived, or threatened– Death of a significant other (this can include an Death of a significant other (this can include an

idol, role model, or a pet), idol, role model, or a pet),

– Breakup of a relationship, divorce or separation, Breakup of a relationship, divorce or separation,

– Loss of a job or housing. Loss of a job or housing.

– Onset of illness for either the person or a Onset of illness for either the person or a significant other significant other

– Anniversary of a lossAnniversary of a loss

– Move to a new areaMove to a new area

– Situation where a guardian is absentSituation where a guardian is absent

– Onset of physical or emotional disabilitiesOnset of physical or emotional disabilities

More clues to look for:More clues to look for:

Behaviors – Extreme changes. Behaviors – Extreme changes. – Have trouble eating or sleepingHave trouble eating or sleeping– Withdraw from friends and/or social activitiesWithdraw from friends and/or social activities– Lose interest in hobbies, work, school, etc.Lose interest in hobbies, work, school, etc.– Write a will and making final arrangementsWrite a will and making final arrangements– Give away prized possessionsGive away prized possessions– Take unnecessary risksTake unnecessary risks– Be preoccupied with death and dyingBe preoccupied with death and dying– Lose interest in personal appearanceLose interest in personal appearance– Increase use of alcohol or drugsIncrease use of alcohol or drugs

Just a few more cluesJust a few more clues

Feelings Feelings – Intense or long lasting painful ones: depressed, Intense or long lasting painful ones: depressed,

alone, hopeless, scared, confused, helpless, angry.alone, hopeless, scared, confused, helpless, angry.

The person at risk of suicide feels they can’t :The person at risk of suicide feels they can’t :– Stop the painStop the pain– Think clearlyThink clearly– Make decisionsMake decisions– See any way outSee any way out– Sleep eat or workSleep eat or work

– Get out of the depressionGet out of the depression– Make the sadness go awayMake the sadness go away– See a future without painSee a future without pain– See themselves as See themselves as

worthwhileworthwhile– Seem to get controlSeem 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 Once the caller makes mention of ending their life, a basic suicide risk assessment their life, a basic suicide risk assessment should be done. (see handout)should be done. (see handout)

The worker should interact with the person The worker should interact with the person at risk in a way to help the individual at risk in a way to help the individual understand their ambivalence about their understand their ambivalence about their decisiondecision

It is important to remember that the It is important to remember that the assessment process is fluid.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)

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)

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

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 AvoidThings To Avoid

Don’t debate whether suicide is right or Don’t debate whether suicide is right or wrong. wrong.

Don’t moralize or judge the person’s Don’t moralize or judge the person’s feeling or situation.feeling or situation.

Don’t allow yourself to be sworn to Don’t allow yourself to be sworn to secrecy.secrecy.

Don’t give advice.Don’t give advice.

Don’t minimize the caller’s pain or Don’t minimize the caller’s pain or situation. situation.

Avoid statements such as , “It could be Avoid statements such as , “It could be worse”, “Don’t worry, things will get better.”worse”, “Don’t worry, things will get better.”

Don’t avoid talking about suicide.Don’t avoid talking about suicide.

Don’t take responsibility for Don’t take responsibility for “saving“saving” the ” the caller. caller.

CRISIS DEFUSEDCRISIS DEFUSED

Once the crisis has been defused, Once the crisis has been defused, you can go to the next level:you can go to the next level:

Explore existing supports:Explore existing supports: Does the caller Does the caller have support from family or friends have support from family or friends available?available?

Assess coping skills:Assess coping skills: Has the inquirer Has the inquirer faced similar situation in the past? How faced similar situation in the past? How did they manage to cope before? did they manage to cope before?

Prioritize:Prioritize: Work with the caller to identify the Work with the caller to identify the different aspects of their situation. Help different aspects of their situation. Help them decide which issues need to be them decide which issues need to be addressed immediately and/or are easiest to addressed immediately and/or are easiest to solve. For example, “You seem most solve. For example, “You seem most concerned with ….so let’s start with that.concerned with ….so let’s start with that.

Collaborate with the caller on finding Collaborate with the caller on finding resources. Help them be responsible for resources. Help them be responsible for their decisions.their decisions.

Referral searching:Referral searching: Explore all possible Explore all possible options. Re-explore options tried.options. Re-explore options tried.

Look forLook for the most relevant resources and the most relevant resources and try to give the individual a number of try to give the individual a number of options. options.

Review sourcesReview sources and offer to transfer and offer to transfer him/her to appropriate agencies. him/her to appropriate agencies.

Try to end call on a positive but realistic Try to end call on a positive but realistic note. note.

Remind caller that they have started in the Remind caller that they have started in the right direction by asking for help and that right direction by asking for help and that there will always be people trying to help.there will always be people trying to help.

Review safe plan and check for Review safe plan and check for understanding of the plan. 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.