Contents. Before you begin

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1 Contents Contents Before you begin What you will learn Competency standard What is expected of a Certificate IV learner Assessment Employability skills How to work through this unit Resources vii vii ix xii xii xiii xv xvi Introduction: Assessing and responding to individuals at risk 1 of suicide Chapter 1: Identifying and assessing the person s current 5 suicide risk 1.1 Recognising and responding to signs indicating that a person may be 6 considering suicide 1.2 Attending to hunches that suggest the person may be considering suicide Asking directly about thoughts of suicide when there are grounds for concern Understanding why the person is considering suicide and identifying their 15 links to life to facilitate the intervention 1.5 Assessing the current suicide risk and imminent threat to safety of the 18 person or others Discussion topics 23 Chapter summary 23 Checklist for Chapter 1 24 Assessment activity 1: Identifying and assessing the person s current suicide risk 25 Record your employability skills 26 Chapter 2: Working to reduce the immediate risk of suicide and 27 increase safety 2.1 Building an empathic relationship with a person at risk Listening carefully and affirming and strengthening links to safety and living Developing and implementing an effective safety plan Managing intervention to reduce risk of harm to others Ensuring work meets legal, ethical and organisational requirements Addressing OHS obligations when managing yourself and others Referring to health professionals when appropriate 49 iii

2 CHCCS521A Assess and respond to individuals at risk of suicide Discussion topics 51 Chapter summary 52 Checklist for Chapter 2 52 Assessment activity 2: Working with the person to reduce immediate risk of 53 suicide and increase safety Record your employability skills 54 Chapter 3: Facilitating and strengthening a person s links to 55 further care 3.1 Enabling a person at risk to make informed choices about their suicidal 56 thoughts and need for ongoing care 3.2 Acknowledging how the current helping relationship provides the 59 foundations for further care 3.3 Exploring, understanding and addressing any barriers to seeking or 62 accepting help 3.4 Developing a plan and initial strategy with the person to access and 65 use supports Discussion topics 68 Chapter summary 68 Checklist for Chapter 3 69 Assessment activity 3: Facilitating and strengthening the person s links to 70 further care Record your employability skills 71 Chapter 4: Providing further intervention support to resource 73 the individual beyond immediate crisis 4.1 Maintaining rapport to discuss ongoing concerns and prioritising actions Affirming a person s decision to seek and accept help Reviewing how a person might seek help in the future to keep safe Supporting the individual to develop coping strategies Identifying and facilitating help for mental health concerns or 86 personal circumstances 4.6 Ensuring supports and coping strategies are documented and 89 communicated to the work team 4.7 Complying with laws, guidelines and policy requirements that affect 92 duty of care Discussion topics 97 Chapter summary 97 Checklist for Chapter 4 98 Assessment activity 4: Providing further intervention support to resource the 99 individual beyond immediate crisis Record your employability skills 100 iv

3 Before you begin Final assessment: CHCCS521A Assess and respond to 101 individuals at risk of suicide Employability skills 105 Glossary 106 v

4 Before you begin Competency standard The following table details the elements and performance criteria for this unit of competency. The second column shows where they are covered in this workbook. CHCCS521A Assess and respond to individuals at risk of suicide Element 1: Identify and assess the person s current suicide risk 1.1 Recognise and respond to signs, (such as statements, reactions, thoughts, feelings or behaviours) indicating that a person may be considering suicide 1.2 Attend to any hunches, while listening as a helper perhaps from indirect communications, that suggest the client may be considering suicide 1.3 Ask directly about thoughts of suicide whenever there are grounds for concern Where covered in this workbook Chapter 1: Identifying and assessing the person s current suicide risk 1.1 Recognising and responding to signs indicating that a person may be considering suicide 1.2 Attending to hunches that suggest the person may be considering suicide 1.3 Asking directly about thoughts of suicide when there are grounds for concern If suicide thoughts are present: 1.4 Seek sufficient understanding of why the person is considering suicide and what links them to life, to inform and facilitate the intervention 1.5 Assess current suicide risk guided by risk assessment considerations outlined in the Range Statement and by whether there is an imminent threat to the person s safety or the safety of others 1.6 Follow steps outlined in elements 2, 3 and Understanding why the person is considering suicide and identifying their links to life to facilitate the intervention 1.5 Assessing the current suicide risk and imminent threat to safety of the person or others Chapters 2, 3 and 4 If the person indicates s/he is not thinking of suicide and no suicidal intent, plans, or behaviour are evident: 1.7 Work collaboratively with the person to provide support and facilitate access to further care as needed guided by elements 3 and Remain vigilant about any emerging indications of suicidality, prompting careful risk assessment and safe management as outlined in elements 1 and 2 Chapters 3 and 4 Chapters 1 and 2 continued ix

5 CHCCS521A Assess and respond to individuals at risk of suicide 1.3 Asking directly about thoughts of suicide when there are grounds for concern When working with someone who may be at risk of suicide it is important to ask direct questions about their intentions. If workers have any concerns about their clients safety they must act on these concerns. Cause for concern may include the client presenting with a number of warning signs as discussed previously. Any indication that a person is thinking of suicide or acts of self-harm should be taken seriously. People may also fall into a higher risk category of suicide if they: are in physical pain or have health concerns are socially isolated have a drug or alcohol problem live in an isolated rural area or are socially isolated are male have financial or legal problems have marriage or family problems have lost their job or experienced some other major loss or traumatic event. Direct questions you may ask include: Are you thinking of killing yourself? Are you planning to harm yourself? If the person indicates that they are thinking about taking their own life, you must ask some further questions. The two most important risk factors associated with suicide are whether the individual has a current plan and whether they have made previous attempts at suicide. You will need to find out: if the person has a plan about how they will kill themselves if they have the means to carry out their plan; for example, if they plan to shoot themselves, do they actually have a gun and know how to use it? if the plan or means are lethal; for example, if they plan to slash their wrists they may not actually die from this, whereas if they shoot or hang themselves they most likely will if they have attempted to suicide before, and how they attempted it if the plans are immediate or for some time in the future. Taking people s suicidal ideation seriously If a person suggests in any way that they have thought about suicide, engaged in deliberate self-harm or have made a plan to carry out suicide that appears to be dangerous or lethal, they must be believed and assisted to obtain help. All of these actions indicate that the client is in severe emotional distress and cannot see a way out of their predicament. You will need to talk about the situation openly with the person, assess the level of risk they are experiencing and discuss with them ways they can obtain help. People who are at risk of suicide should not be left alone or told that they will be okay tomorrow. 12

6 Chapter 2: Working to reduce the immediate risk of suicide and increase safety Chapter 2 Working to reduce the immediate risk of suicide and increase safety In order to help a person at risk of suicide, you must be able to establish rapport with them, listen to their concerns and work with them to ensure their immediate safety. The focus of the intervention at this stage is to deal with the presenting or immediate concerns rather than longer term underlying problems. Your intervention should focus on reducing the immediate risk the person faces and ensuring that others are safe. You should also make sure that you adhere to organisational practices, legal and ethical guidelines and duty-of-care principles relevant to suicide intervention practice. If you are in doubt about what to do, you should seek advice from your supervisor or manager. In this chapter you will learn about: 2.1 Building an empathic relationship with a person at risk 2.2 Listening carefully and affirming and strengthening links to safety and living 2.3 Developing and implementing an effective safety plan 2.4 Managing intervention to reduce risk of harm to others 2.5 Ensuring work meets legal, ethical and organisational requirements 2.6 Addressing OHS obligations when managing yourself and others 2.7 Referring to health professionals when appropriate 27

7 Chapter 2: Working to reduce the immediate risk of suicide and increase safety 2.2 Listening carefully and affirming and strengthening links to safety and living Workers must explore the reasons why a person might be considering suicide and what reasons they may have for continuing to live. It is only when a person has fully expressed their feelings for both living and dying that they can begin to focus clearly on the need to develop a plan to stay safe. Attending to client pain and working towards safe outcomes Once a person has admitted that they have had thoughts of ending their own life and a degree of risk is established, workers should encourage the individual to talk about their sources of pain and thoughts of suicide. The process of talking through these issues and having someone listen often helps to restore a sense of rationality and equilibrium to the person s thinking. You can help someone to talk about their pain by: showing concern for the person s wellbeing listening attentively encouraging the person to talk by offering encouragers such as I see, Go on and asking for clarification when you are not sure what they mean; for example, by saying, Do you mean... being non-judgmental avoiding giving advice. Listening, showing empathy and being non-judgmental are important traits to have when helping a person at risk of suicide. Throughout the intervention, you should try to convey to the person that you accept, value and genuinely care about them. Someone considering suicide often feels very alone and feels that no-one cares whether they live or die. Having another person listen attentively to them and acknowledge their feelings of despair and hopelessness can help them see that they are not alone and that there is hope. 31

8 Chapter 2: Working to reduce the immediate risk of suicide and increase safety is having a psychotic episode has planned a murder-suicide is under the influence of drugs and alcohol is involved in custody issues and has planned to harm children. Seeking police intervention If it is apparent that the person at risk is mentally ill and has made threats of harming themselves or others, workers should call the police to protect both the client and the other people involved. Each state and territory in Australia has its own mental health Act. In most cases these Acts allow the police to take a person involuntarily for treatment if they are deemed to be mentally ill and at risk of harming themselves or someone else. In cases where a person is not obviously mentally ill and is considering suicide but has not actually attempted suicide, the role of the police is less clear. The following example describes a case that illustrates the limitation of police powers in terms of intervening in a situation where someone was clearly considering suicide but not mentally ill. Example A recent case in the High Court considered the role of the police intervening in possible suicide attempts where the person at risk was not deemed to be mentally ill. Two Victorian police officers found a man parked in his car with a hose attached to the exhaust of his car and going through the car window. At the time they approached the man he was writing a note and the car windows were down. They talked to the man for about 15 minutes. He admitted that he had been about to do something stupid but assured them that he was now okay and would go to see his doctor that day. The police officers were aware that under Section 10 of the Mental Health Act 1986 (Vic.) that they could require the man to go to hospital for treatment if he appeared to be mentally ill and was at risk of harming himself or others. They decided he was not mentally ill and left him. Later that day the man was found dead by suicide. Six judges of the High Court found unanimously that the police officers did not owe a duty of care under the Mental Health Act because the man was not suffering from a mental illness and he was not in the act of attempting suicide at the time they found him. You can read more about this case at the ABC Radio National website: lawreport/stories/2009/ htm Practice task 9 This is a self-reflection exercise. Write down in your journal how you would feel about walking into an environment where someone is threatening to harm themselves and other family members. What steps could you take to keep yourself calm? 39

9 Chapter 2: Working to reduce the immediate risk of suicide and increase safety Assessment activity 2 Working with the person to reduce the immediate risk of suicide and increase safety The following table maps the assessment activity for this chapter against the element and performance criteria of Element 2 in CHCCS521A Assess and respond to individuals at risk of suicide. The activity has been designed for all learners to complete. Part Element Performance criteria A 1, 2 1.6, 1.8, 2.1, 2.2, 2.4, 2.5, 2.6 B 1, 2 1.6, 2.3, 2.7 Part A What could a worker do to build a collaborative and empathetic relationship with a person that affirms and builds on a desire for safety? What could a worker do to help a person at risk deal with their pain and affirm and strengthen their links to safety and living? How might a worker intervene to deal with a possible risk to themselves, families and friends in a crisis situation? In what situations might a worker need to seek advice from a supervisor when managing a crisis situation? How can workers address occupational health and safety obligations in relation to themselves and others? Part B Read the case study, then answer the questions that follow. Case study Gina is visiting her client Jason and notices that he does not seem quite himself. She asks him how he is feeling and what is going on with his life. At first he is reluctant to say much but gradually tells her he has been having trouble sleeping, feels depressed all the time and has lost interest in all his usual activities and friends. He says life just seems so pointless and boring that he can t even see the point of continuing to live. Jason has a physical disability but does not seem to engage with any health professionals on a regular basis. He has a history of drug abuse, which he is attempting to overcome on his own. Gina asks Jason directly if he has been considering suicide. He says yes, that he has thought about it quite a bit. Gina engages Jason in further discussion about his thoughts of suicide in order to determine his level of risk. Jason admits he is ambivalent about taking his own life and that he does have some reasons for living; for example, he would really miss his dog and some of his friends, and he really thinks he could make it as an artist if he really tried. 53

10 Chapter 4: Providing further intervention support to resource the individual beyond immediate... continued Communication skill Open and closed questions Paraphrasing Reflection of feeling Summarising Nonverbal communication Description Open questions require the person to give more than a yes or no answer; for example, When was the last time you were having thoughts of suicide and how you were feeling at that time? Open questions are useful for gathering information. Closed questions can be answered with a yes or no; for example, Have you thought about suicide before? Closed questions are useful for obtaining a brief, direct answer that can lead to further questions. Paraphrasing involves restating what the speaker has said in order to confirm that you understand what they mean. Paraphrasing can also be used to draw attention to a particular concern; for example, So you are saying that you only think about suicide when you are alone late at night. Reflecting a person s feelings helps them to get in touch with how they feel and examine their feelings; for example, You seem both sad and angry at the moment. Summarising involves focusing on the main points of what a person has said over a period of time in order to draw attention to these points and check understanding. It is a longer version of paraphrasing. Workers must ensure that their body language is consistent with their verbal communication as a client may be confused by mixed messages. Workers must be aware of their facial expressions, how their body is positioned, their proximity to the person, their hand and arm movements and their level of eye contact. Discussing and prioritising concerns Workers must ask questions, use active listening skills and maintain rapport with the person in order to encourage them to discuss their ongoing concerns. It is important that the worker establishes what the person most needs help with now, so they can work with them to establish priorities for dealing with the concerns that pose the most risk. Workers should ask them directly about what causes them the most problems or what issue they have the most difficulty dealing with. If the person says that they are okay except when they can t sleep late at night, as they start to have suicidal thoughts and there is no-one around to talk to, the worker should discuss ways to deal with this situation which, depending on the person s circumstance may include: seeing a doctor as soon as possible to discuss suitable medication or other strategies for getting to sleep using a range of coping strategies such as having a warm bath, accessing an Internet counselling site for people at risk of suicide, putting on some favourite music or watching a favourite DVD ringing a friend or relative who is willing to support the person at any hour ringing a 24-hour crisis or suicide hotline. 75

11 CHCCS521A Assess and respond to individuals at risk of suicide Workers have a responsibility to ensure that they accurately report and document the plans that they have developed in collaboration with the person they are helping. These plans include those related to ongoing client safety, identified supports and coping strategies. Communicating this information helps ensure that all staff involved in a case are kept up to date and have an accurate record of what plans the person has in place. Laws, policies and ethical guidelines impact on how you carry out your work and how you meet your duty-of-care obligations. In order to work effectively and within the law, you must have a broad knowledge of the legal framework that operates within the community services sector, and how it affects work practices including duty of care. Checklist for Chapter 4 Tick the box when you can do the following. Maintain rapport to discuss ongoing concerns and prioritise actions Affirm a person s decision to seek and accept help Review how a person might seek help in the future to keep safe Support the individual to develop coping strategies Identify and facilitate help for mental health concerns or personal circumstances Ensure supports and coping strategies are documented and communicated to the work team Comply with laws, guidelines and policy requirements that affect duty of care 98