Principles of Assessing and Treatment of Suicide

Transcription

1 Principles of Assessing and Treatment of Suicide Pamela K. Greene PhD, RN Chief Nursing Officer and Senior Vice President of Patient Care Services 7 Categories A. Working with Individuals at Risk for Suicide: Attitudes & Approach B. Understanding Suicide C. Collecting Accurate Assessment Information D. Formulating Risk E. Developing a Treatment & Service Plan F. Managing Care G. Understanding Legal & Regulatory Issues A. Working with Individuals at Risk for Suicide: Attitudes & Approach 1.Mange one s own reactions to suicide. 2.Reconcile the difference (and potential conflict) between the clinician s goal to prevent suicide and the patient s goal to eliminate psychological pain via suicidal behavior. 3.Maintain a collaborative, non-adversarial stance. 4.Make a realistic assessment of one s ability.

2 B. Understanding Suicide 5. Define the basic terms related to suicide. 6. Be familiar with suicide-related statistics. 7. Describe the phenomenology of suicide. 8. Demonstrate understanding of risk and protective factors. C. Collecting Accurate (thorough) Assessment Information 9. Integrate a risk assessment early 10. Elicit risk and protective factors 11. Elicit suicide ideation, behavior, plans 12. Elicit warning signs of imminent risk 13. Obtain records and information from collateral sources D. Formulating Risk 14. Make a clinical judgment of the risk that a client will attempt or complete suicide in the short and long term. 15. Write the judgment and the rationale in the client s record.

3 E. Developing a Treatment and Services Plan 16. Collaboratively develop an emergency plan that assures safety and conveys the message that the client s safety is not negotiable. 17. Develop a written treatment and services plan that addresses the client s immediate, acute, and continuing suicide ideation and risk for suicidal behavior. 18. Coordinate and work collaboratively with other treatment and services providers in an interdisciplinary team approach. F. Managing Care 19. Develop policies and procedures for following clients closely including taking reasonable steps to be proactive. 20. Follow principles of crisis management. 21. Document the following items related to suicidality: informed consent, information that was collected from a bio-psycho-social perspective, formulation of risk and rationale, treatment plan, well described and shown to be followed, consultation with professional colleagues. G. Understanding Legal and Regulatory Issues Related to Suicidality 22. Understand state laws pertaining to suicide. 23. Understand legal challenges that are difficult to defend against as a result of poor or incomplete documentation. 24. Protect client records and rights to privacy and confidentiality following the health Insurance Portability and Accountability Act of 1996 that went into effect April 15, 2003.

4 Interpersonal-Psychological Theory Desire for Death by Suicide Lack of Connectedness Perceived Burdensomeness Capability Lethal Joiner & Van Orden Mental Status Exam The Mental Status Exam is an essential part of the evaluation, formulation of risk, particularly where there may be a subtle hint of a thought disorder or cognitive impairment.

5 Therapeutic Relationship Comfort & Trust Simplicity Other.. 5 Things that Save Lives 1. Easy to understand treatment model 2. Focus on treatment compliance 3. Focus on skills building 4. Taking personal responsibility 5. Easy access to treatment and crisis services 1. Easy to Understand Identifying developmental history: Early skill development/deficiencies related to current functioning Susceptibility expressed through triggering Three targets Thoughts (and core beliefs) Motivation for dying Feelings (physiological/emotional) Behavior (increasing adaptive)

6 Skill Sets That Don t Work in Adulthood Avoidance Cognitive Behavioral Link to Development Emotional Passive-aggressive behavior Submissive behavior Aggression Why do we clinicians like complex models? Challenge? Countertransference Relationship to hope, compliance and recovery 2. Focus on Treatment Compliance (Alliance) Use specific interventions/techniques that target increasing motivation and collaboration Clarity about what to do if nonadherence becomes an issue

7 3. Focus on Skills-building Identify skills deficits with the opportunity to build and practice Emotional Regulation Interpersonal Clarification of what is wrong and what to do about it Emotional Regulation Relaxation Mindfulness Reasons for Living list Survival kit (includes reason for living) Sleep hygiene Recognize the role of shame/guilt/grief 4. Taking Personal Responsibility Emphasis on patient/client self-reliance & self-management Commitment to treatment Crisis management/safety plan

8 What does this involve? Define a commitment to Living Treatment & care Incorporates a crisis management or response plan Specifically identifies responsibilites Patient/client Clinician Crisis Response Plan: Must be in writing Must be simple Self- soothing Strategies/Distracters Integration of an External Support System Identification of healthy support resources Role play how to access PRACTICE Emergency numbers Means Restriction use of receipt 5. Easy access to treatment and crisis services Clear plan of action for emergencies Crisis response plan (and recognize when to us it) Dediation of time to practicing skills necessary to identify true crisis, using crisis response plan, and using external support services

9 PRACTICE PRACTICE PRACTICE When I find myself making plans to suicide, I agree to do the following: 1. Use my survival kit. 2. Review my treatment journal 3. Do things that help me feel better for about 30 minutes, including taking a bath, listening to music, and going for a walk 4. If the thoughts continue, get specific, and I find myself preparing to do something, I call the emergency number XXX-XXXX 5. If I m still feeling suicidal and don t feel like I can control my behavior, I go to the emergency room Creating a Survival (Hope) Kit Include items that generate productive, hopeful thoughts & feelings Review items individually Practice the use of the Survival Kit Review each item Ask the patient/client to describe What are they thinking? What are they feeling? What facilitates HOPE? Expectations are facilitated by making: the implicit explicit the complex simple The confusing understandable The inaccessible available Being flexible, all of these interventions are fluid as the patient and thus treatment changes, so will expectations.

10 Checklists The use of checklists Airlines Healthcare (Surgery) The utility of checklists Complex tasks Memory Attention Making the Complex Simple Engage Build a relationship Evaluate Assess Risk Educate Provide a foundation for treatment Equip Crisis management/safety planning References American Association of Suicidology (AAS) Jobes, D. (2006). Managing Suicidal Risk: A Collaborative Approach. Joiner, T. (2009). The Interpersonal Theory of Suicide: Guidance for Working with Suicidal Clients. M.D. David Rudd, (2013). A Think Tank Conversation: Knowing What Works and What Doesn t in the Treatment of Suicide. 46 th Annual Conference American Association of Suicidology M.D. Rudd, (2006). The Assessment and Management of Suicidality. Shea, S. (2002). The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors. Shneidman, E. (1993). Suicide as Psychache: A Clinical Approach to Self- Destructive Behavior. Suicide Prevention Resource Center (SPRC) Contact information: Pam Greene: pgreene@menninger.edu