An Introduction to Suicide Assessment and Intervention

James D. Raper, PhD, LPCSAssociate Director

Wake Forest University Counseling CenterOctober 14, 2013

Getting Started Impact of working with suicidal and potentially

suicidal clients Increased anxiety Ethical implications

What are your goals for today? What do you want to know? What questions do you have? …fears? Other?

Three Pillars of Competent Practice(Jobes & Berman, 1993)

1. Foreseeability- Assessment and documentation of risk

2. Treatment Planning- Documentation of plan based on determined risk

3. Follow-up/Follow Through- Documentation of executing and following plan

U.S. Suicide: 2010 Official Final Data

Deaths by suicide Nation: 38,364 (12.4/100,000) Males: 30,277 (20.0/100,000) White Males: 27, 422 (22.6/100,000) Non-White Males: 2,855 (9.4/100,000) Black Males: 1,755 (8.7/100,000)

Females: 8,087 (5.2/100,000) White Females: 7,268 (5.9/100,000) Non-White Females: 819 (2.5/100,000)

U.S. Suicide Attempts2010 Estimates

Approximately 922,725 suicide attempts annually~25 attempts for every death by suicide

100-200:1 for young 4:1 elderly

3:1 Female to Male attempt ratio

U.S. Suicide Means2010 Final Data

Firearms: 50.8%All Other: 49.2%

Suffocation/Hanging: 24.4% Poisoning: 17.3% Cut/pierce: 1.8% Drowning: 1.1%

Clinician BeliefsBeliefs Continuum1. Suicide is wrong, does violence to the dignity of life2. Sometimes permissible, when alt. is unbearable3. Neutral: not a moral/ethical issue4. A positive response to certain conditions: person has the

innate right to make any decision, provided it is based on rational and logical thinking, including suicide.

5. Has intrinsic positive value: way in which one can be immediately reunited with valued ancestors.

Risk Factors vs. Warning Signs

Risk Factors Sex Age Race Marital status Diagnosis Prior suicide

attempts Family history Unemployment Firearms

Warning Signs• Current substance abuse• Agitation• Anxiety/panic attacks• Social withdrawal• Insomnia• Purposelessness• Plans/preparations• Desperation• Flight into health

Assessment of Suicidal Thoughts Normalize a certain level of ideation

Gentle assumption: “When did you last think about suicide/killing yourself/ending your life?”

Frequency Duration Intensity/Severity

Assessment of Suicidal Plans

Specificity Lethality – How dangerous are their means? Availability Proximity of Social Support

Interviewing for Suicidal Intent History of previous attempts? Severity?

*History of attempt is greatest predictor of a completed suicide*

What are clt’s reasons for living? (children, religion, etc)Clt’s reasons for dying? (list and rank both)“What has stopped your thus far?”What does intuition tell you? (This is why addressing your own anxiety is important, so that you can clearly listen to your intuition.)

Clinical Interventions“No Suicide Contracts” (Hmmmmm)

Siding with life

Solution-focused approach: “When there have been times when you weren’t

thinking about killing yourself – what was different?”

Clinical Interventions (cont.)Decrease clt’s sense of isolationExternalize suicidality from clt: “this is something that you’re really wrestling with.”Align yourself with client/teamwork: “Lets try and figure this out together.”Speak slowly and clearly, repeating the key, important messages

Clinical Interventions (cont.)

Widen clt’s “blinders” Identify all options, including suicide.Clts can feel relieved to talk about suicideValidate that suicide is one option available to them (just not a healthy one)Reasons for dying vs. reasons for livingConsider other possibilitiesWho is clt committing suicide at?Have clt rate where suicide is on the new list

Still #1, then seriously consider hospitalization

Evaluating Protective FactorsWhat internal coping skills and external supports does client have available to her/him that will help them stay alive?

Desire to live Connection with family and/or friends; pets Connection with faith Engagement in therapy Awareness of how a completed suicide would affect others, and

desire to not have that happen.

Crisis Response/Safety PlanBrainstorm list of healthy coping responsesExplore process of contacting appropriate resources, “what would that be like for you to ask for help if you were feeling unsafe?”

Role play with clt. (Imagine how hard it may be for many clt’s to disclose this info)

3x5 note card of ways in which clt will respond to SI.Be wary of “no-suicide contracts”.

Consultation and SupervisionDo I need to seek consultation before the client leaves?Do I need/want to seek supervision after the session and/or before the next session with this client?

How am I feeling about this? What are my specific concerns for my client? What are my concerns about myself?

Am I ready/able to see my next client? What can I do to help re-center myself?

Documentation Discussed limits of confidentiality Relevant client history Previous records Asked directly about suicidal thoughts/impulses

Specifics of thoughts (FDI); Plans (SLAP)

Documentation (cont.) Consulted (as needed) Staged Client (see below), naming relevant risk and

protective factorsImplemented appropriate suicide interventionsProvided resourcesWhat is the plan for clt for next 24/12/1 hour?

Documentation: Suicide Staging

Criteria

Stage I: Low Risk

No thought pattern of suicide or self-harm Fleeting/existential thoughts about death may be

present with no significant risk factors.

Stage II (Mild) No verbal expressions of intent for suicide or self-

harm unless asked May vigorously deny suicidal thoughts or admits to

intermittent/passing thoughts of death with spontaneous assurance to the evaluator that no attempt will be made

Feeling overwhelmed with crisis, feels hopeless for change

May exhibit somatic complaints

Stage II (Mild) (cont.) Feeling depressed, “the blues” Feelings of rejection or disappointment Support system is available Expresses options (other than suicide) to solve

problems Will make a Safety Plan, usually does so

spontaneously

Stage III (Moderate)

Hesitates when asked if suicidal ideation is present Makes joking or off-hand statements about suicide May have a diagnosis of a chronic or terminal

illness, including chronic emotional illness Thoughts of suicide but nonspecific plan

Stage III (Moderate) (cont.) Suicidal ideation is present and includes: Listlessness, tiredness, depression, neurovegetative

signs Thoughts of wanting to go to sleep and never waking

up, being a burden to others Accident proneness Alcohol/Drug abuse Support system not utilized, significant others/family

not aware of depression

Stage III (Moderate) (cont.)Spiritual thoughts a deterrent to self-harmCan think of options other than suicide to solve problems but sees “not being here” as an optionAgrees to Safety Plan, which includes going to emergency center/calling support if the impulse for self harm becomes strong

Stage IV (Advanced/Severe) Admits to thoughts of deathPlans a suicide attempt and selects a method/weapon (lethality of method: Advanced → Severe)May actually attempt suicide or self-harmSuicidal ideation is present and includes:

Feelings of hopelessness, depression

Stage IV (Advanced/Severe) (cont.) “It will never get better”; “the pain of living is too

much to bear” Thoughts of wanting to “get it over with” Gives needed things away, makes a will, checks

insurance policy Writes letters of goodbye May have history of unsuccessful attempt(s) May disclose suicide plan to therapist

Stage IV (Advanced/Severe) (cont.)No support system, perceives self as a great burden to othersHas rationalized spiritual ideology to encompass a justification of planned actionsCan think of no other option other than suicideHesitant to make a Safety Plan