Addressing Suicide in Your Practice
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Addressing Suicide in Your Practice Gary McConahay PhD ColumbiaCare Services, Inc. [email protected] rg
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Addressing Suicide in Your Practice. Gary McConahay PhD ColumbiaCare Services, Inc. [email protected]. Expanding opportunities for doing therapy with people with suicide thoughts. -National Strategy for SP -Affordable Care Act -OHP Expansion - PowerPoint PPT Presentation
Transcript of Addressing Suicide in Your Practice
Expanding opportunities for doing therapy with people with suicide thoughts
-National Strategy for SP-Affordable Care Act-OHP Expansion-Screening for Depression in Primary Care-Follow up after psychiatric hospitalization
•What is your experience?
•What are your worst fears?
Stone…1971
• Many therapists unwittingly contribute to the probability of Suicide attempts in ‘suicide-prone’ patients by:– “Externalizing the superego” by mirroring the
patient’s self-revilings– “Interrupting autistic defenses” by removing wish-
fulfilling fantasies leading to confrontation of unbearable reality
– Developing a “symbiotic transference”of an extremely primitive nature that is then broken off
Chemtob et al…1989
• Survey says that 22% of psychologists and 51% of psychiatrists had experienced a patient suicide.
• “Both groups reported significant disruptions in their personal and professional lives after the patient’s suicide”.
• “We argue that patient suicide is an occupational hazard for psychologists and psychiatrists”
Hendin et al…2000
• In depth testing and interview with 26 therapists who had lost a patient to suicide
• Shock, grief, guilt, fear of blame, self-doubt, shame, anger, and betrayal were major reactions
• 21 out of 26 said they would change tx decision: change medication, hospitalize, consult with previous therapist
• 19 said they met with family afterwards: almost all were not critical of the therapist
Hendin et al…2004
• Questioned 34 therapists whose patients died by suicide
• 13 of 34 “severely distressed” by the suicide• Sources of distress:– Failure to hospitalize– Tx decision therapist felt contributed to the suicide– Negative reactions from the therapist’s institution– Fear of a lawsuit by patient’s family
Yaseen et al…2013
• Compared 82 therapists who had a patient die by suicide, had a high or low lethality attempt, or die by natural causes regarding how they felt about the patient last visit before they did their act.
• Therapists treating imminently suicidal patients had less positive feelings toward their patient but more hopeful for treatment than those treating non-suicidal patients
• Felt more overwhelmed, distressed by, and avoidant of suicidal patients
1. Maintain appropriate clinician-patient relationships
2. Evaluate risk: intake and ongoing (e.g. management transitions)
3. Take adequate history, including records of past treatment
4. Examine mental status5. Diagnose6. Plan Treatment
Outpatient standards of careBongar 1992
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7. Specify hospitalization criteria8. Obtain consultation & supervision9. Properly evaluate need for pharmacological
intervention10.Properly evaluate suitability of
pharmacotherapy provided11.Safeguard the environment12.Document, Document, Document
Outpatient standards of care (cont)
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How close to suicide is my patient?
*Get some perspective; not all suicide thoughts mean the same thing
*Makes a difference in approach
Let’s break it down…
• Prevent Death• Address External Factors that contribute to
suicide thoughts• Change Internal Factors that foster suicide
thoughts• Change Internal Dynamics that predispose the
person to suicide thoughts
Let’s break it down…
• INTERVENTION: Prevent Death• MANAGEMENT: – Address External Factors that contribute to suicide
thoughts– Change Internal Factors that foster suicide
thoughts• TREATMENT: Change Internal Dynamics that
predispose the person to suicide thoughts
Intervention
• Unless the person has a suicide in progress you have time to talk
• As long as the person is talking to you they are safe• Ask directly about suicide• As the conversation progresses, the person feels relieved• As the person feels relieved of pain and they feel hope• When the person feels hope they are less likely to
suicide• Ambivalence
Intervention 2
• Develop a plan to keep the person safe
• That may involve you and it will likely involve others…working together
• Go for plans that last hours or days, not weeks
Risks and Benefits of Hospitalization
+May keep person safe for now+Relieves the therapist’s feeling of responsibility
-Stigma, Cost-Hospital stay itself usually changes nothing-Post-hospital discharge period very vulnerable time-May damage therapeutic relationship-Where does the person go for help afterwards?
Intervention 3
• Take: Applied Suicide Intervention Skills Training
(ASIST)
www.columbiacare.org/ASIST
Management
• Reasons for dying
Management
• Reasons for Dying can be external or internal
• Every reason for dying has embedded within it a reason for living
• It is not the event itself but the meaning behind the event
• The key meaning is LOSS
ManagementWhen a person is talking about their reasons for dying they are talking their losses.
When a person is talking about their losses, they are talking about what they care about (if they did not care about it, it would not be a loss).
When a person is talking to us about what they care about, they are telling us their reasons for living.
Therefore, the more reasons for dying we can identify within a person at risk of suicide the more we learn about their reasons for living.
Formal resources Link Coordinate Monitor Advocate
Instrumental Support Practical information Direct support
counseling Attract to help-accepting Empower ➔ Participate Motivate Enable (restore/mobilize)
coping
Informal resources Access Establish Mobilize Person in environment
ManagementBryan Tanney MD, SuicideCare, 2012
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Assumption:
Structural and developmental deficits may underlie the suicidal condition.
Treatment
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Meanings of suicidal actsBryan Tanney MD, SuicideCare, 2012
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Strategies Repair or support a deficit state,
whether structural or developmental Resolve a focal conflict through
enhanced insight Integrate unhealthy attachment
patterns by attending to the treatment relationship
Develop skills to support deficit states and overcome maladaptive coping styles
Treatment
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Additional resourcesOregon Youth Suicide Prevention [email protected]
Oregon Suicide Prevention Coordinator-Donna Noonan [email protected]
Clinician Survivor’s [email protected]
Additional Training
• ASIST (for intervention)
• Suicide to Hope (management and treatment)
Gary McConahay [email protected]
