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Telephonic Assessment of Suicidal Ideation Paradigm Brent L. Halderman, Ph.D. James R. Eyman, Ph.D....
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Transcript of Telephonic Assessment of Suicidal Ideation Paradigm Brent L. Halderman, Ph.D. James R. Eyman, Ph.D....
Telephonic Assessment of Suicidal Telephonic Assessment of Suicidal Ideation ParadigmIdeation Paradigm
Brent L. Halderman, Ph.D.James R. Eyman, Ph.D.Sheryl Feutz-Harter, J.D., MSN, CHC
Nashville, TNOctober 7, 2006
This presentation is proprietary and cannot be duplicated, used, or adapted without NDBH permission. For permission, contact: [email protected]
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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Telephonic Assessment of Suicide Telephonic Assessment of Suicide Paradigm Paradigm
Stage 3Recommendations
Stage 2Working
Relationship
Stage 1Suicide Potential
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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Stage 1Stage 1Evaluation of Suicide Risk General Risk Evaluation of Suicide Risk General Risk FactorsFactors Sex Age Marital Status Losses Social Support Medical Illness Alcoholism Affective Disorder Anxiety Disorder Schizophrenia Eating Disorder Borderline Personality Disorder
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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Stage 1Stage 1Specific Risk Factors for SuicideSpecific Risk Factors for Suicide
Anxiety Ruminations Depression with Delusions Hopelessness Global Insomnia Recent Alcohol Use
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Stage 1Stage 1Assessing Suicidal IdeationAssessing Suicidal Ideation
How do you feel now? Ever feel so bad that you wish you were dead? Ask directly about suicidal ideation
Why suicidal? What precipitating event?
Suicidal ideation is on a continuum
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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Stage 1Stage 1Preparation to End LifePreparation to End Life
Usually have more than one plan Note how the person talks about suicidal
ideation and plan Well thought out and developed plans will more
likely succeed Perception of the lethality of the method Availability of the method Efforts to thwart rescue
Suicidal behavior is on a continuum.
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Stage 1Stage 1Past Suicide AttemptsPast Suicide Attempts
How close have you come to killing yourself? Suicide risk increases with escalating
seriousness of past attempts History
External circumstances Internal circumstances
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Stage 1Stage 1Available SupportAvailable Support
Degree of attachment Family crisis Psychological resources
Family Friends Self
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Stage 1Stage 1Meaning of Life and DeathMeaning of Life and Death
Gain from suicide What will happen after you die?
Protective Factors What has kept you alive?
Responsibility to family Fear of act of suicide Fear of social disapproval Religious beliefs
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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Stage 1Stage 1Obtain Information from Other Obtain Information from Other SourcesSources
Family Friends Co-workers
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Stage 1Stage 1Contracts to Prevent Suicide Contracts to Prevent Suicide
Used by 50 percent of all clinicians All three stages involve a form of no suicide
contract No research evidence 1973 American Journal of Psychiatry
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Stage 1Stage 1Shifting from Higher to Lower Shifting from Higher to Lower Suicide RiskSuicide Risk
Convincing? Will it stand up under scrutiny? Consultation
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Stage 1- Desktop ProcedureStage 1- Desktop ProcedureAssessment of Mental Status & Psychological State of Assessment of Mental Status & Psychological State of Suicidal IdeationSuicidal Ideation
Minimum criteria for safety to move to Stage 2 Plan – Yes Intent – No Contract – Yes
Meets criteria? Go to Stage 2 If above criteria not met, can caller shift to
criteria during the call? If criteria cannot be met, implement appropriate
recommendations from Stage 3
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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Stage 2Stage 2ConsiderationsConsiderations
Therapeutic alliance Ambivalence Evaluate from all gathered information Impact of understanding dangers of misleading
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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Stage 2 Stage 2 Factors Interfering with AllianceFactors Interfering with Alliance
Cognitive Psychosis Delusions Alcohol – Drugs Intelligence, brain impairment Decision to die
Emotional Difficulty containing feelings Impulsivity Paranoia
If unable to form an alliance reevaluate information from Stage 1.
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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Stage 2 – Desktop ProcedureStage 2 – Desktop ProcedureDoes Caller Understand Danger of Misleading the Does Caller Understand Danger of Misleading the Clinician?Clinician?
Ask directly Glean from what has been said Using drugs/alcohol? Cognitive functioning (limited, age) Psychological functioning (e.g., Personality
Disorder)
If caller does not understand danger of misleading clinician, re-assess Stage 1 and make appropriate recommendations
from Stage 3.
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Stage 3 Stage 3 Caller’s Role in the Recommendation Caller’s Role in the Recommendation ProcessProcess
Callers must agree to clinically appropriate recommendations
Plan to negotiate to find a recommendation that caller will follow
If caller does not follow recommendations, reassess Stages 1 and 2 and make appropriate recommendations.
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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Stage 3 Stage 3 The Clinician’s ResponsibilityThe Clinician’s Responsibility
Plan that is appropriate for risk Patient safety
Moderate to severe suicide risk, take appropriate action Make appointment and involve family or friends to promote
follow-through Follow-up with referral source
The clinician’s goals Create a reasonable and justifiable referral/intervention plan Transfer to treating clinician
Close the loop.
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Stage 3 – Desktop ProcedureStage 3 – Desktop ProcedureRecommendationsRecommendations Can caller follow recommendations? If not, how can plan be modified?
Partial hospital/IOP Warm transfer to therapist, PCP, psychiatrist, insurance Advise parents of safety precautions Prevention call Talk with Family/supervisor Remove dangers (guns, pills) Follow-up allowed Someone accompany to appointment Someone stay with caller or go to friend/family NDBH & ER 24/7 availability and number Emergency room Inpatient Emergency appointment
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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Stage 3 – Desktop ProcedureStage 3 – Desktop ProcedureRecommendations Recommendations continuedcontinued
Ascertain follow-through Provide clinical to ER and/or providers Ask for confirmation patient was seen
Provide concrete help Offer to call ambulance/transportation Inquire whether family member/friend/supervisor feels safe
transporting patient to facility Wellness check
Advise caller of the need to call police for wellness check Communicate clinical information/urgency to authorities Advise authorities of need for clinical assessment Duty to warn Other
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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Resist Seduction Of Going Along With Resist Seduction Of Going Along With Callers Plan When Not AppropriateCallers Plan When Not Appropriate
Why we get seduced Don’t want to make caller/company mad Hope it will turn out OK Want to help We can fix anything Lack of information (shift change) Second hand knowledge
You are the Clinician.Callers need to follow your plan.
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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When Stage 3 Cannot be MetWhen Stage 3 Cannot be Met
Reassess responses in Stages 1 and 2 Clinical consultation Supervisory consultation Legal consultation
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Legal RisksLegal Risks
ELEMENTS OF LIABILITY Duty Breach of Duty/Malpractice Causation of Injury Damages
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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How to Establish Standards of How to Establish Standards of CareCare
Legal definition: “The level of conduct expect of a similar healthcare professional acting under the same or similar circumstances.”
Laws and court decisions
Professional association standards
Professional journals and research studies
Facility policies/guidelines
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Standards of Care IssuesStandards of Care Issues
Assessment Performance of Documentation
Referral/Intervention Plan Rationale Time Frames Modifications
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Standards of Care IssuesStandards of Care Issues
Informed decision making By Client/Caller Capacity to consent
Actions taken Review prior health information Communications Wellness Checks
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Lessons LearnedLessons LearnedDevelopment of this Paradigm Development of this Paradigm
Right decision – wrong result Don’t wait and hope caller will make good
choices Increase our direction earlier in process Help caller make good decisions Help caller to “walk the walk” All three stages of paradigm must be achieved
Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.
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Evaluation of Paradigm Evaluation of Paradigm EffectivenessEffectiveness
Vast majority of callers are grateful for direction No complaints Positive satisfaction surveys
Most important – no adverse outcomes
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EAP Data EAP Data Evaluation of Paradigm Evaluation of Paradigm EffectivenessEffectiveness
6.58%
3.80%
0.50%
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
2002 2003 2004
Rate of Wellness Checks
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Evaluation of Paradigm EffectivenessEvaluation of Paradigm Effectiveness
Overall reduction in wellness checks 92.48% (p≤.001)
62.3% increase in calls voicing suicidal ideation from 2002 to 2004
2005 – 2 wellness checks for the same 6 month period
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MMH Emergent Data MMH Emergent Data Evaluation of Paradigm Evaluation of Paradigm Effectiveness Effectiveness
34.0%
18.4%
13.8%
0%
5%
10%
15%
20%
25%
30%
35%
2004 2005 2006TD
Rate of Wellness Checks
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Evaluation - Evaluation - ContinuedContinued
Recent application of paradigm for MMH Call Center
Reduction in emergent wellness checks of 59% comparing 2004 with 2006TD
Telephonic Assessment of Suicidal Telephonic Assessment of Suicidal Ideation ParadigmIdeation Paradigm
Brent L. Halderman, Ph.D.James R. Eyman, Ph.D.Sheryl Feutz-Harter, J.D., MSN, CHC
Nashville, TNOctober 7, 2006
This presentation is proprietary and cannot be duplicated, used, or adapted without NDBH permission. For permission, contact: [email protected]