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Risk for Self-Harm

Assessment and management of suicide risk

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Suicide in the U.S.• 11th leading cause of death in the population

overall

• About 33,000 suicides annually – 14-16,000 of these occur while in treatment

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Suicide Risk Assessment• There are no reliable quantitative measures to assess suicidal

risk, which leaves the clinician with guided clinical judgment.

• Assess when– Beginning treatment (intake)– There is a significant clinical change (increased distress, crisis, or

sudden improvement with depressed clients)

• An accurate assessment is largely dependent on the clinicians ability to gain private information from the client.– An unstable or poor therapeutic relationship is a risk factor for

completion.

• Risk assessment involves a multidimensional assessment of several factors, including:– Risk factors (predisposing factors, short-term factors, precipitating event)– Specific suicide inquiry (ideation, intent, plan, means) – Protective factors (current resources, commitment to safety plan)

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Suicide Risk AssessmentThe Threshold Model describes how different types of risk and

protective factors interact to produce a threshold for suicidal behaviour for the individual. The different types of factors are:

– Long term/predisposing risk factors that can be present at birth or soon after birth: these identify people who are in at-risk groups (i.e. race)

– Short term risk factors that can develop later in life: these may predict when someone is most likely to commit suicide (i.e., unmarried)

– Precipitating risk factors which occur due to crisis, a recent life event, or access to a method of committing suicide: these allow a more immediate assessment of risk (i.e. recently lost job)

– Protective factors that may be long or short term: these can offset risk

Mental Health Trust, British National Health Service

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Suicide Risk Assessment: Demographics• Age

– Highest risk is elderly white men (also 6x more likely to complete)– Rate increases each year of age

• Ethnicity– Caucasians and Native Americans at highest risk– Other ethnic groups have similar, low risk levels– Highest risk: Caucasian men, 66% of all suicides.– Lowest risk: African-American women.

• Gender– Women attempt more often, at a ratio of 3:1– Men complete more often, at a ratio of 4:1

• Geography– Highest risk nations are soviet bloc (Top 5: Belarus, Lithuania,

Russia, Kazakstan, Latvia) and southeast Asian nations (Japan, South Korea, Sri Lanka)

– Highest risk states are Central Mountain (Nevada, Montana, Wyoming, etc.) and Alaska

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Suicide Rate 2005-2010

10-14 yrs 15-19 yrs 20-24 yrs 25-34 35-44 45-54 55-64 65-74 75-84 85+ yrs0

2

4

6

8

10

12 Females - Lifespan Suicide Risk by Ethnicity and Age (2005-2010)

Am Indian/AK Native - Females Asian/Pac Islander - Females Black - FemalesHispanic - Females White - Females

Com

pleti

ons

per 1

00,0

00

CDC (2013) http://www.cdc.gov/injury/wisqars/index.html

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Suicide Rate 2005-2010

10-14 yrs 15-19 yrs 20-24 yrs 25-34 35-44 45-54 55-64 65-74 75-84 85+ yrs0

10

20

30

40

50

60 Males - Lifespan Suicide Risk by Ethnicity and Age Cohort (2005-2010)

Am Indian/AK Native - Males Asian/Pac Islander - Males Black - MalesHispanic - Males White - Males

Com

pleti

ons

per 1

00,0

00

CDC (2013) http://www.cdc.gov/injury/wisqars/index.html

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Suicide Risk Assessment• Teens have a lower rate than every group except

children– But, suicide is their third leading cause of death,

following MVA and homicide (2nd leading cause of death for young adults). • Whereas suicides accounted for 1.4% of all deaths in the U.S.

annually, they comprised 12% of all deaths among 15-24-year-olds

– Although rates vary somewhat by geographic location, within a typical high school classroom, it is likely that three students (one boy and two girls) have made a suicide attempt in the past year.

– Most adolescent suicide attempts are precipitated by interpersonal conflicts. The intent of the behavior appears to be to effect change in the behaviors or attitudes of others.

American Association of Suicidology, 2010)

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Adolescent Suicide Ideation

• Percentage of U.S. High School Students Reporting Considering, Planning, or Attempting Suicide in the Past 12 Months, by Sex, United States, 2009

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Suicide Risk – Hispanic Adolescents• 18% of Hispanic adolescents have reported seriously

considering attempting suicide in the last 12 months - a proportion higher than reported by their Non-Hispanic classmates.

• Hispanic female high school students reported a higher percentage of suicide attempts (14%), than White Non-Hispanic (7.7%) or Black Non-Hispanic (9.9%) female students.

• Thus, although rates of completed suicide among youth are lower than those for Non-Hispanics, school-aged Hispanic youth self-report higher rates of feeling sad or hopeless, of thinking about suicide, and of attempting suicide.

American Association of Suicidology (2010)

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Suicide Risk Assessment

• Low socioeconomic status• Living alone• Divorced/widowed• Unemployed• Lack of structured religion• Gay/lesbian

– Attempt 6x/2x more frequently• Immigrant• Veteran

• Prior suicide attempts• Family history of suicide• Recent exposure to suicide

(friend/media)– 5% of adolescent suicides are

part of clusters• Anniversary of important loss• Hx of impulsive, violent, or

reckless behavior– 33% of completers have EtoH

in their system.• Family of origin violence• Victim of physical/sexual

abuse• Domestic violence

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SUICIDE RISKS IN SPECIFIC DISORDERS

Prior suicide attempt 38.4 0.549 27.5

Eating disorders 23.1

Bipolar disorder 21.7 0.310 15.5

Major depression 20.4 0.292 14.6

Mixed drug abuse 19.2 0.275 14.7

Dysthymia 12.1 0.173 8.6

Obsessive-compulsive 11.5 0.143 8.2

Panic disorder 10.0 0.160 7.2

Schizophrenia 8.45 0.121 6.0

Personality disorders 7.08 0.101 5.1

Alcohol abuse 5.86 0.084 4.2

Cancer 1.80 0.026 1.3

General population 1.00 0.014 0.72

Condition RR %/y %-Lifetime

A.P.A. Practice Guidelines (2003)

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Suicide Risk AssessmentMedical/Physical• Decline in physical functioning/recent illness (especially terminal illness)• Traumatic Brain Injury

– Risk appears continually high• Epilepsy

– Temporal lobe epilepsy• Chronic Pain

Loss Factors• Decrease in vocational status/unemployed• Loss of significant relationship• Recently divorced/widowed

– Sense of rage/victimization• Loss of freedom due to legal status• Recent Humiliation, shame, guilt

– Most adolescent suicides are precipitated by interpersonal problems, and may be attempts to gain affection, revenge, etc.

Cognitive Features that Contribute to Risk

• Loss of executive function• Thought constriction (tunnel vision)• Polarized thinking/perfectionism• Closed-mindedness• Inability to adapt to a dependent role• Negative attitude towards help seeking

Clinical Factors• Intense, distressing affective states• Low self-esteem, high self-hate • Hopelessness, poor coping • Helplessness, sense of being trapped• Recent increase/uncharacteristic sub.

abuse• Recent increase/uncharacteristic

recklessness • Currently Psychotic• Unstable or poor therapeutic

relationship

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Suicide Risk Assessment• Availability of weapons!

– Suicide is often an impulsive response to an acute stressor

• Rate of lethality:– Guns - 85%– Suffocation (Drowning, hanging, CO2) – 66-75%– Blunt trauma (jumping from buildings, trains) ~ 33%– Other means (pills, poisoning, etc.) – 1-2%

• The top three methods do not allow for back out.– Ratios of attempted to completed suicides for youth are estimated to

range between 100 to 1 and 200 to 1 (compared to 25 to 1 for adults, and 4 to 1 for seniors).

• Suicide completers are more than 2X more likely to have a gun in the home than attempters.

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Suicide Risk Assessment - Inquiry• Clients will rarely volunteer suicidal ideation - they have to be

asked directly – Timing and clinical skill have a lot to do with how successful this

assessment is.

• Develop rapport first, through empathic listening

• Discuss presenting problem and attempt to fully understand the meaning of the problem to them, the history of the problem, as well as the difficulty they’re experiencing.– Don’t forget to inquire about coping history, how they’re coping with the

problem as well as how they’ve coped with it in the past.

• Pay attention to history, present risk factors (all the factors covered in a good clinical interview – mental health, physical health, social support, substance abuse, etc.). – Despite the presence of absence of risk factors, all assessments should include a direct

inquiry

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Suicide Risk Assessment - Inquiry• Four biggest factors predicting suicide:

– Ideation– Intent– Plan & Means– History

• Intent and plan are the two most dangerous factors by far.

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Strategies to elicit disclosure• Behavioral Incident

– “What did you do after you thought about ____”• Shame Attenuation

-”Sometimes people who are really overwhelmed think about hurting themselves. Do you ever feel that way?”

• Gentle Assumption– “Tell me about another time you cut yourself.”

• Symptom Amplification– “Would you say you think about this every couple of hours? Every hour?”

• Denial of the Specific – Have you ever thought of overdosing?

• Normalization – “Some of the people I work with - who are going through similar problems –

sometimes they find themselves wishing they weren’t alive. Do you ever feel that way?”

Shea, 2002

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Suicide Risk Assessment - Inquiry• Clients will rarely volunteer ideation, they typically have to be asked directly.

The inquiry should follow:– The establishment of rapport– Discussion of the presenting problem (client should demonstrate that they are

comfortable expressing themselves with you).– It can be useful to follow expressions of distress with the inquiry.

• Some possible lead in questions include:– What’s _________ been like for you?– Do you find yourself feeling hopeless?– Desperate?– Is it hard to face each day?– Overwhelmed? Do you feel life is a burden?

• Normalize ideation before asking, and begin with general open-ended questions and transition to more specific questions.– “Often, people that are having a really hard time, like you are, they often wish

they weren’t here anymore. Do you ever have thoughts like that? Do you sometimes feel it’s not worth going on?

• If they say no, ask why, and document – Do you ever think about hurting yourself/ending your life?

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Assessment – Ideation Inquiry• If they disclose current ideation, explore it further.

• View the ideation as a legitimate attempt to cope• When you think about ____, what do you imagine?

• Consider the following elements of the ideation:– Frequency, duration, intensity, time of occurrence– Active or passive – How intense, or overwhelming are these thoughts? (SUDS)

• Understand the function of the ideation (soothing, revenge, attention/affection from others, etc.)– Is there something in your life right now that you think is contributing to these

thoughts?– This may sound like an odd question, but how might it help you to think about

dying?– When you think about (not being here, dying, etc.), what do you imagine it will be

like? What will happen to these problems you’re struggling with?– Do you ever think about your funeral? Who would go? How do you imagine

others would react?

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Assessment – Intent and Plan Inquiry• Intent and plan are two most serious indicators• Planning activities or rehearsals

– When you imagine dying, how do imagine it happening?• Consider passive vs. active means

– Have you taken any steps to put this plan into action? • Have you gotten the things you will need? • Have you ever walked yourself through it/practiced doing it?• Have you thought about saying goodbye to others? What steps have you

taken to say goodbye?• Have you told anyone? If not, why not? If they don’t know, how did you keep

it from them?• Look for rituals/rehearsals, preparations, gambles, attempts to keep it secret.

• Do you have any intention of following through on these plans?– On a scale of 1 to 10, 1 being I definitely won’t follow through on these

thoughts, 10 being I definitely am going to, where are you? (SUDS)– If not, why not? What prevents you from killing yourself?

• How likely are you to die from that, do you think?• How confident are you that you can keep yourself safe?

(SUDS)

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Suicide Risk Assessment - Inquiry• Always ask about prior suicide attempts (ask

even if they deny current ideation) – Have you ever tried to hurt yourself in the past?

• Get information on number of previous attempts, time since last attempt (greatest risk in the first 30 months after 5150 discharge)

• Consider: – Lethality of method– Impulsive vs. planned– Rescued/saved by others– Attempts to avoid discovery

• How do you feel about the fact that you survived?– Disappointed by survival?

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Suicide Risk Assessment• Archinard, Heynal-Reymond, & Heller (2000):

– 59 patients admitted to Geneva University Hospital after a suicide attempt are assessed for risk by the psychiatrist.

– The psychiatrists facial expressions are recorded and coded.– The Psychiatrist’s ratings correctly classify the re-attempters

(10 in 24 months) 22.7% of the time.– The psychiatrist’s facial expressions distinguish them

correctly over 80% of the time.

• The moral of the story? If you feel nervous, you probably should. – Use structured risk assessment, but listen to your clinical

instincts as well.

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Interventions to foster safety• Suicidality is often an acute reaction to stressors, “a

permanent solution to a temporary problem.”• 90% of those who survive a nonfatal attempt do not go on to die by

suicide (Owens, British J Psych, 2002; review of 90 studies of repetition of self-harm)

• The purpose of intervention is to assist the individual in navigating the crisis.

• Suicidal behavior and ideation is an attempt to cope with circumstances in which the individual feels helpless and hopeless.– I have no way to cope with this pain– My situation is not going to get better

• However, exploring their situation further typically reveals ambivalence about suicide itself.

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Interventions to foster safety• Highlight ambivalence

– Although you’re thinking about killing yourself, you haven’t. What’s kept you going?

– Despite being really overwhelmed, it seems that the fact that you’re seeking help today shows that there’s a part of you that still hopes or believes that things can get better.

• Reframe ideation as an attempt to cope– You know, when you talk about what it would feel like to die, it seems that you

really imagine that you would finally stop feeling all this pain. If we could find a way for you to find peace again, would you still want to die?

• Reduce Hopelessness by instilling hope– Have you ever gone through a really difficult time before? Did you get through it?

How?– I know this feels really overwhelming right now, but this is a problem we deal with

a lot, and we know a lot about helping people overcome it.

• Reduce Helplessness by fostering adaptive coping – Recognize and praise them for the positive strategies they’re using already– Develop safety plan . . . . Which is really a coping plan.

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Interventions to foster safety• Remove means

– Typically best to enlist a family member, friend– Even if plan does not include firearms, remove them anyway.– Important to know current medications and potential lethality.

• Remove drugs/alcohol– Again, family members or friends can be helpful

• Increase social support– Identify people/activities that can be distractions– Identify people that can be emotional supports (in distress)– Provide hotline/warmline numbers

• Decrease social stress– Have client identify problematic relationships and consider ways to avoid

them

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Interventions to foster safety• Increase supervision and monitoring

– Increase session frequency– Utilize phone contacts/check-ins– Enlist family members or friends to help

• Explain what will happen if they do not follow through with follow-up: “I will call the police, and they will come to your house to do a safety check”

• Provide concrete affect-regulation strategies– Cognitive techniques, active coping statement– DBT toolbox– Medication/psychiatric support

• If there are adaptive steps they can take to solve the problem, it may be useful to encourage them (for example, identifying openings if they lost a job).

• How willing are you to try these strategies? Is there anything we’re leaving out?

• On a scale of 1 to 10, how committed are you to keeping yourself safe?

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Interventions to foster [your] safety• Document

– Risk determination • Elements of inquiry: ideation, intent, plan• Include SUDS intent rating

– Protective factors (very important!)• Include reasons for living• SUDS commitment to safety

– Interventions taken to insure safety• Referrals to hotlines, elements of safety plan

– Results of follow up contacts, and ongoing assessment of ideation and intent. • Demonstrate repeated assessment of ideation/intent unless client is consistently

no/low risk.• Re-assess if there are future crisis, distress, etc.

• At this point, “contracts for safety” are contraindicated. Legally useless, and potentially dangerous due to their tendency to lull clinicians into a false sense of security.

• Always consult! Peer consultation is proving to be a legal expectation within the standard of care (supervisees, of course, consult supervisors). – Document consultations.

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When to treat outpatient:• Low intent• Willingness to commit to safety and follow up• Available social support and coping resources• Can inhibit impulsivity (no substance abuse, brain

injury, history of recklessness etc).• Stable living situation• Strong therapeutic relationship• Patient has chronic suicidal ideation and/or self-injury

without prior medically serious attempts

A.P.A. Practice Guidelines (2003)

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Hospitalization might be required:• After a suicide attempt or aborted suicide attempt• In the presence of suicidal ideation with:

– Psychosis– Major psychiatric disorder– Past attempts, particularly if medically serious– Possibly contributing medical condition (e.g., acute neurological disorder, cancer,

infection)• Lack of response to or inability to cooperate with partial hospital or

outpatient treatment• Limited family and/or social support, including lack of stable living situation• Lack of an ongoing clinician-patient relationship or lack of access to timely

outpatient follow-up• In the absence of suicide attempts or reported suicidal ideation/plan/intent,

but evidence from the psychiatric evaluation and/or history from others suggests a high level of suicide risk and a recent acute increase in risk– E.g. Previous attempts and current crisis

A.P.A. Practice Guidelines (2003)

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Hospitalization Indicated:• In the presence of suicidal ideation with:

– Specific plan with high lethality– High suicidal intent

• Patient is psychotic• Recent attempt was violent, near-lethal, or premeditated• Precautions were taken to avoid rescue or discovery• Distress is increased or patient regrets surviving• Patient is male, older than age 45 years, especially with new onset of

psychiatric illness or suicidal thinking• Patient has limited family and/or social support, including lack of stable

living situation• Current impulsive behavior, severe agitation, poor judgment, or refusal of

help is evident• Patient has change in mental status with a metabolic, toxic, infectious, or

other etiology requiring further workup in a structured setting

A.P.A. Practice Guidelines (2003)

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CALM Protocol• If you are faced with an imminent emergency (for example, the

client is attempting self-harm in front of you), contact 911 immediately.

• If you identify suicidal ideation and significant intent:– If you are under clinical supervision, you must contact your supervisor to consult

immediately. – If you are unable to reach your clinical supervisor, contact members of the

executive team until you reach someone. – If you are licensed, you are still encouraged to consult with peers.

• Ask CALM staff or law enforcement to sit with client if necessary to maintain safety.

• Contact a support person to assist with supervision, coping, or transportation

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CALM Protocol• If hospitalization is determined to be unnecessary:

– Develop a safety plan with client: remove means, identify and remove triggers or other stressors, develop coping strategies (affect regulation/soothing, positive self-talk, distraction, supportive people to contact/hotlines), increase contact and supervision.

– Additional support may include hotlines: 211• Teens: 1-877-YOUTHLINE /800-852-8336 /800-843-5200/Child Abuse counseling (800) 422-4453• General Suicide Hotlines 1-800-273-TALK/1-800-SUICIDE• Post-Partum Depression 1-800-PPD-MOMS/PEP Warmline (805) 564-3888/Sp. 852-1595

• If hospitalization is determined to be necessary:• Encourage voluntary hospitalization, which can be conducted through the emergency room.

Consider whether client can be transported safely (by a family member or friend – do not allow clients to transport themselves).

• If a client refuses voluntary hospitalization, seek an assessment. – For Children, contact –Safe Alternatives for Treating Youth (SAFTY) 1-888-334-2777– For Adults, call 911.

• If a client refuses to participate in your assessment or safety planning and/or leaves, contact 911.