Objectives
~ Identify general practice points
~ Explore/review risk and protective factors
~ Identify suicide warning signs IS PATH WARMED
~ Learn the SPLASH acronym for suicide screening

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General Practice Points

• Clients should be screened for suicidal thoughts and behaviors routinely at intake and at specific points in the course of treatment
• Screening for clients with high risk factors should occur regularly throughout treatment. (preferably at each episode)
• Counselors should be prepared to develop and implement a treatment plan to address suicidality and coordinate the plan with other providers.
• If a referral is made, counselors should check that referral appointments are kept and continue to monitor clients after crises have passed, through ongoing coordination with mental health providers and other practitioners, family members, and community resources, as appropriate.

• Counselors should acquire basic knowledge about the role of warning signs, risk factors, and protective factors as they relate to suicide risk.
• Counselors should be empathic and nonjudgmental with people who experience suicidal thoughts and behaviors.
• Counselors should understand the impact of their own attitudes and experiences with suicidality on their counseling work with clients.
• Counselors should understand the ethical and legal principles and potential areas of conflict that exist in working with clients who have suicidal thoughts and behaviors.

General cont.
• Suicide risk may increase at transition points in care), especially when a planned transition breaks down. Anticipating risk at such transition points should be regarded as an issue in treatment planning.
• Suicide risk may increase when a client is terminated administratively (e.g., because of poor attendance, chronic substance use) or is refused care.
~ It is unethical to discharge a client and/or refuse care to someone who is suicidal without making appropriate alternative arrangements for treatment to address suicide risk.
• Suicide risk may increase in clients with a history of suicidal thoughts or attempts who relapse. Treatment plans for such clients should provide for this possibility.
General cont.
• Suicide risk may increase in clients with a history of suicidal thoughts or attempts who imply that the worst might happen if they relapse (e.g., “I can't go through this again,” “if I relapse, that's it”)—especially for those who make a direct threat (e.g., “This is my last chance; if I relapse, I'm going to kill myself”).
• Suicide risk may increase when clients are experiencing acute stressful life events. Treatment should be adjusted by adding more intensive treatment, closer observation, or additional services to manage the life crises.

10 Risk Factors
• Mental health conditions
~ Depression
~ Substance use problems
~ Bipolar disorder
~ Schizophrenia
~ Emotional dysregulation
~ Conduct disorder
~ Anxiety disorders
• Serious or chronic health conditions and/or pain
• Traumatic brain injury
10 Risk Factors
• Precipitants/triggering events leading to humiliation, shame, or despair (e.g., loss of relationship, health or financial status – real or anticipated
~ Prolonged stress, such as harassment, bullying, relationship problems or unemployment
~ Stressful life events, which may include a death, divorce or job loss
• Exposure to another person’s suicide, or to graphic or sensationalized accounts of suicide including through media
• Family violence or physical or sexual abuse
• Previous suicide attempts
10 Risk Factors
• Family history of suicide
• Barriers to accessing health care, especially mental health and substance abuse treatment
• Certain cultural and religious beliefs (for instance, the belief that suicide is a noble resolution of a personal dilemma)
Warning Signs IS PATH WARMED
• I – Ideation (suicidal thoughts)
• S – Substance Abuse
• P – Purposelessness/No Reason to Live
• A – Anxiety
• T – Trapped
• H – Hopelessness/Helplessness/Being a Burden
• W – Withdrawal/Isolation
• A – Anger, Aggression, Agitation
• R – Recklessness
• M – Mood changes
~ Esp. Sudden, unexpected switch from being very sad to being very calm or appearing to be happy
• E– Extreme pain
• D- Depression

Additional Warning Signs
~ Significant sleep changes
~ Direct and indirect verbal expressions: “I don’t want to live anymore”, “there is nothing to live for anymore”, “people will be better off without me”
~ Risk taking behavior
~ Lack of self care or outright neglect of self
~ Changes in eating and sleeping pattern
~ Giving away prize possessions and/or making a will; tidying up personal affairs; writing notes; making notes on belongings
~ Reconnecting with old friends and extended family as if to say goodbye
~ Unwillingness to discuss future plans

Protective Factors
~ Sense of responsibility to family
~ Life satisfaction
~ Social support; belongingness
~ Coping skills
~ Problem-solving skills
~ Reality testing ability
~ Religious faith
~ Reasons for living
Protective Factors
~ Family
~ Presence of a child in the home and/or childrearing responsibilities
~ Intact marriage
~ Beloved pets
~ Personal
~ Trait optimism (a tendency to look at the positive side of life)
~ Adaptive coping skills
~ Effective problem-solving skills
~ Self-understanding
~ Sense of competence
~ Spirituality
~ Being clean and sober

Protective Factors
~ Employment
~ Positive relationships with colleagues
~ Professional development opportunities
~ Access to employee assistance programs
~ Community
~ Involvement and opportunities to participate in the community
~ Trusting relationship with a counselor, physician, or other service provider
~ Affordable, accessible supportive services

Assessment: SPLASH

~ Suicidal thoughts
~ Protective Factors
~ Lethality
~ Access/availability of proposed method
~ Seclusion—How long would it take for resources to get there
~ History of suicidal behavior

10 Points to Remember
• Almost all of your clients who are suicidal are ambivalent about living or not living.
• Suicidal crises can be overcome.
• Although suicide cannot be predicted with certainty, suicide risk assessment is a valuable clinical tool.
• Suicide prevention actions should extend beyond the immediate crisis.
• Suicide contracts are not recommended and are never sufficient
• Some clients will be at risk of suicide, even recovering from their presenting issue(s)
• Suicide attempts always must be taken seriously.
10 Points to Remember
• Suicidal individuals generally show warning signs.
• It is best to ask clients about suicide, and ask directly.
• The outcome does not tell the whole story.
~ a good outcome (survival) does not, by itself, equate to proper treatment of suicidal thoughts and behaviors

Points to Remember
~ People in treatment settings may need additional services to ensure their safety.
~ All clients should be screened for suicidal thoughts and behaviors as a matter of routine.
~ Screen for suicide and ask followup questions.
~ Follow up with a client when risk has been previously documented.
~ Take appropriate action when risk is detected.
~ Document suicide-related screening and interventions.
~ Communicate suicide risk to another professional or agency.
~ All expressions of suicidality indicate significant distress and heightened vulnerability that require further questioning and action.

~ Warning signs for suicide can be indirect; you need to develop a heightened sensitivity expressions of hopelessness, feeling trapped, or having no purpose in life, and observable signs such as withdrawal from others, mood changes, or reckless behavior.
~ Talking about a client's past suicidal behavior can provide information about triggers for suicidal behavior.
~ Give clients who are at risk of suicide the telephone number of a suicide hotline; it does no harm and could actually save a life.
Summary
~ Suicidal ideation represents an opportunity
~ Clinicians need to prepare ahead of time for the event of a suicidal client
~ Suicide assessment should be part of every assessment, and ideally a mini-assessment completed at each visit
~ Be aware of and educate clients and their families about suicide risk factors and warning signs and steps to take in the event of a crisis
~ Always document assessments and interventions (checklists are good for this)

Resources
~ NIMH Publications in English and Spanish
~ SAMHSA Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment.
~ Suicide publications for clients by SAMHSA

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