Crisis Intervention and Preventing Suicide
Dr. Dawn-Elise Snipes, PhD, LMHC
~ The student will learn about:
~ How to estimate suicide risk
~ Factors altering risk of suicide and attempted suicide
~ Additional considerations in specific treatment settings
~ Strategies for enhancing motivation and promoting treatment engagement
~ Education points for the client and family
~ Risk management and documentation issues
Crisis Intervention Principles
~ All clients perceive events uniquely
~ All clients participate in care that is respectful and non-judgmental
~ Reflection and empathy is most effective
~ Ego strength is variable among individuals and is influenced by past experiences and social support
~ All clients and families are actively involved in collaboration and decision-making
~ Stress is a normal part of existence and can foster self-development and growth
~ All clients are capable of assuming personal responsibility
Crisis Intervention Principles cont…
~ All clients grow and change in an environment of acceptance, trust and empathic understanding
~ Sustained change occurs when clients feel ready & supported
~ People have a need for self-mastery and control
~ Crises can be construed as danger or opportunity for growth
~ Crisis intervention is an active process that focuses on the immediate problem
~ Crisis intervention is time-limited
~ Client advocacy is essential
~ The focus is always on increasing the client’s level of social, occupational, cognitive and behavioral functioning
10 Step Trauma Management Protocol
• Assess for danger/safety for self and others, this means for the victim, counselor, and others who may have been affected by the trauma.
• Consider the physical, emotional and perceptual mechanisms of injury.
• Victim's level of responsiveness should be evaluated.
• Address medical needs
• Identify signs of traumatic stress.
• Connect with the individual by building rapport.
• Build rapport by allowing the client/person to tell their story.
• Provide support through active and empathetic listening
• Normalize, validate, and educate the individuals emotions, stress and adaptive coping styles.
• Bring the person to the present, describe future events, and provide referrals as needed. (Lerner & Shelton)
~ Facilitate understanding
~ Encourage adaptive coping
~ Restore functioning
~ Prevention is always the best
~ Obtain information about the patient's psychiatric and other medical history and current mental state.
~ Identify specific psychiatric signs and symptoms
~ Assess past suicidal behavior, including intent of self-injurious acts
~ Review past treatment history and treatment relationships
~ Identify family history of suicide, mental illness, and dysfunction
~ Address the patient's immediate safety and determine the most appropriate setting for treatment.
~ Develop a biopsychosocial differential diagnosis to further guide planning of treatment.
~ Remember that suicide assessment scales lack the predictive validity necessary for use in routine clinical practice.
~ Identify specific factors and features that may generally increase or decrease risk for suicide or other suicidal behaviors and that may serve as modifiable targets.
~ Social support network
~ Cultural/religious beliefs, particularly as they relate to death/suicide
~ Nature, frequency, depth, timing and persistence of suicidal ideation
~ If ideation is present, request more detail about plans
~ Identify current psychosocial situation and nature of crisis
~ Appreciate psychological strengths and vulnerabilities of the individual patient
Specifically Inquire About Suicidal Thoughts, Plans, and Behaviors
~ Begin with questions that address the patient's feelings about living, such as:
~ “How does life seem to you at this point?“
~ “Have you ever felt that life was not worth living?“
~ “Did you ever wish you could go to sleep and just not wake up?”
~ Focus on the nature, frequency, extent and timing of suicidal thoughts and the interpersonal, situational and symptomatic context in which they are occurring
Inquire About Suicidal Thoughts cont…
~ Elicit the presence or absence of a suicide plan.
~ If the patient does not report a plan, ask whether there are certain conditions under which the patient would consider suicide.
~ Whether or not a plan is present, if a patient has acknowledged suicidal ideation, there should be a specific inquiry about the presence or absence of a firearm.
~ If the patient has access to a firearm, recommend to the patient or a significant other the importance of restricting access to, securing or removing this and other weapons.
~ Document in the medical record, being sure to include, any instructions that have been given to the patient and significant others about firearms or other weapons.
~ Assess the degree of suicidality, including suicidal intent and lethality of plan.
~ Between age 10 and 24 years and over 70 years are the critical periods
~ Thoughts of death are more common in older adults but as people age they are less likely to endorse suicide.
~ Self-destructive acts by older people are more lethal.
~ This greater lethality is a function of several factors:
~ Reduced physical resilience
~ Greater social isolation
~ Greater determination to die
~ Suicidal elders give fewer warnings.
~ Death by suicide is more 4x as frequent in men than in women.
~ Men are less likely to seek and accept help or treatment.
~ Women have several protective factors:
~ Lower rates of alcohol and substance abuse
~ Less impulsivity
~ More socially embedded
~ More willing to seek help
~ Women have higher rates of depression and respond to unemployment with greater and longer-lasting increases in suicide rates than men.
~ Women who are pregnant or have young children are less likely to kill themselves.
~ Rates of suicidal ideation and attempts are also increased in individuals with borderline personality disorder and in those with a history of domestic violence or physical and/or sexual abuse.
Race, Ethnicity, and Culture
~ Suicide in whites and in non-Hispanic Native Americans are approximately 2x those observed in Hispanics, non-Hispanic African Americans and Asian-Pacific Islanders.
~ For immigrant groups, in general, suicide rates tend to mirror the rates in the country of origin and converge toward the rate in the host country over time.
~ Racial and ethnic differences in culture, religious beliefs and societal position may influence the rates and values about suicide.
~ Suicide can be considered a traditionally accepted way of dealing with shame, distress and/or physical illness.
~ Knowledge of and sensitivity to common contributors to suicide in different racial and ethnic groups as well as cultural differences in beliefs about death and views of suicide.
~ Suicide rate of single persons is twice that of those who are married.
~ Divorced, separated or widowed individuals have rates four to five times higher than married individuals.
~ The presence of another person in the household may also serve as a protective factor by:
~ Decreasing social isolation
~ Engendering a sense of responsibility toward others
~ Increasing the likelihood of discovery after a suicide attempt
~ The presence of a high-conflict or violent marriage can be a precipitant rather than a protective factor for suicide.
Major Psychiatric Syndromes
~ More than 90% of persons who die from suicide satisfy the criteria for one or more psychiatric disorders.
~ Patients with mood disorders who died by suicide were more likely to have:
~ panic attacks
~ severe psychic anxiety
~ diminished concentration
~ global insomnia
~ moderate alcohol abuse
~ severe loss of pleasure or interest in activities
Major Psychiatric Syndromes cont…
~ Suicidal ideation and a history of suicide attempts also augment risk.
~ Co-morbid anxiety, alcohol use and substance use are common in patients with mood disorders.
~ Suicide in patients with schizophrenia is about 8.5-fold higher.
~ In schizophrenia or schizoaffective disorder, psychotic symptoms are often present during a suicide attempt.
~ Command hallucinations account for a relatively small percentage of suicides.
~ Patients with schizoaffective disorder appear to be at greater risk for suicide than those with schizophrenia.
~ Suicide risk is increased in those who recognize a loss of previous abilities and are pessimistic about treatment.
Alcohol Use Disorders
~ Abuse of substances including alcohol may be the second most frequent psychiatric precursor to suicide.
~ Alcohol abuse or dependence is present in 25%–50% of those who died by suicide.
~ Impending interpersonal losses and co-morbid psychiatric disorders have been specifically linked to suicide in alcoholic individuals.
~ Full-time employment appears to be a protective factor in alcoholics.
~ Individuals with personality disorders have an estimated 7x increased risk for suicide.
~ Especially borderline, antisocial personality disorders, avoidant and schizoid personality disorders
~ Personality disorders exist in approximately 30-40% of those who attempt or die by suicide.
~ Factors that increase suicide risk include:
~ Communications of suicidal intent
~ Prior suicide attempts
~ Continued or heavier drinking
~ Recent unemployment, living alone
~ Poor social support
~ Legal and financial difficulties
~ Serious medical or mental illness
~ Personality disturbance
~ Other substance use
Risk Factors Psychodynamic
~ Suicide’s multiple motivations:
~ Anger turned inward or a wish of death toward others that is redirected toward the self
~ Revenge, reunion, or rebirth
~ Suicide is rooted in a triad of motivations:
~ The wish to die
~ The wish to kill
~ The wish to be killed
~ Suicidal behavior has been associated with:
~ Poor object relations
~ The inability to maintain a stable, accurate, and emotionally balanced memory of the people in one's life
~ Other important psychodynamic concepts are shame, worthlessness and impaired self-esteem.
~ Patients may be in the midst of an acute suicidal crisis or display the symptoms and disorders that typically lead to psychiatric hospitalization/increased suicide risk.
~ There do not appear to be specific risk factors that are unique to the inpatient setting.
~ More than half of the patients who die by suicide in the hospital were admitted withOUT suicidal ideation.
~ Extreme agitation or anxiety or a rapidly fluctuating course is common before suicide.
~ Each suicidal crisis must be treated as new with each admission and assessed accordingly.
~ Suicidality may wax and wane in the course of treatment.
~ Sudden changes in clinical status, which may include worsening or unexpected improvements in reported symptoms, require that suicidality be reconsidered.
~ Risk may also be increased by:
~ Lack of a reliable therapeutic alliance
~ Patient's unwillingness to engage in psychotherapy or adhere to medication treatment
~ Inadequate family or social supports
Jail and Correctional Facilities
~ Suicide is one of the leading causes of death in correctional settings.
~ Persons who die by suicide in jails tend to be young, white, single, intoxicated substance abusers.
~ Suicide in correctional facilities generally occurs by hanging.
~ Isolation may increase suicide in correctional facilities.
~ Suicidal behaviors increase:
~ immediately on entry into the facility
~ after new legal complications with the inmate's case (e.g., denial of parole)
~ after inmates receive bad news about loved ones
~ after sexual assault or other trauma
Transference and Countertransference
~ Suicidal patients can activate a clinician's own latent emotions about death and suicide.
~ Feelings of hate and anger at suicidal patients
~ Avoidance of patients who bring up anxieties surrounding suicide
~ Overestimating the patient's capabilities creates unrealistic and overwhelming expectations for the patient.
~ Be aware of becoming enveloped by the patient's sense of hopelessness and despair then responding by becoming discouraged about the progress of treatment and the patient's capacity to improve.
Choice of Specific Treatment Setting
~ Depends on:
~ The estimate of patient's current risk to self/others
~ Medical and psychiatric co-morbidity
~ Strength and availability of psychosocial support network
~ Ability to provide adequate self-care, give reliable feedback and cooperate with treatment
~ Benefits of intensive interventions must be weighed against their possible negative effects.
The Suicide Prevention Contract
~ AKA “no-harm contract”
~ Is not a substitute for a careful clinical assessment
~ Patient's willingness (or reluctance) to enter into an oral or a written suicide prevention contract should not be viewed as an absolute indicator of suitability for discharge
~ Not recommended for use with patients who are agitated, psychotic, impulsive or under the influence of an intoxicating substance
~ Are dependent on an established physician-patient relationship
~ Not recommended for use in emergency settings or with newly admitted or unknown inpatients
~ To treat symptoms such as severe insomnia, agitation, panic attacks, or anxiety
~ Long-acting agents often being preferred over short-acting agents
~ The benefits of benzodiazepine treatment should be weighed against:
~ Their occasional tendency to produce disinhibition
~ Their potential for interactions with other sedatives
~ Their potential for abuse
~ Benzodiazepines being discontinued after prolonged use should be reduced gradually and the patient monitored for increasing symptoms of anxiety, agitation, depression, or suicidality.
Somatic Interventions cont…
~ Evidence for a lowering of suicide rates with antidepressants is inconclusive.
~ Antidepressant effects may not be observed for days to weeks.
~ Patients should be monitored closely early in treatment and educated about this probable delay in symptom relief.
~ Other calming medications
~ Low doses of some second-generation antipsychotics
~ Some anticonvulsants such as Gabapentin or Divalproex
~ Long-term maintenance treatment is associated with major reductions in the risk of suicide in patients with bipolar and recurrent major depressive disorder.
Somatic Interventions cont…
~ Efficacy in patients with severe depressive illness, with or without psychotic features.
~ Associated with a rapid and robust antidepressant response
~ May be recommended as a treatment for severe episodes of major depression that are accompanied by suicidal thoughts or behaviors
~ ECT may also be indicated for suicidal individuals during pregnancy and for those who have already failed to tolerate or respond to trials of medication.
~ Associated with significant decreases in rates of suicide attempts for individuals with schizophrenia and schizoaffective disorder.
~ Should be given serious consideration for psychotic patients with frequent suicidal ideation, attempts, or both
Promote Treatment Compliance
~ While symptomatic, patients may:
~ Be poorly motivated
~ Be less able to care for themselves
~ Be unduly pessimistic about their chances of recovery
~ Suffer from memory deficits or psychosis
~ Have reductions in insight about having an illness or needing treatment
~ During maintenance:
~ Patients undervalue the benefits of treatment and focus on its burdens.
Educate Patient and Family
~ Psychiatric disorders are real illnesses and that effective treatments are both necessary and available.
~ The role of stressors and other disruptions in precipitating or exacerbating suicidality or symptoms of psychiatric disorders.
~ Course of improvement may be uneven.
~ Family history of suicide may increase risk of suicide, but it does not make suicide inevitable.
~ How to identify symptoms that may indicate decompensation in general and specific to the patient.
~ Methods for involving the police for involuntary evaluation.
~ How to react to suicidal behaviors in persons with borderline personality disorder.
Patients with Chronic Suicidality
~ Self-injurious behaviors may or may not be associated with suicidal intent
~ Without having any desire for death, individuals may intentionally injure themselves to:
~ express anger
~ relieve anxiety or tension
~ generate a feeling of “normality or self-control”
~ terminate a state of depersonalization
~ distract or punish themselves
Patients with Chronic Suicidality cont…
~ Self-injurious behaviors are sometimes characterized as “gestures” aimed at achieving secondary gains which may lead to behaviors being downplayed when associated with minimal self-harm.
~ In assessing chronic self-injurious behaviors, determine whether suicidal intent is present.
~ An absence of suicidal intent or a minimal degree of self-injury should not lead the clinician to overlook other evidence of increased suicide risk.
~ Each act needs to be assessed in the context of the current situation.
General Risk Management and Documentation Issues
~ The most frequent lawsuits, settlements, and verdicts against psychiatrists are for patients' suicides.
~ The failure to document suicide risk assessments and interventions may give the court reason to conclude they were not done.
~ For patients who are hospitalized, it is also important to document the aspects of the risk assessment that justify inpatient treatment, particularly when it is occurring on an involuntary basis.
Components of Documentation
~ Reference to the reason for the assessment will set the context for the evaluation.
~ Reviews the factors that may contribute to increased shorter-term or longer-term suicide risk.
~ Reasoning process that went into the assessment
~ Clinical conclusions
~ Changes in the treatment plan should also be noted, along with the rationale for such actions.
~ Interventions or actions that were considered but rejected should be recorded as well.
Suicide Contracts: Usefulness and Limitations
~ The patient's willingness (or reluctance) to enter into a suicide prevention contract should not be viewed as an absolute indicator of suitability for discharge (or hospitalization).
~ It is overvalued as a clinical or risk management technique.
~ It is not a legal document and cannot be used as exculpatory evidence in the event of litigation.
~ It cannot and should not take the place of a thorough suicide risk assessment.
~ Undue reliance on suicide prevention contracts falsely lowers clinical vigilance without altering the patient's suicidal state.
~ Crisis intervention is client centered and comprehensive.
~ Crisis intervention uses patients’ strengths and resources.
~ Empathy and genuineness are key factors.
~ Treatment modalities and settings are based on the client’s level of functioning, dangerousness to self and availability of supports and resources.
~ Documentation is essential throughout the process, not just at assessment.
~ Pharmacological interventions are used to provide acute symptom relief and enable the patient to focus on psychosocial interventions.
~ All clients have the ability to help themselves.