Suicide Prevention and
Intervention Revisited
Focus on Adults
National TASC Workshop/Plenary
May 8, 2014
Judith Harrington, Ph.D.
University of Montevallo
Alabama Suicide Prevention & Resources Coalition (501c3)
Nationally, 38,364 persons died from suicide,
now the 10th cause of death (AAS, 2010).
• Alabama Suicide Prevention and Resources
Coalition (ASPARC) A 501c3 Non-Profit Agency
• This presentation is partly funded by a Garrett
Lee Smith Suicide Prevention grant from SAMHSA
in partnership with the Alabama Department of
Public Health and the ASPARC, your tax dollars
brought home to prevent suicide.
PREFERRED TERMS
• Died from suicide
• Completed suicide
• AVOID: committed suicide, took his own life,
chose to end her life, “successful suicide” (no
such thing as a successful suicide, only successful
prevention)
• Survivor of suicide loss
• Attempt survivor, the lived experience
Definitions - suicide
• Death by suicide, (died by suicide) or completed suicide:
Death from self-inflicted injury, poisoning, or suffocation
where there is evidence that the act was intentional
(purposed, aim, or goal)and led to death
• Suicide intent: Self-injurious behavior with non-fatal
outcome, with evidence of intent to die (was rescued,
thwarted, or changed mind).
• Suicide ideation: Thoughts of suicide related behavior, do
not make an explicit attempt
• Suicide attempt survivors
• Suicide survivors (of loss) (often confused with attempt survivors)
Examples of suicidal behavior
Suicide ideation
Suicide rehearsal
Suicide “gesture”
Suicide attempt
Completed suicide or death from suicide
Days of limited survival from attempt before
death
• Permanent disability from suicide attempt
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Incidence of Suicide
From a 2008 CDC Study
• 2.9 million in U.S. ages 18-29 had suicidal
thoughts
• 2.2 million in U.S. considered adults in U.S.
had suicide plans
• 1.0 million adults in U.S. made a suicide
attempt in the 2007
• Source: Crosby, A. E., Han, B., Ortega, L. A. G. Parks, S. E., Gfroerer, J. (2011).
Suicidal thoughts and behaviors among adults aged ≥ 18 years---United States
2008-2009. Retrieved http://www.cdc.gov
AT RISK GROUPS BASED ON INTENT
TO DIE AND SURVIVAL
Campbell (2005)
Survival: Die
Intent:
Die
Intent:
Live
Survival: Live
SUICIDE
“died by suicide”
[formerly “completed” suicide or
chose to end life]
SUICIDE ATTEMPT
Ambivalence is present
and help reaches them.
Intervention is
successful.
ACCIDENTAL SUICIDE
An attempt gone awry.
PARASUICIDE
So-called "attentionseeking" or "cry for
help" (euphemisms)
40 times more likely to
die by suicide.
FALSE POSITIVE AND FALSE
NEGATIVE SUICIDE ASSESSMENT
Adapted from Granello & Granello (2007)
Counselor
assesses that
client
IS
suicidal
Counselor
assesses that
client
IS NOT
suicidal
Client IS suicidal
Client IS NOT suicidal
Accurate Assessment
False positive
False negative
Accurate
Assessment
COUNSELOR LIABILITY
Harrington (2008)
Client lives
Counselor is
effective
Counselor is
ineffective
Assessment,
intervention works.
Client Dies
"The operation was a
success but the patient
died."
Luck. Something else
prevails, other
resources, hardiness not Potential malpractice.
attributable to
Scope of competence
counselor.
issues.
Is suicide a choice?
Andrew Slaby, M.D., Ph.D., M.P.H., New York University
and New York Medical College:
• People who die by suicide do not want to die; they simply
want to end the pain often caused by depression. If
there were another way to end the pain, they would seek
it. Failing to find a source of reprieve, they become
hopeless. More than depression, hopelessness predicts
who will die by suicide… (p. 11).
Is suicide a choice?
Mark J. Goldblatt, M.D., Harvard University Department of
Psychiatry, in Case Discussion:
…that his [the case under discussion] cognitive function
was impaired by his physical illnesses or by his
depression…he was never really competent to make his
own treatment decisions, because he was impaired by his
mental illness (p. 336).
Is suicide a choice?
Kay Redfield Jamison, Johns Hopkins University, author
of, An Unquiet Mind and Night Falls Fast, has bipolar
disorder and attempted suicide, stated
• In short, when people are suicidal, their thinking is
paralyzed, their options appear spare or
nonexistent, their mood is despairing, and
hopelessness permeates their entire mental domain.
The future cannot be separated from the present,
and the present is painful beyond solace. (p. 93).
OLD VS. NEW PARADIGM FOR
UNDERSTANDING SUICIDE
OLD
• a. Suicide: Killing of
oneself
• b. Goal: End life
• c. It is seen as an event
or a behavior.
• d. Viewed as a decision
and a personal choice.
• e. Viewed as a means of
control or manipulation.
NEW
• a. Penacide: Killing the pain.
• b. Goal: End pain and
suffering.
• c. It is seen as a process of
debilitation.
• d. Viewed as a disease
outcome; no choice involved
beyond crisis point in the
process of debilitation.
• e. Viewed as the result of
severe stress and psychological
pain.
OLD VS. NEW PARADIGM FOR
UNDERSTANDING SUICIDE
OLD
NEW
• f. Seen as a voluntary
action and individual
responsibility.
• g. The individual is seen
as a decision-maker.
• h. Thought to be a
phenomenon involving
the mind.
• i. Etiology: Emotional
disorder, personality
disorder, poor coping
skills
• f. Seen as an involuntary
response.
• g. The individual is seen as a
victim.
• h. Thought to be a
physiological or
neurobiological phenomenon
involving the brain.
• i. Etiology: A biochemical
deficiency created or
aggravated by pain.
CORE COMPETENCIES FOR ASSESSING
& MANAGING SUICIDE RISK
A. Working with Individuals at Risk for Suicide: Attitudes
and Approach
1. Manage one’s own reactions to suicide
2. Reconcile the difference (and potential conflict)
between the clinician’s goal to prevent suicide and
the client’s goal to eliminate psychological pain via
suicidal behavior
3. Maintain a collaborative, non-adversarial stance
4. Make a realistic assessment of one’s ability and time
to assess and care for a suicidal client as well as for
what role one is best suited
CORE COMPETENCIES FOR ASSESSING
& MANAGING SUICIDE RISK
B. Understanding Suicide
• 5. Define basic terms related to suicidality
• 6. Be familiar with suicide-related statistics
• 7. Describe the phenomenology of suicide
• 8. Demonstrate understanding of risk and protective
factors
CORE COMPETENCIES FOR ASSESSING
& MANAGING SUICIDE RISK
C. Collecting Accurate Assessment Information
9. Integrate a risk assessment for suicidality early in a
clinical interview, regardless of the setting in which the
interview occurs and continue to collect assessment
information on an ongoing basis
10. Elicit risk and protective factors
11. Elicit suicide ideation, behavior, and plans
12. Elicit warning signs of imminent risk of suicide
13. Obtain records and information from collateral sources
as appropriate
CORE COMPETENCIES FOR ASSESSING
& MANAGING SUICIDE RISK
D. Formulating Risk
14. Make a clinical judgment of the risk that a client will
attempt or complete suicide in the short and long term
15. Write the judgment and the rationale in the client’s record
16. Collaboratively develop an emergency plan that assures
safety and conveys the message that the client’s safety is not
negotiable
17. Develop a written treatment and services plan that
addresses the client’s immediate, acute, and continuing suicide
ideation and risk for suicide behavior
18. Coordinate and work collaboratively with other treatment
and service providers in an inter-disciplinary team approach
CORE COMPETENCIES FOR ASSESSING
& MANAGING SUICIDE RISK
E. Developing a Treatment and Services Plan
16. Collaboratively develop an emergency plan that assures
safety and conveys the message that the client’s safety is not
negotiable
17. Develop a written treatment and services plan that
addresses the client’s immediate, acute, and continuing suicide
ideation and risk for suicide behavior
18. Coordinate and work collaboratively with other treatment
and service providers in an inter-disciplinary team approach
CORE COMPETENCIES FOR ASSESSING
& MANAGING SUICIDE RISK
F. Managing Care
19. Develop policies and procedures for following clients closely
including taking reasonable steps to be proactive
• Motivate and support clients in getting them to a referral source or to their next
treatment/intervention session
• Engage in collaborative problem-solving with the client to address barriers in
adhering to the plan and to revise the plan as necessary…session by session
• Assure that the client, family, significant others, and other care providers are
following through on actions as agreed
• Assess the outcome of each referral
• Develop and implement follow-up procedures for all missed appointments
• Be available between appointments
• Arrange for clinical coverage when therapist is unavailable
• Assure continuity of care and follow-up contact with all suicidal clients who have
ended treatment
20. Follow principles of crisis management
CORE COMPETENCIES FOR ASSESSING
& MANAGING SUICIDE RISK
G. Documenting
21. Document the following items related to suicidality
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Informed consent
Information that was collected from a bio-psycho-social perspective
Formulation of risk and rationale
Treatment and services plan
Management
Interaction with professional colleagues
Progress and outcomes
CORE COMPETENCIES FOR ASSESSING
& MANAGING SUICIDE RISK
H. Understanding legal and regulatory issues related to
suicidality
22. Understand state laws pertaining to suicide
23. Understand that poor or incomplete documentation
make it difficult to defend against legal challenges
24. Protect client records and rights to privacy and
confidentiality following the Health Insurance Portability and
Accountability Act of 1996 that went into effect April 15, 2003
Continuum of Suicide Risk
Think of risk as a status on a continuum
Doing well
Life stress
Existential
reflection
Crisis, Pile up
High Emergency Risk
Harm in 24 hrs +/-
Build up over weeks,
months
Recent loss/distress
Chronic
Intent
Demographic markers more
important
Lethal Means
Plan
Rehearsals
Warning Signs
Relationship problems
Marilyn Monroe type suicide
Vince Foster type suicide
Assessment of suicidal risk
• IS PATH WARM
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Ideation
Substance abuse
Purposelessness
Anxiety
Trapped
Hopelessness
Withdrawal
Recklessness
Mood Change
There are a plethora of paper & pencil,
authenticated instruments to assess suicide,
such as the PANSI and many more.
• SIMPLE STEPS
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Suicidal
Ideation
Means to complete
Perturbation
Loss
Earlier attempts
Substance use
Trouble-solving ability
Emotion
• Hopelessness,
worthlessness,
depression
• Parent, family history
• Stress and life events
Assessment of suicidal risk
• F.A.C.T.
• Feelings:
Hopelessness, Fear of
loss of control,
helplessness, sadness
• Actions or events:
• Loss, agitation, Sub
Abuse, reckless
• Change in
personality,
behavior, sleep,
etc.
• Threats
• Statements, plans
gestures
• Acute vs. Chronic
• Emergent vs. long
term
• Warning signs vs. risk
factors
• Event vs. relational
Distinguishing risk from warning
• Demographics or Risk
Factors
• Chronic
• Over many weeks,
months, years
• “marker” for suicide, not
a predictor
• Prior attempts
• Hx of abuse
• Poor support syst.
• Warning Signs
• recent loss or defeat
• Changes in mood,
actions, ADL’s
• Hopeless
• Intent, plan, means,
timetable
• rehearsals
• Substance abuse
Chronic vs. Acute Risk
• Chronic
• Ongoing suicidality due to past hx and the presence of
certain risk factors (alcohol or Axis II),
• has no current suicidal intent, no organized plan,
• has reasons for living
• Not considered immediate risk, but under certain
conditions (recurrence of depression, actual or
anticipated relationship loss, financial setbacks, legal
problems, or serious medical dx…could develop into acute
risk
Chronic vs. Acute Risk
• Acute
• Serious recent suicidal behavior, current
psychotic processes, and/or serious suicidal
planning or intent. Can be considered at nearterm risk for suicide within hours, days, or weeks
from the time of assessment.
• Paramount for MHP to intervene immediately
Low, Moderate, High risk
• Low: no hx of past suicidal behavior, no current suicidal
ideation, some chronic risk and anticipated losses, and
protective factors are present
• Moderate: elevated level of risk based on factors such as
suicidal ideation or desire, chronic drug or alcohol use,
problematic relationships or some other current stressor.
• High: hx of multiple suicide attempts, the presence of
recent suicidal ideation and planning, and an anticipated
triggering event
“Purpose” of suicide
• To end the pain
• To stop being a burden or disappointment to
family
• To overcome psychache
• To overcome shame or dishonor
• To escape feeling trapped
• To go be with loved ones (or friend or
significant other) in heaven
• Other….?
Essential Features of Risk
Assessment
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Each person is unique
It is complex and challenging
It is an ongoing process
It uses multiple perspectives
Tries to uncover foreseeable risk
Relies on clinical judgment
Assessment is considered to be “treatment”
Coping skills for suicidal risk
• Safety planning in concert with a clinician
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Means restriction
Soothing
Self-care
Family support
Crisis planning
Community resources
Life skills, problem-solving
Social support
Cognitive behavioral approach
See Rudd (2006)
Good Resources
• Rudd, M. D. (2006). The assessment and management of
suicidality (practitioner's resource). Sarasota, FL: The
Professional Resource Exchange.
• American Association of Suicidology www.suicidology.org
• American Foundation for Suicide Prevention www.afsp.org
• SAMHSA TIP 50 Addressing Suicidality in Substance Abuse
Treatment Settings www.samhsa.gov
• National Suicide Prevention Lifeline (NSPL):
•1-800-273-TALK (8255)
• National Suicide Prevention Lifeline (NSPL)
•1-800-SUICIDE
Thank you for attending!
Comments, questions,
Thoughts, or feelings?
Judith Harrington
harringtonjudith@bellsouth.net
About your presenter
• Facilitator of the Birmingham Crisis Center Suicide Survivors support
group for 14 years
• 5 year Member of the National Suicide Prevention Lifeline Training,
Standards and Practices Committee
• Approved Trainer for the American Association of Suicidology and the
Suicide Prevention Resource Center
• President, 2010-2013, two terms, Alabama Suicide Prevention &
Resource Coalition (ASPARC)
• Former Coordinator of the Alabama Suicide Prevention Task Force (20072008), member since 2004
• Professor, developed Suicide Prevention, Intervention, & Postvention
courses, 3 credit hour graduate Counseling Class, UAB, University of
Montevallo suicidology course
• Full time faculty member, University of Montevallo Counselor Education
and part time private practice after 27 years in full time practice.