Suicide Prevention
Robert Tell, LCSW
Amy Guffey, LCSW,
Joe Bertagnolli, MSW,
Victoria Neindow
Today Continued
Nomenclature.
What do we know about suicide?
How can we understand the problem of
Veteran suicide?
What can we do about it.
What do we know about
suicide?
It’s a big problem
– 11th leading cause of death
– 33,000 suicides occur each year in the U.S.
– 91 suicides occur each day
– One suicide occurs every 16 minutes
– More Suicides than Murders
– In Oregon more likely to die by suicide than in
a car accident.
But it’s confusing…
The warning signs: rage, feeling trapped,
increased alcohol use, withdrawing,
trouble sleeping, relationship problems,
etc apply to lots of people
Yet a tiny tiny fraction will ever attempt
suicide.
What about Veterans?
Deployments are a risk factor, yet half the
Army’s suicides never deployed.
There are record numbers of Active Duty
suicides, but
No evidence for increased rates in
OEF/OIF Veterans relative to sex, age,
and race matched people in the population
as a whole.
WHAT’S THE PROBLEM?
1950-2005: Four wars; seven recessions; unprecedented
advancement in diagnosis & treatment of mental illness and
the overall American suicide rate hasn’t changed
Haloperidol,
1962
Chlorpromazine
1952
Amitriptyline
Lithium 1949 1961
MAOIs
1957
Korean War,
1950-53
Vietnam War,
1961-1975
Clozapine
1989
Aripiprazole
2001
Fluoxetine
1987
First Gulf War,
1990-91
OEF / OIF,
2001-present
We aren’t even speaking the same
language
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Suicidal ideation
Death wish
Suicidal threat
Cry for help
Self-mutilation
Parasuicidal gesture
Suicidal gesture
Risk-taking behavior
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Self-harm
Self-injury
Suicide attempt
Aborted suicide attempt
Accidental death
Unintentional suicide
Successful attempt
Completed suicide
Life-threatening behavior
Suicide-related behavior
Suicide
Type
Sub-Type
Non-Suicidal
Self-Directed
Violence
Ideation
Thoughts
Definition
Preparatory
For example, persons engage in Non-Suicidal Self-Directed Violence
Ideation in order to attain some other end (e.g., to seek help, regulate
negative mood, punish others, to receive attention).
For example, intrusive thoughts of suicide without the wish to die would be
classified as Suicidal Ideation, Without Intent.
Acts or preparation towards engaging in Self-Directed Violence, but before
potential for injury has begun. This can include anything beyond a
verbalization or thought, such as assembling a method (e.g., buying a gun,
collecting pills) or preparing for one’s death by suicide (e.g., writing a
suicide note, giving things away).
N/A
•Suicidal Intent
-Without
-Undetermined
-With
• Suicidal Intent
-Without
-Undetermined
-With
For example, hoarding medication for the purpose of overdosing would be
classified as Suicidal Self-Directed Violence, Preparatory.
Non-Suicidal
Self-Directed
Violence
Terms
Self-reported thoughts regarding a person’s desire to engage in self-inflicted
potentially injurious behavior. There is no evidence of suicidal intent.
Self-reported thoughts of engaging in suicide-related behavior.
Suicidal
Ideation
Modifiers
Behavior that is self-directed and deliberately results in injury or the
potential for injury to oneself. There is no evidence, whether implicit or
explicit, of suicidal intent.
For example, persons engage in Non-Suicidal Self-Directed Violence in order
to attain some other end (e.g., to seek help, regulate negative mood,
punish others, to receive attention).
• Injury
-Without
-With
-Fatal
• Interrupted by
Self or Other
•Non-Suicidal Self-Directed Violence Ideation
•Suicidal Ideation, Without Suicidal Intent
•Suicidal Ideation, With Undetermined
Suicidal Intent
•Suicidal Ideation, With Suicidal Intent
•Non-Suicidal Self-Directed Violence, Preparatory
•Undetermined Self-Directed Violence,
Preparatory
•Suicidal Self-Directed Violence, Preparatory
•Non-Suicidal Self-Directed Violence,
Injury
•Non-Suicidal Self-Directed Violence,
Injury, Interrupted by Self or Other
•Non-Suicidal Self-Directed Violence,
•Non-Suicidal Self-Directed Violence,
Interrupted by Self or Other
•Non-Suicidal Self-Directed Violence,
Without
Without
With Injury
With Injury,
Fatal
Behaviors
Undetermined
Self-Directed
Violence
Suicidal
Self-Directed
Violence
Behavior that is self-directed and deliberately results in injury or the
potential for injury to oneself. Suicidal intent is unclear based upon the
available evidence.
For example, the person is unable to admit positively to the intent to die
(e.g., unconsciousness, incapacitation, intoxication, acute psychosis,
disorientation, or death); OR the person is reluctant to admit positively to
the intent to die for other or unknown reasons.
Behavior that is self-directed and deliberately results in injury or the
potential for injury to oneself. There is evidence, whether implicit or
explicit, of suicidal intent.
For example, a person with a wish to die cutting her wrist with a knife
would be classified as Suicide Attempt, With Injury.
• Injury
-Without
-With
-Fatal
• Interrupted by
Self or Other
• Injury
-Without
-With
-Fatal
• Interrupted by
Self or Other
•Undetermined Self-Directed Violence,
Injury
•Undetermined Self-Directed Violence,
Injury, Interrupted by Self or Other
•Undetermined Self-Directed Violence,
•Undetermined Self-Directed Violence,
Injury, Interrupted by Self or Other
•Undetermined Self-Directed Violence,
Without
Without
With Injury
With
Fatal
•Suicide Attempt, Without Injury
•Suicide Attempt, Without Injury, Interrupted by
Self or Other
•Suicide Attempt, With Injury
•Suicide Attempt, With Injury, Interrupted by Self
or Other
•Suicide
Standard Approach to Suicide
Risk
Differentiate between
Acute and Chronic risk
Chronic Risk Factors
 Psychiatric diagnosis
 Substance abuse
 Previous attempts
 Poor self-control/ impulsivity
 Family History of suicide
 History of abuse (physical, sexual, emotional)
 Co-morbid health problems
 Age, gender, race (elderly or young white male)
 Same-sex orientation
Acute Risk Factors
Hopelessness/ desperation/ sense of ‘no way
out’
Current depression
Recent discharge from a psych unit
Current substance abuse or impulsive overuse
Anxiety, panic, insomnia
Pain and physical discomfort (nausea)
Extreme humiliation/disgrace; narcissistic
mortification
Newly diagnosed co-morbid health problem or
worsening symptoms
Break-down in communication/loss of contact
with significant other (including therapist)
Protective (Mitigating) Factors
 Responsibility to children, elder parents, beloved pets
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Religious Faith
Connections to family and community support
Social Role
Purpose and meaning in life
Problem Solving ability
Resilience
Persistence
Positive Coping Skills
Attitudes towards Suicide
“Psychic Toughness”
Positive professional relationship
Suicide Inquiry
 SI-Frequency, duration, and intensity
 Plan
 Preparatory Acts or behaviors and
Rehearsals
 Level of Intent
 Reasons for living, lying and dying
Sum it all up
Assign a level of risk and a treatment plan
based off of that risk.
Document
Thomas Joiner’s Theory
Perceived burdensomeness
The view that ones existence burdens family,
friends, and/or society
“My death will be worth more than my life to
family, friends, society, etc.”
Assessing for Burdensomeness
Would the people you care about be better
of with out you?
Do you feel like you have failed the people in
your life?
Failed belongingness
The experience that one is alienated from
others, not an integral part of family, circle of
friends, or other valued group
 February 22, 1980-lowest # of recorded
suicides in US history
Annual Sunday with lowest # of suicides in US
Assessing for Belongingness
Are you connected to other people?
Do you feel like an outsider in social
situations?
Do you interact with people who care about
you
Assessing acquired ability to
enact lethal self injury
 Do the things that scare most people
scare you?
 Do you avoid certain situations
because of the possibility of injury or
pain?
 Can you tolerate a lot more pain than
most people?
How do we make sense of it?
We can identify a large group of people
who may be at risk.
What’s harder to do is identify which of
that group will actually commit suicide.
Preventing Veteran Suicides
What’s a framework that can help us
understand Veteran Suicide
And try and make a difference?
The Background
Marsha Linehan, Ph.D.
Military Training
• Stay in Reasonable Mind
• If you’re in emotion mind – Act!
The problem
Veterans are too darn capable
Able to cope with too much which leaves
you vulnerable to being swamped.
Units of Distress
Evidence Based interventions
for suicide prevention
Continuity of Care – Mail Programs
Safety Planning?
Treatment – if there’s a mental health
problem it reduces risk, but if there isn’t a
mental health problem does it help?
CAMS, Cognitive therapy for Suicide, DBT
Similarities in evidence based
approaches
Address Suicide Directly
Overt persistent connecting and
collaborative stance
Work as a team
Mail Program
Dr. Motto identified patients who had
made an attempt and then didn’t show for
outpatient care.
Letters were sent for two years without
expectation. The group that received the
letters had fewer suicides than the control.
Recreated in two other studies using cards
and postcards. Being tested now with
texts.
Safety Planning
6 step guide for getting through an
emotional crisis.
STEP 1: RECOGNIZING WARNING SIGNS
-Depressed thoughts and feelings, crying.
-Thinking of loss of best friends and financial issues.
-Experiencing stress, e.g. in traffic.
-Coping with hearing of troubling news regarding wars in the Mideast.
-Panic feelings including shortness of breath and sweating
STEP 2: USING INTERNAL COPING STRATEGIES
-Reading positive materials.
-Taking long, relaxing walks.
-Prayer.
-Walking my dog.
-Listening to music.
STEP 3: SOCIAL CONTACTS WHO MAY DISTRACT FROM THE
CRISIS
-My brother Rob and sister-in-law Sue.
-The gym.
-Drag races.
-Church and Church activities.
-Attending AA meetings.
STEP 4: FAMILY OR FRIENDS WHO MAY OFFER HELP
These are people that I would be willing to talk to about my thoughts of
suicide in order to help me stay safe:
-My Pastor Rex Smith 503-987-6543.
-My dad Thomas Doe 503-234-5678.
-My brother Rob Doe 541 123-456-789.
-My AA sponsor John Greene 503-321-7654.
STEP 5: PROFESSIONALS AND AGENCIES TO CONTACT FOR
HELP
-1-800-273-TALK(8255)press #1 for vets -The Veterans Crisis Line
-Call 911 or come to the Emergency Department (or go to a local ED at
own expense)
Your Therapist
-Portland VA Suicide Prevention Team 503-402-2857 during business
hours
STEP 6: MAKING THE ENVIRONMENT SAFE
 - Discuss means restriction
 - Guns, guns, guns
A shift in focus…
Instead of focusing on getting help during
the crisis…
A shift in focus…
Get help before it becomes a crisis.
Veteran’s Crisis Line PSA
NY Times Hotline Video
Portland VA Medical Center
Suicide Prevention
Robert Tell, LCSW
– Robert.tell@va.gov
– 503-402-2857 or 503-220-8262 x56198
Amy Guffey, LCSW
– Amy.guffey@va.gov
– 503-402-2857 or 503-220-8262 x56493
Joe Bertagnolli, MSW
– Joe.bertagnolli@va.gov
– 503-402-2857 or 503-220-8262 x59423