Building Hope with At Risk
Clients:
Connection & Means Restriction
Aimee Johnson, LCSW
Suicide Prevention Coordinator
Portland, Oregon VA Medical Center
Friday July, 2014 Bend, Oregon
Today
• What do we know about suicide?
• What are warning signs & risk factors?
• What are resources and how do we prevent it?
VETERANS HEALTH ADMINISTRATION
Background
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In 2007, the Department of Veterans Affairs began an intensive effort to reduce suicide
among Veterans.
In 2008, VA’s Mental Health Services established a suicide surveillance and clinical support
system based on reports of suicide and suicide events (i.e. non-fatal attempts, serious suicide
ideation, suicide plan) submitted by Suicide Prevention Coordinators located at each VA
Medical Center and large outpatient facility.
In 2010, the VA also began an intensive effort to shorten delays associated with access to
National Death Index (NDI) data and increase understanding of suicide among all Veterans by
developing data sharing agreements with all 50 U.S. states.
The integration of information collected through the NDI, state mortality records, Suicide
Behavior Reports, VA’s Veterans Crisis Line, and the VA’s universal electronic medical records
contribute to an increased understanding of suicide and risk management by identifying gaps
in existing knowledge, opportunities for intervention and the impact of VA-sponsored suicide
prevention programs.
All of these data collection systems have matured to the point where VA can now glean
information to better determine if the current suicide prevention program is having an effect,
where gaps may occur, and where there may be potential improvements for the future.
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What We Know About Veteran suicide
2012 Suicide Date Report VHA Response and Executive Summary
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18-22 is the estimated number of Veterans who die from suicide each day (which
has remained relatively stable over the past 12 years).
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The overall number of suicides nationally has increased although those suicides
reported as Veterans has decreased.
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A majority of Veteran suicides are among those age 50 years and older. Male
Veterans who die by suicide are older than non-Veteran males who die by suicide.
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The majority of Veterans who have a suicide event were last seen in an outpatient
setting. A high prevalence of non-fatal suicide events result from overdose or other
intentional poisoning.
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The most common means of male Veteran suicide is firearms and overdose is the
most common means of female Veteran suicide.
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What do we know about suicide? (AAS 2010)
• It’s a big problem
– 10th leading cause of death
– 38,364 suicides occur each year in the U.S.
– 105.1 suicides occur each day
– One suicide occurs every 13.7 minutes
– 6 new survivors of suicide every 13.7 minutes
– More Suicides (#10) than Murders (#16) (national
– In Oregon more likely to die by suicide than in a car
accident.
– 7th leading cause of death for Men and 11th leading cause
of death for Women in Oregon (Oregon Vital Statistics
VETERANS
HEALTH report
ADMINISTRATION
Annual
2012)
The Face of Suicide in the U.S.(AAS 2010)
• Gender
– Men complete suicide at nearly four times the rate of women.
– Women attempt suicide three times more than men.
• Age –
– Suicide is the third leading cause of death among 25-34 year
olds and the third leading cause among 15-24 year olds
– Persons aged 45-54 years have the highest suicide rate
– One older adult commits suicide every 90 minutes
• Veteran Status -Veterans may be at even greater risk than
those in the general population
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Suicidal Behavior =Provider Anxiety
Those At Risk Struggle to Follow-up with Care
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Suicide is Everyone’s Business, Not just mental
health providers
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Standard Approach to Suicide Risk
• Differentiate between Acute and
Chronic risk
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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
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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)
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Protective (Mitigating) Factors
Responsibility to children, elder parents, beloved pets
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
VETERANS HEALTH ADMINISTRATION
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.
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Thomas Joiner’s Theory
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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?
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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?
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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?
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Preventing Veteran Suicides
• What’s a framework that can help us understand Veteran
Suicide to try and make a difference?
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The Background
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Military Training
• Stay in Reasonable Mind
• If you’re in emotion mind – Act!
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Means Restriction: Dispelling MYTHS
If you stop someone from hurting themselves they’ll just go
somewhere else…
•Seiden, R. 1978 515 People restrained from jumping off the Golden Gate Bridge compared to a group of 184
people who attempted suicide and were taken to San Francisco Emergency Room
•http://www.kevinhinesstory.com/
Interview on CNN
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Portland Vista Bridge Barrier
• Summer 2013 barrier was placed on
Vista Bridge
• "Before the barriers were up, we did not
hear of instances of people being
talked down from jumping, because
people just went and jumped," Novick
tells WW. "People have to work to a
place where they can jump, and it gives
them time to think about it. When they
stop and they think about it, the police get
out there to talk to them.“ Commissioner
Steve Novick
• Estimated 174 suicides since 1924 off the
Vista Bridge
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Guns, Guns, Pills and Guns
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Provide Trigger locks and limit access to pills, discuss means restriction as a
routine practice with clients. Because…
• Gun deaths: Firearms were one of the top five leading causes of injury-related
deaths nationwide in 2010.
• Veterans and guns: Data collected between 2003 and 2006 show that Veterans use
firearms more frequently than the general population in acts of suicide.
• Veterans are, respectively, 1.3 and 1.6 times more likely to use firearms compared
with non-Veterans.
• Guns in homes: Research conducted in 2012 showed that firearms could be found
in roughly 34 percent of homes nationwide.
• Weekly dispensing of medications, securing excess medication, getting rid of old
ones.
• Using a pill box that has the Veterans Crisis Line, adding crisis line information to
pill bottle caps
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Safety Planning
• Provides a prioritized list of coping strategies that are preplanned
• Bolsters Wise Mind during times we may be stuck in emotion
mind or reasonable mind.
• 6 steps that are easy to follow, collaborative, Veteran own
words
• Can be kept on a cell phone app or written in purse, wallet,
home, car
Break in to small groups and come up with some
examples of coping strategies for the safety plan
in the next 5 minutes
VETERANS HEALTH ADMINISTRATION
Safety Planning
STEP 1: RECOGNIZING WARNING SIGNS
-Thinking that I am worthless.
STEP 2: USING INTERNAL COPING STRATEGIES
-Listen to music.
STEP 3: SOCIAL CONTACTS WHO MAY DISTRACT FROM THE CRISIS
-Talking to people at the gym.
VETERANS HEALTH ADMINISTRATION
Safety Planning
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.
STEP 5: PROFESSIONALS AND AGENCIES TO CONTACT FOR HELP
-Veterans Crisis Line 1-800-273-TALK(8255) press #1, or chat veteranscrisisline.net
-Call 911 or come to the Emergency Department
STEP 6: MAKING THE ENVIRONMENT SAFE
- Discuss means restriction
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VETERANS HEALTH ADMINISTRATION
CPRS Documentation associated with Suicide Prevention
Note Title:
Suicide Risk
Assessment
• Positive clinical reminder for depression and PTSD
• Veteran seen first time in ED or MH outpatient setting
• Part of admission H&P to inpatient psychiatric unit
• Within 48 hours d/c from inpatient psychiatric unit
• When Veteran reports or clinician determines a change in their status
Note Title:
Suicide
Behavior Report
• Complete for ALL reported suicidal behavior, attempts or deaths by
suicide
• The first person to receive information about the behavior should
complete the SBR
• One report per behavior, only behavior reported in the last 12 months
Note Title:
Suicide Safety
Planning
• Veteran made a suicide attempt
• Reports suicidal ideation
• Otherwise been determined to be at moderate or high risk for suicide
• Has a high risk for suicide flag
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Suicide Data Report Update January 2014,
Janet E. Kemp, RN, PhD
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Suicide rates among the overall population of VHA users have remained more or
less constant over the past several years
Nevertheless, there are indicators that VHA’s program for suicide prevention has
led to positive outcomes: –Decreased rates of suicide among VHA users with mental
health conditions
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–Decreased mortality in the 12 months following a survived suicide attempt
–Decreased rates of suicide among VHA male users aged 35-64 years
–Decreased rates of non-fatal suicide events*
–Decreased percentage of calls to the Veterans Crisis Line resulting in a
rescue**Recent findings regarding suicide rates in young male Veterans and in
female Veterans call for increased efforts
* See also, page 31 of VA Suicide Data Report, 2012 ** See also, page 43 of VA Suicide Data Report, 2012
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Veteranscrisisline.net
VETERANS HEALTH ADMINISTRATION