SUICIDAL CLIENTS:
Assessing and Managing Risk
2011 SUD CONFERENCE
Lansing, MI
September 12, 2011
Jim Bottenhorn, MA, LLP
Forest View Hospital
TRAINING OUTLINE
 Understanding Suicide
Terms & Statistics
 Attitudes and Emotions that Affect Outcomes
 Common emotions
 Risk and Protective Factors
 Interviewing Skills for Eliciting Accurate
Information
 Formulating a Risk Assessment
 Developing a Safety Plan
 Policy, Procedures, Practices
 Documentation

Suicide
Prevention
SUICIDE PREVENTION
• 50% of persons who die by suicide never


receive any form of help
Persons may not spontaneously report suicide
ideation but 70% communicate their intentions to
family/friends
50% of persons who die from suicide, die as a
result of their first try
One only finds what one looks for,
One looks for what one knows.
~ Goethe ~
Terms and
Usage AND USAGE
SUICIDE
TERMS
Completed Death or Death by Suicide: Self-inflicted
death where there is evidence that the act was
intentional and led to the person’s death
Suicidal Ideation: Thoughts of causing one’s death.
Ideation may vary in seriousness depending the
specificity of suicide plans and the intent.
Non-suicidal self-injury: Self-inflicted injury with no
intention to die.
Terms andTERMS
Usage AND USAGE
SUICIDE
Suicide Attempt: Self-injurious behavior with a non-fatal
outcome with evidence that the person intended to die.
It is considered an attempt even if the person had some
ambivalence about wanting to die (Hine’s slide)
Suicide Attempt Survivors: Individuals who have survived
a prior suicide attempt
Suicide Survivors: Family members, significant others, or
friends and acquaintances who have lost a loved one
due to suicide. It is estimated that there are at least six
survivors who are directly affected by each suicide.
NATIONAL
SUICIDE
DATA
National
Suicide
Data
• In 2007 there were 34,598 suicides in the U.S.
That’s about 95 suicides per day, (of which 80% or
76 were men), or one suicide every 15.2 minutes.
• Suicide attempts account for 670,000 ER visits per
year.
• Suicide is the 3rd leading cause of death for
persons aged 15 to 24 and the second leading
cause of death among college students.
National
SuicideSUICIDE
Data
NATIONAL
DATA
• Approximately one fourth of all suicide deaths in
the U.S. are individuals with a chemical
dependency. (Murphy & Wetzel, 1990)
• Lifetime prevalence of completed suicide in
alcoholics is 7%-15%. (Inskip et al., 1998, Murphy et
al., 1992, 1979)
• Alcohol intoxication is indicated in as many as 64%
of all suicide attempts.
• Childhood sexual abuse is the strongest and most
independent risk factor for suicide attempts,
accounting for 9 to 20% of suicide attempts.
ATTITUDES AND EMOTIONS
 Our attitudes can and do leak out and
affect outcomes
 Identify, monitor and manage our
emotions
 Common emotions associated with
suicide
 Fear, Hopelessness, Anger,
Frustration
ATTITUDES AND EMOTIONS
 Clinical anxiety can disrupt judgment
 Denial, avoidance
 Relying solely on “gut” reactions
 Power struggles
 Minimizing attempts
 Hospitalization biases; a panacea or a
failure
ATTITUDES AND EMOTIONS
Negative emotional reactions may lead
to:
 Feelings of aversion, rejection,
abandonment
 Failure to disclose true feelings
 Withdrawal from the therapeutic
relationship
KEY RISK FACTORS
 Prior Suicide Attempt
 Major depression
 Substance use disorders
Other Risk Factors:
 Other mental health disorders
 Chronic pain
 Insomnia
 PTSD,
 TBI
 Recent losses or events leading to shame
SUICIDE RISK FACTORS
- Know what to look for Current and Past Psychiatric Diagnoses:
While 90% of suicides are associated with mental illness,
over 95% of those diagnosed with a mental disorder
never attempt suicide.
Mood disorders, depressed or mixed (bipolar) phase),
psychotic disorder, alcohol/substance use disorders,
personality disorders or traits, eating disorders and
anxiety disorders.
Warning Signs:
Loss of interest or pleasure (anhedonia), impulsivity or
recklessness, anger, hopelessness or despair, social
withdrawal, insomnia, substance use, giving away
possessions, making final preparations/getting one’s
affairs in order; recent onset of illness.
Suicide
Risk
Factors
SUICIDE
RISK
FACTORS
-- Know
Know what
what to
to look
look for
for --
Suicidality: Current suicide ideation, intent, plan. Recent,
or history of, attempts, aborted or rehearsed attempts, or
non-suicidal self injury.
Family History: Suicide, attempts (first-degree relatives
2.6 times greater risk) or a psychiatric diagnosis
requiring hospitalization (1.3 times greater risk).
Precipitants/Stressors: Triggering events leading to
humiliation, shame or despair, e.g., relapse, loss of
relationship, disciplinary action, financial, or health
status, contagion (esp. youth), ongoing medical illness,
chronic pain, and/or intoxication.
SUICIDE RISK FACTORS
- Know what to look for • Access to firearms: Availability of guns to the
individual
• Physical Illnesses: Certain medical diagnoses
and conditions are associated with higher risk of
suicide including:
• cancer, HIV/ AIDS, kidney failure requiring dialysis, pain
syndromes, functional impairment including brain injuries
(TBI), diseases of nervous system, especially multiple
sclerosis, and epilepsy
SUICIDE RISK FACTORS
- Know what to look for Childhood Trauma: Sexual/physical abuse,
neglect, parental loss
Demographic: Male; elderly group; gay/lesbian/bisexual; widowed, divorced or single, particularly
for men
Other High Risk Markers: perceived burdensome,
alienation/loneliness, routine exposure to death
(veterans,physicians/police) T. Joiner
SUICIDE RISK FACTORS

1.
2.
3.
4.
5.
6.
Hendin, et all, (2006) reviewed case narratives of
36 therapists who had patients die by suicide; 6
recurrent problems were identified:
Poor communication among treaters
Permitting patients and/or relatives to control
treatment
Avoidance of sexuality issues
Ineffective or coercive measure taken due to
therapist’s anxieties re. patient’s potential suicide
Not interpreting patient’s communications
Untreated or undertreated symptoms
Predictors of Suicide Attempts in
Alcoholics (n=1,237) over 5 years?
Rate = 4.5% attempted suicide
 Prior attempts
 Earlier onset and more severe dependence.
 Other drug dependence
 Separated or divorced
 More likely to have had treatment (more severe)
 More Panic
 More Substance Induced Psych Disorder
Preuss/Schuckit et al Am J
SUICIDE PROTECTIVE FACTORS
• Identify protective factors – enhance
whenever possible. (The presence of
protective factors does not counteract significant
acute suicide risk)
• Internal factors: Ability to cope with stress,
religious beliefs, frustration tolerance, absence
of psychosis. (“How have you made it through all
this?”)
• External factors: Responsibility to children or
beloved pets, positive therapeutic relationships,
social supports, AA/NA, sponsor, etc.
ELICITING INFORMATION
 It is a myth that talking about suicide with a
person who may be thinking about suicide will
cause the person to attempt to kill themselves.
 Research has repeatedly shown that in fact the
reverse is true - once a person has been asked if
they are thinking of suicide, they feel relief, not
distress; anxiety decreases, hope increases, and
hopefulness reduces the risk of suicide.
ELICITING INFORMATION
 Indirect questions, should always be followed
by direct ones
 Question collateral sources whenever possible
 Utilize self-report tools and review answers
 Normalization “Others in similar positions have
reported…”
 Shame Attenuation (Shea, 1998) “With all that you
have been through, I wouldn’t be surprised if …”
ELICITING INFORMATION
 Gentle Assumption (Pomeroy, Flax & Wheeler, 1982)
 Not “Do you use other drugs”, rather “What other
drugs…” “Tell me about …”
 Symptom Amplification (Shea, 1998)
Counters the impulse to minimize
 Behavioral Incident (Pascal, 1983) “How
many pills did you take (not take)?, Did you load the
gun?, What did you do then”?
 Denial of the Specific (Shea, 1998)
 More accurate responses when asked specific vs.
general questions
RISK FORMULATION
Never rely solely on one piece of information
Risk assessment deals with probabilities, not
predictions
Consider the following when formulating risk:
1. Risk and protective factors
2. Diagnoses
3. Mental status
4. Suicidality
5. Intention of client
S.L.A.P.
(SLAP) Suicide Assessment Tool
A Suicide Assessment Tool
SLAP, is an acronym for a quick and easy way to assist in
assessing suicide risk. However, no objective screening or
assessment tool is 100% effective in assigning accurate risk,
and is there is no substitute for a professional clinical
assessment
• Specificity. How specific is the plan to complete suicide?
• Lethality. What is the perceived lethality of the planned
attempt?
• Availability. How available are the means?
• Proximity. What is the proximity of rescue?
THE SAFETY PLAN
The plan should be collaborative, using the client’s
words, and be concise. Assess barriers to each
step and person’s willingness and capacity to
comply. Develop a support plan for SO’s.
1. Identify triggers to avoid; people, places, etc.
2. List warning signs: how will you know when
you need to use the plan, what will you notice?
3. Suggested coping skills; what helps, including
activities that are distractions?
THE SAFETY PLAN
4. Identify supportive contacts with phone
numbers.
5. Identify agencies or support groups that can
help: AA/NA, etc.
6. Making a plan to remove lethal means;
firearms, stockpile of meds, etc.
Review and update the plan periodically,
especially if there are any major changes
Discuss where copies of the plan should be
placed
DOCUMENTATION
 If it is not written down, it didn’t happen
 Document risk formulation and your rationale
 Remember that protective factors do not
counteract acute high risk
 When in doubt, always consult
 Different clinicians can have different high risk
thresholds
 Clinicians get sued for not following usual
practice, not for poor clinical judgment
POLICY, PROCEDURE,
PRACTICES
Develop a crisis plan to manage suicide risk
Staff should view suicide risk as an expectation



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Client self-assessment tool; symptom checklist
Suicide assessment guide, SAFE-T card
Safety plan template
Protocols to manage crises; who calls police, etc.
Involuntary process, current petitions & certs on
hand, identify physician/FLP to complete
certifications
Relationship with local police and CMH
SUMMARY
• “Suicide is the most preventable death” and
risk should be expected with MH/SA clients
• There are almost always warning signs that
someone is thinking about suicide.
• Look for warnings signs and risk factors
• Always take talk of suicide seriously, even if
it is said in a joking manner.
• Design practices to better screen, assess
and manage suicide risk
RESOURCES
 Suicide Prevention Resource Center, SPRC,
and the AMSR Core Competencies for
Mental Health Professionals.
 The American Association of Suicidology
 Thomas Joiner, PhD, Florida State Univ.
 Survivors of Suicide
 QPR Institute, Paul Quinnett, Ph.D.
 Screening for Mental Health, Douglas G.
Jacobs, M.D.
RESOURCES
American Psychiatric Association Practice Guidelines
Richard Ries, MD Harborview Medical Center and the
University of Washington,Seattle, Washington
www.samhsa.gov Substance Abuse and Mental
Health Services Administration:
www.sprc.org – Suicide Prevention Resource Center
(for suicide prevention basics and training
resources) Publications: (877) 726-4727
www.suicideology.org – The American Association of
Suicidology (an education and resource
organization)