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 Clozapine 1989 Chlorpromazine 1952 Aripiprazole 2001 Amitriptyline 1961 Lithium 1949 Fluoxetine 1987 MAOIs 1957 Korean War, 1950-53 Vietnam War, 1961-1975 First Gulf War, 1990-91 OEF / OIF, 2001-present

We aren’t even speaking the same language Suicidal ideation Death wish Suicidal threat Cry for help Self-mutilation Parasuicidal gesture Suicidal gesture Risk-taking behavior Self-harm Self-injury Suicide attempt Aborted suicide attempt Accidental death Unintentional suicide Successful attempt Completed suicide Life-threatening behavior Suicide-related behavior Suicide This list highlights how difficult it is to accurately & reliably talk about & understand suicide and related behaviors & communications. Do you notice any terms that might be considered pejorative? Are there any that you are not familiar with? Are there some that seem synonymous with others?

Type Sub-Type Definition Modifiers Terms Thoughts Non-Suicidal Self-Directed Violence Ideation Self-reported thoughts regarding a person’s desire to engage in self-inflicted potentially injurious behavior. There is no evidence of suicidal intent. 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). N/A Suicidal Ideation Self-reported thoughts of engaging in suicide-related behavior. For example, intrusive thoughts of suicide without the wish to die would be classified as Suicidal Ideation, Without Intent. Suicidal Intent -Without -Undetermined -With Suicidal Ideation, Without Suicidal Intent Suicidal Ideation, With Undetermined Suicidal Ideation, With Suicidal Intent Behaviors Preparatory 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). For example, hoarding medication for the purpose of overdosing would be classified as Suicidal Self-Directed Violence, Preparatory. Non-Suicidal Self-Directed Violence, Preparatory Undetermined Self-Directed Violence, Suicidal Self-Directed Violence, Preparatory Non-Suicidal Self-Directed Violence 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 -Fatal Interrupted by Self or Other Non-Suicidal Self-Directed Violence, Without Injury, Interrupted by Self or Other Non-Suicidal Self-Directed Violence, With Injury Non-Suicidal Self-Directed Violence, With Injury, Interrupted by Self or Other Non-Suicidal Self-Directed Violence, Fatal Undetermined 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. Undetermined Self-Directed Violence, Without Undetermined Self-Directed Violence, With Injury Undetermined Self-Directed Violence, With Undetermined Self-Directed Violence, Fatal 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. Suicide Attempt, Without Injury Suicide Attempt, Without Injury, Interrupted by Suicide Attempt, With Injury Suicide Attempt, With Injury, Interrupted by Self or Other Suicide We’ll now introduce to you the VISN19 MIRECC-CDC SDV Classification System. Please access your first handout, which is the classification system. As we transition into reviewing the actual materials, we want to reiterate that in its present form, the nomenclature is NOT a suicide risk assessment tool. The hope would be that we can eventually build upon the nomenclature to better assess risk, but we’re not to that point yet. The first order of business is to make sure that we are all describing self-directed violence in a way that is understandable to us all.

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 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 Feb 22nd Team USA won Gold medal Lowest # of recorded suicide for that day (2/22) What was happening at that time Iran crisis hostage situation was in 111th day. The soviet union had invade Afghanistan 30 before. During this research Joiner discovered most suicides happen on a Monday.

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