Lifeline Safety Assessment Model Updates on the Lifeline Safety Assessment Model Shye Louis, M.Ed, Coordinator – Best Practices in Suicide Prevention National Suicide Prevention Lifeline National Crisis Center Conference October 19 2018

Disclaimer The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services.

Overview What are the Lifeline Risk Assessment Standards? Why develop a new assessment? What is the new Safety Assessment and how did Lifeline develop it? Impact for staff and for consumers Q&A

National Suicide Prevention Lifeline Over 160 crisis centers nationwide Linked via 800-273-TALK or 800-SUICIDE Extensive back-up system ensures all calls are answered Both phone and chat based services Centers must adhere to Lifeline established standards Over 2 million calls answered in 2017

Background: Lifeline Process IDENTIFY BEST PRACTICES STANDARDS, GUIDELINES & POLICIES IMPLEMENT TRAINING & T.A. EVALUATION

Lifeline Risk Assessment Standards Lifeline Suicide Risk Assessment Standards (SRAS) (2006) Require three prompt questions Are you thinking of suicide? Have you thought about suicide in the last two months? Have you ever attempted to kill yourself? Full suicide risk assessment Suicidal Desire Suicidal Capability Suicidal Intent Buffers/Connectedness

Lifeline Imminent Risk Guidelines Policy for Helping Callers at Imminent Risk of Suicide (2011) Focus on Active Engagement - make reasonable efforts to collaborate with callers at imminent risk to better secure their safety Active Rescue - take all action necessary to secure the safety of a caller and initiate emergency response with or without the caller’s consent if unwilling/unable to take action Collaboration with other community crisis and emergency services

Why Review SRAS? Decade passed since development Is SRAS consistent with developments in field? Two policies (SRAS/IR) that really need to be one guideline Must address crisis center feedback So many risk factors what to do with them Are some elements more important than others? Concerns regarding rote check off approach Continued requests for scale to predict risk

Lifeline Committee Guidance Maintain the Lifeline four core principles – desire, intent, capability, buffers Provide guidance not just on WHAT to ask but WHY and HOW Develop model based on hotline call flow that Emphasizes connection to the caller Focuses on safety at its core Emphasizes safety and prevention over prediction

About Assessment of Risk Cannot predict who will die by suicide Risk factors, warning signs, drivers Use of scales BUT Many more people think about suicide than make an attempt Limited knowledge on what moves people from ideation to action We do know that the time between ideation to attempt can often be short

Ideation to Action Deisenhammer et al. (2009) Interviewed 82 patients three days after suicide attempt 47.6% (N=39) reported that the period between the first current thought of suicide and attempt was 10 minutes or less. Those patients in which this process had taken longer showed a higher suicidal intent Millner, Lee and Nock (2016) Interviewed 30 patients that had recently attempted suicide Noted onset of suicidal ideation and selection of method often occurred years prior to an attempt However, majority of proximal steps down the pathway to suicide occurred within a week and most within 12 hours of the attempt Many also reported absence of SI until just before attempting

Ideation to Action (contd.) Short time span underscores Role crisis hotlines play Need to focus on safety for now Need for preventative measures – safety plan to be in place for all those at risk

Model Emphasis Phase 1: CONNECT Attention to connection Early and direct focus on suicide – past and present Assess if an attempt is already in progress Safety formulation from the start

Model Emphasis Phase 2: LISTEN TO THE NARRATIVE CLARIFY PLAN Attention to connection Gather information to formulate safety Pay attention to drivers of suicidality CLARIFY Fill in the gaps Desire, Intent, Capability, Buffers PLAN Focus on safety and prevention Use all information gathered to develop safe plan Develop safety plan regardless of risk status

Updated Emphasis on Safety Considerations The contents of the table below will be familiar to crisis centers as the four core principles of the Lifeline Risk Assessment Standards. Crisis centers within the Lifeline network are required to develop a risk assessment that includes all subcomponents contained above – but, as mentioned earlier in this paper, what to ask callers, when to ask, and most importantly HOW to ask about these elements can be difficult to determine and the need to ask about every component is not always necessary.

Model Emphasis Phase 3: OFFER FOLLOW-UP WRAP UP THE CALL

Consistent with leading approaches Assessment and Management of Suicide Risk (AMSR) Pisani, Murrie, and Silverman (2016) Consistent with the Lifeline perspective on moving away from a formulation based strictly on risk labels Stress prevention over prediction and a formulation of risk that is “anchored in the clinical context and patient population in which the assessment occurs” Risk formulation should lead directly to intervention strategies anchored in context and time ASIST 11 Risk is reframed as threats to safety Focus on Safety-for-Now

Strategies for Safety Addresses the connection between WHAT to assess HOW to assess it WHY you’re assessing it and the “SO WHAT” – how does the crisis counselor use that information to collaborate with the caller to address the need for safety?

Example What: Psychological Pain How: “If your current situation didn’t change, could you tolerate the way you feel? (one of several sample questions available to crisis counselors) Why: Psychological Pain is a strong contributor to suicidal desire Strategies for Safety: Listen and validate feelings, allow the person's pain to be heard Collaborate with the person at risk to discuss internal coping strategies that can help de-escalate negative feelings and self- soothe Explore the feeling of pain and clarify desire to die: "It sounds like what you are describing is not so much wanting to die, as it is wanting and needing this pain to end.“ If the desire is more for the pain to end then death, the crisis counselor can highlight this as a need to stay safe for now until additional ways to relieve some of the pain can be put into place

Safety Assessment Tool Online safety assessment resources provide: Brief skill based modules to highlight core content and demonstrate effective interviewing techniques Videos, sample prompts/questions, counselor tips, summary of WHY, literature, data sources, printable tip sheets

https://projects.invisionapp.com/share/QCI3K E58NM5#/screens/323232818

Discussion How will the revised approach better serve individuals at risk? How might operations feel different on both the crisis center side and for the caller at risk?

Questions SARAH We will now turn to questions. Q&A!

Contact Info Shye Louis Coordinator – Best Practices in Suicide Prevention 646-738-6287 slouis@vibrant.org