1. Lets talk about...S* ( Hunanladdiad) Suicidal behaviour is a complex phenomenon that usually occurs along a continuum, progressing from suicidal thoughts, to planning, to attempting suicide, and finally dying by suicide. Source: International Association for Suicide PreventionInternational Association for Suicide Prevention

2. Lets talk about...S* Suicide is an outcome of a process within a person’s life. Suicidal behaviour is a complex phenomenon that usually occurs along a continuum, progressing from suicidal thoughts, to planning, to attempting suicide, and finally dying by suicide. Source: International Association for Suicide PreventionInternational Association for Suicide Prevention There is a development of predisposing, precipitating and even perpetuating events and experiences. During this process, there are choice points where suicide can be made less likely. Some of these are choices available to a person at risk and some are choices made by others or even by society at large. Lester (2000) Why People Kill Themselves: A Summary of Research on Suicide Generally suicide is underreported or included in other figures (misclassified) relating to road accidents etc. http://www.samaritans.org/sites/default/files/kcfinder/files/Suicide%20Statistics%20R eport%202012.pdf

3. How do we talk about suicide? Hunanladdiad

4. Factors associated with increased risk Predisposing Gender Age 14-25, over 75 * in Wales, the age group with the highest number of suicide for males is 15-44 years; for females the age group with the highest number is 45-74 years. Samaritans (2012) Relationships ; absence of a life partner Social Isolation Mental health problems; Schizophrenia, mood disorders, PTSD, Bi-polar, organic disorders, Personality Disorders Addictions Unemployment / retirement; some links to economic factors Occupational Group; access to lethal means & understanding of toxicity Precipitating History of childhood abuse Adult sexual assault Previous attempts or family history of suicide Physical illness Recent trauma Ref: Reeves. A (2010, Pages 31-38 ) ‘Counselling Suicidal Clients’ for analysis of risk factors & Research Evidence

5. To A or not to A, that is the question Reeves (2010) acknowledges that for some counsellors assessment is an integral part of their work; from referral, to review, to end of therapy, for others however the issue of assessment can present personal and theoretical challenges … We may miss, dismiss or avoid the opportunity to recognise the risk, assessing Risk demonstrates; that we take client safety seriously Here are some potential benefits to general assessment: Establish rapport, explore strengths & weaknesses of the client & support networks, gathers information about expectations Shares information about the therapy and issues of disclosure & consent Enables client to select treatment & therapist; client choice Provides data of audit, research; evidence based practice

6. An outline structure for assessment Presenting problem How the client defines their problem, how long it has lasted, rate the severity (Likert Scale) have they tried to improve the problem, what makes things better / worse Functioning Impact on; sleep, appetite, concentration, what support is available, does the person feel able to ask for help / support, how does the client rate their ability to cope Relationships Current family / family or origin, genograms, how does the client describe the quality of their relationships, relationship history Medical History History of emotional or psychologcial distress, substance use, prescribed medications, physical health, previous diagnosis Sense of Self Self confidence, self esteem, does the client feel valued by others, Self Concept Risk Thoughts of suicide? Long standing? Impulsive? Persistent? How does the client mange these thoughts? Self Harm? Previous thoughts or acts of harm to others? Does the client appear to be neglectful of self? Psychological Mindedness What brings the client to counselling now? What is the client’s understanding of counselling, what is their expectation? How does the client relate to you; eye contact, use of ‘emotional language’? Do you have the capacity or experience to work with the client? Do you need to refer to specialist services? Does the client appear willing and able to engage in a therapeutic process? Link this to a client you have encountered recently

7. CORE-OM CORE Systems Group (1998) www.coreims.co.uk Use of CORE can offer one means of identifying high suicide risk Any assessment tool needs to be used in conjunction with and not to replace dialogue with the client regarding suicide risk Counsellors can use session notes to document the nature & degree of risk presented, how they have responded to it & any agreements in respect of safeguarding Use of a system for assessing suicide risk demonstrates the issues have been explored however, we must be cautious not to over rely on assessment tools to predict suicide risk as they will only reflect what the client chooses to disclose “Risk factors are framed not only by their meaning for the client...but by the context in which they are being interpreted” Reeves (2010 p43) Becks suicide intent scale shortened versionBecks suicide intent scale shortened version : h ttp://www.btinternet.com/~p.g.h/newfiles/suicide-25.htm ttp://www.btinternet.com/~p.g.h/newfiles/suicide-25.htm TASR Toolkit for Assessment of Suicide Risk http://bestpractice.bmj.com/best-practice/monograph/1016/diagnosis/step-bystep.html HADS Hospital Anxiety & Depression Scale

8. Talk To Me: A National Action Plan to Reduce Suicide & Self Harm in Wales (2008-13) http://www.wales.nhs.uk/documents/talktomee[1].pdf A culture of prevention pervades, this is reflected in policy & procedure resulting in a lack of harmony between autonomy & the need to intervene This strategy document identifies 7 ‘Commitment areas’ To help people feel good about themselves; talking about feeling s& problems, address shame & stigma, reduce inequality, develop ‘healthy environments’ improving awareness Ensure early action is taken; provide more support services, access to information, improving diagnosis, help & treatment, quick response specialist services Responding to crises; ensure people know about mental health services, increase understanding of self harm amongst professionals, monitor services Dealing with the effects of suicide & self harm; improving care and support for families, professionals & communities Increase research & information; encourage research & make information available, monitoring rates of suicide & SH, establish a national group to look at needs Work with the media to ensure sensitive reporting; discuss MH issues with the media, improve reporting of ‘incidents’ in line with national media guidance (with GOV Depts & Sams) to deliver positive MH messages http://www.mediawise.org.uk/www.mediawise.org.uk/files/uploaded/The%20Media%20and%20Suicid e%20.pdf Restrict access to things that could be used for suicide; access made difficult for those at risk, ensuring institutional settings are safe

9. Working with Suicidal clients Reeves (2010 p108-114) Establish Rapport; If clients are distressed or agitated basic grounding techniques can be used: Breathing Techniques, Noting Support ‘I am here to support you in whatever way I can’. Establishing Contact in the room; bringing the client back into the space, notice the clock on the wall, remind yourself you are safe. Explore: feelings, thoughts, understanding of the client’s problem, gently moving to a position of identifying ways forward Focus; thinking & feelings, ‘what is the best way I can support you at the moment?’, ‘What needs to be in place to help you feel safer?’ Develop action plans; consider short & medium term goals, immediate concern is to enable the client to lower the presenting risk, then to move to address the difficulties that have led them to suicidal ideation and to identify realistic alternatives Ending; when ending a session ensure that the client is no longer ‘high risk’: Who is available to offer support Who could be contacted in a crisis What would prevent to client contacting someone Do formal arrangements need to be in place Does the client need information / contact numbers etc Are ‘additional’ sessions appropriate or available How will the client help themselves to be safe?

10. Accountable Professional practice “ The counsellor is able to articulate to themselves, their client and their agency a clear an informed rationale for the professional decisions made... saying that a decision was based on ‘gut feeling’...or ‘counter transference’ does not do justice to the complex thinking that has almost certainly resulted in the outcome... having to account for decisions in a coroner’s court, arguing that practice decisions were made on ‘gut feeling’ is not likely to get you very far... a clearly thought through plan based on the available information, drawing on theory and knowledge is much more likely to be self supporting.” Reeves (2010, p146)