1. Suicide Prevention Robert Tell, LCSW Amy Guffey, LCSW,
Joe Bertagnolli, MSW,
Victoria Neindow

2. Today Continued Nomenclature. What do we know about suicide?
How can we understand the problem of Veteran suicide?
What can we do about it.

3. 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.

4. 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.

5. 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.

6. WHAT’S THE PROBLEM?
: 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,
Vietnam War,
First Gulf War,
OEF / OIF, 2001-present

7. 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?

8. 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.

9. Standard Approach to Suicide Risk
Differentiate between Acute and Chronic risk

10. 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

11. 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)

12. 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

13. Suicide Inquiry SI-Frequency, duration, and intensity Plan
Preparatory Acts or behaviors and Rehearsals
Level of Intent
Reasons for living, lying and dying

14. Sum it all up
Assign a level of risk and a treatment plan based off of that risk.
Document

15. Thomas Joiner’s Theory

16. 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?

17. 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.

18. 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?

19. 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.

20. Preventing Veteran Suicides
What’s a framework that can help us understand Veteran Suicide
And try and make a difference?

21. The Background
Marsha Linehan, Ph.D.

22. Military Training Stay in Reasonable Mind
If you’re in emotion mind – Act!

23. The problem Veterans are too darn capable
Able to cope with too much which leaves you vulnerable to being swamped.

24. Units of Distress

25. 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

26. Similarities in evidence based approaches
Address Suicide Directly
Overt persistent connecting and collaborative stance
Work as a team

27. 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.

28. Safety Planning
6 step guide for getting through an emotional crisis.

29. 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.

30. 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
-My dad Thomas Doe
-My brother Rob Doe
-My AA sponsor John Greene
STEP 5: PROFESSIONALS AND AGENCIES TO CONTACT FOR HELP
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 during business hours
STEP 6: MAKING THE ENVIRONMENT SAFE
- Discuss means restriction
- Guns, guns, guns

31. A shift in focus…
Instead of focusing on getting help during the crisis…

33. A shift in focus…
Get help before it becomes a crisis.

35. Veteran’s Crisis Line PSA

36. NY Times Hotline Video

37. Portland VA Medical Center Suicide Prevention
Robert Tell, LCSW
or x56198
Amy Guffey, LCSW
or x56493
Joe Bertagnolli, MSW
or x59423