1. Assessing & Preventing the Risk of Suicide AMY LORENZ, MSSW, LCSW DEPUTY, COMMUNITY ACCESS TO RECOVER SERVICES & DIRECTOR OF CRISIS SERVICES MILWAUKEE COUNTY BEHAVIORAL HEALTH DIVISION

2. Suicidology 101 There is no one factor that causes someone to kill herself/himself Most often there is a complicated and confusing mix of -Current stressors and losses -Old psychological wounds -Genetic or biological factors -A psychiatric illness -Alcohol or other drug abuse issues -A readily available way of dying

3. Common Risk Factors Previous suicide attempt *A past history of suicide attempts is one of the strongest risk factors for death by suicide Availability of lethal means Few available sources of support relationships High-conflict or violent relationships Family history of suicide Substance abuse

4. Common Risk Factors Cont. Life loss or crisis Mental illness History of abuse Serious Illness and/or pain Impulsivity or aggression Barriers to healthcare

5. There is no one cause of suicide and no single type of suicidal person.

6. Protective Factors  We know much more about the protective factors that prevent suicide attempts Lack of serious history No active substance abuse issues Connectedness to other people; supportive family and loved ones Long term medication maintenance and monitoring Specific therapist targeting suicidal thoughts and actions Religious and spiritual affiliation (in some) Pets/responsibilities Good insight HOPE FOR THE FUTURE

7. The Bad News: Predicting Suicidality Studies have tested suicide prediction models based on standard risk criteria-none has demonstrated any ability to predict suicide.

8. Research on this Topic Retroactive review of approx. 200 records in 2009 of California “Tarasoff” cases showed no difference in outcome, despite the use of 3 varying scales Meta-analysis of 556 studies (2011, Edmonton) showed no clinical evidence of any one study helping to predict long term SI/HI instances

9. What Can We Do?: Screen for Suicide Screening for suicide risk should be a universal part of primary care, hospital and emergency department care, behavioral health care, and crisis response intervention. Any person who screens positive for possible suicide risk should be formally assessed for suicidal ideation, plans, means availability, presence of acute risk factors, history of suicide attempts, and level of risk. National Action Alliance for Suicide Prevention

10. Screening Tools Regardless of the setting, if a screen yields a positive result for potential suicide risk, then a full assessment should be completed by a professional with appropriate and specific training in assessment for and evaluating suicide risk. Screening Tools: Columbia-Suicide Severity Rating Scale (C-SSRS) PHQ-9

11. IS PATH WARM?  I deation- Threatened or communicated  S ubstance abuse- Excessive or increased  P urposeless- No reasons for living  A nxiety- Agitation/Insomnia  T rapped- Feeling there is no way out  H opelessness  W ithdrawing - From friends, family, society  A nger (uncontrolled)- Rage, seeking revenge  R ecklessness - Risky acts; Seemingly without thinking  M ood Changes (dramatic)

12. You cannot predict death by suicide, but you can identify people who are at increased risk for suicidal behaviors, take precautions, and refer them for effective treatment.

13. What to do if you think a person is having suicidal thoughts?  Ask the person directly if he or she (1) is having suicidal thoughts/ideas “Are you thinking about killing yourself?” “Have you ever tried to hurt yourself before?” “Do you think you might try to hurt yourself today?” (2) has a plan to do so “Have you thought of ways that you might hurt yourself?”

14. What to do…  (3) has access to lethal means. “Do you have pills/weapons in the house?”  Asking these questions will not increase the person’s suicidal thoughts. It will give you the information that indicates how strongly the person has thought about killing him/herself.

15. What to do… ACT! If you think the person might harm him/herself, do not leave the person alone. Say to the person, “I’m going to get you some help”. Get the person help from a professional that can assess the person’s risk and protective factors to help determine the level of care needed and help the individual create a safety plan.

16. Ways to be Helpful Be aware- learn the risk factors and where to get help Be direct- talk openly and matter-of-factly about suicide Be willing to listen Be non-judgmental Be available Don’t act shocked Don’t ask “why” Offer hope that alternatives are available

17. Ways to be Helpful Cont. Take action- remove the means to harm self Get help from others with more experience and expertise Be actively involved in encouraging the person to see a mental health professional as soon as possible and ensure that an appointment is made

18. The Good News: Prevention and Intervention More and more research findings are being disseminated to the general public and a range of professionals (like yourselves) aimed at prevention and early intervention. More therapists are receiving trainings such as: -Certification in Clinical Suicidology (AAS) -Assessing and Managing Suicide Risk: Core Competencies for Mental Health Professionals (SPRC) -Applied Suicide Intervention Skills Training (ASIST) More therapists are being trained to assess and treat survivors and their families.

19. A Voice at the Table www.voiceatthetable.com A 35 minute documentary highlighting the stories of suicide attempt survivors and those with lived experience Those with lived experience are an inspiration to those who are or who have been suicidal Their words educate all of us working toward suicide prevention

20. Resources American Association of Suicidology (www.suicidology.org)www.suicidology.org American Foundation for Suicide Prevention (www.afsp.org)www.afsp.org Suicide Prevention Resource Center (www.sprc.org)www.sprc.org National Action Alliance for Suicide Prevention (www.actionalallianceforsuicideprevention.org)www.actionalallianceforsuicideprevention.org National Suicide Prevention Lifelines (www.suicidepreventionlifeline.org)www.suicidepreventionlifeline.org

21. References “Advances in Suicidology: What We Know and Don’t Know”; Dr. Michael F. Myers, MD; NSPG 2 nd Annual Suicide Prevention Conference; 2014. “Risk Management”; Dr. Tony Thrasher, D.O.; presentation; 2011. National Suicide Prevention Lifeline; U.S. Department of Health and Human Services; Substance Abuse and Mental Health Services Administration. Suicide Risk Assessment Guide; United States Department of Veterans Affairs.