Individual Introductions Introduce myself and my qualifications Do Pre-Test
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Important information to know for assessment. May or may not be appropriate for your audience. Prior attempt - best predictor of future behavior is past behavior. Repeat attempters say subsequent attempts are “easier” than initial attempt in that they struggled less with their ambivalence. Family history - suicide modeling as a coping mechanism by family members can be a powerful motivator. Plan: more specific ==> higher risk. Assess means and lethality of means. E.g., a handgun is usually more lethal than a handful of aspirin or jumping off a 3 story building. Resources available may be a positive influence against suicide
Top line is the my recommendation for asking about suicide. Direct questions often elicit direct answers. If you get a ‘yes’ to the top Q, follow-up with the next 4 about current plan and history. This will help you assess your referral options. Generally, the more detailed their plan, the higher the risk. If they have a plan and the means and the means are lethal, a hospital/ER is probably your only referral option. The last 3 questions are useful for additional information: Odds - a followup to the top Q or for additional confirmation. What’s keeping you alive so far - 2 most common answers are family and religion. Can use these as ‘hooks’ Future - gives clue to hopelessness level. If no future, probably high hopelessness which correlates strongly with increased risk.
Suicide awareness in the corrections environment
Suicide Awareness In TheCorrections Environment Guiding Principles for Suicide Prevention
Definition of Suicide“Suicide is a conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual who defines an issue for which the suicide is perceived as the best solution.”Malaise (mal-āz´) a vague feeling ofdiscomfort. A vague feeling of bodilydiscomfort, as at the beginning of an illness.general feeling of fatigue and bodily unease.
Chronic Risk Factors (If present, these increase risk over one’s lifetime.)Perpetuating Risk FactorsDemographics: White, American Indian, Male, Older Age (review current rates1),Separation or Divorce, Early WidowhoodHistory of Suicide Attempts – especially if repeatedPrior Suicide IdeationHistory of Self-Harm BehaviorHistory of Suicide or Suicidal Behavior in FamilyParental History of:- Violence- Substance Abuse (Drugs or Alcohol)- Hospitalization for Major Psychiatric Disorder- DivorceHistory of Trauma or Abuse (Physical or Sexual)History of Psychiatric HospitalizationHistory of Frequent MobilityHistory of Violent BehaviorsHistory of Impulsive/Reckless Behaviors
Predisposing and Potentially Modifiable Risk FactorsMajor Axis I Psychiatric Disorder, especially:- Mood disorder,- Anxiety Disorder- Schizophrenia- Substance Use Disorder (Alcohol Abuse or DrugAbuse/Dependence)- Eating Disorders- Body Dysmorphic Disorder- Conduct Disorder…Axis II Personality Disorder, especially Cluster B
National Stats 2008There is a suicide every 14.6 minutes900,875 Attempts per year (every 35seconds)25 attempts for every 1 death3 female attempts to 1 male
Jail Suicide Research 2005-06696 Jail Suicides in the 2005-06 StudyIn 1980’s, rate of suicide in county jailswas approx. 107 deaths per 100,000inmates or an approx. rate of 9 timesgreater than the community.2005-06 Data indicate a decrease to 36deaths per 100,000.
Jail Suicide Research, Nat’l 2005-06 (1986 stats)67% of Victims were White (72%)93% Male (94%)Average age was 35 (30)42% Single (52%)43% Personal/Violent Charges (75% nonvio)47% History of Substance Abuse Problems (27%)28% Medical Problems28% Mental Health Diagnosis20% Psychotropic Medication34% History of Prior Suicide Attempt
Suicide Characteristics 2005-06 DataSeasons and Holidays did not account forincrease in suicidal behavior.32% Between 3:01 PM and 9:00 PM23% in the first 24 Hrs.27% in 2-14 days.20% 1-4 Months38% in Segregation
Jail EnvironmentSuicide the #1 cause of death in jails Why?New or Authoritarian EnvironmentLack of controlShame and fearDehumanizing aspects of incarcerationLack of family/social supports
Common myths about Suicide Happens without warning Low risk after mood improvement Once suicidal, alwaysDon’t mention suicide suicidal Intent on dying So rare, they won’t do it Runs in the family No note ==> no suicide
Careful, Thorough BookingThe most important interaction is at bookingObserve signs/symptoms and interact witharresting officerAsk all questions, don’t assume.Don’t get casual (lazy) on the screeningAsk more clarifying questions if neededBe genuine real caring, look at the personRefer to medical/mental health if concerns
Medical ScreeningObserve the Mood and Affect of Pt.Don’t go through the questions too fastIf there are any concerns, Refer to MH
IdentificationCurrent Depression orSevere AnxietyPsychosis or Paranoia,DelusionalDirect or Indirect SuicidalCommentsHopeless/Helpless,BurdensomeBehavior Changes-sleeping, eating etcMood variations, shame,guilt, isolationAgitation, Rage
High Risk PeriodsFirst 24 HoursIntoxication or substance withdrawalWaiting for Trial or sentencingImpending releaseHolidaysDecreased staff supervisionBad news after phone calls or visits, courtSerious Charge/High Profile
Mental HealthRates of Mentally ill inmates increasingLess funding for treatmentNot compliant to treatmentLack of treatment resourcesIncarceration usually the path of leastresistanceIncreases risk of self-mutilation and SI
Symptoms of Mental IllnessProlonged anxiety or panicAbrupt mood changesHallucinationsSevere paranoia and delusionsGrandiosity (I’ll take on the whole dorm)Confusion, disorientationProlonged severe depression
Behavior IndicatorsLoss of appetite orovereatingSleep problems, toomuch or too littleUnusually slow reactionsSocial withdrawalPacingReckless BehaviorGiving things away,writing will, trying to repairold relationshipsSelf-mutilation
InterventionsTry to calm inmate and relieve anxiety bybeing calm, confident, firm, fair, andreasonable.Explain how you see the problem, what isbeing done and what the outcome will be.Do they need a time-out?Is housing appropriate?Instill hopeDispel thoughts of being a burden
Major Predictors of Suicidal Behavior• Current plan: • Specificity of their plan • Availability of means • Lethality of method• Previous History: • A prior suicide attempt • A family history of suicide behaviors• Resources available
ASIST TrainingApplied Suicide Intervention Skills TrainingConnect- Inmate invitesUnderstand- Staff Clarifies-Suicide CPRAssist- Create a Plan and Follow-up
Important Questions/AssessmentHave you been thinking of hurting or killing yourself?How would you kill yourself?Do you have the means available?Have you ever attempted suicide?Has anyone in your family attempted or completedsuicide?What are the odds that you will kill yourself?What has been keeping you alive so far?What do you think the future holds in store for you?Follow Your Gut!
If YesDiscuss with Detention StaffHave Pt. placed in Suicide SmockPut in appropriate housing on a 15 mindocumented watchBest to keep in for 24 hoursHave the Pt. on MH caseload until clearedSometimes we need to make time to talk
Serious Attempt or CompletionCISM Defusing within 24 Hours for staffand inmates.CISM Debriefing as soon as it can bescheduled for staff and inmates.Follow-Up as-needed.Effects can last months to years if notaddressed effectively and appropriately.
Toward a Better Understanding of Suicide PreventionWe do an admirable job of managinginmates identified as suicidal and placedon precautions.Very few inmates successfully commitsuicide while on suicide watch.How do we prevent suicide of an inmatewho is not easily identifiable as being atrisk for self harm?
Guiding Principles for Suicide PreventionThe assessment of suicide risk should notbe viewed as a single event, but as an on-going process.Intake screening should be viewed assomething similar to taking one’stemperature – it can identify a currentfever, but not a future cold.
Guiding Principles for Suicide PreventionPrior risk of suicide is strongly related tofuture risk.Do not rely exclusively on the directstatements of an inmate who denied thatthey are suicidal and/or have a priorhistory of suicidal behavior, particularlywhen their behavior, actions and/or historyspeak louder than their words.
Guiding Principles for Suicide PreventionMany preventable suicides result frompoor communication amongst corrections,medical and mental health staff andinmates.Avoid creating barriers that discourageinmates from accessing mental healthservices.
Guiding Principles for Suicide PreventionCreate more interaction between inmates andcorrectional, medical, and mental health staff in“special housing units.”Create and maintain a comprehensive suicideprevention program that includes the followingessential components: Staff Training, Intake,Screening/Assessment, Communication,Housing Levels of Observation, Intervention,Reporting, Follow-up, Review
Legal LiabilityGrossly Negligent“Deliberate indifference”Definition: “knows of and disregards anexcessive risk to inmate health and safety; the official must both be aware of thefacts from which the inference could bedrawn that a substantial risk of seriousharm exists, and he must also draw theinference”
Rolling Back-UpRemember our Officers and other Staff.