The Nurses’ Global Assessment of Suicide Risk (NGASR)

New! This article has been updated August 9, 2016 to include more information about the scoring and links to useful tools to accompany.

The Nurses’ Global Assessment of Suicide Risk (NGASR) is a tool that nurses can utilize to assess for suicide risk in a clinical, inpatient environment. The tool was originally developed to assist nurses in a UK hospital where suicide risk assessments were originally completed by an intake nurse, without any backup or support to ensure they were done properly.

This DVD series provides videos and vignettes to help you learn suicide and depression assessment and intervention

Suicide risk assessment takes a lot of experience and practice, and the NGASR is one tool that can provide assistance while nurses develop these critical skills.

Indicators of Suicide Risk

The NGASR explored the following indicators. In brackets is the point value if the item is present, which allows you to assess the suicide risk using the score found below.

  • Feelings of hopelessness (3)
  • Recent stressful events (1)
  • Persecutory hallucinations (1)
  • Depression (3)
  • Withdrawal from social interactions (1)
  • Verbalization of suicidal intent (1)
  • Evidence of a specific plan (6)
  • Family history of mental illness or suicide (1)
  • Recent bereavement or relationship breakdown (3)
  • History of psychosis (1)
  • Widow/widower (1)
  • Prior suicide attempt (3)
  • History of socio-economic deprivation (1)
  • History of substance use (1)
  • Terminally ill (1)

It’s important to note that these elements cover the CPR Risk Assessment elements, starting with the verbalization of suicide intent and following on with:

  • Current Plan (Evidence of a specific plan)
  • Previous Exposure to Suicide (family history of mental illness or suicide; recent bereavement; prior suicide attempt)
  • Resources (withdrawal from social interactions)

Each of the variables identified above for the NGASR are assigned a weighting based on the ones most likely to lead to suicide, with five being assigned a score of 3 (for high-risk) and the others being assigned a score of 1.

Scoring

The following scoring system has been developed by Cutcliffe & Barker (2004):

  • 0-5 – Low Risk, Level Four
  • 6-8 – Intermediate Risk, Level Three
  • 9-11 – High Risk, Level Two
  • 12+ – Very High Risk, Level One

Supervision Levels

These supervision levels from Barker & Buchanan-Barker (2005) and reproduced in the RNAO guide.

  • Level Four: Engagement on a structured daily basis (such as by having nurses available to speak with and providing regular programming)
  • Level Three: Formal engagement at least three times per day – morning, afternoon and evening (such as by having nurses perform suicide assessments and check in with patients)
  • Level Two: Regular support (e.g. approximately every 15 minutes, varying between 10 and 20 minutes) from the nursing team throughout the day or night (This is the most common level of “high risk” or “suicide watch” supervision and can help prevent inpatient suicide)
  • Level One: Constant access to a nurse, or other professional for support (This is for imminent risk situations while a patient is being stabilized, or during transition points such as moving to a higher or lower level of care.)

You can download the NGASR at the RNAO website (see page two.)

Bibliography

Barker, P. & Buchanan-Barker, P. (2005). The Tidal Model: A Guide for Mental Health Professionals. New York, NY: Routledge.

Cutcliffe, J.R., Barker, P. (2004) “The Nurses’ Global Assessment of Suicide Risk (NGSAR): developing a tool for clinical practice.” Journal of Psychiatric and Mental Health Nursing. 11. 393-400

Cite this article as: MacDonald, D.K., (2015), "The Nurses’ Global Assessment of Suicide Risk (NGASR)," retrieved on July 23, 2019 from http://dustinkmacdonald.com/nurses-global-assessment-suicide-risk-ngasr/.

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Assessing Elder Abuse with the Caregiver Abuse Screen (CASE)

The purpose of the Caregiver Abuse Screen (CASE) is to detect potential abuse of seniors by caregivers. It is a screening tool, not an assessment tool, so like other screening tools it should be administered to all caregivers whether abuse is suspected or not.

The CASE tool was created by Myrna Reis and Daphne Nahmiash and is designed to be administered to caregivers of elderly individuals. It comprises eight yes or no questions, and can make a handy tool to use in psychosocial assessments if you are a counsellor or a case manager.

The CASE is scored by summing the “Yes” responses; a greater score indicates a greater potential of abuse. There is no cut-off above or below which abuse would or would not be suspected; it must be evaluated in conjunction with other factors as part of your overall assessment.

The CASE reports good psychometric properties. A Cronbach’s alpha of 0.71 was reported for six out of the eight items, 1-4, 6, and 8 (Carver College of Medicine, n.d.) You can download the CASE from NICE, the National Institute for the Care of the Elderly.

Bibliography

Instrument psychometrics summary, n.d., University of Iowa Carver College of Medicine. Retrieved fromhttp://www.medicine.uiowa.edu/uploadedFiles/Departments/FamilyMedicine/Content/Research/Research_Projects/summary.doc

National Initiative for the Care of the Elderly. 2010, Caregiver abuse screen (case), Retrieved from http://www.nicenet.ca/files/Case.pdf



Cite this article as: MacDonald, D.K., (2015), "Assessing Elder Abuse with the Caregiver Abuse Screen (CASE)," retrieved on July 23, 2019 from http://dustinkmacdonald.com/assessing-elder-abuse-with-caregiver-abuse-screen-case/.

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@RealTimeCrisis, Tweeting those in distress

A shorter post this Family Day, I thought I would take a few minutes to talk about the Twitter handle @RealTimeCrisis. Started by a Toronto police officer and a street nurse, they trawl Twitter for people demonstrating signs of lethality and reach out to them.

As I’ve written about in the past on my article on responding to suicide on social media, many people give people hints of their behaviour who never receive the support that they need. Sometimes family members and friends don’t know what to do – or, worse, they’re afraid of the answer they might get.

Enter Marie Batten and TPS Constable Scott Mills. Since 2012 they have been tweeting individuals in crisis and offering a helping hand, connecting them to resources in the community. Sometimes the Toronto Police will directly contact them and sometimes they’ll reach out. But either way – it is heartening to see people getting the support they need.

As online crisis chat and SMS/texting services become more common avenues for receiving emotional support and crisis intervention I suspect we’ll see more services like @RealTimeCrisis. For now they represent a best practice – an innovative strategy of reaching out when people need them most.



Cite this article as: MacDonald, D.K., (2015), "@RealTimeCrisis, Tweeting those in distress," retrieved on July 23, 2019 from http://dustinkmacdonald.com/realtimecrisis-tweeting-those-in-distress/.

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5 Unconventional Ways to Market Your Helpline

Helplines are a strange beast: if their utilization is high, one can assume that either the community is really in need of their service and they deserve more money. On the other hand, if they are effective at diffusing crises, one might see their usage drop as fewer people in the community need them.

Most helplines, though, are seeing calls go up year after year, as their populations get bigger and more people find themselves dealing with mental and physical health, financial and relationship issues, suicide and bereavement and all the other things that bring a person to call.

One way that helplines can improve their position is via funding for grants to meet particular populations needs. For instance, Distress Centre Peel operates seniors services, launched in part with funding from the New Horizons for Seniors program.

So here are some marketing ideas you may not have considered for your helpline:

  1. Host a contest – Have individuals in the community (they could be high school students, community college or University students or even adults) participate in building a part of your organization. Offer a prize equal to a little more than you would have paid. For instance, for a $250 prize have individuals suggest a new slogan for your helpline. Work with local media outlets to popularize the contest – which will also popularize your helpline in the process.
  2. Real Time Tweeting – Each time your helpline intervenes in a crisis (for instance, you dispatch an ambulance or police to someone’s location), tweet using your organization’s Twitter. This is a very “in your face” way of letting people know the impact you are having in your community.
  3. Magnets – For organizations who produce magnets with their phone number on them, get creative. For instance, you can place the magnets on pay-phones in your community so that individuals in crisis can still reach you, especially if you have a toll-free line available.
  4. Giving away products – Produce a guide on deep breathing, cognitive thought distortions or stress management (or maybe you already produce these for your workers to use on the phone) and give it away to local community agencies. They’ll be able to support their clients and your organization’s name gets out there.
  5. Reach out personally – This one may run up against some ethical boundaries at your organization so you’ll want to check with your Executive Director/Board of Directors first, but if you see someone in the newspaper or in the community who you think would benefit from your service, reaching out to them rather than you reaching out to you can be very lucrative. I know of one helpline that runs a suicide survivor support group (not Distress Centre Durham, where I currently volunteer now work) that reads the obituaries looking for individuals who have died by suicide, to offer supportive phone calls and a spot in the next support group. Because all of the services are free, they’ve heard nothing but good from this move.

At the end of the the day, it comes down to being proactive rather than reactive. When people are in crisis you don’t want them to have to find you, you want your information already in their pocket, on the payphone, or in their Twitter feed so that you become a no-brainer.

One advantage of this is that if you target your approaches to particular groups (e.g. seniors or youth) you can see a quantifiable increase in the number of calls from those individuals.

Cite this article as: MacDonald, D.K., (2015), "5 Unconventional Ways to Market Your Helpline," retrieved on July 23, 2019 from http://dustinkmacdonald.com/5-unconventional-ways-to-market-your-helpline/.

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On One Man’s Reason for Suicide

Note: I normally keep to a post every other day, but I think this post deserves to come out now, instead my next post will be on Saturday rather than Friday.

Suicide is an intensely personal decision. What drives a person to kill themselves is a question often asked of those bereaved by suicide (grieving the loss of someone important to them by suicide.) This is a question as important to those left behind as it is to those who are in the throes of a suicidal crisis.

On February 9th, 2015 a popular food blogger named Wilkes McDermid ate his last meal at the Coq d’Argent restaurant in the City of London before jumping off. He posted a final suicide note, apparently penned a year earlier, detailing his reasons for suiciding. He also attached some scientific journal articles, a “Frequently Asked Questions” section detailing some common oppositions to suicide and a previous note he wrote two years prior when he made failed plans to suicide in Cape Town, South Africa.

I thought this post would be a good opportunity to go over some of those reasons, and to offer some interpretation of how he ended up in the predicament that he did.

While his writing is longer than any blog post I have written, at 4500 words, it would take much more than that for most people to truly elucidate every reason they have for dying and explore it in the kind of depth that would convince others around them it was the right thing to do.

I’ll be the first one to say that I am no expert in suicidal autopsies or psychiatric evaluation; I can only offer my opinions based on my knowledge of cognitive behavioural therapy and my interpretations of his writing.

If you haven’t already, I suggest you take a read of his post now, so that you can get a feel for it without my words biasing your interpretation. I’d love for you to share your thoughts.

The blog post opens by noting that McDermid would like to answer the questions of his friends and family but that doing so ‘live’ would be too great a risk because the medical community “values quantity of life over quality of life.” I think this is a reasonable view; disclosing imminent suicide plans would have led to his hospitalization. I don’t think it was reasonable that the quality of his life would have remained at it’s current level, however.

Next, McDermid declares the reason for his death is that women favour men who are tall (he gives 5’10+), of Caucasian or black races and who are wealthy or have “other manifestations of power.”

He goes on to list a number of research studies demonstrating that there is a preference in women for men holding these attributes. And to his science, I don’t disagree. All else being equal, many men will choose a woman with larger breasts over a woman with smaller breasts.

However, this is where I take my first qualm: all is never equal. Rall, Greenspan & Neidich (1984) notes that physical attractiveness is relative. You’re never competing against every other man in the world, only against every other man in the room.

Personality does have a strong influence on people’s physical attractiveness of us, particularly for women evaluating men. While it would be disingenuous to assume that women are not as visual as men – particularly when we have no other information to go on (see the disaster that is online dating for that in action), both genders consistently describe situations where they met a less-than-physically attractive person who “won them over” with their personality.

For some research support to that, see Tepper & MacDonald (2014) which notes that people are less willing to reject potential romantic partners in a real-world situation (e.g. participants in a research study who are not expecting it) than they are when given hypothetical situations.

Additionally, Murray & Holmes (1997) document a sort of “illusion” effect that occurs as you begin to fall for a romantic partner. Negative elements become less emphasized, and you see an illusory version of them. This gives hope and scientific backing to the idea that your personality really can help you get a foot in the door.

McDermid continues by citing a rate of 95%~ of the interracial (Asian/white) relationships he sees being with an Asian woman and a white male, while only 5% of the time is it an Asian male and a white woman.

This may be true (I haven’t evaluated the methodology of the formal and informal studies and surveys he cites but I’ll take them at face-value), but is that such a problem? He appears to be consistently seeking out interracial relationships and refusing to settle for anything but.

Considering that the Asian population in the US is 5-6% (CDC, 2013), it’s not surprising that most Asian women would end up with white men, because non-Hispanic white and black people make up a combined ~75% of the population. These rates are similar in England, and most western countries.

McDermid dedicates a surprising amount of his blog post on refutations of straw-men arguments (“you haven’t counted everyone in the world.”) He quickly dispenses with those arguments, as anyone with basic statistical knowledge should.

It is okay to be at a disadvantage. You can still lead a fulfilling life. Myself, at 5’6 with some physical health issues (retinopathy, scoliosis, exercise-induced asthma) have certainly faced my share of barriers but I have also had some success as well.

Looking at it from an economic perspective, people born in poverty certainly have a harder time accessing social mobility than the rest of us. But many of them do overcome those barriers. Jealousy is okay. You can want what someone else wants. You can be frustrated that you don’t have it! That is a natural, expected, human emotion.

When you’re done getting all your frustration out, though, you have to begin to move forward. If you’re 20 metres back at the starting gate, it can make the race seem pointless, because others have an advantage. But you need not concern yourself with where other people are, only with where you are yourself.

This is not easy. But it takes cognitive energy to continuously ruminate on how others have it better than you, and that energy is far better spent accomplishing something worthwhile.

It’s the latter half of the note (and I call it a note rather than an article or a post because it is a suicide communique to all who knew him, and many who don’t) that I found most interesting.

It begins,

To everyone who says “why don’t you just accept it”, I ask you this. What if your girlfriend/boyfriend/wife/husband was taken away from you through no fault of your own? How would you feel? What if you were then told “it doesn’t matter, just learn to live with it”. Then what if you were told, “it’s your fault, it’s your personality that has caused that” and “stop being so negative”. How would you react. That’s what I’m faced with continuously. I can’t stop people lying to me for the rest of my life… but I can control how long my life will be and therefore how long I will have to suffer.

He equates his pain, of not being able to find a romantic partner, to the pain of someone who has lost their partner through death. In this moment he is mourning his future, the loss of hopes and dreams. These are an extremely strong hook for those experiencing suicidal thoughts, and McDermid had laid his to rest.

He seemed to feel his entire life was suffering, because of his lack of romantic companionship. His entire life, the rest of him was meaningless and valueless because of his inability to negotiate this one element of life.

This reminds me of the classic “Six Stage Process for Coming Out”, also known as the Cass Identity Model (Cass, 1979) In this model there are six stages for a person who is coming to terms with their sexuality:

  1. Confusion
  2. Comparison
  3. Tolerance
  4. Acceptance
  5. Pride
  6. Synthesis.

Essentially, the person finds themselves confused by their sexuality, then realizes they are different from others. They tolerate these differences, then begin to celebrate them. Next, they feel proud and wish to let everyone know, and finally they synthesize their sexuality into their broader identity; it becomes merely another part of them.

Applying this to McDermid’s situation, he had passed through Confusion and was stuck on Comparison. He could not see past the advantages that others had in their life, to move on to tolerance. He was miles away from tolerating being alone, accepting it, being proud of it (if that would ever occur) and certainly nowhere near his romantic life being a single piece of his identity.

Indeed, loneliness had become his identity. It consumed him. He was not English. He was not a food blogger. He was alone. That was him. And it didn’t have to be.

At the end of the “letter” portion of his note, he signs it “Goodbye, I wish you all the best Wilkes McDermid, 03-Feb-2014”; nearly a year to the day that he wrote it, he finally pushed through his innate self-preservational instincts.

The rest of his note consists of a Frequently Asked Questions section, a biblbiography and a draft of a similar note he authored in January of 2013, where a variety of factors including the weather conspired against him. In that note, he discusses his belief that what he is doing is euthanasia, not suicide. My opinion, pro or con on that belief is not helpful, but I truly don’t believe he had exhausted all options yet.

I’d like to go over each of his frequently asked questions, because I think they make a good read for helpers talking to suicidal individuals and the kind of thinking distortions that can be present, as well as to help those considering suicide themselves realize their distorted thinking patterns.

I’ll list them all at once to make reading the page easier:

  1. “Aren’t you being selfish?”
  2. “But people care about you”
  3. “But ‘Suicide is a permanent solution to a temporary problem’”
  4. My boyfriend my [sic] be caucasian and over 5ft10 but he’s ginger… so you’re wrong…”
  5. My boyfriend my [sic] be caucasian and over 6ft2 but he’s overweight… so you’re wrong…”
  6. My boyfriend is Chinese so there, you’re wrong.”
  7. Stop being so negative”
  8. You’re talking shit, that’s simply not true”
  9. OK – You only find those results because you’re in London (Soho/Mayfair…[insert any random geographical location]).”
  10. Lots of people lead long fulfilling lives without a relationship.”
  11. I have a friend who is Oriental with a Caucasian girlfriend… so you’re wrong.”
  12. One of my female friends is white and really likes Oriental guys. So you’re clearly wrong.”
  13. You are clearly mentally ill? Why don’t you go to a psychiatrist?”
  14. But you will burn in hell! Suicide is a sin! The afterlife is real!”
  15. Remember you always have a choice”
  16. So what? You might be right… be an exception!”
  17. Suicide is the cowards way out”
  18. You’re clearly racist”
  19. You’re a Nazi. What you’re promoting is ‘Social Darwinism’”
  20. The reason why you don’t find Oriental guys with Caucasian girls is cultural”
  21. Why don’t you just use a prostitute every few weeks?”
  22. “So what would you tell someone else in the same position?”

They seem to fall into four categories:

  • Anti-Suicide Cliches (1, 2, 3, 14, 15, 17)
  • Denying The Evidence / Pointing Out Exceptions (4, 5, 6, 8, 9, 11, 12, 20)
  • Dismissing The Problem (7, 18, 19, 21)
  • Miscellanous Attempts at Helping (10, 13, 16, 22)

As you can see, the bulk of his writing is spent on trying to convince people that the evidence is as he says it is. On the other hand, those born in poverty don’t spend a lot of time trying to convince others that being in poverty makes it harder to have a middle class lifestyle; it is merely accepted as a truth. And once we’ve accepted that truth, we can begin working on other areas of ourselves so that we can cultivate hope.

I don’t believe individuals who noted that lots of people live fulfilling lives without relationships were being facetious or trying to dismiss his pain as much as they were trying to provide a role model for McDermid. He was well-liked and his blogging was well-known in his niche, but he couldn’t see past the idea that life was not worth living without someone else in it.

#13 mentions that he is mentally ill, and he should see a psychiatrist. I reject the idea that he was mentally ill; at least, I don’t think he had a DSM-IV/V mental illness. He seemed relatively rational and lucid, despite the suicidal tunnel vision.

Unfortunately, it was his rationality, his equation that was faulty. Dating and relationships are only one part of your existence, they are a piece of life. They are not all of life, and if you’re dead, how will you ever be able to find that person?

He did note that he had spent some time in a psychiatric hospital (where, coincidentally a number of patients formed relationships.) He describes the treatment he received there as pseudoscience; he doesn’t elaborate on the particulars (beyond noting that one exercise required him to “stare at an orange for an hour”) but CBT has been well-proven to help eliminate the kind of faulty reasoning that he was experiencing.

#16 discusses the idea of being an exception. This is what we all aspire to. To work hard, to get lucky (pardon the pun), and to fight against the odds. The investment advisor Chris Gardner (whose life was famously the inspiration for the film The Pursuit of Happyness) and the former US Senator and motivational speaker Les Brown, to highlight two individuals came from humble circumstances and did amazing things with their lives.

Instead of being known as the man who fought the odds, McDermid will be known as a man who gave up. Who resigned himself to a self-fulfilling fate. This is to speak nothing of the ways he could have made himself a more attractive potential mate:

  • He could have taken steps to lose the weight and to build muscle
  • He could have relocated to an area where he would be more in the median range for height rather than the lower end
  • He could have poured his efforts into his blog in an attempt to build the wealth or status that he claims is important

But instead, he chose to take his life. I am not judging him harshly, for he took the route he thought most rational in his mind at the time. But I wish he had been able to hold on, to see that his life could be more than having a partner. As a man who has struggled with romantic relationships I have been there, in that pit of despair, but you can get through it if you don’t give up.

Your life can be bigger than your disadvantages. You can rise above them. Keep your heads up, gentlemen (and ladies.)

Blbliography

“Asian American Populations”. (2013) Centers for Disease Control and Prevention. United States Department of Health & Human Services. May 7, 2013. Retrieved February 12, 2015 from http://www.cdc.gov/minorityhealth/populations/REMP/asian.html

Cass, V. (1979). Homosexual identity formation: A theoretical model. Journal of Homosexuality, 4 (3), 219-235.

Joel, S., Teper, R., & MacDonald, G. (2014). People Overestimate Their Willingness to Reject Potential Romantic Partners by Overlooking Their Concern for Other People. Psychological Science (Sage Publications Inc.), 25(12), 2233-2240. doi:10.1177/0956797614552828

Murray, S.L., Holmes, J.G. & Griffin, D.W. (1996) “The Self-Fulfilling Nature of Positive Illusions in Romantic Relationships: Love Is Not Blind, but Prescient” Journal of Personality and Social Psychology. 71(6):1155-1180

Rall, M., Greenspan, A., & Neidich, E. (1984). Reactions to eye contact initiated by physically attractive and unattractive men and women. Social Behavior & Personality: An International Journal, 12(1), 103-109.

Cite this article as: MacDonald, D.K., (2015), "On One Man’s Reason for Suicide," retrieved on July 23, 2019 from http://dustinkmacdonald.com/on-one-mans-reason-for-suicide/.
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