Law Enforcement Suicide Prevention

Introduction

Organizations like the Tema Conter Memorial Trust in Canada and Reviving Responders in the US have highlighted the skyrocketing rate of suicide among first responders, including police officers, paramedics and firefighters. In 2015, there were over 100 suicides by law enforcement officers in the US. (Kulbarsh, 2016) They note the high incidence of PTSD among law enforcement officers and the stigma that prevents them from seeking support.

One way to reduce law enforcement suicide is through police academy training that provides all officers with suicide awareness training. This helps reduce the stigma of receiving mental health support and gives police the opportunity to act as peer supporters for their colleagues.

Overview of Curriculum

The material below comes from the Basic Course for Police Officers authored by the New Jersey Police Training Commission (2016). This 262-page manual provides a complete review of the curriculum that police officers in that state learn during their 24 weeks at the Academy.

One of the instructional units is named “Suicide Awareness and Prevention for the Law Enforcement Officer”. The description is as follows:

The trainee will understand the causes, symptoms, warning signs and risks associated
with officer suicide, and will identify appropriate intervention and prevention strategies
to effectively deal with this issue.

The outcomes of this module are as follows. Once completed, the police recruit will be able to:

  • Define suicide
  • Identify demographics associated with law enforcement suicide
  • Know stressors that contribute to suicide
  • Explain risk factors associated with suicide
  • Identify warning signs associated with suicide
  • Understand suicide myths
  • Explain and apply the AID LIFE acronym for intervening with suicide
  • Identify obstacles to effective suicide intervention
  • Note professional resources helpful to an officer
  • Identify strategies to prevention law enforcement suicide

The content from these modules is summarized below, but I’ve added references where appropriate to back up the un-cited information. The goal is to provide added-value and confirm the veracity of the material.

Defining Suicide

Suicide is defined as the intentional taking of one’s own life (Stedman, 2016).

Demographics of Law Enforcement Suicide

  • There are more deaths to police suicide than in the line-of-duty (Kulbarsh, 2016)
  • The police officer life expectancy is less than the general population (Violanti, 2013)
  • The suicide rate is approximately 14 deaths per 100,000 (Badge of Life, n.d.) compared to 13 per 100,000 in the general population (AFSP, 2014)
  • Although the curriculum maintains that the divorce rate is higher among police officers, the opposite is actually true. The divorce rate is slightly lower, at 14.47% versus 16.96% for all professions over the lifetime (Roufa, 2015)
  • The rate of substance abuse is higher among police officers (Cross & Ashley, 2004)

Stressors Contributing to Law Enforcement Suicide

In addition to the normal stressors such as depression, anxiety, substance abuse and relationship issues, the curriculum identifies some specific job-related stressors. These include:

  • Discipline issues (internal affairs and/or
    criminal investigations); and
  • Management issues (assignment – lack of promotion – supervision);
  • Retirement (loss of identity and sense of belonging).
  • Shift work;
  • Sleep deprivation;
  • Unfulfilled job expectations;

Risk Factors Associated with Law Enforcement Suicide

This section identifies historical, demographic risk factors that may increase suicide. These are listed below, and correspond to those in the SAD PERSONS Scale and the CPR Risk Assessment:

  • Knowledge of and access to lethal means;
  • Age;
  • Gender;
  • Ethnicity;
  • Previous history (self or family member);
  • Cumulative stressors;
  • Feeling of hopelessness and helplessness; and
  • Lack of intervention resources.

Warning Signs of Law Enforcement Suicide

Warning signs, as defined by the AAS (n.d.) are items that represent an imminent, increased risk (active factors) rather than the stable historical factors that don’t necessarily represent increased risk. For instance, being a male does not itself mean someone is suicidal, but being a man does increase the chances someone will die.

The warning signs listed in the curriculum (reproduced verbatim below) represent a mix of risk factors and AAS-type warning signs.

  • Depression:
    • Attitude of hopelessness and helplessness;
    • Unexplained changes in appetite, weight, appearance, and/or sleep habits;
    • Difficulty making decisions;
    • Difficulty concentrating;
    • Overly anxious;
  • Previous suicide attempt;
  • Increase in the use of alcoholic beverages;
  • Overly aggressive or violent behavior;
  • Any changes in mood or behavior that are out of the ordinary, including a neutral mood;
  • Changes in work habits;
  • Behavioral clues of suicidal thoughts:
    • Giving away possessions;
    • Making a will;
    • Talking about a long trip;
    • Sudden interest or disinterest in religion;
    • Substance abuse relapse; and
    • Taking inappropriate duty-related and personal risks.
  • Anger / irritability; and
  • Concern expressed by family / friends / colleagues about a specific individual;

Identifying Common Suicide Myths

The myths that are discussed here include:

  • People who talk about suicide won’t attempt
  • Talking about suicide with someone does not reduce their risk
  • Warning signs are not present before a person dies by suicide
  • Suicidal individuals must have a mental illness
  • Suicidal individuals are beyond help
  • Suicidal individuals are committed to dying

See my article on suicide myths for a more complete discussion of these

AID LIFE for Suicide Intervention

AID LIFE is an acronym that is given in the training for a simple intervention procedure. The steps in AID LIFE are as follows:

  • A – Ask if the individual is thinking about suicide
  • I – Intervene immediately. Listen and let the person know they are not alone.
  • D – Don’t keep their suicidal thoughts a secret. Seek assistance
  • L – Locate help. This can include a supervisor, chaplain, physician, or other members of their support network. (Including crisis workers or the Emergency Room.)
  • I – Inform the Chain of Command. This can help get important resources like counselling in place.
  • F – Find someone to stay with the individual. (Dustin’s note: I’m actually not a big fan of this one, it shows up in the Marine Corps suicide awareness program as well; this is more important for high-risk, imminent suicide than it is for someone who may be low or moderate risk.)
  • E – Expedite. Get help now, rather than delaying it.

Obstacles to Effective Suicide Intervention

These obstacles are reproduced directly from the manual and include a variety of police-specific and more general obstacles to effective intervention with police officers who are struggling with suicidal thoughts.

  • Fear of stigma, isolation, humiliation, suspension, job loss;
  • Fear of change in duty status;
  • The police culture; (seeking mental health support may be perceived as a character weakness)
  • Denial that there is a problem; (by the officer, peer officers, supervisors, the command staff)
  • Reluctance of the officer to seek help for fear of the officer losing control of the situation;
  • The officer’s fear that confidentiality will not be maintained;
  • The officer’s distrust of management;
  • Supervisors and peers who protect or shield a troubled officer; and
  • Lack of knowledge by a troubled individual about the availability of counseling resources, and concern about being able to afford such services.

Professional Resources for Law Enforcement Suicide

Although this is a New Jersey Police manual, the resources presented are general enough to be a good reference. The resources that are recommended include:

  • Crisis Line
  • Employer Assistance Program (EAP)
  • Faith-based support (e.g. Chaplain or Church official)
  • Hospital emergency room
  • Mental Health Counselling (in person or otherwise)
  • Peer Support (from another officer or supervisor)

Strategies to Prevent Law Enforcement Suicide

The following 4 strategies are generally recommended for preventing suicide by both law enforcement officers and the general public. They include:

  1. Understanding the risk factors and warning signs of law enforcement suicide
  2. Using available resources and building a support network
  3. Challenging the stigma in seeking support
  4. Using the AID LIFE mnemonic

Other Police Suicide Prevention Programs

Together for Life was developed by Psychologists as a comprehensive suicide prevention program in Montreal. This program includes a half-day training session for all officers, a confidential telephone helpline, a full-day training session in more in-depth techniques for supervisors and awareness materials. Mishara & Martin’s 2012 evaluation showed:

  • 99% of those who attended the sessions said they would recommend the sessions to a colleague
  • 84% of supervisors were aware of the program
  • Positive increases in knowledge of risk factors and warning signs, and how to intervene
  • A nearly 80% decrease in the rate of Montreal police suicides (versus no change in the rate of police suicides in other police services in Quebec)

Badge of Life: Psychological Survival for Police Officers (Levenson, O’Hara & Clark, 2010) makes “emotional self-care (ESC)” the focus of a series of training modules delivered to police officers, along with mental health screenings and the delivery of peer support by other officers and the use of Critical Incident Stress Debriefing (CISD).

Police Organization Providing Peer Assistance (POPPA) (Dowling, et. al., 2006) is a New York Police Department (NYPD) based program for preventing suicide. It combines a confidential helpline, support groups, printed suicide awareness and intervention materials distributed to all police officers, and tools to assess resiliency and stress. Applied Suicide Intervention Skills Training (ASIST) is also provided yearly.

Additional Resources

The book Police Suicide: Tactics for Prevention provides a comprehensive review of police suicide causes and potential interventions to reduce suicidal behaviour in this group.

References

American Association of Suicidology. (n.d.) “Warning Signs | American Association of Suicidology” Retrieved on September 4, 2016 from http://www.suicidology.org/resources/warning-signs

American Foundation for Suicide Prevention (AFSP). (2014) “Suicide Statistics — AFSP” Retrieved on September 4, 2016 from https://afsp.org/about-suicide/suicide-statistics/

Badge of Life. (n.d.) Police Suicide Myths. Retrieved on September 4, 2016 from http://www.badgeoflife.com/myths/

Cross, C.L. & Ashley, L. (2004) Police Trauma and Addiction: Coping With the Dangers of the Job. FBI Law Enforcement Bulletin. 73(10) Retrieved on September 4, 2016 from https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=207385

Dowling, F.G., Moynihan, G., Genet, B. & Lewis, J. (2006). A Peer-Based Assistance Program for Officers With the New York City Police Department: Report of the Effects of Sept. 11, 2001. American Journal Of Psychiatry: Official Journal Of The American Psychiatric Association, (1), 151. doi:10.1176/appi.ajp.163.1.151

Kulbarsh, P. (2016) “2015 Police Suicide Statistics” Officer.com. Retrieved on September 4, 2016 from http://www.officer.com/article/12156622/2015-police-suicide-statistics

Levenson Jr, R. L., O’Hara, A. F., & Clark Sr, R. (2010). The Badge of Life Psychological Survival for Police Officers Program. International Journal Of Emergency Mental Health & Human Resilience, 12(2), 95-101.

Mishara, B. L., & Martin, N. (2012). Effects of a comprehensive police suicide prevention program. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 33(3), 162-168. doi:10.1027/0227-5910/a000125

New Jersey Police Training Commission. (2016) Basic Course for Police Officers.

Roufa, T. (2015) “What is the Divorce Rate for Police Officers?” The Balance. Retrieved on September 4, 2016 from https://www.thebalance.com/what-is-the-divorce-rate-for-police-officers-974539

Stedman, T. (2016) Stedman’s Medical Dictionary (28th ed.). Philadelphia: Lippincott Williams & Wilkins.

Cite this article as: MacDonald, D.K., (2016), "Law Enforcement Suicide Prevention," retrieved on October 23, 2017 from http://dustinkmacdonald.com/law-enforcement-suicide-prevention/.
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Suicide Prevention in the US Military

Suicide prevention is a significant issue in the US military, with the loss of current service members and veterans a significant public and social health cost. There have been a variety of theories on the causes of the increase in military suicides, which has been termed an “epidemic.” (Pilkington, 2013)

Model of Suicidal Behaviour

A model of suicide behaviour is used to understand the factors that may lead to suicide for a specific population. One model that applies well to explaining military suicides is called the Interpersonal Theory of Suicide (van Orden et al., 2010). This model states that three elements need to be present for a person to become suicidal:

  1. Thwarted belongingness
  2. Perceived burdensome
  3. Acquired capability

Thwarted belonging can occur when a returning service member loses the esprit de corps that characterized their military service, and a large part of their social support. This is especially true if a veteran is disabled.

Perceived burdensomeness can occur when a service member with a disability or mental health issues finds themselves unable to function independently. This may be a particularly difficult adjustment for someone who was used to feeling in control and being independent.

Finally, acquired capability involves fearlessness and experience with physical injury that reduces a suicidal person’s ability to resist suicide. Military members have virtually all acquired the capability for suicide via combat experience and other exposure in their careers.

Prevalence of Suicide in Servicemembers and Veterans

For many years, the military had a comparable or slightly lower rate of suicide than the general population (Armed Forces Health Surveillance Center, 2012) but recent trends have had suicide rates increase significantly (Department of Veterans Affairs, 2010).

Kaplan, McFarland, Huguet & Newsom (2012) note that while the existing research has been mixed on the exact nature of the suicide rate increase, it is definitely elevated. Further research will need to be conducted to determine the exact causes.

Causes of Military Suicide

There are a number of suspected causes of the increase in suicidal behaviour in soldiers since 2006 identified by Hyman, Ireland, Frost & Cottrell (2012) include:

  • Presence of a mental health diagnosis
  • Having been on deployment
  • Taking anti-depressants
  • Taking sleep medications (which were associated with more deployments)

They note that the impact of these on the suicide rate was strongest in National Guard and Army Reserve members and interestingly, quite weak in the Marine Corps. This suggests that perhaps the esprit de corps that is present in the Marines helps to buffer against the negative elements of mental health issues. The lowered suicide rate in Marine Corps members was present despite the fact that Marines were less likely to have protective factors like spouses and children.

As well, Alexander, Reger, Smolenski & Fullerton (2014) in their pilot study using the Department of Defense Suicide Event Report (DoDSER) to collect data on suicide deaths (and matched “control” soldiers who did not die by suicide) found events like “recent failed intimate relationships, outpatient mental health history, mood disorder diagnosis, substance abuse history, and prior self-injury” linked to suicide, all of which fit in one of the three categories of the Interpersonal Theory of Suicide.

Suicide Awareness in the Marine Corps

MCRP611C Combat Stress, the 2000 Marine Corps combat stress control manual includes a section on suicide awareness. In addition to listing common signs of suicide and preparatory behaviour such as:

  • Believes he or she is in a hopeless situation
  • Appears depressed, sad, tearful; may have changes in patterns of sleep and/or appetite
  • May talk about or actually threaten suicide, or may talk about death and dying in a way that strikes the listener as odd
  • May give away possessions

It also includes the acronym AID LIFE:

  • Ask: “Are you thinking about hurting yourself?”
  • I Intervene immediately.
  • D Do not keep a secret concerning a person at risk.
  • L Locate help (NCO, chaplain, corpsman, doctor, nurse, friend, family, crisis line, hospital emergency room).
  • I Inform your chain of command of the situation.
  • F Find someone to say with the person. Do not leave the person alone.
  • E Expedite! Get help immediately. A suicidal person needs the immediate attention of helpers.

Role of Chaplains in Army Suicide Prevention

Army Chaplains provide primary spiritual care to soldiers (Zeiger, 2009) but are also considered the “gatekeepers” who most non-commissioned officers, enlisted leaders in the military, refer soldiers to when they find out they’re suicidal. (Ramchand, Ayer, Geyer & Kofner, 2015) Chaplains are afforded confidentiality like attorneys or therapists and this makes them attractive as first-level referrals.

Ramchand et. al. (2012) also found that a majority (54%) of Chaplains and Chaplain’s Assistants had received some kind of mental health training, but that they their suicide prevention knowledge was lacking and had difficulty intervening because of the stigma of mental health treatment.

Means Restriction

Counselling on access to lethal means (CALM) is one approach that has been proven to reduce suicide rates in the civilian population. CALM refers to the techniques used to limit or disable access to suicide plans, such as removing firearms from the home or locking up prescription medication that a person could use to suicide with.

Hoyt & Duffy (2015) provide a number of approaches for limiting means, including providing space on base for a soldier’s private weapons during a suicidal crisis, emphasize weapon safety (e.g. locking up of firearms) to reduce impulsive use, and engaging the entire chain of command on when means restriction is necessary.

Post Traumatic Stress Disorder

Much has been made of the influence of post-traumatic stress disorder on the suicide rate. Research indicates that both PTSD and traumatic brain injury independently increase the suicide rate. (Barnes, Walter & Chard, 2012) however virtually all mental health issues increase the suicide rate (Harris & Barraclough, 1997) with depression being more important than PTSD in the suicide rate.

Interventions to Reduce Military Suicide

Zamorski (2011) reviews a variety of interventions that have shown evidence or potential in reducing suicide risk in soldiers, though from a Canadian context. Some of these are listed below:

  • Treatment of underlying mental health issues
  • Screening for depression
  • Training of gatekeepers to ask about suicide
  • Systematic followup for suicide attempters and high risk patients
  • Counselling and restriction of access to lethal means
  • Resilience training
  • Systematic monitoring and quality improvement of mental health

Zamorski notes Knox et. al.’s (2003) study of a comprehensive suicide prevention program that included many of the above interventions. Over a 6 year span, the suicide rate declined 33% as a result of the implementation of these techniques.

Bibliography

Alexander, C.L., Reger, M.A., Smolenski, D.J. & Fullerton, N.R. (2014) Comparing U.S. Army Suicide Cases to a Control Sample: Initial Data and Methodological Lessons. Military Medicine. 179. 10:1062

Armed Forces Health Surveillance Center. (2012) Deaths by Suicide While on Active Duty, Active and Reserve Components, U.S. Armed Forces, 1998-2011. Medical Surveillance Monthly Report. 19(6)

Barnes, S. M., Walter, K. H., & Chard, K. M. (2012). Does a history of mild traumatic brain injury increase suicide risk in veterans with PTSD?. Rehabilitation Psychology, 57(1), 18-26. doi:10.1037/a0027007

Department of Veteran Affairs. (2012) Suicide Data Report. Kemp, J., Bossarte, R.

Harris, E.C., Barraclough, B. (1997) Suicide as an outcome for mental disorders. A meta-analysis. British Journal of Psychiatry. 170:205-28

Hoyt, T. & Duffy, V. (2015) Implementing Firearms Restriction for Preventing U.S. Army Suicide. Military Psychology. 27(6) 384-390 DOI: 10.1037/mil0000093

Hyman, J., Ireland, R., Frost, L., & Cottrell, L. (2012). Suicide Incidence and Risk Factors in an Active Duty US Military Population. American Journal Of Public Health, 102(S1), S138-S146. doi:10.2105/AJPH.2011.300484

Kaplan, M.S., McFarland, H., Huguet, N. & Newsom, J.T. (2012) Estimating the Risk of Suicide Among US Veterans: How Should We Proceed From Here?. American Journal of Public Health. 102(S1)

Knox, K.L., Litts, D.A., Talcott, G.W., Feig, J.C. & Caine, E.D. (2003). Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: Cohort study. British Medical Journal, 327, 1376.

Pilkington, E. (2012) “US military struggling to stop suicide epidemic among war veterans”. The Guardian. Accessed electronically on Dec 27 2015 from http://www.theguardian.com/world/2013/feb/01/us-military-suicide-epidemic-veteran

Ramchand, R., Ayer, L., Geyer, L., & Kofner A. (2015) Army Chaplains’ Perceptions About Identifying, Intervening, and Referring Soldiers at Risk of Suicide. Spirituality in Clinical Practice. 2(1) 36-47

United States Marine Corps. (2000) MCRP611C Combat Stress. Accessed electronically on Dec 27 2015 from http://www.au.af.mil/au/awc/awcgate/usmc/mcrp611c.pdf

Van Orden, K.A., Witte, T.K., Cukrowicz, K.C., Braithwaite, S., Selby, E.A., & Joiner, T.E. (2010) The Interpersonal Theory of Suicide. Psychology Review. 117(2)575-600 doi: 10.1037/a0018697

Zamorski, M.A. (2011) Suicide prevention in military organizations. International Review of Psychiatry. (23)173-180

Zeiger, H. (2009) Why Does the U.S. Military Have Chaplains?. Pepperdine Policy Review. Accessed electronically on Dec 27 2015 from http://publicpolicy.pepperdine.edu/academics/research/policy-review/2009v2/why-does-us-military-have-chaplains.htm



Cite this article as: MacDonald, D.K., (2016), "Suicide Prevention in the US Military," retrieved on October 23, 2017 from http://dustinkmacdonald.com/suicide-prevention-us-military/.

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Developing Core Competencies for Suicide Risk Assessment

A number of competencies or skills are required for adequately working with suicidal individuals. Cramer et. al. (2013) examined a number of resources including the AAS Core Competencies (2010) and other resources. This list is adapted from those resources.

Manage Attitudes and Reactions Towards Suicide and Suicidal Clients

This competency involves self-awareness about your attitudes surrounding suicide. Do you feel suicide is always right, always wrong, is it a grey area? Under what circumstances is it appropriate or not to intervene?

Secondly, how do you respond to someone who is suicidal. Are you calm and in control, can you get there with additional training? If you don’t feel this is something you can handle, having a list of referrals for highly suicidal clients can help.

There is no attitude training program that I know of. This is something that can only be properly built through self-reflection. Understanding your own beliefs, however, is a form of building this competency so that you can respond in a way congruent with your values.

Assess Attitudes Towards Suicide

A number of tools exist to assess attitudes towards suicide. These includes the Attitudes Towards Suicide questionnaire (Diekstra & Kerkhof, 1988) and Understanding of Suicidal Patient (Samuelsson, Asberg & Gustavsson, 1997) scale.

Develop and Maintain a Therapeutic Alliance with Client

A strong therapeutic alliance is essential for client change. Standard skills like active listening, displaying warmth,  empathy, and unconditional positive regard come into play.

Recognizing the conflict between the client’s desire to end their psychological pain and your desire to prevent suicide will help the client feel heard. Understanding a model of suicidality and being able to express that to the client helps ensure you’re both on the same page.

Finally, Bordin (1979) identifies three elements making up the “working alliance”: common goals decided between the clinician and client, tasks to be completed and the development of a bond between the clinician and the client.

Build Therapeutic Alliance with Clients

While elements like flexibility, confidence, and trustworthiness are associated with a positive therapeutic alliance (Ackerman & Hilsenroth, 2003) they are difficult to build outside of reflection and supervision.

Elements like Reflection, Interpretation, and Active Listening can be improved by reviewing counselling textbooks (especially video-taped sessions), roleplaying and continuing education in empathy and active listening.

A number of tools are in use to assess the working alliance. The Working Alliance Inventory (Horvath & Greenberg, 1989) is a 36-item tool that focuses on the three elements of the therapeutic alliance. It is available in both therapist and client versions.

Know and Elicit Evidence-based Suicide Risk and Protective Factors

Key to effective suicide risk assessment is the understanding of exactly what factors put someone at risk (risk factors), including what factors constitute elevated baseline risk (for instance a historical sexual assault), what factors increase acute risk (intoxication) and what elements represent a suicide attempt may be imminent (obtaining access to lethal means, putting final affairs in order.)

Understanding suicide protective factors and reasons for living allows one to put in place elements to reduce risk. Finally, understanding suicide-specific language is important in being able to accurately describe a client’s suicidal behaviour.

Understand Suicide Risk and Protective Factors

There is a strong evidence base for suicide risk factors and protective factors. The American Association of Suicidology formed a consensus group to assess the evidence for suicide risk and developed a list of suicide risk and protective factors.

I’ve written a blog post on the elements differentiating suicide attempts from ideators in a youth population.

Taking training such as Applied Suicide Intervention Skills Training (ASIST) or suicideCare can also help, as would programs like the AAS’s Recognizing and Responding to Suicide Risk training.

Suicide specific language can be developed by reading journal articles such as De Leo et al’s (2006) study “Definitions of Suicidal Behavior” or Silverman et. al’s 2007 “Rebuilding the Tower of Babel.”

Beyond evaluation built in to workshops and regular feedback and supervision (from peers or actual supervisors), tools like the Suicide Intervention Response Inventory can help us assess our level of suicide intervention skill.

Identify Current Suicide Plan and Suicidal Intent

Being able to identify the current suicide plan and suicidal intent involves assessing the number, intensity and length of suicidal thoughts, as well as the presence and intensity of suicidal intent.

Additionally being able to understand the suicide plan (and accessibility of that plan) as well as the perceived lethality are important elements in this competency.

The CASE Approach (Shea, 2009) offers one avenue to assessing the suicide plan and intent. Additionally using a structured tool like the DCIB Risk Assessment helps a clinician or telephone crisis worker cover elements relevant to risk.

There are no existing tools that specifically cover a clinician’s exploration of suicidal intent but there are a number of tools the clinician can use with the client to assist them. These include:

Cutter (1999) includes a chapter in his book The Suicide Prevention Triangle discussing a number of assessment measures for suicide and suicidal intent.

Determine Level of Risk

Determining the level of risk means compressing all of the available information to express it in a simple fashion (e.g. Low, Medium, High, Extreme/Imminent) so that decisions about treatment and current status may be made.

This is a process that requires professional, clinical judgement and should only be performed with appropriate clinical supervision and close monitoring until these skills are mastered.

Training and experience in the  Collaborative Assessment and Management of Suicidality (CAMS) approach is one structured method for building competency in suicide risk by completing a number of risk areas and assisting in the building of a treatment plan (see the next section, “Develop a Treatment Plan”)

In my opinion, assessing one’s currently level of skill in suicide risk estimation is something that can only be done by a third party. As the saying goes, we don’t know what we don’t know.

Common methods in hospitals include Grand Rounds and patient consults, while in community settings consultation with supervisors, as well as outside supervision with a supervisor well-trained in suicidality.

Develop a Treatment Plan

Developing a treatment plan includes elements such as designing a suicide safety plan, restricting access to lethal means, gaining buy-in from the client about actions to take to preserve safety in the short, medium and long-term and monitoring suicide risk.

I have a blog post on designing suicide safety plans; additionally the Counseling on Access to Lethal Means course is helpful for learning how to reduce access, especially in young persons.

Other activities to protect safety can include beginning counselling or therapy (or returning there if treatment had stopped), a referral to a psychiatrist or other physician for medication.

For those who work in managed care, a book like the Suicide and Homicide Risk Assessment and Prevention Treatment Planner can help you design treatment plans that meet the stringent requirements of HMO and insurance companies.

Assessing your treatment plans is another activity that requires expert opinion, but something like the Ontario Medical Association’s Key Elements to Include in a Coordinated Care Plan (2014) can give you some ideas as to where weaknesses may exist.

Notify and Involve Others

This competency involves understanding when it is appropriate to notify other individuals. For instance, family and friends, other treatment providers, physicians and pharmacists.

Learning your state or province’s laws on informed consent are an important part of developing this competency. Further down the page, “Understand the Law Around Suicide” may help as well. Where homicide risk may be present, see my article on homicide risk assessment.

Framing communication not as an attempt to subvert the client’s autonomy, but rather to help those close to them better help them may reduce resistance to communication.

Additionally, allowing the client to know each individual who was contacted, what they said, and what was put in their treatment plan or case notes (if anything) helps the client see you have their best interests at heart.

Workshops on the legal ramifications of suicide may allow you an opportunity to assess how your current practices work and to develop new ones.

The Counseling on Access to Lethal Means (CALM) course includes a component on involving parents and other independent verifies of information which is an important element in clinical decision making.

Checking in with your clients on a regular basis to see how they feel about decisions you’ve made, beyond a good practice in the therapeutic relationship, is also a good way to develop your intuition by finding out if the client is willing or interested in allowing you to speak with others around them.

Document Risk, Treatment Plan and Clinical Decisions

Risk assessment and treatment planning is useless without proper documentation, for a number of reasons. First, it allows you to monitor the level of risk over time and ensure you haven’t missed anything. Second, it allows collaboration with colleagues and communication of risk information with preciseness. Finally, it reduces legal liability in the event of a client’s suicide.

Ballas (2007) includes an article on documenting suicide risk assessments, and I have an article on document suicide risk here on my blog. The British Columbia Ministry of Children and Family Development has written a policy and practice consideration guide providing additional guidance.

By comparing your existing suicide risk assessments and case notes against the expert examples included in the above resources you can assess your weaknesses.

Understand the Law Around Suicide

You should be familiar with the law regarding suicide in your state, province or country. For instance, what is the process to get someone committed? When can you breach confidentiality? What are your obligations for recordkeeping related to suicide case notes?

This is an entirely individual process. In Ontario, the Ontario Hospital Association has produced a guide to Mental Health and the Law which will assist you in developing the necessary knowledge and decision-making. Continuing education may be available from your local Social Workers organization as well.

Review of your practice by a lawyer who specializes in mental health may help you avoid embarrassing and expensive legal complications and ensure you’re well protected in the future.

Engage in Debriefing and Self Care

Debriefing and self-care are critical to ensuring your continued success as a practitioner, regardless of your professional standing or position. Working with suicidal clients in any capacity can be extremely stressful and feelings of incompetence or failure can easily appear, even in situations where the client suffers no adverse outcomes.

Ensuring regular supervision (including your own psychotherapy if necessary) while working with suicidal clients is helpful. Seeking out additional supervision or clarification of legal or practice issues can be helpful. Regular self-care (sleeping enough, eating healthy, taking time for hobbies, etc.) is always helpful.

Questionnaires are available, including the Maslach Burnout Inventory-General Survey (MBIGS), the Burnout Measure (BM), the Shirom-Melamed Burnout Measure (SMBM), and the Oldenburg Burnout Inventory (OLBI) for topics like burnout, they can help assess your current level of functioning and give you an awareness if you are beginning to have trouble.

Bibliography

Ackerman, S.J., Hilsenroth, M.J. (2003) A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Review. 23(1):1-33

American Association of Suicidology. (2010). Core Competencies for the Assessment and Management of Individuals at Risk for Suicide. Accessed May 14, 2015 from http://www.suicidology.org/Portals/14/docs/Training/RRSR_Core_Competencies.pdf.

Ballas, C. (2007) How to Write a Suicide Note: Practical Tips for Documenting the Evaluation of a Suicidal Patient. Accessed on May 15, 2015 from http://www.psychiatrictimes.com/articles/how-write-suicide-note-practical-tips-documenting-evaluation-suicidal-patient.

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice, 16(3), 252–260.

Cramer, R.J., Johnson, S.M., McLaughlin, J., Rausch, E.M., Conroy, M.A. (2013) Suicide Risk Assessment Training for Psychology Doctoral Programs: Core Competencies and a Framework for Training. Training and Education in Professional Psychology. 7(1):1-11. doi: 10.1037/a0031836.

Cutter, F. (1999). The Suicide Prevention Triangle. Triangle Books.

De Leo, D., Burgis, S., Bertolote, J.M., Kerkhof, A.F.F.M., Bille-Brahe, U. (2006) Definitions of Suicidal Behavior: Lessons Learned from the WHO/EURO Multicentre Study. Crisis. 27(1).4-15. DOI 10.1027/0227-5910.27.1.4

Diekstra, R.F.W., Kerkof, J.F.M. (1988) Attitudes Toward Suicide: Development of a Suicide Attitude Questionnaire (SUIATT). Current Issues of Suicidology. (1988) 462-476

Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36(2), 223 – 233

Ontario Medical Association. (2014) Platt, Katherin. Key Elements to Include in a Coordinated Care Plan. Accessed on May 14, 2015 from https://www.oma.org/Resources/Documents/CoordinatedCarePlan_June2014.pdf

Samuelsson, M., Asberg, M., & Gustavsson, J.P. (1997). Attitudes of psychiatric nursing personnel towards patients who have attempted suicide. Acta Psychiatrica Scandinavica, 95, 222-230

Silverman, M. M., Berman, A. L., Sanddal, N. D., O’Carroll, P. W. and Joiner, T. E. (2007), Rebuilding the Tower of Babel: A Revised Nomenclature for the Study of Suicide and Suicidal Behaviors Part 2: Suicide-Related Ideations, Communications, and Behaviors. Suicide and Life-Threat Behavi, 37: 264–277. doi: 10.1521/suli.2007.37.3.264



Cite this article as: MacDonald, D.K., (2015), "Developing Core Competencies for Suicide Risk Assessment," retrieved on October 23, 2017 from http://dustinkmacdonald.com/developing-core-competencies-for-suicide-risk-assessment/.

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DCIB Suicide Risk Assessment

Introduction

The DCIB Suicide Risk Assessment follows the new standards of the National Suicide Prevention Lifeline (Joiner, et. al., 2007). The result of the research and expert consensus was the following core principles and subcomponents, listed below. If you prefer to watch, you can see a video below.

Components of the DCIB Risk Assessment

Suicidal Desire

  • Suicidal Ideation (Desire to kill self/others)
  • Psychological Pain
  • Hopelessness
  • Helplessness
  • Perceived Burden on Others
  • Feeling Trapped
  • Feeling Intolerably Alone

Suicidal Capability

  • History of Suicide Attempts
  • Exposure to Someone Else’s Death by Suicide
  • History of/Current Violence to Others
  • Available Means of Killing Self
  • Currently Intoxicated
  • Substance Abuse
  • Acute Symptoms of Mental Illness (e.g. recent dramatic change in mood, out of touch with reality)
  • Extreme Agitation (Increased anxiety, decreased sleep)

Suicidal Intent

  • Attempt in Progress
  • Plan to Kill Self/Other (method known)
  • Preparatory Behaviour
  • Expressed Intent to Die

Buffers/Connectedness

  • Immediate Supports
  • Social Supports
  • Planning for the Future
  • Engagement with Helper
  • Ambivalence for Living/Dying
  • Core Values/Beliefs
  • Sense of Purpose

Example of DCIB Assessment

One suicide risk assessment example using the DCIB Standard comes from the Hospital Association of Southern California (HASC) and has also been adopted by the iCarol helpline management software. In the HASC example specific, concrete elements are given to determine the Low, Moderate or High Risk for each element.

Scoring the DCIB Assessment

If the majority of the elements in each category (Desire, Capability, Intent or Desire) are Moderate or High, the element is scored as present. The HASC example of the DCIB Risk Assessment is scored on the following 5-point scale:

  • 5 – Suicide Attempt in Progress of Imminent
  • 4 – Desire/Capability/Intent ALL Present regardless of buffers
  • 4 – Desire/Intent or Desire/Capability with few/no buffers
  • 3 – Desire/Intent or Desire/Capability or Capability/Intent with many buffers
  • 3 – Capability alone / Intent alone with many buffers
  • 2/1 – Desire alone, many buffers
  • 0 – No  Desire, Capability or Intent

Bibliography

Joiner, T., Kalafat, J., Draper, J., Stokes, H., Knudson, M., Berman, A.L., McKeon, R. (2007) Establishing Standards for the Assessment of Suicide Risk Among Callers to the National Suicide Prevention Lifeline. Suicide and Life Threatening Behaviour. 37(3). 353-365

Cite this article as: MacDonald, D.K., (2015), "DCIB Suicide Risk Assessment," retrieved on October 23, 2017 from http://dustinkmacdonald.com/dcib-suicide-risk-assessment/.

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Risk Factors Predicting Youth Suicide Attempts

Youth suicide represents a significant public health issue and one particularly important given that young people often have fewer tools to deal with their suicidal thoughts.

Demographics

Suicide is the 4th leading cause of death for youth in Canada (Statistics Canada, 2011). There are between 50 and 200 suicide attempts per suicide death in adolescents (Schwartz, 2003).

This rate is higher than the estimated 25 attempts per suicide death in adults (McIntosh, 2012), which could be due to an underestimation of lethality, as Kartakis (1999) noted in an adult population, or because of an ambivalence, a desire not to die. Given youth often have trouble communicating their emotional needs either one could contribute.

The Role of Attitudes and Beliefs about Suicide

One study, by Lake, Kandasamy, Kleinman & Gould (2013) looked at the attitudes of adolescents towards the causes of suicidal behaviour and identified two distinct belief systems:

  • Stress model, that believes that suicidal behaviour is the result of overwhelming stress
  • Medical model, that believes suicidal behaviour is the result of mental illness.

This is backed up by Muehlenhamp & Gutierrez (2004) that found attitudes towards dying in a sample of high school students were associated with suicide attempts but not self-harm.

Youth who believed in the stress model were more likely to believe suicide was something that happened to everyone and that it was not treatable or curable. Assessing youth attitudes towards suicide may therefore represent an opportunity to intervene before suicidal thoughts begin.

Risk Factors for Adolescent Suicide

Taliferro & Muehlenkamp (2014) identify a number of risk and protective factors. Some of them are similar to adult risk factors while others are specific to youth.

  • Alcohol and Drug Use (Cash & Bridge, 2009)
  • Anxiety
  • Bullying Behaviour / Fighting
  • Impulsiveness (Klonsky and May, 2010)
  • Mental Health Issues
  • Parental Substance Abuse
  • Running Away from Home
  • Self-Injurious Behaviour
  • Victim of Childhood Abuse

In addition, a few risk factors were associated more suicidal behaviour in one gender than the other. In males, smoking (cigarettes or marijuana) and truancy were risk factors in males, while being victims of dating violence, having same-sex experiences and perceiving one’s self as being overweight were risk factors in females.

A Note on Impulsiveness

Impulsiveness has been noted in other sources (e.g. the Counseling on Access to Lethal Means course) as a risk factor in that youth can act on suicidal impulses before someone has a chance to intervene, however Klonsky & May (2010) revealed that it was not the impulsiveness that was the danger (when comparing youth who attempted suicide from youth who didn’t), but rather a poor ability to forsee the consequences for their actions.

Protective Factors for Adolescent Suicide

The following protective factors were identified as well:

  • Academic Achievement (Borowsky, Ireland & Resnick, 2001)
  • Enjoying School
  • Parental and Non-Parental Connectedness (trusted adults)
  • Supportive Friendships
  • Involvement in Sports
  • School Engagement and Safety

It’s important to note that liking school was more a protective factor for females, while feeling safe in school was more a protective factor for males.

Bibliography

Borowsky, I.W., Ireland, M., Resnick, M.D. (2001) Adolescent Suicide Attempts: Risks and Protectors. Journal of Pediatrics. 107(3). 485-493. doi: 10.1542/peds.107.3.485

Cash, S.J. and Bridge, J.A. (2009) Epidemiology of Youth Suicide and Suicidal Behaviour. Current Opinions in Pediatrics. 21(5). 613-619.

J.L. McIntosh. (2012) “USA Suicide 2009 Official Final Data” Accessed May 5, 2015 from http://www.isu.edu/irh/projects/ysp/downloads/2009NationalData-AAS.pdf

Kartakis, P. (1999) The Persistently Suicidal: Perceived Lethality, Intent and Hopelessness Among Multiple Attempters. MA Thesis, York University.

Klonsky, E.D., May, A. (2010) Rethinking impulsivity in suicide. Journal of Suicide and Life Threatening Behavior. (40)6. 612-9. doi: 10.1521/suli.2010.40.6.612

Lake, A.M., Kandasamy, S., Kleinman, M., Gould, M.S. (2010) Adolescents’ attitudes about the role of mental illness in suicide, and their association with suicide risk. Journal of Suicide and Life Threatening Behaviour. 43(6):692-703. doi: 10.1111/sltb.12052.

Muehlenkamp, J. J. and Gutierrez, P. M. (2004), An Investigation of Differences Between Self-Injurious Behavior and Suicide Attempts in a Sample of Adolescents. Journal of Suicide and Life-Threatening Behaviour, 34: 12–23. doi: 10.1521/suli.34.1.12.27769

Schwartz, M.W. (2003) The 5-minute Pediatric Consult. Lippincott Williams & Wilkins. pp 796.

Statistics Canada. Table 102-0561 – Leading causes of death, total population, by age group and sex, Canada, annual, CANSIM (database). Accessed May 7, 2015.

Taliaferro, L.A., & Muehlenkamp, J. J. (2014). Risk and protective factors that distinguish adolescents who attempt suicide from those who only consider suicide in the past year. Journal of Suicide & Life-Threatening Behavior, 44, 6-22.



Cite this article as: MacDonald, D.K., (2015), "Risk Factors Predicting Youth Suicide Attempts," retrieved on October 23, 2017 from http://dustinkmacdonald.com/risk-factors-predicting-youth-suicide-attempts/.

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