Youth Violence Assessment and Prevention

The following notes come from “Youth Violence: Theory, Prevention, and Intervention” by Kathryn Seifert, which I read before participating in the SAVRY (Structured Assessment of Violence Risk in Youth).

Youth Violence – Prevalence and Trends

Four Types of Violence

  • Situational
  • Relationship
  • Predatory
  • Psychopathological

There are two types of violence, instrumental and reactive violence. The goal of instrumental violence is to achieve a goal where reactive violence is in response to a situation.

Violence Prevalence

  • Teens and young adults experience the highest rate of violence
  • Juvenile homicides ~5%
  • Juvenile sexual violence 20%
  • 25% of adolescents report dating abuse, 10% report physically hurt last 12 months

Rate of Violence Affected By

  • Age
  • Gender
  • Race
  • Ethnicity
  • Socioeconomic Status (SES)

Young girls are greater victims though young boys engage in more violence-related behaviour (perpetrators)

Community Predictors of Violence

  • Poverty
  • Community disorganization (presence of crime, drugs, gangs, poor housing)
  • Availability of drugs, guns
  • Adults involved in crime
  • Exposure to violence, racial prejudice

Violence Classifications

Violence may be classified based on its:

  • Purpose
  • Mechanism
  • Target

Purpose of Violence

  • Instrumental – to accomplish a goal (e.g. robbery for money)
  • Situational – Emotions getting out of control; rare without other risk factors
  • Predatory/psychopathic – No goal but to harm people

Target of Violence

  • Self-directed – Suicidal behaviour
  • Interpersonal – Against another person; in family or community (instrumental, situational, psychopathic); always occurs within existing relationship
  • Collective – Violence within groups

Dating Violence – Need for control in relationship

Types of Violence

Family Violence

  • Adult family members use violence to control
  • Patricide risk factors, severely abused, dangerously antisocial and severely mentally ill
  • Usually abuse, DV or parental substance abuse/mental illness in home

School Violence

  • Lack of counsellors, support services
  • No sense of community
  • Bullying, marginalized groups
  • Risk factors, history of childhood trauma, school behaviour problems, trouble interacting with prosocial peers, history of aggression, delinquency, substance abuse, lack of appropriate parental discipline, high conflict and low warmth within the family, other behavior problems, especially those that start before the age of 13 years

Homicidal Youth

  • History of family violence, abuse and neglect, mental illness, neurological defects, antisocial behaviour, substance abuse
  • Significant population with psychotic symptoms, gang participation, substance abuse
  • Skill deficits in anger management, impulse control

Gang Violence

  • Median age 17-18
  • More structured gang is, more likely to engage in criminal activity
  • Protective factors: positive role models, organization, absence of substance use and criminality
  • Risk factors: Marginalization, dropped out, rejected by prosocial peers, no opportunities for success
  • Affiliation and acceptance

Hate Crimes

  • Bias motivated
  • 63% of offenders were white, 21% were African American
  • Correlation b/w youth bullying and violence related to hate; attachment problems

Theoretical Perspectives on Youth Violence

Social Learning Theory

  • Most behaviour learned from modeling
  • Ignores DNA, brain development, learning differences that might impact ability to imitate

Intergenerational Transmission of Violence

  • Learn from early home environment; witnessing b/w adult caregivers, experiencing it themselves or both
  • Children victimized are strong candidates for prevention programs

Routine Activity / Event-Centered Theory

  • All crime is a crime of opportunity
  • Underestimates violent crime/offenders, does not examine social causes of crime

Social Exchange Theory

  • Calculated exchanges b/w costs and benefits
  • Assumes people take rational approach to emotional decisions

Psychopathy

  • No empathy, remorse
  • PCL-R; Psychopathy Checklist-Revised (two factors: personality traits and anti-social behaviours)
  • May be developmental disorder
  • DSM-IV does not use term; classifies psychopathic behaviours under ASPD
  • Risk factors include impulsivity/conduct problems, callous/unemotional traits, narcissism
  • 20-30% in children and adults

Neurobiological Theories of Violence

  • Early trauma affects neurotransmitter regulation, brain structure and development
  • Severe chronic stress in childhood can lower arousal point, making it harder to return to homeostasis = Developmental trauma disorder

Developmental Trauma Disorder

  • Behaviourally re-enact trauma as perpetrators or frozen avoidance reactions
  • Not the same as PTSD
  • Behaviour Objective Sequence

Subculture of Violence Theory

  • Within larger societies, subgroups may develop which encourage crime and violence
  • Incomplete view of violence; potentially racist

Feminist Theory

  • Males way of maintaining control of women
  • Do not account for female perpetrators, other individual factors,

Social Structure Theories

  • Relationship between different groups in a society
  • Grievances violating one’s sense of justice
  • Social distance

Strain Theory

  • Strain as failure to achieve positively valued goals
  • Strain as removal of positively valued stimuli
  • Strain as potential of negative stimuli
  • Power prevention technique = teaching people to deal more positively with strain, increasing opportunities to succeed

Control Balance Theory

  • Amount of control people are subjected to vs the amount of control they can exercise
  • Imbalance of control (either not enough power or too much power)

Systems Theory

  • Interplay of various systems
  • Violence caused by many interacting factors
  • Risk factors: high levels of conflict in the family, community and cultural norms that encourage violence, racial and sexual norms that preclude individual from participating in society.

Life Course Theories

  • Follows individual through life; positive and negative influence can change trajectory
  • Biological, psychological and social trajectories
  • Childhood diagnosis of conduct disorder correlated with adult ASPD
  • Early starters vs late starters

Reciprocal Theory of Violence

  • Properties of violence including negative emotional states, alienation, shame, denial, humiliation and lack of empathy, compassion
  • Nine Structural Pathways to violence

Dynamics of Youth Violence

Individual Factors that Affect Youth Violence

  • Parental substance abuse
  • Insecure attachment w/mother
  • Conduct problems
  • Lack of empathy
  • Cognitive dysregulation
  • Dysregulated behaviours
  • Belief in legitimacy of aggression
  • Childhood trauma
  • Parent rating of hyperactivity
  • Low academic performance; school problems
  • Deliquent peers
  • Availability of drugs
  • Early initiation of violence, delinquency, moderate-to-severe behaviour problems
  • Home or family maladjustment

Domains of Violence

  • Physiological
  • Cognitive
  • Psychological
  • Developmental

Physiological

  • Genetics
  • MAO-L increases aggression

Neurobiological Factors

  • Abnormalities in amygdala, hypothalamus
  • Alcohol exposure

Cognitive Factors

  • Low IQ linked to violent, aggressive behaviour

Psychological Factors

0-2 Years of Age

  • Attachment issues predict later violence and aggression
  • Secure, Anxious/Avoidant and Disorganized/Dismissive
  • Mirror Neurons in infants

Toddlers (3-4)

  • Master environment
  • Autonomy vs shame and doubt
  • Theory of Mind important at stage; take perspective of others

Early School Years (5-6)

  • Initiating activities
  • Interact with groups of children
  • Self-soothing, emotional regulation
  • Risk factors: absence of attachment figure, single parent, use of corporal punishment, preference for violent video games, exposure to verbal aggression, aggressive peers, victimization

Middle Childhood (7-10)

  • Preadolescence and Adolescence
  • Puberty
  • Peer group supplants family group as influence
  • Family risk factors decrease in importance
  • Risk factors, poor affect regulation, early onset of puberty, increased arousal patterns

Behaviour

  • Greatest predictor of severe and chronic violent behaviour is early onset of behaviour problems, aggression, disregard for rules, delinquency, substance abuse
  • Late onset antisocial behaviour tends to stop in adulthood, early onset tends to continue
  • Interventions must include family therapy, reduction of home violence

Temperament

  • Behaviour or emotional problems
  • Attract victimization

Mental Health

  • Mental illness alone not a predictor
  • Personality disorder places one at risk
  • Skill building, DBT
  • Substance use: age of onset, perception of drug use among peers

Traits of Violent Preadolescent Boys

  • CARE2 Assessment Tool
  • Family history of violence
  • Skill deficits in problem solving and anger management
  • Twice as many assaulters harming animals, delinquency, fire setting, school behaviour problems, attachment issues
  • 3x as many bullying others
  • Less resiliency

Chronic Violent Teen Boys

Risk Factors

  • Uninvolved parents
  • Ineffective/inappropriate discipline
  • Psychological or substance abuse families
  • Low warmth, high conflict
  • Childhood trauma

Protective Factors

  • Nurturing, supportive caregiver
  • Appropriate discipline
  • Achievable future goals

Chronic Violent Teen Girls

Risk Factors

  • Moderate to severe behaviour problems
  • No remorse
  • Bullying
  • Poor emotional regulation, impulsivity, psychiatric problems, truancy, attachment problems
  • Enuresis
  • Anger management, deficient problem solving skills

Environmental Factors That Impact Youth Violence

Environmental Factors Affecting Youth Violence

 

 

 

 

 

 

 

 

 

 

Special Issues in Youth Violence

Bullying

Four Phases of Bullying

  1. Rejecting phase, identifying with the victims
  2. Performing phase, moving towards becoming a bully
  3. Perpetuating phase, enjoying being a bully
  4. Withdrawing phase, moving away

Bullying Interventions

  • Emotional skills training, teaching children and adolescents how to recognize and regulate emotional states
  • Social skills training
  • Reduce prejudice and discrimination
  • Problem solving, resiliency, prosocial skills

Suicide

  • Most teens would tell their friends first
  • 80% gave verbal clues
  • Friends and peers more aware of clues
  • How a young person responds (perception of stressor, social supports, resources available, skills to cope with stress)
  • Having youth identify three protective factors, linked to 70-85% reduction in suicide attempts
  • Inability to correlate death to permanent and ireverssible final state
  • Yellow Ribbon, ASIST, QPRT

Assessment, Prevention and Intervention

  • By clinical judgement only at chance
  • Youth change rapidly so assessments only valid <6 months
  • Self-report tools less helpful
  • Attachment to caregivers important

Areas of Assessment

  • Youth
  • Caregiver
  • School
  • Peers
  • Community Environment

Risk Assessment Tools

  • SAVRY
  • CARE2
  • Youth Level of Service—Case Management Inventory
  • Positive Achievement Change Tool
  • Psychopathic Checklist—Youth Version
  • Early Assessment Risk for Boys and Girls (EARL20/EARLY21G)

Motivational Interviewing techniques useful

Trauma issues important

Interventions

  • Skill building behavior management programs, cognitive-behavioral therapy, social skills training, “challenge” programs (i.e., wilderness therapy), academic training (GED programs, tutoring), and job-related skills
  • Botvin Life Skills Training
  • Aggression Replacement Training Skillstreaming, anger control, moral education
  • Behavioral Objective Sequence Adaptive, Personal, Task, Interpersonal, Self-management, Communication
  • Individual therapy
  • Family therapy
  • Multimodal Therapy
  • Multisystemic Therapy
  • Multidimensional Treatment Foster Care
  • School-based Mental Health Care
  • Gang Interventions
  • Victim-Offender Mediation



Cite this article as: MacDonald, D.K., (2016), "Youth Violence Assessment and Prevention," retrieved on July 16, 2018 from http://dustinkmacdonald.com/youth-violence-assessment-and-prevention/.

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Jail Suicide Assessment Tool (JSAT)

Introduction

Suicides in prisons and jails are several times higher than the general population (Thigpen, Beauclair, Hutchinson & Zandi, 2010) for a variety of reasons: incarceration is stressful, mental health issues can be exacerbated in the corrections environment, and overcrowding and understaffing mean that suicidality can be hard to detect. This led to the development of the JSAT.

Picture by Michael Coghlan
Picture by Michael Coghlan

The JSAT, or Jail Suicide Assessment Tool (Carlson, 2002) is a semi-structured tool featuring 24 domains associated with suicidality, These categories explore supports in your life, physical health, mental health, suicidal thoughts and attempts, and more. This tool is NOT to be confused with the similarly named Jail Screening Assessment Tool, also abbreviated as JSAT.

Each domain or category in the JSAT features some sample words to help guide the answering of that question. For example, the category “Psychiatric treatment” includes the sample words “counseling, medication, compliance, hospitalization, diagnoses.

Components of the JSAT:

The 24 components of the JSAT can be clustered under five broad categories, Mental Health, Physical Issues, Personality and Emotional State, Social Supports and Other / Situational.

Mental Health

  • Psychiatric treatment
  • Mental status
  • Depression (current signs)
  • Reality testing (current signs)
  • Self-harm history (could also be classified under Physical Health Issues)
  • Recent suicide signs
  • Suicidal intention
  • Character

Physical Health Issues

  • Physical health
  • Physical pain
  • Chemical abuse/use

Personality and Emotional State

  • Hope
  • Help self
  • Cognitive themes
  • Coping resources
  • Measured reasoning
  • View of death
  • View of suicide

Social Supports

  • Important relationships
  • Social Status:

Other / Situational

  • Legal status
  • Institutional adjustment
  • Cooperation
  • False presentation

Scoring the JSAT

Each category is scored + (positive, lack of suicide risk), – (negative or risk of suicidality) or n (neutral). Additionally, the tool provides some ways of operationalizing these categories.

Looking at the category “Suicidal intention”, the category is described as “Resolution to act, lethal plan with available means.” To mark + (absence of risk) the prisoner must convincingly deny any intent to harm themselves, while to mark – (presence of risk) they must express a desire to die by suicide in the near future and/or have a lethal suicide plan with available means.

Time for Administration is between 30 and 120 minutes

Research Supporting the JSAT

There have been no research studies that I am aware of evaluating the JSAT in a corrections population. It was prepared for the Federal Bureau of Prisons based on a previous tool called the Prison Suicide Risk Assessment Checklist (PSRAC), which itself has not been evaluated either.

Evaluation of the JSAT

Although there is no published research review of the JSAT, the general principles of suicide risk assessment can be applied to confirm whether the JSAT is an effective tool for evaluating risk. The principles include:

  • Does the tool appear to measure what it claims to? (face validity)
  • Will the tool cover the important risk factors and warning signs of suicide? (content validity)
  • If two professionals complete the tool on the same prisoner in the same circumstances, will they reach the same conclusion? (reliability)
  • Can the completed tool be defensible in court if a suicide occurs? (documentation)

Let’s review each of these below.

Face Validity of the JSAT

The JSAT includes elements covering history of suicide attempts, current suicide warning signs, presence of depression, self-injury and substance abuse issues, social supports, view of suicide and many other risk factors.

On this basis the JSAT appears to be face valid for suicide – though I would question if all the elements are necessary in a comprehensive assessment. For example, “Cooperation” is identified as whether there is a good rapport between the interviewer and the client, as evidenced by a no-suicide contract. This is clearly not evidence-based (no suicide-contracts do not work), and rapport is not a suicide risk factor.

A minor criticism as well, some of the categories in the JSAT are oddly named. For instance, the criteria for the category Character is listed below:

  • “+” No indication of prominem character disorder traits.
  • “-“A diagnosed personality disorder; prominent, innexible. maladaptive character traits which cause significant functional impairment or distress.

Given the Character item explores the presence of a personality disorder (which is also not a major risk factor for suicide on its own outside of Borderline Personality Disorder) it makes much more sense to simply name it “Personality Disorder.”

Content Validity of the JSAT

Content validity explores whether the elements of an effective suicide risk assessment is covered. The acronym IS PATH WARM (Lester, Mcswain & Gunn, 2011), developed by the American Association of Suicidology (AAS) can be used to verify suicide warning signs.

Mapping the IS PATH WARM mnemonic onto the JSAT criteria we see the following matchup:

Ideation

The presence of suicidal thoughts. This is covered by the JSAT category Suicidal Intention, which has as a risk factor “Expresses desire to commit suicide in the ncar future; has a lethal suicide plan with available means.”

Substance Abuse

Current or former substance abuse issues. This category is found in the JSAT as Chemical Abuse/Use where the risk factor is “Presently intoxicated or going through symptoms of withdrawal; recent history of drug or alcohol abuse”

Purposelessness

Purposelessness is adequately covered by the JSAT category Hope. The risk factor is described as “no future orientation or life goals; cannot identify reasons to live.”

Anxiety

The JSAT category Mental Status is defined as “Significantly impaired orientation; disturbed mood/affect; thought content or form showing signs of psychosis; severe anxiety; severe agitation.”

Trapped

Trapped does not appear to be represented in any of the JSAT categories.

Hopelessness

See purposelessness above.

Withdrawal

See Substance Abuse above.

Anger

See anxiety above.

Recklessness

Recklessness or impulsiveness is explored in the JSAT category Measured Reasoning, defined as “sudden destructive action toward self/others, impulsive. a hot-head.”

Mood Change

See Anxiety above.

Summary of JSAT Content Validity

Given the above, it appears the JSAT has adequate content validity for the risk factors of suicide, though some of them appear to be lumped together in multiple categories. A more effective tool would separate these categories to make sure the nuances are not overlooked.

Reliability of the JSAT

Reliability describes the ability for a tool’s consistency. This makes no claim to the correctness of the evaluation (known as validity), but rather that two people using the same tool with the same person will come to similar results.

Given the detailed operationalization, the reliability of the JSAT should be good. For instance, looking at “View of Death”, the risk and non-risk options are below:

  • “+” Convincingly expresses a desire to survive.
  • “-” Would welcome a natural death; can name good things that would occur as a result of dying

This is specific enough that two assessors should be able to come to the same conclusion.

Documenting a Jail Suicide Assessment

Would the JSAT stand up in court? This is often one of the most important elements of a risk assessment. Even if it is valid, if you can’t “show your work” and demonstrate that you have adequately considered all elements, you may be legally exposed in the event of a client suicide.

Obegi, Rankin, Williams, & Ninivaggio, (2015) explore the elements of a risk assessment required to stand up in court. They use the acronym CAIPS, which stands for:

  • Chronic and Acute Factors
  • Imminent Warning Signs
  • Protective Factors
  • Summary Statement

Chronic and Acute Factors / Imminent Warning Signs

The chronic and acute factors, and imminent warning signs of the JSAT have been adequately explored above.

One major problem with the JSAT is that a simple + or – sign will not provide the detail required to defend the presence or absence of a risk factor. For example, reviewing “View of Death” above, how does the clinician prove the client welcomes a natural death? What good things do they believe would occur upon their death?

Protective Factors

Protective factors are explored fairly extensively in the JSAT, with Social Supports, Important Relationships, View of Death (which explores the idea of a perceived burden), Hope (future plans, reasons for living, hope for the future), Help Self (problem-solving ability and sense of control), Cognitive Themes (presence of optimism), and View of Suicide (beliefs or values  that resist suicide).

Summary Statement

The final element of the CAIPS element is the Summary Statement. This is the major element missing from the JSAT, as noted above. A detailed risk assessment requires both a discussion of the individual risk factors and warning signs, as well as an overall summary noting their risk and prescribing the appropriate interventions (e.g. removal of suicide means or surveillance.)

Case Study Using the JSAT

Brandy et. al. (2008) provide a number of suicide case studies, one of which is adapted here to demonstrate use of the JSAT. For more information see the original source.

  • 49-year-old, single male who is in the county jail for attempted robbery
  • Noose discovered in his personal effects
  • Client is awaiting a 10 year prison sentence
  • Notes if he is sentenced to 10 years he would hang himself, making another noose if the first one was taken away
  • Cares deeply for his girlfriend and her children but feels they don’t care for him
  • Refused mental health support and had nothing to live for

An evaluation using the JSAT would result in negative (risk present) selections in at least the following categories:

  • Important Relationships
  • Legal Status
  • Hope
  • Cognitive Themes
  • Recent Suicide Signs
  • Suicide Intention

The most important elements here are the lack of supports, hopelessness and expressed intent to die. This client would be considered high risk for suicide given the lack of protective factors and should be restricted from accessing means for hanging.

Applying the DCIB Risk Assessment as an alternative risk assessment for confirmation, we note that this client is showing suicide desire, capability, intent and has a lack of protective factors.

Bibliography

Brandy L. Blasko , Elizabeth L. Jeglic & Stanley Malkin (2008) Suicide Risk Assessment in Jails, Journal of Forensic Psychology Practice, 8:1, 67-76, DOI: 10.1080/15228930801947310

Carlson, D.K. (2002) Jail Suicide Assessment Tool. Federal Bureau of Prisons. Accessed electronically on Mar 12 2016 from http://www.usmarshals.gov/prisoner/assessment_tool.pdf

Lester, D., Mcswain, S., & Gunn Iii, J. F. (2011). A TEST OF THE VALIDITY OF THE IS PATH WARM WARNING SIGNS FOR SUICIDE. Psychological Reports,108(2), 402-404. doi:10.2466/09.12.13.PR0.108.2.402-404

Thigpen, M.L., Beauclair, T.J., Hutchinson, V.A., Zandi, F. (2010) National Study of Jail Suicide: 20 Years Later. National Institute of Corrections. Accessed electronically on Mar 12 2016 from http://static.nicic.gov/Library/024308.pdf

Obegi, J. H., Rankin, J. M., Williams, J. J., & Ninivaggio, G. (2015). How to write a suicide risk assessment that’s clinically sound and legally defensible. Current Psychiatry, (3), 50.

 



Cite this article as: MacDonald, D.K., (2016), "Jail Suicide Assessment Tool (JSAT)," retrieved on July 16, 2018 from http://dustinkmacdonald.com/jail-suicide-assessment-tool-jsat/.

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Means Restriction in Suicide Prevention

What is Means Restrictions?

Means restriction is a technique for preventing suicide that involves restricting or preventing access to the tools used to attempt suicide. This can be things like pills (for overdosing), firearms (for shooting), or railways (for jumping.)

Some suicide methods have much higher lethality or chance of causing death than others. For instance, while 85% of firearm suicides results in death, only about 2% of overdoses do. Hangings are approximately 70% (Vyrostek, Annest, & Ryan, 2004).

There is a myth that if we limit one suicide method (like removing firearms from the home), that someone will simply use another suicide method. While it’s true that not all suicide methods exist in all countries and suicides still occur, suicide method restriction does not generally lead to method substitution during that time-limited suicidal crisis.

Support for Means Restrictions

The idea of means restriction (and its connection to means substitution) was first explored in the 1970s and 80s with the change from toxic coal gas to far less toxic natural gas in Great Britain. It was noted at that time that there was no displacement or substitution of suicide method. This was summarized by Clarke (1989).

Daigle (2005) reviewed a number of studies on means restriction and suggested two primary reasons for the reduction in suicide risk associated with restricting means:

  1. Individuals plan their suicide carefully, including becoming attached to specific methods. By restricting access to those methods people are less attached to the idea of dying by suicide at all
  2. Suicidal crises are often short lived periods of intense acute risk. By limiting the most lethal methods people are forced to either delay their suicide plan or switch to a less lethal method, which will either provide time for the suicidal crisis to pass or (in the event of a suicide attempt carried out) time to be rescued

The literature supporting means restriction and it’s relationship to means substitution is reviewed below based on common suicide methods, which are considered high-lethality methods and therefore most affected by means restriction.

Firearms

Anestis & Anestis (2015) examined the impact of four firearm-related laws: waiting periods to receive one, universal background checks, gun locks, and open carrying regulations on their impact of the suicide rate. Their research found that firearm suicides were reduced when each was implemented and background checks, gun locks and open carrying regulations also reduced the overall suicide rate.

This pattern, stricter firearm laws leading to lower suicide rates was observed in both England (Gunnell, Middleton, & Frankel, 2000) and Austria. (Kapusta, Etzersdorfer, Krall, & Sonneck, 2007)

Additionally, Wintemute et. al. (1999) found that the rate of suicide among handgun owners is 57x higher than the general population in the first week of ownership (because of people who buy a gun for the specific purpose of suiciding) and 7x higher at the end of the first year. It is likely that a person’s risk of dying by suicide remains elevated as long as someone owns a firearm.

Railways

Lukaschek, Baumert, Erazo, & Ladwig (2014) examined railway suicides in Germany over 2 separate periods and found that railway suicides were most common on Mondays and Tuesdays. They note that blue lights in Japan and physical barriers have been helpful in reducing railway suicides, in addition to comprehensive changes introduced by the German Railway Suicide Prevention Project.

The changes implemented included “an awareness programme, media approaches, hotspot analysis….and the introduction of a rule regarding announcements to passengers waiting in station or trains, which requires avoidance of the term ‘suicide’, and an indication that the delay is due to a ‘medical rescue operation underway.'”

Jumping

Law, Sveticic, & DeLeo (2014) examined the impact on the suicide rate in Australia after the installation of a suicide barrier on the Gateway Bridge in Brisbane. The barrier reduced the suicide rate 53%, while there was no shifting of means onto the nearby Stony Bridge.

Meanwhile in Auckland, New Zealand, a bridge barrier was removed on the Grafton Bridge and then reinstated; a 500% spike in the suicide rate occurred while the bridge barrier was absent. (Beautrais, 2009)

Counseling on Access to Lethal Means (CALM)

The Counseling on Access to Lethal Means (CALM) course provides a thorough exploration of means restriction to enable a worker to understand the theoretical basis for restricting access, but also the practical tools surrounding how, when and why to have the conversation about restricting means. It is particularly focused on youth but can be helpful for all populations.

Bibliography

Anestis, M.D., Anestis, J.C. (2015) Suicide Rates and State Laws Regulating Access and Exposure to Handguns. American Journal of Public Health. 105(10):2049-58. doi: 10.2105/AJPH.2015.302753

Beautrais, A.L., Gibb, S.J., Ferguson, D.M., Horwood, L.J., Larkin, G.L. (2009) Removing bridge barriers stimulates suicides: an unfortunate natural experiment. The Royal Australian and New Zealand College of Psychiatrists.

Clarke, R.V. Crime as OPportunity: A Note on Domestic Gas Suicide in Britain and the Netherlands. British Journal of Criminology, Delinquency and Deviant Social Behaviour, 29:1. 35

Daigle, M.S. (2005) Suicide prevention through means restriction: assessing the risk of substitution. A critical review and synthesis. Journal of Accident Analysis and Prevention. 37(4)625-32.

Gunnell, D., Middleton, N. & Frankel, S. (2000) Method availability and the prevention of suicide—A re-analysis of secular trends in England and Wales 1950–1975. Social Psychiatry and Psychiatric Epidemiology. 35:437–443

Kapusta, N.D., Etzersdorfer, E., Krall, C. & Sonneck, G. (2007) Firearm legislation reform in the European Union: Impact on firearm availability, firearm suicide and homicide rates in Austria. British Journal of Psychiatry. 191:253–257

Law, C.K., Sveticic, J., DeLeo, D. (2014) Restricting access to a suicide hotspot does not shift the problem to another location. An experiment of two river bridges in Brisbane, Australia. Australian and New Zealand Journal of Public Health. 38(2):134-8. doi: 10.1111/1753-6405.12157

Lukaschek, K., Baumert, J., Erazo, N., Ladwig, K.H. (2014). Stable time patterns of railway suicides in Germany: comparative analysis of 7,187 cases across two observation periods (1995-1998; 2005-2008). BMC Public Health. 14(1)

Vyrostek, S.B., Annest, J.L & Ryan, G.W. (2004) Surveillance for fatal and nonfatal injuries–United States, 2001. Morbidity and Mortality Weekly Report (MMWR). 53(SS07);1-57. Accessed electronically from  http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5307a1.htm on Jan 23 2016.

Wintemute, G.J., Parham, C.A., Beaumont, J.J., Wright, M., & Drake, C. (1999) Mortality among recent purchasers of handguns. New England Journal of Medicine. 341(21):1583-9

Cite this article as: MacDonald, D.K., (2016), "Means Restriction in Suicide Prevention," retrieved on July 16, 2018 from http://dustinkmacdonald.com/means-restriction-suicide-prevention/.
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Understanding and Preventing Male Suicide

Introduction

Suicide is a significant public health issue in most countries. Suicide rates have been constant in the US and Canada, with some age and risk categories experiencing reduced suicide rates while increased suicide rates in other age groups and risk categories have made up the difference.

Male suicide has been commonly overlooked as suicide has not been seen as a gendered issue. Unfortunately, as more men than women die in virtually every country where the World Health Organization publishes data (2012) there exist the potential for significant reductions to be made in the suicide rate by interventions targeted specifically at men.

Suicide Statistics: A Comparison

Suicide rates are presented here for Canada, broken down by age range and gender.

Age Range Male Female Total Male % of Total
10 to 14 12 17 29 41.38%
15 to 19 140 58 198 70.71%
20 to 24 224 77 301 74.42%
25 to 29 198 63 261 75.86%
30 to 34 212 71 283 74.91%
35 to 39 220 68 288 76.39%
40 to 44 267 87 354 75.42%
45 to 49 318 114 432 73.61%
50 to 54 322 121 443 72.69%
55 to 59 273 102 375 72.80%
60 to 64 186 59 245 75.92%
65 to 69 117 33 150 78.00%
70 to 74 107 21 128 83.59%
75 to 79 78 23 101 77.23%
80 to 84 60 16 76 78.95%
85 to 89 36 13 49 73.47%
90 and older 10 3 13 76.92%
Total 2780 946 3726

As you can see, male suicides make up the majority of suicides in every age range except the 10-14 rate, where girls outnumbered boys. That is certainly worthy of further research by child suicide prevention specialists.

In Canada, suicide rates peak for men around 45-54, which contrasts with other countries where suicide rates increase with age after 30 and suicide rates in the elderly are the fastest growing group.

Suicide Methods

The most common method of suicide in the United States is firearms, accounting for 51% of the suicides in the US (Barber & Miller, 2014), followed by suffocation/hanging (25%), overdose/poisoning (17%) and other methods at 7.6%. (Centers for Disease Control and Prevention, 2013)

Because 85% of firearm suicide attempts result in death while only 2% of overdoses do (Vyrostek,  Annest, & Ryan, 2004), and because men most often choose methods like firearm and hanging over overdosing (Callanan & Davis, 2012), reducing access to firearms can significantly reduce the amount of male suicide.

Theories of Suicidal Behaviour

There are a number of theories that attempt to explain suicidal behaviour. These include the Interpersonal Theory of Suicide, the Stress-Diathesis Model, and the Integrated Motivational-Volitional Model. The interpersonal theory is detailed below.

The Interpersonal Theory of Suicide suggests that you need three elements for suicide to take place:

  • Thwarted Belongingness
  • Perceived Burdensomeness
  • Acquired Suicide Capability

Thwarted belongingness involves feeling like you have no social support or that you do not belong in your peer group. This can also be called “alienation.” Men are known to have smaller social circles (McPherson, Smith-Lovin & Brashears, 2006) and fewer access to social support when they are distressed.

Perceived burdensomeness refers to the idea that you feel like a burden on those around you. For men, this can present as being unable to be a provider or support their family.

Finally, acquired suicide capability refers to events that give you the capability to die by suicide. This includes exposure to war, physical abuse, fighting, self-injurious behaviour (cutting, etc.), or other elements that desensitize you to painful or fear-inducing experiences.

Men are more likely than women to be victims and perpetrators of violence (Statistics Canada, 2006), they make up the majority of occupational injuries (Bureau of Labour Statistics, 2013) and sufferers of substance abuse (Cotto, 2010). All of these items can increase men’s suicidality.

Additionally, suicidal intent (desire to die) has been associated with use of more lethal suicide methods. What this means is that although women attempt suicide at a rate of 3x men do, they don’t intend to die. The goal of attempting suicide is to accomplish other means. Update Nov-1/15 This is in fact incorrect and there is research support to the idea that women have similar levels of suicide intent as men (Denning, Conwell, King & Cox, 2000).

Player et. al. (2015) suggest that male coping strategies are responsible. While women increase their social support and look outward when they are feeling suicidal, men often wall themselves off from others to avoid being a burden. This only amplifies their systems and increases their distress, which can prevent an interruption in the suicidal process that may happen with women.

Clinical Interventions to Reduce Male Suicide

Interventions for suicide that can help individual men include:

Counseling on Access to Lethal Means. By reducing access to lethal means like firearms you can reduce an individual’s chance of dying by suicide. Many suicide attempts are made impulsively and having a gun makes a suicide attempt much more lethal.

Treatment for substance abuse.  Many suicides involve drugs and alcohol and so getting off drugs and alcohol can reduce a person’s reason and ability to attempt suicide, both because of the impact of substance abuse on a person’s ability to function in their day-to-day life (especially as it relates to relationships) but also because drugs and alcohol can make people — young men especially — more impulsive.

Increasing social circles. The average man has a social circle smaller than women. This lack of close friends means that men are not able to express themselves emotionally.

Self-esteem training. This can be a part of counselling or therapy or an initiative on it’s own. Group environments in particular provide an opportunity to both build a man’s social skills and his self-esteem. The benefit of high self esteem is that it can reduce a man’s perception that he is a burden, one of the key elements for suicide.

Public Health Strategies to Reduce Male Suicide

From a public health perspective, there are a few interventions we can help reduce male suicide.

Getting more men in front of family doctors. Men have poor records of going to the doctor when they need to, or even for regular checkups. Because physical health issues can prevent men from working or otherwise providing for themselves (creating the feeling of burdensomeness), physical health care is an important element to reducing suicidal ideation.

Screening for suicide and substance abuse by family doctors. Once men are in front of their physician, it’s important that they’re able to recognize the signs and symptoms of suicidal ideation and substance abuse. It has been noted that mental health professionals are less likely to diagnose depression in men and this is also an area for exploration.

Improved services for sexual violence. With as many as 1 in 6 men experiencing sexual abuse/assault in their lifetime (Dube, Anda & Whitfield, 2005) and a lack of services like rape crisis centres that provide service to men, suicide as a result of the after-effects of abuse will continue to be a devastating issue.

Areas for Additional Research

Areas for additional research include whether men respond differently to standard treatments for depression or substance abuse, or if there are any ways to intervene with men experiencing suicidal ideation that are particularly effective.

Bibliography

Barber, C.W., Miller, M.J. (2014) Reducing a Suicidal Person’s Access to Lethal Means of Suicide: A Research Agenda. American Journal of Preventive Medicine. 47(3S2):S264–S272

Centers for Disease Control and Prevention. (2013) Web-based Injury Statistics Query and Reporting System (WISQARS). Accessed Jun 21 2015 from http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html

Denning, D.G., Conwell, Y., King, D., Cox, C. (2000) Method choice, intent, and gender in completed suicide. Journal of Suicide and Life Threatening Behaviour. 30(3). 282-288

Dube, S.R., Anda, R.F. & Whitfield, C.L., et al. (2005). Long-term consequences of childhood sexual abuse by gender of victim. American Journal of Preventive Medicine, 28, 430-438.

Callanan, V.J., Davis, M.S. Gender differences in suicide methods. (2012). Social Psychiatry and Psychiatric Epidemiology. 47:857–869 DOI 10.1007/s00127-011-0393-5

Cotto, J.H. et al. (2010) Gender effects on drug use, abuse, and dependence: An analysis of results from the National Survey on Drug Use and Health. Gender Medicine. 7(5):402-413

“Fatal occupational injuries in 2013.” Bureau of Labour Statistics. (2013). Accessed from http://www.bls.gov/iif/oshwc/cfoi/cfch0012.pdf on Sep 5 2015.

Global Health Observatory Data Repository. (2012) World Health Organization. Accessed from http://apps.who.int/gho/data/node.main.MHSUICIDE?lang=en on Sep 1 2015.

McPherson, M., Smith-Lovin, L., Brashears, M.E. (2006) Social Isolation in America: Changes in Core Discussion Networks Over Two Decades. American Sociological Review. 71(3).

Player MJ, Proudfoot J, Fogarty A, Whittle E, Spurrier M, Shand F, et al. (2015) What Interrupts Suicide Attempts in Men: A Qualitative Study. PLoS ONE 10(6): e0128180. doi:10.1371/journal.pone.0128180

Vaillancourt, R. 2010. Gender differences in police-reported violent crime in Canada, 2008. Catalogue no. 85F0033M, no. 24. Ottawa: Statistics Canada.

Vyrostek S.B., Annest, J.L, & Ryan, G.W. Surveillance for fatal and nonfatal injuries–United States, 2001. Morbidity and Mortality Weekly Report. 2004:53(SS07);1-57.

Cite this article as: MacDonald, D.K., (2015), "Understanding and Preventing Male Suicide," retrieved on July 16, 2018 from http://dustinkmacdonald.com/understanding-and-preventing-male-suicide/.
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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 July 16, 2018 from http://dustinkmacdonald.com/developing-core-competencies-for-suicide-risk-assessment/.

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