Biopsychosocial Model of Suicidal Behaviour

Introduction

There are a variety of models of suicidal behaviour. These models attempt to map suicidal behaviour or put it into boxes so that a helping professional can better understand how suicidal behaviour forms and how it can be treated and resolved. This Biopsychosocial Model comes from Kumar, U. & Mandal, M.K. (2010).

The model is first presented in textual format, followed by an image, and then an explanation.

Biopsychosocial Model

Biological, Environmental and Event factors feed into a Psychological Process. This psychological process leads to the development or exacerbation of a mental health issue and to suicidal behaviour. On a cognitive level, this affects how the individual thinks and feels about the past, present and future.

 

 

 

 

 

 

 

 

 

 

 

 

 

Biological Influences in Suicide

There are a number of biological factors that can increase the risk of suicide which have been reviewed by Pandey (2013). These include genetic predisposition of suicidal behaviour (Turecki, 2001) which may be related to increased prevalence of impulsiveness and aggressiveness.

5HT receptors are receptors in the brain that are activated by the neurotransmitter serotonin. Serotonin plays an important role in mood (Yohn, Guerges & Samuels, 2017), appetite and eating (Sharma & Sharma, 2012), sleep, memory and sexual function. Improperly functioning 5HT receptors may play a role both in depression and in suicidal behavior.

It has been well-documented that teens and adolescents are more impulsive than adults as their brains continue to develop up to age 25 (Kasen, Cohen & Chen, 2011) and this can increase their risk of suicide and homicide. (Glick, 2015) Witt et. al. (2008) examines this through the lens of the Interpersonal Theory of Suicide – suggesting that impulsive individuals are more likely to have acquired capability (through being exposed to pain), which is one of the 3 key elements of that Theory of Suicide.

Environmental Influences in Suicide

Environmental influences on suicidal behaviour include literal environmental factors like sunlight exposure and situational factors like presence of abuse, history of suicide attempts and other items that are commonly known as suicide risk factors.

Souêtre et. al. (1990) found that decreased sunlight exposure and lowered temperature was linked to increased risk of suicide. This may explain the high rate of suicide in Nordic and Scandinavian countries that lack many of the other risk factors for suicide. Lam et. al. (1999) found that light therapy decreased suicidal ideation in a population of women who struggled with Seasonal Affective Disorder (SAD).

Evans, Owens & Marsh (2005) found that an external locus of control (believing that life “happens to one” rather than one having control over their life) was associated with an increased risk of suicide in adolescents. This likely holds true in adults as well.

Other risk factors for suicide include the American Association of Suicidology’s IS PATH WARM mnemonic:

  • Ideation (thoughts of suicide)
  • Substance Abuse
  • Purposelessness
  • Anxiety
  • Trapped (a feeling of being trapped)
  • Hopelessness
  • Withdrawal (from others)
  • Anger
  • Recklessness
  • Mood Changes

Event Influences in Suicide

Sometimes an event occurs in someone’s life that is so devastating that it may lead to suicide. For instance, relational changes and other interpersonal issues (such as a loss of a relationship or fights with a friend) commonly precede a suicide attempt (Yen et. al., 2005; Bagge, Glenn & Lee, 2013; Conner, et. al., 2012)

In addition to interpersonal events as described above, events that may lead to suicidal behaviour include being arrested, charged or sentenced with a crime (Cooper, Appleby & Amos, 2002). Zhang & Ma (2012) also found this in a Chinese sample of suicide attempters, with the most common stressful life events preceding suicide involving family/home, hospital/health and marriage/love.

Conclusion

It’s clear that the biopsychosocial model of suicide has a fair amount of support for its component parts. It may be difficult to apply the Biopsychosocial Model directly in a clinical or therapeutic context. For that reason, other models may be preferred for intervention purposes.

References

Bagge, C. L., Glenn, C. R., & Lee, H. (2013). Quantifying the impact of recent negative life events on suicide attempts. Journal Of Abnormal Psychology122(2), 359-368. doi:10.1037/a0030371

Conner, K. R., Houston, R. J., Swogger, M. T., Conwell, Y., You, S., He, H., & … Duberstein, P. R. (2012). Stressful life events and suicidal behavior in adults with alcohol use disorders: Role of event severity, timing, and type. Drug & Alcohol Dependence120(1-3), 155-161. doi:10.1016/j.drugalcdep.2011.07.013

Cooper, J., Appleby, L., & Amos, T. (2002). Life events preceding suicide by young people. Social Psychiatry & Psychiatric Epidemiology37(6), 271.

Evans, W. P., Owens, P., & Marsh, S. C. (2005). Environmental Factors, Locus of Control, and Adolescent Suicide Risk. Child & Adolescent Social Work Journal22(3/4), 301-319. doi:10.1007/s10560-005-0013-x

Glick, A. R. (2015). The role of serotonin in impulsive aggression, suicide, and homicide in adolescents and adults: a literature review. International Journal Of Adolescent Medicine And Health, (2), 143. doi:10.1515/ijamh-2015-5005

Kasen, S., Cohen, P., & Chen, H. (2011). Developmental course of impulsivity and capability from age 10 to age 25 as related to trajectory of suicide attempt in a community cohort. Suicide And Life-Threatening Behavior, (2), 180.

Kumar, U & Mandal, M.K. (2010). Suicidal Behavior: Assessment of People-at-Risk. New Delhi, India: SAGE Publications.

Lam, R. W., Carter, D., Misri, S., Kuan, A. J., Yatham, L. N., & Zis, A. P. (1999). A controlled study of light therapy in women with late luteal phase dysphoric disorder. Psychiatry Research86185-192. doi:10.1016/S0165-1781(99)00043-8

Pandey, G. N. (2013). Biological basis of suicide and suicidal behavior. Bipolar Disorders15(5), 524-541. doi:10.1111/bdi.12089

Sharma, S., & Sharma, J. (2012). Regulation of Appetite: Role of Serotonin and Hypothalamus. Iranian Journal Of Pharmacology & Therapeutics11(2), 73-79.

Souêtre, E., Wehr, T.A., Douillet, P. & Darcourt, G. (1990) Influence of environmental factors on suicidal behavior. Psychiatry Research. 32(3):253-63.

Turecki, G. (2001). Suicidal behavior: is there a genetic predisposition?. Bipolar Disorders3(6), 335-349.

Witte, T. K., Merrill, K. A., Stellrecht, N. E., Bernert, R. A., Hollar, D. L., Schatschneider, C., & Joiner, J. E. (2008). Research report: “Impulsive” youth suicide attempters are not necessarily all that impulsive. Journal Of Affective Disorders107107-116. doi:10.1016/j.jad.2007.08.010

Yen, S., Pagano, M. E., Shea, M. T., Grilo, C. M., Gunderson, J. G., Skodol, A. E., & … Zanarini, M. C. (2005). Recent Life Events Preceding Suicide Attempts in a Personality Disorder Sample: Findings From the Collaborative Longitudinal Personality Disorders Study. Journal Of Consulting And Clinical Psychology73(1), 99-105. doi:10.1037/0022-006X.73.1.99

Yohn, C. N., Gergues, M. M., & Samuels, B. A. (2017). The role of 5-HT receptors in depression. Molecular Brain101-12. doi:10.1186/s13041-017-0306-y

Zhang, J., & Ma, Z. (2012). Research report: Patterns of life events preceding the suicide in rural young Chinese: A case control study. Journal Of Affective Disorders140161-167. doi:10.1016/j.jad.2012.01.010

Cite this article as: MacDonald, D.K., (2017), "Biopsychosocial Model of Suicidal Behaviour," retrieved on July 21, 2017 from http://dustinkmacdonald.com/biopsychosocial-model-suicidal-behaviour/.
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Ultimate Guide to Starting a Crisis Line

Introduction

Following up on my previous post Starting a Crisis Line or Hotline, I had some reader commentary asking about some more specific nuts and bolts for someone who is passionate and interested in starting a crisis line, hotline or helpline but doesn’t really know where to begin. Obviously, while it is best to bring in experienced individuals sometimes they simply aren’t available. For the purpose of this guide, I will describe the steps to create a fictional crisis line, the Southeast Iowa Crisis Center (SEICC), or “Seek.”

Throughout this article, I use “crisis line”, “helpline” and other terms interchangeably, except in the section “Deciding on Type of Service Provided” where I distinguish between the two.

Staffing a Steering Committee

The first step will be to decide on and form a Steering Committee. This will be a group of individuals who will be responsible for helping to bring your vision of a crisis line to life. Too few people and you may feel overwhelmed. Too many and you risk decision paralysis – not being able to make decisions because of too many disagreements. Perhaps 4-6 people is the optimal size for a Steering Committee.

If (or when) you form a nonprofit, you’ll need a Board of Directors. The members of your Steering Committee often make a suitable Board. Their tasks will include all of the items discussed below.

Choosing a Population and Coverage Area

You likely know this information before you begin, but it’s important to clearly define your population and coverage (or catchment) area as you work on your crisis line. You might choose to create your crisis line based on a specific age range (such as the Kids Help Phone for those 0-25), subject area (like the Rape, Abuse and Incest National Network [RAINN]), geographic region (like Tennessee Statewide Mental Health Crisis Line) or job status such as the Veterans Crisis Line.

Some funders will only fund certain populations or programs but it’s important that you not get into the business of chasing funding by going against your mission – this could lead to you losing your nonprofit status or losing trust among your supporters.

Identifying Mission and Vision

The next step to starting a nonprofit or a new product is to define what you wish to create. An organization’s mission statement is short and punchy, describing what they do. This can be a tagline or slogan, but doesn’t have to be. Distress Centre Durham‘s mission statement is “Helping people in distress to cope.”

Vision is more long-term and describes an outcome. An example vision statement for Habitat for Humanity is “A world where everyone has a decent place to live.” You don’t necessarily have to publicize your visioning statement but your mission and vision will determine whether activities that you pursue are within your organization’s purview.

SEICC’s mission will be “Keeping Iowans safe with 24/7 emotional support”, while the vision will be “Nobody suffers alone.”

Parkinson’s Law of Triviality

There is a concept in management called Parkinson’s Law of Triviality. Essentially it states that organizations spend disproportionate amounts of time on easy-to-grasp issues while neglecting more important but more difficult ones. This is an important trap to avoid when considering things like your organization’s logo, or other elements that are pretty minor in the grand scheme of things.

Picking a Staffing Model

At this stage, you have identified a group of individuals that are going to help you build your crisis line. You’ve also decided on a mission and a vision. You need to decide whether you will use a model of volunteers supported by paid staff, a blended model, or all paid staff. There are pros and cons to each approach.

Volunteers, Staff Supported

Advantages of the volunteers-supported-by-staff model include it is easy to start and individuals can self-select as one or the other (either applying for a staff position in administration or a volunteer position providing direct service.) One downside to this model is that initially your administrative staff will probably have to cover shifts on the helpline until you all get experienced, and that it can be hard to ensure 100% coverage if your service gets popular.

Blended Model

A blended model involves a mix of paid staff and volunteers. This is a more common model in the United States than in Canada, which tends to use purely volunteers. The advantages are that you can attract a more credentialed staff who might hold multiple roles (e.g. a helpline manager might be responsible for 20 hours of helpline work and 20 hours of administration.)

The downsides are that this can make your volunteers uncomfortable, and increase the expenses you need to get your crisis line off the ground.

All Paid Staff

Using all paid staff is an emerging crisis line model. Some helplines like the Veteran’s Crisis Line have used this model for many years. With this model, you can ensure 100% coverage (because your staff are paid to be in the chair), but this will be very expensive. Although research shows that paying crisis line workers does not diminish their importance, it may make it harder for your callers to trust that they’re really interested in listening.

This can also increase the rate of burnout because paid workers are providing many more hours of support each week or month versus a volunteer.

Deciding on Type of Support Provided

It’s important to decide if you’re going to be a distress line, a crisis line, or both. Some organizations will break their services into two distinct phone numbers and lines, with specific caller concerns, while many others (like Distress Centre Durham) will provide all forms of support.

Despite the use of the name “distress line” or “crisis line”, an organization may take all types of calls. You’ll need to read the explanation of the service provided before making a decision about whether or not an agency really does limit or parcel out their support.

Distress Line

A distress line focuses on individuals who are struggling and need to talk to someone but who can still cope. Someone in distress can still think about potential solutions to their problem, is not struggling with high-risk suicide thoughts, and does not need safety planning.

Crisis Line

A crisis line provides support to individuals who are struggling with high-risk suicide, crisis situations (where they can’t think of what to do), or who are otherwise unsafe. Many crisis lines have access to mobile crisis units, may call ambulances to take callers to hospitals or otherwise access more intensive support.

Hours of Operation

Deciding on the hours of operations for a crisis line is an important element. Many crisis lines started as 4-hours a day, 7 days a week operations before moving to 12 or 24 hours. Other organizations started immediately with 24 hours.

Staffing Volume

You’ll need to calculate the amount of staff you need for your crisis line (whether paid or unpaid) once you’ve decided on your hours of operation. One way to do this is the Erlang C formulas that are used to staff call centres (which you can fill with dummy data based on crisis lines in other regions.)

If you’re paying your staff, this will be easier. It might be easier to start small and then build up as your service gets more well known and well supported.

Choosing a Location

Choosing a location for a new crisis line (or any nonprofit really) will depend most commonly on your finances. Many organizations get cheap or free space in an organization like a church starting off, before moving to an office. If you’re really tight on space you might even be able to set up in a large office in someone’s home.

The keys to choosing a location will include availability, security, convenience, and price. While price is obvious, I’ll speak about the others.

One advantage of a stand-alone building is you have 24/7 access to it. If you’re in another type of location you may find it difficult or impossible to access after-hours, which can complicate things. Security is also a factor, in that if you’re not advertising your crisis line location it shouldn’t be obvious where you’re located. While a far-away location might seem to be ideal for security, it complicates accessibility (distance travelled) for your volunteers and limits convenience.

Forming a Nonprofit (or not)

Choosing whether to incorporate is a challenging decision to make. Incorporation provides you with benefits like protection of your assets, tax exempt status (once you’re registered as a charity) and the ability to pursue formal funding. The downsides are that it takes work to form and maintain the nonprofit status.

Finding Sources of Funding

Initial sources of funding may come from your Steering Committee but eventually you’ll need to explore outside sources. When your crisis line has operated for 1-2 years you’ll likely be eligible to apply for formal funding grants such as those at the local, state and federal levels.

Other sources include corporate sponsorship, fundraising events and direct donations.

Developing Policies and Procedures

Policies and procedures are important for ensuring that your volunteers respond in a consistent way. Examples of policies and procedures that you may wish to develop:

  • Call Trace and Intervention
  • Callers as Volunteers
  • Confidentiality
  • Recruitment (Criminal Record Check)
  • Victims of Abuse (Reporting Child Abuse)

Call Trace and Intervention

A Call Trace and Intervention policy will describe under what circumstances you will initiate call trace (to try and find an individual’s address or other identifying information) and under what circumstances you will call police/911 for Active Rescue. Some crisis lines will never initiate Active Rescue, for instance the UK Samaritans, unless the caller requests it. Many crisis lines will always err on the side of caution.

Call Trace will depend on the technology available to your crisis line but may include use of 411 (for non-blocked numbers) or contacting 911 directly to pass available information to them.

Helplines will often describe their intervention policy on the lines as something to the effect of, “We only intervene in cases of imminent homicide, suicide, or disclose of child abuse.”

Callers as Volunteers

Callers to your helpline will usually result in the creation of a call report or other record of that conversation. If you recruit volunteers from the same area that you take calls from, it’s possible that someone who has previously called your line may become a volunteer – and therefore be able to read their call report.

For that reason, you may require that volunteers to your helpline must have not used your service in the amount of time that records are retained. For instance, at Distress Centre Durham call reports are retained for one year so volunteers must not have used the service in that time in order to be eligible.

Confidentiality

Confidentiality is at the core of emotional support. Creating a safe environment is key to helping callers discuss their issues openly. Confidentiality means that volunteers who disclose information about callers outside of the crisis line or make contact with them outside of the line can be dismissed.

Examples of violations of confidentiality:

  • Talking about callers to your friends or family
  • Posting information about callers on social media
  • Giving information from the crisis line to another agency without that caller’s permission

It’s important to establish a very high degree of confidentiality or else callers will quickly lose trust in the helpline.

Data Destruction

A data destruction policy includes information on when and how you’ll destroy data that you’ve collected, such as via call reports or caller profiles. The most important element is to include a timeline for how frequently you’ll destroy data – such as on a quarterly basis for data that is more than 12 months old.

Recruitment (Criminal Record Check)

A Criminal Record Check (CRC), known by other names like a Police Record Check (PRC) or a Disclosure and Barring Service (DBS) Check describes a person’s record of criminal offenses. Many jursidictions include an option specifically for crimes against vulnerable individuals like children or seniors.

Many crisis lines will limit their volunteers only to those who have no criminal record, while some will allow – with approval – individuals who have certain types of non-violent offenses from many years ago.

Victims of Abuse

Nonprofit organizations are often legally required to report abuse, like child abuse or elder abuse. A policy explaining this will help callers better understand when they disclose child abuse, what the volunteer will do. In many crisis lines this means calling Child Protective Services (CPS) or a similar agency (like Children’s Aid Society in Ontario.)

You may also wish to include a statement about how your helpline takes a non-judgemental stance on abuse – not encouraging individuals to leave unless they’re ready to leave on their own.

Volunteers in Counselling or Therapy

Helpline work can be demanding and burnout can be a challenge. For this reason, it’s important to know when your volunteers are undergoing counselling or therapy. One way in which to do this is to have volunteers self-identify if they are receiving counselling or therapy and then giving them a letter to give to their therapist. That clinician will simply sign asserting that the work will not be harmful, and that can be filed away.

Volunteer Recruitment

Recruiting volunteers will depend on your local community. In some communities, United Way may operate a volunteer board online that you can submit your crisis line to. Universities or colleges may allow you to post flyers or distribute information to the students.

A good training class will be between 5 and 20 individuals, but recruiting throughout the year will be important for ensuring consistent service delivery.

Volunteer Screening

Screening involves determining if individuals possess the appropriate attitudes to be successful in helpline training. The American Association of Suicidology Crisis Center Certification identifies these attitudinal outcomes that individuals should experience by the conclusion of training:

  • Acceptance of persons different from oneself, and a non-judgmental response toward sensitive issues (e.g. not discussing suicidal ideation or abortion with a client in terms of its moral rightness or wrongness)
  • Balanced and realistic attitude toward self in the helper role (e.g. not expecting to “save” all potential suicides by one’s own single effort, or to solve all the problems of the distressed person)
  • A realistic and humane approach to death, dying, self-destructive behavior and other human issues
  • Coming to terms with one’s own feelings about death and dying insofar as these feelings might deter one from helping others.

Volunteer screening may include an application form that asks questions about the caller like:

  • Are there situations or topics (such as abuse or abortion) that may place you in a moral or ethical dillema?
  • What are your beliefs on suicide?
  • How do you feel you would talk to someone who is different from yourself?

The screening process does not have to rule out anyone yet, but may be helpful for prepping you on the interview.

Volunteer Interviewing

See also: Interviewing on a Suicide Hotline

The process of the volunteer interview will be to collect more information on the potential volunteer to make sure there is compatibility with your service. For instance, some individuals may only want to work with children or may not want to work with suicide – and your desires for your line may not align with that.

The interview is also an opportunity to see how someone is on the phone, and to help answer more of their questions about what the process looks like.

Volunteer Training

See also: Crisis Hotline Training Curriculum

Volunteer training is the process of teaching a volunteer the core skills that they need to be prepared for the helpline. Rather than reproducing material I’ve written about elsewhere, see the link above. From there you can find posts across my blog that will be useful for building a training program.

Training should run approximately 40 hours, with at least 24 hours of classroom training and 16 hours of supervised “on the phone” training being mentored by a shift supervisor or experienced volunteer before the newly trained volunteer is able to take shifts on their own.

You may find it helpful to bring on a therapist or counsellor to help you develop your initial helpline curriculum, or use a crisis line trainer from an area near you that doesn’t overlap with your catchment area.

Identifying Caller Issues

Caller Issues are the specific issues prevalent in your community that may lead you to develop training modules on them to prepare your volunteers. One example is in college towns where concerns over sexual assault or alcohol and drug abuse may be more prevalent.

The easiest way to do this is with effective helpline management software (see the next section.) With a detailed call report you will be able to pull statistics on exactly what your callers are discussing and this will help you fine-tune your training. Generally, the core elements of emotional support and crisis intervention will be exactly the same.

Helpline Management Software

In order to run a helpline you’ll need some form of helpline management software. I recommend iCarol, which my crisis line has used for several years. iCarol provides all the features you’d expect online helpline software to provide:

  • Shift Calendar so volunteers can sign up for shifts
  • Call Reports so volunteers can record details about their conversations
  • Chatboard for facilitating communication between staff and volunteers
  • Events Calendar
  • News

And a variety of other features, all designed with confidential helplines in mind.

Outcomes Measurement and Evaluation

See also: Methods of Evaluating Helplines and Hotlines

Outcomes Measurement and Evaluation describes the things that you will need to do in order to prove that your helpline is effective. One way in which to do this starts with your Basic Training program. Have your volunteers complete a pre and post training survey that includes questions about the perceived value of the training, their ability to display empathy and their understanding of crisis and suicide risk assessment. You’ll see their scores increase, demonstrating the knowledge transfer.

Another way to evaluate a Basic Training program is with a tool like the Suicide Intervention Response Inventory, which has volunteers rate how effective a series of statements are in providing emotional support. Their scores will change throughout training, indicating their increased skill.

On the phone calls themselves, your call reports can include space for Outcomes Measurement. This can include things like, “Callers says they feel better”, “Decreased distress and anxiety”, “Reduced isolation and loneliness.” These outcomes can be used to show what changes your callers experience throughout the call.

Joining Professional Associations

Finally you may wish to join professional associations like the Association of Crisis Workers or Crisis Lines in your area, or other professional groups that provide support to nonprofits. This will help you network, fundraise and attract volunteers to your organization.

Conclusion

As you can see, a lot goes into developing a crisis line – but it is not unmanageable. If you’ve decided to launch a crisis line, let me know in the comments! And please continue to ask questions if you’d like.

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SIMPLE STEPS Model for Suicide Risk Assessment

Introduction

The SIMPLE STEPS Model (McGlothlin, 2008) for suicide risk assessment provides a simple mnemonic similar to others like SADPERSONS (Patterson, et. al., 1983) or IS PATH WARM (from the American Association of Suicidology). Each of these is correlated with increasing suicide lethality and so this can be a useful short-hand to remember these items.

Suicide risk assessment on the crisis line is mostly concerned with imminent risk, and many suicide screeners designed for lay people may miss important variables in a goal to be simplistic; the SIMPLE STEPS model appears to avoid both of these traps, by providing an assessment tool simple enough to be used in the crisis line environment but comprehensive enough to be used by counsellors or therapists for ongoing monitoring of suicide risk.

Items in the SIMPLE STEPS Model

  • Suicidal – Is the individual expressing suicidal ideation?
  • Ideation – What is their suicidal intent?
  • Method – How detailed and accessible is their suicidal method?
  • Perturbation – How strong is their emotional pain
  • Loss – Have they experienced actual or perceived losses? (Relationships, material objects)
  • Earlier Attempts – What previous attempts has the individual experienced, what happened after those attempts?
  • Substance Use – Is the individual abusing drugs, alcohol, or other substances?
  • (Lack of) Troubleshooting Skills – Are they able to see alternatives or options other than suicide?
  • Emotions / Diagnosis – “Assessment of emotional attributes (hopelessness, helplessness, worthlessness, loneliness, agitation, depression, and impulsivity) and diagnoses commonly associated with completed suicide (e.g., substance abuse, mood disorders, personality disorders, etc.)” (McGlothlin, et. al., 2016)
  • (Lack of) Protective Factors – What is keeping this person safe from suicide? Who are their supports (internal such as personal values and external like people), resources and agencies
  • Stressors and Life Events – What has happened in their life to lead them to suicide?

Sharp readers will identify that these elements map very neatly onto the DCIB Model of Suicide Risk Assessment, but perhaps provide a better mnemonic in order to make sure that clinicians who do not have the DCIB in front of them are able to perform that assessment.

Validation of the SIMPLE STEPS Model

McGlothlin, et. al. (2016) used 13,000 calls over six years to a crisis line and correlated the SIMPLE STEPS items with the lethality risk present in that call. One limitation of this study is that it used self-reported (by the helpline worker taking the call) lethality rather than using another evidence-based risk assessment in order to compare with. I am satisfied that McGlothlin addressed this in his limitations section, where he noted the difficulty with using data collected in this manner.

References

McGlothlin, J. (2008). Developing clinical skills in suicide assessment, prevention and treatment.
Alexandria, VA: American Counseling Association

McGlothlin, J., Page, B., & Jager, K. (2016). Validation of the SIMPLE STEPS Model of Suicide Assessment. Journal Of Mental Health Counseling, 38(4), 298-307. doi:10.17744/mehc.38.4.02

Patterson, W.M., Dohn, H.H., Patterson, J. & Patterson, G.A. (1983). “Evaluation of suicidal patients: the SAD PERSONS scale.” Psychosomatics 24(4): 343–5, 348–9. doi:10.1016/S0033-3182(83)73213-5. PMID 6867245

Cite this article as: MacDonald, D.K., (2017), "SIMPLE STEPS Model for Suicide Risk Assessment," retrieved on July 21, 2017 from http://dustinkmacdonald.com/simple-steps-model-suicide-risk-assessment/.

 

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Suicide Awareness Presentation

IntroductionSuicide Presentation Slide

The following is a presentation I prepared in 2012 on Suicide Awareness for delivery at Durham College. It’s just been sitting on my hard drive since then, so I’ve made it available for other organizations that wish to provide suicide awareness presentations. The content is reproduced below, and you can download the slides here. Although the content takes a Canadian focus, I’ve noted US statistics where possible.

Agenda

  • About Me
  • A Note on Wording
  • Definitions
  • Suicide Statistics
  • Suicide True and False
  • Risk Factors for Suicide
  • Warning Signs for Suicide
  • How to Help
  • Support Networks
  • Case Study

About Me

  • Currently Director of Online Support & Communication @ Distress Centre Durham
  • Distress Centre Durham History
    • 1600+ hours of telephone experience
    • 600+ hours of online chat and text
    • Former Placement Student, Summer Student (x3)
  • Trainer Experience
    • Distress Centre Durham Basic Training
    • DCIB Suicide Risk Assessment
    • Online Chat and Text (ONTX) Training

Before we start…

  • People do not commit suicide
  • You commit a crime, you get committed to a psychiatric hospital
  • Instead, people who take their own lives are said to have suicided or alternately died by suicide, as one dies of lung cancer or a person is murdered.

Definitions

  • Suicide – Intentional taking of one’s own life
  • Suicidal ideation – Clinical term for suicidal thoughts
  • Parasuicide
    • A suicidal attempt that is designed to fail or be discovered
    • Not necessarily attention-seeking behaviour

What is a Crisis?

A crisis is any event that overwhelms someone’s coping mechanisms, those things a person does to solve or deal with a problem

Suicide Statistics

  • Suicide is the 2nd leading cause of death in Canada for 18-24 year olds (behind car accidents) (Statistics Canada, 2015)
  • More than 90% of suicide victims may have had diagnosable mental illness (Bertolote, et. al., 2004) – Note that there is still not consensus on this figure, it still makes an important point about mental health treatment for suicide
  • 21,115 people died by suicide in Ontario in 2005
  • The suicide rate is 12.7 per 100,000 males and 4.1 per 100,000 females in Ontario (Statistics Canada, 2014a)
  • The Aboriginal suicide rate is 11 times higher than the national average (Public Health Agency of Canada, 2011)

Risk Factors for Suicide (CDC, 2016)

  • Mental Illness
  • Clinical Depression, Borderline Personality Disorder (BPD), Schizophrenia all increase risk
  • Financial Difficulties
  • Bullying (+ Cyber-bullying) for young adults
  • Relationship Troubles
  • Academic / School Troubles
  • Legal Problems
  • History of Physical / Sexual Abuse
  • Bereavement Grief and Loss
    • Especially a suicide-related loss
    • Interrupted (or “Complicated” Grief)

Suicide True and False

(See: Common Suicide Myths)

  • Most suicides involve drugs or alcohol…True! Up to 70% percent of suicides involve alcohol or drugs (Pompili, 2010)
  • Talking about suicide can plant the idea in someone’s head False! Most people feeling suicidal want to talk about their feelings
  • Teenagers have the highest rate of suicide False! The highest risk population is 45-54 years of age in Canada (Statistics Canada, 2014b), and in the US (CDC, 2014)
  • The most common suicide method is pills False! The most common method (overall) is hanging (in Canada: Statistics, 2016); in the US it is firearm: Barber & Miller, 2014)
  • Most suicidal people leave notes False! Only about 30% of suicides leave notes (Shioiri, et. al., 2005)
  • Suicidal people want to die False! Most suicidal people don’t want to die, but want the pain to stop

Suicide Risk Factors vs. Suicide Warning Signs

  • Risk Factors are things that increase the likelihood someone will suicide because those things make coping more difficult
  • Warning signs are clues that a suicidal crisis may be imminent
  • It takes careful clinical examination by a trained mental health professional to determine a person’s level of risk in the medium and long-term

Suicide Warning Signs (AAS, n.d.)

  • Sudden Mood changes (either very happy or very sad)
  • Sudden appetite changes
  • Talking about life in the past tense
  • Telling people goodbye, tying up loose ends
  • Talking about suicidal acts, feeling hopeless or helpless
  • Making lethality statements (“I wish I could fall asleep and not wake up”)

How to Help

  • Listen!
  • Provide empathy
  • Refer to resources
  • Distress Centre (1-800-452-0688, 905-430-2522)
  • Durham College Counselling Services
  • Durham Mental Health Services
  • Other resources (e.g. spiritual)
  • Explore options
  • Build support network

Support Network

  • Three levels of support
    • Internal
    • External
    • Peripheral
  • Strong support network allows developing the resources that provides the strongest defence against suicide
  • Internal Supports
    • Things that we do ourselves to cope with stress
    • Examples include:
      • Journalling
      • Listening to music / Playing an Instrument
      • Running / Working Out / Exercise
      • Prayer / Meditation / Spirituality
      • Art
      • Yoga / Massage
      • Deep Breathing
      • Other Hobbies
  • External Supports
    • People in our “inner circle” we reach out to
    • Examples include:
      • Family
      • Friends
      • Pets
  • Peripheral Supports
    • Community agencies and others outside of our inner circle
    • Examples include:
    • Distress Lines (e.g. Distress Centre)
    • Family Doctors
    • Psychiatrists / Psychologists
    • Durham Mental Health Services
    • Clergy

Summary

  • Suicide is usually preventable
  • Asking about suicidal thoughts is the most important thing you can do
  • Never be afraid to reach out to a professional for help

Case Study

The original training included a case study derived from Distress Centre Durham training materials.

References

American Association of Suicidiology (AAS). (n.d.) “Warning Signs | American Association of Suicidology. Retrieved on August 24, 2016 from www.suicidology.org/resources/warning-signs

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

Bertolote, J. M., Fleischmann, A., De Leo, D., & Wasserman, D. (2004). Psychiatric Diagnoses and Suicide: Revisiting the Evidence. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 25(4), 147-155. doi:10.1027/0227-5910.25.4.147

Centers for Disease Control and Prevention (CDC). (2011) Web-based Injury Statistics Query and Reporting System (WISQARS). National Center for Injury Prevention and Control. Retrieved on August 24, 2016 from http://www.cdc.gov/injury/wisqars/index.html.

Centers for Disease Control and Prevention (CDC). (2016) Suicide: Risk and Protective Factors. Retrieved on August 24, 2016 from http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html

Pompili, M., Serafini, G., Innamorati, M., Dominici, G., Ferracuti, S., Kotzalidis, G. D., … Lester, D. (2010). Suicidal Behavior and Alcohol Abuse. International Journal of Environmental Research and Public Health, 7(4), 1392–1431. http://doi.org/10.3390/ijerph7041392

Public Health Agency of Canada. The Human Face of Mental Health and Mental Illness in Canada 2006. Ottawa, ON: Public Health Agency of Canada,  2011. Available at: http://www.phac-aspc.gc.ca/publicat/human-humain06/

Shioiri, T., Nishimura, A., Akazawa, K., Abe, R., Nushida, H., Ueno, Y., & … Someya, T. (2005). Incidence of note-leaving remains constant despite increasing suicide rates. Psychiatry & Clinical Neurosciences, 59(2), 226-228. doi:10.1111/j.1440-1819.2005.01364.x

Statistics Canada. (2014a) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on August 24, 2016.

Statistics Canada. (2014b) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on August 24, 2016.

Statistics Canada. (2015) Table 102-0561 – Leading causes of death, total population, by age group and sex, Canada, annual, CANSIM (database). Retrieved on August 24, 2016.

Statistics Canada. (2016) Navaneelan, T. Suicide rates: An overview. Retrieved on August 24, 2016 from www.statcan.gc.ca/pub/82-624-x/2012001/article/11696-eng.htm

Cite this article as: MacDonald, D.K., (2016), "Suicide Awareness Presentation," retrieved on July 21, 2017 from http://dustinkmacdonald.com/suicide-awareness-presentation/.
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Building a Suicide Prevention Group

Introduction

I’ve had the pleasure of serving on the Durham Region Youth Suicide Prevention (YSP) Action Group since February 2016. The goal of the YSP is to address the rising youth suicide rates in Durham Region in Ontario. This group was financially supported by a 3-year grant from the Ministry of Children and Youth Services.

For other regions interested in implementing similar suicide prevention groups (whether to address youth, elderly, military, or other targeted group suicide rates or others) the following may be helpful. Because my group was focused on youth suicide prevention, more of the resources below apply to that but the concepts are equally applicable to others.

Building Capacity

The first step is for your suicide prevention group to learn about suicide in your targeted population. Academic journals can be helpful in this way, as can other resources depending on the group you are looking for. I’ve linked some examples below, including a number of blog articles.

Learning About Adult Suicide

Learning About Elder Suicide

Learning About Law Enforcement Suicide

Learning About Male Suicide

Learning About Military Suicide

Learning About Youth Suicide

Choosing Your Suicide Prevention Group Members

In order to develop a suicide prevention group, you must identify individuals in the community who can participate. In order to be most effective, a suicide group should be cross-sectorial – that is, it should include individuals from a variety of stakeholders that are affected by that demographic. Examples of sectors and include:

  • Criminal Justice
  • Education
  • Faith / Religion
  • Hospital / Medical
  • Mental Health
  • Substance Abuse

It is important to recognize that regardless of the group you target, many of these stakeholders will be relevant. For instance, in an elderly suicide prevention group, organizations that work with seniors directly (such as seniors centres, long-term care facilities and hospices) will be important, but faith-based organizations, substance abuse workers and criminal justice may provide valuable insight based on their work with elderly clients.

Conducting A Needs Assessment

Once you’ve identified the group of individuals who will make a part of your suicide prevention group, the next step is to conduct a needs assessment. Needs assessments are formal explorations of what exists in your community, and what does not. This allows you to identify the gaps and make a formal plan for eliminating those gaps.

Examples of completed needs assessment for suicide prevention include Shasta County, California and Juneau, Alaska.

This strategic planning tool from TogetherToLive can help you start your needs assessment process. This process should also include community consultation via surveys, focus groups or other methods to collect information from individuals who have lived experience with suicide in your community, especially in your target demographic.

Choosing Interventions

Now that you’ve conducted a needs assessment, you have an idea what elements are lacking in your community. Interventions fall into one of three categories:

  1. Universal Interventions apply to everyone in a particular area. For instance, all individuals who present to an emergency room are administered a suicide screening measure; this is a universal intervention
  2. Indicated Interventions apply to individuals who are identified as high-risk for suicide. For instance, students who appear to be experiencing emotional health issues are referred to school mental health counselling
  3. Selected Interventions apply to individuals who present with suicide risk factors or warning signs. These can include referrals to therapists, crisis lines or transportation to the hospital for emergency mental health treatment.

There are a variety of interventions that your suicide prevention group can choose, targeting four different categories. These categories are Life Promotion (or Primary Prevention), Suicide Prevention, and Postvention.

Life Promotion Interventions

Life promotion interventions are those that focus on “build[ing] their resilience through their personal strengths, available resources and relationships with those around them.” These interventions focus on individuals who haven’t yet experienced suicidality. For youth, this will involve programs about self-esteem, healthy relationships and problem-solving, while for soldiers this might include PTSD awareness, managing combat stress and accessing physical and mental health resources as needed.

Suicide Prevention Interventions

Suicide prevention interventions are those that focus on individuals who have expressed suicidal ideation or at risk for suicide. This is the most common category for intervention because these individuals have begun to slide down the river towards suicide.

  • Restricting Access to Means – Restricting access to lethal means involves training individuals to assess and remove lethal means like firearms or lethal quantities from suicidal individuals so that they are able to stay safer. (Johnson, et. al., 2011)
  • Web-Based Suicide Prevention/Support Services – These include online discussion boards and other resources that provide platforms for suicidal people to discuss their issues, crisis chat services and other web-based programs. The Best Practices for Online Technologies (Reidenberg, Wolens, & James, 2013) can help with this.
  • Suicide Prevention Training for Primary Care Physicians – Primary care physicians represent an important point of contact for suicidal individuals. Primary care physicians often report feeling undertrained to adequately respond to suicide (McDowell, Lineberry & Bostwick, 2011).
  • Suicide Screening – Suicide screening involves administering a tool to individuals without necessarily having identified suicide risk yet. This can be a universal or indicated method. The ED-SAFE study (discussed more under “Emergency Department and Follow-Up Care” explains the advantages of universal screening. Troister et. al. (2015) discusses three screening tools: the Beck Depression Inventory II (BDI-II), the Beck Hopelessness Scale (BHS) and the Psychache Scale.
  • Gatekeeper Training – Gatekeeeper Training equips laypersons with the tools to recognize suicide risk and to connect with medium and long-term resources like crisis lines and therapy. Popular (and validated) crisis lines include ASIST (Applied Suicide Intervention Skills Training; Rogers, 2010) and QPR (Question, Persuade, Refer; Quinnett, 2012).
  • Suicide Hotlines and Crisis Lines – Suicide hotlines and crisis lines provide immediate emotional support, suicide risk assessment, crisis intervention and safety planning. They are an important element in the suicide prevention framework by catching individuals who may be very close to suicide. Crisis line outcomes have been studied (Kalafat, 2007; Gould, et. al., 2007) and found to have a range of benefits to callers.
  • Psychological Treatment / Psychiatric Treatment – Psychological and psychiatric treatment includes therapy, counselling, medication and a range of other treatments that are available and provided by mental health clinicians. The availability of mental health treatment can have an impact on the suicide rate. (Jagodic, 2013; Kapusta, et. al., 2010)
  • Emergency Department and Follow-Up Care – Emergency departments represent an important access point for mental health care. Universal screening with the ED-SAFE Tool has been shown to double the rate of detected suicide versus a control population. (Boudreaux, et. al., 2015) Additionally follow up has been shown to reduce the rate of re-admission. (Harrison, et. al., 2011)
  • Reducing the Harmful Use of Alcohol – Substance abuse is significantly related to suicidal behaviour. (Wilcox, Conner, & Caine, 2004) By assessing the risk of substance abuse and putting in place treatment options for the targeted population, the impact of addiction or harmful use of substances, including alcohol can be reduced.

Postvention Interventions

Postvention interventions refer to those items that are implemented in the aftermath of a suicide death. A number of interventions are listed on the TogetherToLive Postvention section. Some of these resources are explored below:

  • Provide immediate debriefing and information to survivors helps reduce the impact of the loss (Cox et. al., 2012; Parsons, 1996; Celotta, 1995; King, 1999) This debriefing should provide psychoeducation on grieving, depression and potential post-traumatic stress disorder (PTSD) while also emphasizing the importance of grieving.
  • Identify individuals at high risk and reach out to them (Celotta, 1995; Carter & Brooks, 1990). How this occurs will differ depending on the targeted population but it is important that a system is in place to refer individuals for support (an indicated risk strategy) and ensure that all those affected know how to reach out.
  • Ensure the media provides a respectful response to the suicide that acknowledges its impact without glorifying it (Bohanna & Wang, 2012; MediaWise, 2003) Safe messaging strategies can be implemented to reduce the risk of suicide contagion

Implementing Your Interventions

Once you’ve determined the interventions you would like to choose, you must begin to implement them. This can be accomplished by breaking your suicide group into sub-teams that focus on specific interventions. This allows you to begin to tweak your approach by seeing your chosen interventions applied in actual practice. Examples of implementations for some of the above interventions could include:

  • Providing ASIST gatekeeper training to local community members
  • Arranging for training of primary care physicians in suicide risk assessment
  • Distributing posters with information on local crisis lines in schools
  • Working with the hospital to deliver follow-up calls to patients seen in the Emergency Department for mental health issues

This effort usually requires support from the agencies involved (such as the hospital, the school, etc.) and therefore it is helpful if these individuals are present on your suicide prevention group.

Evaluating Your Suicide Prevention Group

Once you’ve implemented your interventions, evaluation will help you see the impact of your suicide prevention group activities. The exact method in which you measure your impact will differ depending on the interventions you choose, but could include things like:

  • Tracking the number of calls to local crisis lines or admissions to hospital for suicide-related behaviours
  • Counting the number of people you delivered gateekeeper training to
  • Providing pre and post-assessment surveys to gauge learning by people attending trainings
  • Measuring the suicide rate in your community or in your demographic

Ensuring that you have an evaluation plan designed before you implement your interventions will prevent you from forgetting to collect data or collecting the wrong data. Your suicide prevention group can then review this information and tweak your strategy as time goes on, altering the strategy or focusing on new interventions and goals.

References

Bohanna, I., & Wang, X. (2012). Media guidelines for the responsible reporting of suicide: A review of effectiveness. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 33(4), 190-198. doi:10.1027/0227-5910/a000137

Boudreaux, E., Allen, M., Goldstein, A.B., Manton, A., Espinola, J., Miller, I. (2015) Improving Screening and Detection of Suicide Risk: Results from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Effectiveness Trial. Society for Prevention Research 23rd Annual Meeting. Accessed Jun 28 2015 from https://spr.confex.com/spr/spr2015/webprogram/Paper23206.html

Carter, B.F., Brooks, A. (1990) Suicide postvention: Crisis or opportunity?. School Counselor. 37(5)

Celotta, B. (1995) The aftermath of suicide: Postvention in a school setting. Journal of Mental Health Counseling. 17(4)

Cox, G.R., Robinson, J., Williamson, M., Lockley, A., Cheung, Y.T.D., Pirkis, J.  (2012) Suicide Clusters in Young People Evidence for the Effectiveness of Postvention. Crisis. 33(4) 208-214 doi: : 10.1027/0227-5910/a000144

Gould, M. S., Kalafat, J., HarrisMunfakh, J. L., & Kleinman, M. (2007). An evaluation of crisis hotline outcomes part 2: suicidal callers. Suicide And Life-Threatening Behavior, (3), 338.

Harrison, P. L., Hara, P. A., Pope, J. E., Young, M. C., & Rula, E. Y. (2011). The impact of postdischarge telephonic follow-up on hospital readmissions. Population Health Management, 14(1), 27-32. doi:10.1089/pop.2009.0076

Jagodic, H. K., Rokavec, T., Agius, M., & Pregelj, P. (2013). Availability of mental health service providers and suicide rates in Slovenia: a nationwide ecological study. Croatian Medical Journal, (5), 444. doi:10.3325/cmj.2013.54.444

Johnson, R. M., Frank, E. M., Ciocca, M., & Barber, C. W. (2011). Training Mental Healthcare Providers to Reduce At-Risk Patients’ Access to Lethal Means of Suicide: Evaluation of the CALM Project. Archives Of Suicide Research, 15(3), 259-264. doi:10.1080/13811118.2011.589727

Kalafat, J., Gould, M. S., Harris Munfakh, J. L., & Kleinman, M. (2007). An evaluation of crisis hotline outcomes part 1: nonsuicidal crisis callers. Suicide And Life-Threatening Behavior, (3), 322.

Kapusta, N. D., Posch, M., Niederkrotenthaler, T., Fischer-Kern, M., Etzersdorfer, E., & Sonneck, G. (2010). Availability of mental health service providers and suicide rates in Austria: a nationwide study. Psychiatric Services, 61(12), 1198-1203. doi:10.1176/appi.ps.61.12.1198

King, K. (1999) High School Suicide Suicide Postvention: Recommendations For an Effective Program. American Journal of Health Studies. 15(4).

Lapierre, S., Erlangsen, A., Waern, M., De Leo, D., Oyama, H., Scocco, P., & … Quinnett, P. (2011). A systematic review of elderly suicide prevention programs. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 32(2), 88-98. doi:10.1027/0227-5910/a000076

McDowell, A. K., Lineberry, T. W., & Bostwick, J. M. (2011). Practical suicide-risk management for the busy primary care physician. Mayo Clinic Proceedings, (8), 792.

MediaWise. (2003) The Media and Suicide. Accessed electronically from http://www.mediawise.org.uk/wp-content/uploads/2011/03/The-Media-and-Suicide-.pdf on November 26, 2016.

Parsons, R.D. (1996) Student suicide: The counselor’s postvention role. Elementary School Guidance & Counseling, 31(1)

Reidenberg, D., Wolens, F. & James, C. (2013). Responding to a cry for help: Best practices for online technologies. Retrieved on November 26, 2016 from http://www.sprc.org/resources-programs/responding-cry-help-best-practices-online-technologies

Rogers, P. (2010) Review of the Applied Suicide Intervention Skills Training Program (ASIST). LivingWorks. Retrieved on November 26, 2016 from https://www.livingworks.net/dmsdocument/274.

Troister, T., D’Agata, M. T., & Holden, R. R. (2015). Suicide risk screening: Comparing the Beck Depression Inventory-II, Beck Hopelessness Scale, and Psychache Scale in undergraduates. Psychological Assessment, 27(4), 1500-1506. doi:10.1037/pas0000126

Quinnett, P. (2012) QPR Gatekeeper Training for Suicide Prevention The Model, Theory and Research. QPR Institute. Retrieved on November 26, 2016 from https://www.qprinstitute.com/uploads/QPR%20Theory%20Paper.pdf.

Wilcox, H. C., Conner, K. R., & Caine, E. D. (2004). Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies. Drug And Alcohol Dependence, 76(Supplement), S11-S19. doi:10.1016/j.drugalcdep.2004.08.003

Cite this article as: MacDonald, D.K., (2016), "Building a Suicide Prevention Group," retrieved on July 21, 2017 from http://dustinkmacdonald.com/building-suicide-prevention-group/.

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