Suicide Prevention
Robert Tell, LCSW
Amy Guffey, LCSW,
Joe Bertagnolli, MSW,
Victoria Neindow
Today Continued
Nomenclature.
What do we know about suicide?
How can we understand the problem of
Veteran suicide?
What can we do about it.
What do we know about
suicide?
It‟s a big problem
– 11th leading cause of death
– 33,000 suicides occur each year in the U.S.
– 91 suicides occur each day
– One suicide occurs every 16 minutes
– More Suicides than Murders
– In Oregon more likely to die by suicide than in
a car accident.
But it‟s confusing…
The warning signs: rage, feeling trapped,
increased alcohol use, withdrawing,
trouble sleeping, relationship problems,
etc apply to lots of people
Yet a tiny tiny fraction will ever attempt
suicide.
What about Veterans?
Deployments are a risk factor, yet half the
Army‟s suicides never deployed.
There are record numbers of Active Duty
suicides, but
No evidence for increased rates in
OEF/OIF Veterans relative to sex, age,
and race matched people in the population
as a whole.
WHAT’S THE PROBLEM?
1950-2005: Four wars; seven recessions; unprecedented
advancement in diagnosis & treatment of mental illness and
the overall American suicide rate hasn’t changed
Haloperidol,
1962 Clozapine
Chlorpromazine 1989
Aripiprazole
1952 2001
Amitriptyline
Lithium 1949 1961 Fluoxetine
1987
MAOIs
1957
Korean War, Vietnam War, First Gulf War, OEF / OIF,
1950-53 1961-1975 1990-91 2001-present
We aren’t even speaking the same
language
Suicidal ideation Self-harm
Death wish Self-injury
Suicidal threat Suicide attempt
Cry for help Aborted suicide attempt
Self-mutilation Accidental death
Parasuicidal gesture Unintentional suicide
Suicidal gesture Successful attempt
Risk-taking behavior Completed suicide
Life-threatening behavior
Suicide-related behavior
Suicide
Type Sub-Type Definition Modifiers Terms
Self-reported thoughts regarding a person’s desire to engage in self-inflicted
Non-Suicidal potentially injurious behavior. There is no evidence of suicidal intent.
Self-Directed
N/A •Non-Suicidal Self-Directed Violence Ideation
Violence For example, persons engage in Non-Suicidal Self-Directed Violence
Ideation Ideation in order to attain some other end (e.g., to seek help, regulate
Thoughts negative mood, punish others, to receive attention).
Self-reported thoughts of engaging in suicide-related behavior. •Suicidal Intent •Suicidal Ideation, Without Suicidal Intent
Suicidal -Without •Suicidal Ideation, With Undetermined
Ideation For example, intrusive thoughts of suicide without the wish to die would be -Undetermined Suicidal Intent
classified as Suicidal Ideation, Without Intent. -With •Suicidal Ideation, With Suicidal Intent
Acts or preparation towards engaging in Self-Directed Violence, but before
potential for injury has begun. This can include anything beyond a • Suicidal Intent
verbalization or thought, such as assembling a method (e.g., buying a gun, •Non-Suicidal Self-Directed Violence, Preparatory
-Without
collecting pills) or preparing for one‟s death by suicide (e.g., writing a •Undetermined Self-Directed Violence,
Preparatory -Undetermined
suicide note, giving things away). Preparatory
-With
•Suicidal Self-Directed Violence, Preparatory
For example, hoarding medication for the purpose of overdosing would be
classified as Suicidal Self-Directed Violence, Preparatory.
•Non-Suicidal Self-Directed Violence, Without
Behavior that is self-directed and deliberately results in injury or the • Injury Injury
potential for injury to oneself. There is no evidence, whether implicit or -Without •Non-Suicidal Self-Directed Violence, Without
Non-Suicidal
explicit, of suicidal intent.
Self-Directed -With Injury, Interrupted by Self or Other
Violence -Fatal •Non-Suicidal Self-Directed Violence, With Injury
For example, persons engage in Non-Suicidal Self-Directed Violence in order
to attain some other end (e.g., to seek help, regulate negative mood, • Interrupted by •Non-Suicidal Self-Directed Violence, With Injury,
punish others, to receive attention). Self or Other Interrupted by Self or Other
•Non-Suicidal Self-Directed Violence, Fatal
Behaviors
•Undetermined Self-Directed Violence, Without
Behavior that is self-directed and deliberately results in injury or the
potential for injury to oneself. Suicidal intent is unclear based upon the • Injury Injury
available evidence. -Without •Undetermined Self-Directed Violence, Without
Undetermined
-With Injury, Interrupted by Self or Other
Self-Directed
For example, the person is unable to admit positively to the intent to die -Fatal •Undetermined Self-Directed Violence, With Injury
Violence
(e.g., unconsciousness, incapacitation, intoxication, acute psychosis, • Interrupted by •Undetermined Self-Directed Violence, With
disorientation, or death); OR the person is reluctant to admit positively to Self or Other Injury, Interrupted by Self or Other
the intent to die for other or unknown reasons.
•Undetermined Self-Directed Violence, Fatal
•Suicide Attempt, Without Injury
Behavior that is self-directed and deliberately results in injury or the • Injury
•Suicide Attempt, Without Injury, Interrupted by
Suicidal potential for injury to oneself. There is evidence, whether implicit or -Without
Self or Other
Self-Directed explicit, of suicidal intent. -With
•Suicide Attempt, With Injury
Violence -Fatal
•Suicide Attempt, With Injury, Interrupted by Self
For example, a person with a wish to die cutting her wrist with a knife • Interrupted by
would be classified as Suicide Attempt, With Injury. or Other
Self or Other
•Suicide
Standard Approach to Suicide
Risk
Differentiate between
Acute and Chronic risk
Chronic Risk Factors
Psychiatric diagnosis
Substance abuse
Previous attempts
Poor self-control/ impulsivity
Family History of suicide
History of abuse (physical, sexual, emotional)
Co-morbid health problems
Age, gender, race (elderly or young white male)
Same-sex orientation
Acute Risk Factors
Hopelessness/ desperation/ sense of „no way
out‟
Current depression
Recent discharge from a psych unit
Current substance abuse or impulsive overuse
Anxiety, panic, insomnia
Pain and physical discomfort (nausea)
Extreme humiliation/disgrace; narcissistic
mortification
Newly diagnosed co-morbid health problem or
worsening symptoms
Break-down in communication/loss of contact
with significant other (including therapist)
Protective (Mitigating) Factors
Responsibility to children, elder parents, beloved pets
Religious Faith
Connections to family and community support
Social Role
Purpose and meaning in life
Problem Solving ability
Resilience
Persistence
Positive Coping Skills
Attitudes towards Suicide
“Psychic Toughness”
Positive professional relationship
Suicide Inquiry
SI-Frequency, duration, and intensity
Plan
Preparatory Acts or behaviors and
Rehearsals
Level of Intent
Reasons for living, lying and dying
Sum it all up
Assign a level of risk and a treatment plan
based off of that risk.
Document
Thomas Joiner‟s Theory
Perceived burdensomeness
The view that ones existence burdens family,
friends, and/or society
“My death will be worth more than my life to
family, friends, society, etc.”
Assessing for Burdensomeness
Would the people you care about be better
of with out you?
Do you feel like you have failed the people in
your life?
Failed belongingness
The experience that one is alienated from
others, not an integral part of family, circle of
friends, or other valued group
February 22, 1980-lowest # of recorded
suicides in US history
Annual Sunday with lowest # of suicides in US
Assessing for Belongingness
Are you connected to other people?
Do you feel like an outsider in social
situations?
Do you interact with people who care about
you
Assessing acquired ability to
enact lethal self injury
Do the things that scare most people
scare you?
Do you avoid certain situations
because of the possibility of injury or
pain?
Can you tolerate a lot more pain than
most people?
How do we make sense of it?
We can identify a large group of people
who may be at risk.
What‟s harder to do is identify which of
that group will actually commit suicide.
Preventing Veteran Suicides
What‟s a framework that can help us
understand Veteran Suicide
And try and make a difference?
The Background
Marsha Linehan, Ph.D.
Military Training
• Stay in Reasonable Mind
• If you‟re in emotion mind – Act!
The problem
Veterans are too darn capable
Able to cope with too much which leaves
you vulnerable to being swamped.
Units of Distress
Evidence Based interventions
for suicide prevention
Continuity of Care – Mail Programs
Safety Planning?
Treatment – if there‟s a mental health
problem it reduces risk, but if there isn‟t a
mental health problem does it help?
CAMS, Cognitive therapy for Suicide, DBT
Similarities in evidence based
approaches
Address Suicide Directly
Overt persistent connecting and
collaborative stance
Work as a team
Mail Program
Dr. Motto identified patients who had
made an attempt and then didn‟t show for
outpatient care.
Letters were sent for two years without
expectation. The group that received the
letters had fewer suicides than the control.
Recreated in two other studies using cards
and postcards. Being tested now with
texts.
Safety Planning
6 step guide for getting through an
emotional crisis.
STEP 1: RECOGNIZING WARNING SIGNS
-Depressed thoughts and feelings, crying.
-Thinking of loss of best friends and financial issues.
-Experiencing stress, e.g. in traffic.
-Coping with hearing of troubling news regarding wars in the Mideast.
-Panic feelings including shortness of breath and sweating
STEP 2: USING INTERNAL COPING STRATEGIES
-Reading positive materials.
-Taking long, relaxing walks.
-Prayer.
-Walking my dog.
-Listening to music.
STEP 3: SOCIAL CONTACTS WHO MAY DISTRACT FROM THE
CRISIS
-My brother Rob and sister-in-law Sue.
-The gym.
-Drag races.
-Church and Church activities.
-Attending AA meetings.
STEP 4: FAMILY OR FRIENDS WHO MAY OFFER HELP
These are people that I would be willing to talk to about my thoughts of
suicide in order to help me stay safe:
-My Pastor Rex Smith 503-987-6543.
-My dad Thomas Doe 503-234-5678.
-My brother Rob Doe 541 123-456-789.
-My AA sponsor John Greene 503-321-7654.
STEP 5: PROFESSIONALS AND AGENCIES TO CONTACT FOR
HELP
-1-800-273-TALK(8255)press #1 for vets -The Veterans Crisis Line
-Call 911 or come to the Emergency Department (or go to a local ED at
own expense)
Your Therapist
-Portland VA Suicide Prevention Team 503-402-2857 during business
hours
STEP 6: MAKING THE ENVIRONMENT SAFE
- Discuss means restriction
- Guns, guns, guns
A shift in focus…
Instead of focusing on getting help during
the crisis…
A shift in focus…
Get help before it becomes a crisis.
Veteran‟s Crisis Line PSA
NY Times Hotline Video
Portland VA Medical Center
Suicide Prevention
Robert Tell, LCSW
– Robert.tell@va.gov
– 503-402-2857 or 503-220-8262 x56198
Amy Guffey, LCSW
– Amy.guffey@va.gov
– 503-402-2857 or 503-220-8262 x56493
Joe Bertagnolli, MSW
– Joe.bertagnolli@va.gov
– 503-402-2857 or 503-220-8262 x59423