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					                                            UTS
                                      STUDENT SERVICES

SUICIDALITY: POLICY/ GUIDELINES FOR ITS PREVENTION, ASSESSMENT & TREATMENT

SYMPTOMS: WHAT TO LOOK FOR
• Long period of depression, other mental illness, epilepsy.
• Previous suicide attempts
• Drug/alcohol abuse
• Symptoms Associated with Mood Disorders (eg low self esteem/self-denigration/
   withdrawal/hopelessness etc)
• Other: eg. Morbid or unusual themes in communication,art etc appearance; apparent "change in
   personality"; preoccupied.

CRITICAL QUESTIONS TO ASK:
•   Can you tell me how long you have had this feeling?
•   Do you have friends, family, G.P or other(s) that you can approach or talk to?
•   Do you live alone or with someone?
•   Have you spoken with anyone about your suicidal intent?
•   Have you made previous attempts? (if so)
    • How? What stopped you?
    • What precautions would you take or have you planned to take against being found?
    • How do you see the future for yourself?

•   Can you identify the reasons why you have the suicidal intentions? i.e. psychological\ physical\
    relationship\ work\ financial.
•   Can you tell me ways by which you have previously coped with your difficulties?
•   Do you use any drugs or alcohol to cope with difficulties?
•   Can you tell me what help you require?
•   Who else do you wish to involve? (i.e. partners/relatives/G.P.)

• How much time have you spent in thinking about suicide?
• Do you have the means available to you?
• Have you left any notes or tape recorded messages?
Call ambulance or refer to medical officer for physical examination where toxic substances ingested.


MANAGEMENT
1. Ensure client's safety.
2. Try to make a safety contract with the client -an undertaking to follow an agreed upon course of
   action if feeling suicidal.
3. Notify Head of Counselling, (or Director of SSU or senior colleague if others unavailable) if high risk
   of suicide
4. If moderate to high risk, refer outside the Counselling service for assessment and management
   /hospitalization, e.g., if high risk. The Area Crisis Team will ususally be the most appropriate referral
   agency.
5. Monitor the ongoing status of the client. If referred elsewhere, ensure that contact and follow up is
   proceding.

CHECK adequacy of assessment / management by completing checklist overpage.
FLOWCHART FOR ASSESSMENT/MANAGEMENT OF SUICIDALITITY
Identify source of referral and reason for attendance or phone call.
What is presenting problem and its background?
Why is person presenting now?
Identify demographic factors and clinical indicators
Is risk of harm to self or others apparent?

Proceed with intake assessment/counselling
Conduct comprehensive clinical interview (eg "critical questions"; MSE)
Identify extent of risk of suicide or harm to others
Is there a risk of suicide?

No to min. risk

Low risk

   Continue monitoring/counselling
   Involve other personnel & external agencies as appropriate
   Document level of risk and management plan.
   Ensure assessment and plan are reviewed in individual S/V or clinical meeting.

Moderate or High Risk

 Ensure a case-manager (main contact person) is nominated to take responsibility for ongoing
    management or external referral
   Consult with Head, Counselling/Director SSU/experienced colleague
   Decide to manage internally or externally

Manage internally

 Formulate management plan
 Make "Safety contract" with client
 Alert Crisis Team and ensure Crisis team phone number is given to client.

Referral to external agency

 Formulate plan for referral process.
 Make referral - phone referral details, including level of risk.
 Ensure written referral details are also faxed/mailed.

Ensure appropriate follow up has taken place. If imminent risk, ensure safety of client in interim and
prompt follow up of client by Crisis Team or appropriate other.

Document assessment, management/referral details.
                                     UTS
                      STUDENT SERVICES

SUICIDALITY: POLICY/ GUIDELINES FOR ITS PREVENTION,
ASSESSMENT AND TREATMENT
Background Guidelines and knowledge

This document should be read in conjunction with documents such as the
"Policy/Guidelines on Assessment and Management"; Intake Procedures document;
Guidelines for making referrals to Area Mental Health Teams; .1990 NSW Mental
Health Act etc.

       BASIC KNOWLEDGE FOR ALL RELEVANT STAFF

•   All staff should be aware of standardized, "best practice" procedures for assessing
    and managing suicidal patients. Staff should also be aware of the criteria and
    procedures for seeking more expert or comprehensive help when required.
•   These skills should be regarded as core clinical skills, subject to review and update
    on a regular basis.
•   Relevant staff understand the provisions of the Mental Health Act (1990) and when
    it should be invoked.
•   All staff should be aware of how to refer to Area Mental Health Case-management /
    Crisis Teams and Admissions Units.
•   All counsellors should acquaint themselves with the literature on assessment and
    management of suicidal risk. Suicide risk checklist is a useful aid to assessment.
    Knowledge of relevant referral agencies and implications of 1990 Mental Health Act
    for hospital admission of suicidal clients.

ASSESSMENT SECTION

MAJOR RISK FACTORS:
• Other serious mental illness: e.g., Bipolar (Manic-depressive) Disorder*;
  Schizophrenia*; Schizo-affective Disorder*; Major Depression (esp. females).
• Previous Attempt(s) (esp. males: 10% go on to suicide)
• Substance Abuse
• Family History of Suicide
• Other Severe, chronic mental illness/disorders.
OTHER RISK FACTORS:

•   Longstanding medical/physical illness/disability; terminal illness; epilepsy.
•   Family & Environment: e.g., Family/peer history of suicidal behaviour; multiple life
    stressors; abuse/neglect; availability of means (e.g., firearms); unreal
    academic/career expectations from parents/others; major dispute with
    family/friends; separation/loss.
•   Other Major "Crisis": Actual or anticipated exam failure; shame/guilt after major
    event (eg rejection of romantic/sexual invitation); legal problems; guilt feelings re
    criminal offence/custody; failure to meet family/peer expectations; sexual/other
    identity crisis;
•   Loneliness/isolation;
•   Failure to adjust to a new environment;
•   Long term unemployment
•   "Cries" not heard or mismanaged (e.g., You're always feeling sorry for yourself)

PREDISPOSING PERSONALITY/ COGNITIVE STYLES

•   Thinking/feelings associated with sense of hopelessness*
•   Poor social skills
•   Hostile or impulsive behavioural style (SB*)
•   Poor problem solving skills: tendency to "catastrophise", think in absolute terms and
    not see other options
•   Perfectionism, inhibition (self absorbed)
•   Poor regulation of affect (SB*)

DEMOGRAPHIC FACTORS

•   In the 15 - 24 years age range SUICIDE RATE stands at approximately 15/100,000
    (Krupinski et al 1994), and has increased markedly in the past 30 years.
•   Males more likely to suicide, but both sexes show suicidal behaviour
•   Location: Rural (increased access to firearms/means; less access to emergency &
    other treatment)

ASSESSMENT
PRINCIPLES FOR ALL ASSESSMENTS

An overarching principle must be that if a member of staff is in doubt about a person's
suicidal potential, then they should ensure that the person is safe and consult with a
senior colleague or peer. This may result in continued observation of that person, with
use of the Mental Health Act (1990) to ensure this, if necessary. Decision to invoke the
Act should be made by those with experience in its application, or in consultation with
such persons.

PLEASE ALSO NOTE policies and procedures on the following issues:

       *       Approaches to notification of suicidal behaviour including how to
               mobilise ambulance and other acute services.
       *       Coordinated responses to notification of concern from family/friends or
               other agencies (eg Police, DOCS,internal security).
       *       Procedures to be followed when consulting with health services (eg A&E
               Units, Admissions wards).
       *       Approaches to ongoing management after initial assessment, with
               specific full review of high risk individuals, including those who are
               repeated presenters.
       *       Procedures to be followed in the event of the discovery of someone who
               has committed suicide.
       *       Procedures to follow with staff, family, local community, workplace or
               university personnel following suicide.

SYMPTOMS: WHAT TO LOOK FOR

•   Long period of depression

•   Previous suicide attempts

•   Drug/alcohol abuse

•   Symptoms Associated with Mood Disorders:
    Low self-esteem/self denigration
    Withdrawal from family/peers.
    Anxiety/worry
    Feelings of hopelessness and helplessness
    Difficulty making decisions
    Loss of interest in previously enjoyed activities
    Loss of interest in personal hygiene and appearance
    Agitated, irritable, aggressive.
    Inappropriate mood changes
    Sleep disturbance: insomnia, hypersomnia, excessive fatigue
    Low energy
    Poor concentration
    Poor academic or work performance
    Morbid thoughts

•   Other:
    Communication difficulties
    Apparent "change in personality"
    Accident proneness
    Wreckless or thrill seeking behaviour (eg driving at high speeds, provoking fights,
    dangerous use of alcohol/drugs)
    Clingy/dependent on others
    Inability to deal effectively with the present and pre-occupation with the past
    Morbid or unusual themes in music, art, poetry, prose etc
    Appearance (eg shaving head, wearing black - not related to fashion)
    Giving away/selling posessions
CRITICAL QUESTIONS TO ASK:

THE SUICIDALITY ASSESSMENT HEIRARCHY

Can you tell me how long you have had this feeling?

Do you have friends, family, social agencies or G.P that you can approach or talk to?

Do you live alone or with someone?

Have you spoken with anyone about your suicidal intent?

Have you made previous attempts?
(if so)
How?
What stopped you?
What precautions would you take or planned to take against being found?
How do you see the future for yourself?


Can you identify the reasons why you have the suicidal intentions?
i.e., psychological\ physical\ relationship\ work\ financial.

Can you tell me the previous ways of coping with your difficulties?

Do you use any drugs or alcohol to cope with difficulties?

Can you tell me what help you require?

Who else do you wish to involve? (i.e. partners/relatives)


How much time have you spent in thinking about suicide?

Do you have the means available to you?

Have you left any notes or tape recorded messages?

Referral for physical examination where toxic substances have been ingested.
MANAGEMENT
Ensuring client's safety.
Where a client is thought to be suicidal, the counsellor should make themselves
available for brief consultation at any time within office hours. Decisions as to how to
safeguard the client should be made whenever possible with the client's active
participation in the decision making process. Counsellors should discuss with clients the
options available, e.g. extra counselling sessions, duty counsellor crisis appointments,
phone contact with the counsellor within office hours, voluntary hospital admission,
referral to medical or psychiatric service, out of hours contact with area mental health
crisis team where appropriate, and with the client's consent, consultation with the
client's family. Other staff should be advised where appropriate to facilitate these
options, e.g. the reception staff should be informed of client's calls which are to receive
priority attention. In some circumstances shared responsibility may be chosen e.g.
ongoing counselling relationship with the client and an understanding that the area
crisis team can be reached by the client in a crisis outside office hours. Always inform
the crisis team if their number is given to a client. The mental health crisis team can be
consulted regarding the management of the client. The team provide a very good
assessment and liase with psychiatric staff. They are able to provide 24 hour contact to
the client, frequent contact within the community or organise hospitalisation if
necessary. Ask client's permission to have the crisis team contact him at homeif the
crisis team think this the appropriate course of action. Always consult the head
counsellor as soon as possible or, in his absence, an appropriate peer, when the situation
is deemed high risk. Such clients should be presented for frequent review in the clinical
meetings.

CRITERIA FOR REFERRAL OUTSIDE THE UNIT

Establish criteria for referral outside the Counselling service for assessment re
hospitalization, e.g. serious mental illness or high risk and no co-operation with suicide
contract or assessment that the home situation does not provide sufficient safeguards.
Referral can be made via the medical service where scheduling is a possibility or by
referral to area crisis team. (detail of our local services)

CONTRACTING WITH THE CLIENT

Try to make a suicide contract with the client -an undertaking to follow an agreed upon
course of action if feeling suicidal. Ask the client if he can give an assurance that he will
follow this plan and not make a suicide attempt at least for a period of time. Give client
the area mental health crisis number. As part of the suicide prevention strategy try to
eliminate ready access to means of self harm, e.g. the client agrees to hand over
weapons or drugs to trusted person. Arrange appropriate follow up and check up on
missed appointments.

In the event of client consulting Student Services about the suicidal potential of a third
party, assess the seriousness of suicidal risk. Counsel consulting client about their
relationship with the suicidal client e.g. helpful behaviours, appropriate responsibility.
Assist consulting client in encouraging the suicidal client in seeking professional help.
Where situation is deemed high risk discuss with the client the options of consulting the
crisis team, informing the family etc. Counsellor should consult with the area crisis
team.
POSTVENTION

In the event of a suicide provide counselling or referral for people affected by the
suicide. Debriefing for staff involved in the care of the client.

                              SUICIDE RISK CHECKLIST


Student Name_____________ Date_______ Counsellor______________
Instructions: Use a checklist and average for final assessment.
Each item carries the same weight.
                           Lower Risk          Medium Risk            High Risk
Score 1
1. Suicide plan
   A. Details              Vague               Some specifics         Well thought out;
                                                                      knows when,
                                                                      where, how
   B. Availability of
      means                Not available,      Available, has         Has in hand
                           will have to get    close by
   C. Time                 No specific time With a few hours          Immediately
                           or in future
   D. Lethality of         Pills, slash wrists Drugs and alcohol Gun, hanging,
      method                                   car wreck, carbon      jumping
                                               monoxide
   E. Chance of            Others present      Others available if No one nearby;
      intervention         most of the time called upon               isolated
2. Previous suicide        None or one of      Multiple of low        One of high
   attempts                low lethality       lethality or one of    lethality or
                                               medium lethality;      multiple or of
                                               history of repeated moderate
                                               threats
3. Stress                  No significant      Moderate reaction Severe reaction to
                           stress              to loss and            loss or
                                               environmental          environment
                                               changes                change
4. Symptoms
   A. Coping Behaviour Daily activities        Some daily             Gross disturbances
                           continue as usual activities disrupted; in daily
                           with little change disturbance in          functioning
                                               eating, sleeping,
                                               school work
   B. Depression           Mild; feels         Moderate; some         Overwhelmed with
                           slightly down       moodiness,             hopelessness,
                                               sadness, irritability, sadness, and
                                               loneliness, and        feelings of
                                               decrease of energy worthlessness
5. Resources              Help available;      Family and friends     Family and friends
                          significant others   available but          not available or
                          concerned and        unwilling to help      hostile, exhausted,
                          willing to help      consistently           injurious
6. Communication          Direct               Interpersonalised      Very indirect or
   aspects                expresssion of       suicide goal           nonverbal
                          feelings and         ("They'll be sorry -   expression of
                          suicidal             I'll show them")       internalised
                                                                      suicidal goal (guilt,
                                                                      worthlessness)
7. Life Style             Stable               Recent acting-out      Suicidal behaviour
                          relationships,       behaviour and          in unstable
                          personality, and     substance abuse;       personality,
                          school               acute suicidal         emotional
                          performance          behaviour in stable    disturbance;
                                               personality            repeated difficulty
                                                                      with peers, family
                                                                      and teachers
8. Medical status         No significant   Acute but short-           Chronic
                          medical problems term or                    debilitating or
                                           psychosomatic              acute catastrophic
                                           illness                    illness
Total                     Low              Medium                     High


2.1     Basic Knowledge for All Relevant Staff

Areas and Districts need to ensure that:

*       All relevant staff are given appropriate education, consistent with their
        experience and exposure, about suicidal behaviour and its possible presentations
        in different age groups and diagnostic categories.
*       Training programmes are established to ensure that this education occurs.
*       All staff have standardised procedures for assessing and managing suicidal
        patients. The criteria and procedure for seeking more expert help when required
        should be clear.
*       These skills should be regarded as core clinical skills, subject to review and
        update on a regular basis.
*       Relevant staff understand the provisions of the Mental Health Act (1990) and
        when it should be invoked.

All counsellors should acquaint themselves with the literature on assessment and
management of suicidal risk. Suicide risk checklist is a useful aid to assessment.
Knowledge of relevant referral agencies and implications of 1990 Mental Health Act for
hospital admission of suicidal clients.

				
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