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.