Mental health & crisis management 7 APRIL qui z

Week12-suicidalideations.pptx

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Care for a patient who is suicidal and risk assessments

https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0.pdf

Introduction

Source: Government of Canada. (2019, July 17). Suicide in Canada. Retrieved from https://www.canada.ca/en/public-health/services/suicide-prevention/suicide-canada.html

Approx. 4,000 deaths by suicide per year

Every day, an average of approximately 11 Canadians die by suicide

1/3 of deaths by suicide are among people 45-59 years

Suicide is the second leading cause of death among youth and young adults (15-34 years)

Suicide rates are approx. 3x higher among men compared to women

Every day an average of 10 Canadians die by suicide

For every person lost to suicide, many more experience thoughts of suicide or suicide attempts

What populations are at higher risk for suicide?

In Canada, the following groups have higher rates or risk of suicide:

Men and boys

Individuals serving federal sentences

Survivors of suicide loss and survivors of a previous suicide thought/intent/expression

Youth (15 to 24 year olds)

second leading cause of death for youth

Source: Government of Canada. (2019, July 17). Suicide in Canada. Retrieved from https://www.canada.ca/en/public-health/services/suicide-prevention/suicide-canada.html

What populations are at higher risk for suicide?

In Canada, the following groups have higher rates or risk of suicide:

Some First Nation and Métis communities, especially among youth

Women have higher rates of self-harm

**Self-harm can be a risk factor for suicide

Thoughts of suicide and suicide-related expressions are more frequent among LGBTQ youth in comparison to their non-LGBTQ peers. This refers to those who identify as lesbian, gay, bisexual, trans, Two-Spirit or queer/questioning youth

Source: Government of Canada. (2019, July 17). Suicide in Canada. Retrieved from https://www.canada.ca/en/public-health/services/suicide-prevention/suicide-canada.html

Canadian Statistics

Source: Government of Canada (2020, March 4). Suicide in Canada: Key statistics (infographic). Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/suicide-canada-key-statistics-infographic.html

Thoughts

11.8% report thoughts of suicide in their lifetime

2.5% report thoughts of suicide in the past year

Plans

4.0% report having made suicide plans in their lifetime

7% of people in lowest income quintile vs. 3% of people in highest income quintile

Key terms

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Suicide or death by suicide

Terms used to describe the act of taking one's own life.

Suicidal expressions

Is the term used to describe potentially self-injurious actions with a nonfatal outcome for which there is evidence that a person intended to end their life

Examples of suicidal expressions include self-harm, suicidal ideation, desire to hasten death, risky behaviour, and suicide threats

Suicidal expressions may or may not result in injury

Nonsuicidal self-injury

Is characterized by self-harming with no intent to die

Stigma

Several terms used in association with suicide add to the stigma and alienation experienced both by people with suicidal ideation (referred to as self-stigma) and by survivors of suicide

Terms such as committed suicide, failed suicide, and successful suicide are avoided

Words like commit and attempt evoke connotations of criminality, which are inappropriate and potentially stigmatizing to suicidal individuals and those touched by suicide

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Stigma

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Failure and success in this regard are equally disrespectful and distort what could never be considered a success

For these reasons, the neutral and factual expression “died by suicide” or “death by suicide” is preferred

Changing the language that we use to describe suicide and suicidal expressions is a first step in addressing the ways in which nurses can sensitively and empathically begin working with individuals who are suicidal

Video: Suicide Myths and Facts (no sound)

Centre for suicide prevention. (2017, April 4). Suicide Myths and Facts. Retrieved from https://www.youtube.com/watch?time_continue=81&v=Lgt0IH1JCJ8&feature=emb_title

Video: “I jumped off the golden gate bridge”

BuzzFeed. (2015, December 9). I jumped off the golden gate bridge. Retrieved from https://www.youtube.com/watch?v=WcSUs9iZv-g

Risk factors & Warning signs

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Warning Signs The American Association of Suicidology (AAS) uses the mnemonic IS PATH WARM to assist people to recognize and identify the warning signs of suicide

I	Ideation
S	Substance use
P	Purposelessness
A	Anxiety or agitation
T	Trapped
H	Hopelessness or helplessness
W	Withdrawal
A	Anger
R	Recklessness
M	Mood changes

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Note that, although patients who exhibit protective factors may still have expressions or death from suicide, multiple protective factors generally contribute to patient resilience in the face of stress and adversity

Protective Factors

Children in the home, except among those with postpartum psychosis

Responsibility to others

Pregnancy

Personal, social, cultural and religious beliefs that discourage suicide and support self-preservation

Life satisfaction

Reality testing ability

Positive coping skills

Positive social support

Positive therapeutic relationship

Hope for the future

Self-efficacy

Supportive living arrangements

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Application of the nursing process

Application of the Nursing Process

Assessment

Verbal and nonverbal clues

Overt statements

Covert statements

Lethality of suicide plan

Assessment tools

SAD PERSONS scale

C-SSRS Scale

Self-assessment

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0.pdf

Taking Seriously –RNAO

Registered Nurses Association. (2009). Assessment and care of adults at risk for suicidal ideations and behaviours. Retrieved from https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0.pdf

All verbal and non-verbal expressions that may convey an expression of dying are taken seriously

The patient is assessed for suicide risk. Here are some suggestions to ask your patient if they are suicidal:

“Are you thinking about ending your life?”

“Are you suicidal?”

“Do you have a plan to take your own life?”

“Do thoughts of death or suicide enter your mind?”

The assessment is documented and communicated to the appropriate members of the health care team

Based upon the assessment, appropriate interventions are initiated

The score is calculated from ten yes/no questions, with one point for each affirmative answer:

This score is then mapped onto a risk assessment scale as follows:

0–4: Low

5–6: Medium

7–10: High

SAD Scale

IMAGE REFERENCE: https://www.bing.com/images/search?view=detailV2&id=6EB9E7C21A3CAF607995C1BD9DEC85EA1E07C254&thid=OIP.us1aJsea4RYj1ymvRyaUMgHaKo&mediaurl=http%3A%2F%2Fwww.ebmedicine.net%2Fspaw%2Fuploads%2FaboutUs%2FModified%2520SAD%2520PERSONS%2520Scale%2520Emergcency%2520Medicine%2520Practice.JPG&exph=619&expw=431&q=sad+scale&selectedindex=0&ajaxhist=0&vt=0&eim=0

The Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS)

Supports suicide risk assessment through a series of simple, plain-language questions that anyone can ask

The answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support that the person needs

Users of the tool ask people:

Whether and when they have thought about suicide (ideation)

What actions they have taken — and when — to prepare for suicide

Whether and when they attempted suicide or began a suicide attempt that was either interrupted by another person or stopped of their own volition

https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/

Application of the Nursing Process

Diagnosis

Risk for suicide

Outcomes identification

Suicide self-restraint

Implementation

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Risk Assessment

Presence of risk factors

Lack or presence of protective factors (e.g. spirituality, hope, future orientation, cultural and/or spiritual factors)

Suicidal intent

Plan

Lethality

Access to means

Timeframe

Hope –what has stopped from acting? What gives hope?

Previous expressions

Interventions

IMAGE REFERENCE: https://www.bing.com/images/search?view=detailV2&id=4CB122F60B330F9ADE8480428B6EA514ADB46A01&thid=OIP.fDA9uz56vH84u5_LnGZZ7AHaD_&mediaurl=http%3A%2F%2Fsouthcentralhealth.com%2Fwp-content%2Fuploads%2F2014%2F01%2FSuicide_prevention.jpg&exph=350&expw=650&q=suicide+help&selectedindex=2&ajaxhist=0&vt=0&eim=0

Nursing Interventions

Taking seriously all statements made by the patient that indicate, directly or indirectly, a wish to die by suicide, and/or all available information that indicates a risk for suicide

Working toward establishing a therapeutic relationship with patients at risk for suicidal ideation & expressions

Working with the patient to minimize the feelings of shame, guilt and stigma that may be associated with suicidality, mental illness and addictions

Provides care in keeping with the principles of cultural safety/cultural competence

5. Assessing and managing factors that may impact the physical safety of both the patient and the interdisciplinary team

Nursing Interventions (cont’d)

Recognizing key indicators that put an individual at risk for suicidal expressions, even in the absence of expressed suicidality. For individuals who exhibit risk indicators, the nurse conducts and documents an assessment of suicidal ideation and plan

Assessing for protective factors associated with suicide prevention

Obtaining collateral information from all available sources: family, friends, community supports, medical records and mental health professionals

Mobilizing resources based upon the patients assessed level of suicide risk and associated needs

Ensuring that observation and therapeutic engagement reflects the client’s changing suicide risk

Nursing Interventions (cont’d)

Working collaboratively with the patient to understand their perspective and meet their need

Using a mutual (patient  nurse) problem-solving approach to facilitate the patients understanding of how they perceive their problems and generate solutions

Fostering hope with your patient

Being aware of current treatments to provide advocacy, referral, monitoring and health teaching interventions, as appropriate

Nursing Interventions (cont’d)

Identifying people affected by suicide that may benefit from resources and supports, and referrals as required

The nurse may initiate and participate in a debriefing process with other health care team members as per organizational protocol

Seeking support through clinical supervision when working with adults at risk for suicidal ideation and expressions to become aware of the emotional impact to the nurse and enhance clinical practice

Inpatient Care and Acute Treatment

Source: Austin, W., Kunyk, D., Peternelj-Taylor, C. & Boyd, M. (2018). Psychiatric & Mental health nursing for Canadian practice (3rd ed.). Lippincott Williams & Wilkins

Protect patient from suicide and establish treatment of underlying psychiatric disorder

Objectives of hospitalization:

Maintain patient’s safety.

Decrease the level of suicidal ideation.

Initiate treatment for underlying disorder.

Evaluate for substance abuse.

Reduce level of social isolation.

https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0.pdf

Biologic Interventions

Source: Austin, W., Kunyk, D., Peternelj-Taylor, C. & Boyd, M. (2018). Psychiatric & Mental health nursing for Canadian practice (3rd ed.). Lippincott Williams & Wilkins

Ensuring safety

Protocol for safety

Engaging in a therapeutic relationship

Observing patient regularly

Removing dangerous objects

Somatic therapies

Medications

ECT (we will cover this next week)

Substance use treatment

Assisting with Treatment of Substance Use

Psychological Interventions

Source: Austin, W., Kunyk, D., Peternelj-Taylor, C. & Boyd, M. (2018). Psychiatric & Mental health nursing for Canadian practice (3rd ed.). Lippincott Williams & Wilkins

Evaluating patient’s ways of thinking about problems and generating solutions

Cognitive interventions

Developing plans to prevent future suicide expressions/thoughts

Social Interventions

Source: Austin, W., Kunyk, D., Peternelj-Taylor, C. & Boyd, M. (2018). Psychiatric & Mental health nursing for Canadian practice (3rd ed.). Lippincott Williams & Wilkins

Help patient develop social skills that can be used in engaging others

Identify family and friends who are willing to be supportive

The nurse can be one of the supportive individuals if successful in establishing a professional therapeutic relationship

Therapeutic Dialogue

Suicide Safety Planning

What is it?

What are the steps?

Video - World Suicide Prevention Day 2019: You Make Today Better

TWLOHA. (2019, September 9). World Suicide Prevention Day 2019: You Make Today Better. Retrieved from https://www.youtube.com/watch?v=xFu8IXDSy1s

https://rnao.ca/sites/rnao-ca/files/Assessment_and_Care_of_Adults_at_Risk_for_Suicidal_Ideation_and_Behaviour_0.pdf

Safety Planning – Introduction

A safety plan is a document that supports and guides someone when they are experiencing thoughts of suicide, to help them avoid a state of intense suicidal crisis

When developing the plan, the person experiencing thoughts of suicide identifies:

their personal warning signs,

coping strategies that have worked for them in the past, and/or strategies they think may work in the future,

people who are sources of support in their lives (friends, family, professionals, crisis supports),

how means of suicide can be removed from their environment, and

their personal reasons for living, or what has helped them stay alive

Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/

NOTES for voiceover:

Suicidal thoughts can burden people and hold them hostage. Experiencing these thoughts is to experience “absolute darkness, hopelessness, pain,” and nothing matters but stopping that pain.

When is a safety plan written?

A safety plan is written when a person is not experiencing intense suicidal thoughts. It may be written after a suicidal crisis, but not during, as at this time an individual can become overwhelmed with suicidal thoughts and confusion and may not be able to think clearly. A safety plan is written when a person has hope for life, or even can consider the possibility of life, so that they can identify their reasons for living, and positive actions they can take to prevent their thoughts from becoming intense and overwhelming.

A safety plan can be developed in one sitting by the person with thoughts of suicide together with you, their caregiver or friend, or over time. The plan can change as the circumstances for the individual change and can be revised accordingly.

Why does it work?

A safety plan is an assets-based approach designed to focus on a person’s strengths. Their unique abilities are identified and emphasized so they can draw on them when their suicidal thoughts become intense. The goal is to draw upon their strengths during subsequent recovery and healing processes (Xie, 2013). Personal resources are another integral safety plan component. Drawing on strengths is the entry-level activity; reaching out for help may also become necessary (Xie, 2013; Bergmans, personal communication, 2019).

The safety plan is organized in stages. It starts with strategies the individual can implement by themselves at home and ends with 24/7 emergency contact numbers that can be used when there is imminent danger or crisis.

The person with thoughts of suicide can verify, along with their caregiver or friend, whether coping skills are feasible, as well as whether or not the chosen contact people are appropriate (Bergmans, personal communication, 2019).

When implemented, safety plans become self-strengthening. For people who experience recurring suicidal thoughts or crises, one strength becomes knowing they have weathered the storm before and have navigated their way out.

Is a safety plan the same as a no-suicide contract?

A no-suicide contract is different from a safety plan in that it is “an agreement, usually written, between a mental health service user and clinician, whereby the service user pledges not to harm himself or herself” (McMyler & Prymachuk, 2008, p.512). It was introduced in 1973 by Robert Drye, Robert Goulding and Mary Goulding. Mental health service users are expected to seek help when they feel they can no longer honour their commitment to the contract (Rudd, Mandrusiak & Joiner, 2006).

The no-suicide contract has been widely used by clinicians working with patients at risk of suicide (Rudd, Mandrusiak & Joiner, 2006). However, there is a lack of evidence to support contracts as clinically effective tools. Both service users and clinicians have voiced strong opposition to their use. Moreover, important ethical and conceptual issues in the use of such contracts have been identified, including the potential for coercion from the clinician for their own protection and the ethical implications of restricting a service user’s choices when they may be already struggling for control. A strength-based approach like a safety plan, on the contrary, not only encourages the service user’s input and agency, it is a true partnership with the physician or caregiver, bound by hope (McMyler & Prymachuk, 2008; Rudd, Mandrusiak & Joiner, 2006).

Source: Centre for Suicide Prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/

Step 1: List warning signs that indicate a suicidal crisis may be developing

Guiding question(s) for the person thinking about suicide

What (situations, thoughts, feelings, body sensations, or behaviours) do you experience that let you know you are on your way to thinking about suicide, or that let you know you are mentally unwell generally?

Think about some of the more subtle cues

Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/

Step 2: List the coping strategies that can be used to divert thoughts, including suicidal thoughts

Guiding question(s) for the person thinking about suicide

What (distracting activity, relaxation or soothing technique, physical activity) helps take your mind away from thought patterns that feel scary or uncomfortable, or thoughts of suicide?

Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/

Step 3: List the places and people that can be used as a distraction from thoughts of suicide

Guiding question(s) for the person thinking about suicide

Where can you go to feel grounded, where your mind can be led away from thoughts of suicide? Who helps take your mind away from these thoughts?

Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/

Step 4: List all the people that can be contacted in a crisis, along with their contact information

Guiding question(s) for the person thinking about suicide

Who among your friends, family, and service providers can you call when you need help (when your thoughts become overwhelming or you’re thinking about suicide)?

Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/

Step 5: List mental health providers and the hours they can be reached, as well as 24/7 emergency contact numbers that can be accessed in a crisis

Guiding question(s) for the person thinking about suicide

Who are the professionals you’ve worked with who can be helpful to you in a crisis? What other professionals or organizations could you call?

Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/

Step 6: List the steps to be taken to remove access to means of suicide from the environment

Guiding question(s) for the person thinking about suicide

What could be used in your environment (home, work)? How have you thought about dying by suicide before, and how can you make that method more difficult to access?

Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/

Step 7: List important reasons to live, or how/why that person is still alive

Guiding question(s) for the person thinking about suicide

When do you feel most at ease during the day? Who do you love? What do you enjoy doing? What did you used to enjoy doing? What is important to you, or used to be important to you? What has kept you alive up until now?

Note: These reasons can become apparent through conversation with the person, and through the process of a suicide intervention. You may need to identify these for the person, based on what they’ve told you.

Source: Centre for suicide prevention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/

How to implement a Safety Plan

Keep in mind that the safety plan is not written in stone: it can be revised as often as is needed. The plan can be reviewed at any time, and especially if the person experiencing thoughts of suicide has found any portion of it ineffective in helping them cope with their thoughts. For example, if one contact person was found to be difficult to get in touch with on several occasions, or if a coping strategy is no longer effective or accessible

Source: Centre for Suicide Intervention. (2020). Safety plans to prevent suicide. Retrieved from https://www.suicideinfo.ca/resource/safety-plans/

Once complete, the person who has had thoughts of suicide should keep copies of the safety plan in an accessible place

The safety plan needs to be accessible to ensure the person can always find it when they are experiencing intense thoughts of suicide

Each step in the safety plan plays a role in supporting the person with thoughts of suicide

Video – Tomorrow needs you

TWLOHA. (2018, September 10). World Suicide Prevention Day 2018. Retrieved from https://www.youtube.com/watch?v=aEzUMnBHHK0

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Canadian - Help Resources

9-1-1

Kids Help Phone: 1-800-668-6868

Text CONNECT to 686868

Chat Services [6 pm–2 am EST]: www.kidshelpphone.ca

Trans Lifeline: 1-877-330-6366

Hope for Wellness Help Line: 1-855-242-3310

Online chat: www.hopeforwellness.ca

Indian Residential Schools Crisis Line: 1-866-925-4419

Canada Suicide Prevention Service: 1-833-456-4566 [24/7]