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TRANSCRIPT: SUICIDE RISK ASSESSMENT

Lesson 1: Background on Suicidality

In the United States, more than 47,000 people die by suicide every year. It is the 10th leading cause of death.

Myth or Fact? Asking about suicide plants ideas about it in the client’s head. Response: Myth People who talk about suicide do not act on it. Response: Myth Self-harm does not always lead to suicide. Response: Fact Suicide rates are highest among middle-aged white men. Response: Fact If somebody really wants to die by suicide, there is nothing you can do about it. Response: Myth Self-injurious behaviors mean the person is just trying to get attention. Response: Myth Further statistics and information on suicide and suicide prevention can be found at the American Foundation for Suicide Prevention: https://afsp.org/suicide-statistics/.

Important Considerations for Social Work Practice

1. This one lesson does not make you an expert on suicidality and suicide assessment. You will constantly be growing in this area.

2. Always consult others and use supervision. 3. Make sure you are in alignment with agency policies around risk. 4. Know your state’s laws around harm to self and others. 5. Know your state’s process of involuntary mental health watch/hospitalization. 6. Be mindful of potential vicarious traumatization. 7. Know the warning signs.

Potential Warning Signs

• Threatening to hurt or kill self

• Looking for ways to kill self; seeking access to pills, weapons, or other means

• Talking or writing about death, dying, or suicide

• Getting affairs in order and giving away valued possessions

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• No future orientation

• Severe distress and ruminative behavior; tunnel vision

• Behavioral change (social, vocational, academic, appearance)

• Loss of self-worth

• Impulsive and/or aggressive tendencies

• Guardedness or inconsistency

• Sudden recovery from depression

Vicarious Trauma: An Issue for Social Workers

Vicarious trauma is a shift in the internal experience and psychological well-being of the social worker. Vicarious trauma undermines a social worker’s sense of safety in the world and sense of control over life situations. Symptoms

• Loss of energy

• Difficulty in maintaining interpersonal relationships

• Cynicism

• Nightmares

• Feelings of hopelessness and despair

• Disruptive frame of reference (i.e., change in worldview)

• Increased emotionality

• Emotional numbness

• Dissociation or depersonalization How to Deal With Vicarious Trauma Awareness

• Be aware of your own history of trauma and recognize when emotions and memories related to your own experience are triggered.

• Seek help to manage your shifting belief about the goodness of self and others. Wellness

• Develop a personal self-care and wellness plan. The plan should include eating healthy, getting adequate sleep, and exercising regularly.

o Emotional wellness: Maintain a sense of humor and engage in activities that promote self-awareness.

o Cognitive wellness: Engage in activities using imagination and problem- solving skills.

o Spiritual wellness: Practice your spirituality, read poetry, get out in nature, meditate, or attend religious services.

o Interpersonal wellness: Foster positive interpersonal relationships.

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Support

• Develop a strong supervisory working alliance.

Lesson 2: Assessing for Suicide

Suicide Assessment Five-Step Evaluation and Triage for Mental Health Professionals (SAFE-T)

1. Identify risk factors. 2. Identify protective factors. 3. Conduct suicide inquiry. 4. Determine risk level/intervention. 5. Document risk, rationale, intervention, and follow-up.

Risk Factors

Current and Past Psychiatric Diagnoses

• Mood disorder

• Psychotic disorder

• Alcohol/substance use disorders

• Posttraumatic stress disorder

• Attention deficit hyperactivity disorder

• Traumatic brain injury

• Conduct problems (antisocial behavior, aggression, impulsivity)

• Family history of mental illness Presenting Symptoms

• Anhedonia

• Impulsivity

• Hopelessness or despair

• Anxiety and/or panic

• Insomnia

• Command hallucinations

• Psychosis Precipitants/Stressors

• Triggering events leading to humiliation, shame, and/or despair (e.g., loss of relationship)

• Chronic physical pain or other acute medical problem (e.g., central nervous system disorders)

• Sexual/physical abuse

• Pending incarceration or homelessness

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• Legal problems

• Inadequate social supports; social isolation

• Perceived burden on others

Protective Factors Internal

• Cultural, spiritual, and/or moral attitudes against suicide

• Coping and problem-solving skills External

• Responsibility to children

• Beloved pets

• Supportive social network of family or friends

• Positive therapeutic relationships

• Engaged in work or school

Columbia-Suicide Severity Rating Scale (C-SSRS) Suicide Assessment Questions

1. Have you wished you were dead or wished you could go to sleep and not wake

up? 2. Have you actually had any thoughts of killing yourself?

If yes, ask Questions 3, 4, 5, and 6. If no, go directly to Question 6. 3. Have you been thinking about how you might kill yourself? 4. Have you had these thoughts and had some intention of acting on them? 5. Have you started to work out or worked out the details of how to kill yourself? Do

you intend to carry out this plan? 6. Have you ever done anything, started to do anything, or prepared to do anything

to end your life? If yes, ask: How long ago did you do any of these? Over a year ago? Between 3 months and a year ago? Within the last 3 months?

Additional Resources

Access this website for more detail on SAFE-T: https://store.samhsa.gov/product/SAFE- T-Pocket-Card-Suicide-Assessment-Five-Step-Evaluation-and-Triage-for- Clinicians/sma09-4432 Access this website for more detail on the C-SSRS, including screeners to download: https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/risk-identification/

Lesson 3: Scenario

Disclaimer: This is a scenario for learning purposes and is not meant to be used verbatim for client interactions, or to represent what is appropriate in all such situations. The goal is to reflect on your problem solving and decision making in situations involving clients at risk.

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Imagine that you are an intern at an agency that assists individuals with accessing job, food, and housing support. Navigate the following scenario by selecting the most appropriate responses from the choices. You are working with client Adam Donovan, a 29-year-old male. Mr. Donovan: I lost my job a month ago. I had that job for almost 10 years. It’s like they have no respect for what I’ve done for them. Zero.

Student choices Client reaction Result

Option 1: Tell me more about the job. What happened?

Client reaction: What happened? They canned me. Said I was slacking off, coming in late, with an “attitude.”

Try again.

Option 2: It sounds like you might benefit from job assistance. How are you doing with your rent, food, and other essentials?

Client reaction: Not too good. I’ve been trying to do odd jobs. Money’s been tight.

Continue.

Option 3: That does sound like a very tough situation. What are you doing to better yourself and move forward?

Client reaction: I don’t want to move forward. I want my job back!

Try again.

Mr. Donovan: I could use some help with food, rent, and the electric bill. Intern: We can see about getting you into a work program and about a food supplement. We can also consider housing if you need to move out due to nonpayment. Mr. Donovan: Thanks. But really, what’s the point? My wife left with the kids. My friends were all from work. I might as well end it; nobody would miss me.

Student choices Client reaction Result

Option 1: Just a minute. Let me get the benefit application forms and we can fill them out.

Client reaction: Okay. Try again.

Option 2: That’s not true. I bet a lot of people would miss you if you were gone.

Client reaction: Sure … then how come nobody ever calls?

Try again.

Option 3: Have you actually had any thoughts of killing yourself?

Client reaction: Yes, ever since Rochelle took the kids.

Continue.

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Mr. Donovan: My life is just … falling apart. Better to not be here.

Student choices Client reaction Result

Option 1: Have you been thinking about how you might kill yourself?

Client reaction: Sometimes when I get really drunk, I think about mixing alcohol and pills.

1. Continue the conversation. Feedback: This could be a good choice depending on agency policy. 2. Get your Field Instructor (supervisor). Feedback: This could be a good choice given the client’s disclosure, depending on agency policy. 3. Call 911. Feedback: Try again. The client’s disclosure does not rise to an immediate and current threat for him or anyone else in the agency.

Option 2: In what ways is your life not falling apart, though? How would you characterize your strengths?

Client reaction: Uh, what strengths? I’ve got nothing.

Try again.

Option 3: Once we get these forms filled out, and you can get services, maybe some of that pressure you are feeling will lessen.

Client reaction: I doubt it. Try again.

Mr. Donovan: I have a bunch of oxy that was prescribed for my neck pain. It’s in the cabinet, and sometimes I bring it out. I think about what it would be like.

Student options Client reaction Result

Option 1: What happened with your neck?

Client reaction: Got in a car accident 6 months ago. It still hurts, mostly on rainy days.

Try again.

Option 2: Oxycodone is a strong pain medication that should not be used in excess.

Client reaction: I know, but it’s the only thing that really helps the pain. I don’t take it all that often;

Try again.

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that’s why I have so much of it just sitting there.

Option 3: Have you had some intention of acting on these thoughts?

Client reaction: I came close the last time. I did take a couple pills before I stopped.

1. Continue the conversation. Feedback: This could be a good choice depending on agency policy. 2. Get your Field Instructor (supervisor). Feedback: This could be a good choice given the client’s disclosure, depending on agency policy. 3. Call 911. Feedback: Try again. The client’s disclosure does not rise to an immediate and current threat for him or anyone else in the agency.

Mr. Donovan: But I never go through with it. Intern: So it sounds like you have started to work out the details of how to kill yourself. Do you plan to drink tonight? Mr. Donovan: No, not tonight. The last time was a little scary. Whenever I’m there with the bottle, I start thinking about my mom and what she’d want for me. She passed a couple of years ago.

Student options Client reaction Result

Option 1: It sounds like you have had a rough couple of years. Who has helped you since your mother’s passing?

Client reaction: I don’t really have anyone now, but my mom is like my guardian angel. She makes sure I’m okay.

1. Continue the conversation. Feedback: This could be a good choice depending on agency policy. 2. Get your Field Instructor (supervisor). Feedback: This could be a good choice given the client’s disclosure, depending on agency policy. 3. Call 911.

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Feedback: Try again. The client’s disclosure does not rise to an immediate and current threat for him or anyone else in the agency.

Option 2: It sounds like you may need some mental health and grief counseling in addition to the other services we are coordinating. Would that be accurate?

Client reaction: Woah, woah, woah—there’s nothing wrong with me. Everyone thinks this way sometimes.

Try again.

Option 3: How did your mother’s death make you feel?

Client reaction: Not great—but I don’t really want to talk about that right now.

Try again.

Intern: Thank you for sharing all of this with me. Let’s see how we can support you. End of Scenario

Reflection

After completing the scenario, reflect on your choices. Then, research your agency’s policies and resources related to clients at risk. Determine your agency’s stance on when you should contact your Field Instructor. How would your decision making in the scenario be different based on your agency’s policies and context?

Lesson 4: Summary

Depending on your agency, you may have more or less autonomy as an intern to complete a risk assessment or engage with a client about suicidal thoughts and behaviors. Be prepared by knowing your agency’s policies and scope of practice. If you do encounter such a situation, consider the following questions:

• Is this a reportable situation? o Know the guidelines for mandated reporting.

• What are your organizational policies? o Ensure you know the following:

▪ Whom to report to ▪ What to report ▪ How to report ▪ When to report

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▪ Where to go for guidance

• How will you document the situation?

• What are the professional and legal consequences for failure to report?