Post a reflection on the decisions you made in the risk assessment client scenario. What did you choose to do, and why? Then, describe your agency ‘s

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TRANSCRIPT: SUICIDE RISK ASSESSMENT IN ADVANCED PRACTICE

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

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• Pending incarceration or homelessness

• 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/

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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.

Imagine that you are an advanced practice intern at an inpatient mental health treatment center. One of your tasks is to assess clients’ readiness and safety for discharge. Navigate the following scenario by selecting the most appropriate responses from the choices. You are working with client Frank Espinosa, a 58-year-old male. Frank was hospitalized

following a suicide attempt at his residence and is nearing completion of the inpatient

program.

Mr. Espinosa: I’m looking forward to getting out of here. I’ve been telling everyone I won’t try that again.

Student choices Client reaction Result

Option 1: I am happy to hear that you are confident enough to share your decision with others. Can you help me see what is behind this decision?

Client reaction: My daughter had a kid, a baby girl. I haven’t seen her yet.

Continue.

Option 2: Well, that’s good to hear. We just need to fill out some discharge planning paperwork first, and you’ll be all set.

Client reaction: Okay, if it’s just some paperwork, let’s get it done. I’ll sign anything.

Try again.

Option 3: What is wrong with this place? Have you been getting good care?

Client reaction: Yes, of course. Nothing’s wrong with it, I just want to get back to my life…

Try again.

Mr. Espinosa: That little girl is really what is keeping me going. Intern: That’s wonderful. Besides your daughter and granddaughter, do you have other people in your life who keep you motivated? Mr. Espinosa: I have a couple friends at work. And some guys I bowl with on Saturdays. But… I don’t know what they think of me now. It’s shameful what I tried to do. They are good Catholic guys.

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Student choices Client reaction Result

Option 1: Your friends will understand.

Really? You don’t know them, you don’t know anything about my culture, the religion goes so deep.

Try again.

Option 2: Let's take a minute to unpack “shameful” and “good Catholics.” Can you tell me about the shame you feel and how that affects your relationships?

Everyone knows that I tried and failed at killing myself. They all treat me differently… They tiptoe around me—trying not to "trigger" me.

1. Continue the conversation. No noted concerns at this point. Feedback: This could be a good choice depending on agency policy. 2. The comment raises concerns. Consult with your Field Instructor (supervisor). Feedback: This could be a good choice given the client’s disclosure, depending on agency policy. 3. Redirect the conversation to focus on strengths. Feedback: Try again. Redirecting does not help assess risk in this scenario.

Mr. Espinosa: I hate being seen this way.

Student options Client reaction Result

I hear that you are worried about what "other people" think." Do these feelings make you think about killing yourself again?

The feelings have come, yes. Once or twice. I get so low, and I just want to end it.

1. Continue the conversation. Feedback: This could be a good choice depending on agency policy. 2. The comment raises concerns. Consult with your Field Instructor (supervisor). Feedback: This could be a good choice given the client’s disclosure, depending on agency policy.

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Mr. Espinosa: If I did do it again, I would use something foolproof, like a gun.

Student options Client reaction Result

Sounds like you have really thought about this… Do you have access to guns? Are there any guns in the house?

Well, I’m moving in with my daughter and her husband—and the baby. I’d have to get a gun and keep it somewhere else.

1. Continue the conversation. Feedback: This could be a good choice depending on agency policy. 2. The comment raises concerns. Consult with your Field Instructor (supervisor). Feedback: This could be a good choice given the client’s disclosure, depending on agency policy.

Mr. Espinosa: I don’t want any guns near the baby.

Student options Client reaction Result

It is a positive sign that you are thinking about safety. I heard you mention Catholicism earlier. Is your Catholic faith important to you?

Yes, it will take me a while to set foot in a church again, though. I do feel a lot of shame about it.

1. Continue the conversation to ask about the shame the client is experiencing. Feedback: This line of questioning could be effective in assessing the shame and how it contributes to risk. 2. Redirect the conversation to focus on strengths. Feedback: Redirecting does not help assess risk in this scenario.

Mr. Espinosa: I’m embarrassed.

Student options Client reaction Result

Tell me more about this shame you carry regarding your suicide attempt.

Trying to kill myself means I couldn’t “take it like a man.” I really don’t

1. Continue the conversation.

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want to be around, it’s too painful, but suicide is a sin. And of course there’s my granddaughter.

Feedback: This could be a good choice depending on agency policy. 2. The comment raises concerns. Consult with your Field Instructor (supervisor). Feedback: This could be a good choice given the client’s disclosure, depending on agency policy.

Mr. Espinosa: My thoughts are all over the place.

Intern: I hear you. It sounds like you have many emotions, all of which impact how you

feel about yourself differently.

Moving in with your daughter also comes with its own challenges. I would like to

continue this conversation to help you transition to the next part of your journey. Would

you like that as well?

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:

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▪ Whom to report to ▪ What to report ▪ How to report ▪ When to report ▪ Where to go for guidance

• How will you document the situation?

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