Background
Suicidal patients are very difficult to engage in treatment : 11% to 50% of attempters refuse outpatient treatment or drop out of outpatient therapy quickly ; Up to 60% of those who attempt suicide do not even attend more than one week of treatment post- discharge from the ED Of those who do attend treatment, 3 months after hospitalization for an attempt, 38% have stopped outpatient treatment . After a year, 73% of attempters will no longer be in any treatment. Overview
—Description of the Safety Plan : The 6 steps of creating the Safety Plan —Demonstrate implementation of the Safety Plan Major Challenges
1. How can a patient manage a suicidal crisis in the moment that it happens? 2. How can a clinician help the patient do this? Improving Your Reactions to Suicidal Patients
Become more aware of your emotional reactions to suicidal behavior. Obtain professional consultation and information about treating suicidal patients. Obtain professional consultation or counseling if you experience a loss of a patient to suicide. It is Critical to Communicate…
that ending the patient’s emotional pain is the most important goal and is possible with treatment. Therapy may offer more effective coping skills. that preserving the patient’s life is essential. support and encouragement that therapy will be helpful. “No-Suicide Contract” No-suicide contracts ask patients to promise to stay alive without telling them how to stay alive. No-suicide contracts may provide a false sense of assurance to the clinician. DON’T USE THEM! No Suicide Contract Safety Plan:
What is it?
—Hierarchically-arranged list of coping strategies for use during a suicidal crisis or when suicidal urges emerge —Written document —Brief, easy-to-read format Who Develops the Plan?
—Collaboratively developed by the clinician and the Veteran in any clinical setting. Veterans who have… — made a suicide attempt. suicide ideation. psychiatric disorders that increase suicide risk. otherwise been determined to be at high risk for suicide. When Is It Appropriate?
—A safety plan may be done at any point during the assessment or treatment process. —Usually follows a suicide risk assessment. —Safety Plan may not be appropriate when patients are at imminent suicide risk or have profound cognitive impairment. —The clinician should adapt the approach to the Veteran’s needs -- such as involving family members in using the safety plan. Overview of Safety Planning: 6 Steps
1. Recognizing warning signs. 2. Employing internal coping strategies without needing to contact another person. 3. Socializing with family members or others who may offer support as well as distraction from the crisis. 4. Contacting family members or friends who may help to resolve a crisis. 5. Contacting mental health professionals or agencies. 6. Reducing the potential use of lethal means. Step 1: Recognizing Warning Signs
—Safety plan is only useful if the patient can recognize the warning signs. —The clinician should obtain an accurate account of the events that transpired before, during, and after the most recent suicidal crisis. —Ask “How will you know when the safety plan should be used?” —Ask “What do you experience when you start to think about suicide or feel extremely distressed?” —Write down the warning signs (thoughts, images, thinking processes, mood, and/or behaviors) using the patients’ own words. Examples
—Automatic Thoughts —“I am a nobody” —Images —“Flashbacks” —Mood —“Feeling depressed” —Behavior —“Crying” —“Isolating myself” —“Using drugs” Step 2: Using Internal Coping Strategies
—List activities that patients can do without contacting another person. —Activities function as a way to help patients take their minds off their problems and promote meaning in the patient’s life. —Coping strategies prevent suicide ideation from escalating. —Examples
—Go for a walk —Listen to inspirational music —Take a hot shower —Walk the dog —Ask “How likely do you think you would be able to do this step during a time of crisis?” —Ask “What might stand in the way of you thinking of these activities or doing them if you think of them?” —Use a collaborative, problem solving approach to address potential roadblocks. Step 3: Using External Strategies: Socializing with Family Members or Others
—Coach patients to use Step 3 if Step 2 does not resolve the crisis or lower risk. —Family, friends, or acquaintances who may offer support and distraction from the crisis. —Ask “Who helps you take your mind off your problems at least for a little while?” —Ask “Who do you enjoy socializing with?” —Ask patients to list several people, in case they cannot reach the first person on the list. Step 4: Seeking Support:
Contacting Family Members or Friends for Help —Coach patients to use Step 4 if Step 3 does not resolve the crisis or lower risk. —Ask “How likely would you be willing to contact these individuals?” —Identify potential obstacles and problem solve ways to overcome them. Step 5: Contacting Professionals and Agencies
Coach patients to use Step 5 if Step 4 does not resolve the crisis or lower risk. Ask “Which clinicians should be on your safety plan?” — Identify potential obstacles and develop ways to overcome them. List names, numbers and/or locations of: —Clinicians —Local urgent care services —VA Suicide Prevention Coordinator —VA Crisis Line 800-273-TALK (8255), press “1” if Veteran Step 6: Reducing the Potential for Use of Lethal Means
—Ask patients what means they would consider using during a suicidal crisis. —Regardless, the clinician should always ask whether the Veteran has access to a firearm. —For methods with low lethality, clinicians may ask Veterans to remove or restrict their access to these methods themselves. For example
if patients are considering overdosing, discuss throwing out any unnecessary medication. —For methods with high lethality, collaboratively identify ways for a responsible person to secure or limit access. —For example, if patients are considering shooting themselves, suggest that they ask a trusted family member to store the gun in a secure place. Implementation
What is the Likelihood of Use?
Ask “Where will you keep your safety plan?” Ask “How likely is it that you will use the Safety Plan when you notice the warning signs that we have discussed?” What is the Likelihood of Use?
Ask “What might get in the way or serve as a barrier to your using the safety plan?” Help the Veteran find ways to overcome these barriers. May be adapted for brief crisis cards, cell phones or other portable electronic devices – must be readily accessible and easy-to-use. Review the Safety
Plan Periodically —Periodically review, discuss, and possibly revise the safety plan after each time it is used. —The plan is not a static document. —It should be revised as Veterans’ circumstances and needs change over time. Safety Plan Use
—Decide with whom and how to share the safety plan —Discuss the location of the safety plan —Discuss how it should be used during a crisis Let’s Create a Safety Plan
Mr. X is a 62-year old Vietnam Veteran who sustained a severe TBI during a motor vehicle accident while in the service. Since his discharge from the Army, Mr. X has had a hard time keeping jobs. He has difficulty getting started on tasks and following multi-step directions. He has not engaged with mental health consistently, preferring only to come in during periods of crisis. He often forgets appointments. Additionally, he is easily frustrated, sensitive to perceived criticism, perseverative, tangential, concrete, and has problems with cognitive flexibility. Mr. X has reported thoughts about suicide since his brain injury and has made three prior suicide attempts by overdose on prescription psychotropic medication, most recently last week. Identifying Warning Signs
T: Before we begin let me briefly tell you what a safety plan is and how it can be useful. A safety plan is a list of steps you can take when you're feeling suicidal. We will develop this safety plan together now so you will have it ready for when you need it. The first thing we will be doing is identifying signs – thoughts or feelings you might be having or have had in the past that can help us to know that you may be at greater risk of hurting yourself. Sometimes these signs are also actions, like participating in an activity that often leads to you feeling suicidal. Something we have talked about in the past is you looking around the house for old medication and counting pills. I think it is helpful to call these thoughts, feelings or actions “warning signs” – because they can help “warn” us that it is time for you to use this safety plan that we are working on here together. So can you tell me about this last time you attempted suicide? What triggered you to feel that way? P: Coping with my TBI. The worst part with traumatic brain injury is that people can’t see it. And they see on the outside that I move around. I do this. I do that. But they don’t see the struggle that’s inside, the memory loss, the struggles to remember, the struggles to forget. So there’s times where it all just gets really overwhelming if you have to write everything down because you can’t remember one day from the next. You read a book and it’s one of your favorite books and you’re reading it and you can’t even remember the last 10 pages that you’ve read. And you’re reading words but not comprehending them. That’s the thing that I’m fighting with all the time is that I get to the point where I fight with my memory and the other things. And it’s just not worth it. T: Okay. So it sounds like your problems with memory feel pretty overwhelming. And maybe that was partly what triggered this past attempt? Let’s see if we can work on this safety plan together, so that you can have some alternatives to suicide during times of crisis. Does that sound okay? P: Alright. A plan I can use to help me out when I feel like I am gonna kill myself. T: It is important that we identify what you think, feel and do when you start to feel suicidal. So when you think of times in the past when you tried to hurt yourself….do you remember what you did, felt, or thought. P: I told you I don’t know. It’s so frustrating for people to keep asking me this because I don’t know. Sometimes I know what I want to say although I get into a thought and about half way through it just dissolves into my brain. It’s like I wouldn’t know where it was, what it was, and five minutes later I couldn’t even remember that I had a thought. So I just don’t know. It adds to a lot of frustration going on. And, ya know, because of my TBI a couple days later I can’t even remember that I was frustrated to begin with. T: That sounds really hard. P: Yeah. It’s a big slap in the face because of the fact that you’ve gone from this manly man and now you have to be taken care of. So you’re still trying to live up to this standard of being a tough military man and then having to turn into somebody that needs help. T: Yeah. Asking for help can be hard, but us being here together working on this safety plan is a great step in the right direction. P: I guess the worst is feeling like there’s nowhere else to go or nothing else to try. That really depresses me. T: Okay. Those sound like things we should put on your safety plan. P: Yes, and I feel like I have lost my mind. T: That sounds like another thing we should write down. Step 1: Warning Signs
1. Nowhere else to go 2. Nothing else to try 3. Lost your mind 4. Feeling depressed 5. Being alone 6. Drinking Internal Coping Strategies
T: Sounds like that link between feeling depressed, being alone, and drinking, is an important one. OK, the idea would be that in the future whenever you pull out your safety plan it will cue you to start using the coping strategies. So what are some things that you can do to distract yourself when you are … [refer back to the list and read a few items from Step 1]. P: Hell if I know. T: Well are there things you like to do for fun or things that are distracting? P: I don’t know. I mean the closest thing that I can say I do for fun would be playing videogames on the computer. T: Great. Shall we write that down? How likely do you think you would be to be able to do this during a time of crisis? P: I don’t know. T: Okay, so the one thing that works as a distracter for you is playing videogames but you’re worried that in a time of crisis you may not even remember that playing videogames distracts you. Is that accurate? P: Yeah. T: Okay. Well one of the good things about having a safety plan is that you don’t have to remember all the details that we are coming up with now. It is all on the plan. We just have to help you remember that the plan exists and to refer to it. Now I know that memory is a problem for you and you need some prompts and cues. What sorts of prompts work for you? What sorts of things help you in general to remember things that are important? For example, how do you remember to come to your appointments at the hospital when you have them? What have you found that works? T: We were coming up with distracting activities we can add to your list to use if videogames don’t work. Do you have anything else you can think of to add here? P: No ideas. T: What about animals? Do you have any pets? P: Yeah T: Okay. So what kind of pet do you have? P: I have a cat. T: You have a cat. What’s your cat’s name? P: Spot. —T: Okay. So would it make sense for Spot to be a second activity to turn to if playing videogames wasn’t a good enough distraction? —P: Yeah. I mean, she’s always there. She’s never going to leave me. —T: Okay. Alright, so let’s put that down as step two: play with Spot. Okay? Step 2: Things I can do to take
my mind off my problems without contacting another person 1. Playing video games 2. Playing with Spot People I Can Ask for Help
P: I mean yeah, but when I get that way I usually don’t feel like talking to anyone so… T: Okay. Alright, are there any places near your apartment that you ever go to where people are around? P: No. T: No. Okay. Are there people who, when you’re feeling okay, who you do socialize with? When you’re not thinking about suicide are there people who you like to spend time with? P: Honestly, I don’t really like people. T: Okay. So there isn’t anyone you like. I’ve noticed though that sometimes just being around people, not necessarily having to talk with them, but just being around people can have a positive impact on our mood. Are there places you like to hang out where there are people who you can be with but with whom you do not have to socialize with but may if the mood strikes you? P: Well there is the 24-hour diner down the street. I guess I could go there and talk to the waitresses they’re pretty OK. T: Okay, good let me write that on your safety plan. Step 3.People who can help to support and distract me
1. Name 24 Hour Diner Phone 2. Name Phone 3. Name Phone People who I can ask for help
T: Alright. So if that doesn’t work and you are not feeling better the next step would be to turn to people you can ask for help and talk about your crisis. Now you said that you really don’t like people and the fourth step of safety planning is to identify people who you really feel like you could turn to for help in a crisis; people who you could actually say to them, “I’m thinking about killing myself and I need some help.” So who are those people in your life? Think about your family and friends first. P: I mean I’ve really not wanted to bother anybody with my problems because it’s embarrassing. It’s embarrassing to tell people that I have a problem so it’s just easier to ignore it or not worry about it. T: Okay. Is there anyone in your family or any of your friends who you would be able to say “I’m thinking about killing myself” to? P: No. T: What about non-family members, non-friends? Are there people at the VA, are there other providers besides me, anyone that you could say to “I’m thinking about killing myself”? P: Other than you? No, I can’t think of anyone. T: Okay, let's leave that blank for now. We can come back to this in the future and we can hopefully add to it then. Step 4: People who I can ask for help
1. Name Phone 2. Name Phone 3. Name Phone Professional Contacts
T: Okay. Well I certainly will continue to be a source of support for you. So, let's write my name and number down on the first line under Step 5. Pete Gutierrez, 303-399-8020 x2280. But the thing is I’m not here all the time. So, fortunately, we do have Psychiatric Emergency Services here. If you couldn’t get a hold of me, you know it was really a crisis, you’ve reached that step on your safety plan, do you feel like you could call PES? P: Maybe. T: Maybe? P: I mean, I don’t want to lie to you. I’ve had three attempts so far where, you know, I didn’t make those calls and so I don’t want to lie to you. T: And I appreciate that. And there’s probably no good way to predict whether or not you’d make that call or not. P: Yeah. T: Yeah, but we can predict that if you don’t have the number in front of you, you’re less likely to make the call. P: Okay. You make a good point. T: And then another thing that the VA has started doing is we now have a staff person who’s called our Suicide Prevention Coordinator and it’s this person’s job to kind of check in with folks who have been, you know, really suicidal lately and to just kind of offer one more set of eyes, one more contact person. Do you remember Michelle Steinwand our Suicide Prevention Coordinator? P: I think I met her on the unit. T: Yes, she’s very supportive and I’d like to put her name on the list as well, again, just so you have an option. You may never get to the point of calling her but just kind of another contact person. Does that seem okay? P: Okay. T: Good, her name is M-i-c-h-e-l-l-e S-t-e-i-n-w-a-n-d, and her number is 303-399-8020 x3093. P: Okay. T: In addition I wonder about the VA Crisis Line. The VA has a national crisis line. It’s a toll-free telephone number that you can call 24 hours a day, 7 days a week. And you will always get a real live human being on the other end of the phone; that’s one of the really great things about the Crisis Line. And you can be totally anonymous. You don’t have to tell them your name. You don’t have to tell them where you live. But their job is to listen to guys like you who are thinking about suicide and to give them that kind of connection that we’ve been talking about. Would it feel less embarrassing to tell a stranger on the other end of the phone that you’re thinking about suicide? P: I mean in some ways yeah. It would feel less embarrassing. Step 5: Professionals or agencies I can contact during a crisis
1. Clinician Name Pete Gutierrez Phone 303-399-8020 x2280 2. Local Urgent Care Services Denver VA Medical Center Urgent Care Services Address 1055 Clermont St. Urgent Care Services Phone 303-393-2835 3. VA Suicide Prevention Coordinator Name Michelle Steinwand VA SPC Phone 303-399-8020 x3093 4. VA National Crisis Line Phone: 1-800-273-TALK (8255), push 1 to reach VA mental health clinician Identify Barriers to Use —Unique to each patient —Problem solve ways to overcome Making Environment Safer
T: Alright, well we’re almost done. The last step of the plan is to think about ways that we can make it harder for you to get access to means for killing yourself. And all three times when you’ve made a suicide attempt you’ve overdosed on your prescription medication. Is that the only way you’ve ever thought about killing yourself, I mean, is that the way that you’d be most likely to do it in the future? P: Yeah, cause I don’t want it to be painful and I don’t want it to be messy. T: And you don't own a gun, right? P: Right. Making the Environment Safer T: Alright, what would you think about making a slight change in the way you get your meds and instead of getting them by mail and having a month or more at a time on hand? What if you only got a week supply at a time? P: That would stink. T: What would stink about it? P: Well because it just makes it harder for me to do that? T: Harder how? P: You know…to want to kill myself. T: Oh, it would stink because it would be harder to kill yourself? P: Well yeah. Step 6: Making the environment safe
1. Getting medication a week at a time Will the Patient Use their Plan?
T: Okay. So we’ve got our plan and, you know, we’ll make multiple copies of this. And I’ll hang on to the original so just in case you lose a copy or you need more it’ll be no problem to make more. We have a plan to help you hang them up when you get home and if I don’t hear from you I will be calling you later today. Next time we meet we’ll revisit the plan to see if it’s working for you, if it’s really helping, if you’ve had a crisis and the plan has helped you get through it then fantastic. But if it hasn’t then we want to be able to make changes to the pieces that aren’t working. Does that make sense? P: Yeah. T: Okay. So how do you feel about, you know, having put together this safety plan? What are your thoughts about what we’ve just done? P: I don’t know. I mean, I don’t know if it makes me feel better because it’s not like my life is going to improve because of this plan. It’s not like I’m never going to be suicidal again. I mean, I get it, but I just don’t know. I don’t feel right making promises to you about whether or not I’m going to kill myself. T: Well I’m not asking you to promise me you’ll never kill yourself. I’m asking you to try and use this plan to deal with the crises that you have. That’s all I’m asking you if you think you can do. P: Yeah, I’ll give it a shot. T: So, what was the most helpful thing that we discussed today? P: I think it was identifying the warning signs and figuring out how I’m going to remember the coping strategies when I’m in a crisis. T. Great! I'm going to go make copies for you. I'll be right back. P. Okay. |
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