• No results found

Assessing for Suicide & Non- Suicidal Self Injurious Behavior: A

N/A
N/A
Protected

Academic year: 2021

Share "Assessing for Suicide & Non- Suicidal Self Injurious Behavior: A"

Copied!
26
0
0

Loading.... (view fulltext now)

Full text

(1)

Assessing for Suicide & Non-

g

Suicidal Self Injurious Behavior: A

Cli i l A

h

Clinical Approach

Dr. Jane E. Atieno Okech, Ph.D

Associate Professor of Counselor Education & Counseling Associate Professor of Counselor Education & Counseling

Coordinator-Clinical Mental Health Counseling Counseling Program

Counseling Program

University of Vermont

(2)

Points to Ponder!

Points to Ponder!

y

“Any therapist, regardless of how

competent,

successful, and skilled, may lose a client

th

h

i id Wh t ill di ti

i h thi

through suicide. What will distinguish this

therapist from another who was clearly

negligent careless and indifferent to her/his

negligent, careless, and indifferent to her/his

client’s suicidal state is the presence of a

well-documented, thorough client record”

well documented, thorough client record

(Freemouw, Perczel, & Ellis.,1990, p. 10).

(3)

Telling Questions

y

How would you define self-injurious

behavior?

y

What are your feelings/reactions/ attitude

y

What are your feelings/reactions/ attitude

towards self- injurious behavior?

Wh

i

/ f li

d

y

What are your reactions/ feelings towards

people who self- injure or who have

previously engaged in self-injurious

behavior?

(4)

Definitions

y Non-Suicidal Self Injury (NSSI)- Episodic self-injurious

behavior (SIB) (e.g. cutting, burning, choking game) is observed among normally developing children and adolescents.

among normally developing children and adolescents.

y Chronic and severe SIB is more common among people with developmental or psychiatric disabilities or other special

populations such as prisoners populations such as prisoners.

y NSSI may be related to specific biological conditions or syndromes.

NSSI b d f i ki lf i l i f

y NSSI can be used for attention-seeking, self-stimulation, or for communication (to either get or avoid something).

y Self-injurious behavior occur without suicidal intentj

y NSSI is primarily conceptualized as a tool for emotion regulation (Nock & Prinstein, 2004)

y Effective intervention programs identify and remedy the cause y Effective intervention programs identify and remedy the cause,

(5)

Telling Questions

Telling Questions

y

What is suicide?

y

What are your feelings/ reactions towards

suicide?

su c de?

y

What are your reactions/ feelings towards

people who are suicidal?

people who are suicidal?

y

What are your reactions/ feelings towards

people who have attempted suicide?

people who have attempted suicide?

(6)

Suicide Defined

y According to Butterworth's Concise Australian Dictionary: Suicide

can be defined as the deliberate act of taking one's life.f f g f

y Kosky et al. further observes that suicidal behavior can be interpreted

as a manifestation of distress associated with loss or abandonment, a as a manifestation of distress associated with loss or abandonment, a release from despair, an expression of hostility or revenge, an appeal for help, a wish to test fate or to be reunited with a loved one, or a response to the disordered thinking of a psychotic illness or drug intoxication.

y David Lester argues that g death caused by one's own voluntary act is y y

not necessarily a sufficient criterion to use when judging whether the psychological process of suicide has occurred. There are examples of cases where people have died accidentally by suicide and other

l f h i t d d t di b t h li d

examples of cases where a person intended to die but who lived because they were accidentally found.

(7)

The Use of Assessment

Instruments

V i i h l b d i f i id i k Th

y Various instruments have also been used assessing for suicide risk. These

include assessments such as the :

9 Hopelessness Scale (Beck Weissman Lester & Trexler 1974) 9 Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974) 9 The Beck Depression Inventory (Beck & Steer, 1987)

9 The BDI-II (Beck, Steer, & Brown, 1996) that were not specifically

designed to measure suicide ideation, but what is measured correlates with suicide ideation

suicide ideation.

y In addition, there have been instruments developed specifically to assess

for suicide ideation. These instruments include:

9 Beck Scale for Suicide Ideation (BSSI) (Beck, Kovacs, & Weissman,

1979)

9 Suicidal Ideation Scale (SIS) (Rudd 1989) 9 Suicidal Ideation Scale (SIS) (Rudd, 1989)

9 Suicide Behaviors Questionnaire (SBQ) (Cole, 1988)

9 Reasons for Living Inventory (Linehan, Goodstein, Nielsen, & Chiles,

1983)

9 Suicidal Ideation Questionnaire (Reynolds, 1987) 9 MMPI-A

(8)

Assessments for Adolescents/ College

Populations

ƒ

Some of the above instruments have also been validated for

use with

adolescent

or

college populations

. In addition,

th

i t

t th t h

b

ifi ll d

l

d

there are instruments that have been specifically developed

for these populations.

9

College Student

Reason for Living Inventory (Westefeld,

Cardin, & Deaton, 1992)

9

Suicidal Ideation Questionnaire

Junior High version

9

Suicidal Ideation Questionnaire –

Junior High version

9

Multiattitude Suicide Tendency Scale –

for adolescents

(Orbach, Milstein, Har-Even, Apter, Tiano, & Elizure,

1991)

1991)

9

Fairy Tales Test (Life and Death Attitude Scale for the

Suicidal Tendencies Test (

(

for children 10 and younger

y

g

)

)

(Orbach, Feshbach, Carlson, Glaubman, & Gross, 1983)

(9)

Common Factors Model of Counseling

Outcomes (Hubble, Duncan, & Miller, 1999)

(

,

,

,

)

Placebo, Hope, Expecta Client/Extra-therapeutic Factors (40%) ncy (15%) Model/ Technique R l ti hi Factors (15%) Relationship Factors (30%)

(10)

Questions to Guide Suicide

Assessment

y Either as part of an intake assessment, or based on information you have gathered indicating that a suicide assessment is in

order, the starting point is (

Frierson et al , 2002)

:

9

Ask directly if the client has thoughts of suicide.

“Have you thought of committing suicide?”

9

“Are you thinking of killing yourself?” In this

case, subtlety is counterproductive.

9

If the response is

p

YES

“How often have you had

y

these thoughts?”

9

“ Do you have a plan on how you are going to

y

p

y

g

g

(11)

To continue or not to continue

with assessment!

with assessment!

y

If the answer is anything but a confident

“NO”,

then assessment should proceed.

y

Even in cases when a client answers by saying

y y g

“NO”,

continued exploration and discussion of

what the client has said or presented that may be

p

y

related to suicidal ideation is warranted.

(Frierson et al , 2002).

(12)

Cont…Assessment

9

Have there been previous attempts? (When, surrounding

circumstances, rescuer?)

9

For example: “When?” “How often?” “What happened?”

“What was going on in your life at the time?”

What was going on in your life at the time?

9

*If attempts were made, then exploration of method and

rescuer should be explored.

9

*If the client indicates having thoughts or having made

9

*If the client indicates having thoughts or having made

attempts in the past, even if there is no current ideation,

past experiences should be thoroughly explored.

(13)

Cont…Assessment

y

*If the client does not answer questions about suicide, the

answers are vague, or if the client conveys that he/she has

entertained thoughts of suicide then…

entertained thoughts of suicide then…

9

Are the thoughts pervasive or intermittent?

9

When was the last time the thought occurred to

the client?

9

Do these thoughts typically occur in times of

9

Do these thoughts typically occur in times of

crisis?

9

Is there a specific precipitating event?

Is there a specific precipitating event?

y

*Even if answers to these questions continue to be vague or

b

i

i

id

f h

h

seem to be more intermittent, ideas of how the person

might commit suicide need to be explored.

(14)

Explore the plan…..

y Is there a plan? What are the details of the plan? How extensive is

the plan?

y Examples: “How have you thought of killing yourself?” “When

would you carry out the plan?” “Do you have a date and time?” would you carry out the plan? Do you have a date and time? “Where would you be?” “Who would you want to find you?”

y What is the lethality of the means/method? y What is the lethality of the means/method? y Is there access to the identified means?

y Examples: “If you were to commit suicide, how would you do it?”

“Do you have the pills?” “Where are they?” “What type of pills y p y yp p would you take?” “What type of gun?” “Where would you get the gun?” “Do you have bullets?” “Where is the gun? The bullets?” “Do you have a rope/cord?”

(15)

Interventions!

y

The previous questions have related specifically to suicide

ideation. In addition, questions that

assess for risk

and

protective factors

are explored All of this information aids

protective factors

are explored. All of this information aids

in determining risk and subsequent interventions.

9

Is the client using drugs or alcohol?

g

g

9

What are the client’s social supports?

9

Does the client have a religious or spiritual affiliation?

9

How is the client discussing suicide and potential

aftermath?

9

Do fantasies seem to be positive or painful?

9

Do fantasies seem to be positive or painful?

9

Is the client able to see any alternatives to suicide?

9

How does the client respond to challenges to distorted

9

How does the client respond to challenges to distorted

(16)

Counselor Skills & Behaviors

y

There are Important skills attitudes knowledge and

y

There are Important skills, attitudes, knowledge and

behaviors when working with clients in crisis or with

suicidal ideation:

9Remain calm and controlled 9Exhibit respect for the client 9Problem-solving skills 9Active listening 9Active listening 9Trustworthiness 9Restatements/ paraphrases 9SincereSincere 9Directive 9Reflections of feelings 9Empathic 9C i i di i 9Cognitive disputation

9Be able to Challenge and confront client 9Ability to develop a Contract

9Ability to involve client in making decisions and 9Ability to involve client in making decisions and

(17)

Potential Actions/

Interventions

y Make psychological contract y Conduct an assessment

y Identify the message! What will committing suicide do for you? What problem will it solve/

you? What problem will it solve/

y Identify reasons for living! What purpose would it serve to live? How would he/others benefit?

live? How would he/others benefit? y Define and impose goals

y Expand client’s view of the problemp p y Build on client’s strengths

(18)

Potential Actions/

Interventions

Interventions

y

Develop a safety contract also known as/

no-y

Develop a safety contract also known as/

harm contract/ suicide prevention contract/

no-suicide decision agreement

suicide decision agreement

y

Remove means-suicide weapons/ substance etc

E

i l/ f

il

t/ i

y

Engage social/ family support/ increase

sessions/ contacts with client

y

Voluntary hospitalization

y

Involuntary hospitalization

(19)

Negligence

y Brems (2000) summarized the following questions related to

negligence: negligence:

①Was the counselor aware or should have been aware of the risk?

②Was the counselor thorough in assessment of the client’s suicide risk? ③Did the counselor make “reasonable and prudent efforts” to collect

sufficient and necessary data to assess risk?

④Were the assessment data misused, thus leading to a misdiagnosis

where the same data would have resulted in appropriate diagnosis by another mental health professional?

⑤Did the counselor mismanage the case, being either “unavailable or

i h li ’ i i ?”

unresponsive to the client’s emergency situation?”

⑥Was the counselor negligent in the way she/he designed her/his

intervention with the client after assessing risk?

⑦ Did the counselor make adequate attempts to keep the client safe (i.e.,

set up a plan of contingencies with appropriate resources, phone

numbers, etc)? Did the counselor remove the means to be used by the client in the s icide attempt?

client in the suicide attempt?

⑧In cases of minors, were parents or caretakers informed of the client’s

(20)

Counselor Duty

y

The following are considered reasonable duty for

counselors in terms of suicide prevention (Remley

& Herlihy, 2001):

9

Counselors must know how to make assessments

of a client’s risk for suicide and must be able to

defend their decisions

9

When a decision is made that the client is a

danger to self, counselors must take whatever

g

,

steps are necessary to prevent the harm

9

Actions to prevent harm must be the least

Actions to prevent harm must be the least

(21)

How to protect yourself and your clients

Counselors should: Counselors should:

① Inform clients of the limitations of confidentiality through standard

“informed consent” procedures.

②B i th i t d f i id t ti l d ti

②Begin their study of suicide assessment prevention early and continue

to stay current through professional development activities regarding suicide and crisis intervention and ethical/legal issues in counseling (Laux 2002)

(Laux, 2002)

③Be familiar with suicide risk factors , procedures for suicide

assessment, and guidelines for intervention (Brem, 2000

④Abide by the standard of practice to consult with other mental health ④Abide by the standard of practice to consult with other mental health

professionals (Remley & Herlihy, 2001)

⑤Must properly document the process of suicide assessment and

intervention through case notes and reports (Brem 2000) intervention through case notes and reports (Brem, 2000)

y As reported by Brems (2000), “as long as mental health and health

f i l h b bl t h d t d ibl

professionals have been able to show prudent and responsible care (through assessment of risk and tailored intervention planning), the courts have tended to rule in favor of the practitioner” (p. 166).

(22)

*SAD PERSONS

(

i f

i

i id

i k)

(a mnemonic for assessing suicide risk)

S ( l ) y Sex (male)

y Age (elderly or adolescent) y Depression p

y Previous suicide attempts y Ethanol abuse

R ti l thi ki l ( h i ) y Rational thinking loss (psychosis) y Social support lacking

y Organized plan to commit suicide g p

y No spouse (divorced /widowed/single) y Sickness (physical illness)

Ad t d f P tt t l (1983) Adapted from Patterson et al (1983).

(23)

Cognitive Behavioral Therapies for NSSI-B

y Problem Solving Therapy (PST; D’Zurilla & Goldfried, 1971)

y PST assumes that dysfunctional coping behaviors result from a y p g

cognitive or behavioral breakdown in the problem solving process (D’Zurilla & Nezu, 2001)

y Dialectical Behavior Therapy (DBT; Linehan, 1993)

y DBT is based upon a conglomeration of Zen Buddhism,

cognitive-behavioral interventions, problem solving, and skills training

y The core dialectical principle underlying DBT is a balance between

encouraging the client to change and accept him or herself simultaneously

y These treatments share common features:

y Time limited

y Structured therapies with immediate targeting of NSSI y Focus on remedying skill deficits

(24)

Problem Solving Therapy (PST; D’Zurilla

& Goldfried, 1971)

y “The goal of PST is to help clients identify and resolve the problems they encounter in their lives, as well as teach clients general coping and problem solving skills that they can utilize in general coping and problem solving skills that they can utilize in the future to deal more effectively with the problems they

encounter” (Muehlenkamp, 2006). y Steps of problem solving:

y Problem identification

y Goal setting (utilizing behavioral analysis of the problem) y Goal setting (utilizing behavioral analysis of the problem) y Brainstorming & assessing potential solutions

y Selecting & implementing a solution

y Evaluating the success of a chosen solution

* Teaching these skills is critical in the therapy process since people who engage in NSSIB have been found to exhibit poor problem solving skills and tend to have rigid thinking styles

(25)

Dialectical Behavior Therapy (DBT; Linehan,

1993)

y Pre treatment phase: y Pre-treatment phase:

y Orienting client to the therapy

y Obtaining a commitment agreement for therapy

y Stage one focus is on reducing NSSI or suicidal behavior

y Validations of clients experience

y Problem solving techniques/ teaching of adaptive techniquesProblem solving techniques/ teaching of adaptive techniques y Behavioral skills training in mindfulness, emotion regulation,

interpersonal effectiveness, distress tolerance etc

y M i t i i th li ll d i di t i t d y Maintaining therapy compliance as well as reducing distress associated

with Axis 1 disorder

y Stage two addresses ways of dealing with traumatic experiences and

invalidating environments

y Stage three emphasizes developing and maintaining self-respect while

(26)

References

1. Brems, C. (2000). Dealing with challenges in psychotherapy and counseling. Scarborough, Ontario:

Brooks/Cole.

2 D'Zurilla T J & Nezu A M (2001) Problem solving therapies In K S Dobson (Ed ) Handbook of 2. D Zurilla, T.J., & Nezu, A.M. (2001). Problem-solving therapies. In K. S. Dobson (Ed.), Handbook of

Cognitive Behavioural Therapies (pp. 211-245).

3. D’Zurilla, T. J., & Goldfried, M. R. (1971). Problem solving and behavior modification. Journal of

Abnormal Psychology, 78, 107-126.

4. Freemouw, W., de Perczel, M., & Ellis, T. (1990). Suicide Risk: Assessment and response guidelines.

New York: Pergammon Press.

5. Hubble, M.A., Duncan, B.L.& Miller, S.D. (1999). The heart and soul of change: What works in therapy.

Washington DC: APA Washington, DC: APA.

6. Linehan, M. M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York:

Guilford Press.

7. Michel, D. Jobes, A.A. Leenaars, J.T. Maltsberger, P. Dey, L. Valach, R. Young. Meeting the Suicidal

Person, Retried on August 1, 2009 from http://www.aeschiconference.unibe.ch 8. National Institute of Mental Health. Suicide facts. Retrieved on June 8, 2009 from:

http://www.nimh.nih.gov/research/suifact.htm.

9 Nock M K & Prinstein M J (2004) A functional approach to the assessment of self mutilative 9. Nock, M. K. & Prinstein, M. J. (2004). A functional approach to the assessment of self-mutilative

behavior in adolescents. Journal of Consulting and Clinical Psychology, 72, 885-890

10. Remley, T.P. Jr. & Herlihy, B. (2001). Ethical, legal, and professional issues in counseling. Upper Saddle

River, NJ: Prentice Hall.

11. Patterson WM, Dohn HH, Bird J, et al. Evaluation of suicidal patients: the SAD PERSONS scale.

Psychosomatics 1983;24(4):343-9

12. Richard L. Frierson, MD., Margaret Melikian, DO; Peggy C. Wadman, MD. (2002). Principles of suicide

References

Related documents

2 Suicidal Behavior: I have a history of past attempts of suicide or self-injurious behaviors 1 Family: I have a family history of suicide or suicide attempts and/or a

STRAND ONE: LEARNING AND INNOVATION SKILLS STANDARD 2- Critical Thinking and Problem Solving.. Students will utilize critical thinking to learn problem-solving skills to apply

Personal computers, monitors, printers, photocopiers, multifunction devices, fax machines, equipment for email and scanners. Energy Efficiency Advisory

In this interactive, practical workshop, the expert workshop leaders will provide participants with an update on the latest CAS issues, as well as the necessary training to prepare

bought Payoffs realized v is revealed Principals submit wage bids in a first- price auction t=3 t=4 t=5 Investor 3 enters market, receives private signal and observes decisions

Ficaria verna abundance and reproductive output (seeds, bulbils, and tubers) were examined in invaded transects spanning a disturbance gradient away from a river.. Site

Le Hong Thang, Tran Quoc Lap, Pham Thao, Nguyen Hoang Viet, Nguyen Minh Duc, Nguyen Thi Hoang Oanh. Effects of Sintering Temperature on the Microstructure and Mechanical