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The Assessment, Management, and Treatment of Suicidal PatientsEthics and Psychology PodcastEpisode #25
Hosted by Dr. John Gavazzi, PsychologistBoard Certified in Clinical PsychologyDr_Gavazzi www.ethicalpsychology.com
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This podcast fulfills Act 74 requirements for Pennsylvania licensed psychologists, social workers, marriage and family therapists, and professional counselors.
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The Assessment, Management, and Treatment of Suicidal Patients
An Introductory Podcast
Special Guest: Samuel J. Knapp, EdD, ABPP
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Disclaimer
This podcast/video can only provide a basic introduction to the assessment, management, and treatment of patients at risk to die from suicide. As an educational program, it does not purport to provide clinical or legal advice on any particular patient.
Participants with concerns about the assessment, management, or treatment of any particular patient are urged to seek clinical or legal advice. Also, individual psychotherapists need to use their clinical judgment with particular patients and incorporate procedures or techniques not covered in this podcast/video or modify or omit certain recommendations herein because of the unique needs of their patients.
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A Note on CompetenceA brief program of this nature can only highlight some important facts about suicide assessment, management, and intervention. It may serve as an update or refresher for experienced clinicians. However, competence in assessing, managing, or treating suicidal patients can only come with more extensive education and supervised experience.
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Learning Objectives
At the end of this program the participants will learn basic information that will help them to
1. Assess patients who are at risk to die from suicide;
2. Manage the risks of suicide; and
3. Treat patients who are at risk to die from suicide.
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General OutlineSuicide is the 10th leading cause of death in the United States and the most frequent crisis experienced by mental health professionals.
This podcast/video reviews basic information about the assessment, management, and treatment of patients at risk to die from suicide.
It fulfills Act 74 requirements for Pennsylvania licensed psychologists, social workers, marriage and family therapists, and professional counselors.
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Outline•Assessment of Suicide
•Screening Instruments
•Suicide Management (4 M’s)
•Interventions
•Quality Enhancement Strategies
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Assessment – Step 1•Asking about suicidal thoughts, plans, and
intentions; does not increase risk.
•Needs to be part of an initial assessment
•If the patient denies current suicidal ideation, plan, and intent, then can revisit later if needed.
•Important to ask about a history of suicidal ideation, plans, and attempts.
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Assessment – Step 1
•If a patient reports a low level of suicidal ideation or history, then it may be appropriate to continue with assessment.
•Passive versus active suicidal ideation
•About 4% of Americans will report SI in the past year and about 1/3 of those with suicidal plan.
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Assessment - Step 1
•Often, people with SI will deny it.
•Fear of hospitalization, negative appraisal of psychologist, or actual desire to complete.
•If a patient denies suicidal ideation with other risk factors, such as a history of attempts, significant depressive symptoms, co-morbid substance abuse, impulsivity, etc., move to the second step.
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Assessment - Step 2•Effective helpers will interview in a
respectful, nonjudgmental and caring manner.
•Baseline Factors
•Acute Features
•Dynamic Variables
•Protective Factors
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Baseline (static) Factors
•Age
•Race
•Gender
•Sexual Orientation
•Unemployment
•Lack of Access to Healthcare
•Substance Abuse
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Acute Factors
•Suicidal ideation
•Prior attempts
•Psychiatric History
•Recent stressors
•Medical Conditions
•Lack of Support
•Access to means to attempt suicide
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Dynamic Variables
• Thwarted belongingness
• Perceived burdensomeness
• Emotional pain (mental illness)
• Physical illness (disability or pain)
• Guilt and/or moral challenges
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Protective Factors
•Religious beliefs or affiliations
•Marriage
•Children
•Other support networks
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Step Three: Screenings
• Columbia Suicide Screening Rating Scale
• Suicide Behavior Questionnaire – Revised
• Beck Hopelessness Scale
• Beck Suicide Ideation Scale (Pearson)
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Balancing Factors•Very difficult to predict which individuals
will act upon suicidal ideation
•Previous attempts single best predictor
•Detailed plans are at higher risk
•May want to quantify: low, medium, high risk
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The Four M’s of Management
Motivate
Means
Medicate
Monitor
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Motivation Tools• Commitment to Life (Treatment) Agreement
• Reasons for living
• Avoid people, places, and things
• Symbols of hope
• How to manage distress
• Crisis numbers if needed
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Means Restriction
•Details of suicide plan and remove guns, medications, etc. away from patient
•Patients seldom substitute one means of suicide for another
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Medication
•A management strategy for schizophrenia or bipolar disorder
•Its effectiveness in reducing short-term suicide risk in other patients is unclear
•Increased risk when starting or getting off medication
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Monitoring•Continue to measure suicidal ideation and plans
•Day-to-day check ins or monitoring with patients consent may be indicated for some patients
•Hospitalization in extreme cases
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Quality Enhancement Strategies
The positive reframe on Risk Management Strategies
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Quality Enhancing Strategies
As the legal risks, the possibility of treatment failure, or patient
complexity increases,the greater the level of attention
should be given to quality enhancing strategies.
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Quality Enhancing Strategies
Consultation
Empowered Collaboration
Documentation
Redundant Protections
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Consultation
Technique oriented information
Emotional reactions
Reduction of emotional turmoil
Thinking through solution together
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Consultation
Write down issues in advance
Need to be open and honest
Be willing to admit mistakes or clinical errors
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Empowered Collaboration
Empowering psychologists respect a patient’s autonomy and decision making skills about the goals of treatment, process of treatment, and life choices.
Examples of tough decisions and ambivalent patients
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Documentation: Legal Purposes
Required by insurers, State Board of Psychology, APA Ethics Code, etc.
A record of treatment for future providers
Useful risk management tool
Write out evaluation, decision-making steps, consultations, and final decision
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Redundant Protections
Multiple layers of information in order to provide the highest level of care
Another health care provider Psychological testing or screening device Family member or significant other Consultation
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Why Redundant Protections?
Avoid errors in judgment
Obtain essential information
Promote greater chance of success
(Obtain prior records)
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Suggested Checklist for Ongoing Treatment
Patient Collaboration Self-Reflection
1. Does the patient think you have a good working relationship?
2. Do my patient and me share the same treatment goals?
3. Does the patient report any progress in therapy?
4. Does the patient want to continue in treatment?
1. Do I believe I have a positive working relationship with my patient?
2. Is my assessment of the patient sufficiently comprehensive?
3. Do unresolved clinical issues impede the course of treatment?
4. Have I documented appropriately?
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The EndPlease complete course evaluation if you are looking for CE credit.
www.papsy.orgPennsylvania Psychological Association