Observations

1. Observations • Human beings do not have to know someone to think they know someone. • The depth of our conviction is totally out of proportion of what we really know. This is related to “the feeling of knowing” – being certain of knowing despite having no, or contradictory evidence. This arises out of involuntary brain processes that function independently of reason.

2. We cannot trust ourselves when we believe we know something to be true.

3. Hierarchy of Evidence: Best to WorseGray GE, Evidence-Based Psychiatry, 2004 • Systematic review of randomized, controlled trials • Individual randomized, controlled trials • Systematic review of cohort studies • Individual cohort study • Ecological study • Systematic review of case-control studies • Individual case-control study • Case series • Expert opinion

4. Risk Assessment • Risk assessment is a field of inquiry with a growing literature over the last 10 years. It has been primarily concerned with predicting the recidivism of offenders who have been released from custody. The product of this research has been various risk assessment instruments.

5. Risk Assessment of Violence • Various actuarial instruments have been developed to try to assess violence risk (VRAG, LSI-R, HCR-20, etc.) Their accuracy is better than chance, but not good enough to be of practical use in a clinical setting. (The VRAG has a sensitivity of 73% and specificity of 63%. Chest X-rays are not used to screen for lung cancer because they have a sensitivity of 84% and specificity of 90%.)

6. There is no one theory of the root cause of suicide • Lifestyle? In some, especially those within the mental health system, suicidal behavior becomes a habitual response to stress. • Passion? In others, suicidal behavior results from impulsivity - a combination of poor problem solving, lack of perspective, and impetuousity. • Premeditation? In still others, suicide is the long-term outcome of years of psychological suffering in a person who has given up hope.

7. Simplified Risk Assessment: 5 Risk Factors, 5 Warning Signs, 5 Steps • Five Warning Signs • 1) Suicidal intention (rumination, planning, preparation, access, giving items away) • 2) Sudden change in mood with no known reason • 3) Anxiety, agitation, insomnia, despair, hopelessness • 4) Feeling like a burden to others, disconnected • 5) Poor treatment alliance • Five Risk Factors • 1) Previous attempts or exposure to violence, self-injury, impulsive aggression • 2) Mental illness, substance abuse • 3) Social isolation, stress, loss • 4) Family history or exposure to suicide • 5) Native-American or white male

8. 1) Ask About Suicidal Behavior • RISK FACTOR • Has the client made previous suicide attempts, or shown self-injurious behavior or violence? • WARNING SIGN • Is the client showing the intention to act?

9. 2) Ask About Mental State • RISK FACTOR: • Presence or history of mental illness, substance abuse • WARNING SIGN: • Anxiety, agitation, insomnia, despair, sudden unexplained change in mood, sudden increase in substance use

10. 3) Ask About Social Connection and Stresses • RISK FACTOR • isolation, stress, losses, exposure to suicide or violence • WARNING SIGN • feeling like a burden, disconnected

11. 4) Assess Treatment Alliance • RISK FACTOR • No treatment alliance, help negation, unreliability and impulsivity • WARNING SIGN • Client show sudden, unexplained improvement • Client tells caregivers what they want to hear in order to avoid supervision, or to go on pass from the hospital, etc.

12. 5) The Plan • What is the plan for reducing suicide risk? Are the client and other participants willing and able to follow the plan? • The basic plan should reduce risk factors and enhance protective factors. • The client must be kept safe. You need to use sound clinical judgment. Denial and wishful thinking are obstacles that can lead to a bad outcome. • Documentation is a must. • Consultation is always a good idea. Every consultation brings you into contact with “the standard of care.”

13. Don’t Worry Alone.

14. Risk Related to Mental Illness • History of mental illness - 95% • Affective disorders 40-60% • Alcohol associated 25-50% • Comorbid Personality Disorder 50% • Relative risk by diagnosis • Prior attempt 38.4 • Bipolar disorder 22.1 • Depression 20.4 • Mixed AODA 19.2 • Dysthymia 12.1 • Ob/comp 11.5 • Panic disorder 10.0

15. Risk from Mental Illness • Relative risk by diagnosis: • Schizophrenia 8.45 • Personality disorder 7.08 • Alcohol abuse 5.86 • Cancer 1.8 • Mental retardation <1 • Eating disorder >1 • ADHD ? • Child abuse 10x? (Sexual abuse is a clear risk factor for psychopathology and suicide attempts in the victim and the victim’s children. Physical abuse is more a risk factor for aggression.) • With exception of substance abuse, suicides tend to occur early in the illness. Age and gender are less important.

16. Severe Suicide Attempters (Hall 1999) • 92% severe anxiety • 92% partial insomnia • 84% no plan • 83% had seen caregiver in previous month • 80% panic attacks • 80% depression • 78% had conflicted relationship with someone close to him • 69% no or fleeting ideation • 67% first attempt • 28% had been asked about suicidal behavior

17. Non-Epidemiological Risk Factors • Mental State • Strong, unpleasant emotions (anger, shame) • Anxiety, panic, obsessive ruminations • Despair, hopelessness • Loss of control, trapped • Lack of perspective, feels to be a burden • Sudden, unexpected improvement, “flight into health”

18. Non-Epidemiological Risk Factors • Social/ Environmental • Single • Losses • Isolation, not belonging, perception of no social support • Life dissatisfaction • Strong religious belief and responsibility for children may be protective

19. College Student Suicide • Rate of 7.5/100,000 (lower than for peers who are not in college - 15/100,000) • Graduate students at highest risk. Foreign students also at high risk. Summer seems to be a high risk time – fewer students? • Major mental disorders often first appear in this age group. • College students are significantly more likely to have alcohol use disorders than non-college peers. • The admission process encourages families to hide mental illness history.

20. College Student Suicide • 40% of college students report feeling so depressed at least once during the year that it was difficult to function. • Substance abuse complicates diagnosis and treatment. • Students with suicidal ideation are more likely to engage in injury-related risky behaviors. Ideation to suicide death – 1,000:1 • Many colleges will now suspend or expel students who are suicidal for liability reasons.

21. An Alternative Approach to Suspension • The University of Illinois requires any student who threatens or attempts suicide to attend 4 sessions with a mental health professional. If he/she refuses, the student is dismissed from the university. • The suicide rate at Illinois is half of most universities, and only one student has refused to go to counseling.

22. College student resource • Jed Foundation • www.jedfoundation.org

23. The Interview: Client Reticence • Ambivalence about future suicide • Embarrassment (weakness, taboo) • Fear of being labeled crazy and put in hospital • Lack of insight

24. The Interview: Decreasing Reticence • Appear unhurried and comfortable • Be direct, calm, and honest • Ask and ask again when risk signs are there • Notice hesitancy, body language suggesting anxiety, discomfort, deception • “Looks like it’s difficult to talk about” • “Take your time describing thoughts”

25. Doing a Risk assessment • Collateral information, especially from significant others • They hear the threats. Confidentiality is not an issue in an emergency. In any case, it is better to be sued for breach of confidentiality than have a patient die of suicide • A treatment plan which includes a determination of treatment setting • Make sure that the plan is one that can be implemented and the patient is capable of following it.

26. No Self-Harm Contracts • There is no evidence that contracts prevent suicide. There is no evidence that legal outcomes are affected by the presence of a contract. • There is evidence that they may increase legal liability in the event of a bad outcome, and that insurance companies may regard a contract as evidence that hospitalization is no longer needed. • In any case, once a patient decides to die by suicide, the clinician is usually regarded as an adversary rather than an ally.

27. The Most Important Risk Management Principle:

28. Don’t Worry Alone.

29. Campus Violence • Study at Univ. Mass: 120 male students (out of 1,882) were responsible for 439 acts of violence. 76 of these men were responsible for 439 acts of sexual aggression and 1,045 acts of physical violence: • 76 men - 1,000 crimes -14 acts each • The similarity to society at large is informative. Campuses are victimized by a small number of men who will continue to perpetrate violence until they are arrested.

30. Overview • The presence of a mental illness and substance abuse increases the chances that a person will act violently in certain situations, independently of the individual’s background or gender. Refusing treatment for mental illness and substance abuse increases this risk.

31. Overview of the Mentally Ill • Although there is no single clinical picture associated with violent behavior, a building paranoid fear in a patient with a history of violence should create concern. • Violent behaviors are often well-planned over a long period of time, but then executed impulsively in a brief period of emotional arousal.

32. Overview of the Mentally Ill • Potentially violent individuals may not provide information regarding their plans because they are well-guarded. • Warning signals may be more frequently observed in public settings than in mental health appointments, where there is a lower level of stimulation. • Mental health does a good job of inpatient treatment, but a poor job of keeping people stable after discharge.

33. Watch Out For: • Young adult males with: • Mental illness, trauma, and violence in their past • Substance abuse in their present • No plans for participating in treatment in their future • Students who are threatening others • Students who are showing increasing paranoia (fear of others) • Students who are showing a significant change in the way the behave • Students with poor impulse control, extreme narcissism, anger problems

34. Historical, Clinical, and Risk Management -20 • Historical • Previous violence • Young age at first violent incident • Relationship instability • Employment problems • Substance use problems • Major mental illness • Psychopathy • Early maladjustment • Personality disorder • Prior supervision failure

35. HCR-20 • Clinical • Lack of insight • Negative attitudes • Active symptoms of major mental illness • Impulsivity • Unresponsive to treatment

36. HCR-20 • Risk Management • Plans lack feasibility • Exposure to destabilizers • Lack of personal support • Noncompliance with remediation attempts • Stress

37. General Risk Factors • Psychiatric patients are 3x more likely to be violent than the general population • Men with schizophrenia are 4x more likely to be convicted of a violent crime • An adult with a previous violent crime is 14x more likely to commit a violent crime in the future. • Substance abuse increases violence in men 20x and violence in women 32x.

38. Context • Context is as important as the individual in determining dangerous situations. Particular people are dangerous in particular situations. It is often the context that can be controlled (substance abuse, treatment adherence) where individual characteristics cannot (gender, age, violent history)

39. Violent Fantasy • A violent fantasy is a thought in which the subject imagines physically harming another person in some way. It is not an intention (immediately aimed at guiding action) or delusion (the distinction between imagination and reality is lost.) An intention would be considered a “threat.” • In one study, 68% of undergraduate students had at least 1 homicidal fantasy - 30% of men and 15% of women had such fantasies frequently.

40. Violent Fantasy • Violent fantasies are present in a large number of “normal” individuals. • The presence of violent fantasy is not proven to signal potentially violent behavior. • However, the nature and quality of violent fantasies, and the degree of preoccupation with them is probably important risk assessment information. This data should be used in conjunction with data about the client’s history and present behaviors.

41. Violence in College • Deaths from college violence are statistically very rare. • In 2004, there were 71,621 criminal offenses reported on campuses, and 15 murders. By contrast, there were 16,137 murders in the United States. • Since 1966, there have been 44 shootings on college campuses, resulting in 147 deaths, 29 wounded, 12 shooter suicides.

42. Taking Charge of Students? • In college, students want to be treated as autonomous adults. This goal is shared by administrators and faculty, who are also interested in helping students distance themselves from over-protective parents. • On the other hand, parents believe that colleges have a responsibility to protect their children from harm – college is not “living on your own.”

43. A Different Kind of Student • 16-24 years old is a time when most major mental illnesses begin to show symptoms. • At the same time, psychiatric treatment, particularly medication has enabled more people to function well enough in the community that they can attend college. • Seung-Hui Cho had been on medication in the past (antipsychotics?) Steven Kazmierczak was taking an antidepressant, anti-anxiety, and sleeping medication.

44. Communication • HIPAA • FERPA • Client/therapist privilege

45. HIPAARANOIA • The Health Insurance Portability Act of 1996 limits disclosure of sensitive information, including HIV status, genetic information, alcohol and substance use, psychotherapy notes, domestic violence, and sexual assault. • The P in HIPAA is not for “privacy.” HIPAA permits disclosure of patient information, without consent, for physician referrals and health care providers who treat the same patient, and in the case of emergency.

46. FERPA • The Federal Educational Rights and Privacy Act of 1974 protects the privacy of student education records and applies to all schools that receive funds from the US Dept of Education. • FERPA specifically exempts health and counseling records. • The only law governing these records is client therapist confidentiality.

47. FERPA • FERPA does not apply when in releasing information to parents if the child is still claimed as a deduction (assumed for all children under age 26), or when there is a need to protect. • Colleges and universities may share any information about dependent students with parent/custodian.

48. FERPA and Privacy • Additionally, what you see or hear about a student is not the educational record. • Internally, officials can communicate with one another. And there is no power to sue given to students if there is a violation. • The Cho family had done a good job of getting him help during his childhood, but they had no idea he was a problem at Virginia Tech, or that he had had a psychiatric evaluation.

49. FERPA • When Cho’s parents were asked what they would have done had they known about his problems, they said, “We would have taken him home and made him miss a semester to get this looked at…but we just did not know about anything being wrong.”

50. Confidentiality • Once treatment begins, clinicians are bound by confidentiality ethics and statutes. • Conversations with faculty and other students are not constrained by confidentiality requirements. • There are no privacy laws applicable to the police who transport people under emergency detention.