Roberta Schweitzer, PhD, CNS Mental Health Consultant, Indiana AgrAbility

1. Preventing Suicide & Opioid Misuse in Farmers & Ranchersat Colorado State University, 12/5/2018AARSchweitzerPPT12.0518 (Rev. 9.1019) Roberta Schweitzer, PhD, CNS Mental Health Consultant, Indiana AgrAbility Breaking New Ground Resource Center Purdue University

2. Content Overview • Characteristics of normal stress • Negative outcomes of stress overload • Acute/Chronic signs of stress overload in clients • Life threatening/high risk behaviors in clients - violence towards self/others • Development of a Emergency Safety Plan • Referral resources for life-threatening or high-risk situations • Farmer Stress Management Tool Kit • Assessment resources • Practical stress management strategies • Identify local, regional, & national resources for support & referral

3. Setting the Scene • The Farming/Ranching Life • Ranks in top 10 most stressful occupations in US(NIOSH survey) • Same stressors as non-farm families, plus farm specific ones • Concerns about ranch finances, debt loads • Machinery breakdown • Bad weather – variability or natural disasters • Crop/herd loss • Time pressures & long work hours • Handling dangerous pesticides • Farm viability fears

4. What is “Normal” Stress? • A fact of nature • Can help us learn & grow or cause problems • Forces from inside or outside world affect every individual • Emotional well-being, physical well-being, etc. • Individual responds to stressors in ways that affect them and their environment • Internal & external factors

5. What is Stress? • External Factors • Physical environment, job, relationships, home, etc. • Internal Factors • Daily situations, challenges, difficulties, expectations, etc. • Determine your body’s ability to respond to or deal with the external stress-inducing factors • Influence nutrition status, overall health & fitness levels, emotional well-being & amount of sleep/rest you get

6. Stress Response • Occurs suddenly or short term, OR: • Builds up over time • Stress releases neurochemicals & hormones to prepare us for action • If the person doesn’t act the stress response can create/worsen health problems • “Stress creep” – Frog in Boiling Water • Prolonged, ongoing or unmanageable stress causes the most damage • Key to prevent problems - Identify stressors, recognize symptoms and manage stress early

7. Stress Response

8. Signs of Chronic/Prolonged Stress • Physical • Headache • Ulcers • Backaches • Eating Irregularities • Sleep disturbances • Exhaustion • Frequent sickness

9. Signs of Chronic Prolonged Stress • Emotional • Sadness • Depression • Bitterness • Anger • Anxiety • Loss of spirit • Loss of humor

10. Signs of Chronic Prolonged Stress • Cognitive • Memory loss • Lack of concentration • Inability to make decisions • Self-Esteem • “I’m a failure” • “I blew it” • “Why can’t I…?”

11. Signs of Chronic Prolonged Stress • Behavioral • Irritability • Backbiting • Acting out • Withdrawal • Passive-Aggressiveness • Alcoholism • Violence

12. A Storm Moving In: Adding more stressors • An event extended over time or single acute events • Examples: Flood, drought, etc. • Stress increases & current coping level is challenged • Adds to unpredictability & feeling out of control • May create a crisis point

13. Hit by the Storm • Short term stress overload • Addition of stressor(s) “above & beyond” • Ominous life-changing sense of dread • Feelings of shock, disbelief, rage or panic • May experience intense sense of loss • Increased feeling of vulnerability & fear

14. Hit by the Storm • Short term stress overload • Increased unhealthy coping styles seen in family • Changes in family routines; increased conflict; care of livestock & crops declines; increase in accidents; increase in physical illness; appearance of farmstead/ranch declines • Evidence family may need help coping

15. Hit by the Storm – No Let-Up • Signs of increasing unhealthy coping • Heightened anxiety, agitation • Tachycardia; rapid breathing; palpitations; muscle tension; sweating; increased BP (Sympathetic) • Fatigue; nausea; urinary frequency; urgency (Parasympathetic) • Narrowing focus of attention; diminished ability to problem solve & learn (Cognitive) • Restlessness; purposeless activity; immobilization; insomnia; scanning; vigilance; diminished productivity (Behavioral) • Feelings of dread; anguish; painful increased helplessness; apprehension; irritability (Affective) • Inability to complete tasks

16. Hit by the Storm – No Let-Up • Signs of increasing unhealthy coping • Depression • Mood of sadness, despair, emptiness; decreased interest/pleasure in most activities; changes in eating, sleeping, activity level (fatigue) & libido; feelings of worthlessness or guilt; • Difficulty concentrating, memory & decision-making; recurrent thoughts of death &/or self-harm; apathy, low motivation, social withdrawal; irritability; excessive emotional sensitivity; complaints of pain, e.g. backache or headache that seems to have no physical cause

17. Hit by the Storm – No Let-Up • Other signs of unhealthy coping • Opioid misuse/abuse • Prescription drugs – average 114 deaths daily; 82% are accidental; average 6,748 ER visits daily for prescription drug misuse • Drug classes misused/abused • Main CNS depressants – Benzodiazepines & Alcohol • For anxiety, panic attacks, insomnia, depression (Xanax, Valium, Ativan, etc.) - **Cause cardiac & respiratory depression** • Opioids – for pain relief (Oxycontin, Methadone, Morphine); CNS depressants • Use Narcan to reverse effects of opioids while in the community; available to the public

18. Hit by the Storm – No Let-Up • Dual Diagnosis – Substance misuse/abuse along with depression – creates additional concerns for detox & withdrawal, & maintaining sobriety • Alcohol • Use CNS depressants for detox & withdrawal (can be life-threatening & can last 10-12 days) • Xanax, Valium, Ativan, etc. • For decreased alcohol intake & reduced cravings • Antabuse & Naltrexone/Revial

19. Hit by the Storm – No Let-Up • Opioids • Methadone, Naltrexone, etc. • Used for detox and withdrawal • Buprenophrene • Used for opioid addiction treatment

20. Hit by the Storm – The Crisis Point • Acute/imminent life and death situations • Threat of violence/aggression toward: • Client (self) • &/or • Others in the environment

21. Hit by the Storm – The Crisis Point • Suicidal Behavior • Can be a desperate attempt to escape intolerable pain of stress from severe losses • Lack of pleasure and quality of life • High degree of hopelessness, helplessness • Suicidal Ideation -thoughts of harming self • Suicidal Threat – communicates desire to kill self • Suicidal Action – carries out action to kill self • Suicide attempt – made attempt to kill self

22. Weathering the Storm – The Crisis Point • Suicide is often preventable • Client wants to live – unable to see alternatives to problems; perspective is distorted • Most give warning signs of their intentions; if a stressful event is effecting the whole community, be extra tuned in for cues • Best way to help prevent suicide is to know what to look for in the most severe level of suicidal risk

23. Weathering the Storm – The Crisis Point • At the highest threat level of violence to self/others the client is: • Unable to access healthy ways to cope with overwhelming stress (heightened anxiety, depression; withdrawal, isolation) • Helplessness and hopelessness • Has a plan in place to kill self • Talks about suicide • Has access to weapon • Misusing or abusing a substance (alcohol, opioids, etc.) &/or has a history of previous suicide attempt(s)

24. Weathering the Storm – Crisis Response • Main goal in high suicide risk or aggressive situation with client is to maintain safety of the: • Intervener & others in immediate environment, and • Client • Accurate assessment of risk (verbal/visual cues) helps intervener to determine next steps & save lives • Client may present anywhere on a continuum from very hostile & agitated to very withdrawn

25. Weathering the Storm – Crisis Response • Entering into a high suicide risk situation with client in rural/isolated area • Go in with a partner for backup & support • Call 911 to establish contact with MH crisis team, sheriff/police department, EMT, etc. until they can arrive on site for assistance/follow-up • Use of satellite phone vs cell phone in remote areas • Approach client very slowly with calm voice; maintain safe distance & cover if weapon involved; always leave escape route open • Don’t be a “hero”

26. Weathering the Storm – Crisis Response • High suicide risk situation cont’d • Establish contact with client & engage in conversation if possible • Focus on client & giving hope for future (an ally) • Remember, client focus is narrowed – unable to see hope/solutions to problems at that moment • Provide “a light at the end of the tunnel” until this time period passes • Emphasize that weapon is not needed (if present) & encourage to put it down • The crisis is temporary; can survive unbearable pain; • Help is available; you are not alone

27. Weathering the Storm – Crisis Response • Communication in a suicide risk crisis • Always assume a client still wants to live or they wouldn’t be talking to you. • What to say • “Are you thinking of ending your life?” Will not “cause” suicide • Share things with client that give hope e.g.,; “we/they care about you & will support you”,etc. • What to do • Encourage client to share feelings & reach out for help • Be there to listen

28. Weathering the Storm – Crisis Response • Communication in a crisis – Respectful & Caring • Focus on using/building communication skills that enhance relationships with ranch/farm families during a crisis and in general • Use active listening • Very important skill, especially in crisis or distress – “Being, not doing or fixing” • Listening takes energy – not a passive process; reflect what you hear, back to client • Use empathic response leads, e.g. “So you feel…..?”

29. Weathering the Storm – Crisis Response • Communication cont’d • Same communication techniques also apply to family members; assess stress levels and depression in them as well • Examples • “This must be really stressful for you right now”; “Your reaction is understandable for a situation so difficult” • Family members may also be able to give more insight into their situation

30. Weathering the storm – Crisis Response • Watch for Barriers that break down Communication • Interrupting • Ignoring • Judging • Blaming • Stating opinion as fact • “Fixing” behavior • Insulting/name calling • Focus on self, not client

31. Weathering the Storm – Crisis Response • If you arrive at the scene of a suicide attempt that has already occurred • Don’t leave client alone – assess for pulse & breathing if possible • Call 911or local emergency number • Tell family member, etc., if at the site, what’s going on • Attempt to find out if client is wounded/injured, or under influence of alcohol or drugs, or has OD’d • Get help from trained professionals ASAP • May need hospitalization until suicidal crisis has passed • Make sure client & family member have Suicide Hotline # • National Suicide Prevention Lifeline # 800-273-TALK (8255)

32. Weathering the Storm – Crisis Response • Communication with paranoid, fearful, etc. client • Paranoid person may accuse others of trying to harm him/her, or look around fearfully • Client may talk about protecting self from an attack • Do not argue; ask questions about client’s fears • Use simple directions; let client know you can help – e.g., “Sit down & let’s talk about it”; build trust • Give client enough personal space, so doesn’t feel trapped – at least one arm’s length; move them away from cause of fear (noise, activity, etc.) • Tell client what you are going to do before doing it, e.g., take cell phone from pocket, etc.

33. Weathering the Storm – Crisis Response • Referrals for Crisis Intervention & Mental Health Treatment in Local Colorado communities • Crisis Counseling • Phones, Hotlines, Online • ER in local hospital • Fire Department EMT • Family MD, Psych-Mental Health APN, Psych MSW • Mental Health Counselors • Clergy

34. Weathering the Storm – Crisis Response • Referrals for Crisis Intervention & Mental Health Treatment in Regional/Statewide Colorado • Colorado Statewide Mental Health Network regions • List of Regions with Information

35. After the Storm – Client Follow-up • After suicide risk crisis event • Check in with client & family (phone or in-person) to assess current status and stay apprised of follow-up mental health treatment plan • This allows staff to be another member of client’s support system to reinforce mental health treatment goals & healthy functioning • Also, can support maintenance of sobriety if alcohol or opioids were used previously for unhealthy coping • Continue ongoing periodic contacts with client/family

36. After the Storm - AgrAbility Staff • Set up a staff de-briefing session after suicide crisis • Important to share personal feelings/responses with peers in order “take care” of yourself - enhance personal coping skills & build team support • Also, a time to identify areas of knowledge/skill that could be enhanced through future staff education programs

37. On Firm Ground – Look to the Future • Foundational beliefs – Identified assets • Overall, farm/ranch families & the rural community possesses strong resilience • The community is a key network of support – during crises, and day-to-day • Ag professionals are in a key position to refer clients to services and groups that build mental health and coping skills • Healthy communication and relationships with clients can add support for getting through “tough times” • Making current resource lists available to clients can decrease feelings of helplessness and increase feelings of competence in rural clients

38. On Firm Ground – Look to the Future • Traditional Farm Management Plan vs. • Planning to maintain or increase farm/ranch productivity • Farmer Stress Management Plan • Mental Health Promotion & Wellness Focus • Planning to improve farm family coping skills in the face of uncertainty and potential crisis situations • Enhance rancher’s ability to prevent chronic stress buildup • Taking care of whole self as integral part of the ranch operation/productivity

39. On Firm Ground – Looking Upstream • Focus on Mental Health Promotion & Illness Prevention • Developing a “Farmer Stress Management” Tool Kit • Valuable for ranch/farm families AND Ag Professionals • All of us need to build “self-care” into our daily routines • Includes strategies to enhance overall farmer/rancher mental health & to prepare for future potential crises

40. Farmer Stress Management Toolkit • Mental Health Screening Tools for Illness Prevention - (examples for Ag staff reference) • PHQ-9 Patient Depression Questionnaire • Suicide Risk Screening Tool NIMH • GAD-7 Scale - Generalized Anxiety Scale • CAGE-AID Questionnaire, Drugs & Alcohol • Characteristics of Suicide Risk Levels Chart • Patient/Client Safety Plan Template (example for Ag staff reference) • Stanley & Brown, 2008

41. Farmer Stress Management Toolkit • Current Mental Health Referral Resource List • Resource list for referring rural clients to mental health organizations, professionals, and agencies to support farmer/rancher coping • Rural Referral Resource List - Example for Colorado regions • Web-Search Handouts, etc.

42. Farmer Stress Management Toolkit • Holistic Model for Healthy Living • Model for Healthy Living Assessment Tool • Guide to Developing Healthy Life Balance • Mental Health & Wellness • Positive mental health allows people to: • Realize their full potential • Cope with life stresses • Work productively • Make meaningful contributions to their community

43. Farmer Stress Management Toolkit • Stress Management Strategies • Stress Management Worksheets • Practical Strategies for Stress Management: • Stress Management Worksheet • Stress Management Workshop Handout • Stress Management Activities/Tools • Mindfulness & Relaxation • Cognitive Strategies • Other Strategies from the Healthy Living Model

44. Farmer Stress Management Toolkit • Mental Health Web Page resources • Lists

45. Upstream Actions with Rural Clients • During routine rural visits monitor clients for mental health changes via brief targeted screens • Signs/symptoms of anxiety, depression/suicide risk, drug misuse/abuse • Introduce resources for referral early so if find changes in baseline signs/symptoms – include local & support of family MD, Clergy, & other informal resources • Reinforce client use of mental health/support care when indicated; follow-up on continued counselling, med use/prescribed treatment, etc.

46. Upstream Actions with Rural Communities • Build relationships with mental health professionals/agencies to enhance client referrals • Continue updating referral resource list - local, regional, & state • Share & distribute resource lists across rural areas of state to facilitate referrals • Cultivate new connections to build resources • University of Colorado Denver, School of Nursing, Western Slope, etc.