Suicide.ppt

1. Suicide Protocol @ QBH vi

2. Agenda Learning Objectives: After reading this article, CE candidates will be able to: Discuss new approaches to screening for suicidality. Describe evidence-based interventions for suicidal children, adolescents, and adults. Explain the importance of collaboration with suicidal patients. Introduction Building confidence Engaging the audience Visual aids Final tips & takeaways

3. Suicide – Thae Challenge what is frustrating, he said, is that practicing psychologists too often are failing to take advantage of recent advances in clinical research on what works best when it comes to detecting suicide risk and treating patients with proven suicide-focused care.“Psychologists don’t know how much evidence we’ve produced and that clinical practice is lagging behind what works,” said Jobes. “It’s exasperating to know that there is rigorous clinical trial research providing effective suicide-focused interventions…, yet most practicing psychologists don’t know about them.”Part of the problem is that seeing patients who are suicidal can be both challenging and disconcerting, acknowledged Samuel Knapp, EdD, ABPP, author of Suicide Prevention: An Ethically and Scientifically Informed Approach (APA, 2020). All too often, Knapp said, psychologists feel the best way to respond to a patient who is suicidal is to send them to the emergency room and get them on antidepressants as soon as possible. But that is usually not the best approach, he said.

4. Suggested Approaches Today, said Knapp, there are three treatments that are well supported by outcome research—brief cognitive behavioral therapy (BCBT), dialectical behavior therapy (DBT), and Collaborative Assessment and Management of Suicidality (CAMS)—as well as other promising but less replicated strategies

5. The power of communication

6. Navigating Q&A sessions • Know your material in advance • Anticipate common questions • Rehearse your responses • Maintaining composure during the Q&A session is essential for projecting confidence and authority. Consider the following tips for staying composed: • Stay calm • Actively listen • Pause and reflect • Maintain eye contact

7. Psychologists often use one of two screening instruments to assess suicidality: the Ask Suicide-Screening Questions tool or the Columbia-Suicide Severity Rating Scale (PDF, 181KB). But these and other traditional assessments ask the wrong questions, said Craig Bryan, PsyD, ABPP, who directs the Suicide Prevention Program at The Ohio State University College of Medicine. “The traditional approach is to think about suicidal ideation as the gateway to suicidal behaviors,” said Bryan, author of Rethinking Suicide: Why Prevention Fails, and How We Can Do Better (Oxford University Press, 2021). “But there’s increasing recognition that there are different trajectories toward suicide.” Some people may progress through the sequence in a matter of hours; others may not follow the sequence at all. A scale Bryan and colleagues developed called the Suicide Cognitions Scale asks questions that get at emotions that can render people vulnerable, such as feeling that people would be better off without you or that no one can help you solve your problems. Administering that scale alongside the Patient Health Questionnaire-9 (PDF, 40KB) depression screener improved the identification of patients most likely to progress to suicidal behavior in the next month, Bryan and colleagues found (Annals of Family Medicine, Vol. 19, No. 6, 2021). Assessing Suicide Risk Confidence-building strategies

8. Engaging the Patient • The way clinicians ask patients about suicidality can also make a difference. Researchers have found that asking about suicidality in a way that suggests that no is the right response—questions like, “You’re not thinking of harming yourself, are you?”—can cause patients to hide their true thoughts (Ford, J., et al., Patient Education and Counseling, Vol. 104, No. 4, 2021). • Make eye contact with your audience to create a sense of intimacy and involvement • Weave relatable stories into your presentation using narratives that make your message memorable and impactful • Encourage questions and provide thoughtful responses to enhance participation to gather audience opinions, promoting engagement and making sure the audience feel involved

9. Interventions with Those @ Risk In the intervention realm, researchers have found that another big shift is needed—the dismantling of the common idea that suicide is caused by mental illness. “We don’t conceptualize suicide as a symptom of mental illness—diagnosing depression and treating depress One way to do that is through BCBT focused on two key vulnerabilities: emotional dysregulation and cognitive rigidity. In a randomized controlled trial of soldiers with suicidal ideation or recent suicide attempts, Bryan and colleagues found that those who received BCBT were 60% less likely to report a suicide attempt during the follow-up (Rudd, M. D., et al., The American Journal of Psychiatry, Vol. 172, No. 5, 2015).sion,” said Bryan. “We target suicide directly.” CAMS is another intervention based on the idea of targeting suicide rather than depression or other mental illness. “The idea of relegating suicidal ideation and behaviors to a symptom of depression isn’t supported by the evidence,” said Jobes. “The evidence shows that when we target and treat suicidal ideation and behaviors with different psychological treatment, we can significantly reduce suicidal risk.” CAMS also represents a shift from an adversarial model in which the doctor knows best and must control the patient to a deeply collaborative approach in which the patient becomes a “coauthor” of their own treatment plan. The interactive process over six to eight sessions addresses the “drivers”—the problems that patients say make them suicidal, such as losing a job or intense self-hatred. “This approach is compelling to patients,” said Jobes. And it works. A recent meta-analysis of nine CAMS trials found that when compared with other commonly used interventions, CAMS significantly reduces suicidal ideation, overall distress, and hopelessness (Swift, J. K., et al., Suicide and Life-Threatening Behavior, Vol. 51, No. 5, 2021). Asarnow pointed out, the Substance Abuse and Mental Health Services Administration (SAMHSA) guidebook Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth (PDF, 22.4MB) (SAMHSA, 2020) lists just one intervention with strong evidence to back its effectiveness: DBT. Five more programs are promising, according to SAMHSA’s review.

10. Effective delivery techniques This is a powerful tool in public speaking. It involves varying pitch, tone, and volume to convey emotion, emphasize points, and maintain interest. • Pitch variation • Tone inflection • Volume control Effective body language enhances your message, making it more impactful and memorable. • Meaningful eye contact • Purposeful gestures • Maintain good posture • Control your expressions

11. Promising Interventions with Those @ Risk in SUD DBTA Developed by Marsha Linehan, PhD, ABPP, of the University of Washington, and later adapted for adolescents, DBT combines individual therapy, multiple-family skills training, and telephone coaching. Because of how labor-intensive the intervention is, said Asarnow, it may be best to reserve DBT for the highest-risk children and adolescents. Asarnow has developed an easier but still “very DBT-informed” intervention called Safe Alternatives for Teens and Youth (SAFETY). In this 12-week program, young people work with one therapist while parents work with another, then they come together to practice skills and address issues important for increasing safety and reasons for living. A randomized controlled trial by Asarnow and colleagues found that adolescents in the SAFETY group had significantly lower chances of making suicide attempts than those in a treatment-as-usual group (Asarnow, J. R., et al., Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 56, No. 6, 2017 [PDF, 438KB]). Suicide attempt survivors themselves are also offering ideas for improving treatment, said Melanie Hom, PhD, who along with colleagues asked survivors for their recommendations (Hom, M. A., et al., Psychological Services, Vol. 18, No. 3, 2021). Many of those recommendations represent a return to psychotherapy basics: Be empathetic. Use active listening. Collaborate with patients. “These are things psychologists are well trained to do, but they can go out the window when clinicians are focused on risk and safety concerns,” said Hom, a clinical assistant professor of psychiatry and behavioral sciences at Stanford University School of Medicine. Psychologists should also avoid stigmatizing patients who are suicidal. It may be harmful, for example, to tell patients that they have so much to live for or that it is selfish to consider suicide because they have children. “The provider might think that that will bolster someone’s reasons for living, but it unintentionally can make someone feel ashamed about their suicidal thoughts or past behavior,” Hom said, noting that such comments can also shut down honest discussion and make people less likely to seek help in the future. Instead, she said, be curious and ask what led the person to attempt suicide. https://www.apa.org/monitor/2022/06/continuing-education-intervene-suicide

12. Promising Interventions with Those @ Risk in SUD 1st Continuation Using Technology working on technological approaches to expanding access to suicidality assessments and interventions beyond the clinician’s office. In one recent randomized controlled trial, researchers tested brief videos designed to teach DBT skills to college students, for whom suicide is the second most common cause of death (Rizvi, S. L., et al., Behaviour Research and Therapy, Vol. 149, 2022). Participants also underwent ecological momentary assessment—via smartphone surveys—to assess their moods as they fluctuated over the course of a day. The intervention seemed to help prevent a worsening of symptoms as time progressed. And those who watched the videos more than once saw decreases in negative mood and increases in positive mood. Tech approaches like this may be especially appealing to young people, said senior author Evan Kleiman, PhD, an assistant professor of psychology at Rutgers University. “Kids are comfortable using their phones,” he said. “We have to meet them where they’re at.” Kleiman predicts that technological tools that are designed to assess people’s suicidality, supplement therapy, serve as a bridge for those on waiting lists, and help those not yet ready for therapy will become widely available to psychologists in the next two to three years. Emergency departments are already using technology in new ways. Patients who are suicidal often end up in the emergency department expecting to receive care, but what typically happens is long wait times while staff members search for an inpatient facility opening, said psychologist Linda Dimeff, PhD, chief scientific officer at Jaspr Health, a company that develops technology to help health care systems help people in suicidal crises. “If a patient comes in on Friday, they may not leave until Monday or Tuesday when an inpatient facility is identified and they have arranged transport,” she said. “What does a patient do during that time? They get more depressed, ruminating about what’s not right.” To better fill that waiting time, Jaspr created a tablet-based digital platform that gives patients access to evidence-based strategies they can start working on even as they wait for in-person help. Survivors of suicide attempts helped design the program alongside Jaspr psychologists, other experts in suicide science, and representatives from health care systems. The survivors also tell their stories via videos on the platform, sharing the strategies that helped them, but also offering hope. “Suddenly, you’re not only getting suicide care but you’re also having people who really understand where you’re at helping you feel not so alone,” said Dimeff. https://www.apa.org/monitor/2022/06/continuing-education-intervene-suicide

13. Promising Interventions with Those @ Risk in SUD 2nd Continuation Using Technology Emergency departments are already using technology in new ways. Patients who are suicidal often end up in the emergency department expecting to receive care, but what typically happens is long wait times while staff members search for an inpatient facility opening, said psychologist Linda Dimeff, PhD, chief scientific officer at Jaspr Health, a company that develops technology to help health care systems help people in suicidal crises. “If a patient comes in on Friday, they may not leave until Monday or Tuesday when an inpatient facility is identified and they have arranged transport,” she said. “What does a patient do during that time? They get more depressed, ruminating about what’s not right.” To better fill that waiting time, Jaspr created a tablet-based digital platform that gives patients access to evidence-based strategies they can start working on even as they wait for in-person help. Survivors of suicide attempts helped design the program alongside Jaspr psychologists, other experts in suicide science, and representatives from health care systems. The survivors also tell their stories via videos on the platform, sharing the strategies that helped them, but also offering hope. “Suddenly, you’re not only getting suicide care but you’re also having people who really understand where you’re at helping you feel not so alone,” said Dimeff. https://www.apa.org/monitor/2022/06/continuing-education-intervene-suicide

14. Promising Interventions with Those @ Risk in SUD 3rd Continuation Following Up- Focus on Crisis Other interventions focus on crises. Safety planning—written steps to follow in moments of intense distress—has been demonstrated to reduce suicidal ideation, attempts, and suicides, said Megan L. Rogers, PhD, a postdoctoral research fellow at Mount Sinai Beth Israel (Rogers, M. L., et al., Professional Psychology: Research and Practice, Vol. 53, No. 1, 2022). Many suicidal individuals are not in treatment, and even those who are do not see clinicians very often. “Sometimes it is only a 50-minute-a-week session,” said Rogers. “What tools do they have for the other 167 hours of the week?” There are two evidence-based safety-planning interventions, said Rogers: the Crisis Response Plan (Rudd, M. D., et al, Treating Suicidal Behavior, Guilford Press, 2004) and the Safety Planning Intervention (Stanley, B., & Brown, G. K., Cognitive and Behavioral Practice, Vol. 19, No. 2, 2012). Emphasizing collaboration, both interventions consist of recognizing warning signs; listing self-management strategies, like ways to distract oneself; and identifying possible sources of external help, including family and friends, health care providers, and crisis services. The Safety Planning Intervention also calls for removing guns and other items that could be used for suicide. (See the Suicide Safety Plan website for a step-by-step guide and the April/May 2022 Monitor CE Corner on talking with patients about firearm safety.) https://www.apa.org/monitor/2022/06/continuing-education-intervene-suicide

15. Further reading Covid-19 and suicideClay, R. A., Monitor, June 2020 How to talk to your patients about firearm safetyClay, R. A., Monitor, November/December 2020 Commonsense recommendations for standard care of suicidal riskJobes, D. A., Journal of Health Service Psychology, 2020 Limitations of screening for depression as a proxy for suicide risk in adult medical inpatientsMournet, A. M., et al., Journal of the Academy of Consultation-Liaison Psychiatry, 2021 New research in suicide preventionPappas, S., Monitor, September 2021 Research roundup: Treating suicidality through technologyMarzalik, J. S., APA Services, 2021 Stopping military and veteran suicidesNovotney, A., Monitor, January/February 2020

16. Further suggestions

17. Do you need someone to talk to?Are you experiencing feelings of depression or anxiety?Are you worried about a loved one’s mental health?Are you or someone you know struggling with an addiction or substance use disorder?No matter what you’re dealing with, there is no wrong reason to call. CALL OR TEXT 988 Our crisis counselors are prepared to help you get the support you need.Free, confidential, and available 24/7.Currently serving all Michiganders. Further suggestions when not in the office make sure you inform

18. Navigate360's Together for Zero Pledge In the face of a growing mental health crisis among students, Navigate360 is proud to introduce Digital Threat Detection: Self-Harm Alerts, which schools can access at no cost. Recognizing we must put an end to the tragic trend of increased rates of self-harm and suicide, this pledge is a demonstration of our commitment to building a better future for your school community – one where every student is safe and supported. join

19. Navigate360's Together for Zero Pledge Framework:Model School District Policy on Suicide Prevention This document from ASCA, the American Foundation for Suicide Prevention, the National Association of School Psychologists and The Trevor Project, outlines model policies and best practices for school districts to follow to protect the health and safety of all students. It is critically important that school districts have policies and procedures in place to prevent, assess the risk of, intervene, and respond to youth suicidal behavior. Toolkit: Information-Gathering Tool: Suicide ConcernThe suicide informational questionnaire is a guide for having a conversation with a student, not an interview. The priority is to connect with the student and the student’s immediate concerns and needs. Also available in Spanish. Guide:A Quick Guide to Support Students with Suicidal Ideation Position Statement:The School Counselor and Suicide Risk Assessment Position Statement: The School Counseling and Suicide Prevention, Intervention and Postvention Webinar:Legal and Ethical Considerations: Suicidal Risk & Informational Gathering Webinar: Model School District Policy on Suicide Prevention Webinar: Suicide Risk Assessments Pose Legal Risk to School Counselors Webinar: After a Suicide: A Toolkit for Schools Webinar:Suicide Prevention for LGBTQ Youth Webinar:Suicide Prevention and Mental Health During COVID-19 Magazine article:Assessments and Third-Party Software Alerts for Suicide Ideation Magazine article: Suicide Assessments: The Medical Profession Affirms School Counselors' Truth Other Resources American Foundation for Suicide PreventionBlueprint for Youth Suicide and Prevention: Strategies for Community and School Settings Suicide Prevention Resource CenterAfter a Suicide: A Toolkit for Schools Resources/support

20. Further suggestions when not in the office make sure you inform

21. Quick Guide For Clinicians Based on TIP 50 Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment WHAT IS A TIP? The TIP series provides professionals in the behavioral health and related fields with consensusbased, field-reviewed guidelines on behavioral health topics of vital current interest. The TIP series is published by SAMHSA and has been in production since 1991. TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment: • Provides information about suicidality. • Focuses on the information that treatment professionals need to know and provides that information in an accessible manner. • Synthesizes knowledge and grounds it in the practical realities of clinical cases and real situations so that the reader will come away with increased knowledge, encouragement, and resourcefulness in working with substance abuse treatment clients who have suicidal thoughts or behaviors. Other TIPs of interest to readers include: • TIP 48, Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery • TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders Note: You may download TIPs and related products for free through the SAMHSA Store at http://store.samhsa.gov.

22. SAMSHA & QBH In particular, the consensus panel recommends that you: • Screen clients in substance abuse treatment for suicidal thoughts and behaviors routinely at intake and at specific points in the course of treatment (see pp. 31–32 of this Quick Guide). QBH Must Screen: Intake, Treatment Plans, Every individual session- use your clinical sense particularly when is a past history and/or attempts of: Suicide & Self Harm Screening of clients with significant risk factors should occur regularly throughout treatment. • Be prepared to develop and implement a treatment plan that addresses suicidality and to coordinate the plan with other providers. • Confirm that referral appointments are kept whenever a referral is made; also continue to monitor clients after crises have passed through Addressing Suicidal Thoughts and Behaviors in 8 Substance Abuse Treatment ongoing coordination with mental health treatment providers and other practitioners, family members, and community resources as appropriate. • Acquire basic knowledge about warning signs, risk factors, and protective factors as they relate to suicide risk. • Be empathic and nonjudgmental with people who experience suicidal thoughts and behaviors. • Be aware of the impact of your own attitudes toward and experiences with suicidality on your counseling work with clients. • Understand the ethical and legal principles and potential areas of concern that exist in working with clients who have suicidal thoughts and behaviors.

23. Types of Suicidal Thoughts & Behaviors: Some Definitions &Cardinal Signs (SAMSA )Suicidal ideation: Suicidal ideation is much more common than suicidal behavior. Suicidal ideation (or thoughts) exists on a continuum of severity from fleeting, vague thoughts of death to persistent and highly specific considerations of suicide. Thoughts may only occur periodically or may be unrelenting. • Suicide plans: Suicide plans are significant because they signal a more serious risk of carrying out suicidal behavior than does suicidal ideation without planning. Suicide planning exists on a continuum from vague and unrealistic plans to highly specific and feasible plans. Serious suicide planning may also involve rehearsal or preparation for a suicide attempt. • Suicidal intention: Suicidal intention (also called “intent”) signals high, acute risk for suicidal behavior. Having suicidal intent is always serious because it signals that the client intends to make a suicide attempt. Some indicators of high intent include drafting a suicide note or taking precautions against discovery at the time of an attempt. • Suicide preparation: Behaviors that suggest preparation signal high, acute risk for suicide. Preparation can take many forms, such as writing a suicide note or diary entry, giving away possessions, writing a will, acquiring a method of suicide (e.g., hoarding pills, buying a weapon), making a method more available (e.g., moving a gun from the attic to beside the bed), visiting a site where suicide may be carried out (e.g., driving to a bridge), rehearsing suicide (e.g., loading and unloading a weapon), and saying goodbye to loved ones directly or symbolically. • Suicide attempt: A suicide attempt is a deliberate act of self-harm, undertaken by an individual who has at least some intent to die, that does not result in death. Attempts have two major elements: the subjective level of intent to die (from the client’s subjective perspective, how intensely did he or she want to die and to what extent did he or she expect to die?) and the objective lethality of the act (from a medical perspective, how likely was it that the behavior would have led to death?). Although all suicide attempts are serious, those with high intent (client clearly wanted and expected to die) and high lethality (behavior could have easily led to death) are the most serious. • Suicide: Suicide is an acute, deliberate act of self-harm, undertaken by an individual with at least some intention to die, that results in death. • Nonsuicidal self-injury (NSSI): NSSI (e.g., selfmutilation or self-injury by cutting for the purpose of self-soothing with no wish to die and no expectation of dying) is distinguished from a sui cide attempt or suicide because NSSI does not include suicidal intent. NSSI is also commonly referred to in the literature as “deliberate selfharm” or “suicidal gesture.” This Quick Guide and the TIP upon which it is based do not focus on NSSI. However, suicidal behaviors and NSSI can coexist in the same person, and both can lead to serious bodily injury. • Self-destructive behaviors: Behaviors that are repeated and may eventually lead to death (e.g., drug abuse, smoking, anorexia, reckless driving, getting into fights) are distinguished from suicidal behavior because an act of suicide is an acute action intended to cause death in short order. This Quick Guide and the TIP upon which it is based do not focus on self-destructive behavior

24. To Consider Be direct. We must often talk with clients about socially taboo topics. Become comfortable talking with clients directly about their thoughts of killing themselves. Doing so can save lives. Increase your knowledge about suicide. Knowing some of the circumstances in which people become suicidal, how suicidality manifests, what warning signs might indicate possible suicidal behavior, what questions to ask to identify suicidality, and—perhaps most important—the range of effective interventions for suicidality increases your competence and comfort. Do what you already do well. Faced with a suicidal client, many counselors turn into the “suicide police,” aggressively questioning and demanding assurances of safety from the client. Don’t lose sight of what makes you a successful counselor: empathy, good therapeutic skills, and awareness of client resistance. Practice, practice, practice. Nobody does something best the first time around. Get comfortable with asking all clients in substance abuse treatment about suicide. Learn to look for risk factors and warning signs (noted on pp. 19–21 of this Quick Guide). Consider attending a workshop at which you can enhance and practice your skills. Get good clinical supervision. There is no substitute for working with an experienced supervisor to help you fine-tune your skills in working with suicidal clients. Good supervision should offer you opportunities to learn more about suicidality, become more aware of your own strengths and limitations in working with people who are suicidal, and practice new skills. Supervision also provides you with the oversight and input necessary to ensure that you are following the highest level of ethical and professional standards of practice. Work collaboratively with clients. It is an unfounded stereotype that most people don’t want to talk about their suicidality. Most, in fact, do want to talk with you; they want to collaborate and cooperate with you to reduce their pain. We almost always get better results by inviting collaboration than by acting independently. sight of what makes you a successful counselor: empathy, good therapeutic skills, and awareness of client resistance. Practice, practice, practice. Nobody does something best the first time around. Get comfortable with asking all clients in substance abuse treatment about suicide. Learn to look for risk factors and warning signs (noted on pp. 19–21 of this Quick Guide). Consider attending a workshop at which you can enhance and practice your skills. Get good clinical supervision. There is no substitute for working with an experienced supervisor to help you fine-tune your skills in working with suicidal clients. Good supervision should offer you opportunities to learn more about suicidality, become more aware of your own strengths and limitations in working with people who are suicidal, and practice new skills. Supervision also provides you with the oversight and input necessary to ensure that you are following the highest level of ethical and professional standards of practice. Work collaboratively with clients. It is an unfounded stereotype that most people don’t want to talk about their suicidality. Most, in fact, do want to talk with you; they want to collaborate and cooperate with you to reduce their pain. We almost always get better results by inviting collaboration than by acting independently.

25. REMEMBER – But Do Not Ignore IS P A T H W A R M signs & Risk & Protective Factors Almost all clients who are suicidal are ambivalent about living or not living. Wishing to both die and live is typical of most individuals who are suicidal. Take suicidal thinking seriously and consider ways to reinforce a client’s sense of hope. Do everything you can to support the side of the client that wants to live, but do not trivialize or ignore signs of wanting to die. 2. Suicidal crises can be overcome. Fortunately, acute suicidality is a transient state. Even individuals at high long-term risk spend more time being nonsuicidal than being suicidal. Moreover, most people who have made serious suicide attempts but then receive acute medical and/or psychiatric care are relieved that they did not die. The challenge is to help clients survive the acute suicidal crisis period until such time as they want to live again. 3. Although suicide cannot be predicted with certainty, suicide risk assessment is valuable. Suicide risk assessment is a valuable clinical tool because it can ensure that those requiring more services get the help that they need. 4. Suicide prevention actions should extend beyond the immediate crisis. Just because someone is no longer at imminent suicide risk does not mean that he or she is “out of the woods.” Clients in substance abuse treatment who have long-term risk factors for suicide (e.g., depression, child sexual abuse history, marital problems, repeated substance abuse relapse) require treatment of these issues whether or not the clients show any indication of current risk for suicide. Individuals with histories of serious suicidal thoughts or suicide attempts but no recent suicidal thoughts or behaviors need to be monitored to identify any recurrence of suicidality. 5. Suicide contracts are not recommended and are never sufficient. Safety contracts or “no suicide contracts” are never sufficient as a deterrent to suicidal behavior. Use this Quick Guide and its accompanying TIP to choose from among the many other strategies that promote safety. Use contracts sparingly, if at all. 6. Some clients will be at risk for suicide even after becoming clean and sober. Abstinence should be a primary goal for any client with a substance use disorder and suicidal thoughts and/or behaviors. Indeed, risk will diminish for most clients when they achieve abstinence. Nonetheless, some individuals remain at risk even after achieving abstinence. Some clients in substance abuse recovery that remain at risk include those with independent depres-are asked. The questions you need to ask are discussed on page 32 of this Quick Guide under the heading “G: Gather Information.” 10. The outcome does not tell the whole story. Most clients who are experiencing suicidal thoughts—and even those who make an attempt—don’t die. Death by suicide is, fortunately, a relatively uncommon event. You cannot assume that because someone does not die, appropriate treatment has been provided. Likewise, despite the best of assessments and precautions, sometimes an individual does die. This does not mean that the individual has received improper treatment.

26. Speaking impact Your ability to communicate effectively will leave a lasting impact on your audience Effectively communicating involves not only delivering a message but also resonating with the experiences, values, and emotions of those listening 

27. IS PATH WARM: • I = Ideation • S = Substance abuse • P = Purposelessness • A = Anxiety • T = Trapped • H = Hopelessness • W = Withdrawal • A = Anger • R = Recklessness • M = Mood changes Some of the IS PATH WARM warning signs are self-evident (e.g., substance abuse); others require brief explanation. “Purposelessness” refers to a lack of a sense of purpose in life or reason for living. “Trapped” refers to perceiving a terrible situation from which there is no escape. “Withdrawal” refers to increasing social isolation. “Anger” refers to rage, uncontrolled anger, or revenge seeking. “Anxiety” is a broad term that refers to severe anxiety, agitation, and/or sleep disturbances. The phrase “mood changes” refers to dramatic shifts in emotions. Warning Signs Warning signs are often in evidence following acute stressful life events. Among people who abuse substances, break-up of a partner relationship is most common. It is also important to look for warning signs in your clients when relapse occurs and during acute intoxication. Stressful life events include: • Break-up of a partner relationship. • Experience of trauma. • Legal event. • Job loss or other major employment setback. • Financial crisis. • Family conflict or disruption. • Relapse. • Intoxication.

28. Risk & Protective Factors Risk Factors Risk factors are defined as indicators of long-term (or ongoing) risk. They differ from direct warning signs, which signal immediate risk. Risk factors for suicidal thoughts and behaviors among individuals with substance use disorders have been well researched. The following list of risk factors, although not exhaustive, is informed by this research: • Prior history of suicide attempts (most potent risk factor, although about half of all deaths by suicide are first-time attempts) • Family history of suicide • Severe substance use or dependence (e.g., use of multiple substances, early onset of dependence) • Co-occurring mental disorder – Depression (including substance-induced depression) – Anxiety disorders (especially PTSD) – Serious mental illness (schizophrenia, bipolar disorder) – Personality disorder (best researched are borderline and antisocial personality disorders) – Anorexia nervosa • History of child abuse (especially sexual abuse) • Stressful life circumstances Risk factors are defined as indicators of long-term (or ongoing) risk. They differ from direct warning signs, which signal immediate risk. Risk factors for suicidal thoughts and behaviors among individuals with substance use disorders have been well researched. The following list of risk factors, although not exhaustive, is informed by this research: • Prior history of suicide attempts (most potent risk factor, although about half of all deaths by suicide are first-time attempts) • Family history of suicide • Severe substance use or dependence (e.g., use of multiple substances, early onset of dependence) • Co-occurring mental disorder – Depression (including substance-induced depression) – Anxiety disorders (especially PTSD) – Serious mental illness (schizophrenia, bipolar disorder) – Personality disorder (best researched are borderline and antisocial personality disorders) – Anorexia nervosa • History of child abuse (especially sexual abuse) • Stressful life circumstances Protective Factors Protective factors are defined as buffers that lower long-term risk. Unlike risk factors, factors that protect against suicidal behavior are not well researched. Reasons for living are perhaps the best researched protective factors in the literature. Protective factors vary with cultural values. For example, in cultures where extended families are closely knit, family support can act as a protective factor. The following are known and likely protective factors: • Reasons for living • Being clean and sober • Attendance at 12-Step support groups • Attendance at a place of worship and/or internalized spiritual teachings against suicide • Presence of a child in the home and/or childrearing responsibilities • Intact marriage • Trusting relationship with a counselor, physician, or other service provider • Employment • Trait optimism (a tendency to look at the positive side of life) A caution about protective factors: If acute suicide warning signs and/or multiple risk factors are in evidence, the presence of protective factors does not change the bottom-line assessment that preventive actions are necessary, nor should the presence of such protective factors give you a false sense of security. Although protective factors may sustain someone showing ongoing signs of risk (e.g., due to chronic depression), they do not immunize clients from suicidal behavior and may afford no protection in acute crises. GATE - $ Steps f The role of substance abuse treatment counselors in addressing clients’ suicidal thoughts and behaviors can be represented by the acronym GATE: Gather information, Access supervision, Take action, Extend the action. Or ID and Response to Suicide KNOW that - MI state Recognize Tarasoff Law

29. In The Nutshell • Know: EBT APPROACHES: • IS PATH WARM • GATE • TARRASOFF LAW • Make sure to understand that QBH abide by all SAMSHA & Zero Suicide recommendations and Advices • In all incipient, maintaining and discharging therapeutic approaches we use short SCSR questioner that is embedded in our data base eg: “Have you ever tried to kill yourself?” If yes, ask: “How? When? Why?” and assess intent: “Did you think [method] would kill you?” “Did you want to die?” (Intent is as important as lethality of method) Ask: “Did you receive medical/psychiatric treatment?” • Any Yes it prompts to the immediate use of Long Columbia Questionary - > IS PATH WARM, GATE, TARRASOFF LAW

30. https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/adult-outpatient/bssa_outpatient_adult_asq_nimh_toolkit.pdfhttps://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/adult-outpatient/bssa_outpatient_adult_asq_nimh_toolkit.pdf

31. https://www.counseling.org/publications/counseling-today-magazine/article-archive/article/legacy/making-it-safe-to-talk-about-suicidal-ideationhttps://www.counseling.org/publications/counseling-today-magazine/article-archive/article/legacy/making-it-safe-to-talk-about-suicidal-ideation • Suicide prevention is both a professional and a personal area of passion for Cureton, who lost her grandfather to suicide when she was in middle school. Cureton co-authored an article with Matthew Fink on suicide protective factors in the July issue of the Journal of Counseling & Development. • Cureton and Fink developed a mnemonic, SHORES, for mental health practitioners to use when identifying and discussing protective factors with clients: • S: Skills and strategies to cope (emotional regulation, adaptive thinking and engaging in interests) • H: Hope (including goals for the future and ways to meet those goals) • O: Objections (moral or cultural objections) • R: Reasons to live and Restricted means (motives for staying alive, such as responsibility to family or children, and reducing access to firearms, poisons, medications and other means of suicide) • E: Engaged care (receiving care and finding a meaningful connection with a counselor, physician or other medical or helping professional) • S: Support (supportive social environments and relationships, including family and caregivers

32. Thank you