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A Little About Me

EMS Provider for 30 years
Paramedic for 10 years
PA for 26 years
Full-time PA educator
Part-time EMS Educator
Mobile Surgical Services PA
Paramedic in Suburban and Rural areas of NY state
Doctoral student in Curriculum, Instruction, and the Science of Learning

I LOVE Learning!

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Introduction

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Instructional Objectives

At the end of this presentation, the learner will be able to:

Define the aspects of suicide prevention including risk factors
Discuss the dangers of depression in conjunction with drugs and alcohol
Discuss some basic guidelines for interacting with a person who is potentially violent
Review the debriefing process following a completed suicide

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Some Data

44,000 + people die by suicide yearly
123 people die by suicide every day
Over 1.3 million people attempt suicide each year
Suicide is the 10th leading cause of death for all age groups
Suicide is the 2nd leading cause of death for ages 10-24
Someone dies by suicide every 13 minutes
Men die by suicide 3.53x more often than females
Average number of attempts, across the lifespan is 25 per one death by suicide

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More Data

Youth: 100-200 attempts per one death by suicide
Older people: 4 attempts per one death by suicide
10 million adults think about suicide each year
1.2 million plan a method
Recent research (Cerel, 2015) suggests that for each death by suicide 115 people are exposed

Among those 25 experience a major life disruption (loss survivors)

Over 1 million loss survivors each year
Suicide risk is greater in survivors (e.g., 4-fold increase in children when a parent dies by suicide)
Risk is highest in middle aged adults

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Bias? Who’s Biased?

Beliefs of what is right and wrong
Attitudes towards situations and groups
Ideas of why people do what they do
Past stories that provide insight
Past stories marked by pain, sadness and anger

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Bias? Who’s Biased?

Our beliefs, attitudes and past stories at some point will get activated/ triggered by crisis situations.
Patient doing things we hold to be deeply wrong.
Patients belonging to a group with whom we have had negative encounters.
Patients who remind us of people who have hurt us.

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Terminology

TERMS THAT PROMOTE STIGMA

Committed suicide
Failed attempt
Para suicide
Suicide victim
Suicide gesture
Manipulative act
Suicide threat
Successful suicide

PREFERRED TERMINOLOGY

Died by suicide
Suicidal
Self-directed violence
Interrupted suicide attempt
Aborted suicide attempt
Suicide attempt
Non-suicidal self-directed violence

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Response to the crisis situation

Under-response to the crisis situation
Minimization of the situation
Withdrawal
Apathy
“They’re just doing this for attention.”

Over-responsive to the crisis situation
Taking an adversarial approach
Taking a controlling approach
Acting out of anger or fear

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Risk Factors

Demographics: male, widowed, divorced, single, white
Psychosocial: lack of social support, unemployed, drop in socio economic status, firearm access, family history, history of abuse/trauma, recent discharge from psychiatric unit, feeling like a burden, contagion
Psychiatric: psychiatric DX, comorbidity especially with A&D
Physical Illness: chronic pain, debilitating illness

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More Risk Factors

Psychological: hopelessness, psychic pain/anxiety, psychological turmoil, decreased self-esteem, fragile narcissism, perfectionism
Behavioral: Impulsive, aggression, severe anxiety/panic attacks, agitation, intoxication, prior suicide attempt
Cognitive: thought constriction, irrational thinking, all/nothing thinking
Childhood trauma: sexual, physical abuse, neglect, loss of parent, lack of stability

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Suicide Risk in Specific Disorders

A.P.A GUIDELINES PART A PG. 16

Condition	% Lifetime Risk
Prior Suicide Attempts	27.5%
Bipolar Disorder	15.5%
Major Depression	14.6%
Mixed Drug Abuse	14.7%
Dysthymia	8.6%
Obsessive-Compulsive	8.2%
Panic Disorder	7.2%
Schizophrenia	6.0%
Personality Disorder	5.1%
Alcohol Abuse	4.2%
General Population	0.72%

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Warning Indicators

Behavioral
Talking about suicide	Sense of hopelessness
Making a suicide plan	Feeling trapped (like there is no way out)
Self harming behavior	Withdrawing from friends and family
Prior suicide attempt/s	Ceasing activities that used to be important
Finalizing affairs, e.g. making a will	Giving away valued possessions
Unexplained crying	Increased alcohol and/or drug use
Uncharacteristic or impaired judgment or behavior, e.g. risk taking

Physical
Withdrawal from friends, family or society
Ceasing activities that used to be important
Giving away valued possessions
Increased alcohol and/or drug use
Uncharacteristic or impaired judgment or behavior, e.g. risk taking

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Protective Factors

Individual/Personal Level
Gender	Positive sense of self
Good mental health and wellbeing	Sense of control over life’s circumstances
Good physical health	Sense of meaning and purpose in life
Absence of alcohol and other drug use	Good coping skills
Positive outlook and attitude of life

Social Level
Physical and emotional security
Family harmony
Supportive and caring family
Supportive social relationships
Sense of self-determination
Good communication skills
No family history of suicide or mental illness

Life Environment
Safe and secure living environment
Financial security
Employment
Safe and affordable housing

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De-escalation

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Safety First

Do not conduct an interview in a room with weapons present. If the person is armed, you may wish to ask the person why he or she feels a need to carry a weapon. The person’s response to this question may help the responder to formulate a way to request the weapon be put aside with which the person may be willing to cooperate.
Do not interview potentially violent people in cramped rooms, especially if they are agitated and need to pace. Kitchen, bedrooms, and bathrooms are usually poor intervention sites due to the potential presence of items that may be used as weapons.
Be aware of exit routes for yourself and for the person in crisis. A paranoid or agitated person must not feel that they are trapped, and a crisis service provider must have an avenue of escape if the person does become violent.

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Safety First

Pay attention to the person’s speech and behavior. Clues to impending violence include:

speech that is loud, threatening or profane;
increased muscle tension, such as sitting on the edge of the chair or gripping the arms;
hyperactivity (pacing, etc.);
slamming doors, knocking over furniture or other property destruction.

Use person’s emergency contacts as necessary.

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Assessing Risk of Harm to Others

The level of stress and number of concurrent stressors.
The intensity and duration of homicidal or assaultive ideation.
The normal ability to cope with life’s ups and downs — coping skills and mechanisms.
The person’s physical health.
Any history of mental illness, especially command hallucinations?
Does the person wish to control him or herself? And if so can she or he?
Is the person overly controlled?
Does the person have a brain injury or other cognitive impairment that makes control difficult?
The level of external support or external constraints available to the individual.
Collateral information from family, friends, and medical records is very important in intervening appropriately with potentially violent individuals.
Your own intuition or “gut sense” of the seriousness of this particular person’s presentation is a very valuable tool in assessing risk.

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Body Language-Sitting

Show concern for the person. Be respectful and offer some choices, even if they are small. (Where to sit, whether to have a snack or beverage).
Attempt to speak with the person at eye level.
Sit in a manner with feet solidly on the floor with heels and toes touching the floor; hands unfolded in your lap and your body leaning slightly forward toward the person. This position gives the person the feeling that you are attentive to what he or she is saying and it permits you to respond immediately if threatened.

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Body Language-Standing

Stand in a manner with feet placed shoulder width apart; one foot slightly behind the other; weight on the rear leg, knees slightly bent; hands folded, but not interlocked, on the upper abdomen or lower chest; arms unfolded. This stance allows instant response to physical threat. Do not place hands in pockets. This slows response and may add to paranoia of the person. Folded arms also slow response and can be interpreted as threatening. Maintaining weight on rear leg with knees slightly bent also allows quick movement and response to any threat. Practice this stance to become comfortable in it before using it in a crisis situation. If the stance is unfamiliar to you, your discomfort will only add to the stress of the situation. TAKE EVERY THREAT SERIOUSLY, CONSULT OTHERS AS NEEDED. DO NOT STAY IN A DANGEROUS SITUATION.

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Verbal Interaction

Develop some rapport with the person before asking questions about history or intent of violence.
Assure the person that you will do what you can to help them stay in control of violent impulses. Set firm limits but do not threaten or display anger.
If a person is experiencing paranoia, it is best to conduct the intervention as if the person and the intervener are facing the problem together. A crisis situation is not the time to tell the person that he or she is experiencing delusional thinking.
Give the person adequate physical space.
Develop a strategy. Help the person make a decision on a specific, short-term plan. You won’t resolve all the problems; stick to one issue that is doable.

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Do’s and Don’ts in S�Suicide Prevention

DO’S	DON’TS
Remove opportunities Receive and accept suicidal communication Do intrude Prevent isolation and involve significant others Transfer rather than refer Always obtain consultation when unsure Do know your own value system about suicide Get precipitant (identify issues, concerns, and/or events that led up to the current crisis)	Do not worry about saying the wrong thing Do not consider suicidal persons as special Do not assume ability to solve problem(s) Do not try to talk the person out of committing suicide Do not engage in abstract discussion about suicide, death, dying Do not be too accepting of suicide Do not de-legitimatize Do not give cheap general reassurance

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A Safety Plan

Warning signs, ask, “How will you know when this safety plan should be used?” and “what do you experience when you start to think about suicide?
Coping strategies, ask, ” What can you do if you become suicidal again?” Use collaboration, and problem solving to help them self define coping strategies.
Social Contacts, Who May Distract From the Crisis, work with the patient to help him/her understand that if step 2 doesn’t work then try step 3, ask, “Who or what social setting help you take your mind off your problems? "Who helps you feel better when you are with them?”, Help them identify potential safe places they can go to be around people,(peer support center, coffee shop). Ask the patient to identify one or more additional safe places of people incase option one isn’t available. The goal of this step is to distract the client from suicidal thoughts.

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