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SuicidePreventionWebinarSeanConvoy,DNP,PMHNP-BC

CDR,USN,Retired

PresentationDisclaimer

•TheviewsexpressedinthispresentationarethoseoftheauthoranddonotreflecttheofficialpolicyorpositionoftheDepartmentofDefense,DepartmentoftheNavy, ortheUnitedStatesGovernment.• Ihavenoconflictsofinteresttoreport.

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LearningObjectives

• Thistrainingwillintroducestrategiesabouthowtoassess,communicatewithandengageatriskmilitaryservicemembers,veteransandfamilymemberswhoarepotentiallyatriskforharmtoselforothers.• Explorehowtoassessforrisktoself-harmandothersamongmilitaryservicemembersandveterans.

• Discussstrategiesfordeescalatingatriskmilitaryservicemembersandveterans.

• Identifyanticipatorytactics,techniquesandproceduresthatcanbeusedtostreamlinecrisisinterventionwork.

• Developastandardizedapproachabouthowtodiscussgunandweaponownershipwithatriskmilitaryservicemembersandveterans.

Wheremymotivationcomesfrom…

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Perspective…

• Everythingwedo(anddon’tdo)matters.

SuicidePreventionAnalogoustotheRedZone…

• Suicideisthedistalprojectionoftheproblem• Unidentified,untreatedorundertreatedmentalillnessistheproximaletiologyoftheproblem• Mentalhealthcaredeliverysystemcommonlyhyperfocusonthedistalprojection.• Publichealthsectorcommonlyhyperfocusontheproximaletiology.• Today’spresentationisaboutthe“redzone”ofsuicidebutpleasedon’tforgetabouttheother98yards!

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Johari’sWindow

Known Thingsthatweknowthatweknow

Thingsthatweknowthatwedon’tknow

Unknown Thingsthatweknowthatwedon’tactuallyknow

Thingsthatwedon’tknowThatwedon’tknow

Knowns Unknowns

Jody’sCase

• 28yearoldveteranwithunreportedMSThistorywhois9monthspostservicerelease(noVA/DoDfiling)withdualdiagnosishistory(PTSDandAUD)presentlyadversetoDoD/Veterancare(allegedassaulteraffiliatedwithmilitarymedicine).• Traumasymptomsareprofoundlyfunctionallyimpairingmakingschool,workandintimaterelationshipsinconceivable.

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ViewingJody’sCaseThroughJohari’sWindow

Known

• PopulationRiskFactors• SubjectiveHistory• MentalStatusExamination• SafetyAssessment

• IntentionalWithholdingofRelevantClinicalData

• IncidentalWithholdingofRelevantClinicalData

Unknown • ClinicalDeficiencies/Myopias• CounterTransference • Literally EverythingElse

Knowns Unknowns

ViewingJody’sCaseThroughJohari’sWindow

Known

• PopulationRiskFactors• SubjectiveHistory• MentalStatusExamination• SafetyAssessment

• IntentionalWithholdingofRelevantClinicalData

• IncidentalWithholdingofRelevantClinicalData

Unknown • ClinicalDeficiencies/Myopias• CounterTransference • Literally EverythingElse

Knowns Unknowns

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ViewingJody’sCaseThroughJohari’sWindow

Known

• PopulationRiskFactors• SubjectiveHistory• MentalStatusExamination• SafetyAssessment

• IntentionalWithholdingofRelevantClinicalData

• IncidentalWithholdingofRelevantClinicalData

Unknown • ClinicalDeficiencies/Myopias• CounterTransference

• Literally EverythingElse

Knowns Unknowns

ViewingJody’sCaseThroughJohari’sWindow

Known

• PopulationRiskFactors• SubjectiveHistory• MentalStatusExamination• SafetyAssessment

• IntentionalWithholdingofRelevantClinicalData

• IncidentalWithholdingofRelevantClinicalData

Unknown • ClinicalDeficiencies/Myopias• CounterTransference • Literally EverythingElse

Knowns Unknowns

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Jody’sCase

Known

• PopulationRiskFactors• SubjectiveHistory• MentalStatusExamination• SafetyAssessment

• IntentionalWithholdingofRelevantClinicalData

• IncidentalWithholdingofRelevantClinicalData

Unknown • ClinicalDeficiencies/Myopias• CounterTransference • Literally EverythingElse

Knowns Unknowns

Risk AssessmentPopulationScreening

• Patientpopulationidentification• Developinggranularknowledgeofhighvolumepopulation• FeederService/Commands• MilitaryOccupationalSpecialties• CriticalService/CommandHistory

• ReachingouttoareaMilitaryTreatmentandVeteransAffairsFacilitiesforpopulationhealthdata

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Risk AssessmentSiloEffect

• Lackofinformationflowingbetweengroupsorpartsofasystem• Reinforcedbyequaldosesofprivacyconcernsandstigma• Canoccuratmanydifferentlevels

Risk AssessmentPatientScreening

• Milieumessaging• Familyfriendlymessaging• Patienthealthhistory• Twofactorscreening• Serialassessment• Risk&protectivefactors• HIPPAcompliantpatientportals• Ancillarystaffutilization• Establishedcrisisinterventionplan

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Risk AssessmentScreeningInstruments• OutcomeQuestionnaire45.2(OQ®-45.2)https://www.oqmeasures.com/measures/adult-measures/oq-45/

• SuicideAssessmentFive-stepEvaluationandTriage(SAFE-T)https://store.samhsa.gov/product/Suicide-Assessment-Five-Step-Evaluation-and-Triage-SAFE-T-/SMA09-4432

• AskSuicideScreeningQuestions(ASQ)https://www.nimh.nih.gov/news/science-news/2013/file_143902.pdf

• Columbia– SuicideSeverityRatingScale(C-SSRS)http://www.cssrs.columbia.edu/documents/C-SSRSClinicalPracticeScreeners.docx

Risk AssessmentBottomLineUpFront(BLUF)

• Reticencetoaskthequestion(s)isunintentionallystigmatizing• Distinguishingsuicidalityasasymptomtotreat,ratherthanastateofbeing• Reframingsuicidalityinnonabsoluteterms• Clinicallyactingonintent,ratherthanpresence

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De-escalation StrategiesSuicideContracts

De-escalation StrategiesKayR.Jamison’sLocusofControl

• Suicideastheultimatemanifestationofcontrol• Resistingtheurgetotakecontrolfromthepatient• Alternativelyshiftingtherisktotherightand“reshufflingthedeck.”• Employingastrategytorealigneffortsinpursuitoflivingratherthandying

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De-escalation Strategies

•CognitiveRestructuring• EmotionalRegulation•CollaborativeAssessmentandManagementofSuicide(CAMS)• SafetyPlanning

WarriorEthos

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Mental Illness StigmaSussman’s MentalIllnessStigmaQuiz1. There’snorealdifferencebetweentheterms“mentallyill”and“hasamentalillness.”2. Peoplewithmentalillnesstendtobedangerousandunpredictable.3. Iwouldworryaboutmysonordaughtermarryingsomeonewithamentalillness.4. I’vemadefunofpeoplewithmentalillnessinthepast5. Idon’tknowifIcouldtrustaco-workerwhohasamentalillness.6. I’mscaredoforstayawayfrompeoplewhoappeartohaveamentalillness.7. Peoplewithamentalillnessarelazyorweakandneedtojust“getoverit.”8. Oncesomeonehasamentalillness,theywillneverrecover.9. Iwouldhesitatetohiresomeonewithahistoryofmentalillness.10. I’veusedtermslike“crazy,”“psycho,”“nutjob,”or“retarded”inreferencetosomeone

withamentalillness.

http://davidsusman.com/2015/04/30/5-simple-steps-to-reduce-stigma-about-mental-illness/

Risk Assessment VignetteJody’sAssessment

• Purposefuluseofpatientcenteredspace• Onlinepatienthealthhistorygaveinsightintosymptomspriortopatient’sevaluation• Ancillarystaffscreening(byalgorithm)sensitizedprovidertopresentfocusedriskspriortoevaluation• Jodywasactivelysuicidalwithintent,meansandplan.

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Risk AssessmentGun&WeaponSafety

Risk AssessmentGun&WeaponSafety

ThatWhichWeCanPotentiallyControl• Thoroughnessofassessment• Abilitytoaskdifficultquestions• Understandingourroles,responsibilitiesandlimitations• Collaborativelymanagingrisk• Documentation• Stayinguptodatewithlaw

ThatWhichWeCantNecessarilyControl• State&federalgunlaws• Thepatient

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ClinicalPearls

• Rememberthepatient’sremotecontrolandmutebutton• Johari’sWindowcanhelpyougrowthegreenofyourknownknowns• Acommunityhealthassessmentrepresentsaninvestmentintoyourpatient’shealthandwellbeingaswellasyourqualityoflife• Betterutilizingancillarystaffimprovesoutcomesandsavestime• Whenitcomestosuicidecontracts,justsayno• Resisttheurgetotrytocontrolsuicide,rathershifttherisktotheright

De-escalation StrategiesWarriorEthos

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References

• AmericanPsychiatricAssociation(2014)."PositionStatementonFirearmAccess,ActsofViolenceandtheRelationshiptoMentalIllnessandMentalHealthServices."

• Bartlett,M.(2006).TheEfficacyofNo-SuicideContractswithClientsinCounselingonanOutpatientBasis.DoctoralDissertation.A.University.AuburnUniversity.

• Beach,E.K.(1982)."Johari'sWindowasaframeworkforneedsassessment."JContin Educ Nurs13(3):28-32.

• Benner,P.E.(1984).Fromnovicetoexpert:excellenceandpowerinclinicalnursingpractice.MenloPark,Calif.,Addison-WesleyPub.Co.,NursingDivision.

• ConsortiumforRisk-BasedFirearmPolicy(2013)."Guns,PublicHealth,andMentalIllness:AnEvidenceBasedApproachforStatePolicy."

• deVries,P.,etal.(2008)."[Theno-suicidecontract:ariskyritual]."Tijdschr Psychiatr 50(10):667-671.

References

• Gold,L.H.(2013)."Gunviolence:psychiatry,riskassessment,andsocialpolicy."JAmAcadPsychiatryLaw 41(3):337-343.

• Jamison,K.R.(1995).Anunquietmind.NewYork,A.A.Knopf.

• Jamison,K.R.(1999).Nightfallsfast:understandingsuicide.NewYork,Knopf.• Lee,J.B.andM.L.Bartlett(2005)."Suicideprevention:criticalelementsformanagingsuicidalclientsandcounselorliabilitywithouttheuseofano-suicidecontract."DeathStud 29(9):847-865.

• Meade,B.J.,etal.(2013)."MissionCritical:GettingVetswithPTSDBacktoWork."News&Perspectives.fromhttp://www.medscape.com/viewarticle/781380_3.

• Melamed,Y.,etal.(2011)."Assessingtheriskofviolentbehaviorbeforeissuingalicensetocarryahandgun."JAmAcad PsychiatryLaw 39(4):543-548.

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References

• Pirelli,G.,etal.(2015)."PsychologicalEvaluationsforFirearmOwnership:LegalFoundations,PracticeConsiderations,andaConceptualFramework."ProfessionalPsychology:ResearchandPractice.

• Robert,C.andD.Camus(2006)."[A"non-suicidecontract"undertheguiseofprevention]."Krankenpfl Soins Infirm 99(9):46-49.

• Simon,R.I.(1999)."Thesuicidepreventioncontract:clinical,legal,andriskmanagementissues."JAmAcad PsychiatryLaw 27(3):445-450.

• Slovak,K.,etal.(2008)."Clientfirearmassessmentandsafetycounseling:theroleofsocialworkers."Soc Work 53(4):358-366.

• Sutherland,J.A.(1995)."TheJohariWindow:astrategyforteachingtherapeuticconfrontation."NurseEduc 20(3):22-24.

• Verklan,M.T.(2007)."Johariwindow:amodelforcommunicatingtoeachother."JPerinatNeonatalNurs 21(2):173-174.

• Weiss,A.(2001)."Theno-suicidecontract:possibilitiesandpitfalls."AmJPsychother 55(3):414-419.