Assessment and Care of Adults at Risk for Suicidal Ideation and Behaviour

Recovery

Barker, P. (2001). The Tidal Model: Developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric and Mental Health Nursing, 8, 233-240.

Barker, P. (2002). The Tidal Model: The Healing Potential of Metaphor Within a Patient’s Narrative. Journal of Psychosocial Nursing and Mental Health Services, 40(7) , 42-50.

Barker, P., & Buchanan-Barker, P. (2005). The Tidal Model: A Guide for Mental Health Professionals. New York: Brunner-Routledge. Deegan, P. (1988). Recovery: The lived experience of rehabilitation. Psychiatric Rehabilitation Journal, 11(4), 11-19.

Deegan, P. (1996). Recovery as a journey of the heart. Psychiatric Rehabilitation Journal, 19(3), 91-97.

Deegan, P. (2000). Spirit breaking: When the helping professions hurt. The Humanistic Psychologist, 28(1-3),194-209.

Harding, C., & Zahniser, J. (1994). Empirical correction of 7 myths about schizophrenia with implications for treatment. Acta Psychiatrica Scandinavica, 90(384), 140-146.

Jacobson, N. (2004). In recovery: The making of mental health policy.Nashville, TN: Vanderbilt University Press. Assessment and Care of Adults at Risk for Suicidal Ideation and Behaviour 114-115.

Hope

Byrne, C., Woodside, H., Landeen, J., Kirkpatrick, H., Bernardo, A., & Pawlick, J. (1994). The importance of relationships in fostering hope. Journal of Psychosocial Nursing and Mental Health Services, 32(9), 31-34.

Centre for Suicide Prevention. (2006). Fostering Hope in the Suicidal Client. SEIC Alert # 63, October 2006. [Online]. Available: www.suicideinfo.ca/csp/assets/alert63.pdf

Moore, S. L. (2005). Hope makes a difference. Journal of Psychiatric and Mental Health Nursing 12, 100-105.

Russinova, Z. (1999). Providers’ hope-inspiring competence as a factor optimizing psychiatric rehabilitation outcomes. Journal of Rehabilitation, 65(4), 50-57.

To view Examples of Suicide Risk Assessment Tools click here

The following interventions have been suggested as potentially beneficial to providing supportive care in postvention:

• Information about the manner, timing and circumstances of the death.
• An opportunity to view the body.
• Emotional support at a viewing of the body.
• Information about official procedures and investigations, including an explanation of postmortem and inquest procedures. Written information pertaining to these issues.
• A copy of, or the original suicide note or message shared as appropriate.
• Help and assistance with informing family and others of the death and the circumstances of the death.
• Assistance with interpretation of the postmortem report.
• A package of written information covering: grief and coping strategies for grief; suicide; available resources; a reading list; contact information for local bereavement, and bereaved by suicide, support groups; and, related matters.
• Written information about how to support children bereaved by suicide.
• Advice about responding to media inquiries and requests for information about the death.
• Referral to a general practitioner for information, support, assessment and, perhaps, medication.
• Information about inquests, including the purpose, context and protocols associated with the process, and social and emotional support during the inquest.
• Opportunities to talk about their experience of a suicide death with others who have been bereaved in this way, in the context of a bereaved by suicide support group, if available
• Access to professional individual or group counselling, therapy or psychotherapy as needed, without cost being a barrier.
• Support from religious leaders and clergy.
• Access, in a non-stigmatizing way, to factual information about suicide and mental illnesses with which suicide may be associated.
• Information about how to respond in social environments to questions about the suicide death in their family.
• Information about how to cope with grief and about how others bereaved by suicide have coped during the years following a family suicide.
• Access to information about the impact of suicide on family functioning, how other families have coped after suicide, and strategies for enhancing family communication and functioning after suicide.
• Advice about how, and what to tell children about the suicide death of a close family member, and how to protect them from risk of suicidal behaviour.
• Links with bereavement services.
• Follow-up contact, several times during the first year to reiterate offers of support and assistance, and to provide information.

A safe environment is key for the client evidencing suicidal behaviour and/or ideation in the emergency department or on an inpatient unit. It is challenging to deal with all the safety risks that exist in within a hospital, as well as those brought in by clients and visitors. Staff should scan and/or evaluate the physical (built) environment and focus on what may pose an opportunity for harm. Safety begins with compiling a list of safety features within the inpatient facility. Following this, facilities should consider implementing risk-reduction strategies.

“Creep” factors:

Over time, activities, processes, procedures and even unit improvements can introduce a dangerous item to the client care environment (e.g. changes to the security department or building additions can increase the length of time for security to respond to a Code White). Creep factors also include what the clients, visitors or staff may bring on the units. Polices regarding storage of clients’ belongings and access to nonpatient areas (e.g. staff room, equipment room) may help to address these factors and should be developed with involvement of all staff members (e.g. allied health professionals, housekeeping, patient care aides, security, etc.)

Hanging Risks:

A knotted sheet can serve as a hanging risk when combined with solid core hospital doors on inpatient psychiatric units.
 

The combination of a sheet and solid core door will support the entire body weight off the ground.
 

Plumbing fixtures pose risk but can be enclosed to minimize risk.
 

Grab bars standard for ADA (Americans with Disabilities Act) pose a hanging risk from a sitting position. These can be “plated” to minimize risk.
 

Potential Weapons:

Cabinets can be taken apart to make weapons.
 

Heavy panels such as those from heating devices can be used to break windows or as a weapons against staff.
 

Some beds have removable headboards, which can be used as weapon against staff.
 

Even safety devices can pose a safety risk. Check all items, even those believed to be safe. In this example, safety hooks can cause a puncture wound.
 

Common linen hamper can be broken down into several potential weapons.
 

Crush Risks:

Although manual beds have the advantage of not requiring cords, they may also present a crush risk.
 

Be certain handles have been placed in a manner to minimize patient use to cause injury via crush points.
 

Bed frames should be check to assure safety stops are in place to minimize crush risk to patients.
 

Barricades:

Bed is anchored and locked to the floor to prevent barricade situation. This is thought to be a safety feature.
 

The same bed as in image on left hand side, combined with a nightstand and chair in the room can be used to create a barricade situation.
 

Other Considerations:

• Use plastic silverware and paper plates
• Ensure art work is securely attached to walls and not framed with glass (or use safety glass)
• Watch for tools or equipment left unattended (e.g. stethoscopes, brooms, etc.)
• Identify what the response time is for security to respond to psychiatric emergencies in the emergency department or psychiatry. Timed drills may be helpful.
• Safety rounds should be done regularly, at least weekly. Include “fresh” eyes (e.g. new staff or non-unit staff) when able.

Source: Yeager et al. (2005). Figures published with permission

A. Identify Problem

1. Ask the client to describe what is happening. Who are the other people involved?
2. Help the client break down the problem to focus on the immediate issue (priority).
3. What are the triggers and patterns of possible self-destructive acts?
4. Assist the client to self-monitor through the use of diaries to recall and detail relationships, moods, triggers, and patterns of self-harm behaviour.

B. Explore Past Attempts to Address Issue

1. Help the client identify what has worked in the past.
2. Help the client identify supports/resources/personal strengths.

C. Explore Alternatives/Challenges to Determine Solutions

1. Identify small steps that will provide change and some control.
2. Examine the role of medications to reduce anxiety (APA, 2003).
3. Explore safe alternatives, such as breathing and relaxation (Frazier et al., 2003).

D. Choose Solutions

1. Focus on helping the client identify small steps, coping strategies, stress reduction, problem-solving and self-examination of results.

E. Implement Process

1. Identify when patient will “stop and think” and use collaboratively agreed upon action.
2. Journaling successes, emotions, and learning is helpful (Fontaine, 2003).
3. Provide time limited therapeutic sessions to assist the client in resolving current interpersonal problems (Gaynes, West, Ford, Frame, Klein & Lohr, 2004).

F. Evaluate Outcomes

1. Promote realistic self-appraisal through discussing with the client their abilities and limitations.  Help the client reflect outcomes of purposeful tasks.
2. Encourage – point out small successes and reinforce the client’s ability to appraise themselves (Fontaine, 2003).

A general question about the person’s thoughts and feelings about living is frequently a recommended start to this discussion:

• Sometimes people feel that life is not worth living. Can you tell me how you feel about your own life?
• What are some of the aspects of your life that make it worth living?
• What are some of the aspects of your life that may make you feel or think that your life is not worth living?
• Do you find yourself wishing for a permanent escape from life?
• How would that happen for you? What might you do to achieve that?

It is important to continue with additional questions that are actually about self-harm, suicide and death.

• Do you think about your own death or about dying?
• Have you ever thought of harming yourself or trying to take your own life?
• Do you think or feel this way presently?

If the person expresses thoughts of self-harm, and /or suicide, or even if he/ she seems ambivalent (e.g. says “I don’t know,” or “I don’t remember” or “maybe, I am not sure” or “sometimes, but not right this moment”), continue with these questions:

• When did you begin to experience these thoughts and feelings?
• What happened before you had them?
• Were there events in your life that preceded this such as a sudden loss or feelings of depression?
• How frequently have you had these thoughts and feelings?
• Do these thoughts intrude into your thinking and activities?
• How strong are they?
• Can you describe them?
• Can you stop yourself from having them by distracting yourself with an activity or other more positive thoughts?
• Have you ever acted upon these thoughts?
• Do your thoughts command you to act upon them?
• If you have not acted upon them, how close do you feel you came to acting?
• What stopped you from acting on them?
• Have you ever started to act on your self-harm or suicidal thoughts, yet stopped before actually doing it? For example, did you hold a bottle of pills in your hand to take them all but stopped, or go out on a ledge to jump but then stopped?
• Do you think you might act on these thoughts of self-harm or suicide in the future?
• What might help you from acting on them?
• If you did take your own life, what do you imagine would happen after you die to those people who are important to you?
• Do you have a plan to harm yourself or take your own life? If so, describe your plan.
• Do you have those methods available to you to take your life, such as over the counter pills, prescription pills, knives or proximity to a balcony, bridge or subway?
• Have you prepared for your death by writing a note, making a will, practicing the plan, putting your affairs such as your finances in order, or ensuring privacy such that you would unlikely be discovered?
• Have you told anyone that you are thinking about taking your life or are planning to do this?

If a person has attempted suicide or engaged in self-harm behaviour(s), ask additional questions to assess circumstances surrounding the event(s).

• What happened in your previous attempts to self-harm or take your life? What led up to it? Were you using alcohol or other substances? What method did you use? Sometimes people have many reasons for harming themselves in addition to wanting to die. What might have been some of your reasons for selfharm or suicide? How severe were your injuries?
• What were your thoughts just before you harmed yourself?
• What did you anticipate would be the outcome of your self-harm or suicide attempt? Did you think you would die? What did you think would be the response of others to your self-harm or suicide?
• Were other people present when you did this?
• How did you get help afterward? Did you look for it by yourself or did someone else help you?
• Did you anticipate that you might be discovered? If not, were you found accidentally?
• How did you feel after your attempt? Did you feel relief or regret at being alive?
• Did you receive treatment after your attempt? Did you get medical and/ or psychiatric, emergency help?  Were you assessed in an emergency department? Were you cared for in an inpatient/outpatient department?
• How do you think and feel about your life now? Have things changed for you? Do you see your life in the same way or differently?
• Are there other times in the past when you’ve tried to harm (or kill) yourself? (If so you can re-ask many of these same questions to assess for similar or varying circumstances and presentations).

For individuals with repeated suicidal thoughts or attempts.

• How many times have you tried to harm yourself, or tried to take your life?
• When was the most recent time?
• What were your thoughts and feelings at the time that you were most serious about suicide?
• When was your most serious attempt at harming or taking your life?
• What happened just before you did this, and what happened after?

Assess reasons for living or protective factors for this person.

• How do you feel about your own future?
• What would help you to feel or think more positively, optimistically or hopefully about your future?
• What would make it more (or less) likely that you would try to take your own life?
• What happens in your life to make you wish to die or to escape from life?
• What happens in your life to help you to want to live?
• If you began to have thoughts of harming or killing yourself again, what would you do to prevent them?

For individuals with psychosis, ask specifically about hallucinations and delusions.

• Can you describe the voices you hear?
• Can you tell if they are male or female?
• Can you stop the voices?
• How many different voices do you hear?
• Do you hear these voices from within your own mind, or do they seem to come from somewhere outside of you?
• Do you know who these voices are? Do you recognize them?
• What do the voices say to you? Do they say anything positive, or do they say negative or hurtful things to you? Do they threaten you or anyone else?
• How do you cope with the voices? Do you do anything about them?
• Do they command you to do anything? If so what kinds of things do they ask you to do?
• Have you ever done what the voices ask you to do? What led you to obey the voices? If you tried to resist them, what made it hard to do?
• Have there been times when the voices told you to hurt or kill yourself? How frequently has this happened? What happened?

Consider assessing the patient’s potential to harm others in addition to him/ herself.

• Are you having any thoughts of harming other people?
• Are there other people you would want to die with you?
• Are there others who you think would be unable to go on without you?