Suicide Risk Assessment in HIV and Management Strategies

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Suicide Risk Assessment in HIVand Management
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Dispel some of the myths about suicide Understand
some of the reasons for suicide Know the
classifications of suicide methods Conduct a
suicide risk assessment Referral
indications Counselling issues Management
strategies
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Group Activity
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Common Myths Myth 1
People who think or plan to commit suicide keep
their thoughts to themselves and the suicide
occurs without warning
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Common Myths Myth 2
Those who talk about suicide wont do it
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Common Myths Myth 3
People who talk about suicide are just attention
seeking
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Common Myths Myth 4
Suicidal people are intent on dying
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Common Myths Myth 5
Talking openly about suicide may cause a suicidal
person to end their life
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Common Myths Myth 6
All suicidal people are crazy. Its the act of a
mentally ill or psychotic person
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Definitions
Suicide is the act of killing oneself Para
suicide is the suicide attempt Suicide ideation
is the thought of killing oneself All suicide
threats should be taken very seriously Frequently
people who think of suicide will share that
feeling with someone and are often amenable to
intervention
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Suicide Risk in HIV
Two periods when people are more likely to
attempt suicide After initial diagnosis
impulsive response to emotional turmoil
Late in the disease when central nervous
system complications develop, capacity to earn
income declines and people feel they are a
burden
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Other Factors Contributing to Suicide Risk
Pre-existing mood disorder - (eg. depression,
anxiety or mania) Current psychiatric disorder
-(eg. schizophrenia, bipolar disorder) Presence
of other psychiatric stressors -(eg.
relationship breakdown) Substance use or
withdrawal Inadequate pre-and post-HIV test
counselling Inadequate support network Discomfort
with sexuality and/or gender
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Classification of Suicide Methods
Violent methods eg. hanging, shooting, burning,
planned accidents Non-violent eg. drug overdose,
poisoning, exhaust fumes, suffocation Passive
methods i.e. refusing to accept treatment. May be
an informed decision by the client, but also may
reflect underlying masked mood, inappropriate
guilt or a response to poor palliative care.
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Suicidal Risk Assessment
Good assessment interview can often be enough to
change suicidal thoughts If client presents with
a relative, counsellor should first see the
client alone so they can speak frankly If a para
suicide client, then counsellor must first clear
them medically i.e. check if they have already
taken anything poisonous
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Hopelessness
Suicide ideation is closely related to feelings
of hopelessness Determine clients thoughts about
the future and their beliefs about current
circumstances Adopt structured problem solving
method Check for symptoms of clinical
depression Refer to specialist if necessary
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Activity Role-play
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Suicidal Risk Assessment Guidelines
Guidelines on how to interview a person at
risk Need to add and expand on questions during
the interview Do you sometimes feel so bad you
think about suicide? How often?
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Suicidal Risk Assessment Guidelines (continued)
Do you have a plan? (lethality of plan) Do you
have the means? Have you decided when you would
do it? Have you ever tried suicide before?
(impulsive / planned / used a booster) If you
tried suicide before, what difference, if any,
did it make?
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Suicidal Risk Assessment Guidelines (continued)
Check for symptoms of clinical depression
Neuro-vegetative symptoms sleep appetite
tiredness/lack of energy agitation/slowing
down sex Mood and motivation prolonged
unhappiness loss of interest or pleasure
hopelessness helplessness difficulties
performing at work difficulties carrying out
routine activities withdrawal from friends
check for somatisation
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Exploring the Problem
Why do you think of suicide now? What are you
doing about it? How did you deal with problems in
the past? (ask for examples) What can be the
possible reasons why it does not work now? What
makes your problem better or worse? Who would you
like to know/not know about your problem?
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What do you Need to Stay Alive?
What changes would help you stay alive? What do
you have to do to make this change/s
possible? What barriers to change exist? What can
facilitate the process of change? Whose help
would you need? What can possibly happen to make
you change your mind? What if it happens?
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Problem Solving Plan
Define the problem Brainstorm the options Analyse
the options Choose one option divide it into
steps to follow
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Assessing Risk Level
Use detailed suicide risk assessment
matrix Essential for determining the next steps a
counsellor should take Counsellor completes it
either while the client is present or whilst the
client writes the records
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Low Risk
Only one attempt. Less lethal means used Express
some feelings of hope Well-developed coping
responses to previous crises Gives a valid reason
for not wanting to repeat the experience Single
attempt made impulsively
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Low Risk
Someone else was informed immediately Client
indicates mixed feelings about suicide and can
provide a good reason why they may not commit
suicide Client may express they currently feel a
burden but feels suicide would place a greater
burden on others
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High Risk
Current suicidal thoughts Feels hopeless Use of
maladaptive coping strategies Multiple attempts
in the past and lethal means used Attempt made
when others not present Client says they will try
again
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High Risk
Client says they wont try again but cant give a
good reason for what is now different Declining
health and limited treatment options Client feels
a burden
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Referral Indications
Most dangerous sign is little emotion feeling
dead Client is frank about their intentions but
may deny in order to be released from the VCT
centre Most cases have a history of child
abuse Referral to psychotherapist, clinical
psychologist, psychiatrist if available Referral
to specific helping / support agencies
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Activity
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Next Steps for Management of Suicidal Clients
Depends whether client is at pre-or post-attempt
stage Always assess risk in both stages
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Pre-attempt Stage Next Steps for High Risk
Determine severity of the problem and check for
need to hospitalise Negotiate for voluntary
hospitalisation or refer to doctor Do not leave
client alone Family and friends may be able to
provide suitable supervision
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Pre-attempt Stage Next Steps for Lower Risk
Ensure client has immediate 24 hour access to
suitable clinical care Remove all means of
commiting suicide Encourage client to do
this. Ask family or a friend to
supervise Suicide contract where client
promises not to attempt suicide within an
arranged (short) period of time Provide
options for client to use at times when they
are on the verge of attempting suicide
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Pre-attempt Stage Next Steps for Lower Risk
(cont'd)
Restore hope Environmental intervention
Encourage clients active participation in the
situation Encourage a supportive network
Refer to services as appropriate Help the
client resolve conflicts with others Always
conduct a follow up assessment
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Individuals Who Refuse to Talk
May be afraid they will be prevented from
commiting suicide Client is correct to
believe this May doubt confidentiality of the
session May be overridden to some extent in
situations where the counsellor believes them
to be acutely suicidal May be embarrassed or
ashamed and afraid of being labelled mentally
ill Reassure them and be non-judgemental
If they wont talk openly, provide them with
contact details of someone they can talk to if
they change their mind
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Repeated Suicide Attempts
May be lonely and isolated May be trying to get
attention May be manipulative May lack coping
techniques Regardless, all suicide attempts need
to be taken seriously
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Personality Disorders Frequent Suicide Attempts
May be times when certain behaviours or crises
needs to take precedence over a defined
management plan Such behaviours by hierarchy
are Suicide threats, attempts and other
life-threatening behaviours Behaviours that
interfere with the process of treatment
Behaviours that seriously interfere with the
clients quality of life
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Suicidal Threats, Gestures or Attempts
Rate of suicide completion for individuals with
this personality type is substantial First target
of management should be high risk suicidal
behaviours Once safety is assured, goal of any
intervention should be replacement of suicidal
behaviours with more adaptive ways of problem
solving Studies suggest problem solving is
effective for decreasing further suicidal
behaviours in individuals who repeatedly attempt
suicide
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Advantages of Targeting Suicidal Behaviour as a
Priority for Management
Reduces likelihood of future suicidal
behaviour It communicates that the counsellor
takes suicidal behaviour very seriously Individual
s learn that if they engage in such behaviour
they will spend time with the counsellor
focussing on this behaviour rather than other
topics Suicide completion in such individuals
becomes less likely as they get older
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Medical Complications
After an unsuccessful attempt, clients physical
health will need to be monitored by a doctor Some
seemingly less harmful methods may cause
serious complications (e.g. possible liver
failure following overdose on paracetamol)
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Alcohol Consumption
Many who attempt suicide have drinking
problems Client may be reluctant to admit a
problem The CAGE questionnaire by Mayfield to
identify a large proportion of individuals who
have an alcohol problem Research conducted
correctly identified 81 of problem drinkers
(positive responses to 2 or more questions)
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CAGE Questionnaire
Have you ever felt that you should Cut down on
your drinking? Have people Annoyed you by
criticising your drinking? Have you ever felt bad
or Guilty about your drinking? Have you ever had
a drink first thing in the morning to steady your
nerves or get rid of a hang over (i.e. Eye
opener)?
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Antidepressants
Usually only take effect after two weeks or
more However psychomotor retardation often
associated with depression tends to lift prior
to improvement of mood Consequently there is a
period of severe depression and high
activity level Frequently during this
period many individuals attempt suicide
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Questions Used to Probe for Suicidal Thoughts
Dont be afraid of putting ideas into their head
they are either already there and asking wont
make any difference Do you sometimes feel its not
worth staying alive? Do you ever think of killing
yourself? How would you do it? Have you ever
tried to kill yourself? What happened on that
occasion?
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Suicide Attempts
Many are made in the context of a family row Para
suicide often connected with anger and perceived
powerlessness than with depression Angry client
must be challenged to think of new ways to vent
their anger Dealing with denied anger is a
different task and an indication for referral
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Post-attempt Stage
Clear the client medically Check or assess the
level of risk Explore for future plans for
problem solving and reasons for staying
alive Crisis intervention strategies take
centrestage to remove client from
danger Long-term counselling is required to
address the issues underlying the attempt
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