Suicide Risk Assessment, Manage what you Measure
One of the privileges of being a presenter at conferences, is that I also get to hear other informative keynotes and workshops – for free, with no conference registration fee. This month, I spoke at the 37th Governor’s Conference in Substance Abuse in Des Moines, Iowa. One of the keynote presenters was Terresa Humphries-Wadsworth, Ph.D of Prevention Management Organization (http://pmowyo.org). Dr. Humphries-Wadsworth spoke about screening and assessment of suicide risk – always an important clinical task.
In SAVVY this month, you can peek in on a few of the resources she highlighted. At theTraining Resources website, you can also download her PowerPoint presentation, which is the second last file in the handouts download list: https://www.trainingresources.
Here are a few SAVVY acronyms to keep in focus with suicide assessment:
Address suicidal thoughts and behaviors through GATE
The Treatment Improvement Protocols (TIPS) are always chock full of useful information (for free). Directly on this topic is “Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment.” Treatment Improvement Protocol (TIP) Series, No. 50.
Center for Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2009. http://www.ncbi.nlm.nih.gov/
The consensus panel for this TIP, came up with the following procedures:
G: Gather information
- Screening and spotting warning signs – very brief, uniform questions at intake to determine if further questions about suicide risk are necessary.
- Asking follow-up questions – further questions when clients respond “yes” to one or more screening questions or any time you notice a warning sign(s).
A: Access supervision and/or consultation
- Supervision or consultation is especially important if suicide risk assessment starts to get outside your scope of practice expertise.
- Access supervision if you have a client you suspect may be dealing with suicidal concerns.
- When it comes to suicide risk and what to do next, two heads are better than one.
T: Take responsible action(s)
- Depending on the seriousness of suicide risk, take action(s) that matches the severity of suicide risk.
- How intensively and how immediately you and your supervisor or team takes action, depends on how volatile and dangerous the person’s suicidal thoughts and behaviors appear.
E: Extend the action(s)
- Suicide risk is not just an acute problem that goes away. Vulnerable clients may have flare-ups and further suicidal thoughts or behaviors.
- This requires continued observation and check in with the client to identify a possible return of risk. If the client is referred, coordination and follow up with the provider is important. Suicide risk management requires a team approach.
Take note of Indirect Warning Signs of suicidal risk – IS PATH WARM?
Besides checking out direct assessment and treatment of suicide risk by using GATE, understanding indirect warning signs helps too. Is the situation heating up towards more direct action?:
I – IDEATION
- Threats to hurt or kill him or herself, or talking of wanting to hurt or kill him/herself
- Looking for ways to kill him/herself by seeking access to firearms, available pills, or other means
- Talking or writing about death, dying or suicide, when these actions are out of the ordinary.
S – SUBSTANCE – Increased alcohol or other drug use
P – PURPOSE – No reason for living; no sense of PURPOSE in life
A – ANXIETY – Agitation and unable to sleep or sleeping all the time
T – TRAPPED – Feeling TRAPPED, like there’s no way out
H – HOPELESSNESS
W – WITHDRAWING from friends, family and society
A – ANGER- Rage, uncontrolled ANGER, seeking revenge
R- RECKLESS – Acting RECKLESS or engaging in risky activities, seemingly without thinking
M – MOOD – Dramatic mood changes
Read more at:
SAD PERSONS – A Checklist for Suicide Risk Assessment
Check out the November 2010 edition of Tips and Topics for another acronym:
For direct help and more resources, see The National Suicide Prevention Lifeline
Here are some quick tips Dr. Humphries-Wadsworth covered.
Help a person delay one hour before acting on suicidal impulses
Of course, you want to extend beyond one hour. But if a person can be helped to put off actual action to kill themselves for just one hour, the likelihood of doing something impulsive goes way down.
Ask “Are you thinking of killing yourself?” not “Are you thinking of hurting yourself?”
Some people don’t think of killing themselves as “hurting” themselves. If they see death as an escape from hopelessness and pain that is seen as relief not hurt. So be direct and ask about “killing yourself”.
And certainly don’t say something like: “You’re not thinking of suicide, are you?” (Translation: I hope you are not suicidal, because I won’t know what to do if you are, so please don’t tell me you are suicidal.)
If a person says something like “No, not really”, that might mean “Yes, but can I trust you?”
If in response to asking a person if they are thinking of killing themselves, there is a vague response, explore further. What the person may really be saying is “Yes, I am thinking about killing myself, but I don’t know if you really want to hear it; or whether you can handle these thoughts and impulses that I myself even feel embarrassed to talk about.”
Ask about the intent of the suicidal thoughts and impulses
Getting ideas about what is fueling the suicidal thoughts or behaviors can help zero in on the needs and approach to help the person through especially that first hour of delay. Is the intent behind suicide:
- anger at people who “don’t care”
- escape from overwhelming stress
- revenge to “show them what they’ve done to me”
- death to relieve depression and total lack of joy and hope
Consider suicide risk assessment just like skills for assessing cravings to use
Addiction counselors can feel uncertain about suicide risk assessment, yet comfortable about assessing cravings to use. There is a lot of overlap in skills:
- “How often are you having cravings to use?” – “How often are you having thoughts and impulses to kill yourself?”
- “What people, places and things trigger your cravings?” – “What people places and things trigger thoughts or impulses to kill yourself?”
- “What have you thought about what drugs to use and where and when would you get them and use them?” – “What have you thought about what ways you would kill yourself and when and where would you get those methods and use them?”
- “How overwhelming do the impulses to use feel? Are there any thoughts, beliefs and actions that would delay using?” – “How overwhelming do the impulses to kill yourself feel? Are there any thoughts, beliefs and actions that would delay killing yourself?”
- “How easy or hard would it be to reach out to someone so you don’t use?” – “How easy or hard would it be to reach out to someone so you don’t kill yourself?“
If in any doubt, seek supervision or consultation
Especially if you have a client in your case load who is suicidal, there can be a tendency to either over-estimate the risk and panic (“I don’t want anything to happen to my client”); or you could under-estimate the risk and be too casual (“I have a good relationship with my client and they wouldn’t do that”).
I’ve always liked the power and pithiness of the phrase: “If you don’t measure it, you can’t manage it”. In this day of accountability for outcomes and results, it is a phrase that zeros in on the importance of tracking relevant metrics. Actually, it is also useful in considering your home budget and spending habits.
Apparently other people like this phrase too, or another version of it: “You can’t manage what you don’t measure”- because if you Google that phrase you’ll get 97,600 search results in 0.44 seconds! One site stated that the phrase “you cannot manage what you cannot measure” is actually a paraphrasing of an original quote by Lord Kelvin. The first to use this paraphrasing was Bill Hewlett, the co-founder of Hewlett Packer.”
Whoever said it sure influenced United Parcel Service of North America, Inc. (UPS), one of the largest shipment and logistics companies in the world. National Public Radio aired a fascinating report on what UPS measures and why. http://www.npr.org/blogs/
Here’s a brief list of how technology is being used to track, guide and measure all sorts of things in those big brown trucks:
- A computer now figures out the best way to load the truck in the morning, and the best way to deliver packages all day – this is so the driver doesn’t discover an undelivered package at the end of the day that should have been dropped off at his first stop 20 miles away.
- UPS figured out that opening a door with a key was slowing their drivers down. So drivers were given a push-button key fob that attaches to a belt loop.
- Sensors record to the second when a driver opens or closes the door behind him, buckles his seat belt and when he starts the truck.
- Sensors in the truck predict when a part is about to break.
- For safety reasons, UPS doesn’t like it when their drivers back up too much. So they track exactly how many times the driver is backing up, where you’re backing up, and they also know the distance and the speed that you’re backing at.
- The company lets drivers know if they are backing up too much.
Here’s why UPS does all this:
- Jack Levis, who’s in charge of the UPS data, says: “Just one minute per driver per day over the course of a year adds up to $14.5 million.”
- A typical day for a driver used to be around 90 deliveries – now it’s about 120.
- When you hear people talk about technology increasing workers’ productivity, this is what they’re talking about: same guy, same truck – lots more deliveries.
- As workers have gotten more productive, their pay has gone up. UPS drivers today make about twice what they made in the mid ’90s when you add up their wages, health care and pensions, according to the head of their union.
- Data are just a new way to figure out how to do things better, and faster. And, the drivers benefit from that along with the company.
“They’re the highest paid in the business, which is why my job is to keep them productive so they remain the highest paid in the industry,” Levis said.
A more humble example of the “measure-manage” thing is my Jawbone UP, a fitness tracker bracelet I have worn on my left wrist for over a year. I use it to track the number of steps I take every day, how many hours I sleep, what kind of sleep (how long it took to fall asleep, was it light or heavy sleep, number of times I woke up etc.) It will tell me what percentage of my daily goal I achieved and all sorts of data I don’t have time to analyze and use.
One thing I do notice though is that if I haven’t reached my daily goal of 10,000 steps, I am much more likely to take the steps instead of the elevator, or park my car further away rather than drive around wasting gasoline to find a closer parking space. Same thing for sleep. I’ll go to bed earlier if I am falling short of my nightly goal.
In other words, measuring this stuff really does let me manage steps and sleep better.
Now of course, you can’t and shouldn’t measure everything. How can you measure how much love you give and get, how much compassion and respect you show, how much understanding and acceptance you want?
But when it comes to managing finances, fitness and a few other things, you can’t manage what you don’t measure.