Medical Staff Suicide Prevention and Management Training:
Facilitator Guidelines
NON-Clinical Staff PowerPoint
2018
The goal of these guidelines is to provide you with additional information about each slide in the presentation: the key concepts, any suggestions for how to cover the information, and where additional information can be added that’s more specific to your facility. The guidelines are designed to be used with the presenter notes for each slide.
Reminder: There are a few population-based slides you can decide whether to use or not based upon your audience and the population of your patients. Additional population slides are available through MSPP. You may also choose to not use the IS PATH WARM slide if you use the Adolescent Warning Signs slide.
Title Slide: Maine Suicide Prevention Program:
Education, Resources, and Support-It’s Up to All of Us
•Introduce yourself and your role in the healthcare program. Acknowledge where this presentation fits with any suicide prevention or management efforts underway in the program. .
This is a time to remind the audience that this training is about suicide, an issue that has likely affected some members personally and/or professionally. Let them know they can step out if things are too emotional and remind them where they can get support if needed.
Slide 2: Maine Suicide Prevention Program
This training has been developed and supported through the ongoing education efforts of the Maine Suicide Prevention Program (MSPP); a part of Maine DHHS housed in the Injury Prevention Program. It has been actively supporting suicide prevention in Maine since 1997.
Slide 3: Training Agenda
Goal: clarify agenda for the day.
Briefly cover the range of topics included and introduce the idea of a systemic approach to suicide prevention and management within a healthcare organization.
Note: If less than 2 hours, the Postvention may not be included.
•This is a good point to ask participants what their expectations are, what they would like covered, and any specific questions they may have coming into the training.
Slide 4 and 5: Talking about Suicide;
Goal: Prevention of suicide rests on our ability and comfort in talking about it openly and accurately!
Our main goal is to encourage and support people in talking about suicide. It has been a taboo subject in families, public conversation and the culture. In order to make change to suicide as a public health problem, we need to be able to talk openly about suicide and to be able to ask someone if they are considering suicide.
There are some simple and direct phrases that can be used when talking about suicide. Refer to it as “a suicide,” someone died by or died of suicide, when speaking about a death.
Phrases that should be avoided are things such as ‘failed attempt’ or ‘successful suicide’ as they present the wrong message, equating living as a failure and dying as a success.
Invite audience to consider what words they might use with a child, knowing that suicide deaths as young as age 8 have occurred in Maine. Eg. “Have you ever wished you had not been born? Have you wanted to go to sleep and never wake up?”
Slide 6: Our Ease with Talking About Suicide is Shaped by:
Goal 1: To understand that the significant STIGMA associated with suicide often makes it very difficult to talk about it.
Goal 2: Recognize that the stigma is in the helper as well as the person at risk of suicide.
Discussion about past experiences with suicide and suicide attempts.
Focus on the goals for this segment:
- Engagement—why are we here today? Why do we care?
- Topic of suicide is personal/intense. Emphasize the practice of self -are for participants within the training day.
- Discuss beliefs and attitudes regarding suicide; personal and community views, lingering myths and beliefs
If comfortable sharing what is your experience:
-Someone who has attempted suicide
-Someone who has died by suicide
-Friend or family member
-Professional experience
-During our lifetime, most of us (60%) will personally know someone who dies by suicide.
20% of us in our lifetime will have a family member die by suicide; 60% know someone. This is from a Canadian study. It involves life time exposure, so the suicide could be a relative who had died before the living person knew him or her. Ramsay, R and Bagley, C. Suic and Life Threat Beh (1985).
A more recent study showed that in the last year, 7% of the population knew a person, mainly a friend or acquaintance who killed himself and 1.1% of the population had a family member or relative who killed himself (or herself) Crosby and Sacks, Exposure to Suicide, Suic and Life Threat Beh (2002).
Slide 7-8: Why People May Deny Suicidal Ideation:
Goal: To support your audience in recognizing that there are real reasons why someone would hesitate/deny. Based on the slides before, we know that it may be hard for someone to ask for help; WHY?
Presenter Note: These 2 slides are good ways to generate input and discussion by putting up the blank slide first…. Can move more quickly by just presenting the material as needed.
There are many reasons why someone would hesitate in reaching out for help, it may be especially true for a young person or for a man. It’s good to illicit some sort of dialogue around this piece in order to help participants understand the reasoning for not asking for help.
Slide 9-10: What May Complicate our Response:
Goal: To support your audience in recognizing the importance of doing something for someone in crisis, even if you have concerns about it not being your role or profession.
It’s good to generate some sort of dialogue around this question as well, in order to help participants acknowledge what makes it hard to reach out to someone in distress.
Might add a final one…someone may not want to be stopped!
Often, people are afraid of doing/saying the wrong thing or making matters worse. The message for this slide is that the most important thing is TO DO SOMETHING!
If you feel too uncomfortable to approach the person who’s struggling directly about what they’re going through, bring it to someone else’s attention immediately.
Slides 11 through 15: Suicide in Maine, the Northeast, and the United States:
Suicide rates in Maine vs. the Northeast and USA from 2000-2016
Goal 1: Give relevant facts about suicide to assist in the understanding of how often it happens and differences in rates of suicide by region and in different populations.
Goal 2: Broaden the understanding of how Maine suicide rates compare with other states and also to note the change in rates over time.
Slide 12: Suicide in the US, 2016:
Deaths by Suicide US.
Goal 1: To show how common suicide is in the U.S.
Note that while the number and rates of suicide have risen significantly over the past decade, the rates of homicide and of motor vehicle deaths have been falling. Ask: “What has been done to reduce the death rates in MV and from homicide?”
Goal 2: To show the different impacts it has based on gender and experience in the military.
Discussion opportunity: What are the differences between men and women that we see more men dying by suicide, but more women attempting? Some possible answers…
•Means used-less lethal for women, stronger connection to community for women
•Men tend to be more violent, higher rates of substance abuse D.O., more familiar with guns, talk less, identity from career
•Women reach out for help more easily and a low lethal attempt is a strident outreach for help.
Refer to data sheets for more information. Maine is consistently 20% above national and among the highest rates in the NE (along with Vermont).
In Maine suicide is 9X that of the homicide rate. High suicide rate plus low homicide rate.
Discussion opportunity: What’s happening in Maine (and other rural, northeast states) that may be connected to the increased risk?
Possible responses…
Maine shares high rates with other rural states
Isolation of people from each other and from resources
Maine culture of Stoicism-hesitation in help seeking
Firearm ownership
Stigma
Slide 15: Average suicide deaths by age group and gender 2014-2016:
Average suicide deaths / 1 Minutes
Goal: Participants understand the age distribution of suicide deaths and the gender variation.
In Maine, as the rest of the Nation, men make up a vast majority of the deaths by suicide. The other trend we see from this slide is that the majority of deaths happen in the 35-64 age range with the numbers peaking for both men and women at age 50. Over the past 10 years the suicide rates for women have climbed more rapidly than for men though still remain much lower than for men.
The graph does not show suicide numbers under age 15 due to reporting rules around confidentiality.
Discussion opportunity: What’s going on during that middle age range that might put both men and women at increased risk?
Slide 16: Suicide Attempts:
Goal 1: Participants understand the ratio of attempts to deaths by suicide.
Goal 2: Understand the relative high rate of attempts in adolescents and young adults.
Goal 3: All attempts require a response and intervention with help to reduce stress, increase support and resources for coping. If positive intervention is done, few return to another suicide crisis.
Attempted suicides, acts that are non-fatal where the intention was to die. Also, discussion opportunity could be around the difficulty of collecting valid, national attempt data. Hint: stigma surrounding an admission of suicide attempt.
Having made a suicide attempt is among the most predictive for the risk of future suicidality and death by suicide!
Possible discussion: what contributes to the attempt rate difference between the young and the older populations?
Young: Look at ambivalence, impulsivity, cry for help, lack of knowledge about lethality of attempt (may think a low lethality attempt would kill them) etc.
Older adults: weaker constitution (lower lethality attempt could take life), isolation, planful, targeted, secretive etc.
Slide 17: Non-suicidal self-injury:
Goal 1: Describe why someone would turn to self-injury.
Goal 2: Acknowledge the strong connection between self-injury and suicide risk.
**Handout of Additional Sources of Information is available for use.
This list is not exhaustive. The most important thing people need to understand is the following:
People may return to self-injury after the first experience because it works to quickly reduce level of distress. NOT a healthy coping skill, but in some youth, becomes a pattern used to manage distress.
There is strong connection between self-injury without suicidal intent today and suicide-if you are supporting someone that has self-injured it is always a good idea to ask about their risk for suicide. “How often do you also think about ending your life”?
For many, self-injury is not a pre-cursor to suicide; there are distinct goals and motivations. However history of self-injury strongly increases the likelihood of suicide ideation and behavior. Among Maine HS students who report a suicide attempt in the past year, 77% report having engaged in non-suicidal self-injury! A strong connection between NSSI and suicide risk.
20% of high school students say that their self-injurious behavior is not suicidal behavior.
List of some reasons persons might have to engage in self injury:
•Action is stress release
•Visible and physical expression of emotional pain or provides relief from their emotional pain
•For some, self-injury provides a “rush” or feeling of euphoria, spurred by endorphins released in trauma or fight or flight response of the body to injury.
•For some, it may be a form of self-punishment for feelings of extreme guilt
Slide 18-19-20-21: Role of Hospitals and other healthcare settings in Suicide Prevention
Goal 1: Acknowledge the role and opportunity for hospital systems to address suicide prevention and management.
Goal 2: To acknowledge the current expectation of the Joint Commission for hospitals to address suicide prevention systemically.
Though the actual suicide death of a patient in an inpatient hospital bed is relatively uncommon, many people seek help and may be harboring suicidal ideation, both identified or not. While they may be closely monitored while inpatient, the transition out of an inpatient unit to the community or to a lower level of care represents a significantly increased time of risk. Recognizing the need for greater coordination of care across healthcare systems, recent efforts by the Joint Commission seek to improve coordinated and systemic efforts to manage suicide risk. These efforts align with the Zero Suicide movement and similar initiatives.
Read the Bulleted recommendations of the 2016 JCAO Alert.
Slide 20-21: Role of Primary Care in Suicide Prevention
(Optional if not addressing a primary care audience)
Goal 1: To make a clear connection for the reason primary care and specialty practices engaging in active suicide prevention
The primary care office provides an excellent setting for surveillance for, identification and assessment of and intervention with people exhibiting increased suicide risk.
Most people have an identified provider, and adults are much more likely to see a PCP for an emotional concern than a behavioral health clinician, especially initially.
Though a suicide is a relatively rare event, 77% of the individuals who died by suicide had seen a primary care provider within the last year and 45% had visited within the last month of their life. Many times these visits were for physical complains that could be attributed to a mental health issue.
In contrast, only 32% of the individuals who died by suicide had contact with a mental health clinician in the year before their deaths.
In addition, the primary care setting is an excellent site to connect with specific higher risk groups not easily seen in a mental health setting.
More than 70% of adolescents visit a physician at least once a year for a regular check-up or athletic clearance...
Many adolescents prefer to see their PCP for emotional problems, as there is less stigma and more accessibility;
More than half of depressed adolescents receive treatment from their PCP
Men represent a disproportionate number of suicides, and have a demonstrated challenge in reaching out for help; the PCP presents an opportunity for access as they do visit their primary care provider.
Slide 22-23-24: Working toward “Suicide Safer Care”
Goal: To build a rationale for a coordinated system’s approach to suicide prevention and management as the most evidence-based effective means to prevent suicide.
This field is constantly working toward a time when suicide is not a tragic loss that devastates lives and families.
Read some or all of the typical situations that do or may represent an individual who is at increased suicide risk. We meet these people weekly!
Possible discussion: what are the challenges involved with getting these people the help they may need?
Suicide Safer Care is built on the intentional actions to address the needs of a suicidal individual.
- Recognition of risk and the assessment of that risk, once recognized. Do you have tools and processes for identifying possible risk? (one eg. is PHQ-9) Do you use a standardized tool to assess suicide risk? Once assessed, how do you make decisions on level of care, based on level of assessed risk?
- Once identified as having suicide risk, is there a mechanism and a tool in your EMR for developing a Collaborative Safety Plan with a patient to assist them in their efforts at self-management? Does it include a plan for securing lethal means?
- Can and do you refer the patient to treatment that can address the drivers of suicide, and is the treatment modality evidence-based?
- Examples include Collaborative Approach to Managing Suicide (CAMS), Dialectical Behavioral Therapy (DBT) or Suicide based Cognitive Behavioral Therapy
- Finally is there a process in place that ensures proactive follow-up occurs with a patient at high risk? Can you tract the person to be an option after discharge from a hospital? Is there a tracking/flagging option in your EMR to assist this effort?
When a system exists that covers these elements of care, lives are saved!
Slide 24: Elements of a Suicide-ready Practice
Goal: To underscore the elements that comprise a Suicide Safer Practice.
This slide represents a roadmap to follow in building an effective process for managing suicide. These efforts are best done within an established protocol guiding response