Presenter: Lucy R. Cannon, ED.D, LCSW, CCDP-D, MATS Date ... · • The percentage of older persons who have completed high school has risen from 28 to 84 percent since 1970. •

Suicide in Older Adults and Understanding Suicidality and Cultural

Influences; Treatment Implications Webinar Training

Presenter:

Lucy R. Cannon, ED.D, LCSW, CCDP-D, MATS

Date: August 26, 2020

Time: 9:00 a.m. to 4:00 p.m.

Objectives:

• Ageing Attitudes Quiz

• 1. Key things clinicians need to know about older adults and the second half of life from an older adult perspective

• 2. Participants will learn the causes of older adults’ suicide epidemic

• 3. They will learn common contributing factors that lead to causes of suicide with older adults

• 4. They will identify cultural factors that influences suicide in older adults

• 5. They will identify skills, interventions, and resources needed to work with older adults in crisis

• Activity: The use of a video and case scenario will be used to demonstrate the assessment and treatment of a high risk older adult who attempted suicide. Participants will do an activity around this video and make recommendations related to how to best treat this individual.

Ageing Attitudes Quiz

What do Older People like to be called?

• What should we call those in the middle and later years? Baby boomers? Older people? Senior citizens? Elders?

“In a survey conducted by SeniorMarketing.com of over 1,000 seniors, the results indicated that half of them are not comfortable with the term “senior,” but 71 percent of them are okay with “baby boomers” while others prefer only “boomers.”

In another study by the Journalists Exchange on Aging Preferences are;

First choice is Older” as in older adults, older people, older individuals or older Americans.

The second most widely accepted term for older adults was “seniors,” though many felt it more accurately described those seniors over age 65.

The survey found that “elderly” is the term that seniors dislike the most, while “elders” conveys a sense of respect, as in being an “elder” of a tribe, church or elder statesman.” (Clarke, 2017)

• These studies suggest the reality that there are definitely categories or segments of seniors.

• Clark proposed three categories of seniors: the younger senior, the senior, and the elder.

• The young seniors are the youngest of the boomers, age 50 to 59. The maturing seniors are in the 60 to 75 group, while the elders are 76 and up.

• Here are some of the names currently being used to identify those who are older than 50: seniors, older adults, older seniors, young seniors, elders, active seniors, matures, baby boomers, boomers, active adults, wisers’, advisors, coaches, masters, senior citizens, seasoned citizens, third agers, JALOs (Just a Little Older), EWs (Experienced and Wise), YAHs (Young at Heart), NQYs (Not Quite Young), and sagers’.

• Which do you like most or least?

Why or Why not?

o If there isn’t one name identified on this list, what names would you suggest for the younger, middle, and upper segments of seniors?

Statistical Data

• “Suicide is the tenth leading cause of death in the US, accounting for more than 1% of all

deaths. • More years of life are lost to suicide than to any other single cause except heart disease

and cancer [5]

• 44,000 Americans die by suicide each year. There are 13.8 deaths by suicide per 100,000 persons each year. [6]

• There is one death by suicide for every 25 attempts.

• 40% of persons who complete suicide have made a previous attempt. [8]

• Nine of out ten people who attempt suicide and survive, do not go on to complete suicide at a later date.

• Older white adults have triple the suicide risk than younger, non-white adults.”

• Discussion- Why do older white adults have triple suicide in comparison to younger non-white adults?

• “Suicide rates are highest among adults between 45 and 64 at 19.6 per 100,000.

• The second highest rate is 19.4 per 100,000 among those 85 years or older.

• Compared with middle-aged older adults, younger populations have consistently lower suicide rates.

• While males are four times more likely to do die by suicide, females are three times more likely to attempt suicide. [11]

• Those with substance abuse disorders are six times more likely to complete suicide than those without.

• The rate of completed suicide among men with alcohol/drug abuse problems is 2-3 times higher than among those without a problem.

• Women who abuse substances are at 6-9 times higher risk of suicide compared to women who do not have a problem.”

Average life expectancy* in North America for those born in

2019, by gender and region(in years) Table

Statistics data cont.

• The number of Americans aged 65 and older is projected to double from 46 million to more than 98 million by 2060.

• It will be the first time in history that the number of older adults outnumbers children under age 5.

• In addition, older adults will live longer than ever before: One out of every four 65-year-olds today will live past age 90.

• The number of Americans over age 85 is increasing faster than for any other age group. Why?

• The percentage of older persons who have completed high school has risen from 28 to 84 percent since 1970.

• The proportion of older adults living alone increases with advancing age. Among women aged 75 and over, almost half live alone.

• It is anticipated that the number of older adults with mental and behavioral health problems will almost quadruple, from 4 million in 1970 to 15 million in 2030.

• Mental health disorders, including anxiety and depression, adversely affect physical health and ability to function, especially in older adults.

• Some late-life problems that can result in depression and anxiety include coping with physical health problems, caring for a spouse with dementia or a physical disability, grieving the death of loved ones, and managing conflict with family members.

•

• “Approximately 80% of older adults live with a chronic disease – such as arthritis, diabetes and high blood pressure — and 77% have at least two, according to The National Council on Aging.”

• “A review of what is known about lesbian, gay, bisexual or transgender (LGBT) older adults. It is estimated that 2.4 million LGBT older adults over 50 live in the United States, and that number is expected to double by 2030.”

• “The LGBT aging population is resilient but at risk. Social isolation and victimization are major concerns. LGBT family structures are not necessarily based on blood ties and caregivers should be considerate of diverse familial relationships.”

• Source: https://www.apa.org/pi/lgbt/resources/aging#:~:text=A%20review%20of%20what%20is,expected%20to%20double%20by%202030.

Elderly and Poverty Statistics

• Although the rate of poverty had decreased prior to 2017,approximately 9.2% of Americans aged 65 and older had income below the poverty thresholds in 2017.

• However, the number of aged poor has increased since the mid-1970s as the total number of elderly has grown. In 2017, 4.7 million people aged 65 and older lived in poverty.

• People aged 80 and older have a higher poverty rate than other elderly Americans.

• In 2017, approximately 11.6% of people aged 80 and older lived in poverty, compared with poverty rates of 9.3% among individuals aged 75-79, 8.6% among those aged 70-74, and 7.9% among those aged 65-69.

• Women aged 80 and older had the highest poverty rate among elderly women and men in all age groups, at 13.5% in 2017 for women aged 80 and older, and 18.6% for those living alone.

Race Impact on Elderly and Poverty

• “Poverty rates vary by race and Hispanic origin.

• Hispanic origin is distinct from race, and people may identify with one or more races.

• From 1975 to 2017, the poverty rate for Americans aged 65 and older has decreased for those identifying as non-Hispanic white alone, black alone, and Hispanic.

• In 2017, the poverty rate was lowest among the non-Hispanic white population (5.8% for men and 8.0% for women) and highest among those identifying as black or African American (16.1% for men and 21.5% for women).”

The Second Half of Older Adults lives

• According to Carl Jung, “the first half of life is spent building their sense of identity, importance, and security.”

• In the second half of life, the ego still has a place, but now in the service of the True Self or soul, older adult inner and inherent identity.

• The ego is the container that holds an individual all together, so now its strength is an advantage. Someone who can see their ego in this way is probably what we mean by a “grounded” person according to Jung.”

• Source: C. G. Jung, The Structure and Dynamics of the Psyche (Routledge and Kegan Paul: 1960), 399.

• “In the second half of life the older adult discover that it is no longer sufficient to find meaning in being successful or healthy.

• There is a need for a deeper source of purpose. According to Jung, “Meaning makes a great many things endurable—perhaps everything.

• Jung believed our various problems are not solved so much by psychotherapy as by authentic religious experience.”

• Source: C. G. Jung, The Structure and Dynamics of the Psyche (Routledge and Kegan Paul: 1960), 399.

Older Adult Population

• Older adults are less likely to report suicidal thoughts compared to younger adults.

• They attempt and complete suicide more than other age groups.

• One of the reasons for a higher completion rate is because they use more lethal methods.

• More than 70 percent of suicides in this age group are by a firearm, which men use more often than women.

Risk Factors for Elderly Individuals

• access to lethal methods (e.g., firearms)

• debilitating physical health problems

• presence of a mental disorder

• depression

• divorced or widowed (rates are highest for those who are divorced or widowed)

• Family discord

• Major changes in social roles(e.g. retirement)

• Perceived poor health

• prior suicide attempts

• recent death of a loved one

• social isolation and loneliness; socially

• dependent

• substance abuse

• uncontrollable pain or the fear of a prolonged illness

Key Warning Signs

• “Sleep problems, either sleeping too much or too little, eating problems, or other signs of depression should be taken seriously.

• The presence of firearms in the household certainly increases the risk. “When verbal statements of wanting to die or kill oneself are heard, they should be taken seriously and mental health help sought immediately,” McIntosh says.

• Many older people, particularly men, slip into hopelessness and suicidal behavior because they believe that older age is a descent into loss and suffering,” says Arbore.”(Worthington,2018)

Causes of older adults suicide

• “Older adult suicide is often triggered by elders’ loss of control over health conditions or financial circumstances that results in feelings of hopelessness. (Worthington, 2018)

• Older men are at higher risk of committing suicide than older women. White males aged 85 and older are at the highest risk among all older adults.

• According to Patrick Arbore, EdD, director of the Center for Elderly Suicide Prevention and Grief Related Services Institute on Aging in San Francisco. “An older person who is diagnosed with a complex illness such as cancer, Parkinson’s, diabetes, dementia, etc. can trigger a depression,” he says.

• Losses that include the death of loved ones, pets, and even the potential loss of self can become extremely difficult to manage for elders, he says.

• Fears surrounding the ability to maintain an independent living status “can arouse enormous anxiety, especially when the older person values autonomy above all else.”

• Source: http://www.todaysgeriatricmedicine.com/news/exclusive_03.shtml

• According to John L. McIntosh, PhD, a professor of psychology at Indiana University South Bend. “Health, finances, and social support are extremely important issues in life satisfaction and almost certainly suicide and depression in late life as well,” says McIntosh.

• “Studies consistently show the tremendous relationship between suicide and depression.”

• Other factors associated with suicide are frustration and anger, both of which can lead to aggressive behavior toward oneself, says Arbore.

• Other contributing elements may include physical or psychological pain, frustrated psychological needs, and feelings of helplessness or hopelessness.

• “Alcohol and other substance use disorders also place older people at significantly increased risk for suicide.”

• McIntosh suggests that suicide among older adults is “the result of several factors working in combination.

• “Early stages of dementia, stages of cancer, and other physical health conditions can contribute to suicidal thoughts.

• Problems within the medical, psychological, or social realms or combinations of difficulties in several areas may contribute to thoughts of suicide in older adults. (Worthington, 2018)

• Video- “Robin’s tragic death”

Robin Williams' Widow Discusses Husband's Tragic Death”

- Video Clip/ Discussion

• Medication safety is more important as we age because older people experience a decline in all body systems and are more at risk for negative drug reactions or interactions.

• Older people tend to take more prescription and over-the-counter medications that increase the risk for mishaps.

• Unlike suicides among young people, “Older adult suicide is not an impulsive act,” says Chi.

• “Elderly suicide is contemplated for a long period of time.”

• Source: http://www.todaysgeriatricmedicine.com/news/exclusive_03.shtml

So What is Culture and Why is it important with the elderly?

• Culture is the sum total of ways of living, including values, beliefs, aesthetic standards, linguistic expression, patterns of thinking, behavioral norms, and styles of communication which a group of people has developed to assure its survival in a particular physical and human environment.

• Culture, and the people who are part of it, interact, so that culture is not static.

• Culture is the response of a group of human beings to the valid and particular needs of its members. It, therefore, has an inherent logic and essential balance between positive and negative

• dimensions.

Cultural factors that impact elderly suicide

• Suicidal behaviors often result from experiencing humiliation and shame, lack of support from family members, failure to meet expectations or from environmental factors.

• Although there are many services available—crisis hotlines, therapists, support groups—to those experiencing thoughts of suicide, the decision to seek help can be influenced by

a person’s cultural background.• “Just like there are cultural influences on one’s view of physical health, there are cultural

influences on how individuals might view their mental health distress,” explains Senior Director of Education and Prevention of American Foundation for Suicide Prevention, Doreen S. Marshall, Ph.D.”

Ethnic groups and culture

• “In African American and American Indian culture, environmental factors often increase the likelihood of suicidal behavior.

• “Part of this shared cultural experience in African American families — like values, family connections, expression through spirituality or music, reliance on community networks and church — are enriching and can be great sources of strength and support.”

However, another part of this shared experience is facing racism, discrimination and inequity that can significantly affect a person’s mental health.

• Being treated or perceived as “less than” because of the color of your skin can be stressful and even traumatizing.

• Additionally, members of the Black community face additional challenges accessing the care and treatment they need.”

Ten comments not to say to suicidal people

• “How could you think of suicide? Your life’s not that bad. Perhaps on the outside the suicidal person’s life does not seem “that bad.” The pain lies underneath.

• “Don’t you know I would be devastated if you killed yourself? How could you think of hurting me like that?” Your loved one already feels awful.

• “Suicide is selfish.” This inspires more guilt.

• “Suicide is cowardly.” This inspires shame.

• You don’t mean that. You don’t really want to die.” Often said out of anxiety or fear, this message is invalidating and dismissive.

• You have so much to live for.” In some contexts, this kind of statement might be a soothing reminder of abundance and hope. But for many people who think of suicide and do not at all feel they have much to live for, this remark can convey a profound lack of understanding.

• “Things could be worse.” Yes, things could be worse, but that knowledge does not inspire joy or hope.

• “Other people have problems worse than you and they don’t want to die.” True, and your loved one may well have already considered this with shame. People who want to die often compare themselves to others and come up wanting. They may even feel defective or broken.

• “Suicide is a permanent solution to a temporary problem.” This phrase communicates that the person’s problems are temporary, when they might be anything but.

• “You will go to hell if you die by suicide.” Your loved one has likely already thought of this possibility. Maybe they do not believe in hell. Maybe they believe the God they believe in will forgive their suicide. Regardless, their wish to die remains. Telling them they will go to hell can exacerbate feelings of alienation.

• Discussion – What additional comments should we not make to people who make suicidal threats?

• Source: https://www.speakingofsuicide.com/2015/03/03/what-not-to-say/

Assessment Tools

• Biopsychosocial Assessment

• CANS

• ASI (Addiction Severity Index)

• Simple Screening Instrument for AOD Abuse Self Administered Form

• ASAM ( American Society of Addiction Medicine)

• BDI (Beck Depression Inventory)

• CAGE Questionnaire

• Level of Care Utilization System (LOCUS)

• PRISM (Psychiatric Research Interview for Substance and Mental Disorders)

• Client’s Assessment of Strengths, Interests, and Goals (CASIG)

Key assessments and evaluation tools

• Substance Abuse Subtle Screening Inventory--3 (SASSI--3)

• The SASSI-3 (Substance Abuse Subtle Screening Inventory, 3rd Edition), is one of the most widely used proprietary screening tools in the United States.

• This tool is different from others; it contains both subtle and face valid items validated to screen for high or low probability of having a substance use disorder.

• Described as effective in identifying those in denial or deliberately trying to conceal their substance use, it is longer than brief face valid screens.

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• It also contains a validity scale to identify random responding, and a defensiveness scale, which provides a measure of credibility to the individual’s responses.

• Independently developed and validated adult versions are available in English and Spanish, and briefer, customized, and validated versions are available for clients with disabilities (SAVR-S2) and for those who are deaf or hard of hearing (SAS-ASL).

• An adolescent version in various formats is also available.

• COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)

Assessment Tools Cont.

• DAST:

• All the DAST (Drug Abuse Screening Test) versions screen for problems with the use of drugs only.

• The DAST-10 (Drug Abuse Screening Test-10) is the shortened and more commonly used version of a 20-item (DAST-20) or the original 28-item version.

• The DAST is sometimes combined with the AUDIT (The Alcohol Use Disorders Identification Test) or other alcohol screens to cover both alcohol- and drug-related problems.

• Items apply to over-the-counter, prescription, and illicit drugs. Studies have documented reliability with Spanish versions.

• The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item screening tool developed by the World Health Organization (WHO) to assess alcohol consumption, drinking behaviors, and alcohol-related problems. Both a clinician-administered version (page 1) and a self-report version of the AUDIT (page 2) are provided

• Source: https://www.drugabuse.gov/sites/default/files/files/AUDIT.pdf

Risk Assessment Tools

Managing Safety and Treatment Planning

• High-risk suicidal clients can be safely and effectively treated on an outpatient basis if family members or alternate caregivers are available to provide one-on-one support and supervision in the home and if 24 hour acute care/community crisis stabilization/secure protected environment is available and accessible as required.

• When high risk does not dictate hospitalization, the intensity of outpatient treatment should vary in accordance with risk indicators (e.g., more frequent appointments, telephone contacts, concurrent individual and group treatment).

• The availability of close supervision in the home setting must be assured in cases of high risk.

• Following a suicidal crisis, clients identified as high risk will benefit from intensive follow-up treatment.

• Note: Multiple attempts, psychiatric history, and current diagnostic comorbidity are some of the factors that indicate high risk.

• Video – “Suicide Risk Assessment”

• Video –”How to develop a Suicide Safety Plan”

• Source: https://www.health.gov.bc.ca/library/publications/year/2007/MHA_WorkingWithSuicidalClient.pdf

Video – “Suicide Risk Assessment”

How to develop a Suicide Safety Plan

Family Involvement

• Involve Clients and Family in the Treatment

• Planning Process -Use individual and family approaches, including

• psychoeducation programs to treat the underlying factors

• or disorder (e.g., depression education, including self-management

• information).

• Teaching the family what might trigger an event or how to identify risk is empowering for family members and increases their understanding and support of the client’s difficulties.

• Acknowledge their helpful contributions.

• Assisting the client to engage with supportive social groups

in the community is an important part of a strategy for

involving the client with a connected and caring environment.

• Attendance at Grief Support Groups, A.A., NA, Gambling Anonymous, and other self help groups

• Video – “Senior Peer Program and Suicide Prevention” - Discussion

Senior Peer Program and Suicide Prevention

Best Practice Treatment Models/Theories

• Solution Focused Brief Therapy is a strength based model that utilizes a cognitive-behavioral approach to help clients imagine what could be different and what to do to make changes (Insoo Kim Berg and Steve De Shazer) (Gingerich, 2000).

• Cognitive Behavior Therapy- change thinking, identify beliefs, awareness of automatic thoughts (Aaron Beck & David Burns)

• Stages of Change- (Precontemplation, Contemplation, Preparation, Action, & Maintenance (Prochaska & DiClemente, 1992)

Treatment Models/Theories

• Stages of Treatment- (Osher & Kofoed, 1989, McHugo et al, 1995), Engagement, Persuasion, Active Treatment, Relapse Prevention

• Client Centered Therapy-Self actualization and increase congruence (Carl Rogers)

• Motivational Interview-Motivational interviewing (MI) is a counseling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick.

• Multicultural Counseling- cultural understanding; awareness of values and biases; understanding; change oppressive systems (Deerald WingSue, David Sue, Paul Pedersen, & Patricia Arredondo)

Source-Halbur & Vess-Halbur, 2006

• Dialectical Behavioral Therapy - (DBT) has been developed and evaluated as a comprehensive, behavioral treatment for suicidal and parasuicidal behavior (Linehan, 1993). DBT includes simultaneous individual and group treatment modalities, and is premised in principles of cognitive, behavioral, and interpersonal therapy.

• Source: https://www.health.gov.bc.ca/library/publications/year/2007/MHA_WorkingWithSuicidalClient.pdf

Training Needs of Professionals

• To be effective, the therapist must be skilled in handling trauma processing work, suicidal thoughts/intent, and comorbid personality disorders.

• It is necessary for therapists to provide treatment to victims and family members who have experienced single and multiple traumatic experiences.

• Specialized trauma training/certification is needed for clinicians and paraprofessional staff to successfully treat suicidal individuals and family members.

• Special training on how to develop and use Safety Plans/Suicidal Contracts with high risk clients.

• Video/Activity “Risk assessment with an older man after a suicide attempt”

• Source: http://www.excellenceforchildandyouth.ca/sites/default/files/eib_attach/Trauma-affected_newcomers_Final.pdf

Video – “Risk assessment with an older man after a suicide

attempt”

Activity

• What are high risk behaviors of this older adult?

• What services/treatment would you connect this patient to after he is released from the hospital? Why?

• Can healthcare professionals stop individuals who are determined to end their lives? Laws?

• Wrap-Up• Suicide in Older Adults and Understanding Suicidality and Cultural Influences; Treatment Implications power

point presentation is the property of LEJ Behavioral Health Services, LLC. Information is to be used by healthcare professionals for educational and treatment purposes.

Q & A