Telephonic Assessment of Suicidal Ideation Paradigm Brent L. Halderman, Ph.D. James R. Eyman, Ph.D. Sheryl Feutz-Harter, J.D., MSN, CHC Nashville, TN October.

Telephonic Assessment of Suicidal Telephonic Assessment of Suicidal Ideation ParadigmIdeation Paradigm

Brent L. Halderman, Ph.D.James R. Eyman, Ph.D.Sheryl Feutz-Harter, J.D., MSN, CHC

Nashville, TNOctober 7, 2006

This presentation is proprietary and cannot be duplicated, used, or adapted without NDBH permission. For permission, contact: [email protected]

Copyright 2006 New Directions Behavioral Health LLC. All rights reserved.

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Telephonic Assessment of Suicide Telephonic Assessment of Suicide Paradigm Paradigm

Stage 3Recommendations

Stage 2Working

Relationship

Stage 1Suicide Potential


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Stage 1Stage 1Evaluation of Suicide Risk General Risk Evaluation of Suicide Risk General Risk FactorsFactors Sex Age Marital Status Losses Social Support Medical Illness Alcoholism Affective Disorder Anxiety Disorder Schizophrenia Eating Disorder Borderline Personality Disorder


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Stage 1Stage 1Specific Risk Factors for SuicideSpecific Risk Factors for Suicide

Anxiety Ruminations Depression with Delusions Hopelessness Global Insomnia Recent Alcohol Use


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Stage 1Stage 1Assessing Suicidal IdeationAssessing Suicidal Ideation

How do you feel now? Ever feel so bad that you wish you were dead? Ask directly about suicidal ideation

Why suicidal? What precipitating event?

Suicidal ideation is on a continuum


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Stage 1Stage 1Preparation to End LifePreparation to End Life

Usually have more than one plan Note how the person talks about suicidal

ideation and plan Well thought out and developed plans will more

likely succeed Perception of the lethality of the method Availability of the method Efforts to thwart rescue

Suicidal behavior is on a continuum.


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Stage 1Stage 1Past Suicide AttemptsPast Suicide Attempts

How close have you come to killing yourself? Suicide risk increases with escalating

seriousness of past attempts History

External circumstances Internal circumstances


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Stage 1Stage 1Available SupportAvailable Support

Degree of attachment Family crisis Psychological resources

Family Friends Self


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Stage 1Stage 1Meaning of Life and DeathMeaning of Life and Death

Gain from suicide What will happen after you die?

Protective Factors What has kept you alive?

Responsibility to family Fear of act of suicide Fear of social disapproval Religious beliefs


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Stage 1Stage 1Obtain Information from Other Obtain Information from Other SourcesSources

Family Friends Co-workers


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Stage 1Stage 1Contracts to Prevent Suicide Contracts to Prevent Suicide

Used by 50 percent of all clinicians All three stages involve a form of no suicide

contract No research evidence 1973 American Journal of Psychiatry


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Stage 1Stage 1Shifting from Higher to Lower Shifting from Higher to Lower Suicide RiskSuicide Risk

Convincing? Will it stand up under scrutiny? Consultation


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Stage 1- Desktop ProcedureStage 1- Desktop ProcedureAssessment of Mental Status & Psychological State of Assessment of Mental Status & Psychological State of Suicidal IdeationSuicidal Ideation

Minimum criteria for safety to move to Stage 2 Plan – Yes Intent – No Contract – Yes

Meets criteria? Go to Stage 2 If above criteria not met, can caller shift to

criteria during the call? If criteria cannot be met, implement appropriate

recommendations from Stage 3


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Stage 2Stage 2ConsiderationsConsiderations

Therapeutic alliance Ambivalence Evaluate from all gathered information Impact of understanding dangers of misleading


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Stage 2 Stage 2 Factors Interfering with AllianceFactors Interfering with Alliance

Cognitive Psychosis Delusions Alcohol – Drugs Intelligence, brain impairment Decision to die

Emotional Difficulty containing feelings Impulsivity Paranoia

If unable to form an alliance reevaluate information from Stage 1.


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Stage 2 – Desktop ProcedureStage 2 – Desktop ProcedureDoes Caller Understand Danger of Misleading the Does Caller Understand Danger of Misleading the Clinician?Clinician?

Ask directly Glean from what has been said Using drugs/alcohol? Cognitive functioning (limited, age) Psychological functioning (e.g., Personality

Disorder)

If caller does not understand danger of misleading clinician, re-assess Stage 1 and make appropriate recommendations

from Stage 3.


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Stage 3 Stage 3 Caller’s Role in the Recommendation Caller’s Role in the Recommendation ProcessProcess

Callers must agree to clinically appropriate recommendations

Plan to negotiate to find a recommendation that caller will follow

If caller does not follow recommendations, reassess Stages 1 and 2 and make appropriate recommendations.


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Stage 3 Stage 3 The Clinician’s ResponsibilityThe Clinician’s Responsibility

Plan that is appropriate for risk Patient safety

Moderate to severe suicide risk, take appropriate action Make appointment and involve family or friends to promote

follow-through Follow-up with referral source

The clinician’s goals Create a reasonable and justifiable referral/intervention plan Transfer to treating clinician

Close the loop.


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Stage 3 – Desktop ProcedureStage 3 – Desktop ProcedureRecommendationsRecommendations Can caller follow recommendations? If not, how can plan be modified?

Partial hospital/IOP Warm transfer to therapist, PCP, psychiatrist, insurance Advise parents of safety precautions Prevention call Talk with Family/supervisor Remove dangers (guns, pills) Follow-up allowed Someone accompany to appointment Someone stay with caller or go to friend/family NDBH & ER 24/7 availability and number Emergency room Inpatient Emergency appointment


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Stage 3 – Desktop ProcedureStage 3 – Desktop ProcedureRecommendations Recommendations continuedcontinued

Ascertain follow-through Provide clinical to ER and/or providers Ask for confirmation patient was seen

Provide concrete help Offer to call ambulance/transportation Inquire whether family member/friend/supervisor feels safe

transporting patient to facility Wellness check

Advise caller of the need to call police for wellness check Communicate clinical information/urgency to authorities Advise authorities of need for clinical assessment Duty to warn Other


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Resist Seduction Of Going Along With Resist Seduction Of Going Along With Callers Plan When Not AppropriateCallers Plan When Not Appropriate

Why we get seduced Don’t want to make caller/company mad Hope it will turn out OK Want to help We can fix anything Lack of information (shift change) Second hand knowledge

You are the Clinician.Callers need to follow your plan.


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When Stage 3 Cannot be MetWhen Stage 3 Cannot be Met

Reassess responses in Stages 1 and 2 Clinical consultation Supervisory consultation Legal consultation


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Legal RisksLegal Risks

ELEMENTS OF LIABILITY Duty Breach of Duty/Malpractice Causation of Injury Damages


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How to Establish Standards of How to Establish Standards of CareCare

Legal definition: “The level of conduct expect of a similar healthcare professional acting under the same or similar circumstances.”

Laws and court decisions

Professional association standards

Professional journals and research studies

Facility policies/guidelines


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Standards of Care IssuesStandards of Care Issues

Assessment Performance of Documentation

Referral/Intervention Plan Rationale Time Frames Modifications


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Standards of Care IssuesStandards of Care Issues

Informed decision making By Client/Caller Capacity to consent

Actions taken Review prior health information Communications Wellness Checks


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Lessons LearnedLessons LearnedDevelopment of this Paradigm Development of this Paradigm

Right decision – wrong result Don’t wait and hope caller will make good

choices Increase our direction earlier in process Help caller make good decisions Help caller to “walk the walk” All three stages of paradigm must be achieved


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Evaluation of Paradigm Evaluation of Paradigm EffectivenessEffectiveness

Vast majority of callers are grateful for direction No complaints Positive satisfaction surveys

Most important – no adverse outcomes


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EAP Data EAP Data Evaluation of Paradigm Evaluation of Paradigm EffectivenessEffectiveness

6.58%

3.80%

0.50%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

2002 2003 2004

Rate of Wellness Checks


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Evaluation of Paradigm EffectivenessEvaluation of Paradigm Effectiveness

Overall reduction in wellness checks 92.48% (p≤.001)

62.3% increase in calls voicing suicidal ideation from 2002 to 2004

2005 – 2 wellness checks for the same 6 month period


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MMH Emergent Data MMH Emergent Data Evaluation of Paradigm Evaluation of Paradigm Effectiveness Effectiveness

34.0%

18.4%

13.8%

0%

5%

10%

15%

20%

25%

30%

35%

2004 2005 2006TD

Rate of Wellness Checks


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Evaluation - Evaluation - ContinuedContinued

Recent application of paradigm for MMH Call Center

Reduction in emergent wellness checks of 59% comparing 2004 with 2006TD

Telephonic Assessment of Suicidal Telephonic Assessment of Suicidal Ideation ParadigmIdeation Paradigm

Brent L. Halderman, Ph.D.James R. Eyman, Ph.D.Sheryl Feutz-Harter, J.D., MSN, CHC

Nashville, TNOctober 7, 2006

This presentation is proprietary and cannot be duplicated, used, or adapted without NDBH permission. For permission, contact: [email protected]

Telephonic Assessment of Suicidal Ideation Paradigm Brent L. Halderman, Ph.D. James R. Eyman, Ph.D. Sheryl Feutz-Harter, J.D., MSN, CHC Nashville, TN October.

Documents

suicide potential stage

continuum slide

relationship stage

past suicide attempts

lower suicide risk convincing

specific risk factors

rescue suicidal behavior

family fear of act