CLASS 8 CRISIS AND SUICIDE.pdf

Partnering with persons experiencing crisis, self-harm, suicidality, abuse or violence Class 8: PPN 303 Promoting Mental Health Course What is a Crisis? Crisis Time Limited Response to life event/situation Overwhelms a person’s usual coping mechanisms Threatens and impacts sense of security,...

Partnering with persons experiencing crisis, self-harm, suicidality, abuse or violence Class 8: PPN 303 Promoting Mental Health Course What is a Crisis? Crisis Time Limited Response to life event/situation Overwhelms a person’s usual coping mechanisms Threatens and impacts sense of security, self-concept, efficacy, esteem. Caplan, 1964; Jakubec, 2014 3 Question: Is Crisis Bad? Good? 4 Some Considerations Individuals may be more open and amenable to interventions during crisis Opportunity for personal evolution and growth Resiliency and gain skills and hopefulness for future TIMELY CRISIS STABILIZATION essential to mitigate further negative impact Rosanra Yoon Independent Consultant 5 What types of Crisis are there? Rosanra Yoon Independent Consultant 6 Types of Crisis Developmental/Maturation Crisis • Developmental Life Stage that creates internal conflict • Adolescence, moving away, marriage, becoming parent, retirement, etc. Situational Crisis • Events that are external and un-expected • Loss/change in job, death of loved on, financial troubles, sudden illness. • These events have the potential to become crisis if the person does not have resources or coping to overcome. Disaster or unexpected situation • unexpected, unplanned, or random) crisis results from events that are not part of everyday life (such as natural disasters or violent crime). These crises may threaten survival. Experiencing or witnessing such events can also overwhelm a person’s ability to cope RNAO, 2017; Jakubec, 2014) 7 Phases of a Crisis (Caplan, 1961) Phase 1 Problem arises that threatens self-concept Increasing anxiety stimulates use of usual problemsolving techniques Phase 2 Usual problem-solving techniques are not effective Anxiety continues to rise Trial and error efforts to restore balance Phase 3 If Trial and error attempts fail, the anxiety escalates to severe levels/panic Adopts automatic relief behaviours – compromising needs or redefining the situation to reach acceptable solution Phase 4 All attempts ineffective to reduce anxiety/distress State of overwhelming anxiety which can lead to cognitive impairment, emotional instability, and behavioural disturbances that signal the person is in crisis. 8 Some Considerations Individuals may be more open and amenable to interventions during crisis Opportunity for personal evolution and growth Resiliency and gain skills and hopefulness for future TIMELY CRISIS STABILIZATION essential to mitigate further negative impact 9 Crisis as a response to factors that are holistic & human aspects of the living experience Socio-Cultural Psychological Situational Biological Developmental Spiritual 10 !""#$%&&'()*+,)&-#.&./01230(2$&,'0$0$4 0("2'52("0*( Rosanra Yoon Independent Consultant 11 Roberts 7 Stage Crisis Intervention Model : Figure 17.7 Roberts’ (1991) Seven-Stage Crisis Intervention Model. 12 Trauma-Informed Approach Principles Safety Trust Choice Collaboration/Mutuality Shared Power Cultural, Historical and Gender Issues • Prioritize psychological, emotional and physical safety • Act in ways that are trustworthy and transparent • Enable choice • Ask Permission • Work collaboratively with the person • Empowerment and recognition of power imbalances • Mindful of intersectionality SAMHSA’s Concept and Guidance for a Trauma-informed Approach, 2014) 13 Trauma-informed Approach Applied to Crisis Realize Recognize Respond Prevalence & Impact of Trauma The signs of trauma Ways that reduce re-traumatization Guiding Principles Establish Feelings of Personal Safety Intervening in Person-centered ways Recovery, resilience & natural supports Services are provided in the least restrictive manner Rights are respected Rosanra Yoon Independent Consultant 15 Communication Techniques Demonstrate Empathy & Respect Talk Openly Be self-aware; including body language and facial expressions Feel comfortable with the Unknown Stay Calm and demonstrate emotional regulation Show Genuine Interest by being a good listener The Jean Tweed Centre (2013). Trauma Matters: Guidelines for Trauma informed practices in women’s substance use services, Toronto. 16 Acute Crisis Intervention Rosanra Yoon Independent Consultant 17 Risk to Personal Safety or Safety of Others Active Suicidality Risk to self due to functional impairment Risk to others Intention to Harm others Mental Health Act Form 1 Form 2 • Physician completes when person is at significant risk to themselves or others. • Family/Friend/nonMD professional can request from Justice of Peace (court) • Legally authorizes the person remain in hospital to be assessed for up to 72hrs for emergency assessment • Allows the police to take the person to a hospital for assessment. Community Treatment Order • Allows Physician to mandate supervised treatment of a ptient when discharged from hospital • Goal is to prevent mental health deterioration due to medication noncompliance. 19 Ethical & Legal Considerations? • • • • • • Rights of the Person Limits of the Law Safety Therapeutic Relationship vs Safety of client Professional duty and ethical code of conduct Least restrictive measures Rosanra Yoon Independent Consultant 20 Safety Plan (CAMH, 2016 – personal safety Plan) What makes me feel Safe? What makes me feel unsafe? How do I know When I am becoming or in a crisis? What does it look like when I am in distress or losing control? When I am in distress/crisis, I need What activities or coping strategies can I try to calm and comfort myself? What can others do to help 21 Resources Available in Toronto Area 22 Distress Centre of Greater Toronto https://www.dco gt.com/408-helpline 23 Gerstein Centre 24 Video – Gerstein Centre https://www.hrw.org/video-photos/video/2021/11/19/canada-alternative-waysaddress-mental-health-crises 25 Rosanra Yoon Independent Consultant 27 Mobile Crisis Intervention Team (MCIT) Rosanra Yoon Independent Consultant 28 Nursing Care Crisis intervention • • • • • Early intervention Stabilization Facilitate understanding Focus on problem solving Encourage self-reliance The goals of crisis intervention are to: • Assist individuals to return to an adaptive level of functioning • Prevent or moderate the potentially negative effects of extreme stress Self-Harm Behaviour and Suicide Background • Canada ranks 41st in the world for reported suicides (WHO, 2012) and, within Canada, suicide is the ninth leading cause of death overall; seventh for men and thirteenth for women • Factors that affect suicide risk differently by gender include: • Experiences of violence • Family upbringing • Economic deprivation 31 Question #1 Is the following statement true or false? In Canada, suicide rates for men and women are about the same. Answer to Question #1 False Rationale: In 2011, in Canada, the male suicide rate was approximately three times that of women. Indigenous People • In 2013, Inuit males aged 15 to 19 years are 40 times more likely to kill themselves than their non-Inuit peers. • It is important to note that aboriginal suicide rates may be underreported. • In indigenous communities where there is autonomy and a strong sense of ownership, culture, and community, there are much lower rates of suicide. LGBTQ Sexual Orientation • “Coming out” can be a risk factor. • During adolescence, a gay, lesbian, bisexual, or transgender (GLBT) youth’s search for self-identity may heighten depression and suicidal behaviour. • The risk factors associated with GLBT individuals are in addition to those common to all ages and sexual orientations. Regional Variations Provincial statistics from 2009 show varied rates of suicide across Canada. Eastern and central regions of the far north have some of the highest mortality rates from suicide. As of 2009, the suicide rate per 100,000 people for Nunavut was 56.9, while for the Northwest Territories, it was 21.9 and for Québec, 13.7. Guns and Suicide In 2014, almost 60% of all firearm deaths are suicides, and firearms are used in nearly 20% of all suicide fatalities. Urban areas show the highest rates of completed suicides by firearms. Suicidal Ideation and Self-Harm • It is estimated that 36,560 (0.1%) people have unstated thoughts of suicide or suicidal ideation. • Physical factors. • Psychological factors. • External social risk factors. • Suicidal ideation and self-harm are more common among adolescents than other age groups. • Common Characteristics of Suicide: • Box 19-5 38 Etiology of Suicidality Suicidal behaviour occurs in the context of an individual’s stresses that include: • Physiologic • Psychological • Social situations Usually triggered by stressors that are unmanageable and exceed typical coping efforts. Psychological Theories MDD, generalized anxiety disorder, personality disorders, bipolar disorder, schizophrenia, substance use disorders, and other psychiatric illnesses are frequently present. Substance use disorders have been determined as responsible for approximately two thirds disability adjusted life years allocated to suicide globally in 2010. Cognitive approaches attribute suicide to learned helplessness and hopelessness as an automatic and pervasive pathologic scheme or organizing and interpreting experience. Attachment theory explains social isolation and disrupted interpersonal relationships as being a part of the spectrum of suicide Social Theories Durkheim classified suicide under four headings: egoistic suicide, altruistic suicide, anomic suicide, and fatalistic suicide. Cohen and colleagues: socioeconomic status is a driving factor in what happens to an individual, affecting the physical and social structures available to him or her. Suicide contagion and suicide clusters have occurred. Bullying, cyber bullying as a risk for suicide. Spiritual Theories Spirituality has reemerged as an important component of holistic nursing care. Spirituality can mean a search for meaning, connectedness, energy, and a person’s worldview. Spirituality is being recognized as a source of resilience and coping. It has been hypothesized that not only personal but also contextual differences in religious beliefs may determine an individual's willingness to consider suicide. Effects of Suicide Suicide has devastating effects on everyone it touches. Average cost of hospitalization for suicide and attempted suicide was $5,500 per admission in Canada. Family survivors of suicide report increased stigmatization and rejection than other causes of death. Suicide Terminology Attempted Suicide—the intentional act of killing oneself (Box 19-5) Completed Parasuicide—may mimic suicidal behaviour, but the primary motivating force of action is not to kill oneself Suicide ideation—thinking about or planning one’s own death Lethality—the probability that an individual will be successful in completing suicide 44 Assessment Nursing practice reflects diverse health care settings and can play an important role in suicide prevention. • Comprehensive assessment of risk: • Stressors • Symptoms • Prior behaviour • Current plan • Resources and support • Questions to Guide a Comprehensive Assessment of Risk • Box 19-7 45 Contracting for Safety Having the patient agree and commit to no self-harm or suicide attempt for an agreed upon period of time states that patient will not engage in suicidal behaviour for a specific period of time. The patient must be competent to enter a contract. Avoid or reduce use of substances. Consider Advantages and disadvantages Inpatient Care and Acute Treatment Hospitals were once used for extended periods to protect the patient from suicide and establish treatment of underlying psychiatric disorder. This is no longer the case. Objectives of hospitalization: Maintain the patient’s safety. Decrease the level of suicidal ideation. Initiate treatment for underlying disorder. Evaluate for substance abuse. Reduce level of social isolation. Connect patient and family with ongoing outpatient resources and therapy. Biologic Interventions Ensuring safety • • • • Hospital protocol for safety Engaging in a therapeutic relationship Observing the patient regularly Removing dangerous objects Somatic therapies • Medications • ECT Assisting with treatment of substance abuse Psychological Interventions Evaluating the patient’s ways of thinking about problems and generating solutions Cognitive interventions Developing plans to prevent future suicide attempts Box 19-9 Social Interventions 1 Improving communication 2 Networking and discharge planning 3 Educating the patient and family Supporting Persons With a History of Abuse or Violence Abuse • Most abuse of women, children, and elderly is intimate violence. • Perpetrator loved and trusted person • World is no longer safe. • Empowerment is foreign. • Empowerment is the promotion of the continued growth and development of strength, power, and personal excellence. 52 Woman Abuse Significant health problem crossing all racial, ethnic, and socioeconomic lines. In 2009, there were nearly 1.6 million self-reported incidents of woman abuse in Canada. Single, divorced, and separated women at highest risk. The perpetuation of violence begins early in dating relationships. Patterns of violence and assault are frequently established in early relationships. Abuse of Men Now higher in men than traditionally believed. Men and women experience similar levels of spousal violence. Men were more likely than women to be physically assaulted in a public place. Males were also more likely to be victims of more serious assaults. Men are less likely than women to seek help. Child Abuse Prevalence is far reaching. The most common forms of child maltreatment include: • Witnessing intimate partner violence (34%) • Neglect (34%) • Physical violence (20%) • Emotional neglect (9%) Physical abuse. Sexual abuse. Emotional abuse. Factitious disorder by proxy: Munchausen’s syndrome by proxy. Secondary abuse: children of battered women. S Elder Abuse • Elder abuse, in the context of a growing ageing population, is increasingly recognized as a serious problem in Canada and other countries. • Adult children (34 per 100,000) have been identified most often as responsible for family violence against older adults. • Women are particularly vulnerable. 56 Risk Factors for Elder Abuse Risk within the environment such as a caregiver who is depressed and/or inadequate economic resources/strained Characteristics of the vulnerable elder individual which predispose to abuse, such as cognitive impairment, lack of empowerment or difficulty with activities of daily living (ADLs) Battering Battering can be defined as repeated physical or sexual violence with the intent of coercive control. Estimates of injury related to battering seen in EDs range from 14% to 50%. Single greatest cause of injury to women. The realistic fear of being killed is one factor that keeps many women from leaving abusive partners. A significant danger to unborn children. Human Trafficking Human trafficking in Canada is a lucrative activity with well organized and extensive trafficking networks reaching across the country and international borders (Oxman-Martinez et al., 2005; Public Safety Canada, 2012). Most cases involve sexual exploitation in large urban areas although the reach can extend to smaller centres. T The majority of victims of human trafficking in Canada are female, primarily indigenous women and girls, and almost half are between the ages of 18 and 24 (Karam, 2014; Oxman-Martinez et al., 2005). Special Considerations in Sexual Assault • • • • • • Early treatment & support crucial Diminish survivor distress Supportive, caring, nonjudgemental Unwanted pregnancies STI, HIV Interventions • Education • Counselling • Emotional support 60 Sexual Assault & Domestic Violence Empathic Support Provide Information and offer Choice Assess for injuries. Refer to SA/DVCC: Collect evidence for forensic evaluation. Specially trained 61 Nursing Management: Human Response to Abuse • Approaches to working with people experiencing IPV should be informed by trauma-informed care, an approach grounded in a substantial body of research and practice knowledge. • A trauma-informed approach is based on an understanding of the impact of violence on individual’s lives. • The assessment should be conducted in a private setting, and the number of professionals who interact with the client should be reduced. • Removing children and elders from their families or caregivers often is necessary to ensure immediate safety. 62 Cycle of Violence Figure 34.2 The cycle of violence. Adapted from Walker, 1979, 1984. (Adapted from Walker, L. (1979). The battered woman. New York, NY: Harper & Row;Walker, L. (1984). The battered woman syndrome. New York, NY: Springer Publishing Co.) 63 Biologic Domain/Assessment • Nurses should assess everyone for violence. • Establish a trusting nurse–patient relationship. • Lethality assessment Danger Assessment • Box 34-2 • Develop a repertoire of age-appropriate, culturally sensitive, abuse-related questions using an approach that is trauma informed. • History and physical examination. • Suggestive of Abuse • Boxes 34-3 and 34-4 • 64 Dissociative Identity Disorder #1 • Among survivors of abuse, dissociative symptoms may be part of the symptom picture of ASD and PTSD, or they may be the predominant symptom known as dissociative identity disorder (formerly multiple personality disorder). • Prevalence unknown. • The hallmarks of DID are two or more distinct identities with unique personality characteristics and an inability to recall important information about self or events that is too extensive to be explained by ordinary forgetfulness. 65 Substance Use and Dependence • Association between childhood abuse, PTSD, and substance use and dependence is well established. • Survivors who experience PTSD, depression, and other forms of hyperarousal or emotional distress often use substances. 66 Collective Trauma Occurs when a traumatic event is experienced by a significant proportion of a given social group. It can have long-term consequences for the social group beyond its additive effect on individuals such that social norms, dynamics, functioning, and structure of the group may be modified. Historical Trauma • The process by which a social group is affected by the consequences of multiple, collectively experienced adversities across time that outweigh group resiliency factors, become cumulative, and are carried forward to subsequent generations such that the trauma may be considered as part of a single trajectory. Integrated Holistic Community Approaches: Rebuilding Communities • • • • • Creating public awareness Training of grass root workers Encouraging traditional practices and rituals Promoting positive family and community relationships and processes Rehabilitation and networking with other organizations (Somasundaram, 2007; 2014) 69