Suicide Prevention, Assessment and Management in Healthcare Staff

Suicide Prevention, Assessment and Management in Healthcare Staff

Suicide Prevention, Assessment and Management in Healthcare Staff Training-CLINICAL Maine Suicide Prevention Program In partnership with: NAMI Maine Education, Resources and SupportIts Up to All of Us. Maine Suicide Prevention Program A program of the Maine Center for Disease Control and Prevention since 1998 Statewide Activities Include: Data collection, analysis & dissemination of print materials SAMHSs Information and Resource Center Training on suicide prevention and assessment to a wide range of partners Technical Assistance for organizations and communities addressing suicide risk or coping with a suicide loss. Annual NAMI Maine Walk September 23, 2018 Training Agenda Introduction and rationale for effective suicide prevention and management in medical settings Beliefs, language and attitudes about suicide Working toward Suicide-safe practice in Healthcare settings Warning signs and risk factors

Assessment and management of suicidal risk Resources for Help Importance of Safety Planning Assuring follow-up for patients at elevated risk The aftermath of suicidal behavior Introduction For professionals suicide is a specter that haunts practice. When

you experience the suicide of a patient, it is a devastating loss of life deeply impacting family, friends, community and treatment providers. 71% of psychotherapists report having at least one client who has attempted suicide, while 28% report having had at least one client die by suicide. Lisa Firestone A suicidal crisis is almost always transient and treatable Suicide is the most preventable form of death in the US today. (David Sacher, former US Surgeon General) Preventing Suicide Begins with Our Ability to Talk about Suicide Openly Talking About Suicide Preventing suicide starts with our comfort in acknowledging

and talking about suicide Preferred: Simply use the word suicide died by/of suicide suicide attempt Use clear language that is age appropriate for your audience Our Ease with Talking About Suicide is Shaped by:

Personal and family history Cultural background Personal, regional and community values Religious beliefs Professional ethics Organizational/practice culture and history Other? Why People May Deny Suicidal Ideation?

Why People May Deny Suicidal Ideation? Unwilling to admit needing help Fear of loss of autonomy Shame, embarrassment, fear of stigma

Belief they cannot be helped Unable describe their feelings/needs Concern over disappointing or being a burden to others Not thinking of suicide at this time Do not want to be stopped. Adapted from Berman 2014 What May Complicate our Response? What May Complicate our Response Our own emotional reactions: Fear/anxiety re suicide Frustration/countertransference

Sense of hopelessness about the situation Legal and litigation fears Our own beliefs re. suicide The pace of our work demands Concern re. competence/experience The Burden of Suicide: Maine and the US Suicide in the United States, 2016 13

44,965 Americans died by suicide in 2016; about 1 person every 12 minutes1 Suicide deaths are 2.3 times the number of homicides (homicides=19,362) 1 10th leading cause of death across the lifespan1 2nd leading cause of death for 15-34 year olds Males account for 77% of suicide deaths1 Veterans account for approximately 17% of all suicides3 Since 2009, suicides have exceeded motor vehicle crash related deaths1 1. U.S. CDC WISQARS Fatal Injury Data, 2016 update. Accessed January 2018; 2. Maine Hospital Inpatient Database, Maine Health Data Organization, 2013-2014. Hospital discharge data for intentional self-inflicted injury related hospital discharges defined as hospital discharges in which any listed external cause of injury was coded as ICD-9CM E950-E959 . 3. Suicide Among Veterans and Other Americans 20012014 report, updated 3 August 2016, U.S. Department of Veteran Affairs. Maine consistently has higher suicide death rates than both the U.S. and the Northeast.

Suicide Death Rates: Maine, the Northeast and United States, 2000-2016 (age-adjusted rate per 100,000 population) Maine Northeast United States 15.7 13.4 11.7 10.4 10.2

7.7 2000 2001 2002 2003 2004 2005

2006 2007 2008 Year Data source: U.S. CDC WISQARS Fatal Injury Data, National Vital Statistics System (NVSS) 2009 2010

2011 2012 2013 2014 2015 2016 Suicide in Maine, 2014-2016

9th leading cause of death among all ages (previously 10 , 2012-2014) 2nd leading cause of death ages 15-34 4th leading cause of death ages 35-54 Suicide deaths 9x homicide deaths Every 1.6 days someone dies by suicide

Every other week a young person dies by suicide (ages 10-24 ) 3 female attempts per every 2 male attempts2 227 suicide deaths per year on average Firearms most prevalent method of suicide (52%) 1. U.S. CDC WISQARS Fatal Injury Data, 2016 update. Accessed January 2018; 2. Maine Hospital Inpatient Database, Maine Health Data Organization, 2013-2014. th Average Annual Suicide Deaths, by Age & Sex, Maine, 2014-2016 (3 years combined) Count (Males)

Count (Females) 36 34 27 24 21 18 9

5 12 13 5 4 Supp 0-14 15-24

25-34 13 35-44 45-54 55-64 65-74 7

Supp 75-84 AGE GROUP Data source: US CDC WISQARS Fatal Injury Data, Rates for females ages 75-84 and 85+ suppressed due to fewer than 10 deaths. Supp 85+ Suicide Attempts A suicide attempt may be the first overt sign that someone is struggling! A call for Help Often trigger being seen by a provider! Estimates 25 attempts for every suicide death

200:1 for adolescents 4:1 after age 70 Ask about a history of suicide, especially for a depressed patient A past suicide attempt is most predictive of future suicide behavior. Non-Suicidal Self-Injury

Distinct from suicidal intent, but those who self-injure are at higher risk for suicide Reasons for Self-Injury are many: o Release of tension and anxiety o Relief from emotional/physiological pain o Self punishment o To affect change in others Self-injury requires intervention and treatment to break the cycle; Self Injury often seen as a way to avoid suicide: As a means to cope with negative emotions Is often linked to suicidal ideation: Recent self-injury may be the most predictive of future suicide risk

Making the Case Why Suicide Prevention in Health Care? Role of Hospitals in Suicide Prevention Rates of suicide in the hospital, whether on a medical or psychiatric unit, appear to be substantially lower than community-based suicide rates, but Est. 1007 inpatient suicides 1995-2012 Transitions from inpatient care to outpatient LOC present increased risk. In 2006, the Joint Commission designated the assessment of suicide, for patients admitted to a health care facility for behavioral health reasons, a National Patient Safety Goal. 2016 Joint Commission Sentinel Alert details recommended screening, assessment, treatment, safety planning and follow-up. * Handout-Joint Commission Alert 2016

Specific JCHO Recommendations (Sentinel Event Alert 2-24-2016) Review the patients history for suicide risk Screen all patients, medical & behavioral health, for suicidal ideation (PHQ-9). As indicated, use evidenced-based assessments to determine risk. (eg. C-SSRS) Use Assessments results to guide appropriate level of care/safety measures. Develop and use a collaborative process for care across the provider system.

Develop plans and referral for treatment addressing suicide risk. Educate all staff in patient care settings on how to identify and respond to suicide ideation. Document decisions regarding care and referral of patients with suicidal risk. Making the Case Why Suicide Prevention in Primary Care? Role of Primary Care in Suicide Prevention Of individuals who died by suicide: 77% had seen a primary care physician within the last year 45% had visited within the last month Many visits were for symptoms that could be attributed to a mental illness

Only 32% had initial contact with mental health provider Primary Care; Continued More than 70% of adolescents visit a physician at least once every year Many adolescents prefer being seen by a medical provider for emotional issues oLess stigma oA familiar pathway and known staff Men are much more likely to be seen by a medical provider before a mental health clinician Older adults are least likely to seek mental health treatment Working toward Suicide-Safe Care Within

a System of Care Potential Situations in Healthcare Settings Adolescent placed inpatient post impulsive suicide attempt, anxious depression, episodic binge substance use, resistant to follow-up plan, being discharged to home. Parents worried. 17 y/o female seen in ED post self-inflicted full thickness lacerations to each forearm. Denies suicidal intent but with significant risk factors. Patient evaluated for opioid abuse post unable to access additional medication; agitated distressed and feeling trapped/ desperate refusing detox or treatment options. Male, age 49. PCP screening endorses PHQ-9 for mod/severe depression and thoughts of death. Recently lost job d/t injuries and is separated from wife of 18 years; ETOH use is escalated. 83 y/o male, inpatient for depression and self-care; recently widowed and w/o family support reports praying every night that God will let him go. I dont know how much more I can take. Female ED patient, 24, seen with significant Sx. depression, hopelessness and anxiety states, My

children would be better off without me. Systematic Suicide Care Plugs the Holes in Health Care Develop Collaborative Safety Plan with Lethal Means Restriction Directly Treat Suicidality: Suicide-Informed CBT, DBT, CAMS, Support Suicidal Person

Screen, then Assess for Suicidality Assure Excellent Follow-up, and Stay in Touch Death or Serious Injury Avoided National Action Alliance Zero Suicide Initiative Suicide Prevention-Ready Practice

Recognize that suicide risk is real and regularly seen in our patients ALL staff are aware of risk and receive training on what to do (in their role) For phone calls regarding someone at risk

For new admissions or walk-ins In the treatment rooms For care coordination during transitions and following discharge There are regular processes to screen for depression and suicide risk Clinical staff have tools & skills for suicide risk assessment Partnerships are active with regional crisis provider and other resources Collaborative Safety planning is a practice norm for suicidal patients Proactive, assured follow-up is secured for all patients at risk Warning Signs Risk Factors Protective Factors

Definitions Risk Factors- Stressful events or situations that may increase the likelihood of a suicide attempt or death. (Not predictive!) Protective Factors- Personal and social resources that promote resiliency and reduce the potential of suicide and other high-risk behaviors. Warning Signs- the early observable signs that indicate increased risk of suicide for someone in the near-term. (Within hours or days.) Risk Factors for Suicide in Healthcare Settings Previous suicide attempt Major mood or anxiety disorder Substance abuse Other mental illnesses (eating disorders, psychosis, PTSD )

Comorbidity (psych/SA/medical) Physical illness, esp. chronic, and progressive or lifethreatening Chronic pain CNS disorders/traumatic brain injury Chronic insomnia Impulsivity Failed belongingness Perceived burdensomeness Loss of fear of death/pain What else?

Mental Illness as a Risk Factor for Suicide Mental Health Disorders and Suicide Studies in the last 50 years report consistent outcomes: 90% of people who die by suicide are suffering from one or more diagnosable psychiatric disorders: Major Depressive Disorder Bipolar Disorder, Depressive phase Anxiety Disorders Alcohol or Substance Abuse* Schizophrenia Eating disorders

Personality Disorders such as Borderline PD *Primary diagnoses in youth suicides. Connecting Depression and Suicide According to the National Institute on Mental Health: 9.5% or over 18 million Americans suffer from a depressive illness each year. Lifetime suicide risk for those with untreated depression is about 20%. People with major depression have a 20 times increased risk of suicide. Risk is further exacerbated by active substance abuse, anxiety disorders and agitation. Depression responds to treatment in 60-80% of the cases. Populations at Increased Suicide Risk

Men as a High Risk Group 76% of suicides(2016) Gender disparity highest in elders (especially white) Gender issues include: Poor help-seeking Men less likely to talk to someone Difficulty recognizing and expressing emotions Increased substance abuse Use more lethal means Feeling like a burden Struggle between belongingness and independence LGBTQ Youth/Young Adults

Suicide attempt rates 3-4 times their peers Increase due to societal stigma and rejection Critical risk factors include rejection, depression, anxiety, chronic stress, abuse, victimization, bullying, etc Rejection by family can increase risk up to 8X Family acceptance and school safety are strong protective factors Cultural competence is important in prevention Warning Signs These are changes in behavior or appearance that indicate someone is in crisis! Clear Signs Of A Suicidal Crisis

1. Someone threatening to hurt or kill themselves 2. Someone looking for the means (gun, pills, rope etc.) to kill themselves 3. Someone showing clear distress/ agitation/ anxiety Get the facts and take action! Call 911 if lethal means is present Call Crisis Hotline if no means present Warning Signs I Ideation / threatened or communicated S Substance abuse / excessive or increased? (include withdrawal)

P A T H Purposelessness / no reasons for living Anxiety /agitation / insomnia Trapped / feeling no way out Hopelessness / nothing will ever change W A R M

Withdrawal from friends, family, society Anger (uncontrolled)/ rage / seeking revenge Recklessness/ risky acts / unthinking Mood changes (dramatic) Adolescent Warning Signs for Suicide Is the youth (up to age 24) : Talking about or making plans for suicide

Expressing hopelessness about the future Displaying severe/overwhelming emotional pain or distress Showing worrisome behavior or changes particularly in the presence of the above warning signs. Specifically: o Withdrawal from or changes in social connections o Recent increased agitation or irritability o Anger or hostility that seems out of character or context o Changes in sleep (increased or decreased) AAS Consensus group, 2014 Protective Factors in Medical Settings

Effective clinical care for mental, physical and substance use disorders Easy access to the range of clinical interventions and supports (open access) Restricted access to highly lethal means of suicide Support through ongoing medical and mental health care relationships, especially follow-up care, Compliance/adherence to treatment Skills in problem solving, conflict resolution and self-advocacy

Awareness and symptom management skills through teaching Cultural and religious beliefs that discourage suicide and support self-preservation You! And your making a connection with each person. From a Suicidal Persons Point of View Crisis point has been reached Pain is unbearable Solutions to problems seem unavailable Thinking is affected HOWEVER: Ambivalence exists Communicating distress is common Invitations to help are often extended Ambivalence opens the door for

intervention Intervention: A bridge to help What might prompt an assessment/ intervention in your setting? Reason for current hospitalization/ appointment Concern expressed by family members New patient with history of suicidality Results of PHQ-9 or other signs or history of depression Statements made by individual Observed warning signs, especially if history of suicide exists What Else?

Intervention It all starts with a conversation Allow the patient to tell their story Active intervention is needed Engagement is essential Importance of connections/ breaking isolation Reduce the level of risk by removing all lethal means Invitations are often extended to people based on fit Work to manage your own reactions. Asking About Suicide The answers you get depend upon the questions

you ask. Thomas Kuhn What is Your Reaction When Your Patient Talks About Suicide? Personal Professional What are your concerns? How do you know when youve done enough? When I ask her about suicide, Im thinking How do you take care of yourself? Activity: Small Group Discussion

Asking About Suicide Overcoming Societal Reluctance Talk about suicide directly and without hesitation using concrete and direct language. Are you having thoughts of suicide? Are you thinking about dying today? How often have you considered killing yourself? Vague or indirect questions elicit vague responses: Are you thinking of hurting yourself? Do you feel safe? Youre not going to kill yourself are you? If you doubt the answer, repeat the question differently.

Responding to a Suicidal Statement Do: Listen and encourage sharing Ask How can I help? Act to keep the person safe Actively connect the person with help Dont: Over-react with fear or anger Reassure and redirect before listening to the person Dismiss or minimize the persons concerns or problems Keep secrets where safety is a concern Assessing Suicide Risk

Components of Suicide Assessment and Response What triggers an assessment? What to Assess: Essential Information Needed Use of appropriate tools to Determine Level of Risk Patient query and additional sources of information (if needed) Determine Level of Care to Ensure Safety Assist in Referral to appropriate care; Safety Planning to support ongoing self-management Follow up with patient after the crisis Assessing Risk To ensure a consistent valid risk assessment and documentation of the

assessment, use of a structured instrument is recommended The Maine Suicide Prevention Program supports the use of the Columbia Suicide Severity Rating Scale(C-SSRS) as a tool for screening for and evaluating suicide risk Other tools may be used if they assess the the same elements It is important that whatever tool is used be valid and reliable across a wide range of populations and for the setting where it will be used; ex. inpatient vs. outpatient MGMC HARM Scale A. Attempt of HARM in Hospital or other Yes Treatment Facility * No B. Attempt at Harm to self or others

Within past 7 days Within Life Time Never C. Lethality of Attempts to self or others High Low lethality No attempt

D. Thoughts of Harm within past 24 hours to self or others Constant or intense Intermittent or mild thoughts of doing harm. thoughts of doing harm. Yes No thoughts of doing harm. No

F. History of Family or Friend Suicide Yes Suicide Completed Suicide Attempt No G. Recent behavioral health or medical care sought Admission to hospital or Admission to hospital None RCU within last 7 days. RCU within last 30 days

E. Plans to do Harm in hospital to self or others MGMC HARM Scale H. Recent behavioral health or medical care sought I. Current Symptoms Depressed Hopeless Helpless Anhedonia Humiliation Insomnia Frustrated

Impulsive Shame Angry Guilt J. Alternation in Thought Process Hallucinations Command hallucinations Delusions Thought Insertion Mind Reading Admission to hospital or RCU Admission to hospital RCU None within last 7 days.

within last 30 days Severe Presentation Regarding One or More Items Severe Presentation Regarding One or More Items Mild Presentation Able to manage without impairment Mild Presentation

Able to manage without impairment. None Denies all symptoms None Mental status stable MGMC HARM Scale K. Substance use including alcohol benzodiazepines, pain meds, or any

other L. Significant Loss Family Financial Friend Recent Move Unemployed Spiritual Declining Health Divorced/Relationship Within Last 24 Hours Within Past Month

Severe Presentation Mild Presentation Regarding One or More Items Able to manage without impairment M. RN's Subjective Appraisal of Patient's Reliability

Not reliable Uncertain None None Reliable Columbia Suicide Severity Rating Scale (C-SSRS) Screen Version: An evidence-based screening tool with applications as an assessment instrument Level of information based upon clinical conversation guiding

response Though short and needing little time, it enables more nuanced estimation of risk Versions available for use with children/ adolescents. Currently in use in primary care, inpatient settings, EDs, by Crisis teams Suicide Assessment Interview (C-SSRS; Screen Version) Suicidal Ideation Have you wished you were dead or wished you could go to sleep and not wake up? Have you actually had any thoughts of killing yourself?

Suicide Thoughts with method (no specific plan) Have you been thinking about how you might kill yourself? Intent without specific plan and then with specific plan Have you had these thoughts and had some intention of acting on them? Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? History of suicidal Behavior "Have you ever done anything, started to do anything, or prepared to do anything to end your life?

If yes, when, how long ago and details of the event(s)? *Over the past week or the past month C-SSRS Full Assessment If C-SSRS screen indicates suicide risk, complete a full assessment to determine level of risk and level of care needs, First 6 questions are same as screen version, deeper exploration re. ideation. Suicide attempt history and para suicidal behavior history and details including self-injurious behavior done without suicidal intent Most recent, most severe, trend toward increasing severity of damage Details about attempts aborted by self or interrupted by others, A detailed assessment of current preparatory actions including acquisition or availability of lethal means, rehearsal, writing a note. . . An assessment of potential lethality of means and methods identified

Additional Online Training on C-SSRS The Columbia Lighthouse Project: Offers various versions of the screening and assessment forms as well as online training and other options for training. Assessment of Suicidal Risk Using the C-SSRS This free, online training from the New York State Office of Mental Health and Columbia University provides an overview of the instrument and teaches how and when to administer it in real world settings. Suicidal Ideation Questions for Exploring Ideation

How often do you think about killing yourself? Hourly? Daily? Weekly? When was the last time you had thoughts of suicide? Describe how long they last and the intensity or severity of these thoughts What triggers your thoughts of dying? What helps them go away? Intensity: Can you rate these thoughts/feelings on a scale of 1 to 10? How easy is it to control your thoughts of suicide? Exactly what do you think about when considering suicide? Adapted from M.D. Rudd, The Assessment and Management of Suicidality, 2006

Previous Attempts One or more previous suicide attempts is the single most important predictor for future suicidal behavior. Always ask about attempt history! Attempts: Actual Attempt (in the mind of the attempter) Interrupted Attempt: By someone else Aborted or Self- Interrupted Attempt Preparatory behavior: Method, planning, acquisition of means, rehearsal The more recent the attempt, the more potent a predictor. 50% re-attempt within 1 year Ask about attempts made in medical settings. Short-term (Acute) Risk Factors

and Symptoms These are the additional signs shown to drive short-term risk! Acute psychic distress (including anxiety, panic and especially agitation) Extreme humiliation/disgrace, shame, despair, loss of face Acute Hopelessness / Demoralization Desperation/sense of no way out Inability to conceive of alternate solutions to the problems Breakdown in communication/loss of contact with significant others(including therapist), Isolation Impulsivity/aggression Symptoms of psychosis How to Work with Assessment Results Assessment is often done by an individual.

Management of safety, level of care decisions and ongoing treatment is most effective when approached as a team sport. Triage decisions are best done with consultation. Triage guidance is available for the C-SSRS, but must take into consideration available in-practice resources, clinical judgment and extenuating circumstances. Always ere on the side of safety and caution. Consult, consult, consult! Who do/can you speak with? Resources for Help What are YOUR resources? Resources for your Organization/Setting (for modification) For your organization; answer the following questions for your audience

Who can or should ANYONE notify if they believe a patient is at risk of suicide? Basic response Stay with the patient Stay close to share relevant observations Who does suicide risk assessment in-house? When do we call 911? When do we call in Crisis? When do we send someone to the ED? Can you request Psych Consult? Never leave the person alone; Arrange for One-on-One as needed? When to Call Crisis Crisis clinicians:

Available 24 / 7 Experts at assessing and responding to a crisis. Can often come to your location for an assessment Call for a phone consult when you are: Concerned about someones mental health Need advice about how to help someone in distress Worried about someone and need another opinion The phone call is free 1-888-568-1112 Collaborative Safety Planning

A Safety plan is a written list of coping activities personal, social and professional resources developed with a person, for use during and after a crisis: Allows time to assess if a person is willing, ready & able to engage in planning for their safety Focus on personal coping skills, and activities Allows exploration of family personal and social resources and the ability to mobilize them Focus on professional supports engaged and available Opportunity to plan for lethal means restriction See also: Safety Planning Guide; Quick Guide for Clinicians The Challenge The next crisis will happen when they are not on our unit!

1. How can a patient manage a suicidal crisis as it develops? 2. How can we work with a patient to support their ability to manage through a crisis? 3. How can we help them identify and activate resources and maintain control as crisis looms? The Opportunity Having the ability to support someone outside a treatment setting is important; especially when they are being discharged after a suicidal crisis. Why? The goal of inpatient work is to discharge the patient to a lower level of care, and to support their independence. Moments of crisis typically occur outside a treatment setting, and people benefit from ways to help manage. An act of empowerment. Unfortunately, many people may not engage in recommended follow-up

treatment. 7 Steps of Safety Planning Handout Step 1: Recognize warning signs Step 2: Engage internal coping strategies Step 3: Connect with people and places that can serve as a distraction from suicidal thoughts and who offer support Step 4: Identify and engage family members or friends who may offer help and support Step 5: Identify professional resources Step 6: Reduce the potential for use of lethal means Step 7: Acknowledge what is worth living for!

Ensure Collaborative Safety Planning For all people identified as at risk for suicide For those transitioning levels of care with identified risk To engage the patient on their own behalf. As a tool for self-management As a tool to track progress Implementing the Safety Plan Decide with whom and how to share the safety plan Who will be doing follow-up: problem-solve getting a copy of the plan to that professional. Discuss the location of the safety plan for their use Discuss how it might be used during a crisis Let the person know a copy of the plan will stay with you.

Safety Planning Apps are available! Follow-up After the Crisis or After Discharge As many as 70 percent of suicide attempters of all ages will never make it to their first outpatient appointment. Across all studies, the rate for nonattendance is about 50 percent. Efforts to improve suicide assessments, follow-up and continuity of care and to forestall readmission should target higher-risk patients prone to disengagement and non-adherence. David Knesper, MD Follow-up Care after Discharge For a patient at increased suicide risk, close follow-up is a vital and integral part of care.

Studies support the benefit of follow-up contact in reducing the incidence of future suicide attempts. Presents the opportunity to assess for improvement or lack of improvement Allows for altering treatment and supports. How can you assure that every discharge includes a clear plan for followup contact? Do you have a method of tracking this in your EMR? What are the Resources for Assured Follow-up Current Outpatient providers Therapist Case Manager Psychiatry Primary Care Provider

Imbedded Behavioral Health Clinician Care coordinators School Clinical Staff (for youth) Regional Crisis provider (especially I rural areas) Insurance or PCP care managers Who Else? Remember Most suicidal people: Do not want to end their lives, they want an end to their psychological pain and suffering Tell others that they are thinking about suicide as an option for coping with pain and to seek assistance Are experiencing psychological problems, social problems and limited coping skills all

things health professionals are well trained to tackle Impart Hope and reinforce that help is available! (Jobes, 2006) Questions and Discussion Suicide Loss Survivors Effect of Suicide The Loss is:

Sudden Unexpected Premature Self-inflicted The Reaction is:

Shock, hurt, anger Loss and grief Questions & torment Guilt and regret Survivors of Suicide Loss Who may become a suicide loss survivor?

Impact level varies Dont assume. Struggle to make meaning of the loss Suffer from overwhelmingly complicated feelings May take a long time to grieve Need understanding and support How YOU can be supportive after a suicide

Acknowledge the loss Use the name of the deceased Share your presence; offer to listen, share a cup of Share a special memory/story Acknowledge the good things Support through the Year of Firsts; Stay in touch Recommend grief counseling or grief support groups Resource: Ive lost a loved one to suicide Take Care of Yourself If you are working with someone at risk for suicide. Acknowledge the intensity of your feelings Seek support from others, debrief

Avoid over-involvement. Never act in isolation. Consult Consult! Develop your support/referral team Maintain your hobbies! Have fun! Know that you are not responsible for another persons choice to end their life MSPP Contact Information Training Program Inquiries: Nicole Foster, 207-622-5767 x 2310 [email protected] Content Expert: Greg Marley, LCSW, Clinical Director, NAMI Maine

[email protected], 207-622-5767 x 2302 MSPP Program Coordinator: Sheila Nelson, 207-287-3856 [email protected] Any Questions? Thank you for learning about suicide prevention. . .

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