Suicide intervention skills training

Dear friends -

I have been shocked to learn that mental health professionals, primary care doctors, and even psychiatric nurses are required to take little or no suicide awareness, assessment and intervention training, and that there is no requirement for them to sustain any particular level of training in this area over the course of their careers. This means that someone at risk of suicide or someone dealing with a person at risk of suicide could be seeking support from a professional who does not have the knowledge or skills to provide it.

That was the situation for me when I sought counseling after Cliff was admitted to hospital in early December because he had tried to kill himself. None of the three counselors from whom I sought help had any training in suicide assessment and intervention, and so none were able to help me address the situation in which Cliff and I were in. They were very skilled and supportive in other aspects -- but the risk of Cliff dying was the elephant in the room that never was addressed.

Tragically, the psychiatrist treating Matt Adler, a lawyer in Washington with a wife and two young children, likewise did not have the knowledge and skills to intervene effectively when suicide became a serious risk. Matt died by suicide on February 8, 2010.

Matt's widow, Jennifer Stuber, was instrumental in getting Washington state legislation passed in June 2012 requiring mental health professionals to take 6 hours of suicide assessment and intervention training every six years. Washington is the only state to require this. There are no similar requirements for mental health professionals or primary care doctors in B.C. -- the latter of whom may be the only people from whom a suicidal person seeks help.

Can you imagine doctors, nurses, and paramedics being unable to perform CPR? That is the state of our mental health system. One of my objectives is to lobby the government and professional organizations so that is changed.

Strategy #2: Mental health first aid / Suicide intervention skills training for mental health professionals and lay people

LivingWorks in Calgary has developed programs in suicide awareness and intervention that are now used by the University of British Columbia, the U.S. Military, and other organizations in Canada, the U.S., Australia, Norway, and other countries. I took ASIST (Applied Suicide Intervention Skills Training) through the Crisis Centre of B.C. in October, and highly recommend it. This type of training should be the minimum standard for anyone working in mental health or primary care.

Opportunities for Action

Bruce Lee said, "We don't rise to the level of our expectations. We fall to the level of our training."

1. Training like ASIST saves lives. It might have saved Cliff's life. You don't know ahead of time when you might need this, and by the time you do know, you may not have the opportunity. Don't place yourself in that position. You don't have to be a medical professional to make a difference.

• Find an ASIST workshop (2 days)
• Find a safeTALK workshop (1/2 day)
• Find a mental health first aid course (2 days)

2. Ask your family physician, counsellor, and friends in the medical or mental health professions how prepared they feel to deal with patients who are suicidal or the people who are supporting them. Do they have consistent processes of assessing clients and patients to determine whether someone might be at risk of suicide? Do they feel confident addressing the situation if they do determine someone is at risk? Are there adequate resources to which to refer clients? Are they aware of the training that's available? Just having the conversation raises awareness and helps us move in the right direction.

Good News

On the positive side, I received an email this week from Cliff's psychiatrist letting me know that he and his colleagues at Vancouver General Hospital are preparing a brochure for visitors taking patients in the psychiatric units out on a pass so that they will be better prepared to respond if they have concerns; and another brochure for any family members and friends who may have accompanied someone to hospital as the result of a suicide attempt. I was heartened to know that these steps towards involvement and education of family and friends are being initiated.

Thank you for taking the time to read these updates, provide feedback and questions, and for your words of support. It means a great deal to me that there are people out there to whom this matters.

Family Involvement in Patient Care

Dear friends -

I really appreciate your responses to the initial update I sent last week. From the comments and from re-reading it myself, I realize there's more to say about Strategy #1 before I move to the next one.

First, there was a request for clarification of the recommendations we had for the hospital and doctors.

Referrals for someone who has accompanied a person to hospital because of a suicide attempt
Most of us know little about suicide assessment and intervention, yet need that information when someone close to us is suicidal. When someone is admitted to hospital due to suicidal behaviour or risk, there is an opportunity to provide education and support to the person or people accompanying them. In my experience and the experience of others with whom I've spoken, this opportunity has been missed.

The practice of referring accompanying people to agencies that specialize in suicide prevention and counselling services, such as SAFER, could strengthen the network of care for people at risk. The vast majority of counselors and mental health professionals in B.C. have little or no training in suicide assessment and intervention, and are therefore unable to provide effective support in that area to either the person who is suicidal or the people who love them. (More on that in a future update.)

Provision of basic information to visitors taking a patient out on a pass
Patients in the psychiatric unit are permitted to leave the hospital for progressively longer periods of time, provided they are with a visitor. This implies that the visitor has some responsibility for the patient, yet visitors receive no information on what to do or where to call if something goes wrong. Providing visitors with phone numbers for the hospital ward, mental health police unit, and 911 would at least give them a range of resources to call on if concerns arise.

Assessing opportunities for family involvement in patient care
At Vancouver General Hospital (VGH), where Cliff was a patient, spouses and family members are not invited to participate in meetings with the treating physician, social worker, community mental health worker, or other professionals involved in the care of a suicidal patient. In contrast, family members of patients with diabetes are encouraged to attend appointments and are invited to participate in Diabetes School with the patient. VGH purports to promote family involvement in patient care, yet in the case of suicidal patients this involvement rarely if ever happens. We recommend that treating physicians regularly assess the opportunity to involve, educate, and consult with family members.

If a suicidal patient opposes the involvement of a family member when it is apparent that there is a supportive and loving relationship, this should be taken as cause for concern and inform decisions such as whether the patient is well enough to be discharged.

Family involvement in discharge and transition
I am still shocked at how informal Cliff's discharge process was when later we learned that only the day before he had been assessed by a community mental health worker as highly suicidal. I have since heard of similarly casual discharges for patients who died shortly after. Although patients who have been hospitalized due to suicide risk are at high risk of dying within 48 hours after discharge, there are no provisions for informing family members that a patient is about to be discharged; for discharging the patient into anyone's care; for informing that person of the heightened risk following discharge; for involving family members in safety or transition plans; or for providing the person into whose care the patient is discharged with any information about the patient's risk assessment, what to watch for, or what to do if there are any concerns. Family members of patients at risk of a heart attack or stroke are much more likely to get that type of information and support.

My last email takes an optimistic tone that may belie my anger, frustration and distrust. We've tried to take a non-litigious and collaborative approach to generating change within the hospital system. Although the doctors have been receptive, the response to date hasn't convinced us that this approach will be effective. It may be time to re-examine other avenues.

I welcome your responses, experiences, and suggestions.

Pieces

Dear friends -

It's been eleven months since Cliff died, and an enormous hole was torn out of the lives of his son, daughter, me, and many others who loved him. Since then, I have been on a quest to learn what could have made a big enough difference that Cliff's death might have been prevented, so that this information can be used to make that difference for others.

I'm going to write an update each week for the next four weeks. After that, I plan to write one every two months. Please please feel welcome to refer others who might be interested to this blog or ask them to send me a request to be added to the email distribution list.

Strategies

The areas I've been exploring fall into four categories:

• Changes at the hospital: Admission and discharge procedures, involvement of family and friends
• Support, education, and training for people living with someone with a mood disorder
• Mental health first aid and suicide intervention skills training for both mental health professionals and lay people
• Psychologically safe workplaces

In the next four weeks, I'll give updates on each of these strategies.

Strategy #1: Changes at the hospital: Admission and discharge procedures, involvement of family and friends

Ileah, Christopher and I have met twice with Cliff's doctor from Vancouver General Hospital and others who were involved in his care. As you can imagine, discussing Cliff's situation with them has been highly emotional. 

The benefit of these discussions is that the topic of patient suicide while in hospital or shortly after discharge is being explored more deeply. The psychiatric team has done a review of research in this area and of strategies other hospitals have taken to reduce this risk. It is now a standing topic at their team meetings, and the medical director for the unit has done a session on the subject for doctors in other areas of the hospital.

The doctors have also welcomed hearing our experiences and perspectives on what could have made a difference for us so that we might have been able to better support Cliff. These have included:

• Referrals for someone who has accompanied a person to hospital because of a suicide attempt
• Assessing opportunities for family involvement in patient care
• Provision of basic information to visitors taking a patient out on a pass (e.g. emergency phone numbers)
• Family involvement in discharge and transition

As the research and conversations continue, I hope to see changes in procedures that will strengthen support for people at risk.


Cliff's death left me feeling helpless and confused. As I begin writing these updates, I realize how much I have managed to learn and do this past year (too much to put in one email, I've discovered) and feel heartened by that.

Whether or not you are able to support any of these initiatives or even to read these, I appreciate your care and interest. We each have our own work to do, and varying capacities for anything more.


Lynn