MANAGING THE SUICIDAL PATIENT

Mark L De Santis, M.S., Psy.D.

Suicide Prevention Coordinator for the Ralph H. Johnson VAMC

VISN 7 Lead Suicide Prevention Coordinator

Assistant Professor Department of Psychiatry and Behavioral Sciences Military Sciences Division

Medical University of South Carolina

109 Bee St

Charleston, SC 29401

843-789-6536

INTRODUCTION

Patient suicide and suicidal behaviors generate

more stress and fear among clinicians than any

other behavior

While suicide are rare, many mental health

professionals will experience a patient suicide

during their career

Suicidality can range from internal thoughts

(ideation) to external behaviors inclusive of

attempts, preparatory behaviors and rehearsals

STATISTICS

13.5 % of all Americans report a history of

suicidal ideation or thinking

3.9 % actually made a suicide plan that included

a definite time, place and method

4.6 % reported actual suicide attempts

STATISTICS

Every 14 minutes another life is lost to suicide.

Every 32 seconds there is an attempt

Suicide is the tenth leading cause of death in Americans

Almost four times as many males as females die by suicide.

Older Americans are disproportionately likely to die by suicide

White males 85+ are 4 times higher the nation’s overall rate

SAMSHA 2010

STATISTICS

Homicide in the U.S. (16,259) Suicide (38,364) =

More than twice the number.

There are now twice as many deaths due to

suicide than due to HIV/AIDS.

In the month prior to their suicide, 75% of elderly

persons had visited a physician.

CDC, AAS (11/2010)

Breakdown by Gender / Ethnicity /

Young, Old Age Groups

All Ages Combined Elderly (65+ yrs) Youth (15-24 yrs)

Group Number of

Suicides Rate of Suicide Elderly Suicides

Elderly Suicide

Rate Youth Suicides

Youth Suicide

Rate

Nation 38,364 12.4 5,994 14.9 4,600 10.5

Men 30,277 20.0 4,550 29.5 3,498 16.2

Women 8,087 5.2 854 4.0 714 3.5

Whites 34,690 14.1 5,410 15.9 3,540 10.7

Nonwhites 3,674 5.8 264 5.8 672 7.4

African Amer 2,144 5.1 152 4.8 437 6.7

White Men 27,422 22.6 4,361 32.1 2,945 17.3

White Women 7,268 5.9 779 4.2 595 3.7

Nonwhite Men 2855 9.4 189 10.5 553 12.0

Nonwhite

Women 819 2.5 75 2.7 119 2.7

African Amer

Men 1621 8.7 124 10.3 382 11.5

African Amer

Women 371 1.8 28 1.4 55 1.7

CDC, AAS (11/2010)

Suicide Methods by Gender

Method

Men Women

Men - Percent

of Total

Men –

Number

of

Suicides

(30,277)

Women -

Percent of

Total

Women -

Number of

Suicides

(8,087)

Firearms 56.0% 16,962 30.0% 2,430

Hanging,

Strangulation

suffocation

25.1% 7,592 23.5% 1,901

Poisons 11.8% 3,573 37.4% 3,026

All other

methods 7.1% 2,047 9.0% 730

AAS (11/2010)

SUICIDE RISK FACTORS

Factors that may INCREASE risk

Current ideation, intent, plan, access to means

Previous suicide attempt or attempts

Alcohol/Substance abuse

Previous history of psychiatric diagnosis

Impulsivity and poor self control (related to Cognitive

Impairment)

Hopelessness-presence, duration, severity

Recent losses-physical, financial, personal

SUICIDE RISK FACTORS

Recent discharge from an inpatient unit

Family history of suicide

History of abuse (physical, sexual or emotional)

Co-morbid health problems, especially a newly

diagnosed problem or worsening symptoms

increased pain*

Age, gender, race (elderly or young adult,

unmarried, white, male, living alone)

Same-sex sexual orientation

VETERAN SPECIFIC RISKS

Frequent deployments

Deployments to hostile environments

Exposure to extreme stress

Physical/sexual assault while in the service (not

limited to women)

Length of deployments

Service related injury

ACUTE WARNING SIGNS AND SYMPTOMS

Threatening to hurt or kill self

Looking for ways to kill self

Seeking access to pills, weapons or other means

Talking or writing about death, dying or suicide

ADDITIONAL IMPORTANT WARNING SIGNS

Hopelessness

Rage, anger, seeking revenge

Acting reckless or engaging in risky activities

Feeling trapped

Increasing drug or alcohol abuse

ADDITIONAL IMPORTANT WARNING SIGNS

Withdrawing from friends, family and society (Social Isolation)

Anxiety, agitation

Dramatic changes in mood

Feeling there is no reason for living, no sense of purpose in life

Difficulty sleeping or sleeping all the time

Giving away possessions

INTERPERSONAL STRESSORS

Loss

Death of a loved one

Divorce/Separation

Relationship Breakup

Loss of job (Retirement ,loss of Independence)

Loss of home (declining health, assisted living,

Retirement home)*

Major Financial loss (Retirement)

PROTECTIVE FACTORS

Protective factors, even if present, may not counteract

significant acute risk

Internal: ability to cope with stress, religious beliefs,

frustration tolerance, absence of psychosis

External: responsibility to children or beloved pets,

positive therapeutic relationships, social supports

Ask: Is there anything that would prevent or keep you

from harming yourself?

ASKING THE QUESTION

Are you thinking of killing yourself?

Or

Do you have thoughts about taking your own life?

CRISES HOTLINE

1-800-273-TALK

1-800-273-8255

Or

The United Way Crises Line in SC

211

ASSESSMENT

Suicide Inquiry: Specific questioning about thoughts, plans, behaviors, intent

Ideation: frequency, intensity, duration--in last 48 hours

Plan: timing, location, lethality, availability, preparatory acts

Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun), vs. non-suicidal self injurious actions

Intent: extent to which the person (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious

Explore ambivalence: reasons to die vs. reasons to live

Homicide Inquiry: when indicated

ASSESSMENT

Ask The Question?

Have you had thoughts about taking your own life?

When did you have these thoughts?

Do you have a plan to take your life?

Are you feeling hopeless about the present and/or future?

Have you ever had a suicide attempt?

TREATMENTS

Dialectical Behavior Therapy (DBT) Linehan

Components of CBT, Reality Testing with concepts of

distress tolerance, and Mindfulness introduced in

individual sessions

Group sessions address Skills related to mindfulness,

interpersonal effectiveness, emotion regulation and

distress tolerance.

TREATMENTS

Collaborative Assessment and Management of

Suicidality (CAMS) Jobes

SSF III (Initial, Tracking and Outcome)

Rate Psych Pain, Stress, Agitation, Hopelessness,

Self-hate, and Overall Risk

Complete diagnostic on initial including TX plan

Key Components are Reviewed and tracked during

sessions

SAFETY PLAN: BASIC COMPONENTS

1) Recognizing warning signs that are proximal to an impending suicidal crisis.

2) Identifying and employing internal coping strategies without needing to contact another person.

3) Utilizing contacts with people as a means of distraction from suicidal thoughts and urges. This includes going to healthy social settings, such as a coffee shop or place of religion or socializing with family members or others who may offer support without discussing suicidal thoughts.

SAFETY PLAN: BASIC COMPONENTS (CONT.)

4) Contacting family members or friends who may help to resolve a crisis and with whom Suicidality can be discussed.

5) Contacting mental health professionals or agencies.

6) Reducing the potential for use of lethal means. Safety Plan Treatment Manual to Reduce Suicide Risk:

Veteran Version Barbara Stanley, Ph.D. and Gregory K. Brown, Ph.D. In collaboration with Bradley Karlin, Ph.D., Janet E. Kemp,

Ph.D. and Heather A. VonBergen, Ph.D.

REFERENCES

1. Operation S.A.V.E. Guide Training VA Edition

2. http://www.cdc.gov/violenceprevention/suicide/statistics/

3. http://vaww.mentalhealth.va.gov/suicide.asp

4. http://mentalhealth.samhsa.gov/suicideprevention/elderly.asp

5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107573

6. http://suicide.org/elderly-suicide.html

7. National Center for Injury and Prevention Control. WISQARS (Web-based Injury Statistics Query and

Reporting System). http://www.cdc.gov/ncipc/wisqars/ accessed Dec 2012.

8. American Psychiatric Association. Practice guideline for the assessment and treatment of patients with

suicidal behaviors. Am J of Psychiatry 160:1-60, Nov. 2003.

9. Mellqvist, M, Wiktorsson, S., Joas, E., Svante, O., Ingmar, S. & Waern, M. Sense of coherence in elderly

suicide attempters: The impact of social and health-related factors. International Psychogeriatrics 23:6 986-

993, 2011.

10. Huang C., BiRong, D., Zhen-Chan, L., Yuan, z., Yu-Sheng, P., &Qing-Xiu, L. Collaborative care

interventions for depression in the elderly: A systematic review of Randomized controlled trials. Journal of

Investigative Medicine 57 (2) Feb 2009.

VIOLENCE & PEOPLE WITH SEVERE

MENTAL ILLNESSES: TOWARD A

BETTER UNDERSTANDING

James G. McDonagh, Psy.D.

Clinical Psychologist & Local Recovery Coordinator

Ralph H. Johnson VAMC

Instructor: Medical Ethics

Medical University of South Carolina

LEARNING OBJECTIVES:

Identify relative victimization risk of having a

SMI diagnosis

Describe potential clinical correlates to

victimization

Compare explanatory models to account for

violence exhibited by people with PTSD

Identify possible programmatic changes

FOCUS QUESTIONS:

1. What are some of the issues associated with

acts of violence against persons with a Serious

Mental Illness (SMI) diagnosis?

2. What are the research data saying about some

of these issues?

3. Is violence that occurs in/to people with PTSD

unique from other SMI diagnoses?

4. What are some steps that can be taken?

ISSUE MAP *

Individuals w/

SMI

Victimization Perpetration Diagnoses

Treatment

Stigma

Culture

Self-harm

Cost

ZEITGEIST

General: 3:1 ratio of articles addressing

SMI perpetrators : SMI victims

Specific: One of the most comprehensive, cross-sectional, longitudinal studies was conducted by Teplin, et. al. in 2005.

Setting: Chicago – 1997-1999; randomly selected 16 of 75 sites who provided outpatient, day hospital, and residential services to individuals with SMI (diagnosis confirmed by the CIDI; 12 month period).

Procedure: Paid $15 for a 2-4 hour interview (Spanish or English); randomly selected individuals from the 16 sites. All participants stratified on demographic variables.

Used the National Crime Victimization Survey (NCVS); instrument used by the National Bureau of Justice Statistics in collaboration with the US Census Bureau

Self-report victimization.

TEPLIN, ET. AL (2005)

Of the 936 participants receiving services, >25% had been victims of a violent crime (attempted or completed) in the past year…11 times higher than the general population.

17% had been victims of completed violence.

21% had been victims of personal theft; general population 0.2%...140 times higher.

28% had been victims of property crime; general population 8.4%.

Women experienced more completed violence – rape/sexual assault, personal theft and motor vehicle theft; more men than women experienced robbery.

African Americans tended to be victimized at a greater rate than Caucasians and Hispanics.

Incident rates (victimization per 1000 population): 168 per 1000 persons per year – 4 times higher than general population.

Prevalence ratios higher than incident ratios – suggests that victimization is occurring across the SMI population – not just a few being repeatedly victimized.

VICTIMIZATION: SUBGROUPS

Friedman, et.al., (2011), looked at 53 Puerto

Rican females with SMI (MD, BD, SZ) experience

of intimate partner violence over a 2-year period.

32% victimized by partners during study period

(lifetime 68%); BD and SZ had higher rates.

Wolff, et.al., (2007) estimated victimization rates

among prisoners with mental disorders.

2.8x higher rates of sexual assault in prisoners with

mental disorders.

VICTIMIZATION: CLINICAL ISSUES

Lifetime: 79% had 1 or more violent victimization; 87% of the sample had 1 or more trauma experiences.

Lifetime: 31% met criteria for PTSD; 13% currently met PTSD (SCID).

In individuals with SZ, violence victimization worsened dysphoria and anxiety, but did not significantly worsen psychosis.

Non-violent trauma exposure contributed to positive sxs severity.

None of the individuals in their sample had a PTSD diagnosis in their medical record.

Newman, et. al. (2010)

VICTIMIZATION AND FUNCTIONING

Hodgins, et. al. (2009) assessed the community functioning of 225 Canadian and European men with DX of Schizophrenia or Schizoaffective Disorder over a 2 year period post-discharge; developed a multiple regression model to establish predictors of functioning.

The number of victimizations was the strongest inverse

correlate to community functioning.

Life-time dx of Sub Abuse/Dependency, depression, and medication non-compliance – all inversely correlated with community functioning .

Level of education was positively correlated with community functioning.

VICTIMIZATION AND PERPETRATION

Among individuals Dx’d with Schizophrenia, affective

disorders, personality disorder, and history of

violence, personal victimization, and substance

abuse are risk factors for future violence.

Flannery, et. al. (2010) – 20 year, on-going initiative to reduce assaults on staff (n=2,891).

35% of individuals with SMI were victimized in

one year; 12% - 22% of individuals with SMI

perpetrated violence.

Choe, et.al. (2008), their review of literature in context of public policy recommendations

MECHANISMS BY WHICH VICTIMS

BECOME PERPETRATORS?

Variably impaired reality testing?

Disorganized thought processes?

Dysphoria/depression, anxiety, substance use, interpersonal/relational violence, homelessness?

Self-medication?

Limbic system “kindling”?

Learning that violence gets results?

SUMMATIVE INTERLUDE

People with Schizophrenia are statistically more likely to be a victim of violence than to be a perpetrator of violence.

Schizophrenia, in and of itself, contributes a small proportion to violence risk.

Domestic/partner violence appears to be correlate with a SMI diagnosis.

Our colleagues who treat individuals with schizophrenia, should assess for history of assaults and substance-use-related disorders - and plan accordingly in order to reduce violence against providers.

Diagnostic evaluations of individuals with SMI should directly assess for PTSD; Prolonged Exposure appears to be a viable treatment option.

PTSD

Posttraumatic Stress Disorder (PTSD) :

DSM V

Mental health diagnosis marked by:

Exposure to a trauma or series of traumas

Symptoms cluster in three main areas:

1. Intrusion

2. Avoidance

3. Negative alterations in cognitions and/or mood

4. Hyper-arousal

PTSD SYMPTOM CLUSTERS (POST

TRAUMA)

Intrusion – Re-experiencing event (e.g., intrusive memories, nightmares, flashbacks, prolonged distress/stress to reminders).

Avoidance – Avoiding related thoughts and/or external reminders.

Negative alteration in cognitions and mood (e.g., inability to recall details of trauma, persistent negative beliefs about self/others, distorted attributions, persistent fear, anger, guilt, diminished interest, alienation, restricted positive emotions).

Alterations in arousal and reactivity (e.g., aggressive behavior, self-destructive behavior, hypervigilance, exaggerated startle response).

PHYSIOLOGY: PTSD& LIMBIC SYSTEM

*

OIF/OEF VETS AND VIOLENCE

33% of these Vets self-report difficulties with anger and behavioral aggression/hostility.

In one study of Vets entering treatment for PTSD, 91% reported psychological aggression.

______________________________________________

Explanatory Models:

Dissociation/Flashback-Related

Combat Addiction/Sensation Seeking

Mood Disorder-related

Sleep Disorder-related

** Survival Mode Model: Hyper-vigilance and Threat

Perception.

** Information Processing Deficit Model

WHAT CAN WE (THE SYSTEM) DO?

In addition to directly assessing for a history of

victimization (and perpetration), we can…

1. Offer/Provide direct training on personal safety

strategies to all individuals with SMI.

2. Increase care-contact with individuals with SMI

upon discharge – encourage medication compliance,

monitor substance use, and self-harm behaviors.

3. Reduce stigma associated with a diagnosis of

schizophrenia and other SMI diagnoses.

STIGMA?

STIGMA?

"We had a tightrope to walk," said Steve Hannah, the managing

editor of The Milwaukee Journal. "On the one hand, we didn't

want to assault our readers with gratuitous details. On the other

hand, we wanted our readers to appreciate the thrust of the

defendant's case that Jeffrey Dahmer is crazy -- that what he did

was so bizarre, so heinous, that he must be nuts.“ (New York

Times, 1992)

LEARNING OBJECTIVES: REVISITED

Identify relative victimization risk of having a SMI diagnosis

Individuals with SMI are more likely to be victimized than to victimize.

Describe potential clinical correlates to victimization PTSD, poor medication compliance, increase substance use, increase

risk for acting violently.

Identify a leading explanatory model to account for violence exhibited by people with PTSD.

Survival Mode Model: Hyper-vigilance and Threat

Perception.

Identify possible programmatic changes If you are extending care to individuals with SMI diagnosis, regularly

assess for PTSD, develop and incorporate personal safety strategies training, reduce stigma.

WHEN TO SEEK THE HELP OF A MENTAL

HEALTH PROFESSIONAL

…. AND WHO TO CALL

Deborah Shogry Blalock, M.Ed., LPCS,

Executive Director

Charleston Dorchester Mental Health Center

843-852-4100

dsd35@scdmh.org

January 23-24, 2014

IF YOU NOTICE OR BECOME AWARE

OF ONGOING, SIGNIFICANT…..

• Pervasive Sadness

• Lack Of Concentration

• Lack Of Motivation

• Isolative Behaviors

• “Unearned” Changes In Weight And Appetite

• Changes In Sleep Patterns

• Hopelessness

• Helplessness

• Lack Of Joy In Things One Used To Enjoy

• Suicidality

• Risk-taking Behaviors

IF YOU NOTICE OR BECOME

AWARE OF….

• Pervasive Worrying

• Pervasive Nightmares

• Auditory Hallucinations

• Visual Hallucinations

• Believing Things To Be True That Are Not - Delusions

• Paranoia

• Significant Mood Swings

• Grandiosity

• Hyper-religiosity

• Extreme Irritability

• Hyper-sexual Behavior

• Uninterruptable Rapid Speech

Just To Name A Few……

WHO, WHAT, WHERE IN SOUTH

CAROLINA?

• 211 Hotline

• South Carolina Department Of Mental Health (SCDMH)

• Department Of Alcohol And Other Drugs Of Abuse Services (DAODAS)

• Family Services, Etc.

• Private Providers

• School Counselors

• Hospital Emergency Departments

• Shelters

• Pastoral Counseling Programs

• AA, NA, Double Trouble Groups

• NAMI, SC Share, MHA

SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH

THE SKINNY ON SCDMH

MISSION:

TO SUPPORT THE RECOVERY OF THOSE LIVING WITH MENTAL ILLNESS

FACILTIES:

• 17 Mental Health Centers

• 4 Inpatient Facilities

• 4 Nursing Homes

• Sexually Violent Predator Program

SCDMH Contact Info:

• Website: WWW.SCDMH.Org

• Main Number – 1-803-898-8581

• Central Office – 2414 Bull St., Columbia, SC 29202

DMH CENTERS, CLINICS, HOSPITALS &

NURSING HOMES

51

Nursing Home

Sexually Violent

Predator Program

Forensics Program

Alcohol & Drug

Hospital

Adult Hospital

Children’s Hospital

MHC Clinic

Mental Health Center

DMH operates 17

community mental

health centers and 45

clinics across the state.

COMMUNITY MENTAL HEALTH

CENTERS

53

Veterans’ Victory House – a

220-bed skilled nursing care

facility located in Walterboro.

Tucker Nursing Care

Center – a 296-bed nursing

care facility located in

Columbia.

Morris Village Alcohol and Drug

Addiction Treatment Center – a

120-bed alcohol and drug treatment

center in Columbia.

Infirmary – DIS operates an 11-bed

general infirmary located at Morris

Village.

Richard M. Campbell

Veterans’ Nursing Home -

a 220-bed skilled nursing

care facility in Anderson.

Patrick B. Harris

Psychiatric Hospital – a

121-bed intensive, psychiatric

hospital located in Anderson.

G. Werber Bryan Adult

Psychiatric Hospital (Acute) – a

198-bed intensive care hospital

located in Columbia.

(Forensics) – a 185-bed treatment

facility for patients found Not

Guilty by Reason of Insanity

(NGRI) or not competent to stand

trial.

William S. Hall Psychiatric

Institute – a 58-bed complex for

children and adolescents. Located

in Columbia.

Sexually Violent

Predators Treatment

Program – a 122-bed

facility to provide

treatment for persons

adjudicated as sexually

violent predators.

Located at the SC

Department of

Corrections.

DMH INPATIENT HOSPITALS AND NURSING

HOMES

WHERE WE ARE AND WITH WHOM

WE PARTNER

• Schools

• Detention Centers

• DSS

• Family Services

• Crisis Ministries

• DAODAS

• Colleges

• Law Enforcement

• NAMI, SC Share, &

MHA

• DJJ

• FQHCs

• Hospitals

• Courts

• DDSN

• Chaplaincy

Programs

• SCDPPPS

• Vocational

Rehabilitation

WHO WE SERVE

Adults Diagnosed With Serious And Persistent Mental Illness (SPMI), I.E. Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, Post Traumatic Stress Disorder, etc.

Adults diagnosed with Serious Mental Illness, I.E. Anxiety Disorders, Depressive Disorders, etc.

Children Diagnosed With Serious Emotional Disturbances

Anyone In Psychiatric Crisis

WHAT WE DO

• Medication Management • Therapy - Individual, Family, Group • Crisis Intervention – Keep People Safely Out

Of ERs • Crisis Stabilization – Keep People Safely Out

Of Hospitals • Case Management & Care Coordination • Assist With Finding Housing • Pre-employment Skills Training • Entitlement Assistance

To Name A Few…

Our staff do whatever it takes to help families

remain safely intact with children in their homes and schools, and whatever it takes to assist adults in remaining in the community as safe and productive citizens.

OUR GENERAL GOALS

• Increase Community Safety

• Decrease Symptomatology

• Decrease Hospitalizations

• Decrease Incarcerations

• Decrease Homelessness

• Decrease Out Of Home Placement For Kids

• Decrease School Suspensions/Expulsions For Kids

• Increase Community Tenure

• Increase Employment

• Improve Quality Of Life For Clients And Their Families

BEST PRACTICES THAT SUPPORT

OUR GOALS

• Individual Placement And Support Services (IPS) – Pre-vocational Services

• Care Coordination Services

• School-based Services

• Peer Support Services

• Evidenced Based Practices Such As Parent Child Interaction Therapy (PCIT), Dialectical Behavioral Therapy (DBT), Cognitive Behavioral Therapy (CBT), Trauma Focused CBT (TFCBT), Eye Movement Desensitization and Reprocessing (EMDR), Motivational Enhancement Therapy (MET), Motivational Interviewing (MI)

BEST & PROMISING PROGRAMS THAT

SUPPORT OUR GOALS, CONT’D

Mental Health Courts

ACT Teams

Homeshare

Integration with Primary Care

Highway to Hope

School-Based Services

Forensic Services

To Name A Few…

OUR BIGGEST

CHALLENGE IN

CONNECTING FOLKS

TO CARE …..

STIGMA!!!!!

LAST WORDS….

Mental Illness affects every family in

the United States. Thank you for

supporting the recovery of those

diagnosed with a mental illness!

ANY QUESTIONS?

Deborah Shogry Blalock, M.Ed., LPCS,

Executive Director

Charleston Dorchester Mental Health Center

843-852-4100

dsd35@scdmh.org

January 23-24, 2014

SUBSTANCE USE DISORDERS

Chanda F. Brown, Ph.D., LMSW , Executive

Director of the Charleston Center

Steven Donaldson, MAC, CACII, Clinical

Compliance Coordinator and Treatment Director

of the Charleston Center

Screening for Potential Need of Services

SUBSTANCE USE DISORDERS

Drug and Alcohol abuse has many harmful effects and consequences

Drug and alcohol problems can affect multiple areas of a person’s life.

Health consequences

Mental health consequences

Interpersonal conflicts

Educational consequences

Financial consequences

Employment consequences

Legal consequences

Spiritual conflicts

Development of dependency

Accidental overdose and death

STATISTICS

In 2011: 22.5 million Americans >12 yo had used an illicit drug or

abused a psychotherapeutic medication (pain reliever, stimulant, tranquilizer) in the past month.

25.1% of under aged persons reported current alcohol use. 15.8 % reported binge use (5 drinks or more).

30% of men 12 yo and older and 13.9% of women reported binge drinking.

28.6 million people reported driving under the influence at least 1x in past year.

56.8 million Americans >12yo were current cigarette smokers

16.7 million Americans were dependent or had a problem with alcohol.

Alcohol, marijuana, and pain killers were most prevalent for abuse or dependence.

NIDA Drug Facts http://www.drugabuse.gov/pulications/drugfacts/nationwide-trends

HOW DO I KNOW IF THEY NEED HELP?

A person’s use of mood altering substances can range

from no use at all, low-risk use, high-risk use,

problem drinking, abuse, to dependence.

Acute intoxication and withdrawal symptoms may be

occurring.

Intoxication can include mood changes, slurred speech,

unsteady gait, and changes in cognitive and physiological

functioning.

Withdrawal symptoms can include vomiting, nausea,

shakes, hallucinations, delirium, anxiety, depression,

muscle aches, sleep disorders and seizures. Some

withdrawal symptoms can be life threatening.

A person’s level of use helps determine what treatment

modality would be most beneficial

HOW TO SUPPORT A PERSON WHO MAY BE

STRUGGLING WITH SUBSTANCE USE DISORDER

Provide genuine affirmation for their willingness to open up to you about their substance use.

Approach their use from a Medical Model, not a Moral Model. They are not bad people trying to become good. They are people struggling with a substance use disorder.

Remember addiction (dependency) is a disease.

WHAT DO YOU MEAN IT’S A DISEASE?

HOW CAN IT BE COMPARED TO OTHER MEDICAL

DISEASES?

Just like other medical disorders like heart disease,

diabetes, and hypertension, addiction is also:

Chronic

Treatable

Not curable

Can be fatal if not treated

CHRONIC DISEASE

Once you have it, you’ve got it.

“Disease” implies there is a “medical” component.

Causes are usually multifactorial.

Treatments must usually be multi-modal.

Response rates are variable and depend on the

patient, the treatment itself, and outside factors.

DRUG DEPENDENCE,

A CHRONIC MEDICAL ILLNESS

Title of an article in JAMA, Oct 4, 2000, Vol. 284, no. 13, pp 1689-1695.

Compares drug dependence to type 2 diabetes, hypertension, and asthma.

Medication adherence and relapse rates similar across these illnesses.

CHRONIC DISEASE COMPARISON

DIABETES ADDICTION

Genetic predisposition

Lifestyle choices are a

factor in development of

the disease

Severity is variable

There are diagnostic

criteria

Once diagnosed, you’ve

got it

Genetic predisposition

Lifestyle choices are a

factor in development of

the disease

Severity is variable

There are diagnostic

criteria

Once diagnosed, you’ve

got it

DISEASE COMPARISON (CONT.)

DIABETES ADDICTION

Patients who are

partially compliant are

the rule, and outcomes

are better than those

who do not get treatment

Support systems

improve outcomes

Patients who are

partially compliant are

the rule, and outcomes

are better than those

who do not get treatment

Support systems

improve outcomes

SO NOW WHAT? HOW DO I HELP?

Establish rapport with the person.

Provide a brief assessment using an evidenced

based screening tool.

Determine if they are at risk and in need of a

referral.

Assess their readiness for change.

Ask their permission to assist them in accessing

substance use disorder services.

Offer them support.

Make the appropriate referral.

HOW DO I ESTABLISH RAPPORT?

Provide genuine empathy.

Provide positive regard.

Let them know you care about their well-being.

Provide them with affirmation for sharing with

you.

Do not judge.

Motivational Interviewing is a model used to

establish rapport and help a person move

through ambivalence in making life changes.

MOTIVATIONAL INTERVIEWING

Motivational interviewing is a collaborative

approach that seeks to strengthen motivation

and commitment for change.

It is an empathic, supportive counseling style

that supports the conditions for change.

Interviewers are to be careful to avoid arguments

and confrontation, which tend to increase a

person's defensiveness and resistance.

Interviewers do not take on the role of an expert,

but rather a partner working with the client.

What does that mean exactly?

MOTIVATIONAL INTERVIEWING

This is a non-judgmental, gentle, and non-confrontational way of interacting with a person.

Have a conversation.

Express empathy.

Support a client’s belief in their own ability to change.

Do not be confrontational.

Provide genuine affirmations on their strengths (for starters, for coming to see you and sharing with you their alcohol and drug use).

Use open ended questions, not closed ended questions which only yield brief responses.

Reflect on what is said, asking them to tell you more.

Listen for the change talk.

Allow the client to be the agent of change.

ADVANTAGES TO MOTIVATIONAL

INTERVIEWING (SAMHSA)

Relationships will be more therapeutic.

You will better understand that person’s

perception of their problems (Stage of Change).

You will better understand what that person

wants and what motivates them.

You will have better outcomes.

WHAT BRIEF ASSESSMENTS COULD I USE?

There are several brief assessments in the public domain to screen for a substance use disorder. These screening tools are often free and offer Spanish versions.

CAGE:

C-Have you ever felt you should cut down on your drinking?

A- Have people annoyed you by criticizing your drinking?

G- Have you ever felt bad or guilty about your drinking?

E- Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

Ease of use makes this one commonly used. Two positive answers suggest a positive test. This is something that measures a lifetime, so be wary of considering this a present issue. More questions will need to be asked.

OTHER COMMON SCREENING TOOLS

Michigan Alcohol Screening Test:

22 question quiz

Example of questions:

1. Do you feel you are a normal drinker? (“normal” – drink as much or less than most other people)? Y/N

2. Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening? Y/N

(This quiz is scored by allocating 1 point to each ‘yes’ answer except for questions 1 and 4, where 1 point is allocated for each ‘no’ answer.)

Two other screening tools include the AUDIT (Alcohol Use Disorders Identification Test) and the DAST (Drug Abuse Screening Test).

SCREENING SHOWS PROBLEMATIC USE,

NOW WHAT?

Assess their readiness for change.

Ask for their permission to help them connect

with someone who can work with them regarding

their alcohol and/or drug use.

STAGES OF CHANGE

People go through a series of stages when they change health behavior. The stages are cognitive and behavioral. In the early phases, people may focus on thinking about change-whether its something they need to consider. In later stages, people are actively doing things to change or maintaining the changes they’ve made.

The Stages of Change Model has five phases:

Pre-contemplation: Avoidance. That is, not seeing a problem behavior or not considering change.

Contemplation: Acknowledging that there is a problem but struggling with ambivalence. Weighing pros and cons and the benefits and barriers to change.

Preparation/Determination: Taking steps and getting ready to change.

Action/Willpower: Making the change and living the new behaviors, which is an all-consuming activity.

Maintenance: Maintaining the behavior change that is now integrated into the person's life.

THEY ARE READY TO SEEK HELP, NOW

WHAT?

Make referral to an accredited Alcohol and Drug

Abuse Services Center that has licensed and

credentialed addiction counselors.

The counselors will do a comprehensive

assessment and use specific diagnostic and

placement criteria:

DSM-IV-tr (soon to be V) - diagnosis

American Society of Addiction Medicine (ASAM)-

placement criteria to determine if detox, inpatient, or

outpatient services are appropriate.

WHAT TYPES OF TREATMENT OPTIONS ARE

AVAILABLE?

There are several treatment options available to

address substance use disorders.

individual and group formats

several levels of care

short-term detoxification, inpatient services, intensive

outpatient services, outpatient services, education and

prevention.

evidenced-based treatment models

Cognitive Behavioral Therapy, Motivational Interviewing,

Motivational Enhancement Therapy, Motivational

Incentives, Medication Assisted Treatment, and Trauma

focused therapies like Seeking Safety, or TREM to name a

few.

WHO DO I CALL?

Charleston County: The Charleston Center

(843) 722-0100. Detox, Inpatient, Opioid Treatment,

Intensive Outpatient, Outpatient services offered.

Berkeley County: The Ernest E. Kennedy

Center (843) 761-8272 . Intensive Outpatient and

Outpatient services offered.

Dorchester County: Dorchester Alcohol and

Drug Commission (843) 871-4790 . Intensive

Outpatient and Outpatient services offered.

RESOURCES

CRISES HOTLINE

1-800-273-TALK

1-800-273-8255

DAODAS – Resources by County

S.C. Department of Mental Health

Main Number – (803) 898-8581

Central Office – 2414 Bull St., Columbia, SC 29202

THANK YOU FOR YOUR

PARTICIPATION IN

TODAY’S WEBINAR!