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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
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
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!