hello my name is Elizabeth Conti and I'm a clinical psychologist at the Michael
DeBakey VA Medical Center. Today we will be talking about suicide prevention with
a focus on collaborative safety planning for older veterans. Safety planning is a
brief technique that encourages coping and seeking help during a psychiatric
crisis, especially when a veteran may be considering suicide. Safety plans are a
list of warning signs, coping strategies and social supports. They also contain
contact information for professionals who can help the veteran during a crisis
as well as plans for means safety. Safety plans support the idea that individuals
can manage their own suicidal urges and can maintain safety. Our goal is to
improve the quality and usefulness of safety plans for older veterans. We are
focusing on older veterans generally ages 65 and older but much of this
information is useful for younger veterans as well. My name is Rhonda
London and I am a psychiatric nurse practitioner. In my work with veterans at
the VA, I have found safety plans to be a very useful tool. A safety plan should be
a collaborative therapeutic task like a mini therapy session. If it feels like
paperwork, the veteran will treat it like paperwork. Research suggests that
veterans find the collaboration with the provider to be one of the most important
components of the plan. In other words, the magic ingredients in safety planning
is that you do it together. High-quality safety plans are associated
with fewer subsequent hospitalizations, increase coping, and increase use of
mental health services in the VA.
Conti: As you probably know, suicide prevention is a
top priority at VA, but did you know that in 2014, 69 percent of veterans who died
by suicide were over age 50 older. Veterans have special needs and risk
factors that are important to consider when completing a safety plan. Older
people are much more likely to die on their first suicide attempt compared to
younger people and are also less likely to admit to thinking about suicide.
Older adults, particularly men, may be more reluctant to ask for help and may
have fewer close family members and friends. It may be harder to intervene when
they need help. There are many risk factors for suicide but there are some
that are more common or obvious in older people. Feeling isolated, lonely, or
without a purpose, feeling like a burden, disability or changes in ability, pain,
trouble with memory that is frustrating, being rigid or unwilling to try new ways
to cope, and grief and loss. With these risk factors in mind, be sure to
encourage the Veteran to connect with others, help others, or contribute even in
small ways, and participate in their community. Consider what the person is
actually able to do when choosing activities to put on the safety plan.
Think outside the box when choosing activities or coping tools. The safety
plan for older people should be seen as a menu of options, not one by one steps.
Reaching out for support can be done first before thoughts become intense. It
can be important to talk with the Veteran about how they might increase
their social support.
London: Older adults might also have a caregiver or live at a
personal care home or nursing home. Consider who else needs to know about
the safety plan and the individuals risks. Enlisting other people within the
Veterans support system can be very helpful. There might be a role for a
caregiver to remind the veteran to use a coping tool or for the nursing home
staff to make sure no extra pills, belts, ropes, or access to the roof are
available.
Conti: You may already be familiar with the six steps of the safety plan.
We've added a few here helping the Veteran understand the purpose of the
safety plan is key as well as establishing collaboration. The following
vignettes demonstrate a VA provider, Dr. London, working with a Veteran, Joe
Johnson, in an outpatient setting. We hope to illustrate some key points and
techniques to maximize the effectiveness of safety planning. Let's take a look.
London: Mr. Johnson I'm glad you were able to come in today. It sounds like you were
having some serious thoughts about ending your life. I realized that those
thoughts can be pretty overwhelming at times. Today I would like to just work
with you on developing a plan. This plan is something that you can use when you're
having those thoughts about suicide. I want you to have a plan and the tools to
be able to deal with those thoughts when they arise. This will be like a road map
to help you navigate through challenging and rugged terrain. How does this sound to
you?
Joe: Okay. Just call me Joe please.
Conti: A few things to note. The provider made the
task of making a safety plan relevant to the Veteran, explaining its purpose. Also,
notice that the provider sat next to the Veteran, which is a physical way to
increase collaboration. Importantly, if the Veteran does not agree that he or
she had suicidal thoughts or behaviors or doesn't like the term safety plan,
that's fine. Continue with the plan and call it a
crisis plan. Let's move on to step one of the safety plan, recognizing warning
signs.
London: It can seem like crises or thoughts about suicide come out of
nowhere, but usually there are warning signs that you or other people close to
you might notice. By noticing these warning signs, you may be able to diffuse
or avoid the crisis. The first section in the safety plan is where we can write
down some of the early warning signs that you may notice during a crisis. What
do you usually experience when you have those suicidal thoughts?
Joe: Well I feel
really depressed I kind of just want to hide from the world.
London: Okay it sounds like
you isolate yourself.
Joe: yeah
London: When you're feeling really depressed what other
kinds of things might you do or not do
Joe: I sometimes stop taking my
medication. I think what's the point?
London: That's important to know because it can
lead to you feeling even worse. What about using alcohol or other substances?
Do you have urges to use alcohol or other substances when you feel really depressed?
Joe: No drugs. I sometimes drink a six-pack.
London: Is that more than you usually drink?
Joe: Yes. I normally I don't drink at all.
London: I appreciate you
sharing this information with me. I realize that it's hard
to talk about this. Now we have been able to identify some of the specific warning
signs you experience during a crisis. So now when you've noticed these signs it's
time for you to pull out your safety plan.
Conti: So here we see the provider explain
why warning signs are important. That they signal to the Veteran it's time to
get out the plan. We have also pretty quickly obtained some important warning
signs: isolating feelings of depression, not taking medications, the thought
"what's the point," and drinking an amount of alcohol that
could impair his judgement. Alcohol consumption is important to assess for
in older adults at risk of suicide. See lots of examples of warning signs, as
well as examples for each step of the plan, in the free manual referenced at
the end of this video. Let's go to step 2 internal coping strategies.
London: Having a few
tools to get you through moments when you have suicidal thoughts can be really
helpful. These can help you to reduce the stress to a level where you can think,
plan, or reach out to others. What can you do on your own if you become suicidal
again to distract or make yourself feel better?
Joe: I like to go fishing.
London: Good suggestion now have you been able to get out lately to go fishing
Joe: No I don't have
my boat anymore and these legs of mine don't allow me to get around as much.
London: Okay so even though fishing is something that makes you feel better, it's not
really possible right now is that is that so.
Joe: I guess not.
London: Okay, so what about
other things or activities can you do to distract yourself from the suicidal
thoughts and make yourself feel better that is readily available to you at your
home.
Joe: I like to listen to jazz on the app for my phone and having my dog around
you know sit by me on the front porch is very relaxing to me.
London: Those are great tools. How likely do you think you would be to listen to music on your phone or
sit with your dog on your porch if you're feeling really upset.
Joe: I'm pretty likely I have my phone with me all the time and my dog she just like being
around me.
Conti: This provider is doing a good job of explaining why
coping is important and finding coping tools that work for the Veteran. She also
dug a little deeper into the Veterans coping strategy of fishing to make sure
that it was realistic and would be available when he needs it. Turns out it
wasn't. Moving right along to step three.
London: Okay, in this next step let's think about
who can help you take your mind off your problems at least for a little while.
Joe: My kids.
London: Okay and what are their names?
Joe: Daniel and Charlene. But Charlene and I really
don't talk anymore.
London: So maybe Daniel would be a good person to have on the list if
you think that would be someone you would really reach out to and he has a
listening ear.
Joe: Yeah, that's right.
London: Okay so what's his number?
Joe: (9 9 9) 8 8 2 - 7 7 7 1.
London: Thank you. Who else?
Joe: I have no friends and my brother's grown.
London: From what
you told me it seems like you really don't have many people you feel
comfortable reaching out to is that so?
Joe: Yes.
London: That's ok. We can also think about
places you can easily get to where you feel safe and calm and would serve as a
distraction.
Joe: I go to church sometimes
London: That's good. Now
is that a place where you can get to whenever you're in a crisis?
Joe: Not during the week.
London: What about a coffee shop or your son's house? I wonder if maybe
even a Senior Center or the VFW close to you would be a good resource. Let's pick
one or two of these for the plan and we can talk more about this next week when
we meet.
Conti: Notice how this provider used reflection,
guiding the Veteran to come up with the most realistic ideas while acknowledging
that there is still more work to do to get this Veteran connected to others.
It's ok to suggest ideas as long as you make sure that the Veteran is willing
and able to actually use those strategies. Otherwise, they aren't very
helpful. Steps 4 and 5 of the plan proceed in a similar way. In step 4, we
are asking the Veteran who they can reach out to in times of crisis. People
with whom they might actually share their suicidal thoughts. For our Veteran,
he might be willing to share these feelings with his son or perhaps he
doesn't have anyone to list in this section. For right now, let him know
that's okay and something to work on in the future. Perhaps an individual therapy.
Ask how likely would you be to actually contact this person if you were feeling
suicidal. Tt's always better to troubleshoot in advance than for
something on the plan to be unrealistic. Veterans may have concerns about other
people's reactions or concerns about burdening others. You can address these
concerns during your conversation with them. Similarly in step 5,
contacting professionals and agencies, it can be helpful to assess with whom the
Veteran feels most comfortable. If they have never used the Veterans Crisis Line
before, describe it to them so that it seems less intimidating.
London: The VA suicide
prevention hotline is staffed by trained phone counselors who are available 24
hours per day, seven days a week. Veterans have told me it's a very useful
resource whenever you're experiencing suicidal
thoughts and you feel you have no one to talk to. And the counselors who talk to
you on the hotline can actually help you to connect to resources in your local
area.
Joe: Okay, I didn't know that.
London: it's a good resource that is available to you at any
time. In addition, do you have a doctor or therapist who you want to contact in the
event of a crisis?
Joe: Yes my doctor Nadler. My psychiatrist I've known her for years.
London: great we'll put her down here and we'll make sure we get the best number to
reach her. Joe how does this whole plan look to you?
Joe: I feel comfortable with this so far.
London: And do you think that the things that we listed are things that you would
actually use in the future when you're experienced at crisis.
Joe: Yes.
London: I'm glad we
were able to work together on this plan today and it's tailored to you and your
needs.
Conti: This provider is drawing out the strengths and supports that the Veteran
already has while providing some additional information in a way that the
Veteran may not do alone. That's what it means to truly work
collaboratively.
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Conti: The last step on the safety plan is called a few different things. Making the
environment safe, means restriction, or means safety. Although this is the last
step, it is perhaps the most important to preventing suicide deaths. Making the
environment safe means removing or reducing access to means by which the
Veteran might kill themselves. Guns are a particular concern because most Veterans
and older adults who die by suicide use guns. People who have thought about
suicide often have one or two ways or methods that they can imagine themselves
using and you will want to focus on those. If they have ever made a suicide
attempt before, consider what method they used. Research has shown that limiting
means is an effective way to prevent suicide and it's a myth that people will
simply choose any method that is available. Talking to Veterans about guns
may require a delicate approach. Many Veterans own guns and feel strongly
about them and may have multiple guns stored in their home. Here are a few
things to keep in mind: Provide options and allow the Veteran to problem-solve.
Avoid the perception that you are taking their guns away. Emphasize that limiting
means can be temporary, to be used during a period of depression for example.
Anything that the Veteran can do to reduce their immediate access to a
loaded firearm is helpful. Using gun locks. Storing ammunition and
firearms separately. Locking guns in a safe while letting a loved one change
the code or giving firearms to a friend to hold for a while are all steps that
Veterans might be willing to take. Hiding the firearm is not sufficient.
Acknowledge this suggestion and ask for other possibilities.
Considering pills or medications, ask the Veteran if they have been stockpiling
medications intentionally or unintentionally. For example, if the
Veteran has not been taking their medication regularly, they will probably
have extra medication in their home. Suggest that the Veteran dispose of them
in a safe way. Hospitals and pharmacies have different programs to take back
unused medications. Now let's see how Dr. London and Joe managed this conversation
about means safety.
As we discussed before, it is common for suicidal thoughts
to come on quickly. You might become overwhelmed and feel like you can't take
it anymore. When you're upset, thinking of alternatives or solutions can be hard to
do. Having access to guns can be dangerous in this state of mind. You
mentioned Joe that you have a gun in your home. How many do you have and where
do you keep them?
Joe: Well I've got two shotguns that I keep in a gun cabinet
and I got one handgun and I keep beside my bed.
London: If you don't have immediate
access to your guns the chances are you're more likely to find other ways to
manage the crisis that do not result in you harming yourself. So making a plan
for gun safety might save your life. What are your thoughts about how you might
secure the guns?
Joe: I'm not sure about that. I really rely on those guns for
protection. I don't live in a safe neighborhood.
London: I definitely understand
your concerns about safety but right now I think the bigger concern is you being
safe and not hurting yourself. Considering how serious your suicidal
thoughts were, how would you feel about us giving your son your guns to hold for
now?
Joe: I guess that could work. He has a gun safe at his house and I know they
they'll just sit there until I need them.
London: thanks for your flexibility on this. I
think it's important to just take that extra precaution for your safety right
now. How soon do you think you can get your guns to your son?
Joe: Probably by this
weekend I'll drop them off.
London: How about we call him now and talk to him about
this plan.
Joe: Okay.
Conti: Notice that the provider is non-judgmentally and genuinely
expressing her concern. Of course if the Veteran wasn't willing to give the guns
to his son, she could have offered gun locks or at least suggested locking
ammunition and guns separately. If the Veteran was hospitalized on an inpatient
unit, the goal would be to have the gun stored safely before the Veteran
returned home.
London: In the final step, assess the Veterans commitment to using the
safety plan. You can do this by asking the question,
"how likely are you to use the plan" then ask why the Veteran rated their
commitment the way they did and troubleshoot any barriers. One important
consideration is how the Veteran will carry the plan with them. This is really
up to them. At home they can post it on a refrigerator or a mirror. For portability
and privacy, taking a picture of it on their phone using a safety planning app
or writing it on a card and then carrying it in a wallet are some other
helpful options.
Conti: Before we wrap up, I want to say a few words about Veterans with
major neurocognitive disorder or dementia. Veterans with mild to moderate
dementia who are oriented to person, place, and situation, but are forgetful
and may need some help with daily tasks, can still be involved in safety planning.
Complete as much of the plan as possible while avoiding frustration. Practice
encouragement and patience. You can make it a plan for what to do when you feel
really bad. it can include just one or two go-to coping strategies or social
contacts for Veterans with mild cognitive impairment. A card with these
numbers or strategies written on it could be really helpful. With appropriate
authorization, involve family nursing home or personal care home staff in mean
safety by calling them and telling them about the plan. Unfortunately, Veterans
with dementia do die by suicide. For individuals with major neurocognitive
disorder, means safety is most important. Increasing pleasant activities and
addressing pain or other issues in order to improve mood are also helpful. Thank
you so much for joining us today and for your commitment to Veterans and Suicide
prevention. The complete and free collaborative safety planning for older
adults manual and wallet card can be downloaded from the South Central MIRECC
web site. We thank the South Central MIRECC for
supporting the development of the manual and this training video.
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