6 Content The definition of Self-harm & Attempted Suicide. The statistic and trend of Self-harm & Attempted Suicide in Adolescents. The causes behind Self-harm & Attempted Suicide in Adolescents. Signs of Non-Suicidal Self-Injury. Nursing Intervention for Self-harm or Suicidal Patients. Brief of Depression. Community resources. Case sharing & discussion.
7 The definition of Self-harm & Attempted Suicide. Self-harm is the deliberate infliction of damage to your own body and includes cutting, burning, and other forms of injury (Robert T Muller, 2014). Attempted Suicide: A non-fatal, self-directed, potentially injurious behaviour with an intent to die as a result of the behaviour, might not result in injury (Centers for Disease Control & Prevention, USA).
8 Other terminologies: Suicidal Ideation: thinking about or planning suicide. Completed Suicide: death caused by self-directed injurious behaviour with an intent to die. Non-Suicidal Self-Injury (NSSI): not intended to be fatal. Injuries to the body parts that are concealed. NSW Ministry of Health 2016
9 How common is NSSI? In Hong Kong, Shek and Lu (2012) reported 32.7% of secondary school students had engaged in self harm in the past 12 months More common in females (1.3x) then males No difference in rate was seen between local youth and immigrant youth
10 How common is suicide? In Hong Kong, whilst reported rates vary between studies, Shek and Yu (2012) found in the previous 12 months amongst secondary students: 13.7% of adolescents experienced suicidal ideation 4.9% had made a plan 4.7% had attempted suicide
11 The Statistic of Suicide Death in Hong Kong (By Age Group)
12 The Statistic of Suicide Rates in Hong Kong (By Age Group)
13 The Statistic of Method Used in Completed Suicide by Age Group in Hong Kong in 2015
14 Myths & Facts about Suicide (Centre for Suicide Research & Prevention. The University of Hong Kong. ) Myths Pt who talks on suicide will not commit suicide. Pt who die by suicide is very determined. Asking pts about suicide may provoke them to carry out the plan. Only trained mental health professionals can help suicidal pts. Facts Pt who commits suicide usually shows warning signs & cues. Pt is often ambivalent. Timely intervention can save life. This will often make pt feels understood & relieved. Most suicidal pts do not seek help from mental health professionals.
15 The causes behind Self-harm & Attempted Suicide in Adolescents. Coping strategy. Reduce distress, negative feelings or emotional pain. Self- punishment. Relief from strong thoughts or numbness. Demonstrate outwardly intensity of feelings. NSW Ministry of Health 2015
16 Ten Commonalities of Suicide The common stimulus is unbearable psychological pain. The common purpose is to seek a solution. The common goal is cessation of consciousness. The common stressor is frustrated psychological needs. The common emotion is hopelessness. Adapted from Shenidman (1996).
17 Ten Commonalities of Suicide The common cognitive state is ambivalence. The common perceptual state is constriction. The common action is escape. The common interpersonal act is communication of intention. The common pattern is consistency of lifelong styles. Adapted from Shenidman (1996).
18 The Suicidal Mind (Shneidman, 1996) Dominant psychological needs Frustrated Psychological pain become unbearable Constricted thinking Death as the only solution to stop the consciousness of pain Actively sought Suicide
19 The reasons for patient s resistance to disclose suicidal thought Think nobody can help. Wants to die & not be stopped. Suicide is a sign of weakness. Suicide is immoral or a sin. People may think he/she is crazy.
20 Problem solving model of suicidal behaviour Intense negative emotion A passive problem solving style with escape & low emotion tolerance A learned in which suicidal ideation & attempt is associated with short term reduction in distress.
21 Signs of Non-Suicidal Self-Injury Changes in mood Social withdrawal Avoiding activities where body is exposed e.g. swimming Change in school performance Lack of self care Unexplained injuries Wearing unseasonal or uncharacteristic clothing that conceals body Hiding or storing objects like blades, lighters, matches
22 Factors in associated with self harm indicates high risk of suicide: A medically serious act of self harm. Precaution was taken against being found. Previous episode of self harm. Depression or Psychosis. Substance misuse. Impulsive & aggressive personality traits. Loneliness & lack of social support. ( Isacsson & Rich, 2001).
23 Nursing Intervention for Self-harm or Suicidal Patients: Attitude & approach Assessment: Initial & HEADSSS Suicidal precaution Developing Safety & Contingency Plan
24 Attitude & Approach: Stay with the patient in a sympathetic way. Calm & non-judgmental approach. Avoid anger or shock. Listen & speak with respect. Keep patient talking & allow expression of feelings. Be patient & accepting.
25 Attitude & Approach: Express empathy. Acknowledge the patient s feelings. Use reflective communication skills to clarify & don t assume. Ensure safety at this time. Manage physical & medical needs.
26 Initial assessment on admission with three questions: Patient is admitted due to attempted suicide? Patient express suicidal ideation or self-harm behaviour? Patient s relative or friend reveals that patient has suicidal risk?
27 Home Education Eating/exercise Activities Drugs & alcohol Sexuality Suicide Safety Assessment with HEADSSS:
28 Assessment with HEADSSS (Suicide) Have you ever thought about hurting yourself? Have you ever tried hurting yourself? Prior suicide attempts? Do you have a plan? 你有無想過傷害自己 / 自殺? 你之前有無試過傷害自己 / 自殺? 你有甚麼想法或計劃? 你身上有無任何協助你傷害自己 / 自殺的工具?
29 Key Indicators in Assessment Severity of psychological pain. Tolerance of emotional distress. Hopelessness. Evaluation of suicide in solving problem. Strength of survival & coping beliefs.
30 Assess predisposing factors ( Treatment-focused assessment) Thinking style Problem solving style Tolerance for negative feelings Interpersonal deficits Life stress & social support buffers ( Chiles & Strosahl, 2005).
31 Risk Assessment Mental state: depression, psychosis, impulsivity, hopelessness Suicide attempt or thoughts: intention, lethality, access to means, previous attempts Substance use: misuse of alcohol or other drugs Corroborative history: family, records, other service providers Protective factors: e.g. capacity of support persons
34 危機介入 : 視不同自殺風險 (Centre for Suicide Research & Prevention. The University of Hong Kong. 低 - 承認人生有希望 - 持續評估抑鬱程度 / 自殺傾向 - 治療抑鬱症 / 精神病 高 - 限制接触自殺工具 - 自願 / 非自願入院 中 - 考慮全時間陪伴 - 使用熱線, 家探 - 研究應變方法 急 - 移除自殺工具 -24 小時監察 - 住院 - 联絡家人, 朋友
36 Suicidal Precaution:
37 Suicidal Precaution: Remove the objects that patient can use to hurt himself/herself. Advise his/her relative/ friend who trust to accompany with him/her or arrange a security staff to do so. Using the behaviour observation chart to close observe patient s emotion and behaviour. Refer psychiatrist for +/- medication or admission/f.u., clinical psychologist and MSW for counselling.
38 Developing Safety & Contingency Plan Completed in collaboration with the Adolescent Safety plans are used to identify and document: Individual warning signs and triggers Coping strategies Supportive people that can be contacted Professionals or organisations in local area that can be contacted Crisis information and after hours numbers Ways to keep self and surroundings safe A personal statement strengths, goals ( From HA Adolescent Nursing Course) 2016)
40 Positive Action Card( 緊急應對咭 ) (Centre for Suicide Research & Prevention. The University of Hong Kong 當我有自殺意圖, 我会作以下步驟 : 1. 不要喝酒 2. 坐下並深呼吸 3. 做一些我感覺良好的事情至少 30 分鐘, 如聽音樂 4. 和一個關心我的人談談我們的共同興趣 - 如果我想自殺, 我会找 傾談, 电話 若情況沒改善, 我会电 999, 或往急症室
42 Depression 15% individuals diagnosed with Major Depressive Disorder die by suicide. (Clark & Fawcett, 1992).
43 Symptoms of Depression: Psychological Depressed mood most of the day Feeling of worthlessness, helplessness & hopelessness Difficulty in concentration Recurrent thought of death /suicide.
44 Symptoms of Depression: Physical Insomnia Lack of appetite Weight loss Fatique Psychomotor retardation
45 Depression: Common Masked Signs Hostile Uncommunicated Boredom Reduce personal hygiene and self care Truancy Accident prone.
48 Treatment Goals of individual counseling A. help client to understand her cognitive and behavioural patterns and how these affect her emotions B. help client to learn skills to enhance her cognitive functioning C. help client to learn skills to enhance her behavioural functioning 48
49 CBT for depression: Thought Analysis Behavioural activation e.g. mood monitoring; pleasant activities, physical exercise Dealing with Automatic thoughts Dealing with Schema 49
50 Prevention of Depression Primary/Secondary prevention: teaching/ training of optimism Tertiary prevention: Mindfulness-based CBT Mindfulness deliberate awareness of experiential events as they happen in the moment in a non-judgmental way. 50
54 References NSW Ministry of Health (2016) Caring for Young People with Mental Health Issues in Paediatric Inpatient Settings Shek, D.L. & Yu, L. (2012) Self-Harm and Suicidal Behaviours in Hong Kong Adolescents: Prevalence and Psychosocial Correlates. Scientific World Journal, published online 2012 Apr 1 Web page of Centre for Suicide Research & Prevention. The University of Hong Kong. Isacsson, G., Rich,C.L.(2001)Management of patients who deliberately harm themselves. British Medical Journal, 322:
55 References Blumenthal, S.J. & Kupfer, D.J. ( 1988). Clinical Assessment & Treatment of Youth Suicide. Journal of Youth & Adolescence17: Clark, D.C. & Fawcett, J. (1992). Review of empirical risk factors for evaluation of the suicide patient. In B. Bongar (Ed.). Suicide: Guidelines for assessment, management & treatment (pp ). New York: Oxford University Press.
56 Case Discussion 24/3/2017
57 Case Discussion: 1.Using the Suicide Assessment of the HEADSSS to assess the following cases. 2.What is the nursing intervention for the cases?