Good morning, and welcome to this webinar led by Dr. Debra Pinals on Suicide Risk Assessment, Reducing Liability and Improving Outcomes. This webinar is sponsored by the Suicide Prevention Resource Center in collaboration with American Psychiatric Association. Before Dr. Pinals begins her presentation, we have just a few housekeeping items. Next slide. SPRC at the University of Oklahoma Health Science Center is supported by a grant from the Substance Abuse and Mental Health Services Administration, or SAMHSA. The views, opinions, and content in this product do not necessarily reflect those of SAMHSA or the Department of Health and Human Services. Next slide. SPRC is the only federally funded resource center devoted to advancing the implementation of the National Strategy for Suicide Prevention. Supported by SAMHSA, SPRC builds capacity and infrastructure for effective suicide prevention by working with state, tribal, health, and community systems, as well as professionals, public-private partnerships, and other stakeholders. Next slide. There are no conflicts of interest to report for this webinar. Next slide. We would like to make you aware that this activity is accredited and implemented by the APA, which has designated the activity for one AMA PRA Category 1 credit. Next slide. The handout for today's webinar can be downloaded from your screen. If you're using the desktop version of GoToWebinar, the file is located in the handouts area of the attendee control panel. If you have joined from the instant viewer, click the page symbol to display the handout icon. Next slide. If you're using the desktop, use the questions area of the control panel to type questions, which the speaker will address at the end of the presentation. If you're using the instant viewer, click the question mark symbol to display the questions area. Next slide. The speaker for today's webinar is Dr. Deborah Pinals. Dr. Pinals is the Director of the Program in Psychiatry, Law, and Ethics, and Clinical Professor of Psychiatry at the University of Michigan Medical School. She is also Medical Director of Behavioral Health and Forensic Programs at the Michigan Department of Health. Dr. Pinals is past President of the American Academy of Psychiatry and the Law, and holds several leadership roles, including current Chair of the Council on Psychiatry and Law at APA. In addition, she has consulted widely on matters related to mental health and forensic services, as well as authored many academic and policy publications. Some of her recent work has focused on competence to stand trial and related services. Dr. Pinals, welcome and thank you for joining us. Well, thank you very much for inviting me. And it is a pleasure to be here, speaking to all of you on such a really critical and important topic. I think, you know, now more than ever, this is part of the public discourse, which is great. Suicide prevention is something that has received increased attention. And so for all of you that have signed on to this webinar, thank you for your efforts in contributing to the cause. So let me go over what I plan to cover and hope that you get out of today's presentation. First, I'm going to describe the relationship between mental illness and suicide. And then I'm going to give a little bit more information related to firearms and suicide as a specific area that we need to think about. I'm going to then review how malpractice liability works. And finally, I plan to describe risk assessment methods to help reduce liability and focus on risk management to improve ultimate outcomes. So we will start with the first objective. Next slide. Describing the relationship between mental illness and suicide, as well as firearms and suicide. Next slide. So this may be data that you have heard before, but it never hurts to repeat it just to help you understand the magnitude of what we're talking about. Almost 50,000 individuals died from suicide in 2019, and another 1.4 million were reported as attempting suicide that year. Now, we don't know yet what the aftermath or the consequences of the pandemic will be, but already in 2019, that data shows alarming numbers of suicide. The CDC reports suicide in 2019 as the second leading cause of death for individuals ages 10 to 34, and the fourth leading cause of death for individuals ages 35 to 54. And if you follow the data that CDC reports, you'll see that suicide rates have increased over the 20 years prior to 2019, especially for anyone over the age of 14. And it accounts for worldwide 1.4% of all deaths. This is too many, and we need to do whatever we can to reduce these numbers. And we believe that through these types of trainings, we can help achieve some of those goals. Next slide. We have to think about the fact that suicide runs across all populations. However, there are certain populations that have received increasing attention as being at greater risk. And these are not the only ones, but included among them are people who've served in the military, our veterans, as well as others who've served in the military, transgender individuals, and older adults, which seem to be some particularly high-risk categories. Next slide. What about firearms? As I said, I wanted to spend some time covering some of the issues with firearms. Now, this talk is not anything to say whether it's not a pro-firearm or anti-firearm talk. It's really just presenting data to help people understand how we do some risk mitigation for individuals where firearms are involved. And what we know about the United States from surveys is that approximately 37% of the U.S. population owns guns, and 42% of veterans own guns. Next slide. We also know from data that about half of the suicides in 2019 were completed using a firearm. Individuals with mental illness who own a gun are more likely to use it for suicide than for homicide, despite multiple media reports that make it seem like persons with mental illness are more likely to commit violence. That actually doesn't bear out. However, the risk of suicide is great, and we need to be mindful of that risk and think about that as we develop our methodology for risk identification and risk mitigation. Next slide. What about suicide risk and specific diagnoses? Well, most suicides are related to psychiatric disease, especially depression, substance use disorders, and psychosis. And other conditions that increase risk include anxiety disorders, personality disorders, eating disorders, trauma-related disorders, as well as other organic mental disorders. Traumatic brain injury is something that's getting increased attention in the literature as a risk for suicidal ideation and suicide. And then there are other conditions that warrant review and, you know, a higher concern when we have individuals in our care that might have chronic pain or co-occurring health conditions. So you might look at this list and say, well, doesn't that mean that every diagnosis increases risk? And again, what we know is that suicide rates are going up and that we do need to pay attention to them. Although not all suicides are related to psychiatric disease, most are, and these are conditions that when individuals come in our care with these conditions, we want to be mindful, especially about that concomitant increased risk. We also want to think about suicide prevention in a holistic way so that we don't just limit it to those with these diagnoses. Next slide. What about serious mental illness and firearms? Well, in a study looking at 255 recently discharged psychiatric patients compared to 490 census-matched community control residents, there were a total that reported firearm access of about 15%. The patient group, including those with major mental disorders and other mental disorders, were no more likely to perpetrate violence, but were significantly more likely to report suicidality. So again, even though our threshold may be concerned about serious violence, and there are other tools available for you, lessons to learn about violence and mental illness through the SMI Advisor effort that you can get at smiadvisor.org, what's really important to realize is that violence is rare amongst persons with mental disorder. Mental disorder does not account for most violence in our society. However, we do need to think about suicidality. Suicide risk cannot be ignored, especially where firearms are concerned. Next slide. We can go to the next slide. There we go. I think there may have been a... Can you go back? I'm not sure if a slide was skipped. Can you go back one more just to make sure? Yeah. Okay. Sorry. Thank you. Okay. Keep going forward. All right. We are going to move now into objective two. Now that you've heard a little bit about the epidemiology and some of the data related to suicide, mental illness, and firearms related to suicide, I want to talk and shift gears to the meat of this conversation, which is really about as practitioners, what about malpractice? Let's talk about how malpractice liability works because I know that's everyone's concern when they are treating patients that might be at suicide risk. Next slide. First, it's important to realize that when we look at what's called tort law, which is where malpractice lies in the sense of a civil wrong committed to somebody where somebody then sues to say that something was done to them wrongfully, there are important components to realize of negligence that would have to be found in a court of law. First of all, we think about the dereliction of duty that directly causes damages. That's sometimes known as the four Ds of negligence. In other words, what it means is that one person has to have a duty to another person, which if you are a clinician or a psychiatrist treating an individual, you establish that duty through the doctor patient relationship or the mental health professional client relationship. Then there would have to be a dereliction of that duty, meaning some defiance or some disregard of that duty, whether it was knowingly or unknowingly, but something that was done that wasn't in line with what the duty required. And then that would have to cause directly the damages. In other words, if you do something wrong and you make a mistake and no harm ensues, there are no damages. And so the four components of negligence would not be made, would not be met. Furthermore, if there was no direct causation, let's say you see a patient, you speak to them and they are, you make a suicide risk assessment and they go out and get hit by a car randomly. There's no direct causation to what you did in your suicide risk assessment that led to them being hit by the car. If they walked in front of the car, there might be an examination of whether that was a suicide attempt and that might be something that happens. But if it was really a random accident where they get hit by a car, there would be no direct causation that could be attached to the provision of care. Certainly there would be damages because the person would be injured or have died in the car accident. And so the courts will really look at these four elements. And generally, ultimately, if a court case goes to trial, a jury will look at these four elements. Was there a duty? Was there a dereliction of that duty? Did that dereliction directly cause damages? And were there real damages? Next slide. The other elements that you need to realize as we think about malpractice is this expression of a standard of care. So when we look at whether there was a dereliction of duty, what we're really looking at is whether there was a deviation from the standard of care. And the standard of care says that a provider is required to exercise in both diagnosis and treatment that reasonable degree of knowledge and skill, which is ordinarily possessed and exercised by other members of his or her profession in similar circumstances. In other words, if somebody is in your care and you're recommending some outlandish treatment that isn't really a treatment known at all, that wouldn't be exercising in both diagnosis and treatment that reasonable degree of knowledge and skill, which is ordinarily possessed and exercised by other members of his or her profession in similar circumstances. Furthermore, if you are somebody with very nuanced specialized knowledge about the treatment of a condition that's still in its experimental phase, but has a promising practice that is only known to some small group of researchers, but may be effective, you would not be expected to exercise that type of treatment in your activity. Because really the standard of care is not looking at ivory tower standards. The standard of care is really looking at reasonable care, reasonable degree of knowledge and skill, which is ordinarily possessed and exercised by other members of his or her profession in similar circumstances. And that would be something that would be looked at in terms of whether there was a dereliction of duty. Next slide. Another element that comes up in suicide malpractice cases is this issue of foreseeability. Wouldn't it be nice if we all had a crystal ball and could tell the future and then try and change the future from happening? Of course, that would be the number one way that we could prevent all bad outcomes, but that is not what works and there is no way to do that. And so one of the things the court looks at is whether it was foreseeable, not from what we know happened, but from the seat of the person who's looking ahead in terms of reasonable foreseeableness. And that is an examination in malpractice of whether the treating professional had sufficient information or could have had such information so as to make a reasonable judgment. In other words, if you're a treating professional and you're basing your assessment of what you see, but you had access to notes right in the chart that five minutes ago this person said something different, so you could have known what was in that chart and you made a judgment not based on that totality of information, that might not be seen as reasonable when it was reasonably foreseeable that this person may have presented more of a suicide risk. And when we look at reasonably foreseeable as we're doing malpractice reviews, we always have to be mindful because when I get asked to do a case where I'm looking at whether there was potential liability and I might be looking for defense or for prosecution, we want to be careful about what's called confirmatory bias. For example, an attorney may call and say this is a clear-cut, slam-dunk case, no doubt this practitioner deviated from the standard of care. And then we might have a tendency, and we have to work against that tendency, to consciously or unconsciously just confirm the views of the retaining party. In other words, it is our requirement as forensic professionals to look objectively at the data and to try to review the data with the most objective review possible and limitations on bias. Another thing that we have to be careful about besides what's called confirmatory bias is this concept of hindsight bias, exaggeration of foreseeability by knowing the harm that ensued. In other words, if I know that somebody died by suicide, I might have a tendency to look back and say, well, it was obviously foreseeable that this was going to happen. And the more training one has in looking at these cases, the better, because you learn to try and look without that hindsight bias. We've done some studies looking at hindsight bias. I give you the citation and the references that helped examine the potential for hindsight bias, which is, it is a risk in reviewing cases retrospectively. So we really have to be careful as we look at foreseeability, not looking at it based on what we know or what others believe to be the truth of the matter, but we have to look at it again from the seat of the person who was sitting there looking without a crystal ball who had information or should have had information so as to make a reasonable judgment. Next slide. So what are the various steps in a malpractice claim? There are various things that will happen. A complaint may be made. Responses to that complaint will be drawn up. There will be a discovery process that might involve gathering information, gathering records, taking depositions, expert witnesses reviewing the matter for both plaintiff and defense. There may be possible reports at any one of these stages. However, the case may go away if the data just is not emerging to be a case that moves forward. And then there's considerations of options, either settling the case, dropping the case, or proceeding to trial. If it does proceed to trial, a jury will make a determination about whether there was liability that should attach or not to the practitioner and then what damages should be awarded. And these are the various steps that one might see. And it's important to understand that because if you do get pulled into a malpractice claim, to just realize that the process has to unfold and sometimes it unfolds over a long period of time, which can be incredibly stressful for the practitioner. Next slide. So how do we reduce our risk of liability? Well, one of the things we know is that oftentimes bad feelings and a bad outcome can increase the risk of litigation. So we wanna be mindful of our work with our patients and with their families around how we're handling complex decisions that have to be made. And even if we know bad outcomes, how those bad outcomes are managed. It's often advisable to call your malpractice carrier if there is a bad outcome so that you can review with them what the best ways of approaching these situations are. For example, things like, do I go to the funeral of my patient? Do I reach out to the family? And how do I do that? In suicide cases, others initiate lawsuits and they may have feelings distinct from those of the decedent. In other words, your patient may feel like you did everything you could to help them, but when they suicide, they may have other feelings going on in their minds that aren't that. However, family members may not know the nature of the relationship with the patient and they may have other feelings that instigate lawsuits that may need to be addressed. How we respond following a death can sometimes make a difference in terms of reducing the bad feelings, even if we can't change the outcome. Next slide. Another way to reduce the risk of liability by decreasing a bad legal outcome. Again, we may not be able to take away the suicide. We can't take away a suicide that occurs. However, it's important that as we're treating patients, we provide documentation that is clear and shows reasoning in decisions. We may ultimately make decisions that don't prevent a suicide. Hopefully we can do more and more to prevent a suicide, but sometimes in clinical practice, we make decisions and a suicide still happens. But if the documentation is clear and shows reasoning in complex decision-making, it can prevent a bad legal outcome following a bad clinical outcome. For example, the idea of having clear, informed consent documented, and also in some cases, documenting the patient's capacity to provide information and seek help. So for example, if you're working with a patient or a client who struggles with chronic suicidal thinking, documenting that they know how to access their safety plan, seek help, and have the capacity to make informed choices can be helpful. Or documenting how you're gonna provide some strategies surrounding the patient if they've lost that capacity to provide for themselves because they have tunnel vision with their depression. Also having good malpractice coverage is really gonna be important for individuals in practice. Next slide. So moving on to objective three, describing risk assessment methods to reduce liability and improve outcomes is where I'm going to take this talk next. Next slide. It's very important that we conduct a good psychiatric evaluation or evaluation consistent with our professional degrees. If we are working as professionals, if a peer support person is on this call and you're working under the license of a professional or working within your state's guidelines around how to be a peer support professional, it's also important to work along those lines as well. What does that psychiatric evaluation look like? Well, we wanna get a biopsychosocial perspective on the individual's history, understanding developmental history, social history, current circumstances of their mental health condition and any prior treatment, understanding their current mental status examination and helping to make a plan related to the history that's gathered. There may be a need for varied sources of information. So for example, we may talk to a patient, obviously we're gonna get the patient's self-report, but it may be important in suicide risk assessment to speak to collaterals. In an emergency situation, for example, it may be necessary to speak to collaterals. When we have a he said, she said, somebody's brought to the emergency department with some reports saying that they're suicidal, but then the person is no longer saying that they have, and they're saying they never had suicidal thoughts, then you have a disconnect. And in those kinds of situations, it's even more important to get collateral sources of information. Remember the patient who may be very, having a very significant suicidal ideation may see you as the treater is working against what their goals are. And so that collateral information can provide data upon which you can rely that can help resolve where you wanna go as you're deciding as a clinician, what makes sense for a next step, whether the person needs further assessment, whether they need a higher level of care. There also may be files or records that you have available or that again, that you should have available that you look at to help inform your position in terms of the clinical recommendations that you make. We do see cases, unfortunately, where decisions are made and on the record, you can see the nursing report, the report from other providers who were just literally talking to the patient. I recently did a case that involved a consultation liaison service in a medical hospital. Unfortunately, the consultation liaison practitioners came in and did a consult, but it appeared that they did not incorporate in their consult information that was taken directly from the nursing notes and the medical notes in the days and weeks prior to arriving on the scene. And had they done that, perhaps they would have come to a different conclusion about the recommendation that the patient was safe for discharge because there was a lot of information in the record that made it seem like the patient had changed their information at the moment of that assessment and it was relied upon as the sole information that led to a discharge and ultimately the patient suicided. Now, of course, there's no guarantee that that would have changed the decision, but when we are looking at these cases, it does demonstrate the potential for foreseeability that could have been lost by not looking at that information. Next slide. And then it's important to look at the risk factors. What are the patient's current suicidal thoughts and behaviors? Even if they're denying suicidal thoughts, but their behaviors are suggesting significant suicidality. For example, the patient who takes a major overdose where they could have died, but states that it was an accident and they never thought about suicide in the least, that has to be questioned. Again, it doesn't give you the answer of what you would recommend clinically, but it has to be taken into account. Again, certain psychiatric diagnoses, psychotic disorders, substance use disorders, bipolar disorder, major depressive disorder, physical illnesses and chronic pain that could be risk factors. And then psychosocial features, a lack of social support, recent unemployment, a major drop in socioeconomic status that could change that person's view of their world and their sense of hopefulness, poor family relations, especially new disturbances in what would normally be psychosocial supports, domestic partner violence, and then recent stressors that occurred. All can be important features that can change an individual's risk and need to be taken into account as you're doing that risk assessment. Next slide. Now, we're often trained to ask the question, are you having any thoughts about hurting or killing yourself? And this becomes the most frequent question that we see asked and documented, frankly, but again, it may not yield the full picture. And the answer to the question can be something that tells you, gives you some sense of what to do, but it may not give you the full sense of what to do. So if a person denies having thoughts about hurting themselves or killing themselves, but they come in having been brought in from police getting called after a major suicide attempt, after they're found sleeping on a railroad track or intoxicated or any other kind of scenario where the data just doesn't align, again, the question and the answer are important and should be asked and answered to the best of the patient's ability, but for the practitioner, it's important to realize they may not yield that full picture. Next slide. So we think about other types of suicide-specific screening questions that we do in our clinical examination. Again, the current suicidal thoughts, whether the person has any plans and what those plans are to commit suicide or to enact a suicide. Have they taken any steps or attempts to enact the plan of suicide? For example, somebody might say that they looked for a place to hang a rope. That would be steps that they would be taking that could potentially move them closer towards enacting a suicide plan. Have they made any prior suicide attempts? And if so, how lethal were those suicide attempts? We don't wanna minimize suicide attempts that were less lethal, but we do wanna understand how close this person has become to suicide. And also, is there a family history of suicide? That can be important to know because that can increase that individual's risk. And there can be ambiguousness in the family history that also needs to be taken into account and may, again, increase that patient's or that client's risk. Other associated suicide risk screening questions are important, like is there current depression, current anxiety, current psychosis, what is their sense of hopelessness, helplessness? What about current homicidal ideation? Are they having thoughts of not only suicide, but thoughts of harming others, which can go hand in hand? What about their sleep patterns? Have those recently changed? And substance use, we know that substance use, alcohol in particular, nowadays opioid use disorders as well, but other substances as well are real risk factors for somebody committing suicide or somebody having an ambiguous death that looks like a suicide. What about current psychosocial stressors? What's going on in their lives that could be contributing to suicidal thinking? These are gonna be important in the suicide risk assessment overview. Next slide. We also wanna think about risk factors that exist for that person that may be chronic and unchangeable, but may give us further data that helps create the totality of that risk assessment that we need to think about. So for example, childhood trauma can be associated with later life high-risk decisions. So what was going on for them in childhood may have relevance to how they're doing today. What about genetic and familial effects? The genetics of a history of mental illness or history of substance use disorders. And again, we know that suicide does run in families so that suicide risk factor is an important one to take into account. What about psychological features? As I said before, helplessness, hopelessness can be really important pieces that you wanna look at as you're understanding that person's risk factors. Their sense of future in that sense of hopelessness. Do they have a future orientation that's positive or do they only see their world through tunnel vision? What about psychic pain? Is this individual in psychic pain that seems hard for them to navigate? Do they have strategies to manage psychic pain? We know that some suicides occur in a crisis moment and that if people learn to manage those moments of psychic pain, they can move through suicidal crisis into the next phase of whatever they're feeling in that moment. But that takes a lot of energy and skill, frankly, to manage that psychic pain. So understanding that as part of that risk assessment. Anxiety, especially severe anxiety can contribute to suicide risk. A sense of shame or humiliation for anything that has happened to that individual in their lives may increase their risk. For example, they recently lost their job or they recently lost their income or their financial stability, which can create a huge sense of shame or humiliation for individuals. They may be in psychological turmoil. They may have decreased self-esteem and they may have this perception of being a burden to others. So this perceived burdensomeness is another factor to take into account. They may also have what we call narcissistic vulnerability. It may not mean that this person has narcissistic personality disorder, but we all have this sense of narcissistic vulnerability, the things that build our self-esteem, the things that we feel most proud of. When those are removed from us, we have this narcissistic vulnerability that can lead to a suicide crisis. This person may also have a history of impulsiveness, and that may or may not be associated with substance use disorder, but we want to pay attention to that. Again, aggression and violence can correlate with suicidality, and so we want to understand their risk for both violence directed outward as well as violence directed inward. And are they currently agitated? These can be risk factors for suicide. Next slide. Other risk factors we need to think about are cognitive features. Is this individual somebody who's lost recent executive function? We hear stories of famous people, for example, who have been diagnosed with conditions, neurocognitive declining conditions, who feel like they're physically declining conditions, and they feel like they're just not going to be able to live with those, whose risk factor for suicide might be increased. The cognitive feature of tunnel vision is a risk factor where the person feels, again, that sense of hopelessness and helplessness, and they just don't see a way out of it. Polarized thinking, this it's all bad, is a real concern when we look at risk factors, that the individual just can't see that it's not all bad. As they see their situation being polarized more towards the negative, and their mind becoming more closed to possibilities, these are risk factors for suicide. And then there's just demographic features. Males being at increased risk of completed suicide, whereas females being at increased risk for attempting suicide. Widowed, divorced, or single status. Older adults, as well as adolescents and younger age, where we're seeing suicide rates going up. White individuals also being at increased risk. Gay, lesbian, bisexual can be at increased risk, and so we have to think about those as risk factors as well. Additional features, as I've said before, access to firearms, substance intoxication, and unstable or poor therapeutic relationships. Somebody who's not currently in treatment can be at increased risk. Next slide. Other risk factors we need to think about are cultural, ethnic, and religious contexts. Risk for completion versus attempt. We know that whites and non-Hispanic Native Americans have higher rates of suicide than others. We know that the role of suicide, understanding of death, and understanding of higher powers can provide both protective factors as well as risk factors depending on what those cultural or ethnic or religious beliefs might be. The role of shame can increase risk, and so we wanna think about that. So we wanna do our suicide risk assessments with an eye towards cultural, ethnic, and religious contexts. The mechanism of coping with a stressor as accepted or not accepted can also be something to take into account. And the ability of an individual or the way an individual have the ability as much as the way an individual expresses emotionality can also contribute to risk or mitigate that type of risk. And so it's important for us to do, as we do these biopsychosocial assessments, to take into account culture, ethnicity, race, religion. Next slide. Predisposing risk factors such as poor self-esteem, exposure to suicidal behavior, impulsivity, substance use, depression, hopelessness, helplessness, and worthlessness also become key factors to think about. And then precipitating things that might just be those moments where somebody who has some perhaps chronic risk factors or more longstanding risk factors who may have a precipitant that increases that risk more acutely includes a recent loss, an anniversary reaction, the availability of a weapon or means of suicide, or an acute disappointment that we need to think about. Next slide. Communication of suicidal intent is a very complicated area. We know that a suicide communication was seen in approximately half of cases where an individual died by suicide. But what that also tells us is that in another half of cases there was no communication. So it means we have to take suicide communication of intent seriously, but we also have to be aware that individuals may be at risk of suicide even when they're not known to have directly communicated those suicidal ideations. So we have to do that thorough assessment when people come into our care. We have to understand that suicide communication is one point of data in the risk assessment, and also that when somebody does communicate suicidality, not all of those individuals will die by suicide. So this is where the art and the science come together in terms of doing those risk assessments and hopefully taking into account some of those suicide risk factors that I just went over. Next slide. So again, as we look at communication of suicidal intent, we want to think about that it's not clear that all suicidal communications are considered a cry for help. And these may be a matter of personal style. A person may verbalize suicidal ideation without really wishing to die. It can become somewhat common parlance that we see people say, oh, I wish I could just kill myself. And sometimes people say that very loosely. However, they may also verbalize those suicidal ideas and really wish to die. Again, that means that as clinicians, we need to thread that needle very carefully, take these statements seriously, do a proper assessment, and make recommendations that can sometimes be very complicated in terms of understanding what supports need to be put in place to help that individual and to help them learn with those moments where that crisis feels overwhelming, so overwhelming that they would say something about suicide. Next slide. Now what about firearm inquiries and what we know about the standard of care? There are numerous articles and book chapters that recommend that we do some type of firearm inquiry. And more and more licensures are tied to learning a little bit more about how to do such inquiries related to suicide and homicide risk assessments. Next slide. So there are general questions that are recommended. For example, when did you obtain your firearm can be important. We know that the risk of suicide within the first week of gun purchase has been seen to be much higher than in the general population. We also know that most suicides by firearm happen with firearms purchased years prior. So although a recent gun purchase can be a sign of increased risk that we have to pay attention to, some people will die by suicide with the use of their firearm that was purchased years prior. Next slide. Firearm questions can include for people who have firearms, do you have guns at home or any other place to understand where they are, how readily accessible this means is, can you get the gun easily? If there's unregulated gun access, that should also be considered. And then also asking people if they intend to obtain or purchase a gun, remembering that firearm purchase, recent firearm purchase in the context of suicidal thinking can be a risk, a major risk factor. Next slide. And in a paper that we wrote a few years ago, we talked about thinking about two tiers of firearm inquiry. For the general inquiry, we talk about tier one. First of all, does the person own a firearm? Do they have access to the firearm? How is that firearm stored? How is ammunition used for that firearm stored? And what are the social support networks that can assist with firearms if firearms are a risk factor for that individual? And that would be seen as sort of a generalized inquiry. Next slide. If any of those first tier questions become seen as sort of positive questions where further inquiry is required, then we move to the tier two questions, which really helps us understand a lot more about that individual's feelings and relationship to the gun as it relates to their suicide or violence risk. So for example, how acculturated are they with guns? Is this somebody who grew up with guns? Is this somebody who feels good about gun ownership and who feels strongly that gun ownership is important for them? How much time is spent with their gun? Do they have violent fantasies or suicide? When I say violent, I mean violence to oneself or violence to others associated with the gun. What is their psychodynamic attachment to the gun? What would gun removal look like for that person if they are at elevated risk? Would that put them at further increased risk because they would be so distressed about losing their gun possession in that moment? And it may be that still that risk is so high that we need to prevent the suicide, but we want to understand the implications of this. What about hobby or recreational use or other intentionality for that use? Because of course, that's something that's important to people. What about peer and family views? Is anybody else worried about having that gun around? And these kinds of questions and conversation can help us understand what type of risk mitigation might be important in a particular situation. Next slide. Protective factors for suicide that we know about and as it relates to both firearms and generally include effective clinical care for mental, physical, and substance use disorders, easy access to a variety of clinical interventions and support for help-seeking, having some connections to family and community, support from ongoing medical and mental health care relationships, skills in problem-solving, conflict resolution, and non-violent ways of handling disputes. And then culture and religious beliefs, as I mentioned before, that discourage suicide and support instincts for self-preservation. These are important things to keep in mind regardless of the means that the person has been thinking about for suicide. But in our suicide inquiry, we don't only want to think about the risk factors. We want to think about the protective factors. And as we build person-centered planning and mitigate risk, we want to build on the strengths of the individual and build on the protective factors to help offset what the risks might be. Next slide. There's also the use of suicide scales that hopefully you've gone and looked at the resources available through the SPRC. But there's much discussion about suicide risk assessment scales in clinical settings. Some of the older ones include the suicide ideation scales, the Beck hopelessness scale, the Beck depression inventory, the Beck scale for suicidal ideation. These can help in the risk analysis, but they're not going to predict necessarily who will die by suicide. Some of the suicide scales that are being talked about now in clinical settings include the Columbia suicide severity rating scale to help give us a baseline that's uniformly applied to help identify individuals who might be at risk. Or the PHQ-9, for example. And these scales can help anchor people who might be at high, medium, and low risk for consistency. And then also flag who needs a further inquiry because they can't just replace the need for clinical interview and assessment, but they may bring people to attention of providers who can do that more thorough assessment and risk mitigation planning. Next slide. Safety, the Suicide Assessment Five-Step Evaluation and Triage Guide through the National Suicide Prevention Lifeline and SAMHSA, the Substance Abuse Mental Health Services Administration, talks about identifying risk factors, both modifiable and fixed, identifying the protective factors that can be enhanced, as I've said, conducting the suicide inquiry, determining the risk level, as well as the intervention that's necessary, and then documenting those findings. Next slide. And then, of course, there's the Zero Suicide effort to reduce suicides to zero, which talks about aiming to reduce the suicide rates to zero, intervening and developing a monitoring system for individuals who may be at elevated risk so that we ultimately can eliminate suicides. Next slide. Risk mitigation strategies to focus on. Next slide. Selected risk management interventions, including attending to safety, determining the level of care that's needed, treating within the least restrictive setting, working within that clinician-patient relationship, helping understand the client's sense of their own recovery, coordinating treatment amongst providers and client so that we reduce the silos for the individuals that we're serving, providing education to the client and their family members or others when that's indicated to help others help be part of the suicide risk mitigation strategy, and providing somatic treatments when those are indicated. Next slide. In summary, we really want to think about key variables to stop a suicide. We want to think about, is there suicide intent? Does the person have access to lethal means that we can reduce? What is their motivation for suicide? What is their purpose to go on living? What is their quality of their relationship with the treater? What is the family history of suicide? As we look at these key variables, we can help influence the ability to stop the suicide. Next slide. Again, considering the biopsychosocial approach, lethal means restrictions, treatment of underlying conditions through medication and other therapies, addressing substance use, addressing and accessing the proper level of care, considering voluntary treatment options, but involuntary treatment options if necessary and appropriate, and managing suicide risk, even when somebody is in a treatment setting, since we know that suicide can occur in any setting. Considering what types of collateral supports might be available, safety planning, engagement with patient and their support system can be really important to bring in that support system for that individual. Thinking about examples of identifying what those risk factors could be. For example, if a person is experiencing depression, approaching pharmacology and therapy, if they have social isolation, then what can we do to increase their contacts? If they have a co-occurring medical condition, what can we do from a multidisciplinary perspective? If they have a co-occurring substance use, what can be added? How do we minimize their access to suicide means? For example, if somebody is thinking about overdose, how do we limit prescription period so that there's less medications available? If they have a history of multiple serious attempts, then how do we make sure that we're doing periodic risk assessments so that we're refreshing our data so that it doesn't become stale? This is how we move from risk assessment to risk mitigation. We want to debunk the idea of a no suicide contract. We really don't want to say in our notes that we've arrived at a no suicide contract with the patient because these no suicide contracts for somebody who really does have an idea of suicide are shown to be not that helpful, and they certainly don't help in reducing liability. They're not really recommended as part of a treatment plan. What we want to do is a thorough risk assessment. We want to continue to assess that patient and continue to make risk mitigation planning part of the work that we do rather than just getting a promise from a patient that they won't hurt themselves. Next slide. Again, we want to document for liability management that there was a risk assessment that was done. We want to document our reasoning for why we made the recommendations that we made, not just the decision that was made. We want to create a plan that addresses the risk factors, keep our emotions out of documentation, and know that generally speaking, if we didn't write it down, it didn't happen. And so we want to use our opportunity to document our thinking carefully as we weigh the risk assessment and the recommendations. And if you're in doubt, consult. Don't feel like you need to worry alone. Next slide. Reviewing the patient and the system of care is the way to continually identify hazards and risks, evaluate how we're going to manage it, manage the risks, and continue in a cycle of review so that we can help remove the patient from that suicide risk. Next slide. So in conclusion, we know that suicide is one of the leading causes of liability for mental health professionals. Reducing liability involves staying informed on risk assessment approaches, continually reassessing and developing risk mitigation plans, and providing self-care for yourself as a provider, because that can be equally important to help ourselves stay steady given the challenges of caring for populations who are at increased suicide risk to help reduce the overall risks for all involved. And with that, I think I'll conclude and see if there's time for any questions. And you'll see in the slide deck multiple resources. Great. Thank you, Dr. Pinals. That was very informative, and I certainly learned a lot. The floor is open for questions. If any of the webinar participants would like to send a question, you can use the question panel on your screen to type it in. One of the questions relates to what you had mentioned about the clinician's response following the death and how that can make a big difference. So some patients may authorize communication with family members, and others may not. And I was wondering, what are some considerations for clinicians when a patient has not authorized a clinician to communicate about their situation with family members? Are there recommendations in the field or any guidelines and that sort of thing? Yeah. So that can be a complicated area. Certainly I would recommend that people contact their risk management, their malpractice carrier, to help think through some of the issues that may be involved. It may be that the family calls the provider. Remember, it's never a problem to listen to other people. And that is something that you don't need a release to listen. You may not be able to share information, and you may need to say, you know, I'm not really at liberty for sharing information. You can always acknowledge people's pain. There's no harm in doing that in terms of if a family member calls and they're expressing a great deal of distress. It's fair to say how you understand that the distress is strong for that family member, and that you feel badly for their sadness and for their distress. And that may be sufficient to reduce some of those bad feelings, as I said, and reduce the risk of liability. I would recommend, again, in individual circumstances, people call their malpractice carrier to kind of weigh what level of detail other than that that can be shared. Also, it's important to know that family members may become the executors of the estate, and then they may be able to get be the proxy and sign a release and be able to get the records so that they can review them themselves. And that can be helpful for family members. Great, thank you. Another question is, how do you know how much and how frequent documentation is needed? You know, there's no bright line rule about that. You should follow the parameters within, if you work in a clinical setting, you follow those parameters. If something has changed in a patient's clinical condition, it's a pretty good idea to document that. If things are stable and status quo, then, you know, you don't need that more frequent documentation. But if you see something that's different, it's probably a good idea to write that down contemporaneously so that if there is a bad outcome, you don't look back and say, well, you know, you're writing it in retrospect, because that's often seen as something that kind of looks more suspicious from a malpractice point of view. But then again, if you didn't have time to write it down, it is okay to write it down. I know it sounds like I'm saying two different things. I'm really not. I mean, it is okay to write things down retrospectively, but you want to make sure that you're documenting it as a note on the date that you wrote it, not pretend to be writing it as a note from that you didn't write two days before. Thank you. Another question is, when assessing a client and you determine a legal hold for SI, assuming that means suicidal ideation, what is the best approach on how to alert the client in an outpatient setting to avoid a lot of chaos? So one of the things I always recommend is if you think you're going to be doing this, if you know in advance that this is a patient that you're more worried about and you maybe issuing an involuntary hold from an outpatient clinic, get it staged in advance. Make sure that you have the right personnel in place so that it doesn't become chaotic. I really recommend that that gets staged in advance. If it happens in the context of a therapeutic setting where you weren't anticipating the need to do that, you should still have available to you a methodology. For example, if I know I'm going to be seeing a patient, well, I just have a standard way of knowing where my assistant is and knowing what number I would call if I needed to have an emergency intervention. That's just wise for safety for all sorts of reasons to have your kind of emergency plan in place for who you're going to call if there is an emergency. And then, you know, you decide for yourself if you think that it's safe to talk to the patient individually or you wait until you call for help and you say, look, I really feel like we need to move to a, you know, I really feel like you're going to need more care. This may be something that we don't agree on, but I'm concerned about you. I think if you express concern and explain to the patient what's happening, it can always help them feel that they're treated more fairly, but you may want to wait until somebody's in the room with you. For more information, visit www.FEMA.gov

Suicide Risk Assessment

Reducing Liability

Improving Outcomes

Comprehensive Psychiatric Evaluation

Risk Factors

Protective Factors

Firearms and Suicide Risk

Malpractice Liability

Communication with Family Members