Statens helsetilsyn I •i 1984- 99 4 1K- 624 The Bærum Model IK-2568 Norwegian Board of Health Calmeyers gate i Pb 8128 Dep., 0032 Oslo Telephone: 22 24 88 88 Telefax: 22 24 95 90 Translated by Richard Lawson Statens helsetilsyn Calmeyers gate I Pb. 8128 Dep., 0032 Oslo Telefon 22 24 88 88 Telefax 22 24 95 90 Foreword One of the objectives of the European strategy for Health for all by the Year 2000 is to reverse the increase in the incidence ofsuicide in individual countries. In Norway, the National Plan for Suicide Prevention has as its main objective that: during the 1990s, the health service will attempt to arrest the negative development towards an increased incidence of suicide that has occurred during the period from the end of the 1960s. In order to provide the necessary assistance to those who are troubled by suicidal thoughts or who have survived a suicide attempt, there is a need for specialized skilis. The ability to understand the signals before it is too late is dependent on recognizing them. We have currently far too littie knowledge conceming suicide problems. There are also considerable shortcomings in the organization of assistance for suicidal persons. Many suicide attempters are discharged from hospital after receiving life-saving somatic treatment, but without any offer of follow-up or aftercare in relation to the problems that lie behind the suicidal behaviour. Today, systematic procedures are followed to a certain extent in relation to persons who show suicidal behaviour. The Bærum model, which involves cooperation between Bærum Hospital and the municipalities of Asker and Bærum, is the first model for systematic follow-up and cooperation to be adopted in Norway. The model has received a considerable amount of attention, and information about the model has been included by many county medical officers in their training programmes for medical and social work personnel. Some hospitals and some municipalities have developed their own routines on the basis of ideas derived from the Bærum model. The National Plan for Suicide Prevention recommends that municipalities and county authorities enter into permanent and binding cooperation. The Norwegian Board of Health hopes that this publication may stimulate cooperation across both academic and administrative boundaries. Oslo, December 1995 cLc&Å Anne Alvik Director General of Health Contents Authors’ foreword • 7 Summary 8 Part 1 General information 12 1.1. Introduction 12 1.2. Presentation of the cooperation partners 12 1.2.1.Bærum Hospital 12 1.2.2.Asker municipality 12 1.2.3. Bærum municipality 13 1.3. Patient statistics 13 2. The theoretical basis 14 2.1. Definitions 14 2.2. Approaches 15 3. Historical background 15 3.1. Internal organization of work at the hospital 15 3.2. Cooperation project between Bærum Hospital and Bærum municipality 16 4. Challenges of cooperation between agencies 17 4.1. Legal conditions 17 4.1.1 General statutory provisions 17 4.1.2 Confidentiality 18 5. Current organization of suicide prevention work 19 5.1. The model 19 5.2 Current routines 20 5.3. Counselling 20 5.3.1.The reason for providing systematic counselling 20 5.3.2 Counselling practice 21 Part 2 Professional approaches . 22 6. Medical treatment of intoxications 22 7. The approach of social workers in work with parasuicide 24 8. The psychiatrist’s approach in work with parasuicide 28 9. The public health nurses’ approach in work with parasuicide 29 10. Summing up 36 11. References 37 12. Appendix 39 Authors ‘foreword Bærum Hospital and the municipal health service in Asker and Bærum have cooperated for ten years on a suicide prevention team. The form of cooperation practised by this team is known as the “Bærum model”. In January 1994, in connection with the tenth anniversary, a working group was appointed to prepare a description of the Bærum model. This work is now complete. The present report has two purposes. Firstly to provide information to the administrative and political leaders in the county and the municipalities on how we have organized suicide prevention work. Secondly, we hope that through our experience and expertise we will be able to inspire colleagues to establish similar forms of cooperation on the prevention of suicide and attempted suicide. The working group has consisted of the following persons: • Anne Marie Silander Klette, Public Health Nurse (until summer 1994), Asker municipality. • Lillian Aaserud, Public Health Nurse Asker municipality. • Brit Burmo, Public Health Nurse Bærum municipality • Hilde Svellingen Public Health Nurse, Bærum municipality. • Fredrik Jakhelin, Psychiatrist, Bærum Hospital. • Wenche Haukø, Head of Department for Social Services, Bærum Hospital. Chapters 2.2 and 9 of the report were written by clinical psychologist Gudrun Dieserud, Bærum municipality. Chapter 6, “Medical treatment of intoxications”, was written by Dr. Are Normann, Bærum Hospital. The remaining chapters were written by the members of the working group. Bærum Hospital, December 1994 Wenche Haukø Chairman of the working group Summary Part i General Each year approximately 200 patients are treated at Bærum Hospital follow information ing suicide attempts. Since 1 January 1984, there has been a permanent and binding cooperation between the hospital and the municipal health 1. lntroduction services in Asker and Bærum municipalities for treatment and aftercare of suicide attempters. This form of cooperation has been designated the Bærum model. The cooperation involves the following: Bærum Hospital is a local hospital (County Hospital 2) and is owned by Akershus County. The hospital is designed to cover the hospitalization needs of the population of Asker and Bærum municipalities, a total of 140 000 inhabitants. Asker municipality has approximately 43 000 inhabitants. The municipalities have a relatively young population. Bærum municipality is a neighbouring municipality of Oslo. The population totals 94 000. Between 30 and 40 per cent of suicide attempters treated at the hospital are subsequently referred to the public health nurse in the municipality for aftercare. The remaining patients are referred to other forms of first or second line treatment. 2. Theoretical Definitions of suicide and attempted suicide in this report have been taken basis from “Selvmord” (Suicide) (Retterstøl 1990) and from “Nasjonalt Program for forebygging av selvmord i Norge” (The National Plan for Suicide Prevention). (Helsedirektoratets veiledningsserie, 1 — 93). Parasuicide includes: “All intentional intoxications and selfinflicted physical injuries that are followed by medical treatment”. We base our understanding on psychiatric, psychological, social work and sociological, theory. 3. Historical As early as 1978, the former head of the hospital’s social work service, Kan background Halvorsen Holten, pointed out the arbitrary nature of the aftercare given to suicide attempters after discharge from hospital. In 1979, she prepared, in cooperation with the medical department, intemal routines for psychosocial treatment and aftercare of these patients. All hospitalized patients were then referred to a social worker for consultation. In spring 1981, a group of students from a college of social work carried out a project on the treatment needs of suicide attempters and the facilities available in Asker and Bærum. In spring 1983, a cooperation project was started between Bærum Hospital and Bærum municipality. The municipal public health nurses were to provide the patients concemed with aftercare in their own homes. From i January 1984, this cooperation has involved both municipalities. This way of organizing a suicide prevention team has been designated the Bærum model. 4. Challenges of Legal considerations, particularly relating to provisions concerning cooperation confidentiality, have provided the greatest challenge to our cooperation. between public agencies It has transpired that different professions interpret provisions concerning confidentiality in different ways, and there may be a number of reasons for this. Firstly, legal matters are accorded different degrees of emphasis in the basic training of the different professionals involved. Secondly, the legislation conceming matters subject to confidentiality is complex. It is often necessary to consult travaux preparatoires for more detailed informa tion. Both of these considerations concern the legal duty of confidentiality, Le. the legislation conceming professional confidentiality (legal statutes applying to the professions) and the provisions concerning administrative confidentiality laid down in the Public Administration Act. If a disagreement anses in the interpretation of provisions concerning confidentiality, this is likely to concem ethical confidentiality, i.e. a duty of confidentiality founded on the different professions’ ethical guidelines or principles. In our cooperation, the duty of confidentiality of the hospital staff is revoked.by means of written consent from the patient. A standard information document has been prepared for .this purpose. -, 5. Organization TI:ie Bærum model consists of four stages: ot work on 1.. Medical treatment and monitoring. su icide 2. Psychosocial/psychiatric interyention. prevenhion 3. Aftercare by a public health nurse. today 4. Continued residential or non-residential treatment. Written routines have been prepared defining the internal distribution of responsibilities, and regulating the cooperation between the public agencies involved. The routines are reassessed once every two