In Harm’s Way A Primer in Detention Suicide Prevention The Lane County Model July 2003 David Mace, Ed.D Viriam Khalsa, M.S. John Crumbley, Ph.D John Aarons, M.S. 1 Dedication This manual is dedicated to the spirit of nurse practitioner Ginny Gnau. Ginny, in her honesty and care of youth, showed us all the way to make detention a safer place. Her patience, courage and steadfast insistence on the best for detained youth created a legacy that those who knew her are now blessed to carry on. Thank you Ginny. 2 Table of Contents: Preface __________________________________________________________ 9 Policies _________________________________________________________ 12 Adolescent Suicide Prevention and Staff Support __________________ 12 Suicide Prevention ____________________________________________ 13 Chapter 1 - Suicidology__________________________________ 15 History of Suicidology ______________________________________ 15 Rates of Suicide _____________________________________________ 17 Risk Factors __________________________________________________ 22 Primary Risk Factors __________________________________________ 22 Secondary Risk Factors_______________________________________ 23 Detention Risk Factors _______________________________________ 24 Methods of Suicide (Risk Analysis)______________________ 25 Cognitive States in Suicide________________________________ 28 Thinking Patterns in Suicide __________________________________ 28 Motivational Patterns in Suicide ______________________________ 31 Mental Health Diagnosis and Suicide ___________________ 33 DSM-IV _______________________________________________________ 33 Subtyping Behaviorally Disordered Youth ______________ 39 Review of Research in Detention Centers _____________ 45 Legal Issues/Risks___________________________________________ 48 Chapter 2 - Detention Suicide Procedures _______ 52 Adolescent Suicide Prevention ____________________________ 52 Detention Suicide Assessment Procedure____________________ 54 Questions Asked Upon Intake ________________________________ 54 3 Imminent Risk _________________________________________________ 55 Scoring Risk Factors __________________________________________ 55 Detention Policies _________________________________________________ 56 Optional Interventions________________________________________ 57 24 Hour (Constant) Supervision _________________________________ 57 Supervision During Sleep Times _________________________________ 58 Review for Possible Johnson Unit Referral _______________________ 58 Other Options _________________________________________________ 58 JJIS Computer Information ______________________________ 58 Chapter 3 - Suicide Panel_______________________________ 60 Functions_______________________________________________________ 60 History _________________________________________________________ 60 Panel Review of Youth ______________________________________ 60 Process: _______________________________________________________ 60 Panel Re-Review of Cases _____________________________________ 61 Panel Attempt Autopsy _______________________________________ 61 Documentation ________________________________________________ 61 Special Types of Cases ____________________________________ 62 Suicide Risks of Gay and Lesbian Youth ______________________ 62 Definitions of Terms ___________________________________________ 62 Disclosure _____________________________________________________ 63 Resources _____________________________________________________ 63 Summary ______________________________________________________ 63 Panel Practices _______________________________________________ 65 Routine Risk Panel Interview Questions for Risk Level Four Youth __________________________________________________________ 65 Routine Risk Panel Interview Questions for Risk Level Three Youth __________________________________________________________ 66 Panel Availability ______________________________________________ 67 Panel Composition _____________________________________________ 67 4 Panel Meetings ________________________________________________ 67 Panel Member Selection ______________________________________ 68 Panel Member Termination____________________________________ 68 Disagreement Between Panel Members_______________________ 68 Supervision of Panel Members ________________________________ 69 Suicide Prevention Training________________________________ 70 Training for Detention/Intake Staff ________________________ 70 Training for Suicide Panel Members__________________________ 70 Panel Disclaimer _______________________________________________ 70 Chapter 4 - Medical Issues in Suicide_____________ 72 Primary Medical Evaluation ________________________________ 72 Medical Response to Suicide Attempts _________________ 73 Hypoxia Assessment ___________________________________________ 73 Bleeding Flow Sheet____________________________________________ 75 Wound Management Flow Sheet _________________________________ 76 Poisoning Event Flow Sheet _____________________________________ 79 Types of Poisoning___________________________________________ 80 Insecticides: __________________________________________________ 83 Diabetic Emergencies _______________________________________ 84 Insulin Shock _____________________________________________________ 84 Diabetic Coma ____________________________________________________ 84 Chapter 5 - Counseling of Depressed and Suicidal Youth ________________________________________________ 86 What Does Counseling Mean in a Juvenile Detention Setting?________________________________________________________ 87 Myths of Suicide ____________________________________________ 90 Detention Stabilization _____________________________________ 93 Description Of Duties Of A Stabilization Team Member____ 93 Center for Family Development Stabilization Protocol_______________ 94 5 Objectives of Stabilization ___________________________________ 96 Objective 1: ___________________________________________________ 96 Objective 2: ___________________________________________________ 96 Objective 3: ___________________________________________________ 97 Objective 4: ___________________________________________________ 97 Objective 5: ___________________________________________________ 98 Objective 6: ___________________________________________________ 98 Objective 7: _____________________________________________________ 99 Pragmatics and Responsibilities of Stabilization Team Members:______________________________________________________ 99 Things that are NOT the responsibility of Stabilization Team Members: ____________________________________________________ 100 Chapter 6 - Detention Setting Risk Mitigation 101 Physical Environment _______________________________________ 101 Brief Analysis of Means/Method of Suicide ________________ 102 Methods of Suicide Ages 10-24 _____________________________ 102 Youth Rooms__________________________________________________ 102 Vents ________________________________________________________ 103 Hooks ________________________________________________________ 103 Video Cameras ________________________________________________ 103 Beds _________________________________________________________ 104 Toilets/Sinks _________________________________________________ 104 Bedding ______________________________________________________ 105 Lighting/Fire Sprinklers _______________________________________ 105 Youth Shower Area __________________________________________ 105 Other Youth Areas___________________________________________ 106 Youth Off Limits Areas______________________________________ 106 Youth Clothing/Suicide Smocks _____________________________ 106 Shoes ________________________________________________________ 107 Youth Access to Dangerous Objects ___________________ 108 MSDS Sheets ________________________________________________ 108 String/Cloth__________________________________________________ 108 Pencils/Pens __________________________________________________ 108 Staples/Paperclips ___________________________________________ 109 6 Other Objects _______________________________________________ 109 Eye Glasses___________________________________________________ 109 Hair Ties _____________________________________________________ 109 Eating Utensils _______________________________________________ 110 Medical Wraps/Prosthesis/Etc_________________________________ 110 Youth Isolation ______________________________________________ 110 Programming Issues __________________________________________ 110 Suicide Checks _______________________________________________ 111 Setting up a Contact Schedule ______________________________ 111 Family as Resource ___________________________________________ 111 Release of Suicidal Youth from Detention____________ 111 Appendix #1 - Practice Cases _______________________ 113 David_________________________________________________________ 113 Suicide Risk Questionnaire ____________________________________ 114 Ginny_________________________________________________________ 115 Suicide Risk Questionnaire ____________________________________ 116 Jim ___________________________________________________________ 117 Suicide Risk Questionnaire ____________________________________ 118 John __________________________________________________________ 119 Suicide Risk Questionnaire ____________________________________ 120 Viriam________________________________________________________ 121 Suicide Risk Questionnaire ____________________________________ 122 Martin _______________________________________________________