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working with young people at risk of deliberate self harm and suicide in an emergency department trish flanagan youth self harm social worker Royal Perth Hospital Emergency Department November 2010 Overview Role of the Youth Self Harm Social Worker (YSHSW) at RPH Case study Statistics relating to suicide/deliberate self harm (DSH) and hospital presentations Define and explore suicidal behaviour & deliberate self harm Challenges unique to the YSHSW role – the environment; the young person; the clinician Summary Resources Overview of YSHSW Role Hospital Deliberate Self Harm Social Work positions were developed and introduced in 1989, funded by the Youth Suicide Advisory Council, as an example of best practice, based on the principles of early intervention and prevention. The aim was to reduce representation rates to hospital for young people with primary presentations of deliberate self harm. Primary responsibilities of the role include: 1.Provide assertive intervention while in the hospital environment; 2.Co-ordinate follow up arrangements for ongoing community-based treatment; 3.Provide support and short term counselling as required until care is taken over by a community service (up to 3 months); 4.Keep up-to-date a database of deliberate self harm patients for outcome monitoring and epidemiological research; 5.Provide an annual report to the DOH that includes details on patient demographics, methods of self harm, admission and follow up statistics. In 2001, the Auditor General of Western Australia reviewed the management of cases of DSH in Emergency Departments identifying a need to implement a variety of strategies to improve the care of young people presenting with DSH – assertive assessment and early intervention services within the community, appropriate follow up and discharge plans upon discharge from hospital, improve links with, referrals to, and timely transmission of details to CAMHS in an attempt to reduce wait times to community based services. Auditor General Western Australia, Life Matters – Management of Deliberate Self Harm in Young People 2001, (Online) Available: http://www.audit.wa.gov.au/reports/pdfreports/report2001_11.pdf (2010, Sept 2) YSHSW - Member of the EDMHLT (Emergency Department Mental Health Liaison Team) accepting referrals for patients aged between 14-25 who present with deliberate self harm/suicidal ideation or behaviour: The role offers: • Provision of initial psycho-social assessment including suicide risk assessment and mental state examination; •Liaison with family; significant others; external agencies-collateral; discharge planning; • Consultation with EDMHLT/ ED clinicians re patient management and discharge planning/admission; •Intensive social work input for inpatients and their families utilising– crisis intervention, problem solving, short term counselling, Psycho-education; •Post discharge follow up- monitoring of safety, interim support/counselling for both the young person and family; referrals and linkage to community services – youth specific and generic; •Follow up for after hours presentations. Case Study Lily is a 16 year old female who was brought to the Emergency Department by ambulance following a premeditated episode of deliberate self poisoning (12 Panadol & 4 glasses of Passion Pop) whilst intoxicated with suicidal intent. Superficial lacerations were noted on both her forearms and lower abdomen. Lily was at home in her bedroom at the time of the overdose. She alerted her friend via text message saying goodbye. Her friend advised her parents who phoned Lily’s mother. Lily denied taking the overdose when confronted by her mother however upon seeing the empty Panadol packet an ambulance was called. This is her second suicide attempt in 3 weeks. Lily cites the relationship breakup with her boyfriend of 12 months and escalating conflict with her mother as primary precipitants. She reports sleep disturbances, loss of appetite and weight and poor concentration over recent weeks. She is unwilling to return home to live with her mother and has no alternative accommodation options available to her. She is not currently active with any youth or mental health services and does not have a regular GP. Lily was resistant to further interview by medical staff. She also refused to see her mother who had been escorted into the distressed relatives room to be supported by nursing staff. Lily lay motionless on a hospital bed with the covers over her head. Nursing staff overheard her crying but were unable to engage her further despite several attempts. Primary Issues for Lily Distressed, emotionally overwhelmed; confused, misunderstood Feelings of guilt, shame, embarrassment Loss of relationship with boyfriend – abandonment/rejection Feelings of hopelessness; helplessness with regard to her situation Ongoing conflict with mother Potential homelessness Depressive symptoms Limited support system Current risk of further dsh/suicidal behaviour Recent suicidal behaviour resulting in hospitalisation Self harm behaviours as primary coping strategies Absence of adaptive distress tolerance/coping strategies – limited ability to tolerate negative states Poor help seeking behaviours Absence of formal counselling/community supports Issues for the clinician Lily’s reluctance to engage Uncertainty around current level of risk – deliberate self harm/suicidal behaviours Current refusal for parental involvement Gathering collateral from parent/guardian whilst developing a relationship with the young person Second suicide attempt – elevates short term risk; premeditated; goodbye text; absence of active help seeking Possible homelessness Potential activation of the Mental Health Act ‘96 if poor compliance with assessment process Prevalence of Suicide & Deliberate self harm Suicide claims on average the lives of seven Australians a day. There are approximately 65,000 suicide attempts each year – and more than 2,200 loved ones will die by suicide in Australia annually. Department of Health, Western Australian Suicide Prevention Strategy 2009-2013 , Everybody's Business. Between 1986-2006 there were 925 reported suicides for young people aged 15-25yrs. Miller, K. & Robertson, D. Completed Suicides of Western Australians – A Psychological Autopsy Study, TICHR, WA Coroner’s Database 2009. Western Australian hospitalisation data indicates that in 2006, 3,182 people were admitted to public and private hospitals following self-inflicted injury (2,014 females and 1,168 males) . The highest admissions for both men and women occurred in people aged 15-24 years. Department of Health, Western Australian Suicide Prevention Strategy 2009-2013 , Everybody's Business (Online), Available:www.mcsp.org.au/files/mcsp_user3/WA_Suicide_Prev_Strat.pdf (2010, Nov 1) Kids Help Line In 2009, 438,474 attempts to reach KHL; 53,111 Counselling contacts (phone, web, email) Mental Health Concerns – 12% (triple the rate of 2008) 1 in 5 young people presented with a suicidal issue or self injurous behaviour 5,067 presented with a suicidal related issue – more than 13 counselling sessions per day. An 82% increase since 2005 Deliberate self harm accounted for 15% of counselling sessions including OD’s considered non-lethal by the young person. Gender split: 80% female / 20% male Top 3 concerns for young people aged 15-25yrs Mental health and suicide related issues Managing emotional and behavioural responses Partner relationships Kids Helpline 2009 Overview (Online), Available: http://www.kidshelp.com.au/upload/22862.pdf(2010,Oct1) Royal Perth Hospital DATA May 2010: 263 presentations identified to be mental health related 72 of these were young people aged 25yrs and under (27.5%) 38 female; 34 male 26 (36%) presented post overdose 16 (22%) presented with dsh ideation and/or suicidal ideation 7 (10) related to deliberate lacerations Hirsch, N. 2010, ‘Review of the Nature and Number of Mental Health Related Presentations to the Royal Perth Hospital’s Emergency Department over 3 months in 2009-2010’. YSHSW Presentations to the RPH ED 2009/2010 194 young people referred to the YSHSW in 2009/2010 compared with 129 in 2008/2009. Data below based on 189 referrals More females presented than males; females - 121 (64%); males - 68 (36%.) Aboriginal patients accounted for 7% of the overall population referred to the YSHSW Poisoning by a solid or liquid substance (including paracetamol overdoses) represented the predominant method of dsh/attempted suicide accounting for 46% of referrals. 22% of all referrals were those presenting with Wrist slashing, stabbing or other laceration; suicidal ideation accounted for 22% of referrals Relationship problems remained the primary precipitant accounting for 34% of all presentations followed by Adjustment to psychiatric disorder at 23%, Family Difficulties at 21% and Education/School stress at 8% In 17% of all cases alcohol was involved; with 10% of presentations involving/suspecting other substances. For 68% of presentations neither alcohol nor drugs were involved Flanagan, P. 2010, ‘Youth Self Harm Social Worker Annual Report 2009/2010’. Unreported Research suggests that most cases of deliberate self harm are invisible to health professionals. Both method (i.e.: one requiring emergency medical assistance) and evidence of help seeking behaviours indicate a likelihood of hospital presentations. Hawton, K & Rodham, K & Evans E. 2006, By Their Own Young Hand, Jessica Kingsley Publishers, London Definitions Suicide : Suicide is a conscious act of self-induced annihilation, best understood as a multi-dimensional malaise in a needful individual who defines an issue for which suicide is perceived as the best solution. Suicidal Behaviour: Suicidal behaviour consists of thoughts, and actions which, if carried out, may lead to serious injury or death. This behaviour can be defined as involving the intent to die or the acceptance of death as a likely consequence. NSW Health. 2004, Framework for Suicide Risk Assessment and Management for NSW Health Staff. (Online), Available:http://www.health.nsw.gov.au/pubs/2005/pdf/suicide_risk.pdf (2010, Sept 2). Self Harm: Self harm is a direct and deliberate physically damaging form of bodily harm which is intentionally not life-threatening, often repetitive in nature and socially unacceptable. Walsh, B.W., & Rosen, P.M. 1988, Self-Mutilation: Theory Research and Treatment. Guildford Press, New York. Self harm is a maladaptive behaviour that reflects severe internal distress (which may not always be evident in the external demeanor) and a limited ability to develop effective coping strategies to deal with difficulties. Distinguishing between ‘self-harm without suicidal intent’ and attempted suicide can at times be difficult. Regardless of motivation or intention both are dangerous behaviours with a heightened risk of dying. Self harming behaviour usually occurs in one of two contexts: the person with a vulnerable personality who is acting out inner distress or the person who is psychotic. A person who is acting out inner distress in this manner often feels he/she is not able to communicate distress in less harmful ways. Although the vulnerable person’s self harming is frequently acting out inner turmoil or an act of self-soothing rather than an attempt to die, people who self mutilate do sometimes attempt suicide. NSW Health. 2004, Framework for Suicide Risk Assessment and Management for NSW Health Staff. (Online), Available:http://www.health.nsw.gov.au/pubs/2005/pdf/suicide_risk.pdf (2010, Sept 2). Deliberate Self Harm How and Why Behaviours: Cutting/stabbing; burning (physically/chemically), overdosing, over/under medicating (e.g.: misuse of insulin); hanging, self strangulation, walking in front of traffic, jumping from a height; ingesting hazardous materials/substances; biting, punching, hitting or bruising the body, head banging, hair pulling, picking/scratching at sores or the skin, episodes of alcohol/drug abuse or over/under eating. Risk taking behaviours that may cause personal harm include: alcohol/drug misuse, train surfing; reckless driving; repetitive unsafe sexual practices. Adapted from: Hawton, K & Rodham, K & Evans E. 2006, By Their Own Young Hand, Jessica Kingsley Publishers, London) Reasons to soothe uncomfortable emotional states that underlie the behaviour; to provide a way to relieve, control or express difficult or painful feelings; to cope with emotional pain; to communicate helplessness, despair and low self esteem, anger, loneliness, shame and guilt (nonverbally); to punish oneself; to distract from problems, to feel connected to something (even pain); to prove to yourself that you are not invisible; provide you with a feeling of control; to feel real; to connect with peers; a form of escape; an outlet for anger/rage; to relay to others the need for some support; care eliciting behaviour; suicidal act. Risk Factors for DSH Individual – depression/anxiety, poor communication skills, low self esteem, poor problem solving, hopelessness, impulsivity, drug or alcohol abuse. Family – unreasonable expectations, neglect or abuse (physical, sexual or emotional), poor parental relationships and arguments, depression, deliberate self harm or suicide in the family. Social- difficulty in making relationships/loneliness, persistent bullying or peer rejection, easy availability of drugs, medication or other methods of dsh. Triggers for deliberate self harm Family relationship difficulties Difficulties with peer relationships e.g.: breakup of a relationship Bullying (including cyber bullying) Significant trauma e.g.: bereavement; abuse Self harm behaviour in others (Contagion) Self harm portrayed or reported in the media Difficult times of the year Trouble in school or with police Feeling under pressure from families, school or peers to conform/achieve Exam pressure Times of change e.g.: parental separation/divorce. Relocation Adapted from: Hawton, K & Rodham, K & Evans E. 2006, By Their Own Young Hand, Jessica Kingsley Publishers, London Cycle of Self Harm Young people and Depression Depression is a broad term that can encompass normal mood states, clinical syndromes and actual mood states (eg: melancholia). At the clinical level, it involves body, mood and thoughts and affects a persons view of themselves. Symptoms include loss of interest and pleasure; loss of appetite; with weight gain or loss ; loss of emotional expression; a persistently sad, anxious or empty mood; feelings of hopelessness, pessimism, guilt, worthlessness or helplessness; social withdrawal and unusual fatigue and low energy. Parker G & Eyers, K. 2009, ‘Glossary’ in Navigating Teenage Depression, Allen & Unwin, NSW. Depression and Anxiety are among the most common mental health problems experienced by young people in Australia. Around 160,000 young people aged 1624yrs live with depression. 2008, ABS, 2007 National Survey of Mental Health & Wellbeing: Summary of Results (4326.0), Canberra ABS. These conditions can be serious, debilitating and life threatening however less than half of those young people experiencing depression seek help. Confusion related to diagnosing depression in young people given normal developmental issues – both emotional and behavioural. Symptoms of depression often go unrecognised or are attributed to being “just a part of growing up”. Long term effects associated with child and adolescent depression – substance misuse, academic problems, high risk sexual behaviour, impaired social relations and increased risk of suicide. Untreated depression is a major risk factor for suicide. Psychological therapies are the recommended first line options for the treatment of depression in children and young people. Limited clinical trials examining the use of antidepressants in young people under 18yrs. Uncertainty about their efficacy and safety for this population. Reviews have found evidence of an increased risk of suicidal ideation and behaviour in young people taking antidepressants however there are no government restrictions placed on the prescription of antidepressants for this age group and doctors are not prevented from prescribing them. Youth beyondblue, Factsheets and Info (Online), Available: http://www.youthbeyondblue.com/factsheets-and-info/(2010,Nov2) Paracetamol MisUsE “I’m not coping very well... I have taken my 10th Panadol about 5 minutes ago and am hoping not to live much longer, even though I know 10 Panadol won’t be enough”. (Kids help line Caller, Age 15) Increasing prevalence of Paracetamol and Ibuprofen Overdoses amongst young people. Frequently used as a means of dsh (with or without suicidal intent) by young people either on its own or with other medications. Ease of availability and accessibility. Financially viable for young people. Overdosing on Paracetamol can be lethal or cause irreversible liver damage. Ibuprofen is harmful to kidneys. Perception amongst many young people and parents that it is not harmful/lethal; often linked with attention seeking behaviours ‘she can’t be serious, it’s only panadol’. Often used as a form of repetitive deliberate self harm – minor overdoses – without help seeking – in an attempt to regulate emotions. Research indicates lack of knowledge amongst young people of the long term effects of chronic toxicity on internal organs. Chronic intoxication of the liver with Paracetamol can result in more pronounced liver damage than acute overdoses, often accompanied by severe renal dysfunction. Abuse of Paracetamol in Young People, 2005 Kids Help Line Newsletter, October 2005. Importance of seeking prompt medical assistance to enable treatment to reverse the effects of the Paracetamol. In the UK Paracetamol is the most widely used means for dsh and is responsible for approximately 70,000 cases per year. It is the most common cause of acute liver failure. Legislation passed in the UK in 1998 to limit the amount of Paracetamol bought in one purchase – 16 @ supermarket; 32 @ pharmacy; supplied in blister packs to make obtaining tablets more difficult. Initial success of these measures has waned and hospital admissions and deaths are on the increase. Paracetamol Poisoning. (Online), Available: http://www.patient.co.uk/doctor/Paracetamol-Poisoning.htm (2010, Nov1) Chronic Suicidality Darkling I listen; and, for many a time I have been half in love with easeful Death, Call’d him soft names in many a mused rhyme To take into the air my quiet breath. - “Ode to a Nightingale” by John Keats Chronically suicidal patients have only a faint hope that their lives will ever be happy or that they can do anything to change their situation. Patients comforted by suicidal ideas – options to escape enables tolerance of distress “half in love with easeful death”. This population poses significant challenges for clinicians Concepts outlined by Joel Paris: Inner world of the chronically suicidal patient – pain, emptiness and hopelessness. Suicidality is an attempt to cope with these states of mind. Chronic suicidality more associated with personality disorders, than depression. It requires a diagnostic concept that reflects continuous dysfunction over time (includes patients with bipolar disorder, melancholic depression, substance abuse and schizophrenia). Methods generally recommended for management of the chronically suicidal are usually ineffective and counterproductive i.e. hospitalisation. Effective therapy requires clinicians tolerating chronic suicidality whilst working toward healthy ways of coping to relieve psychological pain. Paris, J. 2007, Half in Love with Death, Managing the Chronically Suicidal Patient, Lawrence Erlbaum Associates, Publishers, New Jersey. Challenges – unique to yshsw Environmental The Emergency Department – primarily adult environment; foreign – often a young persons first hospital experience; stimulating – bright, loud, devoid of privacy, confronting, unpredictable; Agenda attached. Source of anxiety– can result in withdrawal and/or acting out behaviours – hostility, violence. Environment can be viewed as threatening; workers viewed as authority figures. Pressure to conform with expectations of staff i.e.: participate in the assessment. Interviews - conducted bedside, cubicles, corridor on a chair, seated on the floor, interview rooms. Information gathered inside and outside of the hospital i.e.: sitting with a young person on the footpath. Impact of other patients – absence of privacy; intrusiveness, unpredictable behaviours/violence, predatory element; psychiatrically or critically unwell patients. Use of security – present at interviews if necessary; observation within the ED; used for their presence to assist in the management and control of difficult/obstructive behaviours. Competing agendas - Pressure to arrive at a decision – discharge or admit; when the outcome is not clear. Requirements for extended assessment and gaining collateral. Ongoing consultation with staff. Importance of involvement at the commencement of the assessment process – to establish rapport and trust; to enable successful, ongoing community involvement/follow up. Judgments – staff perception around dsh/suicidal behaviour – often viewed as “attention seekers”; can be time consuming for other ED staff; attempts to dispel the myths and subjective views to maximize appropriate patient care and management via education. Organisational constraints - Bed shortage/blockages; 4 hour rule. Young Person Engagement & Rapport Building Rapport is defined as “a warm, relaxed relationship that promotes mutual acceptance e.g.: between therapist and patient. Rapport implies that the confidence inspired by the former produces trust and willing cooperation in the latter”. (1984, Longman Dictionary of Psychology and Psychiatry). Factors that complicate the development of rapport include: 1. absence of willing participant – young people are not always self referring 2. time limitations with regard to building rapport – important to dedicate time to listening to the young person’s story; validate experiences, provide empathy, support and reassurance. Factors impacting on rapport building with young people in an ED: 1.Acute situation – high levels of distress; possible embarrassment, guilt, shame associated with presentation 2.Medical status – young people often unwell post dsh attempt 3.Resistance to being in hospital – foreign and frightening; refusing assessment in an attempt to expediate discharge. 4.Large medical presence at interviews – reluctance to engage or be transparent when interviewed by a team of clinicians over 1:1. Confidentiality •Important in establishing and maintaining a relationship of trust between health workers and patients. •Research has consistently found that confidentiality is highly valued among children. Fear of breach of confidentiality often prevents children accessing health services. •Importance of explaining the parameters around confidentiality – i.e.: in the event of risk of harm to self or others, risk of physical/sexual abuse - along with who the information is to be shared. •Dedicating time to exploring reasons behind the request for confidentiality – negotiating where possible with the young person. •Communicating limits around information flow i.e.: to parents, verbally and via documentation with other team members to ensure consistency in practice and reduce likelihood of unauthorised disclosures. •Educating parents/guardians with regard to patient confidentiality and risks in relation to breach i.e.: dissolution of the therapeutic relationship. •Clinical supervision is imperative when dilemmas arise with regard to confidentiality. Department of Health. 2007, Working with Youth, a legal resource for community based health workers. Mature Minor Status • ‘Parental responsibility’ in relation to a child means all the duties, powers, responsibilities and authority that, by law, parents have in relation to their child. • It is usually in the best interests of the child/adolescent to have a parent or guardian involved in health care decisions. • Children/adolescents may seek professional assistance without their parent or guardians knowledge. They may also request/insist that parents/guardians not be informed about health care being sought or demand confidentiality with regard to their contact with a health professional. • The law in Australia recognises the concept of Mature Minor (founded in common law). • Philosophy and legal precedent utilised by DCP - the Gillick Principle - used to determine a child’s competence. • The assessment of a child as a ‘mature minor’ is based on age; experience, emotional maturity and intellectual capacity. • Professional judgement (on the maturity of the child/adolescent) to be made on a case by case basis. •Consultation with supervisor; DCP/Crisis Care. Adapted from: Department of Health. 2007, Working with Youth, a legal resource for community based health workers. Clinician Behavioural issues – young people unwilling to engage; manipulative; obstructive; non-compliant; aggressive; violent whilst in hospital. OR alternatively those seeking admission where it is not warranted. Team approach – consistent response to the young person; firm adherence to boundaries; clear and open communication with colleagues – to avoid ‘splitting’; ‘negotiables’ – exploring ways to foster cooperation. Frequent presenters – young people with chronic dsh/suicidal behaviours. Adherence to management plans where possible; liaison with community treating teams; consistent response by medical and psychiatric staff. Time constraints – working efficiently and effectively within a specific timeframe. Prioritising – what is most useful for the patient. Supporting and Educating families/significant others – anxiety and fear associated with taking a young person home post dsh/suicide attempt. Safety – endeavour to be well informed prior to patient contact – medical notes, collateral (past presentations, history of involvement with other services) discussions with nursing staff; interview space; awareness of your environment, other patients and potential risk issues i.e. unchecked bags. Staff education - Attempts to dispel judgments that may impact negatively upon young people and the service they receive whilst in hospital. Burnout - area of high stress; workload pressure; highly emotive issues; collaborative interviews and decision making; importance of self care. Supervision – importance of clinical supervision around complex cases – mature minor; child protection and domestic violence; advocating for admission/discharge – when clinicians opinions differ; barriers to discharge i.e. lack of safe and appropriate accommodation. Young people referred under the Mental Health Act ‘96 – unwilling to agree to voluntary admission; risk of absconding; fear and distress associated with being formed; educating young person and family. First psychiatric admission – emotional support/reassurance and education for both the young person and family. Homelessness – limited accommodation options for young people at risk; history of bans at YSAAP services; consultation with DCP. Obstacles to discharge: • Risk of harm from others i.e.: family/partners • Significant precipitants to dsh unresolved – vulnerability of young person in the community. • Absence of appropriate accommodation • Non compliance with recommendations by medical staff • Unsatisfactory discharge plan i.e.: proposed by the young person • When a family feels an admission is warranted • Supporting youth agencies and relaying their concerns/opinions to staff Feedback Anecdotal Positive feedback from patients and families highlighting the value of the YSHSW role and the EDMHLT. Support and acknowledgement from youth services confirming the usefulness of the position in assisting them when requiring emergency services. Future positive contacts from young people; subsequent crisis; seeking advice/guidance and support; requesting referrals. Summary YSHSW role focuses on assertive intervention and follow up post discharge for young people presenting to the ED with deliberate self harm. Research continues to highlight the prevalence of deliberate self harm amongst many young people in the community struggling to cope with life stressors. Early intervention and prevention of future dsh behaviours remains pivotal. Intensive support and linkage to appropriate youth community services to assist with the development and utilisation of healthy adaptive coping strategies is imperative for young people at risk of dsh/suicidal behaviours. Resources WEBSITES Ministerial Council for Suicide Prevention – www.mcsp.org.au Kids Help Line – www.kidshelp.com ReachOut – www.reachout.com.au Headspace – www.headspace.org.au Youth beyondblue – www.youthbeyondblue.com/ Orygen Youth Health – Victoria www.oyh.org.au/ TEXT Keith Hawton and Karen Rodham with Emma Evans - By their own young hand Steven Levenkron – Cutting – Understanding and Overcoming Self Mutilation Joel Paris - Half in love with Death, Managing the Chronically Suicidal Patient Gordon Parker & Kerry Eyers – Navigating Teenage Depression – A guide for parents and professionals SERVICES Youthlink & YouthReach South – Referrals and Enquiries: 1300 362 569 Youth Focus – 6266 4333 Fremantle Headspace – 9335 6333 Crisis and Emergency Mental Health Emergency Response Line (MHERL) – 1300 555 788 Crisis Care – 9233 2111 Local Mental Health Clinics Questions? Thank you for your attendance