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Suicide awareness and prevention training in a high security setting

An education programme tailored to meet the specific needs of staff at the State Hospital in Scotland will help to save lives, says James Fry
abstract
Staff at the State Hospital, Carstairs, developed bespoke training consisting of an online e-learning module and a one-day workshop in response to the Scottish Governments commitment to reduce rising suicide rates through the education and training of front line workers. The training has met current targets, linked with other practice-based initiatives and supported culture change at the hospital. Keywords High security mental health, mental health training, suicide awareness, suicide prevention
Correspondence jamesfry@nhs.net James Fry is an advanced practitioner working in learning and development at the State Hospital, Carstairs Date of acceptance December 31 2011 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines www.mentalhealthpractice.co.uk

In Scotland there were 781 probable suicides in 2010; that is 35 (5 per cent) more than in 2009 (choose life 2011). the number of suicides can fluctuate significantly from year to year (ranging from 746 to 843 during the eight-year period 20032010). to eliminate the risk of misinterpreting any dramatic rise or fall in a single year, trends are measured using a five-year moving average. Suicide is rated as one of the main causes of death among people under 45 years and the suicide rate in Scotland has long been higher than for other parts of the UK. Incidence of suicide among males is approximately three times that in females and the increasing number of young males who kill themselves is of great concern. on average, two or more people in Scotland die every day from suicide and rates in the most deprived areas are significantly higher than average.

services. of these, commitment 7 specifically focused on suicide, aiming to train front line nHS staff in awareness and preventative techniques. a later publication, Better Health, Better care (SEHd 2007a) updated commitment 7 to include substance misuse services as well as define it as one of the Scottish Governments core set of Health, Efficiency, access and treatment (HEat) targets and performance measures for nHS Boards. commitment 7 and HEat target 5 identically stated, Key front line mental health and substance misuse services, primary care and accident and emergency staff will be educated and trained in using suicide assessment tools/suicide prevention training programmes. Fifty per cent of target staff will be trained by 2010 (SEHd 2006, 2007b).

State Hospital
the Scottish Government encouraged nHS boards to identify their training needs and deliver appropriate training to staff. this was particularly relevant to the State Hospital, a high security forensic mental health facility that serves Scotland and northern Ireland. all patients in the State Hospital are formally detained and all are inpatients, with an unusually high proportion presenting extremes of difficult and challenging behaviour. It has almost negligible rates of suicide, with only two completed suicides in more than 20 years. this is despite having a patient population that matches one or more of the following high-risk categories for suicide: Major mental illness. Personality disorder. drug/alcohol misuse. History of self-harm/suicide attempts. Males aged under 45 years. Victims of abuse. detained in a high security environment.
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National targets
the Scottish Governments strategy choose life (Scottish Executive Health department (SEHd) 2002, choose life 2011) aims to reduce suicide rates by 20 per cent by the year 2013. In 2006 the strategy was further supported by the publication of delivering for Mental Health (SEHd 2006) which expressed 14 national commitments to improve mental health
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In the absence of formal research, we can only speculate as to how the State Hospital has succeeded in keeping suicide rates so low. It may, in part, be due to its relatively small population of patients prior to 2007 around 240 patients; since then, with the expansion of specialist medium secure facilities the population has reduced to less than 140. also, because of the high security function, patients are probably supervised more than in other nHS hospitals. It is likely that the strictly controlled environment, with its close monitoring and high levels of observation, and the positive long-term relationships that exist between patients and staff, all play a part. the average stay for patients in the State Hospital is seven years; for many staff, across all disciplines, length of service exceeds 20, and in some cases, 30 years. this provides stability for patients and enables staff to quickly identify patients who are at risk and take prompt and effective action. risk (Mclean et al 2008). It has been estimated that in Western culture, 90 per cent of completed suicides occur in people who have experienced at least one episode of mental disorder in their lifetime (Kutcher and chehil 2007). during the six-year period from January 2000 to december 2005, the national confidential Inquiry into Suicide and Homicide by People with Mental Illness: lessons for Mental Health care in Scotland (appleby et al 2008) found that among more than 5,000 completed suicides in Scotland, only 28 per cent were committed by people who had been mental health patients during the previous 12 months. of all inquiry cases, 9 per cent were psychiatric inpatients with schizophrenia, and delusional disorders, affective disorders, alcohol and/or drug dependence and personality disorder all featuring prominently. also in this group, 76 per cent had a history of self-harm, and 55 per cent of comorbidity. Mclean et al (2008) asserted that for individuals with schizophrenia or bipolar disorders, the addition of other factors, including for example, substance misuse, bereavement and previous suicide attempt, significantly increases the risk. Several studies identified a correlation between psychotic disorder and suicide (amador et al 1996, cassells et al 2005). Suicide can be directly related to psychotic symptoms, particularly if there is an increase in severity (Mclean et al 2008), but it is more likely to be related to the degree of insight the patient has into future long-term negative outcomes, such as the mental disintegration, decline in social function (Schwartz 2000, cassells et al 2005) and diminished quality of life (Ponizovsky et al 2003). Such insight may lead to feelings of hopelessness and helplessness, similar to those experienced in depression (Schwartz and Peterson 1999, Schwartz 2000, Schwartz and Smith 2004). depression is acknowledged throughout the literature to be the mental disorder most frequently associated with suicide. Evidence suggests that up to 50 per cent of inpatients will actually appear to be clinically improving at the time of suicide (Pompili et al 2003). clinical improvement could lead to changes in levels of insight and may partly explain why such a high proportion of suicides occur either before, or within days or weeks of discharge from hospital. the consensus, however, is that mental illness has a significant impact on the quantity and quality of social support experienced by individuals, and the experience of reduced social support described by many discharged patients can be distressing (crawford 2004).
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Assessing risk
long-term or static risk factors, which are also referred to as actuarial risk factors, traditionally feature in suicide risk profiles and are either historical, fixed or likely to endure for many years. they include: age. Gender. Social class. History of mental illness. History of substance misuse. History of self-harm. although they indicate a persons susceptibility to suicide, they fail to capture the variable nature of risk and are therefore not particularly helpful for clinicians who need to know the likelihood of imminent suicide (Bouch and Marshall 2005, cassells et al 2005). Short-term or dynamic risk factors are concerned with an individuals current state of mind and/or behaviour and are better predictors of suicide (Bouch and Marshall 2005, cassells et al 2005). they include the hopelessness and helplessness experienced in depression, severe psychic anxiety, panic attacks, agitation, delusions and hallucinations, and often fluctuate in duration and intensity. Extreme anxiety and agitation have been shown to occur in as many as 80 per cent of inpatients before suicide (lynch et al 2008). dynamic risk factors can indicate increased risk of suicide during every stage of inpatient admission, regardless of the length of stay (cassells et al 2005). Suicide and mental disorder Mental disorder is perhaps the strongest single determinant of suicide 26 March 2012 | Volume 15 | Number 6

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Malignant alienation Recognised as a significant issue in forensic practice (Watts 2004), malignant alienation is a term originally used by Watts and Morgan (1994) to describe a process where some inpatients show progressive deterioration in their relationships with others, brought about by their own negative behaviours. the provocative, controlling, complaining and demanding behaviours of some patients can lead to loss of staff sympathy and support (Pompili et al 2003). the process is labelled malignant because, as the patient becomes more self-alienating, there is an increasing tendency for staff to fail to see the suicidal risk, leading to a potentially fatal outcome. Childhood abuse Santa Mina and Gallop (1998) identified links between childhood physical and/ or sexual abuse and suicidal behaviour. More recent studies by Roy (2005), Joiner et al (2006) and andover et al (2007) have all reported a strong correlation between childhood abuse, particularly the more violent forms, and suicide. require time to produce results. If suicide is judged to be imminent, urgent measures are needed. Training programmes Suicide intervention training programmes, in particular applied Suicide Intervention Skills training (aSISt) (living Works Education 2011) and Skills-based training on Risk Management (StoRM) (Storm Skills training 2011), are promoted by the Scottish Government as satisfying training need in relation to commitment 7. aSISt is a two-day programme, teaching participants the Suicide Intervention Model, which will enable them to intervene and prevent harm or death until either the risk diminishes or additional help is found. the programme raises the awareness of participants of their own attitudes and experiences, which may affect suicide intervention positively or negatively. StoRM was developed at Manchester University and is a two-day modular course for clinicians (and others) who deal with suicide in a professional capacity. the programme is designed to develop and refine the skills used in assessing suicide risk and managing the crisis effectively. Formal evaluations of aSISt (Griesbach et al 2008) and StoRM (Morriss et al 1999, appleby et al 2000, Gask et al 2006) report positive feedback with regard to the skills learned and willingness of participants to apply the skills. there is clear evidence that the programmes help raise awareness, reduce stigma and equip participants with basic intervention skills. no evaluations have been carried out that can show that the interventions taught actually reduce suicide rates. Griesbach et al (2008) suggested that because of the multitude of factors responsible for causing or preventing suicide, it would be unrealistic to try to measure the impact of one specific training programme. Observation and engagement For inpatients, an increased level of observation is often considered to be a fast, safe and effective intervention, but this depends on how it is applied. In Scotland, 19 per cent of inpatient suicides occurred while the patient was under increased observation (appleby et al 2008). other authors (lynch et al 2008) mirror these findings. Barker and cutcliffe (2002) describe increased observation as being an unpleasant, negative experience for many patients. If carried out by staff with no knowledge of the patient bank or agency nurses, for example who have little interest in finding out details and who do not speak to the patient during the process, observations are likely to be viewed as intrusive, punitive and even
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Management of suicidal patients

the review Effectiveness of Interventions to Prevent Suicide and Suicidal Behaviour (leitner et al 2008) was commissioned by the Scottish Government to support its choose life strategy (SEHd 2002) and is international in scope. Medication In terms of preventive treatment, pharmacological interventions are recorded in the literature considerably more often than any other; however, with the exception of some success with the use of lithium and antidepressants in the treatment of affective disorders, the results are disappointing (lynch et al 2008). Bouch and Marshall (2005) suggested that although medication can be helpful where there is a clear association with mental illness, there is no firm evidence to support prescription medication as effective suicide prevention. Psychotherapy this has shown some promise, particularly dialectical behaviour therapy in the treatment of borderline personality disorder. leitner et al (2008) suggested, however, that further research is necessary if wider use is to be justified. despite some reported successes using other cognitive behaviour approaches, support for these is inconsistent. In the UK these specialist services are not routinely used for the treatment of suicidal individuals, the main reason being that there are too few therapists (leitner et al 2008). neither pharmacological nor psychological interventions provide immediate benefit; both
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dehumanising. observation carried out in this way does not address the root cause of a patients suicidal thoughts or behaviours and risk can increase for patients who feel they have not been listened to. However, if applied in the right way, observations are a means for the nurse to connect with the patient, and provide an opportunity to build a positive, worthwhile relationship (department of Health (dH) 1999). Suicidal patients need to talk about their thoughts, feelings and experience. they need to feel hope, and inspiring hope is a subtle process: no one can be forced into feeling less suicidal (Barker and cutcliffe 2002). the importance of the nurse/ patient relationship in managing suicide risk is again emphasised by cutcliffe et al (2007). Engagement, including forming a relationship, making a human connection, showing interest, acceptance, tolerance and a desire to understand, can help suicidal patients to experience a cathartic release and reconnect with humanity. In the therapeutic alliance model, presented by Vrale and Steen (2005), observation and engagement are used simultaneously. the process begins with the multidisciplinary team assessing the patients suicide risk, although in acute situations assessment can be carried out by a qualified nurse. Initially, there may be a greater emphasis on observations, but engagement remains integral throughout the process to develop the relationship. as the patient speaks more openly and trust is established, a partnership or therapeutic alliance can be considered where the patient is increasingly supported and encouraged to take responsibility for his or her own safety and wellbeing. If the patient is reticent or not engaging, observation remains the main focus. Method Forty members of State Hospital staff participated in the audit, including representatives from nursing, medicine, psychology, occupational therapy and social work. this number represented more than 8 per cent of all front line clinical staff in the hospital. a convenience sample was used; that is, staff who were readily available on the days when the interviews were planned. Participation in the audit was voluntary. Information was collected by semi-structured interview. Participants were asked a range of questions relating to suicide risk, preventive actions, reporting and attitudes to training. Each participant was given a brief explanation of the background to commitment 7 and the rationale behind the questionnaire. Questions relating to suicide risk were based on the information in the hospitals published guideline Suicidal Behaviour: awareness and Good Practice (State Hospitals Board for Scotland 2006). Questions relating to preventive actions were partly based on information contained in the same booklet and partly on clinical experience and practice. the willingness of participants to ask a patient directly if they were thinking about suicide and to explore any suicide plan was recorded. Results an attempt was made to keep participant numbers proportionate to the number of staff employed in each discipline, with nursing (trained and untrained staff) having the largest representation. among all participants, duration of clinical experience varied between one and 25 years. Points were awarded depending on the number of factors identified correctly in response to each question. a considerable proportion of the audit looked at the ability of staff to identify risk factors. Points were awarded for all correctly identified risks, providing they were supported in suicide literature and irrespective of whether they were contained in the guideline or not. Points were totalled to provide a final score for each participant (Figure 1, page 29). the results suggest that most participants have a reasonable knowledge and understanding of suicide risk and preventative measures, but that deficits do exist. the participating untrained staff (four members) all scored above 20 points. Somewhat alarmingly, however, the six members who scored 20 points or fewer were trained mental health professionals. the exact reasons for this are not exactly clear, although it is acknowledged that not all participants were familiar with the guideline and therefore may have been at a slight disadvantage. thirty three participants (82.5 per cent) identified three of the four main diagnostic
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Audit
an audit based on the information contained in the State Hospitals publication was undertaken between august 2008 and october 2008. the purpose was to: Gain insight into the existing knowledge and awareness of suicide risk and appropriate preventive measures among front line clinical staff. discuss with staff their current knowledge of suicide risk and prevention using semi-structured interviews. Identify strengths, gaps and inconsistencies in staffs knowledge. ascertain the willingness of staff to explore suicidal ideation with individual patients. define specific attitudes and preferences with regard to suicide training. Ethical approval of the audit was not considered necessary, because the results were only intended to inform service development. 28 March 2012 | Volume 15 | Number 6

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categories depression, psychotic disorder, personality disorder and drug/alcohol misuse; 28 (70 per cent) named all four. thirty five (87.5 per cent) of the participants identified depression as a major risk factor, with the same number correctly identifying hopelessness. Very rarely are patients given primary diagnosis of depression when admitted to the State Hospital and, although the presence of depressive symptoms in an individual will be recognised and treated, the prevalence of depressive symptoms among all patients in the hospital is not formally recorded. deliberate self-harm and past suicide attempts were recognised by 33 (82.5 per cent) and 29 (72.5 per cent) participants, respectively. thirty two staff (80 per cent) correctly identified childhood sexual abuse as a suicide risk factor, with an equal number recognising physical abuse. twenty-nine (72.5 per cent) named emotional abuse as a factor. twenty one (52.5 per cent) of the participants stressed that having a detailed personal knowledge of the patient was crucial in making an accurate and meaningful assessment of suicide risk. Many of the key changes in a patients mental state or behaviour that constitute dynamic risk factors could only be recognised by someone with an intimate personal knowledge of that individual, gained through the formation of positive relationships with frequent and meaningful interactions. a general opinion was that ward-based nursing staff, who spent most time with patients, were most likely to develop this type of relationship and be able accurately to assess changes in a patients presentation. all 40 participants listed increased levels of observation as a preventive action and in most instances this was given as the first answer, an indication of the importance all disciplines place on observations as a management strategy. twenty eight (70 per cent) identified therapeutic engagement as an essential preventive measure. nursing staff generally scored higher than other disciplines in identifying preventive actions. Participants were questioned about whether or not they would ask a patient directly about their suicidal intent. asking directly was explained as being a direct non-ambiguous question, which could not be misinterpreted by the patient to mean anything else. For example, are you considering suicide? or are you thinking about killing yourself? thirty one (77.5 per cent) stated that they felt confident about asking, with the majority of those expressing strong views about the importance of asking to clearly identify risk, as well as the potential serious consequences of failing to do so.
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Figure 1 Audit scores achieved by participating clinicians 14 12 Number of participants 10 86420 <10 10-15 16-20 21-25 26-30 31-35 > 35

Total score achieved (maximum available 40) of the nine (22.5 per cent) who said they would not ask, four were untrained and felt it was beyond their level of skill and responsibility; their main concern being that they would not know how to respond if the patient admitted to feeling suicidal. only one of the remaining five was an experienced practitioner, the others being newly qualified and inexperienced. despite assurances from all nine participants who said that they would not ask that they would raise concerns or seek advice from senior colleagues, the importance of asking this crucial question is clearly something to include in any training programme. no one identified malignant alienation as a risk factor. Given the types of patient who are detained in the State Hospital, there is perhaps a higher likelihood of alienating behaviours and therefore a need to include this in training. none of the 40 participating staff had ever attended a formal suicide training programme.

Evaluation of programmes
Four options were identified and subjected to a Strengths, Weaknesses, opportunities and threats (SWot) evaluation. the options were: do nothing. aSISt training. StoRM training. develop bespoke training for the State Hospital. Do nothing there is no cost attached to this. despite the State Hospitals excellent record on suicides spanning more than two decades, there is no way of knowing if or when the next suicide might occur. In view of the knowledge deficits identified by the audit, to offer no training to staff was considered
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unacceptable: it would leave the organisation vulnerable and the subject of serious criticism if any patient were to complete suicide. ASIST after close examination of all the evidence, including the formal evaluation (Griesbach et al 2008), attendance at the evaluation conference and speaking with various aSISt trainers, and informal discussion with State Hospital staff who had completed aSISt training, it was decided that aSISt was not a suitable option for the following reasons: It is a short-term intervention aimed at prevention and support until expert clinicians can become involved. It is much more aligned to the needs of community settings. although aSISt recognises mental disorder as a significant risk factor, the training contains no formal mental health component. aSISt has no formal risk assessment and offers no long-term management strategy. among all the individuals trained in the programme, those who felt most comfortable using the taught interventions were already experienced in working with suicidal individuals. copyright precludes flexibility and selectivity in how the programme might be delivered. the cost for training half of all clinical staff (240 people) over two full days would be high. STORM the suitability of this programme was examined by studying the published formal evaluations (Morriss et al 1999, appleby et al 2000, Gask et al 2006), by consulting with StoRM trainers and by reading the training materials. although the training includes risk assessment and short- and longer-term management strategies with greater mental health recognition, the formal evaluations state that those who benefit most are participants with no mental health background. It goes on to state that participants who have expertise in mental health are likely to already possess the skills taught by StoRM. In the State Hospital, where the core business is mental health care, and where front line staff are skilled in dealing with challenging situations, the skills taught by StoRM are likely to be of minimal benefit. again, the costs for two full days of training would be high. meet the specific requirements of the State Hospital. the flexibility and range of delivery options which could be applied would reduce the cost of such training by as much as half. In early 2009, a multidisciplinary working group was formed to develop a bespoke training programme for State Hospital front line staff. as well as incorporating components specific to suicide risk and management in the training, the group agreed that it was important to include other significant issues relating to best practice for example, practices that are rights-based (Millan Principles which underpin mental health legislation in Scotland (Mental Health (care and treatment)(Scotland) act 2003)), values-based (ten Essential Shared capabilities) (nHS Education in Scotland 2007) and recovery-focused (nHS Education for Scotland, Scottish Recovery network 2007) all of which are changing the culture in mental health practice, nationally and locally. any suicide prevention training offered to staff should take account of the organisations unique role and function, focusing on the risks particular to psychiatric inpatients in a high security environment. Group members were all volunteers, who agreed not only to develop but also to carry out the training. the training comprises an intranet e-learning module and a single-day workshop. all disciplines participate and everyone is expected to complete both aspects of the training, to answer randomised questions and to score at least 80 per cent. topics included in the e-learning module are: Facts about suicide in Scotland. Suicide risk factors, particularly in relation to inpatients. Preventive actions. Future risk. Misperceptions about suicide. the interactive workshops are delivered to a multidisciplinary group by two facilitators from different disciplines. Workshops include: Exploring attitudes to suicidal behaviour and its management. Sharing knowledge, expertise and personal experiences relating to suicide. Suicide risk assessment and management from a State Hospital perspective. Role play. Positive risk taking. Wider aspects of suicide colleagues, friends, family, community. By involving multidisciplinary practitioners in developing and delivering training to multidisciplinary trainees, using relevant theory and best practice examples, and linking these with practice-based
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Bespoke training developed

In view of the audit findings, SWot analysis, formal and informal evaluations of aSISt and StoRM programmes and acknowledgement that all staff can benefit from the right training, the decision was made to develop a home-grown package that would 30 March 2012 | Volume 15 | Number 6

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evidence and the organisational culture, training will be relevant to all clinicians, thereby reducing the theory/practice gap (Hart and Bond 1995). all workshop participants are asked to complete a course evaluation. Feedback has been extremely positive, especially in relation to the skills focus on assessment, prevention, and management of suicidal patients, the sharing of experiences with colleagues across a range of disciplines, and the potential for changing and improving their individual clinical practice. the majority agree that the two components of the training (online e-learning and workshop) complement each other with a minimum of duplication. Including other practice initiatives such as recovery-focused, values-based and rightsbased strategies, makes the training described here and other projects complementary. In addition to educating staff about suicide risk and management, the course makes an important contribution to a shifting culture. Suicide awareness and prevention training for State Hospital staff began in June 2009. the target of 50 per cent of staff trained, as stated in commitment 7 and HEat target 5, has been achieved locally and nationally. training in the State Hospital is ongoing; aiming for 100 per cent of staff to complete the programme by the end of 2013, thus exceeding the Scottish Governments expectation that nHS Boards will maintain a minimum of 50 per cent trained over the same period (choose life 2011). the State Hospital presently has around 65 per cent of all clinical staff trained. It is hoped that the success of this project will inspire and inform appropriate undertakings elsewhere.

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