PDS-BEMR SUICIDE RISK ASSESSMENT GUIDE — Version 3 Key Principles to Consider When Conducting Suicide Risk Assessment (adapted from Granello, 2011): - Risk or Protective Factor Absent 0 Risk or Protective *tor Not Assessed Mental Status Exam: In PDS you will be required to select a value for each of the areas below. You can make additional comments. O Level of Consciousness O Mood O Psychomotor Activity O General Appearance O Thought Process O Thought Content In PDS you will be required to select a value for each of the + - 0 STATIC FACTORS OOO Chronic Medical Condition OOO Family Hx of Suicide 000 High Profile Crime OOO Hx of Childhood Abuse 000 Hx of Psychiatric Hospitalization 000 History of Mental Illness 000 Past Suicide Attempt OOO History of Violent Behavior 000 Lack of Family Connections OOO Sex Offender Status + - 0 DYNAMIC FACTORS risk/dynamic/protective 000 Agitation 000 Current Intoxication 000 Current Physical Pain 000 Current Suicidal Ideation 000 Current Suicidal Intent 000 Current Suicidal Plan 000 Fear for Own Safety 000 Feeling Hopeless/Helpless 000 Feels Like a Burden 000 Non-Adherence to Medical Tx 000 Problem Solving Deficits 000 Recent Significant Loss 000 Sleeps Problems 000 Social Isolation OOO Uncontrolled Mental Health Issues O Behavior factors below: + - 0 PROTECTIVE FACTORS OOO Able to Identify Reasons to Live 000 Adequate Problem Solving Skills 000 Denial of Suicidal Ideation OOO Future Orientation O00 Religious Beliefs Against Suicide OOO Social Support in the Institution O00 Supportive Family Relationships OOO View of Death as Negative 000 Willingness to Engage in Tx Additional validated risk factors that may be relevant: Sentence >20 years; Self-harm in past month; Dual Diagnosis; Male Gender; History of Self-Injurious Behavior; Chronic/Uncontrolled Pain; No Spouse (Single, Divorced, Widowed) EFTA00032191

Suicide Risk Assessment in PDS-BEMR Classification of Suicide Related Behaviors Suicide Related Communication: Any verbal or non-verbal interpersonal communication of thoughts, wishes, or intent for suicide that does NOT produce self-injury. Actions do not produce self-injury, although they have that intent. Examples may include - placing a noose around one's neck in the presence of staff: - writing a letter that states. "the world would be better without me': - stating, "I'm going to kill myself." Suicide Related Behavior: A self-inflicted, potentially injurious behavior for which there is evidence that the person either (a) wished to use the appearance of a suicide attempt to attain some other end. or (b) intended. to some degree. to kill him/herself. Yes No Undetermined Suicide Attempt: A non-fatal self-directed potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury. Non-Suicidal Self Directed Violence: If there is no evidence, whether implicit or explicit, of suicidal intent it is not an attempt, it is This is your judgment and includes inmate self-report. Look at the big picture and account for other data that corroborates or contradicts self-report. This is a distinction that the executive staff and/or the IDO need to have made for them. Yes or No Medical interventions are not an injury, but are undertaken to avoid or address an injury. Lethality Assessment Asphyxiation - Hanging Asphyxiation - Other Cutting Fire Ingestion - Prescription Medication Ingestion - Non-Prescription Medication Ingestion - Other Jumping Other Most of these are self-explanatory. Ingestion — Other is appropriate for swallowing razors and other foreign objects. EFTA00032192

Low Lethality: - Death is impossible or highly improbable. - The individual may receive medical attention. Out it is not required for survival. - Frequently. the act is done in a public setting. or is reported by the individual to ensure detection and assistance. - Examples placed noose loosely around neck and did not attach the other end to another object: swallowed 10 Tylenol pills in front of staff; scratches or superficial cuts on neck or wrist. Moderate Lethality: - Death is a possible. but not highly probably, outcome of the act, in the opinion of the average person. - Opportunity for detection and intervention was not certain. - Medical or crisis intervention may be required to reduce the risk of death (e.g.. pumping stomach. suturing cuts). - Examples: swallowed 30 Tylenol cut neck and lost significant blood: placed ligature around neck and applied pressure. High Lethality: • Death is the probable outcome, although immediate and vigorous medical attention may reduce the risk. - The individual took measures to avoid detection and intervention. or the method was so lethal that intervention was not likely to prevent death. - Examples: placed ligature around neck and lost consciousness: attempted to hang self. but stopped when cellmate awoke; took a potentially lethal overdose and did not alert staff. Examples of Protective Factors (Sanchez, 2001; United States Public Health Service, 1999) • Strong connections to family and community support • Sense of belonging, sense of identity, and good self-esteem • Identification of future goals • Support through ongoing medical and mental health care relationships • Easy access to a variety of clinical interventions and support for help seeking cannot be simply compared on a one to one b jive cation • Skills in problem solving, coping and conflict resolution • Cultural, spiritual, and religious connections and beliefs • Constructive use of leisure time (enjoyable activities) • Effective clinical care for mental, physical and substance use disorders • Restricted access to highly lethal means of suicide fact factors. Low Acute Risk Suicidal ideation is absent or is of limited frequency, intensity. duration and specificity. There are NO identifiable plans and NO associated intent. There is good self-control based on both self-report and objective assessment. There may be mild symptomatology and morbid rumination may be present. Few risk factors are present and protective factors are identified, including available and accessible social support. Moderate Acute Risk Suicidal ideation is frequent with limited intensity and duration. Suicidal plans have some specificity, but NO associated intent. There is good self- control. limited to moderate symptomatology. some risk factors are present. and protective factors are identified, including available and accessible social support. Denial of ideation and intent may be present. if objective markers. such as suicide threats to others and agitation, contradict the self-report High Acute Risk Frequent. intense, and enduring suicidal ideation. specific plans. Many risk factors are identified. Objective markers of risk are present (e.g.. lethal method, rehearsal behaviors. saying "goodbye•): self-report of subjective intent may or may not be present. There is evidence of impaired self-control. severe symptomatology. multiple risk factors are present. and few. if any protective factors. Present - Chronic Rick is present when there is a history of two or more suicide attempts Absent - Chronic Risk is absent when there is a history of one or zero suicide attempts. Note: Self-ham behaviors are not counted as suicide attempts. EFTA00032193

Recommendations: If suicide risk is present, consider recommending the following interventions: - Suicide Watch • Brief Cognitive Behavioral Therapy for Suicide - Positive Reinforcement - Safety Plan - Psychiatric Referral - Reasons for Living Card - CBT/DBT Skills Training Groups - Coping Cards - Recommendation for Double Cell - Psychology Alert Code - Change Care Level (UPDATE Diagnostic and Care Level Formulation) - Property Restriction (If Returning to Restricted Housing) - Suicide Risk Management Plan - Consult with Unit Team - Assign a Mental Health Cadre - A suicide watch is not warranted at this time - A suicide watch is to be initiated immediately - A suicide watch was initiated by non-clinical staff and continues to be warranted - A suicide watch was initiated by non-clinical staff and is no longer warranted EFTA00032194

Date_4. Notes EFTA00032195

The Suicidal Mode Predispositions to Suicide Genetic & biological factors Family history of suicide Abuse or other trauma history Impulsivity Aggression Previous suicidal behaviors p sychiatric history Behaviors I ' Substance abuse Self-harm i Preparing for death Practicing / rehearsing suicide Suicide threats Poor expression of emotion --0/ Social withdrawal /Trigger (Perceived Loss) Relationship problems Financial stress Onset of illness Legal problems Traumatic events Recent loss of a significant other \Zher major life changes , Hopelessness .. , Perceived burdensomeness Isolation / loneliness Reasons for living Reasons for dying Impaired problem solving Thoughts Physiology Agitation Sleep disturbance Concentration problems Physical pain Emotions Shame or guilt t_ ._ Anger Anxiety or panic Depression . . 1 EFTA00032196

The Suicidal Mode Predispositions to Suicide K J Behaviors a' I im> Trigger (Perceived Loss) m K J C -.. Thoughts K J Suicidality Physiology i 10 EFTA00032197

PDS-BEMR POST SUICIDE WATCH REPORT GUIDE Watch End Date: Watch End Time: AM/PM Watch Conducted By: Both Inmates & Staff Inmate Staff Transferred to a Medical Center: No/Yes Mental Status Exam: in PDS you will be required to select a value for each of the areas below. Elaborate below. Level of Consciousness O Psychomotor Activity O Mood O Thought Process General Appearance O Behavior Thought Content Na rrativel for Risk Factors Assessed: EFTA00032198

- Risk or Protective Factor Absent 0 Risk or Protective ratniVinBia Mental Status Exam: in PDS you will be required to select a value for each of the areas below. You can make additional comments. 0 Level of Consciousness 0 Mood 0 Psychomotor Activity C General Appearance 0 Thought Process 0 Thought Content In PDS you will be required to select a value for each of the + - 0 STATIC FACTORS 000 Chronic Medical Condition 000 Family Hx of Suicide 000 High Profile Crime 000 Hx of Childhood Abuse 000 Mx of Psychiatric Hospitalization 000 History of Mental Illness 000 Past Suicide Attempt 000 History of Violent Behavior 000 Lack of Family Connections 000 Sex Offender Status + - 0 DYNAMIC FACTORS risk/dynamic/protective 000 Agitation 000 Current Intoxication 000 Current Physical Pain 000 Current Suicidal Ideation 000 Current Suicidal Intent 000 Current Suicidal Plan 000 Fear for Own Safety 000 Feeling Hopeless/Helpless 000 Feels Like a Burden 000 Non-Adherence to Medical Tx 000 Problem Solving Deficits 000 Recent Significant Loss 000 Sleeps Problems 000 Social Isolation 000 Uncontrolled Mental Health Issues 0 Behavior actors below: + - 0 PROTECTIVE FACTORS 000Able to Identify Reasons to Live 000Adequate Problem Solving Skills 000 Denial of Suicidal Ideation 000 Future Orientation 000 Religious Beliefs Against Suicide 000 Social Support in the Institution 000 Supportive Family Relationships 000 View of Death as Negative 000 Willingness to Engage in Tx Additional validated risk factors that may be relevant: Sentence >20 years; Self-harm in past month; Dual Diagnosis; Male Gender; History of Self-Injurious Behavior; Chronic/Uncontrolled Pain; No Spouse (Single, Divorced, Widowed) EFTA00032199

Low Acute Risk Suicidal ideation is absent or is of limited frequency, intensity, duration and specificity. There are NO identifiable plans and NO associated intent. There is good self-control based on both self-report and objective assessment. There may be mild symptomatology and morbid rumination may be present. Few risk factors are present and protective factors are identified, including available and accessible social support. Moderate Acute Risk Suicidal ideation is frequent with limited intensity and duration. Suicidal plans have some specificity, but NO associated intent. There is good self-control. limited to moderate symptomatology. some risk factors are present, and protective factors are identified, including available and accessible social support. Denial of ideation and intent may be present. if objective markers, such as suicide threats to others and agitation, contradict the self-report. High Acute Risk Frequent, intense, and enduring suicidal ideation, specific plant Many risk factors are identified. Objective markers of risk are present (e.g., lethal method, rehearsal behaviors, saying 'goodbye"): self-report of subjective intent may or may not be present. There is evidence of impaired self-control, severe symptomatology. multiple risk factors are present, and few, if any protective factors. Present Chronic Risk is present when there is a history of two or more suicide attempts Absent Chronic Risk is absent when there is a history of one or zero suicide attempts. Reason for referral: Change in risk factors: Reason for removal from watch: b Diagnosis: Recommendations: EFTA00032200

Date Progress Notes Thinks to Christopher Bush & Scott Forbes In the development of this guide Version 3 EFTA00032201