Class Notes: Suicide

Assessing self-destructive threats, gestures, and suicide potential refers to the degree of probability that a person may harm or attempt to kill themselves in the immediate or near future.

Suicidal impulse and suicidal behaviors constitute a response by a person whose coping mechanisms have failed. They are often desperate and feel ashamed. If the person has attempted suicide a medical evaluation and issues of medical stability supersede a clinical interview. Be calm and caring in your approach, establishing a setting conductive to eliciting the necessary information. Be reassuring in letting the person know how you plan to proceed regarding referral for medical evaluation if needed, and that you want to talk to them in order to understand what has been happening in their life which brought them to the point of suicidal intent and suicidal behavior.

SUICIDE ASSESMENT OUTLINE

1. Assessing suicidal ideation
A. Ask directly if they have thoughts of suicide
B. Are the thoughts pervasive or intermittent with a definite relationship to a given situation
C. Do they have a plan; if so, how extensive is their plan
D. Lethality of the means/method defined
E. Is there access to the identified means

2. Suicide attempt
A. Immediate referral for a medical evaluation for medical stability if method of attempt warrants it
1. Means, location, collaborator, rescuer, number of attempts
2. Thoroughness of plan and its implementation
3. Note signs of impairment and physical harm
4. Level of treatment required
*Intention, plan, method, means, lethality, and prior attempts

3. Risk factors
A. Intention and history
1. Recent/prior attempts or gestures
2. Direct or indirect communication of intent
3. Extensiveness of plan
4. Lethality of means
5. Access to means
6. Family history of suicidal behaviors

B. Demographics
1. Age (teens, middle age, and elderly are at highest risk)
2. Gender (males more often succeed at suicide attempts because of the lethality of means, but females make more attempts)
3. Homosexuals (additional stressors/lack of social supports)
4. Race (white)
5. Marital status (separated, widowed, divorced)

C. Helplessness
1. Encourage taking responsibility and making decisions.
2. Include the person when setting goals
3. Provide positive feedback for decision making
4. Facilitate development of realistic goals, limitations, and expectations
5. Identify areas of life and self-care in which person has control, as well as those areas where they lack control
6. Encourage expression of feelings related to areas of life outside person’s control, and let it go

4. Ineffective Development and/or Utilization of Resources and Social Supports
A. Resist desire to withdraw and isolate
B. Identify positive social/emotional supports that they have been avoiding
C. Make commitment to utilize resources and supports in some way everyday
D. Educate regarding role of isolation in maintaining depression
E. Impaired social interaction
1. Convey acceptance and positive regard in creating a safe, nonjudgmental environment
2. Identify people in their life and activities which were previously found pleasurable
3. Encourage utilization of support system
4. Encourage appropriate risk taking
5. Teach assertive communication
6. Give direct, nonjudgmental feedback regarding interaction with others
7. Offer alternative responses for dealing effectively with stress-provoking situations
8. Social skills training in how to approach others and participate in conversation
9. Role play and practice social skills for reinforcement and to increase insight for how they are perceived by others
10. Daily structure to include social interaction

5. Dysfunctional Grieving
A. Evaluate stage of grief that the person is at
B. Demonstrate care and empathy
C. Determine if the person has numerous unresolved losses
D. Encourage expression of feelings
E. Empty char technique or writing a letter to someone they have lose may provoke resolution process
F. Education person on stages of grief, and normalize appropriate feelings such as anger and guilt
G. Support person in letting go of their idealized perception so that they can accept the positive and negative aspects of their object of loss
H. Positively reinforce adaptive coping with experience of loss (talking into consideration ethnic and social differences)
I. Refer to a Grief Group
J. Explore the issue of spirituality and spiritual support

6. Low Self-Esteem
A. Focus on strengths and accomplishments
B. Avoid focus on past failures
C. Reframe failures or negative experiences as a normal part of learning process



Confronting and Understanding Suicide
Everyone is unique in the life crisis that they experience which can contribute or result in suicidal thoughts and behavior. However, there are 12 factors which we know often trigger suicidal thoughts:
_hopelessness/despair
_depression
_feeling overwhelmed or desperate
_life is out of control
_guilt
_loneliness
_chemical imbalance
_low self-esteem
_bad memories/fears
_recent loss
_seasonal anniversary such as a loss
_fatigue/sleep deprivation

Hopelessness And Despair
_no hope that things will ever change and be better
_no hope for the future
_no hope that there will ever be stability and wellness
_no hope that life goals will ever be met
_no hope that there will ever be a feeling of happiness or enthusiasm
_no hope that there will ever be a successful career
_no hope that there will ever be a successful relationship
_a feeling and belief that life is a miserable existence
_no point in being alive


Mood Disorders
Mood disorders are divided into Depressive Disorders and Bipolar Disorders. The defining feature of Bipolar Disorders is the experience of one or more manic or hypomanic episodes. This section will deal more simply with the objects and goals which are related to depressive symptoms and the objectives and goals related to manic symptoms.
According to the DSM IV (‘94), the central feature of mood disorders is disturbance of mood-manic or depressive. The range of the mood disorders include the following: Major Depression, Dysthymia, Seasonal Affective Disorder, Mania, Hypomania, Bipolar, and Cyclothymia.

Depression
Goals
1. Assess danger to self and others
2. Provide safe environment
3. Assess need for medication evaluation referral
4. Improved problem solving
5. Improved coping
6. Develop and encourage utilization of support system
7. Resolve issues of loss
8. Improved self-esteem
9. Cognitive restructuring
10. Improved eating and sleep patterns
11. Develop depression management program
12. Educate regarding medication compliance

Treatment Focus and Objectives
1. Suicide Risk Assessment
A. Thoughts of killing self, or persistent death wish
B. Do they have a plan?
C. Means to carry out the plan
D. Feelings of hopelessness
E. Past history of suicide attempts, or someone close to them that has attempted or committed suicide
F. Recent losses
G. Substance abuse
H. Poor impulse control
I. Poor judgment

During the interview it may be possible to decrease the level of emotional distress by validating the difficulty that they are experiencing, and encouraging them to vent their feelings and intentions of suicide. Talking about these issues, which have resulted in such despair and hopelessness, may not only decrease the level of distress, but may create some opportunities for intervention. As the person talks about their thoughts of suicide they can facilitate to begin to understand what a significant impact their suicide would have on family, friend, and others. Offering them validation and reassurance may increase their ambivalence.