Understanding and Working with Suicidal Clients

1. Understanding and Working with Suicidal Clients A Deer Oaks EAP Services Presentation Presented by: Guy Jeff Powell, Ph.D. A resource you can trust

2. Questions About Suicide Risk • What exactly do we mean by the term suicide? • Which diagnoses, risk factors, and symptoms should be of concern? • Is suicide ever considered acceptable?

3. Terms Used to Convey Suicide • Parasuicidal Behavior • Self-Mutilating Behavior • Self-Abuse • Self-Injury • Morbid Ruminations • Self-Destructive Behavior • Accidental Death

4. Facts About Suicide • Risk for suicide increases with age • 85 years and older at greatest risk • Rates for white males 85 and older is about 70 per 100,000, while in the general population the rate is 11 per 100,000 • Males commit four times more often than females • Females, however, attempt three times more than males

5. More Facts About Suicide • The greatest increase in suicide rates in recent decades has been among individuals aged 15 to 24 (especially among males). • Suicide attempts are greater for young people with 100-200 attempts for every completed suicide, with a ratio of 4 (attempts) to 1 successful for the elderly.

6. More Facts About Suicide • Across all age, whites commit more suicides than non-whites. • However, the rate for non-whites is rising, especially in the 15-24-year old group. • For Native-American males, the suicide rate is highest among the 15-24 year old age group. • For blacks males, the 15 to 44-year old age group is highest. • For whites, suicide rates peak at age 65.

7. More Facts About Suicide • Marriage appears to lessen the risk of suicide. • History of suicide is strong predictor. • Ninety-Five percent of individuals who commit suicide have a diagnosed mental disorder. • Hopelessness is considered the central psychological factor in suicide.

8. Characteristics of Suicide • Intent to die • Evidence of self-infliction • Outcome (injury, no injury, and death) • In accordance with these three features, O’Carroll, Berman, Maris, Mosciki, Tanney, and Silverman (1996) have offered the following definitions:

9. Behavioral Definitions of Suicide • Suicide: Death from injury, poisoning, or suffocation with evidence of self-inflicted injury, and that the decedent intended to kill himself/herself. • Completed suicide is synonymous with death • Suicide Attempt with Injuries: An action resulting in nonfatal injury, poisoning, or suffocation with evidence of self-inflicted injury, and intent to kill one’s self.

10. Behavioral Definitions of Suicide • Suicide Attempt Without Injuries: A potentially self-injurious behavior with a nonfatal outcome, with evidence that the person intended to kill one’s self. • Instrumental Suicide-Related Behavior: Potentially self-injurious behavior with no intent to kill one’s self, but with the added intent to gain some other end (e.g., attention, to punish others, to seek help).

11. Behavioral Definitions of Suicide • Suicide Threat: Any interpersonal action, verbal or nonverbal, stopping short of a directly self-harmful act that could be interpreted as communicating or suggesting suicide might occur in the near future. • Suicide Ideation: Any self-reported thoughts of engaging in suicide-related behavior. It is crucial to take intent, outcome, and self-infliction into consideration before characterizing a behavior as suicidal.

12. Suicide Attempts, Instrumental Behavior, and Suicide Threats: How to Differentiate • The critical variable is intent. • First, was there subjective or expressed intent? Did he or she say “I wanted to kill myself.” Be sure and document exactly what was said. (direct quotes are preferred) • Second, was there objective or observed intent? Describe the behavior in simple and direct terms: see below

13. Objective Intent: Explain in Detail • Did the person prepare for suicide (e.g., write letters to loved ones) • Did the person take actions to prevent discovery? • Was the attempt in an isolated, secluded, or protected area? • Was rescue only a random event?

14. Questioning a Person Who is Processing Suicide • Questions should be formed to investigate frequency, intensity, and duration of thoughts. • Do not provide options related to method. • One indicator of intent is the specificity of the person’s thinking. • Repeat what they say, exactly; this conveys that you are listening.

15. Specific Questions to Ask • How are you thinking about killing yourself? • Have you made plans to get access to [method]? • Have you thought about any other ways to kill yourself? (asked until the person says NO) • How often do you think about killing yourself? • Once a day, more than once a day, once a week, monthly. • You said you think about suicide every day. How many times a day?

16. Specific Questions to Ask • When you have these thoughts, how long do they last? A few seconds, minutes, or longer? • What exactly do you think about for that period? • How intense or severe are these thoughts (rated on a scale from 1 to 10, with 1 being ‘not severe at all’ and 10 being ‘so severe that I will act on them.’) • Have you thought about when and where you would kill yourself? • Be attentive to statements about avoiding detection – this puts them at greater risk.

17. Intent: Specific Questions to Ask • Why do you want to die? • What are your reasons for dying? • Do you have any intention of acting on your thoughts? • Can you rate your intent on a scale from 1 to 10, with 1 being ‘no intent’ and 10 being ‘certain you will act on them as quickly as you can?” • Have you done anything in preparation for your death? • Have you rehearsed your suicide in any way?

18. Protective Factors: Specific Questions to Ask • Even though you have had a very difficult time, something has kept you going. What? • What are your reasons for living? • Are you hopeful about the future? • What would need to happen to help you be more hopeful about the future? • What keeps you going in tough times like this? • Who do you rely on during difficult times? • Has treatment been effective for you in the past?

19. Predisposition for Suicidal Behavior • Previous history of psychiatric diagnoses • Previous history of suicidal behavior • Those with multiple attempts are considered at chronic risk. • Recent discharge from inpatient psychiatric treatment (increased risk within 1 year of discharge; risk is highest during the first month post-discharge)

20. Predisposition for Suicidal Behavior • Same-sex sexual orientation (increased risk for homosexual males) • Male gender • History of abuse (sexual, physical, or emotional) • Substance abuse (particularly intoxication)

21. Identifiable Precipitants or Stressors • Significant loss – financial, interpersonal relationship(s), professional identity. • Acute or chronic health problems – can be loss of independence, autonomy, or function. • Relationship instability – loss of meaningful relationships and related support resources.

22. Symptomatic Presentation • Depressive Symptoms – anhedonia, low self-esteem, sadness, sleeping disturbances • Bipolar Disorder – increased risk early in disorder’s course or in the mixed phase • Anxiety – increased risk with trait anxiety. • Schizophrenia – increased risk following active phases • Borderline and Antisocial Personality Features

23. Presence of Hopelessness • Have person thinking about suicide rate hopelessness on a scale from 1 to 10. • Severity of hopelessness • Duration of hopelessness • Remember, Hopelessness is the central psychological factor in suicide.

24. Previous Suicidal Behavior • Frequency and context of previous suicidal behaviors • Perceived lethality and outcome • Opportunity for rescue and help-seeking • Preparatory Behaviors

25. Impulsivity and Self-Control • Subjective self-control (have person rate on a scale from 1 to 10) • Objective self-control • Substance Abuse • Impulsive Behaviors (e.g., spending, sex, substance use, reckless driving) • Aggression

26. Protective Factors • Presence of social support (present and accessible) • Problem-solving skills and history of coping skills • Active participation in treatment • Presence of hopefulness

27. More Protective Factors • Children at home • Pregnancy • Religious commitment • Life satisfaction – have the person rate life satisfaction on a scale from 1 to 10. • Life satisfaction should correspond with the person’s reasons for living and dying.

28. More Protective Factors • Intact Reality-Testing • Knows name, time, place, situation • Fear of Social Disapproval • Fear of Suicide or Death – This suggests that the person has not yet habituated to the idea of death, a very good sign. We will now review the Acute Suicide Risk Continuum in your handout.

29. References • The Assessment and Management of Suicidality: A Pocket Guide for the Practitioner, M. David Rudd, Ph.D. ABPP • DSM-IV-TR, American Psychiatric Association (2000).

30. This has been a presentation by Deer Oaks EAP Services To contact Deer Oaks EAP Services, call 866-327-2400 A Resource You Can Trust