Lethality and S uicidality

1. Lethality and Suicidality Greg Bohall, M.S., C.R.C., MAC, CADC-II

2. Overview • Prevalence • Predictability • Facts on Suicide • Conceptualizing Suicide • Development of a Suicidal Crisis • Suicidal Intervention

3. Prevalence In 2008, 36,035 people in the United States died by suicide. About every 14.6 minutes someone in this country intentionally ends his/her life. • Suicide is considered to be the second leading cause of death among college students. • Suicide is the second leading cause of death for people aged 25-34. • Suicide is the third leading cause of death for people aged 10-24. • Suicide is the fourth leading cause of death for adults between the ages of 18 and 65. (Clayton, 2012)

4. Prevalence • Suicide and psychiatric diagnoses • Psychological autopsy studies done in various countries over almost 50 years report the same outcomes: • 90% of people who die by suicide are suffering from one or more psychiatric disorders: • Major Depressive Disorder • Bipolar Disorder, Depressive phase • Alcohol or Substance Abuse* • Schizophrenia • Personality Disorders such as Borderline PD • *Primary diagnoses in youth suicides • (Clayton, 2012)

5. Predictability • Suicide is not predictable in individuals • In a study of 4,800 hospitalized vets, it was not possible to identify who would die by suicide — too many false-negatives, false-positives. • All attempts to identify specific subjects were unsuccessful. • Individuals of all races, creeds, incomes and educational levels die by suicide. There is no typical suicide victim. • Suicide communications are often not made to professionals • In one psychological autopsy study, only 18% told professionals of intentions • In a study of suicidal deaths in hospitals: • 77% denied intent on last communication • 28% had “no suicide” contracts with their caregivers • (Clayton, 2012)

6. Prevention may be a matter of a caring person with the right knowledge being available in the right place at the right time. • (Clayton, 2012)

7. Facts on Suicide • Many people who die by suicide have given definite warnings to family and friends of their intentions. Always take any comment about suicide seriously. • Most suicidal people give clues and signs regarding their suicidal intentions. • Most suicidal people are undecided about living or dying, which is called “suicidal ambivalence.” A part of them wants to live; however, death seems like the only way out of their pain and suffering. They may allow themselves to "gamble with death," leaving it up to others to save them. • Men are four times more likely to kill themselves than women. Women attempt suicide three times more often than men do. • Suicide results from having a serious psychiatric disorder. A single event may just be “the last straw.” • (Clayton, 2012)

8. Facts on Suicide • Studies have shown that patients with depression have these ideas and talking about them does not increase the risk of them taking their own life. • Most suicides occur within days or weeks of "improvement," when the individual has the energy and motivation to actually follow through with his/her suicidal thoughts. The highest suicide rates are immediately after a hospitalization for a suicide attempt. • The most common psychiatric illness that ends in suicide is Major Depression, a recurring illness. Every time a patient gets depressed, the risk of suicide returns. • Highest rates of suicide are in May or June, while the lowest rates are in December. • (Clayton, 2012)

9. Risk Factors • Psychiatric disorders • Most common: Depressive Disorders, Alcohol/Drug Dependence, and Schizophrenia. • Past suicide attempts • Symptom risk factors • Desperation, hopelessness, anxiety, aggressive or impulsive personality, psychotic symptoms. • Sociodemographic risk factors • Male, over age 65, white, separated, widowed, or divorced, living alone, unemployed or retired. • Environmental risk factors • Easy access to lethal means and local clusters of suicide have a “contagious effect.” • (Clayton, 2012)

10. Conceptualizing Suicide (1) • 1. Suicide is viewed as an alternative or as a solution to a problem of intense emotional pain that the person feels is not resolvable by any other means. • You can ask: • “What’s going on in your life right now that makes you think death is the best way out?” • This focuses the person on the concrete and specific life circumstance that has led to the current suicidal crisis. • Their response identifies for you and them the precipitating problem and you immediately become part of the solution as opposed to continuing to be an observer. • May have emotional or cognitive confusion or the complexity of the problem itself may require you to probe further by asking guiding, directive questions to assist in articulating what finally got them to the point where suicide seems to be the only way out. • (Yufit & Lester, 2005)

11. Conceptualizing Suicide (1) • Suicidal thoughts and impulses can feel chaotic and overwhelming therefore the person may need directive exploration on the interventionist. • Concrete questions and comments that help clarify the person’s state of mind. • Although the end result of suicide is death, questions about why a person wants to die is counterproductive. • The main purpose of suicide is the cessation of pain, so questions about death miss the point. • (Yufit & Lester 2005)

12. Conceptualizing Suicide (2) • A person who is thinking about suicide is in crisis. • Cognitive constriction/Tunnel thinking • A way to reduce anxiety that causes tunnel thinking is to acknowledge the person’s feelings and encourage them to express or ventilate them. • Beware this can be difficult, even for seasoned professionals, to simply listen to the despair without prematurely trying to pursue a resolution. • Short-circuiting their expression can relieve you, the listener, however the person feels only half-heard or misunderstood. • Many suicidal persons feel disconnected from their feelings and the world and you can accidently reinforce this disconnection by problem solving . • Taking time to listen to nuances and complexities within their hopelessness and desperation can diminish the intensity and reduce the feelings of isolation. • (Yufit & Lester, 2005)

13. Conceptualizing Suicide (3) • The thinking of most suicidal clients is characterized by ambivalence. • Awareness of two feelings exist simultaneously • The wish to live vs. the wish to die or escape • Reminding suicidal people that ambivalent thinking is normal is a critical intervention! • Dichotomous thinking: Only see extremes • Clients not used to experiencing dichotomous thinking may be even more confused therefore reassuring them that it is normal is important. • The wish to live and the wish to die/escape must occur in tandem (both be addressed) or the person may see that if you ignore or minimize their wish to die that you are being dismissive of their troubling feelings. • (Yufit & Lester, 2005)

14. Conceptualizing Suicide (3) • A useful way to emphasize and support the person’s wish to live is to engage in a conversation about their reasons to live. • Regardless how trivial or mundane the reasons may be • Honesty and genuineness are critical at this point because clients in crisis are keenly perceptive of disingenuous reassurance. • Be aware of your own thoughts, feelings, and attitudes about suicide and how you may express them unconsciously (nonverbal communication) • Initially, person’s cannot offer more than one or two reasons to live however after continued meetings, the number usually increases, even if the reasons to die do not decrease. • (Yufit & Lester, 2005)

15. Conceptualizing Suicide (4) • There is an irrational quality to suicidal thinking. • When asked what will happen when they die, many will relate with some degree of righteous satisfaction, details of their funeral or what they expect in their honor after they die. • Ex: Plaque of me, moments of silence, etc. • Very challenging to refute because details of afterlife are only the view of those deceased. • Instead of engaging in futile discussion about irrational discussions that cannot be proved or disproved, return to previous conversation about reasons to live. • Why? The reasons are specific directly out of the person’s mouth. • Also, what they identified about afterlife can indicate life struggles • Ex: A plaque in school so all the kids who were mean to me can feel sorry for how they treated me. • (Yufit & Lester, 2005)

16. Conceptualizing Suicide (5) • Suicide is an act of communication. • “Whom did you want your suicide to send a message to and what is that message?” • This returns the person to a higher level of verbal functioning where healthier coping options can be explored. • There is usually convergence in this answer with the presenting problem, life struggles and it can be helpful to draw that connection. • “I want to send the message to my ex-wife who left me for another man and I want her to know that she is missing out!” • Irrational • Presenting problem is the divorce • Crises can compromise communication skills. • Ever just “lose it” or vent? • Your job is to create a safe, predictable, and supportive presence where the person can find the hope and strength for resolution of a suicidal crisis. • (Yufit & Lester, 2005)

17. Development of a Suicidal Crisis • In addition to conceptualizing suicide, it is helpful to understand their experiences that led to a crisis • Cognitive steps that allow a person to gradually think of suicide as an acceptable means for dealing with pain: • 1. Be faced with a problem that is perceived as unsolvable. • 2. View the problem as continuing despite their efforts to solve. • 3. See suicide as the only solution. • 4. Disregard all other problem-solving options. • 5. Believe death will bring relief. (Yufit & Lester, 2005)

18. Development of a Suicidal Crisis • Others have conceptualized the suicidal crisis as a tunnel into which a person descends as they struggle with what feels to be an unsolvable problem. • As the tunnel narrows, the person feels increasingly alone, discouraged, and helpless in their pain. • The tunnel finally narrows to its end point, which is suicide. • Even one crisis contact can return the suicidal person to the domain of a healthy problem-solving alternative • Saying “hello” to a stranger. • Acknowledging and tolerating their morbid feelings, identifying the precipitants of their crises, and exploring alternatives while providing a safe, structured environment can help! • (Yufit & Lester, 2005)

19. Suicidal Intervention-Warning Signs • Look for observable signs of depression • Increased alcohol/drug use • Threatening suicide or expressing a strong wish to die • Recent impulsiveness and taking unnecessary risks • Unexpected rage or anger • Making a plan • Purchasing a firearm/weapon • Giving away prized possessions • Obtaining other means of killing oneself • (Clayton, 2012)

20. Suicidal Intervention- Intervention • Three basic steps • Show you care • Be genuine, listen carefully, reflect what you hear, use appropriate language, TAKE ALL SUICIDE TALK SERIOUSLY. • Ask about suicide • Be direct, but non-confrontational (Talking about suicide won’t put the idea in their head). Chances are, if you are noticing signs, they’re already thinking of it. • Ask about treatment (attending regularly, taking medication, etc.) • Get help • BUT DO NOT LEAVE THE PERSON ALONE! • Know referral sources (suicide hotlines, mental health agencies, trauma hospitals, etc.), reassure the person, outline a safety plan, encourage the person to engage in this helping process. • (Clayton, 2012)

21. References Clayton, P. J. (2012). Suicide prevention; Saving lives one community at a time. American Foundation for Suicide Prevention. Yufit, R. I. & Lester, D. (2005). Assessment, treatment, and prevention of suicidal behavior. Hoboken, NJ: John Wiley & Sons.