Suicide Intervention for I&R
John Plonski
Liquid Logic Learning –
Interacting With the Person at Risk of Suicide
A suicidal person like any person in crisis is, by definition, a person faced with an intolerable life issue for which they are seeking a solution. In working with the Suicidal Caller we must remember that the suicidal activity is not, in itself, a crisis. Suicidal activity is both a means for resolving this situation and a method of communicating the intense feelings of hopelessness and helplessness surrounding it. As such our goal in working with the suicidal caller is twofold:
- To assist the caller in focusing on the issue thus enabling them to communicate their feelings verbally instead of behaviorally;
- To explore more adaptive resolutions to the issue presented.
In interacting with the suicidal caller we operate under the assumption that the Caller is ambivalent about their decision to suicide otherwise they would not be contacting us. This bestows upon us the moral right and responsibility to attempt to intervene. To effectively intervene with the Suicidal Caller we need to accomplish three tasks:
- Establish a relationship (Connecting)
- Evaluate the suicidal potential (Understanding)
- Formulate a Safeplan and mobilize resources (Assisting)
Establishing a Relationship (Connecting)
Persons at risk of death by suicide present themselves in a variety of ways, ranging from vague allusions to death, to specific verbal threats, to actual suicide-in-progress calls. When the communication of the ideation is indirect it is the task of the Crisis Worker to recognize the intent of the disguised message and bring the issue of suicide up for open discussion. This can be problematic because there are many reasons the person at risk may not be forthcoming with talking about their intent. If the Caller shares anything with you that gives you the impression they are considering suicide a coping mechanism ask them if they are feeling suicidal. Directly asking a Caller if they intend to commit suicide will not cause them to do so. The asking of the question establishes an atmosphere of openness and honesty that will encourage fruitful exploration of the issue they are experiencing. On the other end of the spectrum, suicide-in-progress calls require special efforts toward obtaining intervention and/or medical assistance without neglecting the Caller and the problem that has led them to the action. In short a suicide in progress is an emergency situation requiring immediate life saving intervention.
All suicide threats must be taken seriously. Some suicidal activity may have a manipulative quality, but that characteristic in itself does not make the situation any less dangerous. There is strong evidence that a number of completed suicides were attempts by persons who did not actually intend to take their lives. The unfortunate reality is that accidents happen when one attempts manipulation through the use of suicide.
The methods of establishing a relationship of trust and open communication in the suicidal call are the same ones we use in all our calls. In all calls the Crisis Worker should be accepting, respectful, and empathic. They should present themselves as being patient, interested, self-assured, and knowledgeable. Through their attitude the Crisis Worker will communicate to the Caller that they have done the right thing in contacting the hotline. The message the Crisis Worker’s attitude sends to the Caller is that they are concerned and both able and willing to help.
Many suicidal situations will arouse within the Crisis Worker feelings of inadequacy and self-doubt. They can begin to feel their skills will not enable them to handle such a critical situation. While moderate anxiety is appropriate and actually expected, too much anxiety will seriously hamper the Worker’s ability to interact with the suicidal caller who, at the time of their contact, is depending on the Worker to solve their problem. It is possible the anxiety of the Crisis Worker may be transmitted to the Caller reinforcing their own sense of stress and anxiety. In other words, the Crisis Worker needs to try to stay calm and sound confident even if they do not feel either. The Crisis Worker can develop greater poise and confidence through continuing training and experience.
The fact the suicidal caller contacted the Hotline indicates they have at least some desire to get help in resolving their problem. The suicidal caller, just as with any other Caller, should be accepted without challenge or criticism. They should be allowed to explain and explore their situation in their own way and time. We may feel it appropriate to manipulate the Caller through moralistic pronouncements about suicide: They will not go to heaven; It’s against the law; It’s a sign of emotional or moral weakness. We might be tempted to point out how the Caller’s suicide will affect those closest to them in an effort to have them stop feeling suicidal. It’s possible we might think it helpful to point out that there are those who are dependent on them. We might feel that pointing out the Caller’s responsibility to others would be appropriate. We might even consider minimizing the Caller’s presenting problem by trying to convince them “it’s not so bad” or trying to perk them up (the “Don’t Worry Be Happy Syndrome”). These actions are unacceptable, will prove ultimately unsuccessful, and have the potentiality to compound the problem. The most useful thing the Crisis Worker can do is to listen, empathize, and accept the Caller’s feelings without argument. It is through the use of the Crisis Intervention Skills that a trusting relationship between Caller and Worker is established. In this manner the Caller becomes empowered to share their pent up pain, anxiety, and stress. It is this empowerment can lay the groundwork for resolution of the situation that led to the suicidal ideation.
Establishing our relationship with the Suicidal Caller does not mean we cannot take a stance that would encourage the Caller to choose to live. A basic tenet of Suicide Intervention is that the person at risk of suicide is ambivalent about committing the act. The level of the ambivalence is unique to each Caller. The worker should listen for, indicate, and support any and all messages from the Caller that reflect a reluctance to die. Working on short-term goals without trying to remove suicide as a later option can help the Caller to retain a feeling of control without actually having to kill themselves. Statements to the effect that suicide can continue to remain an option if they continue to live but that life will not be a future option if they die serves to reframe the perspective of the Suicidal Caller.
Some workers will protest that there is not enough time to establish open, trusting relationship in life threatening situations. This is a mistaken assumption. Granted the process can be time consuming but unless the Caller feels safe in their interaction with the Worker they will not stay on the phone. Once the Caller ends their contact with us there is nothing we can do to protect their lives. The relationship also becomes important when it is time to formulate a plan. If the Caller is not secure in their relationship with the worker there is no way the worker will have all the information necessary to formulate a plan the Caller can follow. For example, if the possibility of past hospitalizations is not explored the worker may suggest the Caller go to the hospital. Since the Caller is looking to us to help them, and in seeking help see us as an authority figure, they will quite possibly agree. However, if past hospitalizations were painful for the Caller once the call is ended they will opt not to follow through with the plan.
There can be many factors to consider when assessing lethality. Some of these factors are as follows:
Changes Related to Loss or Threat of Loss
Symptomatic Patterns
Statistical Patterns
Cultural Influences
Physiological Changes
Psycho-Sexual Changes
Changes Related to Loss or Threat of Loss
Any recent loss indicates heightened lethality. The loss can be the death of a significant other (this can include an idol, role model, or even a pet), divorce or separation, the breakup of a relationship, the loss of a job or housing. The threat of any of any of the above losses can also trigger elevated lethality. The onset of illness for either the Caller or a significant other also indicates heightened lethality. The anniversary of a loss can trigger suicidal thoughts. Other losses may not be quite as evident. A move to a new area represents a loss of a familiar way of being. A situation where a guardian is absent, for whatever reason, can signal a loss of boundaries and guidelines. The onset of physical and emotional disabilities can represent a loss of normalcy. In this case something the Worker may view as mundane, such as new glasses or braces, may actually be a suicidal trigger for the Caller.
Symptomatic Patterns
Suicidal behavior can occur in many different psychological states. Many people who have completed suicide exhibited signs of severe long-term depression. Some of these signs are:
Sleep disorders
Loss of appetite
Major weight change
Panic attacks
Changes in sexual activity (promiscuity or abstinence)
Social withdrawal
Apathy
Despondency
Physical and psychological exhaustion
The depressed individual may present themselves as feeling sad experiencing crying spells when alone or in the company of others. When we talk to the depressed person on the phone the person will sound lethargic, speaking in a slow labored manner. Conversely, the depressed person can sound agitated and restless citing their inability to contain the pressure of their feelings and anxieties. The presence of any or all of the symptoms in their severe form would indicate high lethality.
Psychotic states when combined with suicidal ideation represent a highly lethal situation. A psychosis will usually be characterized by delusions (irrational beliefs), hallucinations (visual or auditory distortions), loss of contact with reality, disorientation (not knowing who or where on is, etc.), or highly unusual ideas or experiences. A Caller whose suicidal plans are obviously bizarre or who claims to have voices telling them to suicide represents a high risk factor. Callers who are changing medications either at the recommendation of their doctor or by their own choice also represent increased intent. Exploration of past psychiatric history or current treatment might prove helpful in this instance.
Substance abuse is also connected to high suicidal risk. It may be the abuse is used to mask the depression. It is also possible the drugs and alcohol are being used destructively as a slow form of suicide. In either case the fact that substance abuse clouds one’s judgment increases the risk of suicide as an impulsive act. It is important to keep in mind that the person contemplating a suicidal gesture by using drugs can accidentally overdose due to the synergistic effect of mixed drugs. Taking all this into consideration shows that substance abuse is an indicator of heightened risk.
While on the topic of drugs we need to address the issue of drug overdose. When a person talks to use about suicide by drug overdose they will sometimes ask us if a certain quantity of a specific drug will be sufficient to kill them. The asking of the question itself indicates elevated lethality. However, our tendency to want to consult the Physician’s Desk Reference or Poison Control is not appropriate. The effect of any drug on any person is dependent on many variables: Weight; Age; Tolerance; Other drugs consumed; Timing of meals; Shelf life of the drug, etc. Our stance is that if a person is considering consuming, or has consumed, any amount of drugs in an effort to suicide, that dosage is lethal.
Statistical Patterns
Statistical patterns can be a window into the level of risk. The elderly represent the highest suicide rate, followed by the 15-24 age group. More females attempt suicide than males. Males complete more suicides then females and their method of suicide is generally more violent.
Young people attempt suicide in the morning and late afternoon when there is a chance for them to be found and “rescued”. Adult attempts happen in the very late night or early morning hours when there is little risk of discovery. Guns represent the prevalent means of attempted suicide and the account for the majority of completed suicides.
Cultural Influences
The society in which we live places many pressures upon us. Generally, people handle the pressure without feeling the need to escape through suicide. However, some people can feel crushed by the effects and demands of society on their lives. Family breakdown is a fact in our society. Divorce, death, family members focused on careers instead of the family unit all contribute to the dissolution of the nuclear family. Without the perceived support, nurturing, and safety of a stable family a Caller can have a sense of no belonging and no direction. This can contribute to the Caller’s feeling the world would be better off without them.
The increased mobility of our society is another factor in suicidal risk. For any of a number of reasons ranging from employment issues to the desire to live someplace new, families frequently pack up and move to new places. These moves often distance the family from what and whom they have been accustomed. This creates a sense of impermanence, instability, and lack of continuity, all of which represent another factor in suicidal risk.
We are constantly bombarded with messages to strive for success, for something bigger and better. Television, family, friends, teachers, coaches, bosses, and, most importantly, ourselves urge us to reach higher and farther with our goals and dreams. The person who feels obliged to respond to these messages can come to feel overwhelmed. When they feel they are not living up to the expectations they feel others have of them or, more importantly, feel they have not lived up to their own expectations, suicide can become a factor in their lives. Additionally, perceived inability to cope with successive failures in school performance, peer and family relationships are another suicidal indicator.
Physiological Changes
When we talk about physiological changes and suicide we generally think in terms of adolescent suicide. The adolescent has to cope developmentally with their physical growth rate as well as puberty and the hormonal changes that accompany it. These changes place a large emotional pressure on youths and they have been cited for the increase in adolescent suicide. However, we cannot let ourselves forget that as we age we undergo physical changes. Though the changes of an adult are of a more gradual nature they represent change and can be an indicator of suicidal risk. The Caller saying they cannot keep up with the younger people on the job or talking about the effects of menopause is dealing with a physiological change they feel helpless to control. It is these senses of helplessness could be an indication of suicidal risk.
Psycho-Sexual Changes
Again adolescent suicide is what we think about when we discuss psychosexual change. Adolescents have a short time to come to terms with relationships, dating, first sexual experience, and their own sexuality. With so much to cope with developmentally the adolescent can come to feel overwhelmed by the changes within themselves and the worries about how their world views them. Again, as with physiological changes, psychosexual changes are not limited to adolescents and can represent a suicide risk for adults. The aging process does produce psychosexual changes in persons over the age of 18. While these changes would seem not to be as many or as intense as those experienced in adolescence, it is the perception of the person involved in the changes who decides the impact the changes have over their lives.
When evaluating suicidal risk and lethality, no single criterion need be alarming. The only exception to this is if the plan is very specific and lethal. The situation should be appraised on the general pattern of all the above criteria within the individual case. When we establish a trusting and open relationship with the Suicidal Caller we create a mosaic of their situation. Just as one tile of the mosaic does not detail the whole picture neither does one criterion of suicide assessment necessarily indicate suicidal risk. The Crisis Intervention Skills enable us, and our Callers to stand back from the presenting situation and see the whole picture. It is the picture seen in its entirety that will form the basis of our assessment of risk and danger.
We should note that many of the factors that indicate suicidal risk relate to change. Change is something that can be exciting or scary. Some changes we are initiate ourselves other changes happen without our active participation. The changes we are not actively involved in have the potential to make us feel helpless and powerless. When interacting with all our Callers it is a prudent idea to thoroughly explore what changes they are experiencing and how they view the impact of those changes.