What is Suicide?

DEFINITION OF TERMS
Suicide Death from Suicide Threat - A verbal or
intentional self-inflicted injury nonverbal interpersonal
with evidence of intent to kill interaction communicating a
oneself. desire to die or kill oneself.
(Plan & Intent)
Suicide Attempt Intentional
self-injurious behavior with a Suicide Ideation - Self-
nonfatal outcome with reported thoughts of self-
evidence of intent to kill injurious behavior which could
oneself. lead to death. (Thoughts)
WARNING
SIGNS
VERBAL WARNING SIGNS
Who is at risk of
dying by
suicide?
ANYON
RISK FACTORS
male; widowed, divorced, single; increases with
Demographic
age; white
lack of social support; unemployment; drop in
Psychosocial
socio-economic status; firearm access
Psychiatric psychiatric diagnosis (es); comorbidity
malignant neoplasms; HIV/AIDS; peptic ulcer
Physical disease; hemodialysis; systemic lupus
Illness erthematosis; pain syndromes; functional
impairment; diseases of nervous system
hopelessness; psychic pain/anxiety; agitation;
Psychological
psychological turmoil; decreased self-esteem;
Dimensions
fragile narcissism & perfectionism
RISK FACTORS
impulsivity; aggression; severe anxiety; panic
Behavioral
attacks; agitation; intoxication; prior suicide
Dimensions
attempt
Cognitive
thought constriction; polarized thinking; rigidity
Dimensions
sexual/physical abuse; neglect; parental loss;
Trauma
traumatic events
Genetic &
family history of suicide, mental illness, or abuse
Familial
CONNECTING

How are you?

Ask About Suicide
Are you thinking of suicide?
Im worried about you and I need to ask; are you
thinking of suicide?
Are you suicidal?
Have you been contemplating about suicide?
Sometimes people who say things like that are
thinking of suicide. Are you thinking of suicide?

Be calm
General Principles of
Suicide Risk Assessment
Be quiet and listen
Dont advise, lecture, interrogate or judge
Be calm and non-judgmental
Asking open ended questions
Never promise unlimited confidentiality
Suicidal thoughts are not uncommon
Dont be afraid to say the word suicide
Be Aware of your Tone and Expression
How to Help
Life is absurd.
- Albert Camus
I am not what happened
to me; I am what I choose
to become.

- Carl Jung
BRIEF PROBLEM-
SOLVING
APPROACHES
Cognitive Behavioral Therapy
Cognitive-behavioral therapy (CBT)
integrates a problem-solving component
as a core intervention for reducing
suicidal ideation, and related
symptomatology such as depression,
hopelessness, and loneliness.
Cognitive-behavioral treatment focuses
on the cognitive distortions and deficits
that disrupt a clients ability to solve
interpersonal problems, as well as on
the capacity to regulate emotions (van
der Sande et al., 1997). In CBT, clients
are actively challenged on their negative
beliefs, and their tendency to view
themselves, their circumstances and
their future in unrealistically negative
terms.
Goal setting, self-monitoring, homework
assignments, and focused skill building
in the areas of coping, problem solving,
assertiveness, and interpersonal
communication, are all key features of
this therapeutic approach (Rudd et al.,
1999). By actively educating clients
about mental disorders such as
depression, as well as suicide, and by
improving clients ability to recognize
and understand their own self-limiting
and negative beliefs, CBT enables
clients to become better regulators of
their own moods and experiences.
Problem-Solving Skills Training
The development of problem- Educating clients regarding stress
solving skills aids in reducing suicidal reactions.
behavior by making suicide a less viable
Introducing and practicing coping
option (Jobes, 2000). Problem-solving
skills training has been shown to skills such as relaxation, problem-
improve interpersonal cognitive problem- solving skills and social skills.
solving skills by increasing clients ability Offering opportunities to express
to generate alternative courses of action, emotions including feelings of anger,
increasing their sensitivity to the
frustration, guilt, sadness and failure.
consequences of their behavior, and
assisting clients to respond to everyday Promoting both group and individual
interpersonal problems (McLeavy et al., exercises to improve self-esteem and
1994). self-efficacy (group treatment helps
members reduce their social
Problem-solving skills training is
isolation).
part of overall competency building.
Treatment that aims to build client
competency includes:
Solution-Focused Brief Therapy
Solution-focused brief therapy Therapeutic Techniques used in
(SFBT) emphasizes solutions, SFBT
competence, and strength capabilities of
the suicidal client. SFBT is a goal-
focused approach in which the client is A question-based, individualized
considered the expert in his or her approach (e.g., What brings you here
treatment plan, and the clinicians role is today? How can this meeting be
to facilitate the recognition and helpful to you?).
implementation of goals and solutions
The use of the miracle question: If a
(Fiske, 1998).
miracle happened today, and all of
Clients are invited to tell their the problems and concerns that have
stories, and through reflective and brought you here today were to
careful listening, efforts are made to disappear, how would your life be
introduce solution-talk where exceptions
different? What would you notice?
to problems are discussed, which can be
used as the foundation for finding
solutions.
Solution-Focused Brief Therapy
Utilization of the clients own
competencies, strengths, resources,
and successes.
Elicitation of goals, existing
resources, and solutions from the
client.
A therapeutic stance necessary of
curiosity or not knowing.
Fiske (1998) has applied SFBT to
the ten commonalities of suicide as
defined by Shneidman (1996; see Table
7) to illustrate how the needs and
challenges of the suicidal client might be
addressed by SFBT.
Therapeutic Tasks of Solution-
Focused Brief Therapy (SFBT) using
Shneidmans Ten Commonalities of
Suicide
The common purpose of suicide is to
seek a solution
Understand how the individual views
suicide as a personal solution.
Find out what else could serve as a
solution for the client.
Solution-Focused Brief Therapy
The common goal of suicide is
cessation of consciousness
Help the client understand the
consequences of suicide.
Help the client consider alternatives
to suicidal behavior that may achieve
similar consequences.
The common stimulus in suicide is
intolerable psychological pain
Accept the reality of the clients pain.
Help the client identify anything that
can help relieve pain, even slightly
(even those thoughts and activities
that may be undesirable or unhealthy
- e.g., substance abuse).
Increase awareness of small
changes that make a noticeable
difference.
The common stressor in suicide is
frustrated psychological needs
Understand the meaning of unmet
needs for the client.
Shift the focus from a problem state
to a goal picture (e.g., use of Miracle
Question).
The common emotion in suicide is
helplessness-hopelessness
Seek exceptions to feelings of
helplessness-hopelessness.
Solution-Focused Brief Therapy
Explore the degree to which client
has the ability to behave in a non-
suicidal manner.
Use presuppositional language that
conveys implicit assumptions of
action, efficacy, and hope (e.g., you
have done things to assist your own
survival; thoughts of suicide do not
last indefinitely; you have the ability
to modify these thoughts).
The common cognitive state in
suicide is ambivalence
Recognize and support the clients
desire to live without trivializing their
pain and distress.
Identify the clients reasons to stay
alive (e.g., children, spouse, family;
the use of the Reasons for Living
Inventory by Linehan, Goodstein,
Neilson, & Chiles, 1983 may be
useful in this regard).
The common perceptual state in
suicide is constriction
Seek opportunities to interrupt
perceptual constrictions by
redirecting attention from failure and
disaster to consideration of
accomplishments, strengths and
resources.
Solution-Focused Brief Therapy
The common interpersonal act in
suicide is communication of intention
Highlight that communication of
intention is not universal, and that
communication is not always
conveyed in a manner that is
understood by the recipient at the
time.
Ask the client about suicidal intent
within a context of the client as a
whole person with healthy attributes,
as well as psychiatric symptoms and
plans for suicide.
The common action in suicide is
egression (or escape)
Recognize the desire to exit a painful
situation and seek alternatives and
goals that are more palatable than
suicide.
Define goals for treatment
collaboratively with client.
The common pattern in suicide is
consistency in lifelong coping
patterns
Even in a crisis situation, seek
evidence of a clients coping skills.
Assume that client can learn from
and rely on his or her own
accomplishments, even in the midst
of pain, fear, and apathy.
Assessing Suicidal Risk
Clinicians may find the following 22 factors useful in assessing suicidal
risk. Making certain that we consider such factors with each patient
can help us prevent the ethical lapses that come from neglect.

1. Direct verbal warning 12. Race

2. Plan 13. Religion
3. Past attempts 14. Living alone
4. Indirect statements and behavioral 15. Bereavement
signs 16. Unemployment
5. Depression 17. Health Status
6. Hopelessness 18. Impulsivity
7. Intoxication 19. Rigid thinking
8. Marital separation (distinct from 20. Stressful events
divorce). 21. Release from hospitalization
9. Clinical syndromes 22. Lack of a sense of belonging
10. Sex
11. Age
General Guidelines for Practice and Treatment

1. Establish a clear treatment plan with the client as to

how suicidal thoughts, feelings, and behaviors will
be managed on an outpatient basis.
2. Closely monitor and document ongoing suicidality
until it resolves.
3. Consider and use all appropriate modalities (e.g.,
various therapies)
4. Routinely seek professional consultation and
document such.
5. Document the resolution of suicidality; monitor for
any future reoccurrence.
Learning Warning Signs (prodromals) - Identifying thoughts,
emotions and behaviors which are or could lead to suicidal
state.

Coping/Crisis Card - List of different strategies (internal and

external behaviors) client can use in case of a crisis situation.
On card, smart phone, or other immediately available form.

Developing a Hope Kit aid to reminding individual why they

want to live can be written (such as gratitude lost), or
something like a box filled with life-affirming items and
meaningful mementos that instill a sense of hope. Anything that
reminds client of why struggle to live is worth fighting for.
ETHICAL AND
LEGAL ISSUES
OF SUICIDE
Common Errors of Suicide Interventionists
1. Superficial reassurance.
2. Avoidance of strong
feelings.
3. Inadequate assessment of
suicidal intent.
4. Passive rather than active,
structuring responses.
5. Sidestepping the issue
dont ask, dont tell.
6. Keeping a secret.
7. Leaving the person alone.
8. Feeling responsible for
saving the person.
9. Being shocked, morally
outraged, angry or
disgusted.
10. Giving advice.
11. Not listening!!!!
 NONMALEFICENCE is the ethical
principle addressing the counselors
responsibility to do no harm including
the removal of present harm and the
prevention of future harm (Gladding,
2004). Of course, harm can be defined
in a variety of ways.
CONFIDENTIALITY
For counselors, confidentiality is Association Section B.1.a speaks to
a foundational ethical standard. respect for client privacy.
Confidentiality is the ethical duty to Confidentiality becomes a legal as
fulfill the promise that client well as an ethical concern if it is
information received during therapy broken, whether intentionally or not
will not be disclosed without (Gladding, 2004).
authorization. As such, it follows that
breaching confidentiality can result
in harm to the counseling
relationship and subsequently the
client.

Confidentiality is addressed in
Section B of the Ethical Standards
of the American Counseling
CONFIDENTIALITY EXCEPTIONS
Because confidentiality is such a
critical issue within counseling,
exceptions to confidentiality must
also be heavily considered. What if
not breaking confidentiality leads to
harm?
Section B.1.c. outlines the
exceptions to confidentiality
including the fact that confidentiality
does not apply when disclosure is
required to prevent clear and
imminent danger to the client.
This exemption was written with the
suicidal client in mind, clarifying that
counselors have a duty to protect
client from harm and that this
supersedes the harm that may
happen due to a breach of
confidentiality.
The complexities surrounding
confidentiality are brought to the
forefront when dealing with a
suicidal or potentially suicidal
client. Any decision to breach
confidentiality should be made with
careful consideration. The difficulty
in making a decision, even in cases
of suicide risk, lays in assessing
clear and imminent danger.
CONFIDENTIALITY EXCEPTIONS
Determining that a client is at risk of committing
suicide leads to actions that can be exceptionally
disruptive to the clients life. Just as counselors can be
accused of malpractice for neglecting to take action to
prevent harm when a client is determined to be suicidal,
counselors also can be accused of wrongdoing if they
overreact and precipitously take actions that violate a
clients privacy or freedom when there is no basis for
doing so (Remley & Herlihy, 2001).
NEGLIGENCE
Negligence results from some
type of wrongful action committed by
one person, which results in injury
to another person. As a general
legal principle, a court must find the
following four to be true:
1. A duty was owed by the
counselor to the client
2. The duty owed was breached
3. There is sufficient legal causal
connection between the breach
of duty and the clients injury
4. Some injury or damages were
suffered by the client
With regard to the first issue,
counselors have a duty to take steps
to prevent client suicide.
Counselors have established
themselves as mental health
professionals, and the law imposes
on counselors practicing in all
settings the responsibility of knowing
how to accurately determine a
clients risk for suicide (Remley &
Herlihy, 2001).
It is not required that counselors
always be correct in making their
assessments of suicide risk, but they
need to operate from an informed
NEGLIGENCE
position and fulfill their professional
obligations to a client in a manner
comparable to what other
reasonable counselors operating in
a similar situation would have done
(Remley & Herlihy, 2001).
The following are considered
reasonable duty for counselors in
terms of suicide prevention (Remley
& Herlihy, 2001):
Counselors must know how to
make assessments of a clients
risk for suicide and must be able
to defend their decisions
When a decision is made that the
client is a danger to self,
counselors must take whatever
steps are necessary to prevent
the harm
Actions to prevent harm must be
the least intrusive to accomplish
that result
Brems (2000) summarized the
following questions related to
negligence:
1. Was the counselor aware or
should have been aware of the
risk?
NEGLIGENCE
2. Was the counselor thorough in unavailable or unresponsive to the
assessment of the clients clients emergency situation?
suicide risk?
3. Did the counselor make 6. Was the counselor negligent in
reasonable and prudent efforts the way she or he designed her
to collect sufficient and or his intervention with the client
necessary data to assess risk? after assessing risk?
4. Were the assessment data 7. Did the counselor make
misused, thus leading to a adequate attempts to keep the
misdiagnosis where the same client safe (i.e., set up a plan of
data would have resulted in contingencies with appropriate
appropriate diagnosis by resources, phone numbers,
another mental health etc)?
professional?
5. Did the counselor mismanage
the case, being either
NEGLIGENCE
8. Did the counselor remove the means to
be used by the client in the suicide
attempt?
9. In cases of minors, were parents or
caretakers informed of the clients
potential risk?
What can counselors do to protect
themselves and subsequently their clients?
Counselors should inform clients
of the limitations of confidentiality
through standard informed
consent procedures.
Counselors should begin their
study of suicide assessment
prevention early and continue to
stay current through professional
development activities regarding
suicide and crisis intervention
and ethical/legal issues in
counseling (Laux, 2002)
Counselors should be familiar
with suicide risk factors,
procedures for suicide
assessment, and guidelines for
intervention (Brem, 2000)
Counselors should abide by the
standard of practice to consult
with other mental health
professionals to aid in assessing
for suicide risk and interventions.
It is important to look for
consensus and follow the advice
in making decisions (Remley &
Herlihy, 2001)
Counselors must properly
document the process of suicide
assessment and intervention
through case notes and reports
(Brem, 2000)
Felo-de-se
(felo-de-se: the act of suicide or a
person who commits suicide.)
-HazelDelgadoPlanco-
I have built walls around me
As I hid inside my shell
Ive also pushed people away
And kept all the pain and sorrow inside
me
I'm drowned by my own tears
Ive struggled for years to face my fears
I was so lost, I felt so alone
I am very depressed
Everything now seemed hopeless
With no one to call my own
My life has been shattered
My dreams have been crushed
I am nothing, I am nobody
I am but a worthless person
All I see is darkness
Perhaps death is the only way out
For the pain I feel is too much to bear
And no one seems to care at all
I was abandoned, and isolated,
Taken for granted and disregarded
I became invisible in everyone's eyes
I see no reason for my existence
I am living in a world of hopelessness and lies
What is the purpose of living
When I don't even know what happiness means
It feels like all the world's burden
Had been cast upon my shoulders
I don't deserve all these
Perhaps if I commit suicide
It'll free me from all this pain
Everything might fall into place
If I simply shot myself and bleed to death
The pain inside me will be more valid
If I let the blood flow along with my tears
Maybe when I reach my death, my troubles will
also end
Who will grieve for me anyway?
It'll just be merely a passing death
Because none of you were there for me
Not even tried to understand me at least
But if I kill myself now
I will also no longer be able to see
What could have been on the other side
Of the blinding darkness that has
clouded my senses
Because amidst all these
The only reality is I am dying to seek
help
Hoping it'll come the soonest possible as
it can be
Will you be kind enough to listen to me
I don't need you to sympathize nor err
with me
I just need someone who will lend his
ears
Or a shoulder to cry on so to speak
As I am now knocking on deaths door
I hope for once, you'll take one last look of me
And spare me some of your precious time
All I need is to let this feeling out
Or else you'll never know what's it all about
For I will carry the story upon my grave
That day might be too late
For you to ask why
Because death has already taken me
If only you can take me now out of the darkness
And make me believe that life is more powerful
than death
Please, please! All I need now is your help
Please save me from a hapless death!