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"I wish I were dead..."

Interventions with Suicidal Individuals

By: Ed Rawlinson

The following article was originally published in:
CPI National Report, Volume 8, No. 3 Winter 1989

and also reprinted in:
The Journal of Safe Management of Disruptive and Assaultive Behavior, Volume 1, Issue IV, April, 1993


Suicide & Self-Inlicted Injury

Self-inflicted injury behaviors and successfully completed suicides present an ever-increasing concern to the human service worker. It is estimated, conservatively, that official recording of suicide is under-reported at a rate of 25%, and that for every successfully completed suicide there are 100 non-fatal self-injury behaviors (Ramsay et al., 1987).

Suicide: The Magnitude of the Problem

To appreciate the magnitude of the problem, let's examine a hypothetical situation: In Townville (population 100,000) there were 12 suicides reported for the year 1987. The figure of 12 suicides per 100,000 population is representative of the rate of death by suicide recorded on a yearly basis in Canada and the United States (Report of the National Task Force on Suicide in Canada: Suicide in Canada, 1987). According to the figures outlined above, there were three deaths of which were incorrectly recorded as accidental or as undetermined that were really suicides. Therefore, there were 15 actual suicides in 1987. For each of the 15 suicides there were 100 people who engaged in some self-injury behavior, or 1,500 persons who harmed themselves in some way--with a potential risk of death!

A total of 1,515 people either harmed themselves or died as a result of self-injury behaviors. Let's further assume that each of these persons, who harmed themselves or died, had at least seven significant social contacts. The number of people whose lives might be affected by these behaviors would be 10,605 plus the original 1,515. Therefore, a total of 12,120 people were directly or indirectly affected by suicide and self-injury behavior--over 10% of the population.

Finally, if we assume that the rate of self-injury and suicide behaviors are relatively stable and that the people engaging in self-injury behaviors change significantly from year to year, then in 10 years it is very likely that every member of the Townville Community will have contact with a person who has either killed themselves or engaged in some self-injury behavior. This is a significant problem.

Total Behavior Clues to Suicide

Any given behavior involves four significant components--feelings, thinking, acting, and physiology (Glasser, 1984-46). A person at risk of suicide is experiencing a crisis, and in each of the four components which make up a total behavior, there are common clues which a trained intervener should assess. Look for the following things in the four components of a total behavior:

Feeling

Thinking Acting Physiology

When many of these clues are present from each component of a total behavior, the intervener should be alerted to the potential--not the likelihood--of a suicide risk. At this point it is essential to identify if the person is contemplating some self-injury behavior. Asking the Question

When the assessment of a total behavior corresponds with the common clues to suicide, you should be prepared to ask a question in order to identify the presence of suicidal thoughts. A standard crisis intervention strategy for a potential risk of suicide is a simple, direct question, such as the following:

"Do you feel so low that you are thinking about killing yourself?"

Be direct. Don't mince words or beat around the bush.

Asking the question gives your client permission to discuss suicidal thoughts or intentions, if they exist. A question, of the nature outlined above, should be in your normal repertoire of questions as a trained crisis intervener.

Contrary to popular belief, asking a person to discuss suicidal thoughts will not likely cause an act of self-injury. The person who has no suicidal thoughts will simply say so. The potential person-at-risk of suicide likely feels very ambiguous about their ideas, and when confronted directly with a question from a friend and sensitive crisis intervener, the likelihood of essential information of suicidal thoughts emerging is increased.

Factors in Assessing the Risk of Suicide

In assessing a person's potential risk of suicide as high, medium or low, the emergence of suicidal thoughts must be facilitated by the crisis intervener through the asking of questions. The questioning process should be guided by research done on crucial factors shown to be associated with the risk of suicide (Lettieri: 1974).

Questions: Resources

  1. Do you have any family or friends?
  2. Are you married/divorced?
  3. Do you have children/grandchildren?

RISK FACTOR: 1

Resources: Does the person perceive him/herself as alone? The greater the perceived lack of resources, the greater the risk.

Questions: Current Suicide Plan

Have you thought about how you might kill/harm yourself?

RISK FACTOR: 2

Current Suicide Plan: The more specific a person's plan is, such as:

the greater the risk.

Questions: Prior Suicidal Behavior

  1. Have you ever tried to kill/harm yourself before?
  2. Has anyone in your family tried this before?

RISK FACTOR: 3

Prior Suicidal Behavior: Persons who have engaged in self-injury behaviors previously, or who have had family members kill themselves, may be up to 40 times more at risk than other members of the population.

Questions: Symptoms

Are you taking drugs/abusing alcohol, or both?

RISK FACTOR: 4

Symptoms: Persons at risk of suicide or who are disposed to suicidal behaviors are 6 times more likely to harm themselves than other members of the population, if they are also drinking, taking drugs, or doing both.

Questions: Stressors

What has got you feeling so bad that you're contemplating suicide?

RISK FACTOR: 5

Stressors: Usually a precipitating factor, viewed as perceived "loss" by the person at risk--loss of a wife, a fortune, a treasured possession. This is as varied, unique and specific as the number of persons there are at risk.

Questions: Sex and Age

How old are you?

RISK FACTOR: 6

Sex and age: Statistical information compiled on successfully completed suicides indicates that younger males (20-29), middle year females (50-59), middle and older males (40-69) are more predisposed to successfully completing suicide (Ramsey et al., 1987)

In making a risk assessment, it should be noted that the factors, examined through your questions, have been weighed (Ramsey et al., 1987), so that when you are trying to determine if there is a high, moderate or low degree of risk in a client, one is not simply engaging in a numerical exercise. For example, the presence of a current suicide plan and prior suicidal behavior in one client would mean more than a negative assessment of symptoms, stressors, sex and age in another client.

Planning with Suicidal Clients

Once you've assessed the risk of suicide in your client, it is time to plan or contract an agreement that will reduce the immediate risk of suicide. Although there are several key components to a good plan, the chief component would be to get a verbal commitment from the person-at-risk that they will do nothing to harm themselves for the duration of the plan. This type of contract has proven to be a reliable tool for reducing the immediate risk of death by suicide, and provides the time to commence counselling or to make a referral to another health service worker.

The following are several points to consider when planning (Gossen) with a person in crisis, or one who represents a potential risk of death by some self-injury behavior.

  1. There must be a partnership between the helper and person helped.
  2. There must be an examination of alternatives, both positive and negative.
  3. The plan must be specific and limited.
  4. The plan must be short term: "Will you try it for one day?"
  5. There must be a mutual commitment to the plan.
  6. The persons-at-risk must agree not to do anything to harm themselves for the
  7. duration of the plan.
  8. Never drop a plan--either graduate from it or replan.
  9. Don't over-extend yourself; the person helped must take at least 50% of the responsibility and increase this.

References

Glasser, Williams, M.D. Control Theory: A New Explanation of How We Control Our Lives. New York: Harper & Row Publishers, 1984.

Gossen, Diane. Steps In Planning. N.P.:n.d.

Lettieri, D.J. Los Angeles Suicide Prevention Centre. Unpublished Manuscript, 1974.

National Task Force on Suicide in Canada. Report of the National Task Force on Suicide in Canada: Suicide in Canada. Ottawa: Health and Welfare Canada, 1987.

Ramsay, Richard F., et al. A Suicide Prevention Training Program: Trainer's Handbook, third edition. Calgary: Ramsay, Tanney, Tierney, and Land, 1987.


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