suicide assessment

Suicide and Crisis of Lethality

Posted on by Mark Moran

Crisis Intervention specialists deal with an array of issues.  Usually issues of self harm, harm of others and suicide are a very common theme.  In crisis, logical thinking and hope are erased and the person can sometimes do things out of character that are very lethal in nature.  Understanding suicide, suicide assessment, prevention and intervention are key components of helping individuals in crisis not make a permanent and fateful decision.

Suicide is rarely a conscious choice but one with emotional and mental implications that remove one from a state logical thinking

It is critical for crisis counselors, grief counselors, pastoral care givers and ministry, licensed mental health professionals, as well as those in healthcare to have a strong training and educational background in suicide and crises of lethality.  AIHCP offers certifications in Grief Counseling but also in Crisis Intervention to help train members in those fields with the additional knowledge and abilities to handle crisis of lethality.

Suicide

While in the past, AIHCP has offered blogs, as well as video content on the nature of suicide, this particular blog will focus on the crisis element of it.  It will identify suicidal signs, assessments, but also focus on intervention in particular.

James points out that a person in suicidal crisis is engaged in an expressive act of homicide where emotional state looks to reduce psychological pain (2017, p. 203).  According to statistics, James point out that 600, 000 to 100, 000 suicides are attempted each year in the United States and 30, 000 to 60, 000 die each year in those attempts, with 19, 000 permanently injured (2017, p. 204).  While different groups within the US  have different rates of suicide as compared to others, the leading group is older white males.

Theories surrounding suicide share many common features but also have different emphasis on certain reasons why one attempts to kill oneself.  Freud’s psychodynamic theories saw suicide as a reaction of some inner conflict with external stressors (James, 2017, p. 206).  Erickson saw reasons for suicide correlated with developmental issues that prevented the person from advancing and reaching certain goals in life.  Individuals who become stagnant and unable to develop sometimes choose suicide as an option to escape (James, 2017, p. 206).   Escapist theory views suicide as the only way out of a bad situation during fight or flight.  Within this theory, individuals feel they fell short, blame themselves, focus on narrow deficits only, and only see a view of perfectionism that if not met can only end in suicide due to the hopelessness perceived (James, 2017, p. 206).   Hopelessness remains a common theme in all situations where the person feels they have no power over the situation.

Another important theory was developed by Edwin Shneidman, the founder of suicidology.   In understanding suicide he measured one’s psycheache or pain in the mind, one’s perturbation or the degree of the pain, and the press or stress due to external factors (James, 2017, p. 206),   With the combination of these things, Shneidman saw how psycheache frustrates  or blocks psychological needs leading to hopelessness and suicide and reaching the state of critical mass to activate suicide.

Durkeim in the 19th Century proposed the sociological theory which looks at a person’s connections to society and how social norms and society based on a person’s integration with those norms plays a large role.  Egoistical suicide refers to one’s lack integration with any group.  Anomic suicide refers to when economic and financial systems of society break down all around the person.  Altruistic suicide refers when a person commits suicide for cultural reasons or the perceived better good according to the society.  Fatalistic suicide refers to if a person is an intolerable or unescapable situation such a concentration camp (James, 2017, p. 207).  According to Van Orden interpersonal states are also key in the mind of those contemplating suicide.  Suicidal individuals may acquire capability by decreasing innate fear of pain and death gradually.  In their personal views, they perceive themselves as burdensome to others as well as failing to belong to anyone or find attachment to anything (James, 2017. p. 207).   Existentialism and meaning also play an important role in suicide theory.  Ideas on death, existential isolation, meaning and meaningless in making sense of the world and the freedom of existentialist thought to make choices all play a role in the construction of existentialist thought.    When challenges to existence and death are overwhelmed and an existentialist anchor is lost, then many individuals can fall into hopelessness without any reason to exist (James, 2017, p. 208).

Another interesting theory follows a basic suicide trajectory model based on various risk factors that correlate with suicide.  This includes, biological, substance abuse history, genetic predispositions, gender, self esteem, psychological maladies, cognitive thinking and environmental stressors (James, 2017, p. 207).    Psychology also points to imbalances within the brain, neurochemical reactions that do not allow a person to better respond to a situation (James, 2017, 208).

From these theories and multiple other ones, one has a better understanding that suicide is rarely a free choice but is committed in a state of emotional turmoil without true cognitive reasoning.  This is why so many religious views on suicide as a choice or sin have been replaced with a better recognition that most if not all are victims of it.

Characteristics of Suicidal Individuals

For the most part, those thinking of suicide exist in an acute state of crisis or a chronic state of depression that leads to certain characteristics that manifest emotionally, socially, mentally and physically.

Many suicidal individuals suffer from depression or hopelessness. Please also review AIHCP’s Crisis Intervention Certification

Situationally, individuals face an endurable pain they cannot overcome.  A stressor frustrates the psychological need (James, 2017, p. 209).  Hence situations involving trauma, death, loss, finances, relationship or anything that creates a perceived unbearable loss appears.  Motivation wise, individuals look to seek a solution and that solution entails to remove the stressor via cessation of consciousness.  Accompanied with this are the affective emotions of hopelessness and helplessness.  Cognitively, individuals see solutions in a very narrow scope with out any alternatives to think their way out of the situation.  Relationally, an individual wishes to communicate intent and find mutual justification in it and acknowledgement of that right to do so.  Serially, characteristics reveal a long history of trying everything else but no other option remains (James, 2017,p. 209).

Within these characteristics of the suicidal mind, it important to dismiss certain myths that distort.  First, one needs to dismiss fears of discussing suicide as if it will cause it.  In fact, discussing suicide and being very upfront is key.  Second, one needs to dismiss the notion that those who say they will commit suicide rarely carry through with it.  In fact, many who say they are contemplating are very high risk of attempting it.  To the individual suicide is perceived as a very rational act.  Third, individuals who commit suicide are insane.  Most who commit or attempt suicide are only acutely affected with emotional issues.  Fourth, suicide is only impulsive.  In fact, most suicides are planned and plotted outside acute crisis.  Fifth, suicide is painless.  Many suicides can be very gruesome and some go awry and very wrong.  Sixth, suicidal thoughts are rare.  In fact, they are more common than one may think with 8.3 million have some type of suicidal ideation (James, 2017. p. 212).

Suicide Assessment is Key

Assessment is critical in saving a life.  While some crisis specialists deal with suicidal individuals in an acute and heated moment, many suicides are well planned and plotted.  Counselors need to be aware of the possibility and assess the lethality

James points out that there are a variety of verbal clues, statements and written letters.  As well as behavioral clues such as self harm or isolation.  Also situational clues that involve death of another person, financial woes, loss job, or divorce should be acknowledged.  In addition, syndromatic clues such as depression, hopelessness and unhappiness with life can play key indicators in possible suicidal.  This is why it is so important to also ask someone in assessment (2017, p. 212).

Another tool to utilize is PATHWARM.  This  is an acronym from the American Association of Suicidology.  It utilizes the letter within the acronym to better identify various warning signs.  Within the acronym is: Ideation, Substance Abuse, Purposefulness, Anxiety, Trapped, Hopelessness, Withdraw, Anger, Recklessness and Mood.

There are many, many assessment keys, questions, or triages one can utilize.  We will briefly go over a select few.

First, the basic clinical interview is essential in determining suicidal ideation.  Within it is a long laundry list of observations and questions.  Here are a few: Does the person exhibit suicidal intent or tendencies?  Does the person have a family history of suicide?  Does the person have past suicide attempts? Does the person have a specific plan?  Has the person experienced a death recently? Does the person have a history of drugs and substance abuse? Does the person display radical changes in mood and behavior?  Does the person display hopelessness?  Has the person experienced past trauma?  Has the person discontinued medication?  Does the person exhibit extreme emotions?  Has the person faced financial troubles or loss of job?  Does the person feel threatened?  Does the person see everything as all or nothing?  Does the person feel as if he or she does not belong? Does the person struggle with identity and self esteem?  Does the person have access to firearms?  Has the person explored suicide through online search or literature?  Has the person not seen a medical professional within the last 3 to 6 months? (James, 2017, p. 215).

SIMPLE STEPS is another acronym that can utilized in assessment during interview. Again it emphasizes the importance of asking the question are you thinking of killing oneself?  Within the acronym are the following points.  Suicidal? Ideation? Method? Pain? Loss? Earlier attempts? Substance abuse? Troubleshooting for alternatives? Emotions? Parental history? Stressors? (James, 2017, p. 216-17).  This triage captures the basic essence again of all assessment in that it asks the difficult question and looks to identify potential lethality and danger of a plan.  Not all cases may present an immediate acute threat while others may require immediate intervention and reference to medical professionals or notification of authorities and family.

Suicide Intervention

In intervention, whether in acute setting or discussing possible plans of a person to commit suicide, professionals need to not judge the person, or demean the person’s perceived tragic nature of life.  Instead, crisis professionals are encouraged to gain an understanding, form a bond and offer alternative options.

The Three “I”s are essential to know if looking to defuse suicidal situations.  The person feels the situation is inescapable, intolerable and interminable (James, 2017,p. 218).  Hence it is important to help the person feel secure, less painful, and offer hope with solid solutions.   When a person is facing crisis, they may feel there is no other way out and may need alternatives presented and applied to the situation.  In addition, the crisis counselor may try to help the person reframe the situation with attributes of CBT to see the situation from a different light.  The crisis counselor must also help the individual face the pain and discover that is not forever.  Helping focus on not so much the lethality but the perturbation of the person can help the person see more clearly, utilize problem solving abilities, and offer alternatives to the current issue.  Addressing stressors and helping the person see hope is the biggest key.  At this core, Crisis Management looks to help the person plan a response to suicidal issues (James, 2017, p. 222).

Those in suicidal ideation need alternatives and options. They need to know the there is escape and an end to the pain that involves not ceasing consciousness

In counseling, professionals should help clients reframe.  This involves not only a new line of thinking but also validating emotions and discussing future suicidal behaviors and how to counter them.  It is important to help the person learn real problem solving skills for issues but also address teaching individuals how to cope with pain and emotions in better ways.  In addition, counselors can help clients find better social connections to prevent isolation as well as play an important role in life coaching with positive thoughts, plans and goals.  Importantly as well, a counselor should obtain from the person a no harm commitment through a suicide “Do not Harm Contract” or “Stay Alive” contract which the individual signs.  It is important to let the person know he or she is not alone and can reach out or call when certain triggers may appear that seem unbearable (James, 2017, p. 227)>  In some cases, calls to the authorities may be needed, or a person may need observed for a period of time before the crisis has subsided.

Conclusion

Suicide is not simply a call for help but a true crisis situation that demands attention.  Through warning signs, assessment and proper intervention, crisis counselors can save lives.  It is also important to note that suicide is not something rationally chosen but one that is mentally and emotionally chosen when in a illogical state of mind.  Hence negative social stigmas need removed and professionals as well as society need to see these individuals who attempt or complete suicide as victims.  This is why it is so important to be educated on the subject and listening and observing with empathy for those who shows signs of suicidal ideation.

Please also review AIHCP’s Crisis Intervention Program and see if it meets your academic and professional goals.  The program is online and independent study and open to qualified professionals seeking a four year certification.  Counselors, first responders, clergy and other mental health professionals can play a key role crisis intervention and saving lives from suicide.

 

Resources

James, R & Gilliland, B. (2017). “Crisis Intervention Strategies”. (8th). Cengage

Additional Resources

Clay, R. (2022). “How to assess and intervene with patients at risk of suicide”. APA. Access here

Are you thinking about suicide? How to stay safe and find treatment. Mayo Clinic.  Access here

Ryan, E. & Oquendo, M. (2020). “Suicide Risk Assessment and Prevention: Challenges and Opportunities”. Psychiatry Online. Access here

Suicide and suicidal thoughts. Mayo Clinic.  Access here

Suicide Prevention Tools for Public Health Professionals. CDC.  Access here

988 Life Line  Access here

 

 

 

 

 

Crisis Intervention and Suicide Assessment Video

Posted on by Dominick Flarey

Counselors, certified, licensed or both, need to possess skills to access clients that are suicidal.  Social workers, pastoral counselors and even family and friends should have basic suicide assessment skills to recognize high risk versus low risk.  The video below offers some questions to ask and things to consider in determining if someone is high or low risk.

Suicide assessment is key in saving lives. Please also review AIHCP’s Crisis Intervention Counseling Program

 

Grief Counselors and Crisis Intervention Counselors may deal with these types of situations on a more regular basis and require the training needed to help others save their own life from the horrible decision of suicide. Please also review AIHCP’s Crisis Intervention Counseling Program and see if it meets your academic or professional goals.

 

Please also review the video below

Crisis and Suicide Assessment

Posted on by Dominick Flarey

Suicide is vital in any counseling whether clinical or pastoral.  Pastoral counselors should refer patients or members of the community to a professional counselor if he or she feels the person is experiencing depression and suicidal ideation.   In most cases, suicide assessment will consider a person to be low risk or high risk.  As opposed to low risk, high risk individuals have a far worst depression and a more lethal plan.

Suicide assessment is key in assigning low or high risk individuals. Please also review AIHCP’s Crisis Intervention program

 

When anyone feels depressed, especially over time, it can become overwhelming.  This is why when helping depressed and grieving individuals to probe and ask questions about suicide.  It is critical to ask if one wishes to hurt or harm oneself when interviewing the patient.  It is important to see if those types of thoughts or ideas are entering the person’s mind.  If someone who is experiencing depression states they feel hopeless, then this is definitely a warning sign.  Not all hopeless individuals commit suicide, but anyone who has ever attempted or committed suicide definitely felt hopeless.

If the seriousness of an assessment manifests, then one needs to determine if one is low risk or high risk.  Many individuals in pain or depressed may think occasionally of killing oneself, but do not have the intention, desire or capability to do so, but as thoughts of suicidal ideation become more frequent and loud, then an assessment is definitely needed.  Hence after assessing symptoms of depression and the thought or at least implicit idea of suicide within the patient’s mind, it is important to access whether this person is low or high risk.  High risk individuals will require more intense observation and measures, while low risk will require less intense intervention.

If one makes comments about harming oneself, the next question is to determine lethality of the plan.   Is the plan doable?  Are the means, times and places for the event possible? If someone dictates one would like to shoot oneself, then access if this person has access to firearms.  A person who points out that he owns a gun that is at home and currently loaded in his closet poses a severely high risk.  Hence the more detailed the plan the higher the risk level.  If a person has access to the weapon named in the thought and a time planned, then immediate intervention is required. Police should be called or the person should be submitted to a psych ward for observation.  If the person on the other hand does not have access or ability to commit immediately, one should be immediately referenced to professional counseling for depression.

Someone who is high risk has more detailed plans, numerous thoughts, deeper depression, more drinking and drug issues, and access to carry out the plans. High risk individuals are also individuals who have survived past attempts.  So it is important to ask these questions as well, but also including family history of suicide.   Unfortunately, many individuals due to mental health stigmas, keep their sadness and depression to themselves.  No-one is aware of the high risk involved with the loved one or friend.  Many times, friends and family miss the subtle comments about life and death or the anxiety and depression someone is enduring.  Awareness, questions and listening are key in helping depressed individuals find the help they need.  Assessments can later be employed to determine the risk level.

When one is in crisis, it is important to ask questions about self harm or hurting oneself and see if anyone is frequently thinking of it or planning it

 

If anyone manifests any level of suicidal ideation, it is important to convince the person to make a no-suicide contract in which the individual promises to call someone if the person feels low, hopeless, or ideation of killing oneself manifests.   This last outlet may be the helping hand one needs not to take it to the next step. In this type of contact, the person promises to call a loved one or yourself if ideation manifests.  Sometimes this last call for help is the difference between life and death.  It is also important to discuss the frequency of alcohol and drug use during this period of time and how it can play a role in poor decisions.

Individuals kill themselves not because they want to die but because they do not feel life is worth living.  Many of them are not in the proper state of mind due to depression, trauma or extreme pain.  These individuals need counseling and help so they do not fall victim to suicide itself.  With so many stigmas surrounding suicide, it is important to remember that someone who commits it or attempts is dealing with temporary mental illness.  One should not blame but try to help.  It is not a true sin in the classical sense that once was attributed to it but a true mental state of imbalance.

Pastoral caregivers can play a key role in helping members of the congregation work through suicidal thoughts.  They can be the first line of defense for those who have noone to talk to or discuss their feelings with.  They can mentor, guide and help individuals find hope when they are depressed.  Christian Counselors, pastoral counselors and those in ministry should all have crisis intervention training and suicide prevention training.  This will enable them to better help individuals suffering from these types of thoughts.

Please also review AIHCP’s Grief Counseling, Christian Counseling and Crisis Intervention Counseling Programs.  The programs all to some extent touch on suicide.  The Grief program discussing the role of depression and loss in suicide.  The Christian Counseling Program discusses the pastoral implications from a Christian perspective and the Crisis Intervention Program discusses suicide prevention, assessment and helping individuals who are in a state of acute crisis.  All the programs are online and independent study and open to qualified professionals who work in the counseling and ministry fields.  Please review and see if the program meets your academic and professional goals.

Again, if in any type of counseling, whether professional or pastoral, be sure to have a complete understanding and working suicide assessment list.  Also, if anyone is feeling worthless or hopeless, please call the National Suicide Hotline and seek help.  Simply dial 988. Hurting oneself is never the answer.

Additional Resources

988 Suicide & Crisis Lifeline.  Access here

“Suicide Assessment”.  Access here

“How to assess and intervene with patients at risk of suicide”. Clay, R. (2022).  APA.  Access here

“Adult Outpatient Brief Suicide Safety Assessment Guide”. National Institute of Mental Health. Access here