Responding to Suicide Risk

 Responding to Suicide Risk
This article was published on Wednesday, July 13th, 2011

Suicide is a serious health problem. The World Health Organisation estimates that one suicide attempt occurs every three seconds and one completed suicide occurs approximately every 40 seconds resulting in almost one million people dying from suicide each year; a “global” mortality rate of 16 per 100,000 (WHO, 2000, 2010).
In the last 45 years suicide rates have increased by 60% worldwide. Each day, approximately 210 Australians attempt to end their life and each year over 2500 will commit suicide. Suicide in Australia kills 8.5 times more people than homicides and 1.5 times more than motor vehicle accidents. Consequently, reducing suicide has become an important international health goal.

Suicide Definition
Suicide is considered to be an attempt to ‘communicate’ or to ‘solve a problem’. When a client is communicating a need, the counsellor’s perspective is to seek to clarify what, and to whom, the act of suicide will communicate. When a client is trying to solve a problem through suicide, the counsellor’s aim is to clarify what problem or problems the client is aiming to solve and then committing with the client to finding more effective ways to address such problems.
Suicidal behaviours include suicide, attempted suicide and suicidal ideation.

1. Suicide is any self-injurious act intended to end one’s life which results in death. It is defined as death by self-inflicted, intentional injury.
2. Attempted suicide is any potentially self-injurious act intended to end one’s life but does not result in death.
3. Suicidal ideation is thinking about engaging in suicidal behaviour, with or without a specific suicide plan.

Categories of Suicide
Individuals contemplating suicide usually fall within two categories. These are impulsive and planned suicide. Both categories should be taken seriously and responded to appropriately because each type places the person at risk. While there are numerous variables to consider when responding to suicide risk, one variable that will influence the type of response is whether the suicide risk is impulsive or planned.
Impulsive Suicide: Impulsive suicide relates to the impulsive thoughts of suicide that may occur as a response to a crisis or trauma. In a state of crisis, individuals can lose the capacity to rationally control their thinking, behaviour and emotions. In the context of potentially irrational and uncontrolled responses to trauma, it is important to remember that it is not necessarily the crisis or trauma itself that pushes the client into such impulsive thoughts of suicide. It is more to do with the perception they have of the trauma and the meaning or significance they place on it.
In the context of impulsive suicide there is usually no history of self-harming thoughts or behaviour. Situations which cause pain, despair and distress can range from, for example, catastrophic events like a plane crash or earthquakes, to individual experiences like being assaulted, a relationship break-up or death of a loved one.
Conventional counselling techniques that focus on discussing the situation and problem solving can at times deepen the state of crisis. Thus a crisis management approach to assist the client in dealing with the here and now can provide clinicians with strategies to stabilize the client and reduce the risk of self-harm. Once crisis management has been achieved, future counselling sessions can then include more in depth discussions of the situation (Pelling, Bowers and Armstrong, 2007).
Planned Suicide: In the case of planned suicide, the individual is not in a state of crisis (or is in a mild state of crisis) and therefore, their interactions with others and their behaviours can appear to be calm. The individual is focused and their thought processes around the notion of suicide, rom their perspective, are rational. They will usually appear to be in control of themselves, but will also usually appear unhappy. After considering all options available to them, they will come to the conclusion that ending their life seems the best option. The individual is committed to solving the problem, even if this requires them to suicide.
Individuals who do not seek counselling are not ambivalent about suicide. Therefore, counsellors will usually not be visited by individuals who are not ambivalent about committing suicide. Those who do seek assistance from a counsellor about thoughts of suicide will often be ambivalent about it, whereby their planning and level of conviction may not be completely settled or decided. In this context, rather than wanting to die, the individuals are more likely to not want to live as they currently do. It is in the context of this ambivalence where the clinician can arrest the act while seeking alterative options.
Responding to Suicide Risk
Individuals who have experienced a traumatic event can show their stress and distress emotionally, cognitively, behaviourally and/or physiologically. Counsellors may notice the following types of reactions and common symptoms to identify when a person is in a state of crisis:

• Emotional reaction: anxiety, fear, panic attacks, guilt, hopelessness, grief, anger, frustration, numbness, shock.
• Cognitive reaction: Confusion, poor concentration & attention, flashbacks, nightmares, disorientation of place and time, obsessive thinking about the event, difficultly remembering the event, preoccupation of it happening, inability to understand one’s reaction.
• Behavioural reaction: Withdrawal, fatigue, apathy, sleep disturbances, black humour, work absenteeism, increased use of drug and alcohol, angry outbursts, irritability, crying, antisocial acts, unresponsiveness, hysteria.
• Physiological reaction: Dizziness, sweating, trembling, nausea, diarrhoea, loss of appetite, pain, heightened sensitivity to sound.

(Pelling et al., 2007)
A Six-Step Model of Response to Impulsive Suicide
The aim of this model is to restore the client to a stable state of being that abates the impulse to suicide. It does not aim to explore and solve issues. The Six-Step Model of Crisis Intervention ideally should be used in a general flow, rather than six separate stages.
The first three steps are considered to be the ‘listening’ steps and the last three steps are described as ‘acting’ steps. Once the counsellor has gained a sound overall understanding of the client’s current position, the ‘acting’ steps are used to develop short term goals that the client can commit to and can also play a part in assisting the client to feel safe. Steps 4 to 6 may need to be revisited, until both the client and counsellor are satisfied with the outcome.
Step 1: Define the problem

1. Acquire an understanding of the traumatic event and how the individual perceives the event
2. Identify the current and longer term problems the individual is having
3. Acknowledge what has happened to the individual and why they are seeking assistance

Step 2: Ensure client safety

1. Assess risk of self-harm and harm to others
2. Short term focus of reducing impulsive actions (later to be followed up with a long term suicide risk assessment)

Step 3: Provide Support

1. Communicate a sense of stability and calmness
2. Overtly and actively offer your support
3. Assist to identify other people in the individual’s life who can offer support.

Step 4: Examine alternatives

1. Assist the client to develop realistic options on issues which they can change to help develop a sense of control over their life

Step 5: Making Plans

1. Develop a plan of action, taking into consideration what the client is able to cope with, is willing to do and the resources available.
2. The focus must be on the client choosing the options for themselves rather than it being prescribed to them

Step 6: Obtaining commitment

1. Develop joint commitment to following through with the plan
2. Include clear guidelines of the responsibilities belonging to the client and counsellor and ensure follow-up.

Asking four key questions
When responding to an impulsive suicide risk, there are four key questions counsellors need to consider. The following table provides these questions with a guide to how and when to consider them in relation to The Six-Step Model of Crisis Intervention:

The Four Key Orientating Questions	Applying the Questions to The Six-Step Model of Response
Question 1 Is this person in a crisis state?
Assess: Make an assessment of the client’s state of being using rating scales such as the Triage Assessment System. If your answer is ‘No’, choose another intervention strategy such as counselling. If your answer is ‘Yes’ choose the crisis intervention strategy.
Question 2 Why is this person in a crisis state?	Step 1: Define the problem
Understand: Try to grasp what has happened to this client and meaning the client is attaching to the event. Make sense of the client: do not expect the client to make sense.
Question 3 What does this person need from me right now?	Step 2: Check Safety Step 3: Provide Support
Determine: A client in a crisis state always needs to have safety and support addressed but you need to determine just how assertively you need to provide this, with what level of structure and support.
Question 4 What is an immediate pressing problem that needs to be addressed?	Step 4: Generate alternatives Step 5: Select and formulate a plan Step 6: Check commitment
Intervene: What immediate problem can be addressed right now that will engage the client in making choices and taking action on the way to restoring stability and mobility?

(Pelling et al., 2007)
Responding To Planned Suicide
Presenting perspectives such as reasons not to suicide, clarifying their responsibilities to uphold when living and proposing any moral or religious perspectives to a client is not considered to be overly beneficial. These strategies have shown to actually encourage the act. The best strategy to assist a client contemplating a planned suicide is by following these three steps:
Step 1: Address the client’s needs

1. Assess the situation, the client and the risk that is present
2. Commit to finding alternative solutions to what the client hopes the suicide will achieve
3. Focus on short-term achievable goals
4. Use strategies which give time to work on alternative options

Step 2: Reduce Lethality

1. The higher the level of risk the more quickly, directly and assertively the counsellor needs to ensure client safety
2. Negotiate the removal of items which might be used to harm the individual
3. Identify a safe environment where the individual will not be alone and will be supported. This may require negotiating with the client to tell other people of their risk
4. Seek commitment from the individual not to harm themselves for a period of time. This may include a ‘no suicide’ contract. The agreement should include that within this time alternative solutions wills be explored.
5. Identify any medical or mental health issue, and assist the individual to obtain treatment.
6. Anticipate any triggers which may influence the individual’s ability to abstain from suicide and make contingency plans.

Step 3: Look after Yourself as the Counsellor

1. Regardless of how experienced a counsellor is, they should never work in isolation with a suicidal client. Discussing their observations and actions with peers and a supervisor assists the counsellor on both a personal and professional level while also ensuring support if the client does act out their intentions.

Note: If the therapist’s assessment of the situation is that the client’s suicide is imminent, this justifies breaking confidentiality. This may include declaring your concerns to relatives or friends of the client and alerting the police. Breaking confidentiality in this position is the best option to keep the individual safe from self-harm.
Responding to people who are from culturally and linguistically diverse backgrounds
Challenges resettling into a foreign culture including language difficulties, little access to meaningful work, and experiencing trans-generational conflict, may place migrants at a particular risk of suicide and self-harm. Migrants may have experienced torture and trauma prior to their settlement in their new country which may increase their risk to mental health issues and suicide. When dealing with such populations, it is important to note that:

1. Responses to suicide risk in culturally diverse communities should be developed in collaboration with multicultural organizations to ascertain the issues that may exacerbate their risk to suicide.
2. Interpreters should be available whenever necessary to overcome the language barrier
3. Professionals should become aware and familiar with culturally appropriate methods and protocols when working with such individuals.
4. Professionals should be aware of the different ways individuals may choose to deal with and respond to suicide.

References:

• Pelling, N., Bowers, R., & Armstrong, P. (2007). The practice of counselling. Sydney: Thomson.
• World Health Organisation (2000). Preventing Suicide. A resource for prison officers. Mental and Behavioural Disorders. Department of Mental Health.

Source: www.mentalhealthacademy.com.au
 http://www.aipc.net.au/articles/?p=283

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