Suicide Prevention Training Program for Washington Healthcare Professionals (6 Hours)
Suicide Assessment, Treatment, and Management
CONTACT HOURS: 6
Copyright © 2020 Wild Iris Medical Education, Inc. All Rights Reserved.
LEARNING OUTCOME AND OBJECTIVES: Upon completion of this continuing education course, you will demonstrate an understanding of the complex nature of suicide, how to assess and determine risk for suicide, and appropriate treatment and management for at-risk individuals. Specific learning objectives to address potential knowledge gaps include:
- Discuss the epidemiology and etiology of suicidal behavior.
- Summarize the risk and protective factors for suicide.
- Describe the process of assessment and determination of level of risk for suicide.
- List the elements of appropriate documentation of suicide risk, actions, and plan of care.
- Outline the management and treatment modalities that may be used for persons at risk for suicide.
- Discuss the public health approach for suicide prevention.
- Relate specific epidemiologic data, risk factors, protective factors, and interventions specific to the veteran population.
TABLE OF CONTENTS
- Understanding Suicide
- Epidemiology
- Etiology and Risk Factors
- Suicide Screening amd Assessment
- Models of Care for Patients at Risk of Suicide
- Management of the Patient at Risk for Suicide
- Treatment Modalities for Patients at Risk for Suicide
- Suicide Prevention Strategies
- Ethical Issues and Suicide
- Conclusion
- Resources
- References
UNDERSTANDING SUICIDE
Suicide, the taking of one’s own life, has been the subject of deliberation throughout history, and making a judgment about whether life is or is not worth living is a question that underlies philosophical thought. Suicide is always controversial, raising questions of rationality and morality. Depending on one’s philosophical point of view, it is either acceptable at any time, acceptable under certain circumstances, or never acceptable.
The will to live arises from instinctual self-preservation, and it takes a great deal of willpower to overcome this natural instinct. Humans are motivated by the pursuit of pleasure and the avoidance of pain, and suicide is usually prompted by a desire to be rid of unbearable pain or distress, which can be ended by an impulsive act. Suicide is the culmination of many and varied interactions between biological, social, and psychological factors that operate at the levels of the individual, the community, and society.
Healthcare professionals play a critical role in the recognition, prevention, and treatment of suicidal behaviors, and the attitudes of these providers are paramount in how patients are treated. Historically, the stigma associated with suicide affects the attitudes of those who manage and treat these individuals.
Studies have shown attitudes toward self-harming individuals are often negative—that many people, including healthcare professionals, believe people who are suicidal are weak, unable to cope with problems, selfish, cowardly, manipulative, or attention-seeking. The truth is that those who talk about suicide or express thoughts of wanting to die are at risk and do need attention, not judgment (Rothes & Henriques, 2018; Carpiniello & Pinn, 2017).
Talk of suicide must always be taken seriously, recognizing that people who are suicidal are in physical and/or psychological pain and may have a treatable mental disorder. The vast majority of people who talk of suicide do not really want to die. They simply are in pain and want it to stop. Suicide is an attempt to solve this problem of intense pain when problem-solving skills are impaired in some manner, in particular by depression.
Many healthcare professionals express concern that they are ill prepared to deal effectively with a patient who is suicidal. By developing adequate knowledge and skills, these professionals can overcome feelings of inadequacy that may otherwise prevent them from effectively responding to the suicide clues a patient may be sending, thereby allowing them to carry out appropriate interventions. They can also develop a better understanding of this choice that ends all choices.
Changing the Language
The term committed suicide suggests that a person was involved in a criminal act. It implies that the person was a perpetrator and not a victim of a pathology that led to death. It ignores the fact that suicide is often the consequence of an unaddressed illness, such as depression, and it perpetuates harmful stigma. It also implies that suicide is an act of free will, a choice one makes to live or die.
There is a great deal of evidence indicating that thought processes are gravely impaired at the time of death by the effects of trauma, mental health conditions, or substance use, and many have reported experiencing something akin to command hallucinations right before attempting to kill themselves. So, if a person cannot rationally choose due to impairment of the mind, the decision is not a choice.
Stigma surrounding mental illness, and suicidality in particular, has been documented as an immediate and profound barrier to help-seeking behavior. The following table provides recommendations for changing the language that surrounds the topic of suicide in order to remove the harmful stigma that can profoundly affect both the person with suicidal thoughts or behaviors and those closest to them.
| Inappropriate | Appropriate |
|---|---|
| (Spencer-Thomas, 2019; MSPP, 2020; Carpiniello & Pinn, 2017; Keller et al., 2019) | |
| Committed suicide | Died of or by suicide |
| Successful attempt | Suicide death |
| Unsuccessful attempt | Suicide attempt |
| Suicide attempter | Person with suicidal thoughts or behavior |
| Completed suicide | Suicide |
| Manipulative, suicidal gesture, cry for help | Describe the behavior (e.g., nonsuicidal self-injury) |
LEXICON OF SUICIDAL BEHAVIOR
- Altruistic suicide
- Suicide to benefit others, such as a soldier falling on a live grenade to save fellow soldiers
- Assisted suicide
- Death by suicide with the help of another person, sometimes a physician
- Attempted suicide
- A suicidal act that is not fatal, such as surviving after taking a nonfatal dose of medicine, cutting one’s wrists, or crashing an automobile
- Copicide, death-by-cop, suicide-by-cop
- Acting in a threatening way so as to provoke a lethal response by a police officer
- Cluster suicides
- Suicides, often of young adults, that occur in the same city or town within a few months of each other following media coverage of a suicide
- Copycat suicide
- A suicide that resembles other highly publicized suicides
- Euthanasia
- From the Greek, meaning “good death”; the intentional causing of a death to relieve pain or suffering, a mercy killing
- Interrupted suicide attempt
- When an individual is stopped by an outside force (person or circumstance) before making an attempt
- Mass suicide
- Suicide by a group of people, such as the 1978 cult suicide of 918 members of the People’s Temple in Jonestown, Guyana, and the 1997 Heaven’s Gate mass suicides in California
- Murder-suicide
- When a person kills another person(s) and then kills themself
- Nonsuicidal self-injury
- Deliberate, direct destruction or alteration of body tissue without a conscious suicidal intent, such as cutting, burning, or bruising oneself
- Obligatory suicide
- A suicide completed because the victim felt a personal duty to perform the act to honor the family, a cause, or a nation (e.g., Japanese Kamikaze pilots)
- Suicide
- Death caused by self-directed injurious behavior with evidence, either implicit or explicit, of intent to die as a result of the behavior
- Suicide attempt
- Any non-fatal potentially injurious behavior with intent to end one’s life
- Suicide attack
- A violent terrorist act in which the attacker intends to kill others or cause destruction expecting to die in the process, such as suicide bombers
- Suicide contagion
- Exposure to suicide or suicidal behavior within one’s family, one’s peer group, or through media report which can result in suicide and suicidal behaviors (copycat)
- Suicidal ideation
- Thinking about dying by suicide
- Suicide pact
- An agreement between two or more individuals to die by suicide at the same time and/or place
(USDHHS, 2019a; Singer & Erreger, 2019; MSPP, 2020)
Suicide Myths and Misunderstandings
Myths and misunderstandings abound concerning the subject of suicide. In order for a provider to be effective in intervening with a person who is suicidal, these myths and misunderstandings must be replaced with facts. Following are ten common myths and associated facts:
| Myth | Fact |
|---|---|
| (Naval Health Clinic Annapolis, 2018; The Samaritans, 2019) | |
| People who talk about suicide are seeking attention. Attempted suicides are often not seen as genuine efforts to end one’s life but as a way to manipulate other people into paying attention to them. | People who talk about suicide may be reaching out for help or support. They are looking for an escape and are unable to think of any other way than through death, and they do indeed need attention. |
| Once a person has made a serious suicide attempt, that person is unlikely to make another. | The opposite is often true. A prior suicide attempt is the single most important risk factor for suicide in the general population. |
| People who attempt or die by suicide are selfish. | Suicide is seldom about others. Indeed, it is selfish to make someone else’s suicide about you and demonstrates a lack of empathy and compassion for others. |
| All people who are suicidal have access to help if they want it, but those who die by suicide do not reach out for help. | The truth is, it is necessary to ask whether the individual was able to ask for help. Many seek support and help but do not find it. This is often due to negative stereotyping and the inability and unwillingness of people to talk about suicide. Financial barriers may include the lack of access, especially for those in rural areas who might not be able to easily travel to another community to seek help. Additionally, prejudices and biases among healthcare professionals can make the healthcare system unfriendly. |
| Only people who are crazy or have a mental disorder are suicidal. | Many people living with mental disorders are not affected by suicidal behavior, and not all people who die by suicide have a mental disorder. They may be upset, grief-stricken, depressed, or despairing, but extreme distress and emotional pain are not necessarily signs of mental illness. |
| Reaching out for help is the same as threatening suicide. | People who are suicidal are hurting, not threatening, and should be provided with the tools, support, and resources they need. |
| Suicide always occurs without any warning signs. | There are almost always warning signs, such as saying things like “everyone would be better off if I wasn’t here anymore.” |
| Once people decide to die by suicide, there is nothing you can do to prevent it. | Suicide is preventable. Most people who are suicidal are ambivalent about living or dying. Most do not want death but simply want to stop hurting. The impulse to “end it all,” however overpowering, does not last forever and can be overcome with help. |
| If you ask a person who is suicidal whether they are thinking about suicide or have chosen a method, it can be interpreted as encouragement or give them the idea. | It is important to talk about suicide with a person who is suicidal in order to learn more about the person’s intentions and thinking and to allow for diffusion of the tension that is underlying. Talking openly can give the person other options or time to rethink the decision. |
| When people who are suicidal start to feel better, they are no longer suicidal. | A person who is suicidal sometimes begins to feel better because they have reached the decision to die by suicide and may have feelings of relief that their pain will soon be over. |