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Tips for Preventing Suicide

Take action based on the level of risk
Preventing Suicide
Image: IVP

Preventing Suicide

Unfortunately, there is no miraculous human intervention that resolves suicide risk. But there are specific actions you can take to prevent suicide, actions that become more extensive with increasing risk. Following are several ideas for pastoral care, which is different from mental health counseling, an important distinction that argues for referral to mental health services. Whenever there is suicidal risk, it’s best to consult with and refer to a mental health professional.

As you intervene, focus on first aid, not surgery. If you’re at a park and have a heart attack, you don’t want the people around you to perform heart surgery. You want them to perform CPR. Your job with suicidal people is to focus on safety, not on solving the problem that is causing the suicidal crisis. For example, if someone is in a suicidal crisis because she is processing childhood sexual abuse, your job is to keep her safe, not to heal the memories of abuse.

No risk. A person without any risk is a person who has no suicidal thinking and never has had suicidal thinking. The main intervention is to continue to provide this person with all the usual pastoral care.

Low risk. A person with low suicide risk is

• A person with persistent passive wishes to be dead but no intent and no history of suicidal thinking or behaviors.

• A person who experiences brief suicidal thoughts but has no intent or plan and no history of suicidal thinking or behaviors.

Some suggestions for low-risk individuals are consultation, referral to a mental health professional and creation of a safety plan.

Consultation. It is always best to consult with a mental health professional, hospital emergency department or crisis hot line to see if you missed something important, to get help with assessing risk and intervening, and to get support for yourself. No matter how much experience you have, it’s best to consult with professionals who have experience working with suicidal people.

Referral for mental health treatment. Suicidal thinking often occurs in the context of a mental health problem, which requires professional treatment and therefore a referral to a mental health professional. Making referrals sounds straightforward but can be challenging. A pastor my team interviewed told us that lack of known mental health resources was just about the scariest thing he faced. Pastors say they prefer to have a referral list before a crisis, which they develop by talking to trusted people in their community. The second challenge with referral relates to the therapist-client relationship, which is one of the keys to a positive outcome in therapy. If the therapist-client connection isn’t positive and trusting, the person may need help finding another therapist with whom she can connect.

Once you refer, check to see if the person followed up on the referral. And then stay involved. See yourself as part of a multidisciplinary team; you are providing an important part of the treatment. Stauffacher writes:

We clergy need to see our role as being part of a larger treatment team that is concerned with the care of a person in Body, Mind and Spirit. As a vital part of that team, it is appropriate to see what we do as different from the work of physicians, therapists, and social workers. We represent the sacred within the secular and bring with us both Testament and Sacrament with Covenant.

Being part of the team means you may want to speak with the mental health professional yourself. You are allowed to talk to the therapist, but the therapist is not able to talk to you about the client because of confidentiality laws. The exception is if the client authorizes the therapist to talk to you about her treatment. Any decision to share confidential information will be carefully discussed between that person and the therapist. Confidentiality is one of the most important aspects of therapy, but collaboration is also important. If it makes therapeutic sense, the person will sign an authorization, either limited or unlimited. For example, she can limit the sharing to emergency situations or to the fact that she is attending therapy sessions or to spiritual aspects of the treatment. Therapists can also share information with a parent or guardian who makes medical decisions for a minor (under 18 years old), and therapists are usually allowed under state law to break confidentiality when a person is at high risk for suicide.

Safety plan. A safety plan, or crisis response plan, is a short, easy-to-read plan for the person to implement during a suicide crisis, complete with a list of calming activities and contacts. It is like a life jacket. Its purpose is to keep a person afloat and alive in the midst of a flood of suicidal thinking. Suicidality fluctuates; low risk can turn into medium or high risk quickly. The person may have no suicidal thinking when she leaves your office but, two hours later, after a call from her ex-husband, she may become suicidal. A safety plan gives her something else to do besides contemplate suicide and tells her what to do when she feels suicidal. Basic content includes:

1. How to cope with distress

• Increase social support (list nontoxic helpers and contact information)

• Manage distress (praying, walking, playing with the dog, listening to music)

2. Emergency numbers (1-800-273-TALK)

The goal of a safety plan is to interrupt the chain of events leading to suicide. One of the messages of a safety plan is that the person can be successful in battling the thoughts of suicide. Blauner writes, “I’ve experienced the ‘I want to die’ moment thousands of times over the last

eighteen years, which means suicidal thoughts have passed just as many times.”

It’s important to develop this plan while not in crisis and to put it someplace where it is very accessible. Jane, who had multiple personalities, had an alter ego who would hide the safety plan. So she left a second safety plan in a sealed envelope with her neighbor.

Here’s an example safety plan:

When my ex-husband calls and I feel hopeless:

• Call my mom or my friend.

• Pray.

• Go to the gym.

• Get out my hope kit.

• Call my pastor.

• Call my therapist.

• Call 1-800-273-TALK.

Notice that this example includes a hope kit, which will remind the person of reasons to live. It can be a memo in her cell phone or a shoebox with keepsakes that will cue her to think of her reasons to live. Suicidal people can develop a very personal hope kit by putting in items that remind them of

• A time when someone helped them in the past

• Something they like to do that gives them hope

• A quote that helped in the past to prevent a suicide attempt

• A time when they felt proud of themselves

• A photograph of something or someone that represents hope

This example safety plan also includes the number for the National Suicide Prevention Lifeline (1-800-273-TALK). A crisis line is important because you or others may not be available when the person needs help. Talking to someone may interrupt the spiral to suicide. The National Suicide Prevention Lifeline is a 24-7 line that’s staffed by more than 120 crisis centers throughout the United States. When you call the number, your call is automatically forwarded to the crisis center closest to you and therefore the one that knows your local resources. Take time now to visit the website at suicidepreventionlifeline.org. Notice the many resources for veterans, the hearing and speech impaired, and Spanish speakers. In addition to the lifeline, a safety plan could include the phone number of a local suicide prevention center such as the Samaritans (samaritanshope.org), started by an Anglican priest. Or it could include the phone number for emergency services or mobile crisis teams in the community. Current research supports the effectiveness of these crisis lines. Keep in mind that these lines will accept calls from suicidal people and also from caregivers such as you.

Notice that a safety plan is not a safety contract, which is a binding promise that the person makes not to kill herself. Such a contract, written or verbal, answers the question, “Do you promise to not kill yourself between now and the next time we see each other?” Unfortunately there is no evidence that these are effective. For example, the Minnesota Office of the Ombudsman investigated cases of suicides that had occurred in inpatient acute care facilities and found that a no-harm contract was in place in almost every case. In one study, patients with no-suicide contracts had a significantly higher likelihood of self-harm behavior. Some suicidal people find these contracts unhelpful. A contract doesn’t encourage the person to speak freely about her suicidal thoughts and doesn’t tell her what to do, just what not to do. In my experience, suicidal people hesitate to make a promise they aren’t sure they can keep. But refusal to sign one is not necessarily evidence of high risk.

Medium risk. A person with medium risk of suicide is someone who

• Has no suicidal thinking but has a past history of suicidal behavior

• Has occasional to daily suicidal thinking without intent, with or without prior history of suicidal thinking or behaviors

• Has occasional to daily suicidal thinking with intent but no plan and no imminence

Remember that for each additional point along the suicide continuum, you want to be more extensive in your intervention. For medium risk, do what you do for low risk (consult, refer for mental health treatment and develop a safety plan), and add additional interventions, such as more frequent visits to allow for more frequent monitoring. Keep in mind that suicide risk fluctuates. A person may be at medium risk now but at high risk in an hour. Clergy are in a position to be aware of fluctuation more than some other professionals. Stauffacher and Clark write, “Visiting parishioners is a pastoral tool and skill. Use it.” A clergy person’s relationships with people are closer than those of some other professionals. Few professionals meet with their clients in their homes or over a potluck supper and discuss spiritual truths. Keep in mind that pastoral visits do not need to be undertaken by clergy alone. Lay people in the church can also be involved.

If a suicidal person with medium risk moves to the right on the suicide continuum, she or he may begin to formulate a suicide plan. If this occurs, be sure to refer the person for an immediate evaluation at a mental health outpatient clinic or hospital emergency department. After this evaluation, you may be called on to help with means restriction. Means restriction involves reducing the availability or taking away the method or means that a person is contemplating

using to kill herself. It is best that the suicidal person avoid exposure to the method. For example, take some time to brainstorm how you could help restrict access to these means:

• Aspirin

• Antidepressant medication

• Razor blade

• Gun

• Belt

• Balcony

• Bridge

Here are a few ideas: One of my clients put a big bookcase in front of her balcony door so that she had time to use her safety plan while taking the books out before being able to move the big bookcase. We also worked on her moving to a lower floor. Prescribers of medication can provide weekly or even daily prescriptions or not prescribe certain medicines that are more lethal. (Any unused medication should be flushed down the toilet so that it can’t be retrieved from the garbage.) Police can keep a gun for safekeeping, or it can be given to someone else.

One of the concerns you may have about means restriction is that you think the suicidal person will just substitute another method for the one he is currently contemplating. Interestingly, people don’t usually do this because of their ambivalence. Not having the means available provides an ambivalent person with enough time to reconsider the decision to die. The best example comes from the United Kingdom, where toxic coal gas was replaced by natural gas in the late 1950s. Not only was there a steady decrease in coal gas suicides, the overall suicide rate decreased by a third. In one study of 515 people who were restrained from jumping from the Golden Gate Bridge, only 4.9 percent, or twenty-five of them, eventually died by suicide. Seven eventually jumped from the Golden Gate and one from the Bay Bridge. Ninety percent did not die of suicide or other violent means. In another US study, each 10-percent decline in household firearm ownership over a twenty-two-year period was associated with significant declines in rates of firearm suicide and overall suicide.

It’s important to note that means restriction, while effective, isn’t fail-safe. The decision to die remains with the suicidal person. However, even though you can’t restrict every means on earth and a person might still substitute an alternate means, it’s justifiable to restrict the means.

High risk. A person with a high risk of suicide is someone who

• Has occasional to daily suicidal thinking with intent and plan and may or may not have the means readily available

• Hears voices that tell him to kill himself

• Has imminent intent and the means to follow through on a specific suicide plan

Jill, who thinks once or twice a week about jumping from her balcony, is at high risk. She is at almost the highest risk point on the suicide continuum and could resolve her ambivalence and choose death at any time. David, who calls you with a gun sitting next to him, is at the highest risk point—imminently at risk. Suicide is impending.

For Jill, your focus is facilitating an immediate evaluation with a mental health professional in an outpatient office or in the emergency department. If you’re not sure which to do, consult with a crisis line. Transportation-wise, consider whether a trusted friend can drive Jill to the emergency department or whether an ambulance or the police will need to drive her to the hospital. Don’t leave her alone.

For David, your focus is keeping him alive. Keep him on the phone. On another phone line, call 911, explain the situation and ask the police to go to his house while you continue to talk to David. You can tell him what you’re doing and that you’re concerned for his life.

The reason to keep David on the phone talking with you and never leaving Jill alone is that while suicide plans are typically developed over time, suicide decisions can be made impulsively. In one seventeen-country study, most suicidal people (60 percent) took one year to transition from thinking about suicide to making a plan and attempting suicide. But the ultimate timing and final decision to act are often determined in moments.

The emergency department. Unfortunately, when Jill arrives at the emergency department, the wait time might be long because emergency departments tend to be overcrowded. When she is seen, the visit will involve a medical evaluation, then usually a suicide risk evaluation and then a disposition or decision about whether Jill is able to be safe in the community or needs hospitalization. Typically, one of three criteria needs to be met before Jill is hospitalized: (1) she’s at high risk of harming herself, (2) she’s at high risk of harming others, or (3) she can’t take care of herself because of a mental health problem. At least one criterion needs to be met or it’s unlikely that Jill will be hospitalized. In fact, during the wait, Jill’s will to live may emerge and she might not be at high risk when evaluated.

If David remains at high risk, hospitalization is often viewed as the safest approach because it decreases availability to means, increases monitoring and may allow David to start a medication. Hospitalization can help, but it is not foolproof in preventing suicide. About 3 to 10 percent of suicide deaths in the United States occur during hospitalization.

Hospitalization. You may have some concerns about hospitalization, though my perspective is that none of these should keep a person from being hospitalized. A first concern might be that if the emergency department isn’t connected to a hospital, it can take several hours to be transferred to a hospital—the average wait is seven hours. Another concern might be that David shouldn’t be exposed to other “mental patients.” Keep in mind that mental health problems are not contagious.

A third concern might be that people don’t heal in the hospital, and that is somewhat true. As the American Psychiatric Association notes, “Hospitalization, by itself, is not a treatment.” Think about hospitalization as a time of stabilization, not healing. A fourth concern is how to care for a person’s children or pets, or Jill’s car in the parking lot. Make sure you talk through these concerns with the suicidal person. As far as telling children about a parent’s hospitalization, Greene-McCreight provides this advice:

Children need communication at times even as horrible as these, but it must be judicious communication. Do not mention suicidal thoughts or gestures. Just something simple. “Mommy is sick. She is very sad. She needs to go to the hospital. She will get better and be home soon. The doctors will take good care of her.” . . . Don’t bring in half-truths for the sake of protecting the children. Speak matter-of-factly, quietly, calmly. Stress that the hospital is a good place for those who are sick.

One last concern I hear often is that people don’t want to be “locked up forever.” Every state has different mental health laws, so learn your state’s laws. Someone like David will be offered the least restrictive option possible (which may be voluntary unlocked hospitalization, where David can leave if he chooses, depending on where he is on the suicide continuum). The most restrictive option is involuntary locked hospitalization, where his civil right to leave is taken away for about seventy-two hours (depending on state law) because suicide crises are believed to abate within several days. In some circumstances, David might be kept involuntarily longer than seventy-two hours following reevaluation. State laws protect David’s civil rights by requiring reevaluations.

Taken from Preventing Suicide by Karen Mason. Copyright (c) 2014 by Karen Mason. Used by permission of InterVarsity Press, P.O. Box 1400, Downers Grove, IL 60515-1426. www.ivpress.com


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