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Working with suicidal clients (patients)

Dr Kirin Hilliar: Assistant Professor of Psychology

By Dr Kirin Hilliar: Assistant Professor of Psychology

Assistant Professor of Psychology at Heriot-Watt University Dubai Campus, and Psychologist at OpenMinds Psychiatry, Counselling and Neuroscience Centre, Dubai.

COVID-19 has introduced additional stressors and anxieties on all of us. For some individuals, this might be what triggers a suicide attempt. The COVID-19 pandemic is anticipated to have a wide-ranging and long-lasting effect on mental health, including increases in suicides and suicide attempts

Previously, clinicians in the GCC working with a suicidal client have faced a difficult legal conundrum. Attempting suicide is a criminal act in some countries, punishable with fines and/or a custodial sentence. Thus, clinicians working with a client recovering from a suicide attempt had the legal obligation to report the act to the police – thus putting the client under the additional strain of potential arrest and prosecution. Recently, however, Police have been trained on responding to a suicide attempt as a mental health issue, rather than a criminal justice concern.

Research has suggested that most people who commit or attempt suicide had previously verbalized suicidal thoughts to at least one person. Healthcare clinicians have an important role in identifying those clients at-risk of suicide, formulating safety plans, and referring these individuals to specialist services. Too often, however, clients report that clinicians can be unempathetic, perceive disclosures of suicidal ideations as “manipulative” or “attention-seeking”, or just be unwilling or reluctant to ask about suicidal ideation at all.

 Did you know?

Do I hold any misconceptions around suicide?

  1. Statistically, males are less likely to attempt suicide compared to females – but are more likely to succeed in a suicide attempt compared to females. This appears to be related to the methods of suicide that males tend to use (firearms, gassing, hanging) compared to females (cutting wrists, deliberate overdosing on medications).
  2. Of all mental illnesses, depression is most associated with suicide.
  3. Contrary to some common misconceptions, asking someone about any suicidal thoughts or intent does not increase the risk of that person trying to commit suicide (see literature review by Dazzi et al., 2014).
  4. A safety plan is different to a no-suicide contract. A no-suicide contract is a written agreement that a client will not attempt suicide; these have been shown to not have much clinical benefit. A safety plan is a practical, step-by-step guide that the client always has with them, which lists their coping strategies, reasons for living and supports in one place.
  5. There are different types of suicidal thoughts and actions:
    1. Passive suicidal thoughts: the person desires death, but has no specific plan(s) to commit suicide (e.g. “If I didn’t wake up tomorrow, that would be fine”; “I just think things would be easier for everyone if I was no longer around”).
    2. Active suicidal thoughts: the person is thinking about the means and consequences of committing suicide (e.g. “If I were to kill myself, the way I would do it would be…”; “my biggest worry after I’m gone would be the impact on the children…”; researching ways to commit suicide).
    3. Explicit suicide planning: suggest that the individual has started actively planning the commission of a suicide attempt and acquiring the means for suicide (e.g. “I have a loaded gun in my car”; “I’m going to do it next weekend while the family are at a friend’s house”).

However, clients can move across all 3 types and some research suggests that these distinctions may not be that helpful in determining suicide risk. All expressions of suicidal thoughts, intents or plans must be taken seriously and addressed immediately.

What do I know about suicide risk assessments?

Do I know the risk factors to look out for?

There are a number of different risk assessment tools out there, including:

  • AISRAP Protocol Suicide Risk Assessment
  • Beck Scale for Suicide Ideation (BSS)
  • Chronological Assessment of Suicidal Events
  • Tool for Assessment of Suicide Risk (TASR)

Even if you do not use any tools explicitly in your professional practice (although this is recommended… more on this later), you should be familiar with the risk factors that all of these tools tend to highlight. These are:

  • Previous suicidal thoughts, behaviours or attempts
  • Male gender
  • Physical health (e.g. chronic pain or disability) or mental health difficulties, including addiction or substance abuse disorders
  • A sense of hopelessness, and/or a feeling of lack of control over one’s circumstances (consider how much these are increasing for many people in this era of COVID-19.)
  • Unemployment, economic and/or housing insecurity, poverty, financial stress (again, these are rising with COVID-19)
  • Poor coping skills
  • A pattern of reckless or impulsive decision-making and behaviours
  • Poor communication skills
  • Low self-esteem and/or a lack of meaning in their lives
  • Sense of guilt and/or shame over some event, incident or outcome
  • Perceived or real social isolation (again, COVID-19!) and/or social rejection
  • History of being a victim of abuse and/or violence
  • Lack of access to support services (e.g. due to lack of services, inability to pay for them, stigma associated with accessing such services, etc.)

What are the more immediate warning signs?

Ok, that’s great to know the general risk factors, but how do I identify if a particular client is at a more acute risk of attempting suicide?

Common warning signs that suggest a more acute risk of suicide include the following:

  • Withdrawing from others
  • Finalizing affairs (e.g. making a will, unenrolling from studies, quitting a job, purchasing or updating life insurance, funeral planning)
  • Giving away their belongings
  • Talking about suicide
  • Having a preoccupation with death or themes surrounding death
  • Getting the means to take their own life, such as buying a gun or a rope, or stockpiling drugs
  • Sudden personality or mood changes
  • Acute substance intoxication (this can increase impulsive behaviours)

 I believe I have a client who is at-risk of attempting suicide. What do I do now?

And what are my legal and ethical responsibilities that I need to consider?

The approach you will take will differ with each individual. Broadly, however, there are 5 guiding principles:

  1. Ask questions in a curious, supportive way: encourage them to be open with you regarding everything that’s been going on for them, the types of thoughts they are having, and any planning they have done.
  2. Formulate a safety plan. The complexity and exact components of this will differ for each client. A useful template can be found here, and a quick guide for clinicians can be found here. A safety plan supports and guides someone when they are experiencing high distress and having suicidal thoughts. The primary goals of the safety plan is to have the client identify:
    1. their personal warning signs,
    1. their coping strategies: what has worked in the past, and/or what they might like to try in the future,
    2. people and places who are sources of support in their lives
    3. how means of suicide can be removed from their environment, and
    4. their personal reasons for living, and/or what has helped them stay alive.
  1. This safety plan will often include telling others about the client’s difficulties so they can be actively involved in the client’s care plan (e.g. watching out for warning signs, reminding them of their coping strategies, removing means of suicide from the family home). Ideally, your client will agree with and consent to you sharing this information – and thus, breaking confidentiality is not needed. However, you have the legal right and obligation to break confidentiality if you think your client is at-risk of serious physical or psychological harm. This responsibility is even more explicit when it comes to the safety of a child (anyone below age of 18): according to Article 42 of Wadeema’s Law (2016), all “educators, physicians, social specialists or others entrusted with the protection, care or education of the child” shall be obligated to notify relevant child protection services (e.g. Police, Community Development Authority, Federal Ministry of Interior or Ministry of Education) “in case of anything that threatens the child’s physical, psychological, moral or mental integrity or health”.
  2. Breaking confidentiality should be done in consideration of what is going to help keep this person safe. Consider personal, cultural, social and religious sensitivities when determining:
    1. Who will be told;
    2. What they will be told;
    3. When they will be told; and
    4. How (including where) they will be told.
  3. Document your discussions and decisions. Keep copies of completed suicide risk assessments, signed consent forms and safety plans. As well as enhancing your own legal protections, studies have shown that written plans and agreements (compared to verbal agreements only) reduce the likelihood of a completed suicide attempt.

It is important for clinicians to reflect on their own reactions if a client were to reveal thoughts about suicide (given our values, culture, religion, possible past experiences, and more), as well as their confidence and competence in handling a crisis situation. Being able to listen in an open, professional, curious, and non-judgmental way, will allow a client to feel safe sharing information with you, and thus enable you to work with the client to formulate a safety plan and longer-term action plan to enhance their wellbeing.

CONTACT DR KIRIN [email protected] 

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