Suicide Resource Page
Suicide first requires conceptualization in order to appreciate the best approaches to helping suicidal people. While it is a serious issue and one that is rightfully considered the number one cause of death in the mental health field, the best approaches to helping those at-risk for suicide are grounded in psychological care rather than medical care. To emphasize this, when a person struggling with suicidal thoughts and behaviors is met with empathy, honesty, and collaborative care all from a suicide-focused approach, the person will likely recover from their suicidal misery. However, if this same person is relegated to a traditional medical approach where people search for a mental illness that is causing the suicidal thoughts and behaviors, hospitalization is strongly encouraged, threatened or forced, medications are prescribed, and contracts are signed where the person promises to not kill him/herself this person typically gets worse. It follows that a number of myths have persisted due to this traditional medical approach.
Myths
1. Hospitalization or an equivalent in-patient setting is the best setting for a suicidal person.
Polling data indicates that
hospitalization and other in-patient settings appear to increase suicidal
misery and actual suicide. It is well
documented that people who have been released from an in-patient setting are at
far greater risk for suicide than before they went in. People who have been hospitalized state that
the reason for this is that the experience of hospitalization and other
in-patient settings is often punitive and shaming, not therapeutic, and
humiliating. It is also important to
mention that this level of care is the most restrictive and most expensive*,
begging the question of when this measure would be appropriate. The answer is in the event of an actual
suicide attempt (something objectively lethal has been done) or when a person
is about to attempt suicide (they have disclosed a plan, expressed intent and
they have the means readily available).
*It is cheaper than private care in a socialized healthcare system, but this further encourages ineffective practices.
2. Medications are helpful to reduce suicidal thoughts and behaviors.
There is no substantive evidence indicating that any medication works consistently to treat suicidal misery. While some studies show promising results with certain medications, an equal and opposing set of studies show no benefits or even worsening of symptoms. This is difficult to understand given that even the United States Food and Drug Administration (FDA) and other reputable organizations list medications as beneficial for treating suicide risk. What this demonstrates is the lack of knowledge of even reputable organizations and the need for further investigation into the potential benefits of certain pharmacological treatments. Ketamine is an example of a drug where excitement has grown, but long-term alleviation of suicidality is lacking. Short-term alleviation has been found, but this means that there is still a critical need for treatment that works in the long-term and that is not found with medications. Relapsing back to a suicidal state after a week or a few months following a medication treatment is not successful treatment.
3. Talking about suicide or asking about it will cause suicidal thoughts and behaviors or encourage them.
The opposite is the case in that people find frank and direct questioning to be helpful because it relieves distress and even de-stigmatizes when promoted on an organizational level. This can be difficult to process as our fears can become the priority over and above facts. The result is that we can easily slip into a space where we continue to believe that we need to still exercise caution or at least implement very careful, delicate questioning which simply hampers our ability to be direct and frank.
4. Depression is the reason someone becomes suicidal.
Depression is certainly something that puts a person at risk for suicidality, but it is not the cause. The cause of suicidality is something that needs to be identified by speaking to the person who is suffering. It requires direct questioning about the factors that contribute to this person's suicide risk. Thinking that depression is the cause avoids the core issues that are inherently unique to the individual who is in distress. Based on research, more than 90% of people who are struggling with depression are not suicidal. If depression was the cause, all people who are depressed would be suicidal. It follows that treating a suicidal person for depression does not necessarily alleviate suicidality as depression treatment misses the target. This is the most critical piece as a healthcare provider may be well intended by offering antidepressants or depression focused therapy and yet this is not aligned with best practices for reducing suicide risk.
5. A person who states that they are suicidal is just attention seeking.
Someone who shares that they are thinking about killing themselves is seeking help. They are expressing the severity of their suffering. They are not looking for attention. What they need is someone who will listen to them carefully to understand their suffering. This is where a suicide-focused healthcare provider is perhaps required, but certainly a friend or family member who can listen carefully.
Stepped-Care Model
The reason this last point is emphasized is based on a model of care referred to as the “stepped-care model”. What is required for anyone who is in a state of distress is essentially a triage focus. We first need to look at the situation and listen carefully. Obviously, this requires education such as what to look for and how to listen. Sending the person to the hospital is the last resort as the model indicates. There are many steps that need to be considered prior to hospitalization.
For more on what you can do to help someone who is suicidal, see the presentation here.
What if you are not able to help your loved one or your loved one needs a higher level of care as represented by the stepped-care model?
For this, it is important to understand the various treatment options that are considered effective for helping people who are suicidal. To be clear, there are 3 options that have substantial research support. This means that they have passed the test of the “Gold-Standard” in research validation which requires randomized-controlled trials (RCTs).
The first option is called Dialectical Behavior Therapy (DBT). This is a treatment that was designed to help people who are suffering from Borderline Personality Disorder (BPD). For people who struggle with BPD, suicidality and self-harm is often an issue. DBT has been found to work well for preventing both suicidal and self-harm behaviors. As a treatment, DBT is based on a theory that people need a balance between acceptance of their emotional state and encouragement to change. Acceptance is critical for when a person feels misunderstood. This is when the listening previously noted is critical. When the person feels motivated is when encouragement to change is required. This is a critical balance because if the focus is placed only on so-called “DBT skills” this can no longer be called DBT.
The second option is Cognitive-Therapy for Suicide Prevention (CT-SP). This treatment was designed to specifically treat suicidal people by identifying the thoughts, behaviors, and interpersonal problems that put the person at-risk for suicide. These three components make up what is called the suicidal mode and treatment focuses on developing effective coping skills that essentially disarms this suicidal mode. The disarming happens by identifying weaknesses in coping, strengthening these weak areas, and relapse prevention with the use of guided imagery and designing a hope kit to function as a reminder for avoiding suicidal behavior.
The third option is the Collaborative Assessment and Management of Suicidality (CAMS). What distinguishes CAMS apart from being suicide-focused is 1) its “non-denominational” nature and 2) the reduction of suicidal ideation that it accomplishes. Being non-denominational means there is no required theoretical orientation, so the mental health provider is able to use their best tools to help the suicidal person rather than feeling obligated to use a new or unfamiliar technique. While DBT and CT-SP reduce suicidal behaviors, CAMS targets suicidal ideation as the logical precursor to suicidal behavior. To be clear, CAMS emphasizes the assessment, management and continuous monitoring of the person's suicidal state. This is done by use of the Suicide Status Form (SSF) which is filled out with the guidance of the suicidal person in a collaborative side-by-side fashion. Rather than the mental health provider acting as the expert, this position is relegated authentically to the person who is suffering. Together, the person and provider seek to map out the person's suicidal mind to understand how to effectively manage suicidal thoughts.
Additional Points of Consideration
As a footnote, there are two more considerations when thinking about how to help someone who is suicidal. The first is most critical as it has to do with basic safety. Creating safety is critical for keeping a suicidal person alive and this requires a safety plan. This is distinct from a “no-suicide contract” where a person signs a document agreeing to not kill him/herself. A suicide safety plan is designed together with a support person to 1) identify and reduce access to lethal means, 2) develop ways to cope differently with a suicidal state, 3) identify people who can be called in case of a suicide crisis, 4) and people who can be contacted to reduce isolation and loneliness. If the suicidal person is willing, referral to a suicide-focused treatment provider would be valuable, but not everyone will agree to this. This is where the second point of consideration comes in. One of the most historic studies on suicide prevention was done by Jerome Motto in the 1970s where he found that simply maintaining contact with a suicidal person was lifesaving. This was as simple as sending the suicidal person a message every month to just let him/her know that you are 1) thinking about them, 2) hope they are well, 3) and invite them to be in touch if they like. His work was called “caring-contacts” and it revealed the power of even minimal connection with people who are suffering.
To view a video recording on Transformative Strategies for Supporting Loved Ones Through the Darkness of Suicidality click here.
The above information was provided by Dr. Asher Siegelman.
