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| Six Steps to Stop Suicide: A Crash Course in Emotional Life Saving |
| Feature Articles - Mental Health | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Written by Howard Rosenthal, EdD, CCMHC, MAC | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Thursday, 30 November 2006 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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The news couldn't be worse. This year 30,000 U.S. citizens will kill themselves; 5,000 will be teenagers between the ages of 15 and 24. In the case of men, about three out of every 100 who end their own lives will kill somebody else first - usually a spouse or co-worker. Does the wisdom of mature age not provide a protective barrier? I think not. The rate for folks over 65 is more than double or triple what it is for the general population, depending on the age bracket we are examining. And yes, the population is getting older. Simply stated, suicide is an equal opportunity tragedy that knows no age, race or ethnic boundaries. Consider this: Although homicide is a devastating problem, suicide takes the lives of nearly twice as many people each year. But don't take my word for it; check it out for yourself. Ask most counselors what they fear the most in their job and you will nearly always hear something about a client who has verbalized a wish to kill himself. Suicide prevention does not work in every case (what does?), but it does prove effective in many instances. Six suicide prevention steps Rather than complicate the issue I have outlined six concrete steps that help prevent suicide. I highly recommend that you keep this issue of Counselor Magazine handy and use this article as a reference. Sort of an emotional first aid kit, if you will. As you carry out the six steps it is imperative that you act confident! There's an old joke in the field that your employer provides you with a desk so suicidal clients won't hear your knees chattering! Verbal statements like, "I've helped many persons in your situation," or "I really, truly believe we can turn this around," are desirable. And what pray tell should you do if you really, truly aren't confident? Fake it! Some counselors view this as a criticism of Rogerian person-centered therapy which stipulates that the counselor should always be genuine. Not so. First, suicide prevention is not counseling or psychotherapy, but rather, crisis intervention. Second, in defense of Carl R. Rogers, the word suicidology was not even coined when he set forth his conditions for effective psychotherapeutic intervention. Step One: Ask the client if he or she is thinking about committing suicide. It often occurs to me that I should get a refund from my early psychology courses, since they gave me (along with countless other students) some deadly misinformation. Way back when, young upstarts like me were erroneously instructed not to ask a client if he or she was suicidal because the mere act of asking the question might put the idea in the client's head. Today we know that this is absolute balderdash and that you should ask every client is he or she is suicidal! Most clients will tell you the truth. Incidentally, if the client denies having suicidal feelings and it just doesn't seem sincere, ask one of his or her friends. In a very high percentage of cases the suicidal person has told a friend. Unfortunately, friends are very often sworn to secrecy and hence, do not come forward on their own. If you provide suicide prevention seminars or education, you want to emphasize that secrets kill! Recently, I was working on a case where an eighth grade boy threatened suicide the entire way to school on the bus. From what we were able to ascertain, every kid on the bus was aware of his intent. Care to guess how many children told an adult, a teacher, a guidance counselor, school social worker, or a mental health professional? I think you know the answer. Unfortunately, the story has a tragic ending; the child went home and put a bullet in his head. How many more school tragedies must we endure before this message hits home? I once had a 16-year-old client who lost a limb as a result of a suicide attempt involving an overdose of pills. Before he tried to kill himself, he swore his best friend to secrecy. However, when he regained consciousness in a hospital bed he had tremendous anger toward his friend, and he told him so. "Why didn't you tell someone? I mean, you could have told a teacher, or even my parents?" His friend remarked, "But you swore me to secrecy." "Yes," he replied. "But I didn't really mean it." Step Two: Perform a lethality assessment. Before I cover the most desirable course of action at this juncture let me be extremely specific about what you should never do! A statement such as this is clearly inappropriate: "Why would a nice girl like you with two super parents, a nice house, an awesome car, a cute dog, and a white picket fence want to commit suicide?" Let me be as blunt as possible: If the client wasn't suicidal before, they might have a few thoughts about hurting themselves after hearing a question like that. (Okay, I'm exaggerating a tad, but you get my point.) Your next step should always be to perform what suicidologists have termed a "lethality assessment." Lethality assessment is simply a big fancy term that means the counselor tries to evaluate how likely it really is that the client will attempt suicide. The best way to begin a lethality assessment is merely to ask the client if he or she has a plan. The general rule of thumb is that the more specific the suicide plan, the higher the risk or so-called lethality. Thus, a client who says, "I really don't have a plan yet," is less likely to do herself in than a client who says, "I am going home at noon and I'm using my dad's old army rifle to shoot myself." Another key issue relates to whether or not the client has the means (e.g., the gun, the knife, the pills, etc.) to carry out the plan. If the answer is yes, then the statistical likelihood that the client will get the job done skyrockets. Step Three: Eliminate the means. I am now going to reveal one of the finest techniques to prevent suicide. The problem seems to be that the strategy is so simple that many counselors fail to perform it. Step three suggests that you throw a monkey wrench in the person's plan. That is to say, you will do something to thwart the plan. Get rid of the gun. Eliminate the knife. If Johnny takes a pain killers for his football injuries then his parents should leave him a bottle with four pills; not 400. In many, if not most cases, you won't be able to ameliorate the means on your own since you would be arrested for breaking and entering! Nonetheless, you can and by all means should, call a parent, a brother, a caretaker, or a roommate and have that person abate the means. And why would foiling the plan prove so effective? Wouldn't a client who planned to use a firearm and now did not have access to one just jump off of a building or perhaps run his car off a near cliff? The surprising answer is a resounding no! It could happen and most likely does occur in a very small percentage of suicides. Nevertheless, the good news about suicide prevention is that the majority of suicidal individuals seem hell bent on having a high degree of control over their suicide plans. The quintessential example is provided in the 1986 movie Night, Mother based on Marsha Norman's Pulitzer Prize winning play. In the movie, Sissy Spacek plots her suicide. She debates the issue of using her husband's gun or her dad's gun, and ultimately opts to use her father's. Obviously, from a purely pragmatic standpoint, either weapon could be utilized. Like an individual with an eating disorder who controls caloric intake, the suicidal person who feels helpless to control his or her emotions can at least have power over his or her final decision. Again, a person who plans to pull the trigger could change his plans and pull the car into the garage and turn on the engine, but this type of change in the plan is rare. (Just as an aside, lower auto emissions in newer cars have made suicides via carbon monoxide poisoning much more difficult and time-consuming.) Step Four: Use a contract. Create a written or oral contract stipulating that your client will not make a suicide attempt. In this age of legal-mania where lawyers' ads appear on television, highway billboards, and fill the back cover of the local telephone directory, signing a document can have a tremendous impact. Needless to say, written documents are preferable, but not always possible (e.g., you work on a helpline or perhaps you are not able to see the client in person). A good contract might say something like: "I Jimmy Smith will not commit suicide. If I feel I cannot control my suicidal urges I will call Dr. Freud at xxx-xxxx for assistance. If Dr. Freud is not available, I will call the 24-hour suicide prevention hotline at xxx-xxxx." When I was the coordinator for a suicide prevention hotline I discovered that a high percentage of clients (especially teens) who insisted that they would "never call that stupid hotline" did indeed pick up the phone and call when they were really and truly hurting. Here again, this is excellent news for suicide prevention intervention. It helps to make the contract look as legal/professional as possible by writing or typing it on professional stationery. Have the client sign it, as if it were a legal document. Moreover, the effect of the contract can be enhanced by letting the client see you copy it and put a photocopy in the record. Always tell the client to carry the contract with them at all times. Allow me to get on my psychotherapeutic soapbox for a moment. I am well aware that there are world renowned experts in the field who put little stock in the act of contracting with suicidal individuals. My position is that science or effective treatment can be defined as what works. I can unequivocally tell you that over the years, I have been approached by countless individuals who insist that the only reason they are alive today is because they signed a contract or gave their word, if it was a verbal agreement. "I'm only standing here talking to you because six years ago I promised my chemical dependency counselor I wouldn't kill myself," a 43-year-old truck driver told me. If a client refuses to sign a contract then their will to live is waning, and hospitalization - although it is not a panacea - is highly recommended. Step Five: Refer the person for ongoing counseling. This may seem all too obvious, yet I can assure you it is often ignored. Just this week I spoke to a woman who rushed her 16-year-old daughter to the ER as she was threatening suicide. A psychiatrist spoke with the teen and released her without a referral. Shame on you Dr. Whatever Your Name Is! Perhaps even more amazing, is the fact that the medical building just a softball throw away from the ER is packed wall-to- wall with masters and doctoral level therapists. In the case of a parent who refuses to cooperate and secure help for a child, I would pick up the phone and call the local child abuse and neglect protective hotline. If the danger is imminent then the police should be contacted. Step Six: Refer your client to a psychiatrist or other medical doctor. Many of us who are non-medical helpers (myself included) are often very critical of medical doctors and more specifically, psychiatrists. We often say, "All they do is give medicine. That's the last thing an addictive client needs." Now, although I am hardly the biggest fan of the biomedical model, I must ask you how you would feel if the client's suicidal depression was being caused by fluctuations in blood sugar, thyroid, or worse yet, a brain tumor. Suffice it to say, that when you have a life on the line it is hardly a time for a game of let's play doctor.
Could this be the most important article you will ever read? At least one arrogant author and card carrying counselor says has the guts to say "you bet it is."
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