Healthcare professionals can play a pivotal role in identifying patients who might be at risk for suicide, as well as in providing these patients with the resources they need to cope.
“The signs — I can’t believe I didn’t see them.”
“I just wish there’s something I could have done.”
“They needed me and I should have been there for them.”
Friends, loved ones, colleagues and even acquaintances commonly share such regrets when they’ve just lost someone to suicide.
Unfortunately, these sentiments are heard all too often.
A quiet epidemic
One person dies by suicide every 40 seconds, according to the World Health Organization (WHO). In 2021, the American Foundation for Suicide Prevention cited suicide as the 12th leading cause of death in the United States.
WHO also estimates that “for each adult who died by suicide, there may have been more than 20 others attempting suicide.” Unsurprisingly, the COVID-19 pandemic has not helped lessen these numbers.
Healthcare professionals, however, can play a vital role in identifying patients who might at risk for suicide, cultivating relationships with these patients and providing them with the necessary support and resources.
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Identifying those at risk
The state of being suicidal can be thought of as an assembly line, says Pamela Garber, LMHC, a New York-based psychotherapist and owner of Grand Central Counseling Group.
“The earlier levels on the assembly line can have different signs than the later stages.”
Healthcare professionals who have an ongoing professional relationship with a patient have the best chance at recognizing when and if that patient is at risk, she says, noting that signs typically stem from differences in a person’s typical conduct.
“Under all circumstances, the first line of defense is establishing enough rapport to engage the patient in talking. If the patient seems to be at high risk … and the goal is taking the legal steps available for prevention, there can still be an opportunity for communication with the healthcare professional if the relationship has longevity or connection.”
Still, identifying real risk is often out of the realm of dedicated professionals and loved ones, says Garber. This is true even when an individual displays some of the textbook signs—changes in mood, giving away belongings, displaying frivolousness with money, suddenly feeling at peace after crisis, or verbalizing hopelessness or the recent loss of a loved one, for example.
Of course, signs of suicidal ideation can be difficult for even seasoned professionals to detect.
“This is because thoughtfully planned suicide takes time and effort,” says Patti Ashley, PhD, LPC, a Boulder, Colo.-based psychotherapist, author and speaker. “Someone who has a serious intention to commit suicide might not mention it all, because they don’t want to be stopped.”
As such, clinicians must pay close attention to less obvious cues, family history, support systems and other factors, says Ashley.
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Signs and factors
For example, increased use of alcohol or drugs, anxious feelings, sleeping too little or too much might be subtle signs that a patient is feeling suicidal.
“If a client reports one or more of these over a period of time, clinicians can assess risk by asking if they have ever thought of suicide. And if so, do they have a plan to carry it out? If they have a thought-out plan, then this would be considered a high-risk patient, and safety precautions should be put in place.”
Family history is a factor to consider as well, says Ashley, noting that individuals with one or more family members who have committed suicide pose a higher risk.
“It’s also important to note that any other family history, such as alcoholism or substance use, schizophrenia or other psychotic disorders might lead to a greater risk of suicide,” she says, adding that children who have experienced bullying or harassment are also at higher risk.
Providing a safe space
Of course, current pandemic conditions have added a degree of difficulty in administering care for all types of patients.
The nature of this crisis means more healthcare systems are relying on telehealth services to connect with patients. The effectiveness of remote therapy for patients at risk of suicide, however, all depends on the patient and therapist, and can also vary based on the circumstances at hand, such as immediate crisis or physiological changes, says Garber.
Remote therapy, she says, eliminates the need to deal with the logistics associated with office visits—traffic, waiting room back-ups, for example—and the immediacy it affords makes telehealth potentially ideal for patients at risk for suicide.
“But in some cases, being remote may interfere with getting an accurate [risk] assessment,” says Garber.
“Some people might actually open up and reveal more candid details about their level of risk in a remote setting where they are on their own turf. Others may mask more.”
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“Delicate, risky, and subjective”
Whether done in-person or via remote therapy, effective risk assessments ultimately hinge on knowing the patient, says Garber.
“And, even then, this task is delicate, risky and subjective, no matter how educated or experienced the professional. People only show you what they want you to see, and reading them is never 100 percent objective.”
In an effort to help patients feel comfortable opening up, “it’s crucial to give patients permission to feel whatever feelings they might be feeling,” adds Ashley.
“Trying to talk someone out of feelings can actually make them worse. All feelings are OK, but all behavior isn’t. When a client has a safe space to express all feelings without shame or judgment, it can be a tremendous protective factor in preventing suicide.”
Empathy is key
This type of empathy is key to effective treatment, Ashley continues, noting that clients who feel a sustained connection with an empathetic listener also feel a sense of “unconditional positive regard, which helps to build self-compassion and resilience.”
“Paying attention to feelings and finding healthy outlets to express them takes compassion, connection, curiosity and courage. Clinicians provide a safe space to guide clients through feelings in the hopes of getting them to a better emotional state.”
At least one mental health professional should also be part of the care team in clinical settings, says KaRae’ Powers-Carey, PhD, a core faculty member in Walden University’s MS in Clinical Mental Health Counseling program.
Screenings and assessments
“The licensed mental health professional can provide screenings, administer appropriate assessments, mitigate suicide risks and meet any other healthcare needs,” says Powers-Carey. “A visit with a mental health professional at routine medical appointments should be a standard practice at every outpatient visit and before discharge from an inpatient hospital stay.”
Indeed, screening for suicide risk is an essential part of any healthcare visit, adds Jasleen Chhatwal, MD, chief medical officer at Tucson, Ariz.-based residential treatment center Sierra Tucson.
“This can be done with two-to-six question screening tools that ask about any recent or current thoughts of death, dying or suicide. [And] screening for risk factors such as asking about early life trauma in the form of an Adverse Childhood Experience scale helps to add context,” says Chhatwal, adding that healthcare providers throughout the enterprise should receive appropriate training on suicide risk, for patients’ benefit as well as their own.
“Providing education about suicide and its risk factors to healthcare providers at every level of the organization, and providing training on ways to reduce stigma, can go a long way in creating a safe space for our patients (as well as staff) to be able to reach out for support.”
- World Health Organization, 2016. Accessed July 26, 2020. [https://www.who.int/mental_health/prevention/suicide/suicideprevent/en/]
- Centers for Disease Control and Prevention, 2018. Accessed July 27, 2020. [https://www.cdc.gov/injury/wisqars/fatal.html]
- U.S. News & World Report, 2020. Accessed July 27, 2020. [https://www.usnews.com/news/healthiest-communities/articles/2020-05-22/experts-warn-of-a-surge-of-suicides-tied-to-the-coronavirus-pandemic]