By Dr. Shahul Ameen, M.D.
(Article continued from Part I)
What can be done to help someone who may be suicidal?:
1. Take it seriously.
Myth: “The people who talk about it don’t do it.” Studies have found that more than 75% of all completed suicides did things in the few weeks or months prior to their deaths to indicate to others that they were in deep despair. Anyone expressing suicidal feelings needs immediate attention.
Myth: “Anyone who tries to kill himself has got to be crazy.” Perhaps 10% of all suicidal people are psychotic or have delusional beliefs about reality. Most suicidal people suffer from the recognized mental illness of depression; but many depressed people adequately manage their daily affairs. The absence of “craziness” does not mean the absence of suicide risk.
“Those problems weren’t enough to commit suicide over,” is often said by people who knew a completed suicide. You cannot assume that because you feel something is not worth being suicidal about, that the person you are with feels the same way. It is not how bad the problem is, but how badly it’s hurting the person who has it.
2. Remember: suicidal behavior is a cry for help.
Myth: “If someone is going to kill himself, nothing can stop him.” The fact that a person is still alive is sufficient proof that part of him wants to remain alive. The suicidal person is ambivalent – part of him wants to live and part of him wants not so much death as he wants the pain to end. It is the part that wants to live that tells another “I feel suicidal.” If a suicidal person turns to you it is likely that he believes that you are more caring, more informed about coping with misfortune, and more willing to protect his confidentiality. No matter how negative the manner and content of his talk, he is doing a positive thing and has a positive view of you.
3. Be willing to give and get help sooner rather than later.
Suicide prevention is not a last minute activity. Unfortunately, suicidal people are afraid that trying to get help may bring them more pain: being told they are stupid, foolish, sinful, or manipulative; rejection; punishment; suspension from school; written records of their condition; or involuntary commitment. You need to do everything you can to reduce pain, rather than increase or prolong it. Constructively involving yourself on the side of life as early as possible will reduce the risk of suicide.
Give the person every opportunity to unburden his troubles and ventilate his feelings. You don’t need to say much and there are no magic words. If you are concerned, your voice and manner will show it. Give him relief from being alone with his pain; let him know you are glad he turned to you. At times everyone feels sad, hurt, or hopeless. You know what that’s like; share your feelings. Let the child know he or she is not alone. Avoid arguments and advice giving. If the child’s words or actions scare you, tell him or her. If you’re worried or don’t know what to do, say so.
5. ASK: “Are you having thoughts of suicide?”
Myth: “Talking about it may give someone the idea.” People already have the idea; suicide is constantly in the media. If you ask a despairing person this question you are doing a good thing for them: you are showing him that you care about him, that you take him seriously, and that you are willing to let him share his pain with you. You are giving him further opportunity to discharge pent up and painful feelings. If the person is having thoughts of suicide, find out how far along his ideation has progressed.
6. If the person is acutely suicidal, do not leave him alone.
If the means are present, try to get rid of them. Detoxify the school or home.
7. Urge professional help.
Persistence and patience may be needed to seek, engage and continue with as many options as possible. In any referral situation, let the person know you care and want to maintain contact.
8. No secrets.
It is the part of the person that is afraid of more pain that says “Don’t tell anyone.” It is the part that wants to stay alive that tells you about it. Respond to that part of the person and persistently seek out a mature and compassionate person with whom you can review the situation. Distributing the anxieties and responsibilities of suicide prevention makes it easier and much more effective.
Interventions with a suicidal student:
Schools should have a written protocol for dealing with a student who shows signs of suicidal or other dangerous behavior. The following steps may be effective in dealing with a student who expresses active suicidal intent.
1. Calm the immediate crisis situation. Do not leave the suicidal student alone even for a minute. Ask whether he or she is in possession of any potentially dangerous objects or medications. If the student has dangerous items on his person, be calm and try to verbally persuade the student to give them to you. Do not engage in a physical struggle to get the items. Call administration or the designated crisis team. Escort the student away from other students to a safe place where the crisis team members can talk to him. Be sure that there is access to a telephone.
2. The crisis individuals then interview the student and determine the potential risk for suicide. a. If the student is holding on to dangerous items, it is the highest risk situation. Staff should call an ambulance, the police and the student’s parents. Staff should try to calm the student and ask for the dangerous items. b. If the student has no dangerous objects, but appears to be an immediate suicide risk, it would be considered a high-risk situation. If the student is upset because of physical or sexual abuse, staff should notify the appropriate school personnel and contact the police. If there is no evidence of abuse or neglect, staff should contact parents and ask them to come in to pick up their child. Staff should inform them fully about the situation and strongly encourage them to take their child to a mental health professional for an evaluation. The team should give the parents a list of telephone numbers of crisis clinics. If the school is unable to contact parents, and if the police cannot intervene, designated staff should take the student to a nearby emergency room. c. If the student has had suicidal thoughts but does not seem likely to hurt himself in the near future, the risk is more moderate. If abuse or neglect is involved, staff should proceed as in the high-risk process. If there is no evidence of abuse, the parents should still be called to come in. They should be encouraged to take their child for an immediate evaluation. d. Follow-Up: It is important to document all actions taken. The crisis team may meet after the incident to go over the situation. Friends of the student should be given some limited information about what has transpired. Designated staff should follow up with the student and parents to determine whether the student is receiving appropriate mental health services. Follow-up is crucial, because most suicides occur within three months of the beginning of improvement in depressive symptoms, when the youth has the energy to carry out plans conceived earlier. Regularly scheduled supportive counseling should be provided to teach the youth coping mechanisms for managing stress accompanying a life crisis, as well as day-to-day stress.
In a counseling situation, a contract can be an effective prevention technique. The suicidal adolescent can be made to sign a card which states that he or she agrees not to take the final step of suicide while interacting with the counselor.
Role of the teachers:
Teachers play an especially important part in prevention, because they spend so much time with their students. Along with holding parent-teacher meetings to discuss teenage suicide prevention, teachers can form referral networks with mental health professionals. They can increase student awareness by introducing the topic in health classes.
Some schools have automatic expulsion policies for students who engage in illegal or violent behavior. It is important to remember that teens who are violent or abuse drugs may be at increased risk for suicide. If someone is expelled, the school should attempt to help the parents arrange immediate and possibly intensive psychiatric and behavioral interventions.
Role of the peers:
Peers are crucial to suicide prevention. According to one survey, 93% of the students reported that they would turn to a friend before a teacher, parent or spiritual guide in a time of crisis. Peers can form student support groups and, once educated themselves, can train others to be peer counselors.
Adolescents often will try to support a suicidal friend by themselves. They may feel bound to secrecy, or feel that adults are not to be trusted, and this may delay needed treatment. Ideally, a teenage friend should listen to the suicidal youth in an empathic way, but then insist on getting the youth immediate adult and professional help.
Role of the parents:
Parents need to be as open and as attentive as possible to their adolescent children’s difficulties. The most effective suicide prevention technique parents can exercise is to maintain open lines of communication with their children. Sometimes teens hide their problems, not wanting to burden the people they love. It is extremely important to assure teens that they can share their troubles, and gain support in the process. Parents are encouraged to talk about suicide with their children, and to educate themselves by attending parent-teacher or parent-counselor education sessions and from nearby libraries or the internet. Once trained, parents can help to staff a crisis hotline in their community. Parents also need to be involved in the counseling process if a teen has suicidal tendencies. These activities may both alleviate parents’ fears of the unknown and assure teenagers that their parents care.
The rationale for school-based postvention/crisis intervention is that a timely response to a suicide is likely to reduce subsequent morbidity and mortality in fellow students, including suicidality, the onset and exacerbation of psychiatric disorders, and other symptoms related to pathological bereavement.
An attempted or completed suicide can have a powerful effect on the staff and on the other students. One study found an increased incidence of major depression and posttraumatic stress disorder 1.5 to 3 years after the suicide. There have been clusters of suicides in adolescents, and some feel that media sensationalization or idealized obituaries of the deceased may contribute to this phenomenon.
The school should have plans in place to deal with a suicide or other major crisis in the school community. The administration or the designated individual should try to get as much information as soon as possible. He or she should meet with teachers and staff to inform them of the suicide. The teachers or other staff should inform each class of students. It is important that all of the students hear the same thing. After they have been informed, they should have the opportunity to talk about it. Those who wish should be excused to talk to crisis counselors. The school should have extra counselors available for students and staff who need to talk. Students who appear to be the most severely affected may need parental notification and outside mental health referrals. Rumor control is important. There should be a designated person to deal with the media. Refusing to talk to the media takes away the chance to influence what information will be in the news. One should remind the media reporters that sensational reporting has the potential for increasing a contagion effect. They should ask the media to be careful in how they report the incident. Media should avoid repeated or sensationalistic coverage. They should not provide enough details of the suicide method to create a “how to” description. They should try not to glorify the individual or present the suicidal behavior as a legitimate strategy for coping with difficult situations.
It is imperative for crisis interventions to be well planned and evaluated; otherwise, not only may they not help survivors, but they may potentially exacerbate problems through the induction of imitation.
COMMUNITY BASED PREVENTION PROGRAMS
Crisis Services (hotlines):
Crisis centers and hotlines are based on the premise that suicide is often associated with a critical stress event, it is usually approached with ambivalence, and the wish to commit suicide is seen as a way to solve an immediate problem. Crisis centers and hotlines are designed to deal with the immediate crisis, and use the individual’s ambivalence to convince them that there are other means of solving the problem other than suicide.
Restricting access to lethal means:
The underlying rationale for means restriction is that suicidal individuals are often impulsive, they may be ambivalent about killing themselves, and the risk period for suicide is transient. Restricting access to lethal methods during this period may prevent suicides. The following steps may be useful:
* Safe storage of guns
* Fences on bridges
* Restricting drugs/poisons
* Other restrictions on guns
Educating the media:
This includes educating media professionals about contagion, in order to yield stories that minimize them, and encouraging the media’s positive role in educating the public about risks for suicide and shaping attitudes about suicide.
Suicide attempts and completed suicides among adolescents are problems of increasing significance. School staff, parents, and health professionals should be sensitized about the risk factors and warning signs of suicide, and about the ways to deal with suicidal adolescents.
* Gould, M.S., Greenberg, T., Velting, D.M. & Shaffer, D. (2003) Youth suicide risk and preventive interventions: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 4, 386-405.
* Hawton, K. & James, A. (2005) Suicide and deliberate self harm in young people. British Medical Journal, 330, 891-894.