INTRO

Special guest, Amy Vogel led a webinar on Caring for Clients who may be Suicidal. Amy is a licensed Mental Health Counselor, specializing in traumatic grief and disenfranchised bereavement with over 10 years experience in providing crisis counseling and grief support services. Her research and advocacy focus on effective suicide bereavement interventions. Amy has led survivor support groups and serves on boards for Suicide Prevention and Operation Solid 7. She is a certified Clinical Trauma Professional and is certified in Thanatology. She is currently pursuing a PhD in counseling, education, and supervision.

She presented the learning objectives, saying, “Is suicide a problem? How big of a problem is it? We’re going to look at the scope of the problem, the risk factors of suicide, suicide risk in abortion, and assessments in planning to help you really understand: Is suicide involved? How do I ask if suicide is involved? And what do I do if they say yes?”

PREVENTING SUICIDE

“Suicide is a very complex health issue, yet despite it’s complexity, it can be prevented,” Amy said as she introduced the topic of suicide and prevention.  

Amy likened the warning signs and risk factors for suicide to those for other health crises like cardiac arrest, emphasizing their importance in preventing deaths by suicide. She pointed out how similar to other conditions, prevention can occur early or closer to the time of crisis, but stressed how important time itself can be, stating, “Time can be a critical and life saving measure. Typically a life can be saved if you allow time for the person’s suicide risk to subside or to get through that period of distress and get them to help.” She said that help can come in the form of a professional, someone who may know how to do an intervention, or simply listening and connecting. 

Amy said that identifying people who may be suicidal is an integral step in preventing suicide in addition to taking an active role in connecting them to help before they take action to end their lives. 

She discussed how using and modeling appropriate language is important so as to not perpetuate the stigma of suicide or mental health concerns. She recommended avoiding the use of phrases such as, “committed suicide,” or “failed suicide,” as they carry negative connotations. She explained that the term “committed” originated from suicide being a crime until the laws were changed in the mid-20th century, and using words like “failed” can convey ideas like passing or failing a test. 

Amy encouraged use of more appropriate phrases such as, “died by suicide,” “ended their life,” or “attempted suicide” instead. 

Amy highlighted the critical nature of education in regards to suicide to encourage seeking help, raising awareness of risks in vulnerable populations, and advocating for new interventions and prevention strategies for those at risk, stating, “When suicide is talked about safely and accurately, we can reduce the likelihood of its occurrence.” Caring and compassionate language around suicide is important, as highlighted in a Words Matter document from the Centre for Addiction and Mental Health.

HOW BIG OF A PROBLEM IS SUICIDE?

“Currently suicide is the 11th leading cause of death,” Amy said. She explained that prior to 2020, suicide held the 10th spot, but that number lowered in 2020. She stated that each year 700,000 people die by suicide worldwide, and 48,183 in the U.S. She explained that while that number sounds high, suicide deaths are underestimated. She attributed this to overdose deaths where it is unknown whether it was accidental or not and no suicide note was tied to the death. She further broke down the numbers, stating, “That’s 132 suicides per day, and an estimated 1.7 million attempts per year.” She shared that the socioeconomic costs and consequences total $44 billion each year.    

Amy emphasized that suicide rarely occurs outside of mental health disorders. She noted that as a major public health issue, suicide takes more lives than homicide, natural disasters, and car accidents. She said that for every suicide death, it’s estimated that twenty-five others attempt. She shared her concern over this, stating, “We have a lot of people who are attempting suicide that we don’t know about and who could be alone and afraid to talk about their feelings and thoughts about suicide because of the lack of public awareness and stigma.”

RISK FACTORS FOR SUICIDE

“Why do people take their own lives?” Amy asked. She then answered, “That is the golden question in suicide research that I’m not sure we will ever answer, as there is no single cause.” However, she explained, there are potential risk factors that fall into three different categories: health, historical, and environmental factors. 

HEALTH FACTORS

The first category Amy presented, health factors, entails elements such as biological and psychological medical conditions, the most significant being mental health. She reiterated that most people who die by suicide have an active mental health problem at the time of their death, whether diagnosed or not. She stated that depression is the most common mental health condition associated with suicide and while bipolar disorder is also a high risk factor, it’s less common than depression. 

Amy highlighted the importance of detecting the presence of a mental health condition through identifying symptoms, stating, “Many people might not even realize that their distress has actually become a health problem. So it’s very important to observe different kinds of things that people might be doing, not just what they’re saying, but how they’re reacting or even dressing, different things, something that’s out of the ordinary of their norm.”

Amy highlighted that individuals with serious or chronic health issues, particularly those with mental health conditions, face an increased risk. Conditions such as chronic pain, head injuries, and traumatic brain injuries also raise the risk. Notably, traumatic brain injuries can alter brain structure, potentially leading to suicidal ideation. Amy referenced studies comparing the brains of individuals who died by suicide with those who died from other causes, revealing distinct physical disparities, specifically in the areas related to stress response and impulse control.  She affirmed the validity of studies such as these by sharing her personal experience with Dr. Daniel Amen, a psychiatrist who performs brain scans in the U.S. to identify mental health disorders. She recounted, “Last year, I got my brain scanned to identify what’s going on in there. I attempted suicide 20 years ago, and I’ve had a lot of family members die by suicide. I learned that my brain is highly impulsive, which makes sense that the research is showing that impulsive brains can be a risk for suicide.”

HISTORICAL FACTORS 

The next set of factors Amy presented was historical factors, which includes family history of suicide or mental health conditions, past trauma such as sexual abuse, and combat stress. She noted the crucial research being done in epigenetics, which is the study of how behaviors and environment can cause changes that affect the way genes work, which ties in to the potential impact of generational trauma on individuals. Additionally, she stated that a history of childhood abuse and previous suicide attempts are also both risk factors, noting the importance of collecting this type of information when meeting with a client to determine their level of risk. 

ENVIRONMENTAL FACTORS

The last risk factor Amy spoke about was environmental factors. These involve the circumstances of a person’s life that commonly contribute to the overall risk level. This can include having access to “lethal means,” such as firearms, prescription medications, illegal drugs, vehicles, or bridges. She said, “There are many different ways people can think about killing themselves or have killed themselves, so identifying what a suicidal person may have access to is essential in identifying risk.” 

She shared that research has also shown “contagion” to be an environmental factor. This includes exposure to another person’s suicide or to very graphic accounts of suicide especially in those already at high risk. Therefore, it’s important that suicide not be “over-glamorized.” 

Prolonged stress is another environmental factor. This may include harassment, bullying, relationship or legal problems, unemployment, or a stressful life event. She said, “This is what might be coming into your offices – the event itself and anything with trauma. The actual event doesn’t always cause trauma. It’s how we respond to the event and what resources we have to be able to respond to that particular event.” She then shared her own experience about a hurricane that impacted her community and the increase in suicide within the county following the event. She stated that not everyone who went through the hurricane was thinking about suicide or died by suicide. For some, it was an exciting time to help others, supporting the fact that it wasn’t the hurricane itself, but rather the response to the traumatic event. 

PERSONAL EXPERIENCE

“I’ve had thoughts of suicide. It’s something that doesn’t go away for me. It’s something that I’ve learned to live with,” Amy stated. My husband, who is very supportive, always tells me, I’ve never, ever had that thought. You might be sitting here today thinking, I just can’t even go there, I can never imagine taking my own life.” She explained how the theory may help people to understand how someone can get to the point of considering suicide. 

Amy shared what this has looked like in her own life, noting that while everything appears perfect on the outside — great family, parents who are still together, having everything she needs, college education, and a good career — she has struggled with suicidal thoughts since the age of 15. She explained, “It’s just something in the way my brain thinks, but I’m able to cope.” She likened her ability to manage her thoughts to someone who has to manage a disease like diabetes. She explained diabetics cope by eating right, exercising, and checking insulin levels, while she copes with her suicidal thoughts by doing a puzzle, taking medication, or speaking with her therapist. 

INTERPERSONAL THEORY OF SUICIDE

“Why would someone want to kill themselves?” Amy asked as she introduced the Interpersonal Theory of Suicide

The theory, developed by psychologist and psychology professor, Dr. Thomas Joiner at Florida State University, suggests that two important feelings can make someone more likely to consider suicide. The first is feeling like they don’t belong or fit in anywhere, which is referred to as “thwarted belongingness,” and the second is feeling like they are a burden to others, also known as “perceived burdensomeness.”

The theory also considers another aspect, “acquired capability for suicide.” Amy explained how this involves some individuals becoming more capable of engaging in suicidal behavior over time. “It’s like a combination of feeling disconnected and burdensome, along with the ability to act on those feelings,” Amy said. She suggested that it’s not just about wanting to die, but also having the means and ability to do so. 

“By understanding these factors, we can better identify and help those at risk for suicide. It emphasizes the importance of social connections and support in preventing suicide. So what the Interpersonal Theory of Suicide gives us is a framework to understand why some individuals may be more vulnerable to suicidal thoughts and behaviors. By addressing these feelings of isolation, burdensomeness, and building support systems, we can work toward preventing suicide and supporting those in need.”

Amy went on to share a recent personal experience she had on a girls trip with friends to tie together the information shared thus far. She said that although the location was beautiful and the company was great, she was anxious because something within her was not allowing her to feel like she actually belonged. Her perceived lack of belonging led to thoughts such as, “Do I belong here? Are these people really my friends? Do they like me, and am I weird?” Those thoughts further raised her anxiety and led to her feeling like she was a burden, a pain to deal with and didn’t fit in – perceived burdensomeness. She recognized how her internal dialogue was most likely not true, existing only in her own mind; however, the thoughts were there and she had to intentionally redirect them, or “cope”, which she described as exhausting. 

Through her story, she illustrated how at-risk individuals, such as herself, may find themselves in vulnerable situations as they cope with the daily barrage of intrusive thoughts. “If we add in those who are capable of suicide, who may have previously attempted suicide, who have had a family history of suicide, who have an impulsive brain,” she said, “we’re creating the perfect storm.” Because all of those factors are applicable in her own life, Amy shared that she felt suicidal in that moment, but that didn’t necessarily mean that she was going to kill herself. 

Instead, she was able to pull on her support system, who in turn followed the steps to minimize the risk by first eliminating the means by which Amy could accomplish suicide. In Amy’s case, her family knew that was items like pills and knives. She shared the importance of her support system being familiar with the environmental factors that put her at higher risk, and being able to separate her from them, keeping her safe. She said, “I like to use myself as an example because it keeps it real and I think it helps people understand that individuals who struggle with suicidal ideation can be very successful people.”

Amy described suicidal ideation as being on a spectrum, similar to the autism spectrum, having varying levels. She gave the example of how some people on the autism spectrum may be non-verbal or unable to care for themselves, while others, like Elon Musk, are extremely successful and able to live life well. In the same way, suicide can be viewed on a spectrum of varying degrees. 

She shared how important it is to understand the levels, because when someone says they are thinking about killing themselves, it doesn’t necessarily mean right at that moment. “You have time,” she said. “If you’re talking to them, that is time. Talking to them is just keeping that time away from their means.” 

LEVELS OF SUICIDAL IDEATION

Amy presented a chart demonstrating the various levels of suicidal ideation created by the same people who developed the Columbia Suicide Severity Rating Scale, which are discussed next.

Level 1 – Suicidal Thoughts – General desire to not be alive

– May involve thoughts of wanting life to end, but with no specific plan or intent to carry out

Level 2 – Suicidal Thoughts – Stronger desire to end one’s life

– Nonspecific, active suicidal thoughts

– Has thoughts about a plan, but no intent

Level 3 – Suicidal Intent – Suicidal thoughts with methods

– May be considering specific methods

– Intends to attempt, but has no specific plan 

Level 4 – Suicidal with plan and intent – Clear intention or purpose to end their life

– Has a specific plan and intends to carry it out

– Actively planning and preparing to carry out a suicide attempt

Level 5 – Suicide attempt – Intent to die by suicide with a detailed plan of how and when to do it

– Highest risk of attempting suicide with plan or impulse

“At level 5, this is where you would either call 911 or have someone who can do a suicide intervention,” Amy said. She followed by saying, “Not every suicidal person needs 911 called on them, it’s when they’re really not listening or working with you.” She pointed out that if a suicidal person is reaching out, it’s for a reason such as needing validation, and that is a moment to intervene in a safe manner. She also cautioned that if a suicidal person enters your building with intent, a plan, and the means, such as a gun, you should immediately leave the room without further discussion and call 911. 

RISK ASSESSMENTS: WHAT SHOULD I DO IF I THINK SOMEONE IS SUICIDAL?

COLUMBIA SUICIDE SEVERITY RATING SCALE

Amy introduced a widely-used tool called the Columbia Suicide Severity Rating Scale, also known as C-SSRS. It is used at the National Suicide Prevention Hotline, in emergency rooms, and by the military, VA, and US government. She likened usage of the scale to a compass, stating, “It guides the helper in understanding the depth of someone’s thoughts and feelings when it comes to suicide.” She highlighted that all of the information shared thus far is the foundation for comprehending the C-SSRS

Amy asked the audience to imagine the scale as a ladder with different rungs, each representing a level of severity in suicidal thoughts. The bottom rung represents a general feeling of not wanting to be alive. She said, “As we climb higher, we encounter non-specific, active suicidal thoughts, where the desire to end one’s life becomes more pronounced. Further up this ladder, we reach suicidal thoughts with methods indicating thoughts about how one could harm themselves. So we’re moving even higher, and we find suicidal intent, where the individual is actively planning to end their life. And at the very top, we have suicidal intent with plan. Again, this is the most critical level where a detailed plan for suicide is in place.”

Amy highlighted the difference between the Levels of Suicidal Ideation Chart and the C-SSRS in that the C-SSRS does not stop there. It also delves into the intensity of the thoughts, how often they occur, how long they last, whether they can be controlled, what might prevent the person from acting on them, and why the thoughts are present. 

She compared the use of the scale to unraveling a person’s story. She said, “By assessing both the severity and the intensity of suicidal ideation, health care providers can offer the right support and intervention to those in need, potentially saving lives and providing hope in those times of darkness. This is not just a tool, think of it as a beacon of light in the journey on suicide prevention. It’s guiding us to a better understanding of individual thoughts and emotions and paving the way for compassionate care and support.”

Amy took the audience through the C-SSRS questions, prefaced by encouraging connection to the suicidal person rather than rote reading, simply ticking boxes off on a checklist. She shared about a time when she went to a crisis center. The woman completing her intake had a checklist and a pencil and didn’t look Amy in the face. Instead she stared at her paper as she asked Amy the questions, just making check marks. Amy recollected how this made her feel unvalidated, unsafe, unheard, and misunderstood. She stated that when a person is suicidal, they are in the worst pain of their life. In conveying how hard it can be for that person to answer these questions, she suggested attendees think about the worst physical pain they have ever had and imagine how difficult it would be to give detailed directions to your house while in such intense pain. Amy shared how the method the woman used felt insincere and judgmental. She emphasized the importance of making this scale a conversation using a caring voice.

She encouraged modeling a calm and relaxed demeanor as you go through the questionnaire to help the person struggling with suicidal ideation to be calm and relaxed as well. She explained how stress responses can be minimized, helping them get out of fight or flight mode. 

Amy recommended identifying personal attitudes and biases about suicide prior to using the scale with anyone. She suggested a method she referred to as a “brain dump” where a timer can be set for three minutes and all the thoughts one has about suicide can be quickly jotted down. This can include thoughts like, ‘It makes me angry,’ ‘Why would people do that?’ and ‘That’s selfish.’ She said, “You can think of the nastiest things, but the important thing is to get it all out. You can burn it, trash it, or shred it when you’re done, but it’s very important to sit in your attitudes and personal biases about suicide because you want to be fully present for this person.” 

Amy reminded us that it’s not necessarily the suicide that is really going on, but how the person is responding to a particular trauma or event. She went back to the example of her girls’ trip and how the Interpersonal Theory of Suicide was at play with the build up of thoughts and historical factors converging, negatively affecting her response to the event itself. This puts into perspective what may be happening with a client seeking help after an abortion or with someone who is fearful of an unintended pregnancy. Keeping in mind, it’s not the actual event, it’s how they are responding to it. Being able to get past our own judgements plays an important role in being able to understand more in order to help people thinking about suicide cope through their responses to the events they are going through. 

STANLEY BROWN SAFETY PLAN

“Whether they are suicidal or not, it’s very important to create a safety plan with a client,” Amy said as she introduced the Stanley Brown Safety Plan

The first step in creating a plan is identifying warning signs. She shared how many times people who are suicidal may not realize what their warning signs are. Being able to identify the warning signs functions as a light bulb. It brings to their awareness things they may do before thinking about suicide, such as cutting or negative self-talk, triggering them to begin working on their coping strategies. She recommended asking them to identify at least three warning signs. 

The next step, she explained, is to identify internal coping strategies. These are things they can do to distract themselves without contacting another person, such as listening to music, playing a game on their phone, completing a puzzle, journaling, or drawing.  

The next component she shared was listing people and social settings that provide distractions. This would not include people you go to for help in a crisis, rather people or places that feel safe and serve as a distraction. They’re not going to do a deep-dive intervention. 

Section four of the plan would be identifying people who can be asked for help during a crisis. For Amy, this includes her mom, husband, and a close friend who is also a counselor. 

Section five is where to include professionals or agencies that can assist during a crisis. She suggested having them write down their resources, and if they don’t have any, provide them referrals to the types of agencies that would best serve them. This is also where you would include emergency contact numbers like a local non-emergency line or emergency department, suicide prevention hotline, or 988 which is the suicide and crisis hotline. 

The final part of the safety plan covers how to make their environment safer. This entails identifying the person’s lethal means and how to keep their means in a safe place that may restrict their access to it. 

CONCLUSION

“I want to emphasize the crucial role that we can all play in suicide prevention,” Amy said. “Suicide is a serious public health issue that affects individuals, families, and communities all across the globe. However, it’s important to remember that suicide can be prevented through awareness, compassion, and timely intervention. Throughout this presentation, we have explored the scope of the problem, the factors that contribute to suicidal desire and capability, and the tools available for assessing and managing suicide risk.”

“We’ve also discussed the significance of using appropriate, non-stigmatizing language when we talk about suicide to create a supportive environment,” Amy said. “One of the most important things we can do to help prevent suicide is to be there for others and actively listen to their concerns. When someone is experiencing suicidal thoughts, they might feel isolated, helpless, and alone. By offering a non-judgmental and supportive presence, we can help them feel heard, validated, and connected. Active listening involves giving that person your full attention and asking those important questions, like Are you thinking about suicide? and not being scared if they say yes. It involves showing them empathy and understanding.” 

“In addition to being there for others,” Amy continued, “it is crucial to know the resources available for suicide prevention, including helpline numbers, websites, and local support services. Familiarize yourselves with these resources and provide valuable information and support to people in need.” 

“I want to leave you with a message of hope,” Amy said. “Suicide is preventable, and help is available. By working together, we can create a world where everyone feels supported, valued, and connected. I encourage each of you to continue learning about suicide prevention. Every life is precious and every person deserves the right to be heard and supported. Together we can make that difference in the fight against suicide.”

HANDOUTS

Click here for the Columbia Suicide Severity Rating Scale.

Click here for the Stanley Brown Safety Plan.

Click here for the Community Care Card for Clients.

NEXT STEPS

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