INTRO

 

In today’s deep dive webinar, special guest, Amy Vogel, brought us Suicide Intervention Toolbox, Part 2 of 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.

 

SUICIDE INTERVENTION TOOLBOX

 

“As helpers, we all know how challenging and emotionally taxing it can be to work with clients who are in such a vulnerable state. We want to do everything we can to support them, keep them safe, and help them find reasons to keep living. But sometimes, it can feel like we’re not quite sure what to do or say,” Amy said as she introduced the idea of the Suicide Intervention Toolbox. Developed and validated by experts in the field of suicide intervention, it covers a range of practical tools, strategies, and resources that can be used when working with suicidal clients. 

Amy took a moment to acknowledge the profound importance of the work, stating, 

“Suicide is a major public health issue, and it devastates individuals, families, and communities. As helpers, we have a unique opportunity and responsibility to intervene, to help our clients find hope and meaning even in their darkest moments,” she continued, “Throughout this presentation, we’ll be focusing not just on the practical tools, but also on the underlying spirit of compassion and empathy that is so essential to this work. Caring for suicidal clients requires us to bring our full selves to the task – our knowledge, our skills, and our humanity.”

 

ASSESSING SUICIDE RISK

 

When it comes to assessing for suicide, it’s important to understand that traditional methods may not always be the most effective,” Amy said. She explained that in the past, most assessments focused on asking people if they were depressed or thinking about harming themselves, however research has shown that approach may potentially miss some important factors. She stated that instead of just looking at suicidal thoughts as a sign that someone might attempt suicide, the different paths that can lead to suicidal behavior must be considered as well. This involves asking questions that address the emotions and experiences that can make people feel vulnerable, such as the belief that others would be better off without them or the feeling that no one can help them solve their problems. 

Amy also pointed out the importance in recognizing that suicidal behavior can look different among different groups of people. As an example, she said that black teenagers may engage in risky or aggressive behaviors that could lead to harm or death, rather than directly attempting suicide. She stated, “When assessing for suicide risk in these populations, it’s important to ask about these kinds of behaviors and to look for sources of strength and support within their communities.”

She explained that another challenge in assessing suicide risk is that young people might be hesitant to open up about their suicidal feelings because they’re worried about confidentiality. They may fear that helpers will tell their parents about their thoughts without their permission. To address this, helpers should work together with young people to come up with a plan for sharing information with parents when necessary, in a way that makes the teenager feel as comfortable as possible.

Amy highlighted that the way questions are asked about suicide is also important, stating, “If we ask in a way that suggests we expect the answer to be “no,” people might hide their true feelings. Instead, helpers should ask about suicidal thoughts and behaviors in an open, non-judgmental way.”

She reiterated that assessing for suicide risk involves more than just asking about depression and thoughts of self-harm. Amy emphasized the importance of using

evidence-based screening tools and considering the unique factors contributing to suicidal ideation and behaviors in various individuals and communities. She suggested that by adopting a comprehensive and collaborative approach to assessment, those at risk can be more effectively identified and connected with the support they need.

 

ATTITUDES AND BELIEFS

 

“Attitudes and beliefs about suicide are complex and multifaceted, influenced by various factors such as religion, culture, and personal experiences. Financial situations, religious beliefs, and mental health all play a role in shaping our perceptions of suicide,” Amy said. She highlighted the importance of recognizing that different communities and cultures can have vastly different views on the subject. She gave the example of China being a place where, although religion may not be a significant part of life, opinions on suicide can be mixed. For this reason, understanding the diverse attitudes towards suicide is crucial in supporting those affected by suicide and working towards prevention.

Amy stated that research indicates individuals at higher risk of suicide often hold negative views towards those who attempt or die by suicide. She explained that these stigmatizing attitudes can create barriers, making it challenging for people to open up about their struggles and seek help. Furthermore, the fear of judgment or discrimination may influence how they contemplate ending their lives.

She shared that a recent Australian study discovered that individuals who hold negative perceptions of those who die by suicide, such as viewing them as cowardly or immoral, are more inclined to have negative attitudes towards seeking help for their own emotional issues. Additionally, the study revealed that individuals contending with suicidal thoughts or depression tend to harbor more negative attitudes about seeking help and are less inclined to reach out for support compared to others. This underscores the significance of fostering a supportive and empathetic environment where individuals feel encouraged to seek assistance. 

On the flip side, Amy noted that the research revealed that individuals with higher levels of suicide literacy – understanding warning signs, causes, and risk factors for suicide, as well as its preventability and treatability – tend to have more positive attitudes towards seeking help. 

Amy said the study also pointed out that younger people and men tend to have more negative attitudes about getting help compared to older individuals and women. She stated this suggests that public education campaigns aimed at increasing knowledge about suicide and reducing negative attitudes should focus on reaching these groups.

“While there has been progress in how society views suicide over time, a significant amount of stigma still lingers. This stigma can manifest in various forms of discrimination and prejudice, casting a shadow on individuals’ willingness to seek support and talk about their mental health challenges openly. Certain beliefs about suicide, such as the misconception that most individuals who die by suicide are mentally ill, did not show significant variations based on factors like gender or age, suggesting a potential lack of understanding within the general population,” Amy said. She went on to say that in order to address these issues, it’s crucial to focus on increasing suicide literacy and decreasing the stigma associated with suicide, saying, “By fostering a more supportive and understanding environment, we can create space for open conversations and effective support systems for those grappling with suicidal thoughts and mental health challenges. This can be a powerful step in preventing suicide and supporting those who may be struggling.”

 

IDENTIFYING FACTORS

 

“In assessing the risk of suicidal thoughts, it’s crucial to consider both risk factors and protective factors,” Amy said. She stated that risk factors are elements that can increase the likelihood of suicide. This includes things such as past trauma, triggering events, and feelings of hopelessness or anger. Amy said it’s important to identify which of these risk factors can be changed to reduce the risk of suicide. 

“On the other hand, protective factors are like shields that can buffer individuals from suicidal thoughts and behaviors,” she said. Protective factors include access to support, strong relationships, coping skills, and cultural or religious beliefs that discourage suicide. Amy stated that by enhancing the protective factors, an individual’s resilience can be strengthened, thereby reducing the risk of suicidal ideation.

Amy shared that through addressing and modifying risk factors while increasing protective factors, we can work towards reducing the risk of suicide and promoting mental well-being. She emphasized the essential nature of considering both aspects when assessing and supporting individuals who may be experiencing suicidal thoughts. 

 

NEUROANATOMY

 

Amy presented a slide with information aimed at understanding the neurological factors that can increase suicidal thoughts. 

 

 

 

She asked the audience to picture the trauma and stress they face over the course of their lives. She stated that those experiences can contribute to suicidal behavior over time. She highlighted how our bodies, when stressed, have a stress response system which involves the hypothalamic-pituitary-adrenal axis, or HPA Axis. The HPA Axis system works in conjunction with serotonin, norepinephrine, and polyamine systems, which are influenced by our genes.  

“So, when we’re under stress, our hypothalamus releases a hormone called corticotropin-releasing hormone (CRH). CRH then triggers the pituitary gland to release another hormone called adrenocorticotropic hormone (ACTH). ACTH then stimulates the adrenal glands to release cortisol, which is a stress hormone. Researchers have discovered that people who have died by suicide or attempted suicide often have abnormal levels of these hormones,” Amy said. 

She went on to explain how serotonin and norepinephrine, which are neurotransmitters, also play a role in suicidal behavior, stating, “Studies have found that people who have died by suicide have deficits in serotonin signaling and increased norepinephrine activity.”

Amy further elaborated that suicidal behavior and the development of psychiatric disorders are not solely determined by hormones and neurotransmitters; rather, the expression and function of our genes also play a significant role in contributing to these phenomena. She said, “Here’s where it gets fascinating. Traumatic events can have lifelong effects on our genes through epigenetic changes. These changes can lead to suicidal behavior. For instance, changes in a gene called FKBP5 can make a person more vulnerable to stress.” Amy stated that epigenetic changes can also impact neural plasticity, which is the brain’s ability to adapt and change. This happens because epigenetics influence neurotrophic deficiencies.

In summary, Amy explained how researchers have proposed the Life Span model. This model combines the Stress-Diathesis Model and the Interpersonal Theory of Suicide, covered in part 1, and tries to provide a neurobiological explanation for suicidal behavior. However, she emphasized that suicide is a multifaceted issue, underscoring the importance of ongoing research to fully comprehend suicidal behavior. She highlighted that there are many contributing factors, and biology should also be considered one.   

 

COLUMBIA-SUICIDE SEVERITY RATING SCALE

 

Amy reintroduced the Columbia-Suicide Severity Rating Scale or C-SSRS, which was previously discussed in the Part 1 webinar. She reminded us that the C-SSRS is a powerful and widely-used tool designed to help identify and assess suicidal thoughts and behaviors in individuals. Developed by leading universities in the United States, including Columbia University, with support from the National Institute of Mental Health, the C-SSRS has been extensively researched for over 20 years and is considered the gold standard in its field.

She stated that one of the key advantages of the C-SSRS is its simplicity and ease of use. The scale features straightforward questions that can be administered by anyone, even those with minimal training. It is available in more than 150 languages and can be easily integrated into electronic medical records, making it accessible and convenient for helpers worldwide.

Amy explained that when administering the C-SSRS, helpers ask a series of questions about the person’s suicidal thoughts and behaviors. The questions are designed to gauge the seriousness of the individual’s risk and determine the urgency of the needed support. The exact questions asked depend on the person’s answers, creating a personalized assessment tailored to their specific situation.

She said the C-SSRS questions cover various aspects of suicidal ideation and behavior, from passive thoughts like wishing to be dead to active thoughts about specific methods of suicide. The scale also asks about any steps taken to prepare for a suicide attempt, such as collecting pills, obtaining a gun, or writing a suicide note. By asking these direct, clear questions, the C-SSRS helps identify individuals at risk of suicide, enabling helpers to connect them with appropriate support and resources.

Amy shared that studies have demonstrated the C-SSRS’s effectiveness in detecting signs of suicidal thinking, with a sensitivity of 67% and a positive predictive value of 14%. This means that the scale can identify a significant portion of at-risk individuals, and when it does, there’s a good chance they truly need help. Amy suggested that organizations using the C-SSRS can establish their own guidelines for action based on individuals’ responses, which may range from immediate hospitalization to referrals for counseling or other support services.

 

C-SSRS QUESTIONS – DEEP DIVE

 

Next, Amy broke down the C-SSRS questions to provide a deeper understanding of how to use the tool. 

She explained that questions one and two are crucial for gauging a person’s suicidal thoughts and the questions are asked in relation to the past month, as recent thoughts and feelings are often the most relevant when assessing someone’s current risk.

The first question is, Have you wished you were dead or wished you could go to sleep and not wake up? This question is designed to identify passive suicidal thoughts. Passive suicidal thoughts are when a person feels like they don’t want to live anymore, but they don’t necessarily have a plan to end their life. They might wish they could just go to sleep and never wake up again. While these thoughts may not indicate an immediate risk of suicide, they’re still concerning and need to be taken seriously.

The second question is, Have you had any actual thoughts of killing yourself? This question goes a step further and asks about active suicidal thoughts. Active suicidal thoughts are when a person is actually considering ending their life. They might be thinking about specific methods or making plans. This is a more serious level of suicidal ideation and indicates a higher risk of suicide.

Amy said that by asking these two questions, we can get a sense of whether a person is experiencing suicidal thoughts and how serious those thoughts are. If someone answers “yes” to either of these questions, it’s a red flag that they may be at risk of suicide and need support.

Amy highlighted the importance of understanding that asking these questions directly doesn’t put the idea of suicide in someone’s head. If a person isn’t having suicidal thoughts, asking them about it won’t make them start. But if they are having these thoughts already, asking directly lets them know it’s okay to talk about it and that help is available.

She stated that if a person answers yes to the second question, then the C-SSRS directs us to ask a series of follow-up questions. These questions – numbers three through five – are designed to gauge the severity and intensity of the person’s suicidal thoughts. 

The third question asks, Have you been thinking about how you might do this?

She stated, “This question is trying to determine if the person has considered specific methods for ending their life. Have they thought about using pills, a gun, or another method? Having a plan indicates a higher level of risk, as it suggests the person has given serious thought to how they would attempt suicide.”

Question four goes a step further, asking, Have you had these thoughts and had some intention of acting on them? This question is assessing whether the person has not only thought about methods, but has also had some intention to follow through with those thoughts. Intention to act is a serious warning sign that the person may be moving closer to attempting suicide.

Amy explained that question five is perhaps the most critical. It asks, Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan? This question is looking for concrete steps the person may have taken to prepare for a suicide attempt. Have they collected pills, obtained a gun, or written a suicide note? Have they made a specific plan for when, where, and how they would attempt suicide? And most importantly, did they intend to follow through with this plan?

She shared that answering “yes” to any of these questions is a major red flag. It suggests that the person’s suicidal thoughts are serious and that they may be at high risk of attempting suicide in the near future. She said, “The more “yes” answers a person gives, the higher their risk.”

Amy emphasized the importance of remembering that asking these questions is not about judgment or getting someone in trouble. It’s about understanding the severity of their situation in order to provide the right level of support. If someone is having serious suicidal thoughts, with plans and intent, they need immediate help to stay safe.

Amy said the last question, number six, is one that is always asked, regardless of how the person answered the previous questions. Question six asks, Have you done anything, started to do anything, or prepared to do anything to end your life? This question is looking for any actions the person may have taken to prepare for or attempt suicide. This could include things like giving away possessions, writing a suicide note, collecting pills, or obtaining a gun. Amy stated that if the person answers “yes” to this question, we then ask a follow-up question: Was this within the past 3 months? This helps us understand how recent the action was. A recent action is more concerning than something that happened a long time ago, as it suggests the person may be in a current suicidal crisis.

Amy stressed the importance in noting that this question isn’t just asking about suicide attempts. It’s also asking about preparatory behaviors. She said, “Someone might not have actually tried to end their life, but if they’ve started giving away their possessions or have bought a gun with the intention of using it on themselves, that’s a serious warning sign.” She continued, “Answering “yes” to question six is an emergency situation. It means the person has taken steps to end their life and may be in imminent danger. They need immediate support and intervention to ensure their safety.” She explained that this is why question six is always asked, even if the person said “no” to the previous questions about suicidal thoughts. Sometimes, a person might deny having suicidal thoughts but still have taken action towards suicide. Asking this question directly can uncover critical information that might otherwise be missed.

 

STANLEY-BROWN SAFETY PLAN

 

“Depending on the severity and your organization’s protocol, safety planning is essential,” Amy said as she re-introduced The Stanley-Brown Safety Plan she first addressed in the Part 1 webinar. She reminded us that this tool is a widely used, evidence-based tool designed to help individuals who are experiencing suicidal thoughts or behaviors. Developed by Dr. Barbara Stanley and Dr. Gregory Brown, this plan is a practical, step-by-step guide that clients can use to manage their suicidal thoughts and stay safe during a crisis.

Amy highlighted the beauty of the Stanley-Brown Safety Plan, stating, “It’s not just a generic, one-size-fits-all document. Instead, it’s a personalized plan that the client develops in collaboration with their mental health provider. This collaborative approach ensures that the plan is tailored to the individual’s unique needs, circumstances, and preferences.”

She explained that the Stanley-Brown Safety Plan typically includes six key steps:

 

  1. Identifying warning signs: The client learns to recognize the thoughts, images, moods, or behaviors that typically precede a suicidal crisis.
  2. Employing internal coping strategies: The plan lists coping strategies that the individual can use on their own to manage their thoughts and emotions, such as relaxation techniques, physical activity, or positive self-talk.
  3. Utilizing social contacts and social settings for distraction: The client identifies people and places that can provide a healthy distraction from their suicidal thoughts.
  4. Contacting family members or friends who may offer help: The plan lists trusted individuals whom the client can reach out to for support during a crisis.
  5. Contacting mental health professionals or agencies: The client includes the contact information for their therapist, psychiatrist, or local crisis line.
  6. Reducing the potential for use of lethal means: The plan includes steps for making the client’s environment safer, such as removing firearms or stockpiled medications.

 

She said, “What’s powerful about the Stanley-Brown Safety Plan is that it empowers clients to take an active role in managing their own safety. It’s not just about what the helper can do for the client, but what the client can do for themselves.”

Amy stated that research has shown the Stanley-Brown Safety Plan to be a highly effective tool for reducing suicidal behaviors and increasing treatment engagement. She emphasized that when working with clients who are at risk of suicide, incorporating the Stanley-Brown Safety Plan into your organization can be a powerful way to enhance your clients’ safety and wellbeing.

 

SELF-CARE

 

“When working with suicidal clients, it’s crucial for helpers to prioritize self-care. Engaging in regular self-care practices can help prevent burnout, maintain emotional well-being, and ensure that we’re providing the best possible care to our clients,” Amy said. 

She explained that one important aspect of self-care is debriefing. Regularly debriefing and discussing challenging cases and emotions with colleagues can provide invaluable support, perspective, and guidance. These conversations, whether informal or structured, offer an opportunity to process difficult experiences and learn from others.

Amy stated that another key element of self-care is setting boundaries between our work and personal lives. Maintaining a healthy work-life balance involves setting clear boundaries, such as not checking work emails outside of work hours and dedicating time to hobbies and activities unrelated to work. She explained that by creating a clear separation between our professional and personal lives, we can recharge, avoid becoming overwhelmed, and ensure that we have the time and space to take care of ourselves and engage in activities that bring us joy and relaxation.

Lastly, Amy suggested incorporating mindfulness and relaxation techniques into our daily routine as a powerful self-care practice. Techniques such as deep breathing, meditation, or yoga can help manage stress, promote a sense of calm, and improve overall well-being. Taking even a few minutes each day to focus on our breath or engage in a relaxation exercise can help us stay grounded and better equipped to handle the emotional challenges of our work.

She stressed the importance of prioritizing self-care, saying, “Through practices like debriefing, setting boundaries, and engaging in mindfulness, we as helpers can maintain our own emotional resilience and well-being. This, in turn, allows us to provide the highest quality care to our clients who are struggling with suicidal thoughts and behaviors.”

 

CASE STUDY: APPLYING THESE TOOLS IN A REAL-LIFE CRISIS SITUATION

 

Amy shared a case study to demonstrate how the tools and strategies discussed in this presentation, such as the C-SSRS and Stanley-Brown Safety Plan, can be applied in a real-life crisis situation. She said that it also highlights the importance of empathy, active listening, and self-care when working with individuals experiencing suicidal thoughts.

Sarah, a 25-year-old woman, calls a helpline after having an abortion. She’s been feeling overwhelmed with emotions and has been experiencing suicidal thoughts. The call is answered by Emily.

Emily begins by establishing rapport and creating a safe, non-judgmental space for Sarah to share her feelings. She listens actively and validates Sarah’s emotions, acknowledging the complexity of her situation.

Using the Columbia-Suicide Severity Rating Scale (C-SSRS), Emily assesses Sarah’s risk of suicide. She asks the first two questions:

  1. “Have you wished you were dead or wished you could go to sleep and not wake up?” 
  2. “Have you had any actual thoughts of killing yourself?”

Sarah responds “yes” to both questions, indicating she has been experiencing suicidal ideation. Emily then proceeds with questions 3, 4, and 5 to gauge the severity of Sarah’s thoughts:

  1. “Have you been thinking about how you might do this?”
  2. “Have you had these thoughts and had some intention of acting on them?”
  3. “Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?”

Sarah reveals that she has thought about overdosing on pills but hasn’t made a concrete plan or taken any steps to acquire the means. Emily then asks question 6:

  1. “Have you done anything, started to do anything, or prepared to do anything to end your life?”

Sarah says she hasn’t taken any actions to end her life.

Based on Sarah’s responses, Emily determines that while Sarah is experiencing suicidal thoughts, she doesn’t appear to be at imminent risk. However, she recognizes the seriousness of the situation and the need for ongoing support.

Emily works with Sarah to develop a personalized Stanley-Brown Safety Plan. They identify Sarah’s warning signs, internal coping strategies, social contacts for distraction, family and friends who can offer support, and professional resources. They also discuss steps to make Sarah’s environment safer.

Throughout the conversation, Emily remains compassionate and non-judgmental. She reassures Sarah that her feelings are valid and that help is available. She provides Sarah with resources, including the number for the crisis line, and encourages her to reach out anytime she needs support.

After the call, Emily takes a moment to practice self-care. She takes a few deep breaths, does a brief mindfulness exercise, and then debriefs with a colleague about the emotionally challenging call. This helps her process her own emotions and prepare to continue supporting others.

Through this process, “this person who was suicidal has felt validated, heard, cared for,” Amy said. She talked about the need for, and different ways to achieve, ensuring that at-risk individuals always keep their safety plan with them “because we never know when a crisis might be triggering, and that safety plan is like their light in that dark hole.”

 

HANDOUTS

 

Click here for the Columbia Suicide Severity Rating Scale.

Click here for the Stanley Brown Safety Plan.

 

NEXT STEPS

 

Click here to watch the video of this webinar.

Click here to register for the next Men’s Healing Matters webinar.

Click here to register for the next Abortion Healing Provider webinar.

Click here to access Support After Abortion’s Resource Library.

Click here to explore Support After Abortion’s services, resources, and training for Abortion Healing Providers.