suicide core competencies

7/28/2019 Suicide Core Competencies

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Assessing and Managing Suicide Risk RS #1: Page 1 of 4

ResourceSheet#1: CoreCompetenciesfortheAssessmentandManagement

ofIndividualsatRiskforSuicide

Thefollowingcorecompetenciesweredevelopedbyexpertsinclinicalsuicidologytoserveasthefoundationfor

courseson

assessing

and

managing

suicide

risk,

for

both

graduate

students

and

experienced

mental

health

professionals. Thecompetenciesreflectcurrentempiricalevidenceandexpertopinion.

Thecompetenciesarenotintendedtoserveasastandardofcareforpsychologicalormedicaltreatment.Core

competenciesrelatedtospecifictreatmentinterventionshavenotbeendeveloped.

WorkingwithIndividualsatRiskforSuicide:AttitudesandApproach

1. Manageonesownreactionstosuicidea. Becomeselfawareofemotionalreactions,attitudes,andbeliefsrelatedtosuicide

b. Understandthe

impact

on

the

client

of

clinicians

emotional

reactions,

attitudes,

beliefs,

or

lack

of

understandingculturalimplications

c. Tolerateandregulateonesemotionalreactionstosuicide

d. Obtainprofessionalassistanceifneeded

2. Reconcilethedifference(andpotentialconflict)betweenthecliniciansgoaltopreventsuicideandtheclientsgoaltoeliminatepsychologicalpainviasuicidalbehavior

a. Understandthatsuicidalthinkingandbehaviormakessensetotheclientwhenviewedinthecontextof

hisorherhistory,vulnerabilities,andcircumstances

b. Acceptthataclientmaybesuicidalandvalidatethedepthoftheclientsstrongfeelingsanddesiretobe

freeofpain

c. Understandthefunctionalorusefulpurposeofsuicidalitytotheclient

d. Understandthatmostsuicidalindividualssufferfromastateofmentalpainoranguishandalossofself

respect

e. Maintainanonjudgmentalandsupportivestance

f. Voiceauthenticconcernandtruedesiretohelptheclient

g. Vieweachclientasanindividualwithhisorherownuniquesetofissuesandcircumstancesandsomeone

theclinicianseekstounderstandthoroughlywithintheclientsownminiculture(familyandcommunity

context)rather

than

as

astereotypic

suicidal

patient

3. Maintainacollaborative,nonadversarialstancea. Listenthoroughlytoattainasharedunderstandingofclientssuicidalityandgoals

b. Communicatetoclientsthathelpingthemresolvetheirproblem(s)isparamount

c. Obtaininformedconsent


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d. Createanatmosphereinwhichtheclientfeelssafeinsharinginformationabouthisorhersuicidal

thoughts, behaviors,andplans

e. Sharewhatyouknowaboutthesuicidalstateofmind;beempathictothesuicidalwish

f. Begenuineandexpresstotheclientwhyitisimportantthatthepersoncontinuetolive

g. Workwith

the

client

and

do

not

abandon

him

or

her

4. Makearealisticassessmentofonesabilityandtimetoassessandcareforasuicidalclient,aswellastheroleforwhichoneisbestsuited

UnderstandingSuicide

5. Definebasictermsrelatedtosuicidality6. Befamiliarwithsuiciderelatedstatistics7. Describethephenomenologyofsuicide8. Demonstrateunderstandingofriskandprotectivefactors

CollectingAccurateAssessmentInformation

9. Integrateariskassessmentforsuicidalityearlyoninaclinicalinterview,regardlessofthesettinginwhichtheinterviewoccurs,andcontinuetocollectassessmentinformationonanongoingbasis

10. Elicitriskandprotectivefactors11. Elicitsuicideideation,intent,plans,andrelatedbehaviors12. Elicitothersignsofsuiciderisk13. Obtainrecordsandinformationfromcollateralsourcesasappropriate

FormulationofRisk

14. Makeaclinicaljudgmentoftheriskthataclientwillattemptorcompletesuicideintheshortandlongterma. Integrateandprioritizealltheinformationthathasbeencollected

b. Assessacute

risk

of

suicide

c. Assesschronicorongoingriskofsuicide

15. Writethejudgmentandtherationaleintheclientsrecord


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TreatmentandServicesPlanning

16. Collaborativelydevelopacrisisresponseplanthatassuressafetyandconveysthemessagethattheclientssafetyisnotnegotiable

17. Developawrittentreatmentandservicesplanthataddressestheclientsimmediate,acute,andcontinuingsuicideideationandriskforsuicidebehavior

a. Addressriskandprotectivefactorsthatareamenabletochange

b. Specifythesettingandfrequencyofinterventionsforspecificperiodsoftime:immediate,acute,

continuingcare,maintenanceofresolvedsuicidality

c. Identifyarangeoftreatmentalternatives

d. Developtheplancollaborativelywiththeclient,familymembers,andsignificantothers

18. Coordinateandworkcollaborativelywithothertreatmentandserviceprovidersinaninterdisciplinaryteamapproach

ManagementofCare

19. Developpoliciesandproceduresforfollowingclientscloselyincludingtakingreasonablestepstobeproactive

a. Motivateandsupportclientsingettingthemtoareferralsourceortotheirnexttreatment/intervention

session

b. Engageincollaborativeproblemsolvingwiththeclienttoaddressbarriersinadheringtotheplanandto

revisetheplanasnecessarysessionbysession

c. Assurethat

the

client,

family,

significant

others,

and

other

care

providers

are

following

through

on

agreed

uponactions

d. Assesstheoutcomeofeachreferral

e. Developandimplementfollowupproceduresforallmissedappointments

f. Beavailablebetweenappointments

g. Arrangeforclinicalcoveragewhentherapistisunavailable

h. Assurecontinuityofcareandfollowupcontactwithallsuicidalclientswhohaveendedtreatment

20. Followprinciplesofcrisismanagementa. Takeaproblemsolvingapproach

b. Maintainamatteroffactdemeanor

c. Perceivecrisesasopportunitiesforgrowth

d. Knowthatcrisesareshortlived

e. Neitherpunishnorreinforcesuicidalbehavior.


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Documentation

21. Documentthefollowingitemsrelatedtosuicidalitya. Completeassessmentinformationrelatedtobiopsychosocialculturalconsiderations

b. Formulationandstatementofsuiciderisk,includingrationale

c. Suicidespecifictreatmentplanthatjustifiesoutpatientcareortheneedforinpatienthospitalization

d. Howsuicideriskandcrisesaretobemanaged

e. Interactionsandconsultationswithprofessionalcolleagues

f. Treatmentprogressandoutcomes

g. Dispositionandterminationinformation

LegalandRegulatoryIssues

22. UnderstandStatelawspertainingtosuicide.23. Understandlegalchallengesthataredifficulttodefendagainstasaresultofpoororincomplete

documentation

24. ProtectclientrecordsandrightstoprivacyandconfidentialityfollowingTheHealthInsurancePortabilityandAccountabilityActof1996thatwentintoeffectApril15,2003.


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ResourceSheet#2:TheLanguageofSuicide

ThedefinitionsofsuicideideationandsuicidalbehaviorprovidedinthisresourcesheetarefromtheColumbiaSuicide

SeverityRatingScale(CSSRS)*

SuicidalIdeation

Wishtobedead

Thepersonhaswishedtobedeadornotaliveanymore,orwishedtofallasleepandnotwakeup.Wishtobe

deadalsoisreferredtoasmorbidruminationsandisdistinguishedfromsuicidalthoughtsprimarilybytheintent

(i.e.nothoughtsoftakingonesownlife).Forexample,IwishIwerenotaround,deadornothere.Aclarifyingquestionregardingintentisneededtodifferentiatebetweenawishtobedeadandsuicideideation.

Forexample,youmayask,Yousaythatyouvehadthoughtsofbeingdead,haveyouhadthoughtsoftakingyour

ownlife?

Nonspecificactivesuicidalthoughts

Thepersonhasgeneralnonspecificthoughtsofwantingtoendhisorherlife(diebysuicide)withoutthoughtsof

waystokilloneself(associatedmethods),intent,orplan.Forexample,Ivethoughtaboutkillingmyself. Thisisincontrasttothenexttypeofsuicideideationinwhichtheindividualmentionsamethodofkillingoneself.

Activesuicidalideationwithanymethod,butwithoutplanandwithoutintenttoact

Thepersonhasthoughtsofsuicideandhasthoughtofatleastonemethod.Thepersondoesnothaveaspecific

planwithdetailsoftime,placeormethodworkedout.Forexample,IthoughtabouttakinganoverdosebutInevermadeaspecificplanastowhenwhereorhowIwouldactuallydoit..andIwouldnevergothroughwithit.

Activesuicidalideationwithsomeintenttoact,withoutspecificplan

Apersonhasactivesuicidalthoughtsofkillingoneselfandreportshavingsomeintenttoactonsuchthoughts.

Activesuicidalideationwithspecificplanandintent

Thepersonhasthoughtsofkillingoneself,detailsofplanfullyorpartiallyworkedout,andhassomeintenttocarry

itout.

*ColumbiaSuicideSeverityRatingScale(CSSRS)developedbyPosner,K.;Brent,D.;Lucas,C.;Gould,M.;Stanley,B.;Brown,G.;Fisher,P.;Zelazny,

J.;Burke,A.;Oquendo,M.;Mann,J..DefinitionsofbehavioralsuicidaleventsinthisscalearebasedonthoseusedinTheColumbiaSuicideHistory

Form,developedbyJohnMann,MDandMariaOquendo,MD,ConteCenterfortheNeuroscienceofMentalDisorders(CCNMD),NewYorkState

PsychiatricInstitute,1051RiversideDrive,NewYork,NY,10032.(OquendoM.A.,HalberstamB.&MannJ.J,Riskfactorsforsuicidalbehavior:utility

andlimitationsofresearchinstruments.InM.B.First[Ed.]StandardizedEvaluationinClinicalPractice,pp.103 130,2003.)ForreprintsoftheC

SSRScontactKellyPosner,Ph.D.,NewYorkStatePsychiatricInstitute,1051RiversideDrive,NewYork,NewYork,10032;inquiriescontact

[email protected]


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SuicidalBehavior

ActualAttempt:

Apersoncarriesoutapotentiallyselfinjuriousactwithatleastsomewishtodie,asaresultofact.Theintentdoesnothavetobe100%.Ifthereisanyintentordesiretodieassociatedwiththeact,thenitcanbeconsideredan

actual

suicide

attempt.

There

does

not

have

to

be

any

injury

or

harm,

just

the

potential

for

injury

or

harm.

For

example,ifpersonpullsthetriggerwhileagunisinhisorhermouthbutthegunisbrokensonoinjuryresults,this

isconsideredanattempt.

Inferringintent:Evenifanindividualdeniesintentordesiretodie,itmaybeinferredclinicallyfromthebehavior

orcircumstances.Forexample,itcanbeinferredthatahighlylethalact(e.g.,gunshottohead,jumpingfroma

windowofahighfloor/storyofabuilding)thatisclearlynotanaccident,isasuicideattempt.Inaddition,if

someonedeniesintenttodie,buttheythoughtthatwhattheydidcouldbelethal,intentmaybeinferred.

InterruptedAttempt(bysomeoneorsomething)

Apersonisinterrupted(byanoutsidecircumstance) fromstartingthepotentiallyselfinjuriousact.Ifnotforthe

interruption,an

actual

attempt

would

have

occurred. Forexample:1.)Personhaspillsinhandbutisstoppedfrom

ingesting.Oncetheyingestanypills,thisbecomesanattemptratherthananinterruptedattempt.2.)Personhas

gunpointedtowardself,gunistakenawaybysomeoneelse,orissomehowpreventedfrompullingtrigger.Once

theypullthetrigger,evenifthegunfailstofire,itisanattempt.3.) Personispoisedtojump,butisgrabbedand

takendownfromledge.4.)Personhasnoosearoundneckbuthasnotyetstartedtohangbecauseheorsheis

stoppedfromdoingso.

AbortedAttempt(byself)

Apersonbeginstotakestepstowardmakingasuicideattempt,butstopsbeforeheorsheactuallyengagesinthe

selfdestructivebehavior.Examplesaresimilartointerruptedattempts,exceptthattheindividualstopshimor

herself,

instead

of

being

stopped

by

someone

or

something

else.

Preparatoryactsorbehavior

Actsorpreparationtowardsimminentlymakingasuicideattempt.Thiscanincludeanythingbeyonda

verbalizationorthought,suchasassemblingaspecificmethod(e.g.buyingpills,purchasingagun)orpreparingfor

onesdeathbysuicide(e.g.givingthingsaway,writingasuicidenote)Preparationinvolvesbehaviorinanticipation

oftakingoneslifebutnotassociatedwiththeplanitself(e.g.writingletterstolovedones,writingawill,making

financialarrangements,etc)

Rehearsal

Rehearsal

is

implementing

the

steps

of

a

plan

for

suicide

short

of

making

a

suicide

attempt

(e.g.,

putting

a

rope

aroundonesneckorputtingaloadedguntooneshead).

CompletedSuicideorDeathbySuicide

Deathfrominjury,includingpoisoningorsuffocation,wherethereisevidencethattheinjurywasselfinflictedand

intendedtocausedeath.

Thetermcommittedsuicideisdiscouragedbecauseitconnotestheequivalencyofacrimeorsin.


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AdditionalTerms

Suicidality

Suicideideationorbehaviorsasdescribedabove.

Deliberateselfharm(DSH)

DSHisintentionalselfinjuriousbehaviorwherethereisnoevidenceofintenttodie. DSHincludesvarious

methodsbywhichindividualsinjurethemselves,suchasselflaceration,selfbattering,takingoverdoses,or

exhibitingdeliberaterecklessness. TheintentofDSHisvariableandcanincludesuchthingsasemotionregulation,

anger,revenge,andthedesiretoinfluencethebehaviorofothers.Unintentionalinjury(accident)

Fatalornonfatalinjuresthatwereunplannedandnotintendedtohappen.

Suicidegesture

Theword

gesture

is

not

recommended

language

because

it

implies

low

intent

when,

in

fact,

there

is

routinely

insufficientdatatosupportsuchasassessment.Itismorehelpfultorefertospecificbehaviordescribedinthis

resourcesheet.

Suicidethreat

Anyverbalornonverbalinterpersonalaction,stoppingshortofadirectlyselfharmact,whichcommunicatesor

suggeststhatthepersonwishestodieormayattemptsuicide.Theintentofthepersonmakingthethreatcannot

bedetermineduntilathoroughassessmentiscompleted.

Suicidology:Thescientificstudyofsuicideandsuicidalbehavior

Prevention

Interventionsdesignedtostopsuicideattemptsorcompletionsfromoccurringbyfocusingeffortsonatrisk

individuals,environmentalsafeguards,and/ortheavailabilityoflethalmethods.

InterventionorTreatment

Thecareofsuicidalpeoplebylicensedmentalhealthcaregivers,healthcareproviders,andothercaregiverswith

individuallytailoredstrategiesdesignedtochangethethoughts,behaviors,mood,environment,orbiologyof

individualsandhelpthemidentifyandsatisfytheirneedswithoutengaginginselfdestructivebehaviors.

Postvention

Thistermisusedtodescribeactionstakenafterasuicidehasoccurredlargelytohelpsurvivorssuchasfamily,

friends,andcoworkerscopewiththelossofalovedone.


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Survivors

Thetermsurvivorsoriginallyreferredtopeoplewhohadlostalovedonetosuicide.However,itisnowusedto

meanbothsuicideattemptsurvivorsandthosewhohavelostalovedonetosuicide.Itisimportanttoclarifytheuse

ofthistermwhendiscussingorwritingaboutsuicide.

SuicideAttempt

Survivors

or

Survivors

of

aSuicide

Attempt

(SOSA)

Individualswhohavesurvivedapriorsuicideattempt.

SuicideSurvivors

Familymembersandsignificantotherswhohavelostalovedoneduetosuicide.


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ResourceSheet#3:SuicideRelatedStatistics

Deathbysuicide1

In2005:32,637peopleintheU.S.diedbysuicide.Thisis1.3%ofalldeaths.Thisistheequivalentofone

persondying

by

suicide

every

sixteen

minutes

and

has

the

same

death

toll

as

ajetliner

full

of

people

crashing

everytwodays.

Suicideisthe3rdleadingcauseofdeathamongAmericansbetweentheagesof1524andthesecondleading

causeofdeathamongthosebetweentheagesof2534.

Suicideisthe11thleadingcauseofdeathoverall.

Suicideattempts(estimated)

In2005,anestimated816,000peopleintheU.S.attemptedsuicide(usingaratioof25attemptsforeach1

completedsuicide).2

Note:Estimates

of

the

ratio

of

suicide

attempts

to

suicide

deaths

range

from

200:1

for

youths

to

3:1

for

elders.Thevariationishighlydependentonthelethalityofmethodused.

Amongadults(1854)respondingtoanationalsurveyin20012003,0.6%reportedhavingattemptedsuicide

inthepast12months.3

Amongcollegestudentsrespondingtoalargesurveyin2000,1.5%ofstudentsreportedhavingattempted

suicideduringthepast12months.4

Amongstudentsingrades912respondingtoasurveyin2005,8.4%(10.8%offemalesand6%ofmales)

reportedhavingattemptedsuicideinthepast12months.5

Suicideideation

(estimated)

Foradults(1854)respondingtoanationalsurveyin20012003,3.3%reportedhavingseriouslyconsidered

suicideinthepast12months.4

Amongadultsaged18orolderwhoexperiencedapastyearmajordepressiveepisode,56.3percentthought,

duringtheirworstormostrecentepisode,thatitwouldbebetteriftheyweredead,40.3percentthought

aboutcommittingsuicide,14.5percentmadeasuicideplan,and10.4percentmadeasuicideattempt.6

Forcollegestudents,9.5%ofstudentsrespondingtolargesurveyreportedhavingseriouslyconsidered

suicideduringthepast12months.5

Forstudents

in

grades

912,

14.5%

(18.7%

for

females

and

10.3%

for

males)

reported

that

they

seriously

consideredsuicideduringthepast12months.Theprevalenceofsuicidalthoughtswashighestamong

Hispanicfemales(21.1%).7


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Survivors(estimated)2

Survivors:eachsuicidedeathaffectsintimatelyatleast6otherpeople.2Manyconsiderthisestimatetobe

conservative.

Methodofsuicide1

Firearms:52%

Suffocation/hanging:22%

Poisoning:18%

Cut/pierce:2%

Other:6%

Suicideandmentalillness

Ninetypercent

of

suicides

in

the

United

States

are

associated

with

adiagnosable

mental

illness,

substance

usedisorder,orboth.8 Childrenandyoungerteenswhodiebysuicidearemuchlesslikelytohavethese

disorders.

Fiftypercentofthosewhodiebysuicidewereafflictedwithmajordepression,andthesuiciderateofpeople

withmajordepressioniseighttimesthatofthegeneralpopulation.9

Gender,Ethnic,andAgeDifferencesinSuicidalBehaviors10

Malesarefourtimesaslikelytodiebysuicideasfemales,althoughfemalesarethreetimesaslikelyasmales

tomakeanonfatalsuicideattempt.

WhiteAmericans

are

more

likely

to

die

by

suicide

(rate

=12.3/100,000)

than

non

white

Americans

(rate

=

5.5/100,000).

ElderwhitemaleshavethehighestsuicideratesintheU.S.Thedeathrateofsuicideforwhitemales65+

yearsoldis32.6/100,000. ThedemographicgroupwiththelowestrateisAfricanAmericanwomen(rate=

1.8/100,000)

Amongyouth(ages1524),AmericanIndian/AlaskanNativemaleshavethehighestratesofsuicide

(32.5/100,000); Hispanicfemaleshavethehighestratesofsuicideattempts.

Youth(ages1019)1

Variationby

age.

The

suicide

rate

increases

from

late

childhood/early

adolescence

(10

to

14

years)

to

later

adolescence(15to19years).Thesearehighlysignificantdifferences.

o The2005suicideratewas1.89formales1014yearsofage;itwas12.39 morethansixtimes

higherformales1519yearsofage.

o The2005suicideratewas0.67forfemales1014yearsofage;itwas3.0241/2timeshigherfor

females1519yearsofage.


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Variationbyrace/ethnicity.

o Among1519yearoldmales,the2005suiciderates(per100,000)were:

24.14forAmericanIndian/AlaskanNatives

13.24forWhites

7.20forBlacks

4.81forAsian/PacificIslanders.

o Amongfemalesinthisagegroup,therateswere:

14.86forAmericanIndian/AlaskanNatives

3.13forWhites

3.11forAsian/PacificIslanders

1.43forBlacks

Variationovertime(20002005).

o Therehasbeenmuchmediaattentiontochangesinyouthsuiciderates,particularlyinrelationto

thecontroversyconcerningtheefficacyandsafetyofantidepressantmedicationsforthetreatment

ofdepressivedisordersinchildrenandadolescents. Althoughyouthsuicidecontinuestobea

national

tragedy

and

the

rates

are

far

too

high,

the

overall

rates

for

males

10

to

19

years,

and

females10to19yearswerelowerin2005than2004.

o The2005suicideratewasatorbelowthe6yearaverageformales1014yearsofage,males1519

yearsofage,andfemales1014yearsofage.

o The2005suicideratewashigherthanthe6yearaverageforfemales1519yearsofage. However,

itwasstillmeaningfullylowerthanthe2004rate. Therewere355suicidedeathsamong1519year

oldfemalesintheUnitedStatesin2004and310suicidedeathsforthisgroupin2005.

1NationalCenterforInjuryPreventionandControlandtheCentersforDiseaseControl.(2008).Webbasedinjurystatisticsquery

andreportingsystem(WISQARS).Retrievedmultipledatesin2007and2008,fromwww.cdc.gov/ncipc/wisqars

2American

Association

of

Suicidology.

(2008).

USA

Suicide:

2005

Official

Final

Data.

Retrieved

April

7,

2008,

from

http://mypage.iusb.edu/~jmcintos/usa2005summary.htm

3Kessler,R.,etal.(2005).Trendsinsuicideideation,plans,gestures,andattemptsintheUnitedStates,19901992.TheJournalof

theAmericanMedicalAssociation(JAMA),293(20),24872495.

4SuicidePreventionResourceCenter.(2004).Promotingmentalhealthandpreventingsuicideincollegeanduniversitysettings.

Newton,MA:EducationDevelopmentCenter,Inc.

5Eaton,D.K.,etal.(2006)YouthriskbehaviorsurveillanceUnitedStates,2005.MMWRSurveillanceSummaries,55(SS5)

RetrievedApril7,2008,fromhttp://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf

6SAMHSAsOfficeofAppliedStudies.(2006).Suicidalthoughts,suicideattempts,majordepressiveepisode,andsubstanceuse

amongadults.TheOASReport,34.Retrievedfromhttp://oas.samhsa.gov/2k6/suicide/suicide.pdf

7Eaton,D.K.,etal.(2008)YouthriskbehaviorsurveillanceUnitedStates,2007.MMWRSurveillanceSummaries,57(SS04)

RetrievedApril

7,

2008,

from

http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5704a1.htm?s_cid=ss5704a1_e

8Jacobs,D.,Brewer,M.,andKleinBenheim,M.(1999).Suicideassessment:Anoverviewandrecommendedprotocol.InD.Jacobs

(Ed.),The HarvardMedicalSchoolguidetosuicideassessmentandintervention.SanFrancisco:JosseyBass.

9SubstanceAbuseandMentalHealthServicesAdministration.(2001).NationalStrategyforSuicidePrevention(Goal1).Rockville,

MD:UnitedStatesPublicHealthService.

10CentersforDiseaseControlandPrevention.(2004).Suicide:Factsheet.Retrievedfrom

www.cdc.gov/ncipc/factsheets/suifacts.htm


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Assessingand

Managing

Suicide

Risk

RS#4:

Page

1of

12

ResourceSheet#4:SuicidePreventionResourcesandReferences

CrisisLines

NationalSuicide

Prevention

Lifeline

1800

273

TALK

(8255)

TheNationalSuicidePreventionLifelineisa24hour,tollfreesuicidepreventionserviceavailabletoanyonein

suicidalcrisis1-800-273-TALK (8255).Callersareroutedtotheclosestpossiblecrisiscenter.Withover120

crisiscentersacrossthecountry,themissionistoprovideimmediateassistancetoanyoneseekingmentalhealth

services.Callersmaydiscussthemselvesorsomeonetheycareabout. Callsarefreeandconfidential. TheLifeline

isnotaresourceforpractitionersinprovidingcare.

VeteransAffairs(VA)SuicideHotline1800273TALK(8255)andpress"1"toreachtheVAhotline

Toensureveteranswithemotionalcriseshaveroundtheclockaccesstotrainedprofessionals,theDepartmentof

VeteransAffairs(VA)hasbegunoperationofanationalsuicidepreventionhotlineforveterans.Tooperatethe

nationalhotline,

VA

is

partnering

with

the

Substance

Abuse

and

Mental

Health

Services

Administration

of

the

DepartmentofHealthandHumanServices(HHS)andtheNationalSuicidePreventionLifeline.Veteranscancall1

800273TALK(8255)andpress"1"toreachtheVAhotline,whichisstaffedbymentalhealthprofessionalsin

Canandaigua,N.Y.whoworkcloselywithVAmentalhealthprovidersinthecallerslocalareatorespondtocallers

needs.

TheTrevorHelpline 8664UTrevor 8664887386

TheTrevorHelplineistheonlynationalcrisisandsuicidepreventionhelplineforgay,lesbian,bisexual,transgender

andquestioningyouth.TheHelplineisafreeandconfidentialservicethatoffershopeandtrainedcounselorsto

talkto,24/7.

Organizationsdedicatedtosuicideresearch,trainingandeducation,prevention,andissuesrelatedto

survivors

AmericanAssociationofSuicidology(AAS): www.suicidology.org

ThegoaloftheAmericanAssociationofSuicidology(AAS)istounderstandandpreventsuicide.Foundedin1968

byEdwinS.Shneidman,Ph.D.,AASpromotesresearch,publicawarenessprograms,publiceducation,andtraining

forprofessionalsandvolunteers.Inaddition,AASservesasanationalclearinghouseforinformationonsuicide.

ThemembershipofAASincludesmentalhealthandpublichealthprofessionals,researchers,suicideprevention

andcrisisinterventioncenters,schooldistricts,crisiscentervolunteers,survivorsofsuicideandavarietyoflay

personswho

have

an

interest

in

suicide

prevention.

AASsAnnualConferenceforresearchers,clinicians,survivors,schoolpersonnel,volunteers,andothermental

healthprofessionalsincludespresentationsandworkshopsonlatestresearchfindings.AASpublishesSuicideand

LifeThreateningBehavior,aquarterlypeerreviewedjournalforcliniciansandresearchers.Alistofnotable

referencesinsuicidologyarelistedonthewebsite.


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Assessingand

Managing

Suicide

Risk

RS#4:

Page

2of

12

TheResearchDivisionofAASisdedicatedtoadvancingknowledgeaboutsuicidalbehaviorthroughresearch.

Activitiesofthisdivisioninclude:

SelectedresearchpaperspresentedattheAASannualmeetingareavailablefordownloading. ConsultationNetworkTaskforce(CNT)hasbeencreatedtohelpresearchersatalllevelsofexperiencein

theirresearchendeavors,forexample,relatedtoprogramevaluation,outcomemeasures,methodology,

finding

data

sources,

questions

about

theoretical

approaches

to

the

study

of

suicide,

prevention,

and

postvention.TheCNTisopentoallmembersofAAS.

TheClinicalDivisionofAASisdedicatedtopreventingandinterveninginsuicidalbehaviorthroughthesharingof

clinicalexpertiseandexperience.Recentprojectsinclude:

RecommendationsforInpatientsandResidentialPatientsKnowntobeatElevatedRiskforSuicide Jail/CustodySuicide:ACompendiumofSuicidePreventionStandardsandResources

TheCrisisCentersDivisionofAASsupportstheworkofcrisiscentersandhotlinesthroughtraining,educationand

certification.

AASlistservisanonlinediscussionforumforclinicians,researchers,educators.Tosubscribegoto

http://listserve.apa.org/archives/suicidology.html.Suicidology

archives

may

also

be

viewed

and

searched

at

this

location.

AmericanFoundationforSuicidePrevention(AFSP):www.afsp.org

TheAmericanFoundationforSuicidePrevention(AFSP)isdedicatedtoadvancingourknowledgeofsuicideand

ourabilitytopreventit.TheFoundationsactivitiesinclude:

Supportingresearchprojectsthroughgrantstohelpfurthertheunderstandingandtreatmentofdepressionandthepreventionofsuicide

Providinginformationandeducationaboutdepressionandsuicide Promotingprofessionaleducationfortherecognitionandtreatmentofdepressedandsuicidalindividuals Publicizingthemagnitudeoftheproblemsofdepressionandsuicideandtheneedforresearch,preventionandtreatment Supportingprogramsforsuicidesurvivortreatment,researchandeducation

TheFoundationpublishesscientificarticlesonsuicideintheLifesaversnewsletterpublishedquarterlyand

availableonthewebsite.AFSPfundsresearchstudiesandconductsworkshopsandconferencesthroughoutthe

country.

CentersforDiseaseControlandPrevention(CDC)http://www.cdc.gov

TheCDCisoneofthemajoroperatingcomponentsoftheDepartmentofHealthandHumanServices. Itsmission

istopromotehealthandqualityoflifebypreventingandcontrollingdisease,injury,anddisability.WithinCDC,the

NationalCenter

for

Injury

Prevention

and

Control

and

the

National

Center

for

Health

Statistics

provide

essential

informationtosupportsuicideprevention.

GlendonAssociation:www.glendon.org

TheGlendonAssociationisa501(c)(3)nonprofitwhosemissionistosavelivesandhelppeoplecreatemore

meaningfullivesbyaddressingthesocialproblemsofsuicide,violence,childabuseandtroubledinterpersonal

relationships,throughresearch,publiceducationandprofessionaltraining. Glendonproduceseducationalfilms,


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forbothprofessionalandpublicaudiences,addressingtopicssuchassuicideprevention,parenting,andcouple

relationships. Publicationsincludebooks,articles,andcomplimentarybrochures. Glendonstafftravelnationally

andinternationallytoconducttrainings. PsychologicalAssessmentResources,Inc.(www.parinc.com)distributes

thefollowingassessmentinstrumentsdevelopedbyGlendonstaff:FAST(FirestoneAssessmentofSelfDestructive

Thoughts);FASI (FirestoneAssessmentofSuicideIntent);andFAVT(FirestoneAssessmentofViolentThoughts).

For

more

information

contact

Jina

Carvalho

at

1

800

663

5281

or

[email protected].

InternationalAssociationforSuicidePrevention(IASP)http://www.med.uio.no/iasp/

IASPisdedicatedtopreventingsuicidalbehavior,toalleviateitseffects,andtoprovideaforumforacademicians,

mentalhealthprofessionals,crisisworkers,volunteersandsuicidesurvivors.

NationalInstituteofMentalHealth,SuicideResearchConsortium:

http://www.nimh.nih.gov/suicideresearch/consortium.cfm

ComprisedprimarilyofNIMHscientistsacrosstheInstitutewhoalsoadministerresearchgrants,theConsortium:

CoordinatesprogramdevelopmentinsuicideresearchacrosstheInstitute

Identifies

gaps

in

the

scientific

knowledge

base

on

suicide

across

the

life

span

StimulatesandmonitorsNIMHsponsoredresearchonsuicide Keepsabreastofscientificdevelopmentsinsuicidologyandpublicpolicyissuesrelatedtosuicide

surveillance

Preventionandtreatment Disseminatessciencebasedinformationonsuicidologytothepublic,media,andpolicymakers.

NationalOrganizationforPeopleofColorAgainstSuicide(NOPCAS):www.nopcas.org

TheNationalOrganizationforPeopleofColorAgainstSuicide(NOPCAS)supportsthedevelopmentofinnovative

researchtoidentifytheuniquefactorsinminoritycommunitiesthatcontributetosuicide;andcommunitybased

strategiestopreventsuicideandtheassociatedproblemsofviolenceanddepression.Suicideresources,research,

articles,andpublicationsareavailableontheNOPCASwebsite.

SubstanceAbuseandMentalHealthServices/CenterforMentalHealthServices(SAMHSA/CMHS)

http://mentalhealth.samhsa.gov/cmhs/default.asp

TheCenterforMentalHealthServicesistheFederalagencywithintheU.S.SubstanceAbuseandMentalHealth

ServicesAdministrationthatleadsnationaleffortstoimprovepreventionandmentalhealthtreatmentservicesfor

allAmericans.SAMHSA/CMHSpursuesitsmissionbyhelpingStatesimproveandincreasethequalityandrangeof

treatment,rehabilitation,andsupportservicesforpeoplewithmentalhealthproblems,theirfamilies,and

communities.CMHSprogramsandactivitiesinclude:

The

Jed

Foundation

http://www.jedfoundation.org

TheJedFoundationisthenationsleadingorganizationworkingtopreventsuicideandpromotementalhealth

amongcollegestudents.Weareguidedbyanexpertboardofmentalhealthprofessionalsinoureffortstoidentify

theunderlyingcausesofsuicideandproduceeffectiveprevention,awarenessandinterventionprograms.

TheSuicidePreventionActionNetwork(SPANUSA)http://www.spanusa.org/


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SPANUSAisa501(c)(3)organizationdedicatedtopreventingsuicidethroughpubliceducationandawareness,

communityactionandfederal,stateandlocalgrassrootsadvocacy.Theorganizationwasfoundedin1996by

GeraldandElsieWeyrauchofMarietta,Georgia,survivorsofthesuicideoftheir34yearoldphysiciandaughter,

Terri.Theirgoalwastocreateawayforsurvivorsofsuicide thosewhohavelostsomeonetosuicide to

transformtheirgriefintopositiveactiontopreventfuturetragediestoraiseawareness,buildpoliticalwill,and

take

action

with

regard

to

creating,

advancing,

implementing,

and

evaluating

a

national

strategy

to

address

suicide

inournation.

SPANUSAsmissionistoleveragegrassrootssupportamongsuicidesurvivors(thosewhohavelostalovedoneto

suicideandthosewhohaveattemptedsuicide)andotherstoadvancepublicpoliciesthathelppreventsuicide.

SPANUSA'sprojectsareguidedbyitsfourunderlyinggoalpriorities:

Advancingpublicpolicy, Organizingcommunities, Engagingsurvivors,and Promotingtheapplicationofbestpracticesinsuicideprevention.

SuicidePreventionResourceCenter(SPRC):www.sprc.org

TheSuicidePreventionResourceCenter(SPRC)supportssuicidepreventionwiththebestofscience,skillsand

practice.TheCenterprovidespreventionsupport,training,andinformationalmaterialstostrengthensuicide

preventionnetworksandadvancetheNationalStrategyforSuicidePrevention.Fundedthroughacooperative

agreementbetweentheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)andtheEducation

DevelopmentCenter,Inc.,(EDC),theSPRCworksincollaborationwithmanypartnerorganizationstoadvance

suicideprevention.

SPRCLibraryCatalogisasearchabledatabaseoftheSPRClibrarycollectionandcontainsadetailedrecordforeach

resource.A

professional

librarian

selects

resources

from

avariety

of

sources

such

as

published

works,

peer

reviewedresearch,curricula,andwebbasedresources.TheresourcescontainedintheSPRClibrarypromote

suicidepreventionefforts,fosterpreventionnetworks,andprovideinformationonthescopeofthesuicide

problem.

ResearchNewsBriefssectionoftheSPRCwebsiteprovidessummariesofcurrentresearchinsuicidology,selected

fortheirgeneralinterestandrelevancetosuicideprevention.

SPARK.Subscriberstothiselectronicnewsletterreceiveaweeklyenewslettercontainingannouncements,the

newsheadlinesandsummaries,summariesofthelatestresearch,andfundingnews.

SPRCTrainingInstituteTheSPRCTrainingInstituteprovidesaneverexpandingarrayofcurriculadesignedtobuild

capacityforsuicidepreventioninstate,tribal,local,andcommunitybasedorganizations.Thesehighquality

curriculareflecttheemphasisontrainingfoundintheNationalStrategyforSuicidePrevention,andinthatspirit,

areprovidedatthelowestcostpossibletoindividualsandcommunitiesacrossthecountry.Pleasecontactusat

[email protected]:

AssessingandManagingSuicideRisk:CoreCompetenciesforMentalHealthProfessionals StrategicPlanningforSuicidePrevention:Thismultidayworkshopisdesignedforsuicideprevention

coalitionsandplanninggroups.Usingapublichealthapproach,thecoursecoverstopicssuchas:


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accessingandusingdata;evidencebasedpractices;creatingaframeworkforevaluation;actionplanning;

andworkinginpartnerships.SPRCpartnerswiththeSuicidePreventionActionNetwork(SPANUSA)to

disseminatethecourse.

WebbasedSeminars:SPRCResearchtoPracticewebinarsfosterdialogueonsuicideandsuicidepreventionamongpractitioners,researchers,andothersworkinginthefield.Recordingsoftheseperiodic

web

based

seminars,

as

well

as

supplementary

materials

from

each

session,

can

be

accessed

online.

OnlineWorkshops:Fourselfpacedonlineworkshopsareavailablefreeofcharge.Eachworkshopfocusesonyouthsuicidepreventionbutmuchofthecontentisapplicabletosuicideacrossthelifespan.

Continuingeducationcreditsareavailable.

Journals

Muchoftheprimarysuicideresearchispublishedinthefollowingjournals:

ArchivesofGenPsychiatry JournalofConsultingandClinicalPsychology AmericanJournalofPsychiatry JournalofClinicalChildandAdolescentPsychology AmericanAcademyofChildandAdolescentPsychiatry SuicideandLifeThreateningBehavior,theofficialjournaloftheAmericanAssociationofSuicidology TheJournalofCrisisInterventionandSuicidePrevention,publishedundertheAuspicesofthe

InternationalAssociationforSuicidePrevention(IASP)

ArchivesofSuicideResearch,publishedundertheAuspicesoftheInternationalAcademyforSuicideResearch

Otherresources

ResourcesforFamilies

Ellis,T.E.,&Newman,C.F.(1996).Appendix:Guideforconcernedfamilymembersandfriends.InChoosingtoLive:HowtoDefeatSuicideThroughCognitiveTherapy.(pp.169181).Oakland,CA:New

HarbingerPublications,Inc.

Woolis,R.(1992).WhenSomeoneYouLoveHasaMentalIllness.NewYork,NY:PenguinPutnam,Inc. SAMHSAsNationalMentalHealthInformationCenter

Afteranattempt:Aguidefortakingcareofyourfamilymemberaftertreatmentintheemergencydepartment,http://mentalhealth.samhsa.gov/publications/allpubs/SVP0159/

Afteranattempt:Aguidefortakingcareofyourselfafteryourtreatmentintheemergencydepartment,http://mentalhealth.samhsa.gov/publications/allpubs/SVP0157/


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UnderstandingSuicidefromthePerspectiveofConsumersandSuicideAttemptSurvivors

FirstNationalConferenceforSurvivorsofSuicideAttempts,HealthCareProfessionals,andClergyandLaity.OnOct.1921,2005,over100participantsmetinMemphis,TN,fortheFirstNationalConference

forSurvivorsofSuicideAttempts(SOSAs),HealthCareProfessionals,andClergyandLaity. Asummaryof

theconferencereportmaybefoundontheSPRCwebsiteathttp://www.sprc.org/library/SOSAconf.pdf

LifelineServiceandOutreachStrategiesSuggestedbySuicideAttemptSurvivors;FinalReportoftheAttemptSurvivorAdvisorySummitMeetingandIndividualInterviews.Eightattemptsurvivorsattended

thesummitmeetinginNewYorkCityonJanuary16,2007.Fourotherattemptsurvivorswhowereunable

toattendthemeetingcontributedtheirsuggestionsduringindividualindepthphoneinterviews

conductedbetweenJanuary25andFebruary1,2007.Thereportoftheseinterviewsmaybefoundonthe

NationalSuicidePreventionLifelineNetwork(Lifeline)websiteat

http://www.suicidepreventionlifeline.org/media/pdf/NSPLSOSA_Report73107_FINAL.pdf

Ameetingheldwith26preventionprofessionals,healthcareproviders,researchers,policymakers,andconsumerswithpersonalexperienceinsuicideinAnnapolis,MarylandonNovember2829,2007. A

reportof

this

meeting

is

being

prepared

and

may

be

obtained

by

contacting

the

Office

of

Consumer

Affairs,SAMHSACenterforMentalHealthServicesat

http://mentalhealth.samhsa.gov/consumersurvivor/about.asp

NationalConsensusStatementonMentalHealthRecovery,producedataDecember,2004,meetingofmorethan110expertpanelists:consumers,familymembers,providers,researchers,publicofficials,and

others.ThefullstatementcanbefoundonSAMSHAsWebsite,

http://mentalhealth.samhsa.gov/publications/allpubs/sma054129/

References

Thefollowing

are

references

to

the

body

of

literature

that

undergirds

the

AMSR

curriculum.

WorkingwithIndividualsatRiskforSuicide:AttitudesandApproach

Brown,G.K.,Steer,R.A.,Henriques,G.R.,&Beck,A.T.(2005). Theinternalstrugglebetweenwishtoliveandwishtodie:Ariskfactorforsuicide. AmericanJournalofPsychiatry,172,19771979.

Chiles,J.A.,&Strosahl,K.D.(1995).Examineyourattitudes:affective,ethical,andlegalissuesinthetreatmentofthesuicidalpatient;Thecliniciansattitudeandbehavior:themediumisthemessage.InThe

SuicidalPatient:PrinciplesofAssessment,Treatment,andCaseManagement.Washington,D.C.:American

PsychiatricPress,Inc.

Chu,J.A.(1999).TraumaandSuicide.InD.Jacobs(Ed.).TheHarvardMedicalSchoolGuidetoSuicideAssessmentandIntervention.(pp.332354).SanFrancisco,CA:JosseyBassPublishing.

Ellis,T.E.(2004).Collaborationandaselfhelporientationintherapywithsuicidalclients.JournalofContemporaryPsychotherapy,34,4157.

Hendin,H.,Haas,A.P.,Maltsberger,J.T.,Koestner,B.,&Szanto,K.(2006)Problemsinpsychotherapywithsuicidalpatients.AmericanJournalofPsychiatry,163(1),p.6772.


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Jobes,D.A.(2000).Collaboratingtopreventsuicide:Aclinicalresearchperspective.SuicideandLifeThreateningBehavior,30(1),817.

Jobes,D.A.,&Drozd,J.F.(2004).TheCAMSapproachtoworkingwithsuicidalpatients.JournalofContemporaryPsychotherapy,34(1),7385.

Jobes,D.A.,&Mann,R.E.(1999).Reasonsforlivingvs.reasonsfordying:Examiningtheinternaldebateofsuicide. SuicideandLifeThreateningBehavior,29,97104.

Kovacs,M.,&Beck,A.T.(1977). Thewishtodieandthewishtoliveinattemptedsuicides. JournalofClinicalPsychology,33,361365.

Linehan,M.M.(1993).RelationshipStrategies.InCognitiveBehavioralTreatmentofBorderlinePersonalityDisorder.(pp.514519).NewYork,NY:TheGuilfordPress.

Maltsberger,J.T.,&Buie,D.H.(1974).Countertransferencehateinthetreatmentofsuicidalpatients.ArchivesofGeneralPsychiatry,30(5),625633.

Maltsberger,J.T.(2001).Treatingthesuicidalpatient.AnnalsoftheNewYorkAcademyofSciences,932,158168.

Maltsberger,M.K.,Jobes,D.A.,Leenaars,A.A.,Orbach,I.,Sadler,K.,Pascal,D.,Young,R.A.,&Valach,L.(2002).Discoveringthetruthinattemptedsuicide.AmericanJournalofPsychotherapy,56(3),424437.

Norcross,J.C.(Ed.).(2001).Empiricallysupportedtherapyrelationships:SummaryreportoftheDivision29TaskForce.Psychotherapy,38(4).

Orbach,I.(2001).Therapeuticempathywiththesuicidalwish:Principlesoftherapywithsuicidalindividuals.AmericanJournalofPsychotherapy,55(2),166184.

Shea,S.(2002).Beforetheinterviewbegins:Overcomingthetabooagainsttalkingaboutsuicide.InThePracticalArtofSuicideAssessment:AGuideforMentalHealthProfessionalsandSubstanceAbuse

Counselor.(pp.109123).Hoboken,NJ:JohnWiley&Sons.

Shneidman,E.S.(1985). Definitionofsuicide. NewYork:JohnWileyandSons. Werth,J.L.(2002).Incorporatingendoflifeissuesintopsychologycourses.TeachingofPsychology,29

(2),106111.

Werth,J.L.(2001).U.S.involuntarymentalhealthcommitmentstatutes:requirementsforpersonsperceivedtobeapotentialharmtoself.SuicideandLifeThreateningBehavior,31(3),348357.

Werth,J.L.,&Holdwick,D.J.(2000).Aprimeronrationalsuicideandotherformsofhasteneddeath.TheCounselingPsychologist,28(4),511539.

Specialsectiononculturalcompetency: Barnes,D.H.(2004).CulturalCompetency.InNationalOrganizationforPeopleofColorAgainstSuicide

(NOPCAS)TaskForceReporttoSPRCpostedonwww.nopcas.org.


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Constantine,M.G.&Sue,D.W.(2005)StrategiesforbuildingmulticulturalcompetenceinMentalhealthandeducationalsettings.JohnWileyandSons,Inc.

Goldston,D.B.,Molock,S.D.,Whitbeck,L.B.,Murakami,J.L.,Zayas,L.H.,&Hall,G.C.N.(2008).Culturalconsiderationsinadolescentsuicidepreventionandpsychologicaltreatment.AmericanPsychologist,

63(1),1431.

Griner,D.&Smith,T.B.(2006).Culturallyadaptedmentalhealthinterventions:Ametaanalyticreview.Psychotherapy:Theory,Research,Practice,Training,43(4),531548.

Hwang,W.(2006).Thepsychotherapyadaptationandmodificationframework:ApplicationstoAsianAmericans.AmericanPsychologist,61(7),702715.

InstituteofMedicine(2003).Unequaltreatment:Confrontingracialandethnicdisparitiesinhealthcare,TheNationalAcademiesPress,Washington,DC.

Leach,M.M.(2006).Culturaldiversityandsuicide:Ethnic,religious,gender,andsexualorientationperspectives.NewYork:TheHaworthPress,Inc.

Martin,M(2002).SavingOurLastNerve:TheBlackWomansPathtoMentalHealth,HiltonPublishingCompany,Munster,IN

Munoz,R.,Primm,A.,Ananth,J.,&Ruiz,P(2007).Lifeincolor:CultureinAmericanPsychiatry,HiltonPublishingCompany,Chicago,Illinois

Sue,S.(2006).Culturalcompetency:Fromphilosophytoresearchandpractice.JournalofCommunityPsychology,34(2),237245.

Whaley,A.L.&David,K.E.(2007)Culturalcompetenceandevidencebasedpracticeinmentalhealthservices:Acomplementaryperspective.AmericanPsychologist,62(6),563574.

Firstnationalconferenceforsurvivorsofsuicideattempts,health`careprofessionals,andclergyandlaity:Summaryofworkgroupreports http://www.sprc.org/library/SOSAconf.pdf

Lifelineserviceandoutreachstrategiessuggestedbysuicideattemptsurvivors.http://www.suicidepreventionlifeline.org/media/pdf/NSPLSOSA_Report73107_FINAL.pdf

UnderstandingSuicide

InstituteofMedicine.(2002).ReducingSuicide:ANationalImperative.(pp.69216).Washington,D.C.:TheNationalAcademiesPress.

Jacobs,D.&Brewer,M.(2004).AmericanPsychiatricAssociationpracticeguidelinesprovidesrecommendationsforassessingandtreatingpatientswithsuicidalbehaviors.PsychiatricAnnals,34(5),

373380.

Joiner,T.E.(2006).WhyPeopleDiebySuicide.Boston,MA:HarvardUniversityPress. Linehan,M.M.,&Laffaw,J.A.(1982).Suicidalbehaviorsamongclientsatanoutpatientpsychologyclinic

vs.thegeneralpopulation.SuicideandLifeThreateningBehavior,12,234239.


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Linehan,M.M.(1986).SuicidalPeople:OnePopulationorTwo?AnnalsoftheNewYorkAcademyofSciences,487,1633.

Luoma,J.B.,Martin,C.E.,&Pearson,J.L.(2002).ContactwithMentalHealthandPrimaryCareProvidersbeforeSuicide:AReviewoftheEvidence.AmJPsychiatry159:909916.

Maris,R.W.,Berman,A.L.,&Silverman,M.M.(2000).PartII:SociodemographicandEpidemiologicIssues.InComprehensiveTextbookofSuicidology.(pp.126308).NewYork,NY:TheGuilfordPress.

O'Carroll,P.W.,Berman,A.L.,Maris,R.W.,Moscicki,E.K.,Tanney,B.L.,&Silverman,M.M.(1996).BeyondtheTowerofBabel:Anomenclatureforsuicidology.SuicideandLifeThreateningBehavior,26(3),

237252.

Shneidman,E.S.(1996).Commonalitiesofsuicide.InTheSuicidalMind.(pp.129137).London:OxfordUniversityPress.

Styron,W.(1992).DarknessVisible:AMemoirofMadness.NewYork,NY:VintagePublisher. Wise,T.L.(2003).WakingUp:ClimbingThroughtheDarkness.Oxnard,CA:PathfinderPublishingof

California.

Statistics

CentersforDiseaseControlandPrevention(CDC)http://www.cdc.gov/Typesuicideinthesearchwindowtoobtainpublicationsandfactsheets.Typesuicidestatisticsinthesearchwindowtoobtainsourcesforcurrentdatarelatedtosuicide.

NationalCenterforInjuryPreventionandControl(NCIPC)http://www.cdc.gov/ncipc/WISQARS(WebbasedInjuryStatisticsQueryandReportingSystem)isaninteractivedatabasesystemthat

providescustomizedreportsofinjuryrelateddata(brokendownbyage,gender,race/ethnicity,state,

etc.)that

may

be

accessed

at

the

following

url:

http://www.cdc.gov/ncipc/wisqars/default.htm

OnlinecustomizedsearchespresentU.S.injurymortalitydataandnationalestimatesofnonfatalinjuries

treatedinU.S.hospitalemergencydepartments.

NationalViolentDeathReportingSystem(NVDRS)http://www.cdc.gov/ncipc/profiles/nvdrs/default.htmIn2002CDCreceivedfundingtoestablishtheNVDRStocollectdataonviolentdeathsfromavarietyof

sources,includingdeathcertificates,policereports,medicalexaminerandcoronerreports,andcrime

laboratories.Individually,thesesourcesprovidefragmenteddatathatexplainviolenceonlyinanarrow

context.Together,thesesourcesofferamorecomprehensivepictureofthecircumstancessurroundinga

homicideorsuicide.Asaresult,NVDRSprovidesinsightintotheoptimalpointsforintervention,thus

improvingviolencepreventionefforts.

CollectingAccurateAssessmentInformation

AmericanAcademyofChildandAdolescentPsychiatry.(2001).Practiceparameterfortheassessmentandtreatmentofchildrenandadolescentswithsuicidalbehavior.JournaloftheAmericanAcademyofChild&

AdolescentPsychiatry,40(Suppl.7),24S50S.


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Bongar,B.,Maris,R.W.,Berman,A.L.,&Litman,R.E.(1998).Chapter1:OutpatientStandardsofCareandtheSuicidalPatient.InB.Bongar,A.L.Berman,R.W.Maris,M.M.Silverman,E.Haris,&W.L.

Packman(Eds.).RiskManagementwithSuicidalPatients.(pp.433).NewYork,NY:TheGuilfordPress.

Brown,G.K.(2002).AReviewofSuicideAssessmentMeasuresforInterventionResearchwithAdultsandOlderAdults.TechnicalreportsubmittedtoNIMHunderContractNo.263MH914950.Bethesda,MD:

NationalInstituteofMentalHealth.http://www.nimh.nih.gov/suicideresearch/adultsuicide.pdf

Brown,L.M,Bongar,B.,&ClearyK.M.(2004).Aprofileofpsychologistsviewsofcriticalriskfactorsforcompletedsuicideinolderadults.ProfessionalPsychology:ResearchandPractice,31(1).

Goldston,D.B.(2003).MeasuringSuicidalBehaviorandRiskinChildrenandAdolescents.Washington,D.C.:AmericanPsychologicalAssociation.[Note:Muchoftheinformationinthisbookisalsoavailable

throughtheNIMHwebpublisheddocument:AssessmentofSuicidalBehaviorsandRiskamongChildren

andAdolescentsbyDavidB.Goldston.(2000)TechnicalReportsubmittedtoNIMHundercontract263

MD909995.Acriticaloverviewofinstrumentsusedtoassesssuicidalityinyouth.

http://www.nimh.nih.gov/suicideresearch/measures.pdf]

Jobes,D.A.,Eyman,J.R.,&Yufit,R.I.(1995).Howcliniciansassesssuicideriskinadolescentsandadults.CrisisInterventionandTimeLimitedTreatment,2,112.

Range,L.M.(2005).Thefamilyofinstrumentsthatassesssuiciderisk.JournalofPsychopathologyandBehavioralAssessment,27,133140.

Rudd,M.D.,Joiner,T.E.Jr.,Jobes,D.A.,&King,C.A.(1999).Theoutpatienttreatmentofsuicidality:Anintegrationofscienceandrecognitionofitslimitations.ProfessionalPsychology:Research&Practice,30

(5),437446.

Shea,S.(2004).TheDelicateArtofElicitingSuicidalIdeation.PsychiatricAnnals,34(5),374400.FormulationofRisk

AmericanAcademyofChildandAdolescentPsychiatry.(2001).Practiceparameterfortheassessmentandtreatmentofchildrenandadolescentswithsuicidalbehavior.JournaloftheAmericanAcademyofChild&

AdolescentPsychiatry,40(Suppl.7),24S50S.

Jacobs,D.,&Brewer,M.(2004).AmericanPsychiatricAssociationpracticeguidelinesprovidesrecommendationsforassessingandtreatingpatientswithsuicidalbehaviors.PsychiatricAnnals,34(5),

373380.

Joiner,T.E.Jr.,Walker,R.L.,Rudd,M.D.,&Jobes,D.A.(1999).Scientizingandroutinizingtheassessmentof

suicidality

in

outpatient

practice.

Professional

Psychology:

Research

&

Practice,

30

(5),

447

453.

Shea,S.(2002).Puttingitalltogether:Safeandeffectivedecisionmaking.InThePracticalArtofSuicideAssessment:AGuideforMentalHealthProfessionalsandSubstanceAbuseCounselors.(pp.191247).

Hoboken,NJ:JohnWiley&Sons.

TreatmentandServicesPlanning


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Baldessarini,R.J.,Tondo,L.,&Hennen,J.(1999).Effectsoflithiumtreatmentanditsdiscontinuationonsuicidalbehaviorinbipolarmanicdepressivedisorders.JournalofClinicalPsychiatry,60(Suppl.2),7784.

Berman,A.L.,Jobes,D.A,&Silverman,M.M.(2005).AdolescentSuicide:AssessmentandIntervention(2

nded.).Washington,D.C.:AmericanPsychologicalAssociation.

Brown,G.K.,TenHave,T.,Henriques,G.R.,Xie,S.X.,Hollander,J.E.,&Beck,A.T.(2005).Cognitivetherapyforthepreventionofsuicideattempts:Arandomizedcontrolledtrial.JournaloftheAmerican

MedicalAssociation,294(5),p.563570. Abstractat:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16

077050&query_hl=1

Ellis,T.E.(2001).Psychotherapywithsuicidalpatients.InD.Lester(Ed.).SuicidePrevention:ResourcesfortheMillennium.(pp.129152).AnnArbor,MI:SheridanBooks.

Guthrie,E.,Kapur,N.,MackwayJones,K.,ChewGraham,C.,Moorey,J.,Mendel,E.,etal.(2001).Randomisedcontrolledtrialofbriefpsychologicalinterventionafter deliberateselfpoisoning.BMJ,

323(7305),

135

138.

Jacobs,D.G.(Ed.).(1999).Appendix:Guidelinesforidentification,assessment,andtreatmentplanningforsuicidality.InTheHarvardMedicalSchoolGuidetoSuicideAssessmentandIntervention.(pp.579582).

SanFrancisco,CA:JosseyBass.

Jobes,D.A.,Wong,S.A.,Conrad,A.,Drozd,J.F.,&NealWalden,T. (2005). TheCollaborativeassessmentandmanagementofsuicidalityvs.treatmentasusual:Aretrospectivestudywithsuicidaloutpatients.

SuicideandLifeThreateningBehavior,35,483497.

LinehanMM,ComtoisKA,MurrayAM,BrownMZ,GallopRJ,etal.(2006).Twoyearrandomizedcontrolledtrialandfollowupofdialecticalbehaviortherapyvstherapybyexpertsforsuicidalbehaviors

andborderline

personality

disorder.

Archives

of

General

Psychiatry,

63(7),

p.

757

766.

Abstract

at

http://archpsyc.amaassn.org/cgi/content/abstract/63/7/757

Litts,D.A.,Radke,A.Q.,Silverman,M.M.(Eds.).(2008).SuicidePreventionEffortsforIndividualswithSeriousMentalIllness: RolesfortheStateMentalHealthAuthority.Washington,D.C.National

AssociationofStateMentalHealthProgramDirectors/

SuicidePreventionResourceCenter.(http://www.sprc.org/library/SeriousMI.pdf)

Meltzer,H.Y.(1999).Suicideandschizophrenia:ClozapineandtheInterSePTstudy.InternationalClozaril/LeponexSuicidePreventionTrial.JournalofClinicalPsychiatry,60(Suppl.12),4750.

Meltzer,H.Y.,Alphs,L.,Altamura,C.,Kerwin,R.,Chouinard,G.,Green,A.,etal.(2001).Effectofclozapineon

the

reduction

of

suicidality

in

schizophrenia

and

schizoaffective

disorder.

Paper

presented

at

the

AmericanCollegeofNeoropsychopharmacologyAnnualMeeting,Kona,Hawaii.

Motto,J.A.,&Bostrom,A.G.(2001).Arandomizedcontrolledtrialofpostcrisissuicideprevention.PsychiatricServices,52(6),828833.

Neimeyer,R.,Maltsberger,J.,&Leenaars,A.(1994).TreatmentofSuicidalPeople.NewYork,NY:BrunnerRoutledge,Inc.


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Assessingand

Managing

Suicide

Risk

RS#4:

Page

12

of

12

Simon,R.I.(2004).Collaborativetreatment.InAssessingandManagingSuicideRisk:GuidelinesforClinicallyBasedRiskManagement.(pp.105124).Washington,D.C.AmericanPsychiatricPublishing,Inc.

ManagementofCare

Chiles,J.A.,&Strosahl,K.D.(1995).Chapter7:CrisisandCaseManagementwithRecurrentSuicidalBehavior.

In

the

Suicidal

Patient:

Principles

of

Assessment,

Treatment,

and

Case

Management.

Washington,D.C.:AmericanPsychiatricPress,Inc.

Jobes,D.A.(2006). ManagingSuicidalRisk:ACollaborativeApproach. NewYork:TheGuilfordPress.

Documentation

Bongar,B.,Maris,R.W.,Berman,A.L.,&Litman,R.E.(1998).Chapter1:OutpatientStandardsofCareand

the

Suicidal

Patient.

In

B.

Bongar,

A.

L.

Berman,

R.

W.

Maris,

M.

M.

Silverman,

E.

Haris,

&

W.

L.

Packman(Eds.).RiskManagementwithSuicidalPatients.(pp.433).NewYork,NY:TheGuilfordPress.

Shea,S.(2002).AppendixA:Howtodocumentasuicideassessment.InThePracticalArtofSuicideAssessment:AGuideforMentalHealthProfessionalsandSubstanceAbuseCounselors.(pp.249285).

Hoboken,NJ:JohnWiley&Sons.

LegalandRegulatoryIssues

Bongar,B.(2002).LegalPerspectives.InTheSuicidalPatient:ClinicalandLegalStandardsofCare(2nded.,pp.3980).Washington,D.C.:AmericanPsychologicalAssociation.

Simon,

R.

I.

(2004).

Assessing

and

Managing

Suicide

Risk:

Guidelines

for

Clinically

Based

Risk

Management.

Washington,D.C.:AmericanPsychiatricPublishing,Inc.

Werth,JL.(2001).U.S.involuntarymentalhealthcommitmentstatutes:requirementsforpersonsperceivedtobeapotentialharmtoself.SuicideandLifeThreateningBehavior,31(3),348357.Abstract

at:http://www.ncbi.nlm.nih.gov/pubmed/11577919

SummaryofStateStatutesonInvoluntaryOutpatientCommitmentBazelonCenterforMentalHealthLaw,June2004 http://www.bazelon.org/issues/commitment/moreresources/iocchart.html


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ResourceSheet#5

SectionI:ClinicallyRelevantRiskandProtectiveFactors

Thissectionidentifiestheriskandprotectivefactorsthataremostsalientfortheclinicalassessmentandmanagementofsuiciderisk.

RiskFactors:

Riskfactorsaretraits,attributes,characteristics,orothervariablesthatareassociatedwithsuicideorsuicidal

behaviors.Thepresenceofriskfactorsisassociatedwithanincreasedriskforsuicideorsuicidalbehaviors.

Suicidality

Previoussuicideattempt

Multipleattempts=higherrisk

Suicideideationorbehaviors

Especiallywithintent,evidencedbyspecificplansandpreparatorybehaviors

Contextual/Interpersonal

Social

isolation

Exposuretosuicidalbehavior Mediaexposure Localclusters(e.g.,school)

Developmental/familyhistory

Historyofphysicalorsexualabuse

Familyhistoryofmentaldisorder,drugabuse,suicide

Chaoticfamilyhistory(e.g.,separationordivorce,changeincaretaker,changeinlivingsituationor

residence)

Victim

of

bullying

Discriminationrelatedtobeinglesbian,gay,

bisexual,transgender(adolescentsuicidal

behavior) Accessto,orfamiliaritywith,lethalmeans

Firearms

Medications

Stressors/Precipitants

Triggeringeventsleadingtoshame,humiliation,

ordespair

Foryouth:lossofrelationship,legal/disciplinary

problems/incarceration,conflict

Foradults:lossofrelationship,financialorhealthstatusrealoranticipated;legalordisciplinary

problems/incarceration;unemployment

Severephysicalillness,impairment,orpain

Pain

Centralnervoussystemdisorders,including

traumaticbraininjury

MentalHealth

Mentaldisorders

Mooddisorder:depressiveorbipolardisorder

Psychoticdisorder:schizophrenia

Alcohol/drugabuse/dependence

ClusterBpersonalitydisorder(antisocial/borderline)

Conductdisorder

Bulimia/anorexia

Anxietydisorder/PTSD

Mentalstatus/stateofmind/behavior

Impairedmentalstatus,particularlythoughtdisorder

Psychicpain:hurt,anguish,misery.Notethisisnotstressorphysicalpain

Perceivedburdensomeness

Stress:generalfeelingofbeingpressuredoroverwhelmed

Agitation:emotionalurgency;feelingthatyouneedtotakeaction;notirritation;notannoyance

Hopelessness:expectationthatthingswillnotgetbetternomatterwhatyoudo

Selfhate:generalfeelingofdislikingyourself;noselfesteem;noselfrespect

Depressedmood

Anxiety/panic

Anger

Anhedonia

Impulsivity

Poorrealitytesting

Sleepdisturbances

Commandhallucinations

Intoxication

Aggressivetendenciesorhistoryofviolentbehavior

Recklessness

Changeintreatment

Dischargefrompsychiatrichospitalization

Changeintherapist

Changeintreatmentapproach/medication


25/34


ProtectiveFactors:

Protectivefactorsaretraits,attributes,characteristics,orothervariablesthatareassociatedwithlessenedriskfor

suicideorsuicidalbehaviorsacrossthelifespan.

Clinicalcare

Effectivecareformental,physical,andsubstanceabusedisorders

Positivetherapeuticrelationships

Easyaccesstoavarietyofclinicalinterventionsandsupportforhelpseekingindividuals

Family&communitysupport

Strongconnectionstofamilyandcommunitysupport

Responsibilitytochildrenandbelovedpets

Supportthroughongoingmedicalandmentalhealthrelationships

Resilience

Copingskills

Frustrationtolerance

and

emotion

regulation

Culturalandreligiousbeliefsthataffirmlifeanddiscouragesuicide


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ResourceSheet#5

SectionII:OtherRiskFactors

Thissectionprovidesamoreglobaloverviewofsuicideriskfactors,endingwithtwoexercisestobecompletedbeforethestartoftheworkshop. Thediscussionofmoreclinicallysalientfactorsismuchmoregeneralthanthechartin

SectionIabove.Overviewofepidemiology

Everyyearapproximately30,000peoplediebysuicideintheUnitedStates.Approximately650,000peopleyearlyreceive

emergencytreatmentafterattemptingsuicide. ItisthethirdleadingcauseofdeathamongAmericanyouthsandthe

eleventhforAmericansofallages.

Overthelast100yearssuicideshaveoutnumberedhomicidesbyatleast3to2.

Theratesofsuicideareexceptionallyhighamongcertainpopulationsandtheratesamongworkingagedadultsarerising.

Inalmostallindustrializedcountries,men75yearsofageandolderhavethehighestsuiciderateamongallagegroups.In

theU.S.,thisdistinctionistrueonlyforWhitemales.TherateofsuicideamongAmericanIndiansandAlaskaNatives

(AI/AN)oftheUnitedStatesisabout1.7timestherateofthenationasawhole;youthsuicideratesarehighestforthis

racialgroup.Suicideratesforjailinmatesare9timesgreaterthanthatofthegeneralpopulationand15timeshigherfor

menalone.Younghomosexualorbisexualmalesareatgreaterriskthanheterosexualsforsuicideattempts,butfindings

arelessclearregardingsuicidecompletion.

Over90percentofsuicidesintheUnitedStatesareassociatedwithmentalillnessand/oralcoholandsubstanceabuse.

Yetisimportanttorememberthatasmanyas10percentofpeoplewhocompletesuicidedonothaveanyknown

psychiatricdiagnosis. Thispercentageappearshigherinsomepopulations,especiallyyoungerteens.

Psychological,biological,socialandculturalfactorsallhaveasignificantimpactontheriskofsuicide. Whileriskfactors

areoftendiscussedindividually,theneedforanintegratedunderstandingismostimportant.

Psychologicalfactors

Psychiatricdisorder

Thevastmajorityofindividuals(over90%)whodiebysuicidesufferfromdiagnosablepsychiatricdisorders.Almostall

psychiatricdisorders,includingalcoholandsubstancedisordersareassociatedwithanincreasedriskofsuicide.

Suicidemostcommonlyisassociatedwithadiagnosisofdepression.Recentresearchhasincreasinglyestablishedanxiety

disordersandborderlinepersonalitydisorderassignificantlyelevatingsuiciderisk.Comorbidityofpsychiatricdisorders

and/orsubstanceabusefurtherincreasessuiciderisk. About90percentofsuicidesareassociatedwithmentalillness,but

over95percentofthoseafflictedneverevenattemptsuicide.

Alcoholabuse

Aboutone

fourth

of

all

completed

suicides

in

the

U.S.

are

individuals

with

alcohol

use

disorders.

Alcohol

intoxication

is

indicatedinasmanyas64percentofsuicideattempts.Alcoholorsubstanceusedisorder,conductdisorder,and

impulsivity/sensationseekingoftencooccurandrepresentparticularsuicideriskforyouth.

Hopelessness

Hopelessnessisrelatedtosuicidalityacrossage,diagnoses,andseverityofdisorder.Hopelessnessisacritical,modifiable

riskfactorforreducingsuicide.Effectivetreatmentsexistforreducinghopelessness.


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Biologicalfactors

Dysregulationofthehypothalamicpituitaryadrenal(HPA)axis

DysregulationoftheHPAaxisappearsassociatedwithsuicidalityacrosspsychiatricdiagnoses.SuchHPAaxisdysfunction

oftendevelopsfollowingadversedevelopmentalexperiencesandtraumaticorchronicstress.

Reducedserotonergicandalterednoradrenergicfunction

Lowlevelsofserotoninand/oritsmetabolitehavebeenfoundinthebrainsandcerebrospinalfluidofserioussuicide

attemptersandthosewhocompletesuicide.Studiessuggestthatimpairedserotoninfunctionspecificallyinfluences

suicidalityviaincreasedimpulsiveaggression.

Geneticinfluences

Studiesfindevidenceofgeneticinfluencesonsuicidalityviafamilialaggregationofsuicide,highsuicideratesamong

adopteeswhosebiologicalfamilieshaveelevatedrates,andhighconcordanceofsuicideamongidenticalvs.fraternal

twins.

Childhoodtrauma

Childhoodtrauma,especiallychildsexualabuse,hasemergedasastrongandindependentriskfactorforsuicidalbehavior

inadolescentsandadults.Ofthemanytypesofchildhoodtrauma,childhoodsexualabuseisthestrongestandmost

independentriskfactorforsuicideattempts,accountingfor9to20percentofsuicideattempts.

Exposuretochildhoodtraumacanaffectthedevelopingbrainwithpotentiallylifelongalterationsinthephysiological

stressresponsesystemandcognitivedevelopment(aswellaspsychologicalandbehavioraleffects).

SocialandCulturalFactors

Familialfactors

Arelativewhohasattemptedorcompletedsuicidecanserveasabehavioralmodelforanotherfamilymember;orcan

signalagenetic

or

biochemical

vulnerability

to

suicide.

Parentalpsychopathology(suchasdepression,substanceabuse,oradmissiontopsychiatrichospital)isassociatedwith

increasedriskforsuicide.

Familyhistoryofsexualabuseandfamilydiscordareassociatedwithincreasedriskforsuicide.

Contagion

Thecopycateffectisthetermusedtodescribethephenomenonofwhathappenswhenahighlypublicizedsuicidal

actiondescribedindetailstimulatesotherstoengageinthesameorsimilarbehavior.Contagionunderliesclustersof

suicide.

Perceptionof

suicide

Culturestronglyinfluenceshowindividualsviewsuicide.Culturalvaluesandsocialstructureslargelydeterminethetype

anddegreeofbothstressorsandsupport,availabilityoflethalmeans,accesstotreatment,andsocialprescriptionsor

proscriptionsconcerningsuicidalbehavior.Culturesvaryintheirstigmaagainstsuicide,mentalhealthtreatment,andin

theinfrastructureformonitoringdeathbysuicide,renderingcrossculturalcomparisonsofsuicidalbehaviordifficult.


28/34


RiskFactors:associatedwithanincreasedoccurrenceofsuicidalbehavior1

Sociocultural

Historyoffamilyviolence:childhoodtrauma

Familyhistory

of

alcoholism

Socialisolation:loworlackofsocialsupportand

senseofisolation

Exposuretosuicidalbehavior:familyhistoryof

suicide

Exposuretosuicidethroughthemedia

Stigmaassociatedwithhelpseekingbehavior

Barrierstoaccessinghealthcare,especiallymental

healthservicesandsubstanceabusetreatment

Certain

cultural

and

religious

beliefs

(e.g.,

suicide

is

anobleresolutionofapersonaldilemma)

Societalbreakdown

Bullying

Beingbullied

Familyconflicts

Environmental

Easyaccesstolethalweapons:accesstoafirearm

Unemploymentor

financial

loss

Relationalorsocialloss

Localclustersofsuicidethathaveacontagious

influence

Frequentmobility

Demographics

Malegender(forcompletions)

Femalegender(fornonfatalattempts)

Olderage

Whiterace

NativeAmerican(youth)

1ThelistofriskandprotectivefactorsisinadditiontothoselistedinSectionI. Itisneitheracompletelistnorprioritizedinanyorder.


29/34


PreworkshopExercise

PartA:Refertothechartsaboveandcircleriskfactorsandunderlineprotectivefactorsdescribedinthe

followingcasestudies

Penny

Pennyis12yearsold.Hercocaineaddictedfatherwalkedoutwhenshewas5,onlyweeksafterherbrotherwasbornand

diagnosedas

having

cerebral

palsy,

never

to

be

seen

again.

As

asingle

parent,

Pennys

mother

was

overwhelmed

with

the

demandsofattendingtoherbrothersneeds;Pennyfrequentlywasthrustintoasurrogateparentroleinordertohelpher

mothermerelycope. Occasionallybabysitterswerehiredtoalleviatehermothersstress.Onebabysitter,amiddleaged

womanandafriendofthemother,hadateenagesonwho,wheneverhecould,sexuallyabusedPenny.Pennywassworn

tosecrecylestsomemoreintolerablefateweretobefallherorherbrother.

Pennywithdrewintoherself.Abrightstudentatfirst,herschoolperformancefalteredandshehaddifficultyconcentrating.

Shecomplainedofdysmenorrhea.Sheincreasinglythrewtempertantrumsandwasoppositionaltowardhermotherand

teachers.Moreoften,shesimplywouldavoidschool.Twice,unbeknownsttoanyone,shetriedadifferentkindof

withdrawal,toyingwithsomeofhermotherssleepingpills,takingafewtotestouthowlongshewouldsleep,

Threedayspriortoherarrivalintheemergencyroom,Pennywatchedatelevisionmovieaboutsexualabuseandthewalls

cametumblingdown.Pennysrage,fear,andsenseofworthlessnesstearfullypouredouttohermother,alongwithher

storyofabuse.Withhermothersdisbelief,therenowemergedinPennyapanicthatherabusersthreatsnowwouldbe

enacted.Heranxietysimplyoverwhelmedher. Shefoundthe.22caliberhandgunhermotherhadhiddenintherearofher

nightstandandpulledthetrigger.

PR

PRsfirsthospitaladmissionwasattheageof12.Diagnosedashavingamajordepression,hewasadmittedwithahistory

ofschoolvandalismandstealing,eneuresis(12times/week),andmorbidobesity.Atadmissionheadmittedtoincreasing

suicideideation.Hewashospitalizedfor7monthswithmajortreatmentfocibeinghisbodyimage,anxietyandanger

management,andsocialwithdrawal.

Hissecondhospitalizationoccurredattheageof17.Broughttothehospitalbyhismotherforepisodesofangryoutburst,

paranoia

(he

feared

he

was

being

watched

through

holes

in

their

apartment

wall),

self

cutting

(xs

on

arms

in

honor

of

thosewhohadturnedagainsthim)andsymptomsofvisualhallucinations,hewasinvoluntarilyadmitted.Afterfourdays

hewasdischargedwithanAxisIdiagnosis:Adjustmentdisorderwithmixeddisturbancesofemotionandconductandan

AxisIIdiagnosis:BorderlinePersonalityDisorder.

PRhadbeenunemployedforsixmonthsandhadgivenuplookingforwork.Hereportedlyranoutofmarijuanathreedays

agoandsaidhewasgoingcrazy.Duringhishighschoolyearshereportedlydealtdrugsandwasdependenton

amphetamines.HecurrentlywastakingDepakoteandZoloft.

PartB:HighlightriskandprotectivefactorsinPreworkshopReadingResourceSheet#6:ThePhenomenology

ofSuicide:FirstPersonNarratives


30/34

AssessingandManagingSuicideRisk RS#6:Page1of5

ResourceSheet#6:ThePhenomenologyofSuicideFirstPersonNarratives

Phenomenologyofsuicide,theexperienceofsuicidefromaclientsperspective Developmentalhistory.Clientnarrativesandpsychologicalautopsystudiesrevealthatsuicidedoes

nothaveasimplecause.Itistheculminationoflifeeventsandhasadevelopmentalhistory.

Psychicpain.Thementalanguishcalledpsychicpainmaybeanoverarchingdescriptionoftheexperiential/phenomenologicalstatethatleadsanindividualtoseekdeaththroughsuicideasan

escape.

FromVoicesofSuicide:LearningfromThoseWhoLiveADVDavailablefromTheGlendonAssociation(http://www.glendon.org/index.html)

Kevin,talkingabouthissuicideattempt:September24,2000rollsaround. Idecidethisisit. TomorrowImgoingtoendmylife. Iwasreadyto

go. Iwasjustgone. Itwasover. Iknewwhatwasgoingtohappen. Imgoingtogotothebridge. Im

goingtojump. Itsjustthatsimple. Thatsit. Theresnoifs,ands,orbuts. Itsdone.

IwentouttotheGoldenGateBridge.OnthebusIbegantocrysoftlyintheback. Thebuswaspacked. On

thebusIbeganthinking:IfonepersoncomesuptomeandsaysAreyouOK?Illturnaround. Ifone

personcomesuptomeandasksifanythingswrong,Iwilltellthemeverything.

IgotoutattheparkinglotandIthought:Kevin,turnaround. Getonthebusagain. Goback. ThenIheard

voices:Youmustdie. Youmustdie.

SoIwalkedontothespan. Imusthavebeentherefortyminutes. Andonceagain,Ithought:Oneperson

hastocomeuptomeandsay,AreyouOK? Oneperson. Anybody. AwomanwasapproachingmeandI

thought:Oh,thankGod. ThankyouGod. Shehadsunglassesonandanaccent. Shecameupandshe

said:Willyoutakemypicture?Itookherpictureaboutfivetimes. Isaid:Nobodycaresaftersheleft. I

turnedaround,backeduptotherailingnexttotheroadway,ran,andcatapultedmyselfoverwithmy

armsThesplitsecondIhitfreefall,Ithought:OhmyGod. Idontwanttodie.WhatdidIjustdo? Iwas

wideawake. Thevoicesweregone. Iwasrighttherefacingultimatedeath.

Kevintalkingabouthisrecovery:WhenIgotbetterinmylastcyclein2005,Ijuststarteddoingthelittlethings. Istartedbrushingmy

teeth. IshavedmybeardthatIhadgrownthreeinches. Itookashowereveryday. Andallthosethings

seemsmallbutIhadtostartatbabystepstogetbetter. Today,unlikeinthepast,whereIwasnt

followingaroutine,unlikethepastwhereIusedtonottakemymedicationsomedaysandthentakeit

otherdays,unlikethepastwhereIwouldtellmypsychiatristandtherapistliestogetthemtoleaveme


31/34


alone,Imcompletelyhonestintherapyabouteverythingthatsbotheringme. Itakemymedicationdaily

atthesametimeeveryday.

Ivehadsymptoms,obviously,andthatsgoingtohappenprobablyfortherestofmylife,asIunderstand

it. Ivehaddepressionsbutinsteadofthemlastingaweek,twoweeks,oramonth,theylastfifteen

minutesorlessbecauseIactivelyworktogetoutofthedepression. So,whenIfeelthatcomingon,andI

knowits

clinical,

Ill

tell

Marge,

my

wife,

Hey,

Im

going

to

need

someone

to

talk

to

right

now.

Or

Ill

get

up,andgetdressed,andgoonaruntoreleasesomeendorphinsintomybraintofeelbetter. AndifI

becomemanic,thefirstpersontonoticeitisme,insteadofeveryonearoundme.Isitdownandkindof

meditate,slowingdownmythoughts.

FromDarknessVisibleByWilliamStyron,copyright1990byWilliamStyron.UsedbypermissionofRandomHouse,Inc.

WhatIhadbeguntodiscoveristhat,mysteriouslyandinwaysthataretotallyremotefromnormal

experience,thegraydrizzleofhorrorinducedbydepressiontakesonthequalityofphysicalpain.Butitis

notan

immediately

identifiable

pain,

like

that

of

abroken

limb.

It

may

be

more

accurate

to

say

that

despair,owingtosomeeviltrickplayeduponthesickbrainbytheinhabitingpsyche,comestoresemble

thediabolicaldiscomfortofbeingimprisonedinafiercelyoverheatedroom.Andbecausenobreezestirs

thiscaldron,becausethereisnoescapefromthissmotheringconfinement,itisentirelynaturalthatthe

victimbeginstothinkceaselesslyofoblivion

AndsoWilliamStryron,awardwinningwriter,describeshisexperiencewithdepressionultimatelyleading

tosuicidalideationandbehavior.Thefollowingpassagesareexcerptedfromhisbookandtobeusedfor

instructionalpurposesinthetrainingofmentalhealthprofessionalsworkingwithindividualsatriskfor

suicide.

InParis

on

achilly

evening

late

in

October

of

1985,

Ifirst

became

fully

aware

that

the

struggle

with

the

disorderinmymind,astrugglewhichhadengagedmeforseveralmonths,mighthaveafataloutcome.

OnlydaysbeforeIhadconcludedthatIwassufferingfromaseriousdepressiveillness,andwas

flounderinghelplessinmyeffortstodealwithit.AsIdrovepastHotelWashington,ahotelIhadnotseen

innearly35yearsIrecalledmystaytheresomanyyearsbeforewhenIwrotemyfirstnovelandwasa

youngcelebrity,causingmetofeelthatIhadcomefatallyfullcircle.IrecallsayingtomyselfthatwhenI

leftParisforNewYorkthenextmorningitwouldbeamatterofforever.Iwasshakenbythecertainty

withwhichIacceptedtheideathatIwouldneverseeFranceagain,justasIwouldneverrecapturea

luciditythatwasslippingawayfrommewithterrifyingspeed.

Ifthe

pain

were

readily

describable

most

of

the

countless

sufferers

from

this

ancient

affliction

would

have

beenabletoconfidentlydepictfortheirfriendsandlovedones(eventheirphysicians)someoftheactual

dimensionsoftheirtorment,andperhapselicitacomprehensionthathasbeengenerallylackingdueto

thebasicinabilityofhealthypeopletoimagineaformoftormentsoalientoeverydayexperience.For

myself,thepainismostcloselyconnectedtodrowningorsuffocation,buteventheseimagesareoffthe

mark.


32/34


Neverletitbedoubtedthatdepression,initsextremeform,ismadness.Themadnessresultsfroman

aberrantbiochemicalprocess.Ithasbeenestablishedwithreasonablecertainty(afterstrongresistance

frommanypsychiatrists,andnotallthatlongago)thatsuchmadnessischemicallyinducedamidthe

neurotransmittersofthebrain,probablyastheresultofsystemicstress,whichcausesadepletionofthe

chemicalsnorepinephrineandserotonin,andtheincreaseofahormone,cortical.Withallthisupheavalin

thebraintissues,thealternatedrenchinganddeprivation,itisnowonderthatthemindbeginstofeel

aggrieved,stricken,

and

the

muddied

thought

processes

register

the

distress

of

an

organ

in

convulsion.

Sometimes,thoughnotveryoften,suchadisturbedmindwillturntoviolentthoughtsregardingothers.

Butwiththeirmindsturnedagonizinglyinward,peoplewithdepressionareusuallydangerousonlyto

themselves.

Loss,inallofitsmanifestationsisthetouchstoneofdepressionintheprogressofthediseaseand,most

likely,initsorigin.AtalaterdateIwouldgraduallybepersuadedthatdevastatinglossinchildhood

figuredasaprobablygenesisofmyowndisorder;meanwhile,asImonitoredmyretrogradecondition,I

feltlossateveryhand.Lossofselfesteemisacelebratedsymptom,andmyownsenseofselfhadallbut

disappeared,alongwithanyselfreliance.Thislosscanquicklydegenerateintodependence,andfrom

dependence

into

infantile

dread.

One

dreads

the

loss

of

all

things,

all

people

close

and

dear.

There

is

an

acutefearofabandonment.Beingaloneinthehouse,evenforamoment,causedmeexquisitepanicand

trepidation.Mylossesmountedandproliferated.Thereisnodoubtthatasonenearsthepenultimate

depthsofdepression,whichistosayjustbeforethestagewhenonebeginstoactoutonessuicide

insteadofbeingamerecontemplatorofitthatacutesenseoflossisconnectedwithaknowledgeoflife

slippingawayatacceleratedspeed.

Itishopelessnessevenmorethanpainthatcrushesthesoul.Sothedecisionmakingofdailylifeinvolves

not,asinnormalaffairs,shiftingfromoneannoyingsituationtoanotherlessannoyingorfrom

discomforttorelativecomfortforfromboredomtoactivitybutmovingfrompaintopain.With

depression,youbecomethewalkingwounded.Thesuffererfromdepressionisthrustintothemost

intolerablesocial

and

family

situations

and

there

he

must,

despite

the

anguish

devouring

his

brain,

presentapleasantface,trytouttersmalltalk,beresponsivetoquestions,andknowinglynodandfrown

andGodhelphim,evensmile.

AfterIhadreturnedtohealthandwasabletoreflectonthepast,Ibegantoseeclearlyhowdepression

hadclungclosetotheouteredgesofmylifeforyears.Suicidehasbeenapersistentthemeinmybooks.

Myfatherbattledthegorgonformuchofhislifetime,andhadbeenhospitalizedinmyboyhoodaftera

despondentspiralingdownwardthatinretrospectIsawgreatlyresembledmine.ButImpersuadedthat

anevenmoresignificantfactorwasthedeathofmymotherwhenIwasthirteen.

Forthosewhohavedweltindepressionsdarkwood,andknownitsinexplicableagony,theirreturnfrom

theabyss

is

not

unlike

the

ascent

of

the

poet,

trudging

upward

and

out

of

hells

black

depths

and

at

last

emergingintowhathesawastheshiningworld.There,whoeverhasbeenrestoredtohealthhas

almostalwaysbeenrestoredtothecapacityforserenityandjoy,andthismaybeindemnityenoughfor

havingenduredthedespairbeyonddespair.


33/34


FromWakingUp:ClimbingThroughtheDarknessByTerryL.Wise(www.TerryWise.com)

Theseexcerptshavebeenreprintedwiththeconsentofthepublisher,PathfinderPublishing,Inc.,120

SouthHoughtonRoad,Tucson,Arizona85648,andaretobeusedforinstructionalpurposesinthetraining

ofmentalhealthprofessionalsworkingwithindividualsatriskforsuicide.

TerryWisestruestorytoldinnarrativeformisofloveandpainandincludesherdialoguewithatherapist

whowaswillingtostickwithherandhelpputherbrokenhearttogetheragain.Terrytriedtokillherselfbut

survived.

Thefollowingpassagesareexcerptedfromherbook.

March2000Ivehadunbelievableanxietyforweeks,Iadmitted...Ivetriedtokeepthingsundercontrol.Ihate

havinganxietyattacksandtalkingabouthowtheyfeelonlyexacerbatestheangst,Iexplained,already

feeling

the

resurgence

of

palpitations

in

my

chest.

Anxietyandloneliness.EvenwhenImwithpeople,Ifeelalone...ExceptfortheyearsKurtwashealthy,

Iveprobablyfeltlikethismostofmylife.

Ifinallydecidedtobravemymostprivate,definingcharacterflaw.Itshardtotellyou...ThetruthisthatI

amaloser.

TheyseetheimageIvecreatedthatImmorepopularandgroundedthanIreallyam...Ireallyfeelthat

Iwasbornwithsomethinginsideofmethatmakesmealoser.

IthinkIfirstnoticeditsomewherearound10yearsold.

Im

innately

a

malcontent.

I

get

bored

or

uninterested

in

things

so

quickly.

Its

really

hard

for

me

to

find

anythingoranyonethatIenjoyforanylengthoftime...Ivespentamajorityofmylifeboredand

unhappy...Ivealwaysfeltlikedyingwasbetterthanliving.

Icantrememberexactlywhenitbeganbut,Idistinctlyrememberbeinginthefourthgrade,walking

acrosstheschoolfield,scuffingmyheelsthroughthegrass,thinkinghowIcouldntwaituntilthiswas

overlife,thatis.

December2000IclosedthebookIhadstudiedonassistedsuicideandpouredwhatremainedofthemorphineintoa

glass,wonderingifIcouldspeedilygulpdownthethicksyrupasinstructed.

Ibegananothercount:60dosesofmorphine,200Percosets,andalargeglassofgin.Aplasticbaglaynext

tomypillow...Whatwasthecorrectamount?Whatwastoomuch?Toolittle?ShouldIusetheplastic

bag?...Intheeventofadrugmiscalculation,sealingitovermyheadbeforeIwentunconsciouswould

ensuresuffocation.Itwasa100percentsuretythatIwouldneveragainopenmyeyes.ButhowcouldI

mercilesslyallowmyfamilytodiscovermeinascenemorefittingforahorrormovie?Thehideoussight

ofmylifelessface,shrinkwrappedinsideaplasticbag,wouldbeapermanentimagereplayedintheir


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mindsforever...Ultimately,bynotfactoringinthebag,Idecidedtotakethe10%chancethatanoverdose

wouldfail.

ThiswasnotthefirsttimeIhadgonethroughtheprocessionoflayingoutthenecessaryaccoutrements.

However,thiswasthefirsttimeIhadmeticulouslycoveredeverylastdetail.Iputmymailonhold,

cleanedouttherefrigeratorandtidieduptheclosets.Iprepaidallofmybillsandmadesurethedonot

resuscitate

directives

of

my

health

care

proxy

could

be

easily

located.

I

wore

the

consoling

fabric

of

Kurts

jeansandhisfavoritetshirtthatIhadsaved...Ihadbecomereclusiveenoughsincethefuneraltocover

myabsencewithobscurereferencesthatIwasgoingoutoftownforafewdays.Myneedtogetaway

fromthedifficultatmosphereoftheholidayseasonwasunderstandable.Everyonewouldbetoo

distractedbytheirownholidayengagementstogiveasecondthoughttomywhereabouts.

...Hourspassed...Itsstrangetolookbackonwhatwasgoingthroughmymind...Mythoughts,whichwere

ordinarilytooactiveformetobear,vacillatedbetweenhostinganunfamiliarblanknessandracingwith

unrelentingconcerns.Itwasanadrenalinerushofclarityandcatatoniainoneaninexplicable

combinationofemotionlessfear.

Iwaspreoccupiedwiththeminutiae.Myfocuswaslargelyonlogisticsandminimizingthe

aftermath...ShouldIdrinktheentirejugofmorphineandskipthePercosets?ShouldIcrushthepillsor

justleavethemintabletform?ShouldIjustgoaheadandtakeeverything,despitetheriskofvomitingthe

fataldose?...IfIwasdoomedtowakeup,whatkindofbraindamagewouldIsustain?...Rivalingasoneof

mymostacutefearswastheterrorofwakingupinrestraints,confinedtoapsychiatricward.WouldIlose

myfreedomandindependence?

...Istruggledwiththeobsessivecycleofconcernsabouttheimpactonothers.

WhowouldnoticeIwasnotheardfromindays?...WhatwouldIhavedonetothemoncetheycaughtthe

indelible,firstglimpseofmymotionlessfeet?Shamefully,Iadmitthatintheend,myinclinationto

prioritizethefeelingsofothersmeantshittome.Allthatreallymatteredwastofinishthejoband

overcomemyfearthatIwouldwakeupandlivetobeheldaccountableformyactions.

...However,afterlivinginthehellofovertwodecadesofexhaustivecontemplation,forthefirsttimein

mylife,Istoodonthethresholdofdeathsdoorwiththenumbnessofafirmresolve...ThefinalthingI

recallwasswallowingthelastfistfulofPercosets.Ididnotmakeasuicideattempt.Ikilledmyself.

suicide core competencies

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