Procedures for Handling a Suicidal Threat
A suicide threat is an expression that life is hopeless and a desire to end one's own life, and may range from a casual reference to death, usually expressed disgust about the conditions of one's own life, to a specific planned method, time, and place for the event to occur.
A. Assessment phase: With the possible exception of the one item, i.e., having a very lethal and specific plan for suicide, no single criterion should be alarming. Rather the evaluation of the suicidal potential should be based on the general pattern within the framework of the fourteen criteria which follow:
1. Age and Sex. Suicidal communications from males are usually more dangerous than from females. The older the person, the higher the probability of suicidal intention. Both age and sex should be considered. A communication from an older woman is more dangerous than one from a younger boy. Note, however, that younger people do make attempts, even if the aim is to manipulate and control people.
2. Mood. If the person sounds tired, depressed, "washed out," then the suicidal risk is higher than if he/she seems in control of him/herself. Exuberance, flight of ideas, screaming and yelling are to be considered ominous signs also. Strong denial of suicidal intention should be considered a definite danger signal. If the client's mood undergoes marked change for the better during the conversation, this is an important positive sign of suicidal potentiality.
3. Prior attempts or threats. Recent studies show that in about 75% of actual suicides, there have been previous attempts.
4. Acute or chronic situations. An acute situation is a sign of greater immediate danger than would be chronic recurring situations. An acute event, although a sign of immediate danger, has a better prognosis for improvement (once the crisis has been dealt with) than is true of chronic, recurring situations. When did the problem develop?
5. Means of possible self-destruction. The most deadly means are shooting, hanging, and jumping. If the persona has used or is threatening to use any of these methods, and the means are available, you must consider the threat to be serious and that suicidal danger is high. Other methods can be lethal and should not be discounted because they appear slower and less dangerous, such as barbiturate ingestion, carbon monoxide poisoning, and wrist cutting.
6. Specific details of the method. If the person not only has specifically named the method that he/she intends to use, but also goes on to give details of time and place, he/she should be considered to be in danger.
7. Recent loss or separation from a loved one. If death of a loved one and/or divorce and separation come into the picture, the danger goes up. The separation need not have already taken place, but he/she may feel that it is impending andhe/she is therefore depressed. If there is any actual or pending loss of a loved one, suicidal danger rises.
8. Medical symptoms. If such facts as unsuccessful surgery, a positive HIV test, chronic debilitation, cancer or fear of cancer, asthma, fatigue, impotence, loss of sexual desire or any medical symptom come into the picture, the suicidal danger goes up.
9. Diagnostic impressions. Making a psychiatric diagnosis is a professional task; however, record any symptoms given you so that an evaluation may be made later. Obvious signs such as hallucinations, delusions, loss of "contact with reality" will reveal a disoriented state. If such states as depression, anxiety, alcoholism, homosexuality enter the picture, than suicidal danger rises.
10. Resources. If the person is under financial stress, if he/she has no friends, or if he/she is all alone and has few or no social contacts, then the suicide danger is high.
11. Living arrangements. The greater the satisfaction of the client in this area, the lower the risk. Four questions are useful. Who is(are) the person(s) the client is living with in the same dwelling at the present time? What is the quality and quantity of their relationships? Is the client satisfied? Are these arrangements economically, emotionally, and socially adequate and supportive for the client at the present time? Clients who live alone, have few friends or other support systems or are unhappy in their living arrangements are greater risks.
12. The client's perceptions of the problem. The client who feels that his/her situation is hopeless, and they are powerless to change it, is at higher risk. How realistic are the client's perceptions of the situation? Are they accurate, distorted, confused? Remember: Suicide is often an emotional decision, not a rational one.
13. Disruption of daily living patterns. The client who is not going to school or work, who is not eating well, who has lost weight and who is not able to carry on daily routine is a higher risk than one who is not so affected.
14. Coping strategies and devices. How has the client dealt with crises in the past? Have formerly used coping methods been tried? If so, and they have been proven ineffective, why are they not working now? Is the client impulsive? Does the client habitually resort to excessive drinking or misuse of drugs or other acting out against self or others?
B. Intervention phase.
1. As a proactive measure, the counselor should ask the site supervisor about school/agency policy regarding suicidal clients at the start of the placement. They should be aware of this policy before seeing clients individually at the site.
2. The counselor becomes aware of the steps to take in working with and assessing of suicidal potential.
3. The counselor remains calm during the session in which the threat occurs. The counselor does not become distressed or excited by the threat.
4. The counselor listens to what the client is saying, asks questions appropriate to determine the lethality of the threat, and reviews the "Criteria for Assessment of Suicide" in his/her own mind during the session to determine if the threat is serious. Generally speaking, however, any threat of any kind should be reported to both the site supervisor and the faculty supervisor at the earliest possible moment.
5. At no time should the client be left alone. In the case of a school placement, not only should the supervisor be notified, the building administrator and parents should be notified as well. Confidentiality should be broken when a client presents a danger to themselves. In the case of an agency, the counselor discusses the situation with the supervisor prior to the client leaving the site. The counselor and supervisor decide on an appropriate response. If there is a need for a referral, the appropriate referral agency is involved.
6. In those situations when the session is completed, the counselor and the supervisor review the session together and determine what specific action is appropriate.
Source: "Criteria for Assessment of Suicidal Potentiality" (adapted from Slalken, 1979, and Hatton, Valente, and Rink, 1977).