Suicide Assessment, Diagnosis, Prevention and . . . Choice

By Ofer Zur, Ph.D.

We engraved my mother’s gravestone, as she had requested many years prior to her death, “Trees Die Erect”, testifying to her refusal to retire from her role as an educator, psychologist and social activist. She chose to die at the top of her career in what my sister called “Suicide by work.”

The question of suicide reared its head to me again when I worked in East Africa as a fish-ponds expert and was shocked to notice how so many rural tribesmen did not hesitate to chop down the few palm trees left in the oasis and let the cattle defecate in the only water hole in an arid area. It looked normal to them but pretty suicidal to me. Part of this experience helped me shift my focus from fish to people. Early in my career as a psychologist, I encountered suicide when I worked in a mental health clinic in a local jail and was ordered to conduct a suicide assessment on a death row inmate. My bafflement quickly turned to outrage at how ludicrous it was for me to determine whether a prisoner should be placed on suicide watch so he would not kill himself before the state had a chance to execute him. Then, like most clinicians, I have encountered many situations, in which depressed, psychotic, disillusioned, hopeless or depleted clients felt desperately suicidal and where suicide prevention was necessarily and often welcomed by them. (OZ)

  • NIMH reports that in 2001 there were twice as many deaths from suicide as from HIV/AIDS. Four times as many men kill themselves than do women. Nearly 75% of all suicide deaths in 2001 were males.
  • Vulnerable populations such as youth and the elderly are far more likely to die by suicide than others do. In addition, those with psychiatric and medical conditions also pose higher risks for suicide.
  • Comprehensive assessment of suicidality requires evaluation of an individual’s: ideation; intent, plan and lethality; motivation to die; emotional and physical state; coping skills; and epidemiological risk factors.
  • Successful treatment planning for managing suicidality involves:
    • Identification of a range of treatment alternatives
    • Involvement of appropriate friends, relatives and medical team members
    • Incorporation of current treatment modalities into the long-range plan
    • Selection of appropriate levels of client observation and supervision
    • Documentation of suicidality as well as treatment plan components
    • Heightened awareness of the increased risk presented by many concomitant psychiatric disorders.
  • While we may be aware of the risk that mood disorders play in suicide, we may be less aware of the risks associated with chronic mental illness such as schizophrenia. Research by Harvard Medical Institutions suggests that nearly 75% of patients with schizophrenia have suicidal ideation. Nearly half those with schizophrenia attempt suicide at one time or another, and suicide is far more common in those who are in the early phase of their illness, are feeling hopeless and recognize deterioration.
  • While many clinicians are aware of risk factors associated with an individual’s psychological state, they may underestimate the impact of sociocultural risk factors such as: barriers to access to mental health treatment (geography, transportation, $); stigma associated with psychiatric disease and suicidality often inhibit help-seeking behaviors; cultural and religious beliefs; suicide “epidemics” in groups, such as school, ethnic, online communities, etc.
  • As clinicians, we often look at suicide prevention from our clinical or medical perspective and concern ourselves with one patient at a time. We may have far greater impact by approaching suicide from a Public Health perspective, which examines the roots of our current society for this phenomenon.
  • Most clinicians are well-aware of the risks posed by post-partum depression but often misconstrue those risks as purely hormonal or biochemical in nature. Careful attention must be paid to the impacts of long-term sleep deprivation, both for new parents as well as for the elderly.
  • Complaints of poor or non-restorative sleep increase with age and impact half our elderly population. Research suggests that poor sleep strongly correlates with depression and eventually with increased risk for suicide.
  • Incarcerated persons are significantly more likely to suicide than those in the general population.
  • Research suggests that there is higher suicide potential among LGB youth. Four factors are suggested as prime reasons for increased suicidality: increased drug use and alcoholism; heightened sexual activity; increased risk of victimization or violence by others; and heightened risk of becoming defensively violent as a result of persecution about being visibly gay.
  • Debate about the legality of suicide, or death control, has continued for decades. As a culture, we continue to struggle with the concept of suicide. Over the years Szasz has continued to remind us that suicide is neither a crime nor a sin nor a mental illness, it is a personal choice. The much debated Oregon suicide assistant law has led the way in accepting terminating one’s life as a legitimate conscious choice. The increased number of baby boomers who nurse their elderly parents and are facing the question of how to die, place the issue of suicide high on our personal and professional issues.
  • The way we choose to die is closely tied to the way we choose to live. We must keep the dialogue regarding suicide open and ongoing.

The Suicide Assessment, Prevention, and Risk Management course will:

  • Provide you with updates on facts and statistics for suicide
  • Recap ways to conduct suicide risk and lethality assessment
  • Provide you with two basic forms, Suicide Contract (to be used selectively and cautiously) and Suicide Risk Review
  • Help you design and implement treatment plans for suicidal clients
  • Provide you with ways to identify increased risk for suicide in vulnerable populations
  • Help you think of the moral, existential, biological, medical and other considerations regarding suicide

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