Suicidal Thoughts and Plans

The rates of suicide in Alaskan communities, and particularly among Alaska Natives, are often higher than the rates of suicide in other regions and among other ethnic groups. Thesuicide mortality rateis the total number of deaths due to suicide per 100,000 people. Although specific rates vary by region, during 2012-2015 the statewide suicide mortality rate was 40.9 deaths per 100,000 and suicide was the fourth leading cause of death among Alaska Native people (Alaska Health Analytics and Vital Records Section).

Definitions

Suicide is the act of taking one's own life. Suicidal thoughts are thoughts and ideas about killing oneself. They are sometimes called suicidal ideations and they are grouped in two basic types:

• Passive ideations are passing thoughts about suicide, such as wondering what it would be like if you were not alive.
• Detailed ideations are regular and long-lasting thoughts about killing oneself. They may include details of a plan for how and when the suicide will happen.

A suicide plan is a person’s plan to kill himself. It may contain multiple components, including:

• The when, where, and how of the act (the chosen method, time of day, and people likely to find him).
• Makes efforts to prepare others (e.g., saying “l love you,” organizing the environment, taking care of personal duties).
• Thoughts of killing someone else as well as himself (e.g., suicide pacts and homicides).

A suicide attempt is an individual’s uncompleted effort to kill herself.

Warning Signs of Suicide

People are at a higher risk to complete suicide when they have:

• Significant changes in mood or behavior lasting longer than usual.
• Alcohol and drug abuse.
• Regular thoughts of suicide.
• A plan for how they want to die.
• Talked about suicide.
• A history of suicide attempts.
• Given away personal belongings.
• Access to the tools needed to complete suicide.
• Said their final goodbyes or written a suicide note.

When a client expresses any suicidal ideation or intent to commit suicide:

• Follow your organization’s safety and security policies and procedures.
• Take seriously any time a person has suicidal ideations, develops a suicide plan, or attempts to commit suicide.
• Keep yourself safe first, even if that means leaving the client momentarily so you can get more help.
• Know the limits of confidentiality and be honest about them with your client. If at any time you become aware that the person intends to commit suicide, you may have to breach confidentiality to ensure the person's safety.
• Show the client genuine concern, compassion, and care for her wellbeing. Demonstrate your willingness to talk, listen, and help.

Females attempt suicide more often, but males complete it more often.

• For every three females who attempt suicide, there is one male who attempts.
• For every female who completes suicide, there are four males who complete suicide.

Talking with a person about suicidal thoughts and behaviors will not cause the person to act on those thoughts.

• Suicide is preventable with early intervention.
• If the person has ideations but no immediate desire or plan to act on them, it is still important to discuss them.
• In some cultures, people believe that talking about suicide will bring the spirit of suicide to the community, which could lead to more suicides. However, it is important to remember that when you open the discussion about suicide, you can make it easier for people to tell you about suicidal thoughts, putting you in a position to help. Additionally, you cannot truly assess your clients for their risk of suicide unless you ask them.

Depression is the biggest contributing factor to suicide. Depression is also one of the most treatable symptoms of psychological distress. People experiencing suicidal thoughts should be screened and/or treated for depression.

Alcohol and other abused substances can also contribute to suicidal thoughts and behaviors, impair thoughts, cloud judgment, and heighten emotions. A person who screens positive for problems related to substance use may benefit from an integrated assessment to help identify a treatment plan that can address both the mental health and substance use problems. For more information on co-occurring disorders, see Chapter E-2: Co-occurring Disorders.

Lots of things can trigger suicidal thoughts, including:

• A family or community history of suicide.
• Stressful situations, dynamics, and difficulties in the family or household.
• Major life changes, such as death or divorce in the family.
• A history of abuse or neglect.
• A recent breakup or divorce.
• Other social stresses.

Other things affect the severity of suicidal thoughts for youth. Sometimes the severity is related to developmental factors, such as the child’s limited language skills or concept of death.

• Suicidal youth may view death as a temporary situation, a pleasant state of being, sending a message that people can't ignore, or an easy way to reduce stress and relieve psychological pain.
• A young person may engage in risky or self-injurious behavior without realizing that it could end in death.

Hope is a powerful insulating factor. The more hopeful and connected a person feels about the future, the less likely she is to act on suicidal thoughts.

Some people may have suicidal thoughts frequently or over long periods of time without ever acting on them. Instead, they develop coping skills to manage their thoughts and will need prompting to seek extra help when necessary. For individuals who experience these thoughts more frequently, it is important to work with them to identify symptoms that, when present, require them to engage in their safety plan.

Referral information, including reports from medical providers, school staff, clinicians, or other sources regarding the client's wellbeing.

Releases of Information ( ROIs ) that are current or updated before getting information about the client from other sources.

Client history related to sensory functioning, development, and psychological history.

Treatment Plan, including a history of the presenting problem and recommended course of treatment. Review the DSM-5 for criteria on Depression and Mood Disorders.

Emotions/mood

• Has symptoms of depression
• Has other behavioral health concerns
• Previously hospitalized for behavioral health issues
• Feels unloved
• Feels valueless or like a burden to others
• Feelings of hopelessness
• Emotional numbness
• Excessive crying or being unable to cry

Negative thought patterns

• Has thoughts of suicide or wonders what life would be like if he were dead
• Sees no future for himself
• Sees suicide as a solution to current problems or situations
• Is unable to identify reasons for living
• Expresses odd or bizarre thoughts
• Has made a plan for committing suicide
• Thinks he is a failure

Behavioral patterns

• Has recently used or abused alcohol or other drugs
• Has attempted suicide in the past
• Seems disinterested in day-to-day activities
• Has an unkempt appearance and a limited interest in hygiene
• Participates in reckless and potentially life-threatening behaviors
• Behaves unpredictably
• Reacts impulsively to conflict, loss, or disappointment

Other risk factors

• Trauma history (including abuse or neglect)
• Limited or unsupportive social system
• Recently lost a significant relationship (through breakup or divorce)
• Recent death in the family or community
• Has a learning disability
• Bullied or picked on by others
• Access to lethal means (e.g., gun in the home)
• Does not get along with family members
• Uncertainty about issues related to her sexuality (e.g., sex, sexual orientation, gender identity, or role)

This list is designed for your session with the client and can be adapted if you are also speaking with family members, parents, or caregivers. If you are working with a minor client, consider asking these questions one-on-one with the client and speaking separately with the parent. Asking them these questions together may discourage honesty as they try to protect each other from the difficult feelings that arise from speaking the truth.

Suicidal thoughts

• Tell me about the thoughts you have had about death.
• How often do you think about death?
• How long have you been thinking about suicide?
• What causes these thoughts of suicide?
• What has happened that makes you feel like killing yourself?
• How often do you have these thoughts and how long do they stay with you?
• Are there certain times or places that you have these thoughts more often?
• Is this the first time you have felt this way? If the answer is no, ask:
  • When was the last time you felt this way?
  • What did you do the last time you felt this way?
  • Was there anything that helped you feel better?
• Is there anyone else that you have felt comfortable talking to about these thoughts?
• Is there anything you have found to help you to stop having these thoughts?
• Are there parts of your life you wish could be better?
• What keeps you from acting on your thoughts?
• Is there anything I can do right now to prevent you from taking your life?
• Would you be willing to agree to NOT hurt yourself or attempt to kill yourself?
• Would you be willing to agree to a safety action plan?

Suicidal plans

• Do you have a plan to kill yourself? If the answer is yes, ask:
  • Have you decided how you are going to kill yourself?
  • What is your plan?
  • Have you already done things to prepare for killing yourself?
  • Do you feel safe?
  • Is there anyone else you have told about your thoughts or plans to take your life?
  • Who did you tell, and were they able to help?
• Have you attempted to kill yourself in the past? If the answer is yes, ask:
  • Have you shared your plan with anyone?
  • When and how did this take place?
  • How did you attempt?
  • What was the outcome?

Feelings of failure, hopelessness, or being a burden to others

• Tell me about your relationships with some of the people in your life.
• Have there been any changes in these relationships recently?
• What are your reasons for wanting to die?
• What are your reasons for wanting to live?
  • Do you have pets?
  • Who are family members you'd like to continue spending time with?
  • Do you have valued elders in your life?
  • What games and activities do you enjoy?
• Do you have any hope that things will change in the future? What do you hope will change?
• Tell me about your home life.
• Tell me about your school/work/community life.
• What kind of problems are you having at home? In school/at work? With others in the community?
• Have you ever been hurt or picked on by anyone?
• Do you feel alone or lonely most of the time?

Feeling that this is the worst time in their life, that life will not get better, or that other people would be better off without them

• Is this the worst you’ve ever felt in your life? If the answer is yes, ask:
  • What is it about what you are experiencing now that makes it the worst time in your life?
  • What are some steps you can take to make this time in your life more manageable? (See Chapter A-4: Self-Care for BHA/Ps and Clients )
• Is there another time when you felt worse than you do now? If the answer is yes, ask:
  • Can you describe that time and what was going on then?
  • Was there anything that was helpful for you during that time?

Emotions/mood

• How have you been feeling lately?
• Do you feel tired a lot?
• Are you having a hard time sleeping?
• Have you eaten, drunk, or taken anything that might cause you to feel this way?
• Are you taking any new medications that could affect your mood?
• Have you become less interested in things that usually make you happy?

Routinely review Chapter C-4: BHA/P Services and Common Interventions for how to prepare for and conduct interventions during appointments and for information on the levels of service available throughout Alaska.

When a client indicates that he is experiencing suicidal ideations or considering taking steps towards completing suicide, it is strongly suggested that you focus on maintaining your client's safety, help him manage the emotional distress, contact your clinical supervisor (or the client's clinician), and develop a safety plan. A safety plan should include the following:

• Specific triggers or environmental factors that make the client feel suicidal (e.g., thinking about my friend who passed away, making a mistake on my schoolwork).
• Warning signs that indicate the client is at risk (e.g., pacing, face is flushed, thinking hostile thoughts about himself or her future, feeling helpless).
• Coping strategies such as Emotion Regulation Skills (DBT) and Distress Tolerance Skills (DBT).
• Specific family or friends in the community that he can contact; include phone numbers on the safety plan.
• Specific short-term goals and protective factors (parts of the client's life that bring him happiness or give him purpose, such as cooking for an elder or taking care of his niece).
• Phone numbers for local, state, and national crisis hotlines.

Depending on the client's level of risk, you may need to contact someone in the community who can help keep him safe. This may be a VPSO, family member, or community leader. Ideally, the client will identify someone he feels comfortable with you contacting. If he is unable or unwilling to do so, contact your supervisor for specific guidance.

Be sure you are familiar with the information in Chapter B-5: Mandatory Reporting and Duty to Warn and Chapter B-8: Documentation and Billing. Report instances of the following, consistent with your organization's policies and procedures:

• Child abuse or neglect.
• Suicidal thoughts or plans.
• Intentions to cause harm or injury to the self or others.