Suicide: Psychological Assessment and Management
Mrs. Sumanpreet Kaur
Lecturer, M.Sc. Mental Health (Psychiatric) Nursing, Royal Institute of Nursing, Jaito-Sarja, Batala
*Corresponding Author E-mail: skaur201989@gmail.com
ABSTRACT:
Suicide is the 10th leading cause of death, claiming more than twice as many lives each year as does homicide. Every year one million people commit suicide, accounting for 1 to 2 percent of total global mortality. Suicide is a leading cause of premature death, especially among young adults. It is the fifth highest cause of year of life lost in the developed world. According to World Health Organization statistics, the annual world-wide incidence of completed suicide was 16 per 100000persons in 2000. This means that globally one person commits suicide every minute (WHO, 2012)1. As the largest continent in the World, Asia accounts for about 60% of World suicides, with China, India, and Japan accounting for about 40% of the Worlds suicides. According to research study, in Asian continent Bangladesh, China, Hong Kong, Japan, South Korea, Sri Lanka, and Taiwan had relatively higher suicide rates (>13.0/100, 000), with Bangladesh having the highest (39.6/100, 000). Suicide is estimated to represent two percent of the total global burden of disease. Suicide is an important issue in the Indian context. More than one lakh (one hundred thousand) lives are lost every year to suicide in our country. In the last two decades, the suicide rate has increased from 7.9 to 10.3 per 100, 000. The majority of suicides (37.8%) in India are by those below the age of 30 years. The fact that 71% of suicides in India are by persons below the age of 44 years imposes a huge social, emotional and economic burden on our society (Shukla et al., 1990)2.
KEYWORDS: Suicide, Suicidal Ideation, Suicide Attempt, Shame Suicide, Extended Suicide, Parasuicide.
INTRODUCTION:
Suicide doesnt end pain. It only lays it on the broken shoulders of the survivors.
Ann-Grace Scheinin.
Definition:
Suicide, derived from the Latin word meaning ones own and to kill is a conscious act of self induced annihilation. It is not a random or pointless act but a way.
Out of a problem or crisis that is causing intense suffering. Suicidal behavior or suicidality can be conceptualized as a continuum ranging from suicidal ideation and communications to suicide attempts and completed suicide. Pokorny (1974)3 introduced the concept of suicidal behavior to cover suicidal ideation, attempted suicide and suicide. There is no single unanimously accepted definitions of suicide, although in most proposed definitions it is considered as a act of self-injury(self-harm) undertaken with more or less conscious self destructive intent, however vague and ambiguous. A common definition of suicide is as follows.
Durkheim (1897)4 defined suicide as "all cases of death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows will produce this result."
According WHO(2012)1, suicide is an act with a fatal outcome which the deceased, with the knowledge and expectation of a fatal outcome, had himself planned and carried out with the object of bringing about the changes desired by the deceased.
Different terms related to suicide are:-
Suicide ideation:
Thoughts about killing himself or herself. Suicide ideation may vary in seriousness depending on the specificity of suicide plans and the degree of suicide intent (Pokorny, 1974)3.
Suicide Attempt:
Life threatening act requiring medical attention that is committed with a conscious intent to end ones life. (Pokorny, 1974)3.
Attempted suicide:
Unsuccessful, but potentially lethal action, a risk factor for future committed suicide (Hammerlin and Enersvedt, 1988)5.
Shame Suicide:
Shame suicides can occur in individuals faced with intolerable humiliation (e.g., scandal, criminal charges).A shame suicide may be an impulsive act in a narcissistically vulnerable person. It may not be associated with a diagnosable mental disorder (Roy, 1986)6.
Extended Suicide:
Also know as complex suicide, is said to take place when one or more persons against their will are involved in the death. It is usually marriage partners or children who are affected, and family tragedies of this kind can develop in connection with mental illness (Retterstol, 1983)7.
Parasuicide:
Behavior includes any deliberate destruction of body tissue, with or without suicidal intent, and as such, may involve a clear intent to die, no intent to die, or varying degree of ambivalence about the intent to die. (Kreitman, 1977)8.
Suicide Gestures:
Behavior purposefully undertaken by an individual in which the outcomes reasonably likely to be self-harm, in the absence of explicit data suggesting that suicide was not intended.(Retterstol, 1983)7.
Self-Mutilation:
Refers to the deliberate, direct destruction or alteration of body tissue without conscious suicidal intent. This includes major self-injuries causing major tissue damage or loss. (Favazza, 1998)9
Deliberate self-harm:
defined as an act with non-fatal outcome, in which an individual deliberately initiates a non- habitual behavior that, without intervention from others, will cause self harm, or deliberately ingests a substance in excess of the prescribed or generally recognized or expected physical consequences ( Platt et al., 1986)10.
Leading Suicide Methods in Different Asian Countries:
Hanging was the most common suicide method in nine Asian countries/regions reviewed (i.e., Bahrain, Iran, Japan, South Korea, Philippines, Saudi Arabia, Taiwan, Thailand, and Turkey). Solid/liquid poisoning (mostly using pesticides) was the leading suicide method in three countries: China, Pakistan, and Sri Lanka, which may be related to their agricultural activities and thus, the easy access. Jumping was the leading suicide method in Hong Kong and Singapore, where around 80% of the residents live in high rise buildings that provide access to this very fatal suicide method. Three countries had uncertain or mixed results: Bangladesh (solid/liquid poisoning, women aged 1050), India (hanging, poisoning and self-immolation), and Malaysia (hanging and jumping in local results) (Medical Council of India New Delhi, 2008)11
Theories of suicide:-
Psychological studies:
Depression, low self-esteem, locus of control, emotional disturbance and recent stressors are the factors which are psychologically involve in suicidal behavior. The ways in which personality traits might interact with one another and with other factors such as the interpersonal milieu also affect suicidal behavior(Joiner and Rudd, 2009)11.
Psychoanalytical Theory of Suicide:-
Freud attempted to explain suicide - related behavior in terms of intrapsychic conflicts between the demands of the id, the super - ego and ego. As a result of these intrapsychic conflicts aggression is turned towards self, resulting in self - harm or actual suicide. Psychoanalytical theory emphasizes on childhood experiences as determinants of adult behavior and experience. According to this theory the seeds for future suicidal potential are shown in the second and third years of life( Anal stage), crucial experiences occur that set the childs ensuing developmental pattern in a rigid mould, which leaves him vulnerable in later life to suicide-related behavior, given specific environmental pressures. A key belief within psychoanalytical theory is that faulty personality traits develop as a result of the unresolved issues in particular psychosexual stage in childhood (Freud, 1905)12.
Menningers theory:
Building on Freuds concepts, Karl Menninger (1983)13 in Man against Himself conceived of sucide as a retroflexed murder or inverted homicide as a result of the patients anger toward another person, which is either turned inward or used as an excuse for punishment. He also described a self- directed death instinct (Freuds concept of Thanatos). He described three components of hostility in sucide: the wish to kill, the wish to be killed, and the wish to die.
Hopelessness Theory of Suicide:
According to this theory, the expectation that outcomes will never be positive and always be negative and the situation is unchangeable is a most common cause of the symptoms of depression, specifically hopelessness depression. The common language term hopelessness captures the two core elements of this hypothesized most common cause: Expectations that highly valued outcomes will be negative and helplessness expectancy i.e. perceived inability to change the negative outcomes(Abramson et al., 1989)14.
The strategic suicide theory:
Youths attempt suicide to signal others that they are unhappy or to punish others for their unhappiness. In this theory, suicide attempts are not primarily designed to result in death. Rather, they are a way for youths to influence others in nonfinancial ways (Gould et al., 1994)15.
The Contagion Theory:
This theory suggests that a social multiplier may amplify the effects of stressors leading to depression or may amplify the effects of factors leading to suicidal signaling as a method of conflict resolution among youths (Gould et al., 1994)15.
The Instrumentality Theory:
This theory has less to do with events that produce suicidal thoughts and more to do with the ability to carry out suicide plans. When youths become particularly unhappy, they commit suicide if the means to do so is readily available. Thus, youths with access to guns with the same level of unhappiness, have higher suicide rates than the youths without access to guns (Brent et al., 1991)16.
The Rational-Suicide Theory:
The rational-suicide theory was developed by Hamermesh and Soss (1974)17 as a way of explaining why suicide seemed to increase monotonically with age. According to this theory, Suicide is a mean of rationally ending ones life, when the individual expects that the value of being alive is less than the value of death and when death is having better future utility than being alive, individual commits suicide. Also there is invariable unhappiness in life and this unhappiness is correlated with other events of life. Although this monotonic increase with age is no longer true generally. Here rational theory explains that youths those have a tendency to discount the available resources, rationalize the suicidal behaviour on this behalf and unhappiness is always invariably correlated with this (Cutler et al., 2001)18.
Social Theories of Suicide:-
Sociological studies of suicide by Durkheim (1897)7
The classic sociological theory of suicide was proposed by Durkheim (1897)7. According to him, the social forces that will increase a person's probability of committing suicide. He proposed that two broad social characteristics resulted in suicide --social integration and social regulation.
It is summaries in following table.
|
Social characteristics |
High |
Low |
|
Social Integration |
Altruistic (extreme altruistic attachment to church and state) |
Egoistic (extreme attachment to self) |
|
Social Regulation |
Fatalistic(following strict rules in society) |
Anomic (extreme attachment to occupational groups) |
The interpersonal Theory of Suicidal Behaviour:
Joiner (2005)19 proposed that an individual will not die by suicide unless s/he has both the desire to die by suicide as well as the ability to do so. The theory asserts that when people hold two specific psychological states in their minds simultaneously, and when they do so for long enough, they develop the desire for death. The two psychological states are perceived burdensomeness and a sense of low belongingness or social alienation. Perceived burdensomeness is the view that ones existence burdens family, friends, and/or society. This view produces the idea that my death will be worth more than my life to family, friends, society, etc. a view, it is important to emphasize, that represents a potentially fatal misperception (Joiner, 2005)19.
The Threshold Model:
There are various scales to assess suicide risk that cover mental health state, symptoms and intent. However, they do not cover predisposing and precipitating factors. A clinical interview should aim to gain a wide range of useful information in line with The Threshold Model. Key stages in applying the Threshold Model to suicide risk assessment are:
Establish rapport: Particularly important is listening with empathy, which in itself can reduce despair.
Enquire about current mental health, physical health and substance problems. Recent loss and mental health problems can constitute imp short-term risk factors.
Establish the problem history and previous coping methods with similar problems. They contribute to assess personality and relevant to long-term risk factors.
Seek information on supports, family, friends and any other services that are being accessed and persons responsibilities. All can constitute protective factors.
Ask about current circumstances, including other current and recent problems, life events and worries. All can be possible precipitating factors.
Assess the existence and specificity of any plans for suicide, availability of means to commit suicide. Judge how close the person is to his threshold for suicide. Suicide behaviour
Biological theories of Suicide:
Genetics Studies:
Twin studies, done as a landmark study in 1991, show monozygotic concordance of 11.3 and dizygotic concordance of 1.8.Suicide risk is eight times greater for first-degree relatives of psychiatry patients, and four times greater among first-degree relatives of psychiatry patients who had committed suicide. In families with a heavy genetic loading for mood disorders the suicide rate was higher. The genetic factor for suicide may be independent or in addition to the genetic transmission of mental disorders.
Neurochemistry:
Studies done on the relationship between tryptophan hydroxylase and a lifetime history of multiple suicide attempts have revealed that there may be a genetic factor of impulsivity. Apolymorphism in humans with two alleles has been found. This may be related to an abnormality in the control of the serotonin system. A decrease in serotonin levels leads to a decrease in 5-hydroxyindolacetic acid (5HIAA) in the cerebrospinal fluid (CSF). This was found in depressed patients who attempted suicide. Studies have shown that there is an association between serotonin decrease in the central serotonin system and poor impulse control. Those who view suicide as an impulsive behavior use this as an explanation.
Peripheral markers Theory:
The peripheral markers may identify patients who are emotionally overwhelmed and vulnerable for committing the suicide. They have increased hypothalamicpituitaryadrenal axis activity, increased 24 hours urine excretions of cortisol, a blunted plasma thyrotrophic stimulating hormone (TSH) response to thyrotrophic-releasing hormone (TRH), skin conductance abnormalities, altered urinary catecholamine ratios, a decrease in platelet serotonin uptake and low levels of platelet monoamine oxidase (MAO) (Andreason and Black, 1995)20.
Risk factors for Suicide:-
|
Individual level/ Personal |
Social level |
Contextual/Broader life environment |
|
Previous suicidal behaviour, Gender (Male), Mental illness or disorder, Chronic pain or illness, Immobility Alcohol or other substance abuse, Low self esteem, Low sense of control over life circumstances, Lack of meaning and purpose in life, Maladaptive coping skill, Hopelessness, Guilt and shame, Low level of help seeking behaviour. Learned helplessness |
Abuse and violence, Social isolation, Family dispute, conflict and dysfunction, Separation, Bereavement, Peer rejection, Imprisonment, Poor communication skills, Family history of suicide or mental illness, Greater stigmatisation of mental health conditions. |
Unemployment and economic in security, Financial stress, Neighbourhood violence and crime, Poverty, School Failure, Social and Cultural discrimination, Homelessness, Exposure to environment stressor, Lack of support services, Geographical isolation, Easier access to highly lethal means of suicide, Reduced accessibility to mental health service provider. |
(WHO, 2012)1
Warning Signs for Suicide:
|
Behavioural warning signs |
Physical warning signs |
|
Talking about suicide. Making a suicide plan. Self-harming behavior. Prior suicide attempt/s. Acting reckless or engaging in risky activities, seemingly without thinking. Unexplained crying. Sense of hopelessness. Feeling trapped like theres no way out. Withdrawal from friends, family or society. Ceasing activities that used to be important. Giving away valued possessions. Increased alcohol and/or drug use. Uncharacteristic or impaired judgment or behavior (e.g., risk taking). Help-seeking behaviours for issues not related to mental health. Rage, anger. No sense of purpose in life. Dramatic changes in mood. |
Loss of interest in personal hygiene or appearance Physical apathy Sudden and/or extreme changes in eating patterns Loss of interest in sex Increase in minor illnesses. Anxiety, agitation, unable to sleep or sleeping all the time. |
(WHO, 2012)1
Protective Factors:-
|
Individual Level |
Social level |
Contextual/Broader life environment |
|
Gender ( female) Good Mental Health and well-being Good Physical Health. Absence of alcohol and other drug-problem. Positive sense of self. Sense of control over lifes circumstances. Sense of meaning and purpose of life. Positive outlook and attitude to life. |
Physical and emotional security Family Harmony. Supportive and caring Family Supportive Social relationships. Sense of social connection. Sense of social determination. Good communication skills. No family history of Suicide or mental illness. Community connectedness. Religion |
Safe and secure living environment. Financial security. Employment Safe and affordable housing Positive education experience Equitable community. Little exposure to environmental stressors. Access to support services. |
(WHO, 2012)1
Myths and facts about suicide:
There are a number of commonly held incorrect beliefs about suicide. These myths can stand in the way of providing assistance for those who are at risk. Some common myths are set out below.
|
Myths |
Facts |
|
People who talk about suicide never attempt suicide. People who threaten or attempt suicide are just seeking attention. Talking about suicide will encourage suicide attempt. Only certain types of people become suicidal. |
Talking about suicide can be a plea for help and a sign that someone is thinking about taking their own life. Do not dismiss a suicide attempt as simply being an attention-seeking episode. This behaviour is more likely to be a way of dealing with painful feelings. Talking about suicide provides the opportunity for communication and is more likely to reduce the risk of suicide than increase it. There is not a type of person and feeling suicidal is not a sign of weakness. However, there is evidence that there are risk factors that make certain groups of people more likely to end their lives, and having a mental health condition such as depression may make someone more likely to attempt suicide. |
(Andover, 2001)21.
Characteristic Thinking patterns of suicide individuals:
Dichotomous (black-white) thinking.
Cognitive rigidity and constriction.
Perfectionistic standards toward self and others with high levels of self-criticism
Lack of specificity in autobiographical memory- Such overgeneral and vague autobiographical memory has been associated with depression, PTSD, and suicidal behavior. Ellis and Rutherford (2008)22 highlight that such overgeneral memories interfere with interpersonal problem-solving suicide, while behaviours at the milder end of the spectrum merge with other reactions to emotional pain. (Platt et al., 1986)10.
The Process of Assessment:
Assessment of Suicidal Behaviours:
A comprehensive assessment of suicidal behaviours is fundamental to effective counselling intervention and prevention activities. The primary goal of suicide assessment is to provide information for prevention and counselling. Assessment subsequently guides clinical judgment, counselling intervention, prevention and postvention. A suicide assessment should include:
Socio-demographic details.
A review of relevant risk factors.
Any history of suicidal behaviour.
Unchangeable, biological, psychosocial, mental, situational or medical conditions.
The extent of current suicidal symptoms including the degree of hopelessness.
Precipitant stressors.
Level of impulsivity and personal control.
Other mitigating information.
Protective factors.
(3) CONDUCT SUICIDE INQUIRY
Suicidal thoughts, plans behavior and intent
(4)DETERMINE RISK LEVEL and APPROPIATE INTERVENTIO--N to address and reduce risk.
(5) DOCUMENT
Assessment of risk, rationale, intervention and follow-up.
(1) IDENTIFY RISK FACTORS
That can Be modified to reduce risk
(2) IDENTIFY PROTECTIVE FACTORS
That can be enhanced(W.H.O, 2006)23
[Suicide Assessment Five-step Evaluation and Triage (SAFE-T) for Mental Health Professionals.
1. Risk Factors:
Suicidal behaviour:
History of prior suicide attempts, aborted suicide attempts or self-injurious behaviour.
Current/past psychiatric disorders:
Especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality disorders, conduct disorders (antisocial behaviour, aggression, impulsivity).Co-morbidity and recent onset of illness increase risk.
Key symptoms:
Anhedonia, impulsivity, hopelessness, anxiety/panic, insomnia, command hallucinations.
Family history:
Family history of suicide, attempts or Axis I psychiatric disorders requiring hospitalization.
Precipitants/Stressors/Interpersonal:
Triggering events leading to humiliation, shame or despair (e.g., loss of relationship, financial or health statusreal or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication, Family turmoil/chaos. History of physical or sexual abuse. Social isolation.
Change in treatment:
Discharge from psychiatric hospital, provider or treatment change
Access to firearms
2. Protective Factors:
Even if present, may not counteract significant acute risk.
Internal:
Ability to cope with stress, religious beliefs, frustration tolerance
External:
Responsibility to children or beloved pets, positive therapeutic relationships, social supports.
3. Suicide inquiry:
Specific questioning about thoughts, plans, behaviours, intent.
Ideation:
Refers to cognition that can vary from fleeting thoughts that life is not worth living to concrete, well thought out plans for killing oneself, to an intense delusional preoccupation with self-destruction.(Hawgood and De Leo, 2008)24 Questions Related to frequency, intensity, duration--in last 48 hours, past month and worst ever.
Intent:
Extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious;
Plan:
Timing, location, lethality, availability, preparatory acts. The presence of a specific plan for suicide (date, place, and means) signifies a person at high risk.
Behaviours:
Past attempts, aborted attempts, rehearsals (tying noose, loading gun), vs. non-suicidal self -injurious actions.
Lethality:
Assess how lethal the method of suicide is.
Explore ambivalence:
Reasons to die vs. reasons to live.
4. Risk level / Intervention:
Assessment of risk level is based on clinical judgment, after completing steps 1-3
Reassess as patient or environmental circumstances change.
5. Document:
Risk level and rational; treatment plan to address/reduce current risk (e.g. setting, medication, psychotherapy, E.C.T., contact with significant others, consultation); follow up plan. For youths, treatment plan should include roles for parent and guardian.
(Davidson(2000)25.
|
Risk level |
Risk/Protective Factor |
Suicidality |
Possible interventions |
|
High |
Psychiatric disorders with severe symptoms, or acute precipitating event; protective factors not relevant. |
Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal |
Admission generally indicated unless a significant change reduces risk. Suicide precautions. |
|
Moderate |
Multiple risk factors, few protective factors |
Suicidal ideation with plan, but no intent or behavior |
Admission may be necessary depending on risk factors. Develop crisis plan. Give emergency/ crisis numbers. |
|
Low |
Modifiable risk factors, strong protective factors. |
Thoughts of death, no plan, intent /behavior |
Outpatient referral, symptom reduction. Give emergency/ crisis numbers. |
(Davidson, 2000)25
Psychological Management of Suicide Patients:
In providing therapeutic care for clients who exhibit suicide -related behaviour, the practitioners most powerful tool is the therapeutic relationship he has with the client. All forms of therapeutic interventions will only develop from this relationship. Both helplessness and hopelessness are shown as key elements on the path to suicide - related behaviour (Barbe et al., 2004)26. Therefore, practitioners and clients need to consider the type of therapy that would help clients regain control over events in their lives or regain hope for the future. Therefore, practitioners and clients need to consider the type of therapy that would help clients regain control over events in their lives or regain hope for the future.
Hospitalization:
Patients with a plan, access to lethal means, recent social stressors and symptoms suggestive of a psychiatric disorder should be hospitalized immediately. The family should be informed of the decision to proceed with hospitalization, and the patient should not be left alone while he or she is transferred to a more secure environment. Occasionally, patients may not allow the clinician to contact their families. When someone's life is in imminent danger, confidentiality may be breached. Legal consultation may be advisable if there are any questions about infringing on a particular patient's autonomy. Patients may also refuse to be hospitalized.
The grounds for involuntary commitment are
Imminent danger to self or others
An inability to care for one's self.
In most states, procedures are in place to allow for an involuntary hospitalization of 48 to 120 hours before a hearing is held with a judge to extend the hospitalization.20 If the physician is unsure of the steps to take, a crisis center or emergency-department psychiatrist can be contacted for assistance. Intoxicated or psychotic patients who are unknown to the clinician and who say they are suicidal should be transported securely to the nearest crisis center. These patients can be dangerous and impulsive; sometimes the police must be called to assist. Often, these patients require prolonged evaluation, which is done most effectively in a crisis center or emergency department, rather than in an office.
Outpatient treatment:
There are no definite criteria to help a clinician chose between inpatient or outpatient care of a suicidal patient. Generally, the physician should assess the patient's level of impulse control, judgment and degree of social support. One technique that is frequently employed is to ask the patient to sign or verbally agree to a no-harm contract. Such a contract is not legally binding and can never be a substitute for a thorough assessment; it serves mainly to solidify the therapeutic alliance. The patient's family should be involved in the formation and implementation of the contract. For patients who have a suicidal plan but who firmly state that they will not carry it out, the physician should ask the family to remove all lethal means and implement a system of monitoring the patient. If such family support is not available, conservative action is warranted, and the physician should consider hospitalizing the patient. In a family practice setting, many patients with suicidal ideation will be found not to have a specific plan and will easily be able to enter into a no-harm contract. These patients must be diligently and persistently evaluated over time for the presence of major depression or substance abuse.
Therapeutic Alliance:
It is a process in which patient allow a therapist to enter his or her personal world in order to initiate a process of intra-psychic change. A therapist who can be trusted and a patient who is motivated to share his or her inner experience are the essential elements of a therapeutic interpersonal dynamic. Gaston and Lubrosky (1993)27 distinguished three universal aspects of therapeutic alliance. First the patient perception that the intervention offered are both relevant and potent; second congruence between the patient and therapists expectations of the short term and medium term goal of therapy and third the patients ability to forge a personal bond with the therapist and the therapists ability to present as caring, sensitive and sympathetic helping figure. An early therapeutic alliance has consistently been found to have a significant influence on therapy outcome (Horvath and Symonds, 1991 )28
Therapeutic alliance with suicidal patients:
Acknowledgement of the patient own thoughts and feelings; understanding the experience of failure, self hate and mental pain from patients perspective and communicating ones awareness of understanding requires an empathetic stance.
Recognition of patients goal and patients need for autonomy: patients have their own conscious and unconscious beliefs and goals, which need to be respected and understood. While trying to reach empathetic understanding of the patients goals of death by suicide, the therapist should carefully probe for the clients life oriented goals and facilitate the clients movement towards them.
Working together in a joint effort: a meaningful working alliance requires a shared model of understanding of the patients vulnerabilities and the development towards suicide.
The therapist engagement and competence: the therapist conveys a non-judgemental attitude providing a sense of safety and trust and uses his or her professional skills in maintaining a meaningful therapeutic relationship. Patients in a suicidal crisis need someone who cares and who is not frightened by suicidal impulses.
No Suicidal Contract:
Also called no harm agreement, life maintenance contract or safety agreement is an agreement between the client and the therapist that the client will refrain from any type of self harm. No suicide contract is a common therapeutic intervention for suicidal or potentially suicidal individual (Motto, 1999)29.
The agreement has some standards and optional components
One standard component is time parameter which is typically from a few hours to few days. Idea is that person is making a short term agreement, which may be easier to keep than a longer agreement. Depressed person feeling that they face eternity of unhappiness, may feel better and more in control if they can hold off an suicidal action for one day or even one hour
Another standard component is whether no suicide agreement is oral or written. If oral, it may include handshake. If written it may be statement personalized for the specific client and situation and may include formal statements of treatment goals and responsibilities for client and the therapist. (Gutheil, 1999)30.
CONCLUSION:
Suicide is a multifaceted problem and hence suicide prevention programmes should also be multidimensional. Collaboration, coordination, cooperation and commitment are needed to develop and implement a national plan, which is cost-effective, appropriate and relevant to the needs of the community. In India, suicide prevention is more of a social and public health objective than a traditional exercise in the mental health sector
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Received on 11.08.2016 Modified on 16.08.2016
Accepted on 29.08.2016 © A&V Publications all right reserved
Int. J. Nur. Edu. and Research. 2018; 6(1): 114-121.
DOI: 10.5958/2454-2660.2018.00028.5