Overview about Suicide

Kayla was experiencing suicidal ideation and self-injurious behavior, two of the strongest predictors of suicide attempts. Suicide is defined as “death caused by self-directed injurious behavior with any intent to die as the result of the behavior” (CDC, 2013a). In a sense, it represents an outcome of several things going wrong all at the same time (Crosby et al., 2011). The Center for Disease Control and Prevention (2019) reports that suicide is the second leading cause of death for people ages 10-34 in the United States, and that 12 million American adults seriously thought about suicide, with 1.4 million people having a suicide attempt (CDC, 2021). Even more alarming, 19% of adolescents (high school age, 14 to 18) report suicide ideation in the previous year; 16% report making plans for a suicide attempt; and 9% report having a suicide attempt. (Ivey-Stephenson et al., 2020). This is quite literally a matter of life and death, and the most alarming part of this statistic is that suicide prevention is possible. Every life is precious. When we lose a child to suicide, we lose a family member, a classmate, and a community member. We lose a smile and the possibilities of that child’s potential.

One of the most relevant and frequent questions about suicide is why do people want to end their lives? Various theories explain the phenomenon of suicide. Emile Durkheim is credited with one of the first theories of suicide, and he focused on social influences such as social integration and social regulation (Durkheim, 2006). Suicide was the result of either not belonging in a community, being overwhelmed by a group’s collective beliefs and expectations, lacking social direction, or wanting to escape a society that is not worth living in (Durkheim, 2006). With this theory, Durkheim tried to situate suicide in a social context to understand why people die by suicide and delve into the social functions suicide responds to and creates. What is interesting about this is that it is relationally driven and less about locating suicide as a purely internal, individual phenomenon.

Early psychological theories built on the concept of drives, such as Freud’s sexual drive theory, and in this context, suicide would be contrary to the fundamental drive to life and mastery. More formal theories appear later in the 20th century, with Roy Baumeister’s escape theory of suicide. His theory presents a sequential model where someone falls short of standards and internalizes those failures, and then a harsh self-concept is reified (Baumeister, 1990). From these early parts of the sequence, negative consequences such as depression arise from the reified negative self-concept, which can create tunnel vision through cognitive restriction and rejection of meaningful thoughts (Baumeister, 1990). Finally, maladaptive behaviors or affect become a daily norm, and suicide becomes the way out because death appears no worse than these negative patterns of behaviors (Baumeister, 1990). The ideas of the pain of depression and a cycle of negative affect previews the concept of psychache, the intense emotional pain rooted in shame, guilt, fear, and anguish (Shneidman, 1993) that arises a few years after Baumeister’s theory. Similar to the escape theory of suicide, Shneidman’s (1993) theory highlights how psychache can lead someone to have a suicide attempt not to die but to end the psychological pain and anguish of psychache. This pain becomes unbearable because of factors such as thwarted belonging, feeling of loss of control, negative self-image, and damaged relationships (Shneidman, 1993). The idea of thwarted belonging is a key element of another theory of suicide, Joiner’s Interpersonal Theory of Suicide.

In Joiner’s (2005) theory, three factors present the intersection of elevated risk conditions and the opportunity or means to act towards suicide. The desire for suicide is generated by two concepts: thwarted belonging, which is described as the lack of meaningful connections, and perceived burdensomeness, which is the sense that a person feels like a liability to others or creates an undue burden on others (Joiner, 2005). The means to act towards suicide are represented by the concept of acquired capability for suicide (Joiner, 2005). In the earlier referenced psychological theory, there is an assumed drive towards life and a fear of death that can condition people towards life-affirming activities and behaviors. Acquired capability for suicide occurs when a person becomes conditioned to lose that innate fear of death through experiences like traumatic exposure and self-injurious behavior (Joiner, 2005), thus making suicide appear feasible.

In addition, there are two theories that have connections to cognitive-behavioral therapies. Aaron Beck believes that hopelessness is what drives suicidal intent, even more so than depression (Weishaar & Beck, 1992). Marsha Linehan, the founder of the third-wave cognitive behavior therapy (CBT) model, Dialectical Behavioral Therapy (DBT), articulates a theory that relates to intense emotion dysregulation, invalidating environments, and the need to avoid these intense affective states (Brown, 2006). These theories have a direct clinical application, as clinicians would target hopelessness or the intensity of effect and dysregulation in respective clinical approaches.

These theories are not a de facto explanation of suicidal behavior, but the core concepts can guide the clinician to understand relevant risk and protective factors related to suicide, and present different understandings of how to tailor treatments to this phenomenon. Suicide is not a psychological disorder; rather, it points to the various intersections of psychosocial distress, a capability to act towards suicide, and the means to take one’s life. As presented in the case vignette, Kayla’s suicidal thoughts had a connection to not feeling like she fit in, and she was experiencing negative emotional states as a result. Thoughts, emotions, behaviors, and environments/contexts are interconnected to better understand her current situation and suicide risk.

Causes of Suicide and Self-Injurious Thoughts and Behaviors in Children and Adolescents

The CDC (2021) reports various risk factors for suicide, which includes having a prior suicide attempt, depression, substance abuse disorder, other mental health disorders, a family history of mental health disorders, a family history of suicide attempts, a family history of violence, being in prison or jail, medical illness, and access to lethal means. Exposure to adverse childhood experiences and bullying victimization are also seen as important relational risk factors. Lastly, social influences such as social and internalized stigma associated with help seeking pose as a risk factor that can increase the likelihood of suicide attempts.

For clinicians, consider clinical risk factors or warning signs of suicide including clients expressing wishes to die, reporting hopelessness, withdrawing and isolation from friends and family, and changes in eating or sleeping habits (CDC, 2021). Protective factors for suicide include clients having coping and problem-solving skills, social connectedness, accessibility and connection to care, and restricted access to lethal means, as well as religious/cultural beliefs that discourage suicide (CDC, 2021). Clinical protective factors include engagement in treatment (CDC, 2021), and, as we will see later in the chapter, clinicians conducting ongoing risk assessment, evidence-based intervention, and follow up (Stanley et al., 2018). However, over 50 years of research indicates that no single risk factor reliably predicts suicide attempts; this highlights the importance of assessing multiple risk factors across the individual and the contexts where they are embedded (Franklin et al., 2017). For Kayla, the clinical contact with her school counselor can be lifesaving; it is up to the counselor to continue meeting with Kayla, develop a therapeutic alliance, and work towards recovery.

Developmental Systems Considerations for Suicide and Self-Injurious Thoughts and Behaviors in Children and Adolescents

School is an immediate context where children and adolescents spend a significant amount of time. Considering the risk factors that lead to suicide, let’s start with the natural settings of the child. Schools may be a primary setting where bullying victimization occurs, with approximately 5-20% of schoolchildren being victims of bullying (van Geel et al., 2014), but more and more, bullying can be present online via social media, also known as cyberbullying (van Geel et al., 2014). In children, peer victimization has a relationship with suicidal ideation and suicide attempts, with cyberbullying being more strongly related to suicidal ideation when compared with traditional bullying (van Geel et al., 2014). In our case illustration, we can see that Kayla was experiencing bullying. Considering the high use of social media by teens, the likelihood of cyberbullying is also high. Social media can foster some social networks that could be protective, so discussing emotional safety with social media is imperative.

 Parental supervision of the child’s online activity should account for the possibility of cyberbullying in hopes of intercepting potential bullying. This may require some education for parents and working with the parent-child dyad on developing a shared understanding of how to safely engage in online activities. The family system itself can be a clinical place of interest in relation to suicide. If we recall that family history of suicide attempts can be a risk factor for child suicide attempts, a risk assessment should include screening for family history. If there is such a history, consider how to support the parent in managing their own stress and to be a support for the child in the case of a crisis.

As noted in an earlier section, adolescents are at high risk for suicidal ideation and attempts (van Geel et al., 2014). In the context of developmental systems, while universal screening should take place across all age groups (as young as 5 years old, per recent recommendations), extra care should be taken with the adolescent age group. Part of the risk of suicide for adolescents is that their frontal lobes are still developing, which is the part of the brain that is responsible for executive functioning and impulse control. These ideas about adolescence should not cloud our judgment when we consider younger children, as we will see in the next section, as there has been an increase in suicide attempts in recent years.

Experiences Across Race and Ethnicity. Rates of suicide attempts for Black youth ages 5 to 12 are rising faster than any other racial and age group (Bridge et al., 2018; Plemmons et al., 2018). Another important context where we see significant racial/ethnic disparities is in the juvenile legal system (JLS). There is a 4.7 to 1 ratio of Black to White youth in the JLS, something known as the disproportionate minority contact (Development Services Group, 2014). Given this, it is important to consider the particular vulnerabilities created by the juvenile legal system. Reports indicate that youth that enter detention have 3-4 times higher likelihood of death by suicide than their counterparts without exposure to the JLS (National Action Alliance for Suicide Prevention, 2013). Two-thirds of detained youth have been diagnosed with at least one psychiatric disorder (Abram et al., 2015; Underwood & Washington, 2016). Furthermore, 90% of youth in detention have been exposed to a potentially traumatic event (Abram et al., 2015), with increased rates of polyvictimization than their peers without exposure to the JLS (Ford et al., 2013). A meta-analysis indicated that 19-32% of detained youth had suicidal ideation, with 12-15.5% reporting past-year attempts (Stokes et al., 2015). In addition, youth with deeper involvement in the system have higher rates of suicidal ideation and behavior, especially those who are either post-adjudicatory status or post-disposition and held in a secure facility (Stokes et al., 2015). Conditions in detention such as separation and sleeping in locked rooms may also serve as potential risk factors for suicide attempts in detention (Abram et al., 2014).

A study by Assari et al. (2017) showed that higher perceived discrimination was associated with higher odds of suicidal ideation for Black adolescents. Brooks et al. (2020) report that for Black young adults, perceived discrimination can act as a painful and provocative experience that is associated with increased capability to overcome their own fear of death. This link was previously examined with black adolescents (Arshanapally et al., 2018). These studies call for clinicians to address the psychological consequences of perceived discrimination. Simply put, racism kills people in varied ways. Therefore, there is an ethical imperative for clinicians to provide the therapeutic space to discuss racism and discrimination (for further reading, consult the Racial Trauma chapter), and its impacts on suicide risk. Additionally, Opara et al. (2020) offer a theoretical framework for understanding how to integrate the interpersonal-psychological theories of suicide and intersectionality theory. A recent review on Black youth suicide also cited stigma as a significant factor driving disparities in youth suicide (Meza et al., 2022). In fact, Black students endorse the highest rates of stigma related to seeking/receiving mental health treatments, and these ratings of stigma are predictive of higher odds of past-year suicide (Goodwill et al., 2020).

Asian American youth are also a marginalized group that need to be centered in the discussion of youth suicide, specifically in terms of the myths and the realities of suicide. The lifespan perspective of the developmental systems can help us tease apart the realities of Asian youth experiencing suicide. There is a cultural phenomenon of hidden suicidal ideation that elevates the risk for suicide (Chu et at., 2018). Asian American students are more likely to have their internalizing mental health needs go unmet (Kim et al., 2018), and this can be related to problems with being screened for suicide risk in their school, to the likelihood that parents will decline mental health services, and to actually having services initiated after the assessment when compared to Latinx students (Kim et al., 2018). For Asian-American college students, rates of suicidal thoughts and likelihood to attempt suicide are higher than White American students (Wong et al., 2011). Could this point to a cumulative effect of not having their mental health needs met from their primary or secondary schools?

Overall, Black and Latinx adolescent girls have the highest rates of suicide attempts, with current rates indicating that White adolescent girls have a prevalence of suicide attempts of 9.4%, while Black and Latinx adolescent girls have rates of 15.2% and 11.9%, respectively (Ivey-Stephenson et al., 2019). Many culturally relevant risk factors among Latinx youth have been examined. For example, in a study of Latinx college students, lower levels of ethnic identity attachment were related to greater suicide risk (Oakey-Frost et al., 2021). Other studies focusing specifically on Latina adolescents found that large acculturation gaps with their parents/caregivers and immigration stress were significantly associated with suicide attempts (Cervantes et al., 2014). In a recent meta-analysis, discrimination was associated with increased suicidality among Latinx adolescents, and this association was stronger for girls versus boys (Vargas et al., 2021). However, there are culturally relevant protective factors that can mitigate suicide risk among Latinx adolescents. For example, one study of Latinx young adults found that higher affective ethnic identity (i.e., feelings of belongingness and evaluations of one’s ethnic group, as well as preferences for ethnic behaviors and practices) reduced the odds of suicide attempts (Forster et al., 2019).

For clinicians, universal screening should be just that: universal, not overlooking any racial or ethnic groups. Clinicians may need to offer more psychoeducation (e.g., frequent outreach to parents) for ethnoracially minoritized groups in hopes of decreasing stigma or uncertainty of engaging in mental health care. Consider Kayla from an intersectional approach. What would you need to know about her family background and history, race/ethnicity, cultural upbringing, experiences of discrimination, or even immigration status? These factors are important for clinicians to consider especially when working with youth from ethnoracially minoritized backgrounds.

Experiences of LGBTQ Youth. Smith et al. (2020)’s review of the literature indicates that sexual and gender minority adolescents and young adults report higher rates of internalizing and externalizing symptoms, and these challenges lead to vulnerability to suicidal thoughts and behaviors. Specifically, in their article, Smith et al. (2020) tested how minority stress impacts this population and found that participants reported higher levels of discrimination and self-criticism than cis-gendered individuals, which in turn increases emotional dysregulation and maladaptive cognitive styles. Recent research suggests that transgender and gender-nonconforming youth experience more suicidal ideation than their cisgender peers (Perez-Brumer et al., 2017), and in a cohort study, over half of transgender and gender-nonconforming youth engaged in self-injurious behavior within a year of the study (Hatzenbuehler, 2017). As a result, clinicians must screen and assess for suicidality especially with these youth and know that targeting both emotional dysregulation and cognitive appraisal can be helpful in the prevention of suicide attempts. Clinicians need to have LGBTQ+ competence in this area and provide resources for their clients, whether online or in-person, which can provide affirmative support.

Assessment

Screening tools can be helpful to guide the clinician in using validated language to discuss suicide with a client, and suicide screening is an essential part of any clinical encounter. Clinicians should note that while screening is essential, any instruments or measures must be formulated into a suicide risk assessment.

With children, a few options emerge as appropriate for use. In their review of freely available measures for child suicidality, Becker-Haimes et al. (2019) found that most measures are designed for youth ages 5 and older. The Alexian Brothers Urge to Self-Injure Scale (ABUSI; Washburn et al., 2010) was rated as “excellent” with respect to its psychometrics, and the Columbia Suicide Severity Rating Scale (CSSR-S) had a “good” rating with respect to its psychometrics (Heise et al., 2016). The CSSR-S is a well-validated tool used to provide definitions of and quantify suicidal ideation and behavior, and it distinguishes between suicidal versus non-suicidal behavior (Posner et al., 2011). It also provides data and trends over time, making it ideal for guiding treatment for suicidal patients (Posner et al., 2011). The CSSR-S is known to have sensitivity to change over a six-week period (Becker-Haimes et al., 2019), which is a critical strength because suicide risk is elevated in the three months after suicidal behaviors. Furthermore, the Ask Suicide-Screening Questions (ASQ; Horowitz, 2012) was developed to use in pediatric emergency departments and has shown sensitivity and evidence for ruling out risk (Newtown et al., 2017). New computerized adaptive screening measures for suicide are emerging to facilitate (in terms of speed and accuracy) risk assessments (Gibbons et al., 2020), and have been validated across settings, including acute settings like Emergency Departments (O’Reilley et al., 2022).

You may have noticed in the case vignette that the counselor used one of the items from the CSSR-S. While Kayla didn’t directly say yes, it was clear that she was experiencing some form of suicidal ideation. From there, the counselor would have proceeded to understand the extent of ideation, considering if there was intent or a plan, and clarifying the frequency, duration, and magnitude of her suicidal thoughts. The specificity of the spectrum of suicidal ideation helps build a risk formulation; the screening is not enough by itself. Please note that with suicidal ideation, “passive ideation” is not an accurate term. Passive could indicate the means by which to end their life (e.g., running into traffic). As a result, it is critical to use the distinction offered by the C-SSRS between a wish/desire to be dead and active ideation.

Intervention

Suicide attempts are the culmination of various stressors, so intervention and prevention efforts should recognize this complexity. The CDC (2021) offers a comprehensive public health approach to suicide prevention that spans economics to mental health systems to social domains. They recommend strengthening economic supports such as household financial security and housing security (CDC, 2021). From a social lens, the CDC (2021) advocates for creating protective environments through reduced access to lethal means among persons at risk for suicide and promoting connectedness through peer norm programs or community engagement activities. Formal mental health system-related recommendations include strengthening access and delivery of suicide care through reduced provider shortages, teaching coping and problem-solving skills through parenting programs and social-emotional learning programs and identifying and supporting people at risk via gatekeeper training and crisis intervention (CDC, 2021). Most effective treatments will focus on unique problems of the presenting client and consider how to support the client with problem-solving, regulation of intense emotions, and developing social connections.

The reviews for psychosocial intervention related to suicide are mixed. In terms of prevention, Calear et al. (2016) found 17 effective psychotherapeutic interventions, with over half of those interventions including CBT and problem-solving therapy. These programs show varying levels of impact on suicidal ideation, suicide attempts, and deliberate self-harm. The other half of identified programs had less formal psychosocial interventions such as social support and psychoeducation. However, the less formal interventions were reported to have a positive effect on suicidal ideation and suicide attempts.

Nonetheless, there is promise in some interventions. In their evidence base update of psychosocial treatments related to suicidality, Glenn and colleagues (2019) report Dialectical Behavior Therapy for Adolescents (DBT-A) as a “Level 1: Well-Established” (i.e., demonstrated efficacy across two independent randomized controlled trials [RCTs]; Mehlum et al., 2014; Santamarina-Perez et al., 2020), intervention for reducing deliberate self-harm and suicidal ideation in youth. However, there currently are no Level 1: Well-Established interventions for the treatment of suicide attempts in youth, given that only one DBT RCT has demonstrated efficacy for suicide attempts in adolescents (McCauley et al., 2018). Still, the consistent support for DBT for reducing self-harm across the three RCTs is impressive, particularly considering that the three trials tested different variants of DBT, with different treatment manuals, formats for skills training (multi-family vs. separate youth and parent groups), treatment dosages, and comparator conditions (Individual and Group Supportive Therapy matched to DBT for dose offered in McCauley et al., 2018, versus treatment as usual in Mehlum et al., 2014, and Santamarina-Perez et al., 2020. The efficacy of DBT for reducing self-harm and suicide could be explained by the fact that it includes a wide range of skills training (i.e., emotion regulation, interpersonal effectiveness, distress tolerance, mindfulness, etc.) that are taught to both the youth and their caregivers/parents, and it includes weekly therapy homework to practice the skills at home/school, provides phone coaching for crisis management, and also includes separate individual and family therapy to supplement the skills training group. Although DBT is a comprehensive intervention that lasts about 6 months (and about 3-5 hours a week), new evidence also supports brief interventions.

Doupnik et al. (2020) identified that brief acute care suicide prevention interventions are associated with reduced subsequent suicide attempts. Furthermore, these brief interventions can increase the likelihood of linkage to follow-up care. The common elements of these interventions include care coordination, safety planning, brief follow-up contacts, and brief therapeutic interventions. One of the most studied of these brief interventions include the Safety Planning Intervention. The Safety Planning Intervention (SPI) is a brief intervention that grew out of CBT for suicide prevention (Stanley & Brown, 2012; Stanley et al., 2009). The SPI works most effectively after a comprehensive suicide risk assessment, for instance, the C-SSRS (Stanley et al., 2012; Posner et al., 2011).

The SPI intends to lower the risk for imminent suicidal behavior by improving coping skills, social support, and help-seeking behavior (Stanley & Brown, 2012). It includes the patient recognizing warning signs of an impending crisis, identifying internal coping strategies, using social support as a distraction, contacting family members who may help or mental health professionals, and lastly, reducing the potential use of lethal means by keeping the patient’s environment safe (Stanley & Brown, 2012). SPI is recognized by the Suicide Prevention Resource Center/American Foundation for Suicide Prevention Best Practices Registry for Suicide Prevention as a best practice (Stanley & Brown, 2012). One of the prevailing myths for clinicians is the contract for safety, where a patient promises to not engage in self-injurious behaviors, including a suicide attempt, and affirms this through a contract with their provider. Reviews of this intervention show that such contracts are ineffective (Stanley et al., 2018) and from a theoretical perspective, this type of approach decreases the self-efficacy of a client. It lacks specific ways to manage a crisis, it does nothing to address isolation, and contracts are inconsistently created. The SPI has been known to be a systematic way to prevent future suicide attempts and is an acceptable, appropriate intervention (Stanley et al., 2018).

The SPI is grounded in a stress-diathesis model of suicidal behavior, in which stressors trigger suicidal crises for individuals with vulnerabilities to suicidal behavior (Glicksohn & Naor-Ziv, 2017; Stanley et al., 2009). In light of this model, SPI is intended to focus on acute need and risk reduction for suicidal behavior, not all the needs of a patient. While this intervention does not focus on long term needs, it is known to reduce suicidal behavior by patients by 50% after six months, as well as double the likelihood of the patient attending mental health treatment during the 6-month follow up period, compared to those who receive treatment as usual (Stanley et al., 2018). While the review in the previous paragraphs shows that there can be variance in outcomes among interventions, engagement in ongoing care is critical (Calear et al., 2016).

Fidelity, or keeping to the prescribed steps of the intervention, to the SPI is paramount for its effectiveness. Proper administration of SPI generally takes approximately 45 minutes to complete because it involves getting the crisis narrative, mapping it on a risk curve, and using the risk curve to brainstorm how to complete the safety plan steps. Anything on the SPI sheet should be specific and ready at hand. If a client has to deliberate on what adaptive steps to take in the midst of a crisis, the crisis itself can escalate more quickly, as opposed to proactively attempting to delay the onset of a crisis peak. The following are the steps to properly complete the Safety Planning Intervention (Stanley & Brown, 2019):

1. Identify and Assess Suicide Risk

2. Obtain Crisis Narrative

3. Psychoeducation and Introduce Safety Planning

4. Identify Warning Signs

5. Explain How to Follow the Steps

6. Complete Safety Plan

7. Implement Safety Plan

8. Follow-up

The videos available at https://vimeo.com/355995975 briefly summarize the proper implementation of the Safety Planning Intervention, as demonstrated by one of its developers, Dr. Gregory Brown.

Revisiting the case vignette, the counselor could have completed the Safety Planning Intervention with Kayla during the crisis session. Seeing that Kayla was engaging in self-injurious behavior, a DBT approach could be helpful to help Kayla with distress tolerance, mindfulness, interpersonal skills, and crisis management. Based on clinician judgment, it may be worthwhile to understand more about the thoughts Kayla was having. Safety is the priority across any type of intervention, and incorporating multiple social supports can help generalize safety. Safety is the foundation to increase the quality of life for Kayla so she can live the life she imagined.

Clinical Dialogues: Suicide and Lived Experiences with Dese’Rae Lynn Stage, MSW

Sean E. Snyder, LCSW: For this interview, I’m taking a different approach than other chapters. Suicide is one of those topics that can be hard to talk about, and there are evidence-based practices out there that can really help people. Those best practices may not get to the people we help because either they do not have the training, or they do have the training and things get in the way of implementation, like our emotional responses or stress. Suicide can be one of those things that can create emotional reactions in clinicians; it can throw us for a loop.

And we have theories about suicide (discussed in the chapter), but suicide is not something to be wholly abstract about. So, for today’s interview, I want readers to get a sense of lived experience of folks with suicide. This way, we can be grounded in our use of EBPs, knowing that our job is really to help, not hurt someone who is really suffering. I have Dese’Rae Lynn Stage with me to talk about suicide and the project she’s been working on, Lived Through This. So, Des, can you tell me a little bit about your background?

Dese’Rae Lynn Stage, MSW: I’ve been working on a series of portraits and stories of suicide attempt survivors called Live Through This over the past 11 or so years. I’ve been doing research using the narratives of survivors, and I’m working on a grant right now about how researchers and people with lived experience can work better together. I consult a lot, I do speeches across the nation, and I run two podcasts. One is called “Suicide and Stuff,” and it’s really irreverent, but it’s also kind of an amazing way to bring in people with various kinds of knowledge about suicide and to talk to them about their work, their experiences, and what they think needs to be changed.

Snyder: Thank you! To start, suicide can be a very uncomfortable topic for really anybody, even for professionals who are trained in how to respond to suicide or suicidal behavior ideations. Let’s say from the experience of a client that someone is experiencing suicidal ideation or is having some sort of crisis, what’s the best way to engage somebody from the client’s perspective?

Stage: Well, I think there are a few things there. First, not enough providers are trained in-depth about working with suicide, where there seems to be a knowledge gap. In terms of engagement specifically, people can vary on the spectrum of suicidality, so really understand where they are on that spectrum. Suicidality isn’t zero to crisis; there are places in between. As a person who experiences chronic suicidality, mostly I encounter the in-betweens. At this point, there are things that trigger my thoughts, and I know the ways that I cope with this. Maybe I just need to take a shower, go to sleep, and to distract myself. So first, you have to discern where this person is on that scale and their history of suicidality; they could have done some of their own work, and they just need reminding to work their own care plan.

With the thoughts, you ask specific questions about them: do they just wish to be dead, or is it they really want to kill themselves? With the history of suicide, we have to find out if they have a history of suicide attempts or a history of non-suicidal self-injury. There’s a link between the two, but they are different. So that’s where being specific is critical for the provider to know how to act but also to help the patient clarify their own experience. So, with engagement, everything here is nuanced, and we cannot treat people like we’re all clones of one another. We’re unique snowflakes, for better or for worse.

For the providers or people in the helping role, it’s scary every single time, but what I also think is that you have to run toward your fear because this can be life and death. It isn’t always, but really, we are talking about life and quality of life. Especially as social workers (I complete my MSW in the coming year), we are tasked with treating people ethically. Whether or not we are fearful, we must act in accordance with our ethics regarding quality of life, self-determination, and the healing power of relationships. Really, it’s just preserving the other person’s dignity as you’re attempting to help.

Snyder: There is a spirit of suicide prevention and care that really puts people at the center, not to sterilize it.

Stage: Right, so you start asking questions and try to actively engage the person, approach it with a kind of curiosity, asking, “What’s going on with you? What do you mean when you say, ‘I don’t want to wake up anymore?’ What’s going on in your life that is making you feel that way? What do you need?” It all comes down to what do you need because as humans, we all need something. I think when we’re working in suicide prevention or the mental health field, we really only get to the part where you ask the question and very rarely do we get beyond the question and the risk management response.

And what we’ve learned in my work is that this is not just a thing for people with mental health treatment histories; we need to go beyond suicide as just something for people that are already in therapy or whatever. The CDC released a report in 2018 (and you can tear apart the methodology, but I think it tells us something really important) that said 54% of people who died from suicide over a 17-year period did not have a mental health treatment history. This information came from police reports, coroner reports, and reports from the family right after the death happened. The factors that were coming into play were relationships, things were financial, medical things, basically just life things. I think this is a way that we are not thinking about suicide that would do us a lot of good to think about.

Snyder: This CDC Suicide Prevention approach takes a multi-faceted, public health approach, and considers domains such housing and how life stressors like eviction could precipitate a suicide attempt. Their prevention guidelines talk about increasing ways to be connected to somebody in your community. That more public health approach reframes suicide not as a personal character trait or something constitutional with the person.

Stage: The focus on suicide as something related to mental illness definitely has roots in the medical model, and I think with the way we do healthcare, suicide prevention clings to treating suicide as something that is mental health related, like an individual person that gets individual treatment. So, I think the way it’s approached is limited and maybe even a way to keep medical providers in a position of power.

Snyder: Right, I just heard a talk about behavioral economics and implementation science, and when we think about changing paradigms or even just introducing a new intervention or way of doing a task, we would consider the role of loss aversion. Providers can be afraid of the idea that something else other than their clinical skill, or what they do, can be the answer for a suicidal problem. If a provider has to contend with approaches that have to do with things like social determinants or something that’s a structural thing, it may feel uncomfortable because that may not be in the skill set. You may lose something in trying a new approach.

So, I’m not saying, blow up the model we have, because there are definitely things that are helpful. But we need to broaden our approach, and it requires a different response that could ultimately have providers give up some specialized knowledge about how to care for folks with suicidality.

Stage: And I think social workers are poised to change that because there’s the idea that we are walking alongside the person we’re serving, and we are not trying to locate the issue within the person. I will be willing to bet that most of those people who are looking at contexts are people with lived experience.

Snyder: That last point echoes what is most likely true with mental health providers, that providers probably have had some sort of lived experiences with mental health challenges. So, we can’t ignore lived experience; mental health is interpersonal. To summarize where we are at, you mentioned with engagement that providers need to be exposed to more strategies or just given time in their training in regard to suicide. Clients have unique experiences, and engagement requires understanding that unique experience in terms of spectrum of ideation and of suicide history.

Stage: Something else to consider is the provider can experience a challenge by what policies they are working under. Are you working in private practice or are you working within an agency that has very stringent policies around suicide that are informed by liability? Understanding the policy context gives a guide with trying our best to maximize the self-determination of the person we are helping. The provider’s aversion to screening to suicide may be the worry of the spillover effect of a positive screen; it could lead to having to clear out a schedule to follow a protocol to engage a crisis unit or whatever. Of course, though, we need to screen everyone, but sometimes the contextual pressure is there.

Snyder: Hmm, it’s almost less a care conversation when we screen, it’s more of a risk management conversation.

Stage: Right, and transparency from the start is key, giving the information up front, making a collaborative effort, and maybe just doing a wraparound or recovery action plan so you can get a sense from the client where it’s joining with them to see what they need in particular moments. It is a matter, too, of being transparent, so a crisis doesn’t catch the provider and client off guard, where it’s scrambling to help and then falling back on things like the hospital. That’s a place that could do more harm than good.

Snyder: Well, we need to encourage care in natural settings, with natural supports and familiar resources.

Stage: The shame with hospitals is that people again are not trained, and people in mental health facilities may not have professional standards that go along with something like a medical credential. And they also are not paid enough. But thinking of the hospital as a suicide prevention strategy, what is it that we are really preventing? If we want to prevent that outcome of death, we have to be thinking of the long game, and not just prolonging life in a moment of crisis game.

Snyder: Sure, and that’s where our system of care is oriented towards medicalizing stress and medicalizing wellness promotion, and segregating it from the everyday, natural experiences of people. Here’s my mantra of natural settings again and less of a medicalized approach. The disclosure of suicide should not be met with a prescription or a hospital; we need to support recovery where people live, work, and play. Yes, adults play, too. Natural support can support someone’s agency and also the agency of communities to care for each other. A hospital disrupts natural relationships. Relationships are critical when we look at the theories of suicide too.

Stage: Anybody who knows anything about suicide will tell you that isolation is huge risk factor. And yet, those same people will say, “Well, you got to get them hospitalized if that’s what’s going to keep people alive.” But they rarely talk about how hospitalization does interrupt those relationships and the natural setting, and it takes all your comforts and your safety. It can limit access to lethal means, but is that all the hospital does?

Snyder: Right, because it is focused on death, and while that’s super important, we need to also see what value we are adding to the person’s quality of life, what’s a positive approach where something meaningful is added. We’re not just delaying death in this way, rather, thinking of how can we add something so this person has a meaningful life.

Stage: Mainstream Suicide Prevention feels like it’s centered on the prevention of death versus how do we find quality of life for somebody, or how do we make them want to stay as opposed to just not die?

Snyder: Very much so. Now, I usually ask about screening questions in these interviews for the book. I think part of the equation here is that we have our instruments, and we need folks to be comfortable using them. Trust in their own skills and trust the instruments to guide the process. The key thing is just asking; what we need to do is ask people about these questions right and when we get that, then what do we do once we ask.

What we do should be in the context of a formulation; it’s not enough to get some checkboxes. Consider risk factors for attempting, get to know the person, get some collateral information, and the clinical decision making is based on the formulation.

Stage: I think that time can be a big constraint in formulation; consider what happens when you get a positive screen in a clinic setting where you have an hour. It’s probably still not enough, but that is a gift of time that maybe providers can be up against the clock in their clinic. So one client that expresses suicide can, like what was mentioned before, affect that clinic schedule.

And to take a step back, I probably sound really negative toward providers and science and everything, and it’s a negativity that is born of love because I want to learn how to help our colleagues doing the work.

Snyder: What have you seen with the people you’ve interviewed? What are the things that folks are hoping for from providers?

Stage: A lot of the time again, it’s wanting a feeling of control. People feel hopelessness; a lot of people feel backed into a corner. Preventing suicide in a crisis is about distraction, to get someone in the place to feel like that they have some sort of control.

Snyder: Right, as we see with some interventions, it is trying to ride out the stress.

Stage: It goes back to how you can retain self-determination.

Snyder: I like that you brought up self-determination, because I think that cuts across the provider perspective, the “why” of our interventions. Think about if you have that at the core of your approach when you do a safety planning intervention. Let’s say you teach some coping skills, and you teach some distraction skills. It’s different if you’re just doing a mechanical scripting, “the patient says x, then I do y.” Self-determination goes way down when stress goes very high, so a distraction skill created in the lens of self-determination realizes that we are trying to help the client be in a place to truly make an informed decision about whatever it is. I think what grinds my gears is seeing the Safety Plan as just a piece of paper, like an exit ticket to get out of a hospital. It really takes a connection, taking a deep dive into the client’s situation when doing a safety planning intervention.

Stage: Yes, there’s a self-advocacy piece there, too, that also doesn’t get talked about enough. How do we create a space where clients can advocate for themselves, where the providers will listen. And it comes down to whether or not the provider feels comfortable and competent enough to have that kind of encounter. So, in wrapping up, I would say to providers, from the client perspective, run toward your fear, and it is okay to be afraid. It’s okay to even acknowledge you’re afraid of the person you’re working with, because that can model “This scares me, but I want to help you. What can we do?” Because we’re people. We’re people and we care about the people we’re working with. People are what live through the experience of suicide.

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