Disclaimer: This is general information and is not advice, consultation or recommendations. Please contact your local community professionals, crisis services or law enforcement if you need help, consultation or services.
Job interview question: You have five suicidal persons. One who is intoxicated, another is severely depressed. Another who has been in the ER three times this week with suicide thought. One who is acutely psychotic. And the last one notes that they have a lot on their plate, with stressors of relationship, finances, loss of job and a history of PTSD. Again, using the mental status exam, tell us, which is which, what are the general treatment recommendations and when and why would you detain them?
The following are thoughts and ways to conceptualize suicide investigation, evaluation and intervention. These are thoughts for your consideration based from my clinical experience as a crisis MH evaluator and consultant. One of the aha moments was the idea to conceptualize suicide as violence toward oneself. Suicidal thoughts are born out of feelings of anger and rage that turn into depression and despair of being in a cage; powerless. Unable to change what is happening. Wanting these feeling to stop. Unable to figure out how to make these feelings stop and unable to change the situation. This begins to eat at a person, their self-confidence, their self-worth; unsure and unable. It becomes an endless cycle despite their best efforts. Hopelessly sinking further into despair. Becoming despondent… without meaning or purpose… nothing. All that remains is only a splinter of control; only one choice, to choose, if they are out of here… dead, gone, no more!
Suicide thoughts are normal. Most folk’s come across a time where things are overwhelming and “omg just kill me now.” Anecdotally, many intelligent and high functioning folks, have a suicide plan, resources and means. They have a “threshold scenario” of if this happens, “I’m out of here.” It’s mostly a suicidal fantasy, unless it becomes real. Yet they are prepared with a plan and means.
Likewise, violent thoughts are normal. Something makes us highly upset and pissed-off (reactive). Yet rarely is there further overt behavior. Then there is rage versus predatory or pre-meditative first degree homicide versus manslaughter. In the criminal realm, it’s about a past behavior verses civil MH side, it’s about the potential or risk of a tragic event in the future. The focus is not the either/or of figuring out the “why and how” of an event that has occurred as in criminal behavior. But focus is on an investigation and evaluation of the spectrum of potential risks of tragedy in the future and relative to the client’s thoughts, feelings, intensity, motivation, time, reactivity, intent, means, plans, resources, etc.
Suicide as a violence toward oneself.
As result of a “mental disorder and casual nexus” an act or threat of aggression towards another person, self, or property which threatens or is likely to result in: 1) physical injury to another. 2) to themselves, 3) destruction of property or 4) grave disability, i.e., unable to maintain their physical health and safety or there is repeated and escalating loss of cognitive and volitional control. (https://lovechangegrow.com/involuntary-treatment-act-part-2/)
- We usually think that violence is directed to another person.
- When violence is directed toward themselves; it is either self-harming or suicidal behaviors or actions.
- Are behaviors “disorganized” and reactive to perceptions of their experience. Which can be either as result of an internal state or as a reaction to external stressors. The key is sorting out the client’s perceptions, i.e., their experience, motivations and their resulting behaviors.
- There are also the passive condition of “diminished capacity . Or “grave disability,” i.e., loss of cognitive and volitional functioning demonstrated by severe deterioration in routine functioning.” This can be result of drugs, alcohol, delirium, dementia, TBI, developmental, etc. It’s not particularly intentional, but due to a lack of their cognitive and volitional ability/control. And perhaps a lack of support in their environment results in violence (or potential). Examples are irritability, frustration, rage, increased stress, anxiety, etc. In these types of cases, the intervention involves a sorting out and discussion of “rule-outs” (elimination of causes). These rule-outs often involve medical investigation/evaluation, is treatment available, the ability to consent, physical containment, criminal and what is reasonable and available treatment. Usually this requires discussions that frequently involve several systems or parties. Frequently an ITA officer has little or no purview beyond a narrow criteria of the “casual nexus.” Yet is involved as a consultant. In which they initiate a discussion as an act of advocacy for the client, relative to other parties that are involved. Such as; family, medical providers, social agencies, care facilities, first responders, law enforcement, guardians, etc.
The Why:
- Situationally driven?
- What are the internal vs external perceptions/experience of the client?
- Does the client have inadequate, underdeveloped or maladaptive skills?
- Diminished capacity or gravely disabled, i.e., under the influence, inability, e.g., dementia, TBI or developmental disability, etc.
Risk factors and (remember there are also protective factors)
| Static | Age, gender, race Criminal history and family criminality Antisocial behavior Intellectual functioning Family structure and rearing practices Socioeconomic status |
| Dynamic | Antisocial personality and or mental health diagnosis, companions/peers and social achievement, criminogenic needs, interpersonal conflict and relationships, personal distress/coping skills, substance abuse |
| Contextual | Weapon availability, social support, victim availability, access to treatment access to drugs and alcohol, suicide/assault ideation, intent, plan, means, resources. |
| Fluid | Presence of a life threatening medical condition, pain, substance or alcohol intoxication, mental status, treatment compliance, actual immediate threats or dangerous behaviors, availability of lesser restrictive alternatives. |
Remember violence is a spectrum; intensity/acuity, risks and interventions. A range of thoughts, feelings, motivation, intent, plans, means/resources, attempt/execution, capacity or ability to act. Versus likely results versus available interventions.
Model of affective and predatory modes of violent behavior (The Psychopathic Mind, J Reid Maloy, 1988). A forensic evaluation for a case of “not guilty by reason of insanity.” The legal defense focuses on the mental state at the time of the crime. AND evaluates if the person is able to participate in their defense. Whereas in civil MH detainment and commitment focuses on the potentials, intervention and prevention of a future tragic event from happening. The focus is evaluating the risks of when, why and the intervention to prevent a future tragic act/event.
House Cat Example
| Affective | Predatory |
| Defensive | Aggressive |
| Rapid displacement of the target | No displacement of the target |
| Time limited | No time limited behavioral sequence |
| Preceded by a public ritual | Preceded by a private ritual |
| Primarily emotional | Primarily cognitive and conative |
| Heightened and defused awareness | Heightened and focused awareness |
| Random, i.e., available victim | Can predict the victim pool |
| Disorganized and reactive | Organized, intentional and strategic |
| Contextual, fluid | Static, dynamic (see below) |
| Diminished cognitive, volition control | Intact cognitive and volitional/willful control |
Predatory violence presentation/profile is often referred to the criminal side. However, it is useful to view predatory structure when it is directed toward self-destructive/harm and/or suicide. And the evaluation of whether it is a reactive/disorganized response or intentional/strategic, with self-predatory intent.
Types of suicide: Predatory (directed to themselves), disorganized or reactive, failed and completed. Predatory and completed versus disorganized and failed. Completed is done, often looks like self-predatory. And there is the third type of a failed suicide attempt might be disorganized or a mis-calculated attempt that may result in an un-intended completed suicide or a survival of an intended suicide. Determination of motivation, intention and goal are key in understanding the what and why of suicide. Such as, is it rage or revenge, wanting surviving family to feel bad, wanting out of the situation, depression, self-loathing, control, tired, burden, anger, disappointment, loss, etc.? Understanding the motivation, intention or goal leads to the clinical formulation (why) and thus is a guide to the subsequent matching of the intervention that may be the most appropriate.
Spectrum: Each of these categories can further be laid out on a spectrum. Thoughts, Feelings, Intentions/motivations/drives, Behaviors and Beliefs of the self, world and future.
Context/environment: Plans, means and resources.
The Why: Clinical Formulation
6 General Themes of Why: What is it, clinical formulation and treatment recommendations?
- Unable to adaptively cope with a perceived stressful situation (overwhelmed)…counseling and life mgt. skills. Homelessness and food and shelter which is often correlated to social-economic-class factors or issues.
- Learned behavior or anxiety/ritual or stress/tension release, maladaptive coping (para-suicidal behavior) that sometimes results in miscalculation. Counseling and education and emotional/anxiety. modulation skills.
- Acute or severe depression with a significant disruption in sleep, energy, appetite…antidepressant meds and stabilization.
- Psychotic or bizarre self-harm or suicidal behaviors…antipsychotic meds and stabilization.
- Drugs and Alcohol…Detox, CD evaluation and treatment. Basically the treatment is to stop doing drugs and alcohol; it’s not doing psychiatric treatment. Needs detox, then building a wellness routine. There is often underlying or co-morbid MH issues. The general treatment is dual dx program if the client is willing and a placement is available. But detox is first.
- Geriatric/Dementia/Delirious/TBI-head injured/DD Persons. Is it, a matter of medical work-up, pain, frustration, containment, change of environment, community support and services and facilities/staff training and/or increased resources, i.e., staffing? What has been done and failed (see check list https://lovechangegrow.com/involuntary-treatment-act-part-3-odds-and-ends/).
Remember Wellness? (https://lovechangegrow.com/what-is-mental-health/) Well there are types drivers of desperation, hopelessness and suicide/violence versus wellness. Where is the client’s focus and are there openings or opportunities that their focus can be changed?
- Physical, e.g., pain, disability, amputee vs exercise, walks, etc.
- Energy, e.g., debilitating, dialysis, chemo vs sleep, energy/activity, appetite.
- Social/interactional, isolation; mobility and access. Be useful or help to someone that is in a worse situation than you are. Volunteering, animal rescue or helping a neighbor.
- Emotional, depression, rage, frustration (or otherwise). Emotions are the power, drive or pressure of manifesting behavior. The question is what do you want? You reap what you sow. You want hope, joy and love? Plant it, give it away, make someone else’s day better.
- Intellectual, avoidance vs engagement to drill down… psycho dynamic or personality.
- Meaning and Purpose, not finding or knowing your purpose; existential and introspective realm. Acorn Theory https://lovechangegrow.com/parenting-part-1-of-5/ and SWOT analysis. which is simply an assessment and inventory of strengths, weaknesses, opportunity and threats. But you can change your SWOT by learning, education and developing your SWOT… enhancing yourself.
- Spiritual, (world view or belief of self, world, future) sin, redemption, forgiveness. Surrendering is letting go of the past. It doesn’t matter where you are from or what you have done. It matters more where you are going and what you want to do. And what matters the most, is what you decide and do today and do it. The doing it, is the claiming who you are. Everything is a choice, what do you choose? What you choose and do is what you are.
The Hamster Wheel
If we think of the dynamic as pressure that waxes and wanes; it cycles. There are peaks and valleys of acuity or energy. A build up of tension and release or relaxing over time. Where are the risks, opportunities and leverage? Understanding the profile, dynamics and risk are the basics. But being able to create the sacred space of empathic witnessing (https://lovechangegrow.com/the-gift-of-empathic-witness-mh2/) is providing the opportunity to leverage or help the client to change their focus. Types of therapy: Deep focus, Skills based, and supportive relationship; and educational/teaching.
Suicide assessment is a tool for profiling risk. Yet the suicide assessment can also be a tool of intervention. The problem with cycles is that it is repeating and the great thing with cycles is that it is repeating. So the question with repeating cycles is how do we use this knowledge to change? Yet for the client, they often recognize that it’s a crazy hamster wheel they run on, but the problem is they don’t go anywhere. It’s the same old crap. They are sick and tired of being sick and tired, whether it is addictions, trauma-abuse, overwhelming life stressors, depression, anxiety, relationships, etc. When it comes to suicide, they just want it to end. It’s often not that they want to actually kill themselves. But it’s the only way they have figured out to end it. It’s the question of: How in hell do I get off the damm hamster wheel without killing myself?
Intervention Matters:
What is the intervention? Suicide takes a lot of courage, energy and determination. It’s not easy. It is awareness of the situation. In any intervention, the earlier the recognition or awareness, the better. There are many aspects or frameworks to the suicide spectrum. Basic are the what, when, where, how and why ways of looking at suicide. In a sense the intervention is to help the client to develop some “situational awareness” of their predicament that helped bring in the thought and feelings of suicide. When a client develops some situational awareness and understanding of their predicament. Then it can offer some insight and guidance leading to a strategy of how get off the hamster wheel.
Contextual and Fluid (environment and time)
In MH detainment it is the imminence window. The past 24-48 hours or the future 24-48 hours. The energy or “death wish” of the actual suicide attempt behavior is very brief. In my estimation is 20 to 90 minutes if the person is stone cold aware. It’s really the ability to maintain concentrated focus. Of course there are often factors of intoxication, impulsivity and miscalculation. Thus it is about the fluid risk factors of the mental status exam. And what is in the immediate environment during this brief period of time concerning the available means and opportunity to commit suicide. Versus at the static and dynamic levels of risk, is a larger time window. For example, with drug and alcohol abuse, it is easy to predict 95% that at some time during an alcoholic’s life, some thing has tragically happened or will happen. But it is difficult to note “what, when and where.” In crisis management, it’s about managing the client’s response and presenting an intervention that the client understands, accepts and will engage with. And the prevention view is best handled with education, awareness and demonstrated by doing a wellness routine prior to and even preventing the crisis https://lovechangegrow.com/what-is-mental-health/. And Thus what is the person doing (contextual and fluid risk factors) or NOT relative to a wellness (or illness) routine?
Suicide assessment/evaluation is also a tool of intervention. Which is simply “Empathic Witnessing (https://lovechangegrow.com/the-gift-of-empathic-witness-mh2/). Listening, asking questions that motivates and inspires and a bit of guidance of how they might jump off the hamster wheel of hell. Being chased all over hell by one’s fears, demons and anxieties. And jump on to the wheel of wellness; chasing your dreams, passions and joy. In a sense it is helping a client to move through the process of breaking down, breaking open in order to breakthrough… (jumping on the wheel of wellness… living your dreams, passions and joys).
Generational Precedence
Parents, families and individuals, there are times where all seems lost. The struggles are real and heartbreaking. When a person suicides; a completion and dies. This sets a statistical precedence that is shown for about 5 generations in a family’s linage. The precedence is that when life gets hard and the parent or loved one checks out. Then it becomes an option for others in the family. Especially for the surviving child regardless of their age. Despite the age of the child, at some point they will become aware that mom or dad checked out. That they, the surviving child (and spouse/parent) were abandoned. That when life gets tough, the precedence of suicide is an option has been established. And this effect is statistically seen for several generations. Any reasonably responsible parent is horrified by this thought. Can the suicidal client/parent, imagine their son or daughter (grand kid and great grandkids) also taking their life?
Yet there is another precedence. The precedence is despite the struggles and difficulties of life. A parent continues to make it through the day, week, month and year. That no matter how hard it gets, they have faith, hope and belief there is a meaning and purpose to their existence. Parents, your child will at some point, become aware, that for a while, your life was rough, hard and shitty. Perhaps was recovering from an addiction, abuse, a suicide attempt. But by your example of being their role model, they will see adversity as a challenge instead of a defeat. And this sets the other precedence of survive, thrive and the triumph of a life lived; regardless of the good, the bad and the ugly. And this sets a different family history, story and precedence for future generations that becomes a family legacy.
Here’s the thing: kids, family and close friends at some level are aware of a loved one’s struggles. Even despite suicide attempt(s). The attempt can change from a story of struggle to a heroic story (precedence) of crawling out of a dark hole of despair, depression and desperation and finding hope, meaning and purpose. This becomes a story of inspiration for your family’s future generations.
I’m kind of a hard-ass about this. And say: “Hey, it’s your choice. Ultimately it’s your responsibility to decide to kill yourself or NOT. I’m not superman or your angel. I can’t be with you 24/7 and prevent you from killing yourself. And if I thought and told you that I could, I’d be the crazy one. And you would know I was full of bullshit. So, if you are interested in other options besides killing yourself, I can help you figure out some things and get you some help to get your life back on track. So what do you want to do?”
If the client is unable, to open up and consider options other than suicide, for whatever reasons, then it’s time for serious consideration of psychiatric hospitalization.
Thanks and Blessings!
Tim