A rather far-reaching question involving suicide assessment was asked on a nursing forum:
http://www.pronurse.co.uk/topics/1845-what-to-say-to-a-suicidal-patient/posts
This is my attempt to answer the question.
Suicide assessment
First I have to say that in my opinion it is almost impossible to reliably assess suicidal intent over the telephone. It’s hard enough to assess it when you’re there in the same room – to do so over the phone is incredibly difficult.
Therefore I’d strongly advise you to refer on if you have any doubt. What follows is information that may help you notice some of the danger signs. Use it to notice suicidal ideation you’d otherwise have missed – don’t rely upon it to reassure you that someone is not suicidal. If you have any doubts get a proper assessment done ASAP.
Caldicott guidelines demonstrate that you can always alert emergency services if you think it appropriate. If you think someone is at immediate risk contact the police. If you think their CPN or GP needs to know then there is nothing to prevent you from passing on information. Confidentiality does not mean secrecy it means ‘need to know’. The services named above will need to know if they are going to maintain proper care. You need to pass on the information in order to fulfil your duty of care if you reasonably believe an assessment is needed.
You can learn more about Caldicott and the rules of confidentiality here:
The six Caldicott principles, applying to the handling/transfer of patient-identifiable information, are:
1 justify the purpose(s) of every proposed use or transfer,
2 don’t use it unless it is absolutely necessary, and
3 use the minimum necessary.
4 access to it should be on a strict need-to-know basis.
5 everyone with access to it should be aware of their responsibilities, and
6 understand and comply with the law.
You are obliged to disclose in certain circumstances. Remember that whilst confidentiality is a right, citizens also have the right to effective services and this includes mental health care. If you don’t tell the crisis team then the person will effectively be denied their right to mental health care resulting in their premature suicide. The two rights need to be balanced and often the right to services will outweigh the right to confidentiality. If someone is about to hang themselves call for help with or without their consent.
What follows then is a way to make sense of what you might hear – it is not designed as a suicide assessment tool in itself – that will take time and training. A little article on a website like this is no substitute for that.
If in doubt seek help – without delay!
Does Self-Harm naturally lead into suicide?
This is not an easy question to answer when thinking about individuals. In general we can say that usually it does not – that Deliberate Self-Harm is a coping strategy and that it has nothing to do with suicidal intent.
However, for some people Deliberate Self-Harm is very definitely a lead-up to suicide. It’s as though the person is rehearsing in their own minds – a way of preparing themselves for the final act. For these people we can think of the ‘suicide ladder’:
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Suicide
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Preparation for suicide
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Potentially fatal deliberate self-harm
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Moderate deliberate self-harm
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Mild deliberate self-harm
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Help-seeking behaviour
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Problem-solving behaviour is unsuccessful
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It is always a good idea to assess for signs of suicidal thinking and get professional help if there is any doubt but remember that the majority of people who harm themselves are not about to commit suicide. However, in broad terms if someone’s behaviour is moving up the ladder in stages then it is definitely time to seek professional help.
Suicide Risk Assessment
Assessing risk is essentially an impossible task. It is an attempt to predict the future and is therefore always flawed. Like the weather forecast, the greater the period of time that passes following the assessment the less accurate the predictions may be.
However, this does not mean that the process of risk assessment is pointless – merely that it has limitations and can never be said to be wholly reliable. Few clinicians who are regularly involved in suicide risk assessment can honestly say that they have never made the wrong decision and for many of us those occasions have, from time to time, had tragic consequences.
So the first thing to remember about risk assessment is that it is always fallible and the fact that your predictions are not always accurate does not necessarily mean that the process of your decision making is at fault.
Inquiries into suicides acknowledge this and so tend not to focus upon the actual events so much as upon the process by which the decision was made.
Identifying vulnerable groups
Before we can clearly identify people who are at risk of suicide we need to understand a few preliminary points. These are:
- Suicide and Deliberate Self-Harm are not the same thing (although they are sometimes linked);
- The study of ‘demographics’ is the study of large groups of people – it’s a statistical analysis;
- There are three kinds of lies : ‘Lies’, ‘D**N lies’ and ‘Statistics’;
- People are individuals and do not always fit easily into the boxes we have created for them.
Having said that certain groups of people are more prone to suicide than others. If you have concerns about someone who fits into several of these groups you must take the risk seriously. The more demographic boxes you tick the greater the statistical risk.
Demographics
q Adolescents of both sexes
q Young men
q Middle aged women
q Men over 65
q Widowers
q Recently divorced
q Retired or redundant men
q Parents who’s children have died recently
q Farmers
q Doctors
q Teachers
q Other professionals (to a lesser extent)
q Members of ‘fundamentalist’ or ‘cult’ religious groups
q Anyone who had a relative who committed suicide
q Anyone with a history of abuse as an adult or of childhood sexual abuse
q Unhappy marriage
q People living in poverty
q Anyone with rapid access to lethal implements (so can act impulsively)
Psychological/Diagnostic
q Diagnosis of schizophrenia (this is a particularly high risk for clients immediately after their second or third psychotic episode).
q Depression – risk is greatest as people recover
q Bipolar Affective Disorder types I & II (Manic depression)
q Alcohol or substance related disorder.
q Post Traumatic Stress Disorder.
q Borderline Personality disorder.
Social
q Isolated individuals.
q Those who are ridiculed or otherwise ostracised by significant social groups.
q Those experiencing significant social change (ie loss of status/financial security/following bereavement).
Cognitive (thinking)
q Those who have had to re-evaluate cherished beliefs (religious or otherwise).
q Those who feel guilty or ashamed (whether rationally or not).
q Those who express hopelessness.
q Those who express Anhedonia (lack of enjoyment).
q Those with low self esteem.
q Those with generally poor coping strategies.
Other indicators
q The client says they are considering suicide. It‘s a dangerous myth that people who intend to kill themselves don’t tell anyone. Most people who have completed suicide have told at least one person and often several about their plans. People begin to have suicidal thoughts and feelings before they actually take them seriously and there is usually (although not always) a period of contemplation during which they seek help in order to avoid actually killing themselves.
q The client has made active preparation such as buying a rope, leaving a will, putting their house in order, writing a note, giving away their possessions.
q The client is unable to talk about future plans – for example they can’t tell you where they plan to go on holiday next year or even what they would like to eat on Sunday.
q The client has ‘means’ (a stockpile of medications for example).
q The client has made a plan and taken steps to prevent discovery (arranged to be alone all night for example to allow time for an overdose to work).
q If in the past the client has attempted suicide and failed, they were unhappy to recover or their recovery was unexpected.
q The client has a previous history of ‘escalating’ severity of self-harm.
q They are facing a crisis, which they had previously warned or otherwise indicated would be insurmountable for them.
Perhaps the most important indicators are helplessness and hopelessness. The person believes themselves helpless to solve their problems and they see no hope of anyone else doing so either. If you see someone expressing both of these together seek help immediately.
How to get help from others
When liaising with statutory services it’s always important that we ‘speak their language’. For most purposes this means that we need to record and report ‘symptoms’ in the way that diagnoses are structured.
Diagnosis considers thoughts and feelings, behaviours and physical signs and symptoms but often only to see what is present ‘now’. It does not necessarily consider the formation of those problems – simply their presence.
The Medical model of mental disorder is a biological model. It places the cause of mental disorder within the physical body. That is why doctors rely heavily upon physical treatments like medication which are designed to change how the physical body functions.
When preparing to refer to statutory services for assistance take a few minutes to plan how you will describe the problems you’re facing. This allows the doctor or other professional to see clearly what the problems are. It also helps ensure that you don’t miss anything out. Just go through a quick checklist of biological, psychological, emotional and behavioural symptoms and organise your information.
Also, be sure to point out clearly to the doctor what you’re asking for and if you don’t think that you or your organisation is able to cope without assistance make a point of saying so. Never assume that the doctor knows that you’re struggling. Often if you don’t spell it out like that the Dr. will assume that you are managing and will not give much assistance.
In order to present diagnostic evidence (symptoms) in the best possible light put it into the same categories that doctors do. These are:
q Physical (within the body)
q Psychological (within the mind/emotions)
q Psychomotor (speeding up or slowing down of the body)
q Behavioural (what the person does)
The more preparation you do the more likely you are to be listened to and taken seriously. Stamping your feet in the GP’s surgery doesn’t help and is likely to make the task harder for you next time. Below are some of the more common diagnostic groupings for depression, anxiety and psychosis. Don’t bother trying to memorise them – just keep the list handy for reference.
Those in bold may indicate suicidality more strongly than some of the others – be sure to report them.
Physical symptoms of anxiety
q Restlessness
q Tremor
q Tension and headaches
q Sweating
q Tachycardia (heart rate increases)
q Intestinal problems (constipation, diarrhoea, nausea etc)
q Dizziness
q Dry mouth
Psychological symptoms of anxiety
q Worry
q Apprehension
q Fear
q Negative predictions about the future
Biological symptoms of depression
q Lethargy(tiredness and slowness)
q Sleep disturbance
q Appetite disturbance
q Slowing of movement
Psychological symptoms of depression
q Reduced concentration and attention
q Reduced self esteem and confidence
q Ideas of guilt and unworthiness
q Bleak and pessimistic views of the future
q Ideas or acts of self harm or suicidality
q Helplessness
q Hopelessness
Symptoms of Psychosis
Disturbances of:
q Perception (hallucinations)
q Belief (Delusions)
q Thinking process (Thought disorder)
Basic risk factors for quick assessment
Why this? why first? why ever? why now?
Psychological profile
How does the service-user normally deal with stress and distress? Is there a diagnosis of mental disorder?
Ideation (passive)
What is the service user’s attitude to death and to suicide?
Ideation (active)
What is the service-user’s attitude to their own death? Have they developed a plan?
Plan
How well thought out is the plan? Is it likely to work? What can you do to intervent in the plan?
Preparation to avoid discovery
Has the service-user taken steps to ensure that they will not be discovered until it is ‘too late’?
Preparation to ensure lethality
How well has the service-user prepared their plan? Will it work? Do they expect it to work?
Degree of distress
Does the service-user appear distressed? Will suicide represent a ‘release’? What other coping skills do they have?
Method
How feasible is the method of choice?
Means
Does the service-user have the means necessary to complete suicide?
Statistical risk
What is the demographic risk of the service-user?
History
Has the service-user attempted suicide before? How were they discovered? Were they happy to be alive afterwards? Is this situation comparable to previous situations when they attempted suicide?
Regarding your other questions about your helpline’s role:
I’d advise against inviting the person to your place of work. There are health and safety/risk implications here and to be honest what would you expect to do once they arrived? If you’re not trained to assess and deal with suicidaity then you should pass them on to the appropriate person.
As to being drunk – it’s true that we can’t assess for mental disorder when a person is intoxicated but we can make reasonable assessments of suicidality and we still have a duty of care towards intoxicated people. If we refuse to see them and they go and kill themselves it’s arguable that that is clinical negligence.
Anyway – under the mental capacity act intoxication counts as an impairment in the functioning of brain (if not mind) and so there is a duty of care to intervene as they are unable to make their own decision at that time.
I think the bottom line is that if there’s an emergency (or if you’re not sure) call emergency services. That may be police – it may be out of hours social services, it may be the MH crisis team if they’re available to you.
Either way get someone to help. You’re not expected to do everything and you’re certainly not expected to deal with psychiatric emergencies single-handedly and without the proper training.
Cheers,
Stuart
