Indicators of Danger to Self
Determining whether or not a client is suicidal can be stressful to a new provider. Fortunately, guides and indicators are available to assist in making the best determination possible. However, when dealing with humans, the best indicators, preparation and planning can fail. As a clinician, being conscious of that fact and facing it ahead of time is important for stress inoculation.
When evaluating suicidality in a client, it is important to be direct. Ask the client, “Are you suicidal?” or “Do you want to die?” or “Are you planning to kill yourself?” Naming it will not make the person suicidal but may open a dialogue and make it safe for the person to begin to share about the turmoil going on within them. Additionally, a desire for death does not mean active suicidality. The three questions above all indicate a different level of lethality. Suicidal now requires one set of actions, a plan to kill oneself requires another and just the desire to die yet another.
Symptoms to explore for suicidality include: depression (difficulty sleeping, appetite changes, loss or gain in weight, anhedonia, apathy, isolating), other mental disorders, feelings of helplessness and hopelessness, exhaustion, disorganization, confusion, difficulty concentrating, substance-abuse disorder, and feelings of guilt, shame, remorse, anger, rage, revenge and embarrassment.
Stressors to explore for suicidality include: recent loss by death, divorce or separation (1-3 months); loss of job, money or status; criminal involvement or threat of prosecution; family history of suicide; family history of mental disorder or substance abuse; family violence; physical or sexual abuse; firearms in the home; recent changes in life circumstances or environment, successes, increased responsibilities or promotion; exposure to suicidal behavior of others (family, peers or even media/role models). Lack of resources is often in the constellation of indicators for suicidality-if the individual has no resources for help (family, friends, employment) or they have family or friends available who are unwilling to intervene or assist.
Exploring the duration of the person’s situation is important. If the individual has a sharp or sudden onset of their current feelings or situation, the threat is of more concern. Explore if feelings are a recurrent outbreak of similar feelings or issues from the past, a recent increase of long-term traits or issues or if there is no discernable change in events. Acute changes are a greater indicator of danger than chronic conditions.
The individual’s medical status may demonstrate a chronic or debilitating illness, or there may be a new diagnosis of an illness (cancer, cardiac issues). Even if the illness has been present for some period of time, the chronic nature may have taken a toll or pain associated with the illness may have overtaken the person’s healthy coping skills. Exploring previous attempts with therapies or repeated unsuccessful experiences with professionals (physicians, social workers, psychologists) may also be an indicator of helplessness contributing to danger to self.
Suicidal communication is an obvious indicator of danger but should be mentioned. Also, meaningful communication with others that has been broken off and efforts to re-establish the communication are denied. If the individual focuses on guilt, shame or worthlessness, or seeing no alternatives, a problem is evident.
Suicidal plans: All plans must be taken seriously and acted upon for safety. It is a MYTH that people who talk about suicide will not make an attempt on their lives. With that understanding, there are some plans that are more lethal than others. The most lethal category is use of a gun, hanging or crashing a car. Next is a plan to use carbon monoxide fumes, take poison or other drugs. The least lethal is a plan to cut wrists or take aspirin. Availability of the plan is necessary to know, as well. For example, if an individual says they are suicidal with a plan to use carbon monoxide poisoning, but do not own a car and live in the heart of a city where they and their primary support system rely on public transportation. Availability of plans in terms of lethality must also be considered, with high lethality being accessible gun or pills available or in hand, followed in decreasing lethality by: knowing where to purchase or obtain the means to their plan, just has not done it yet; has worked out a plan in detail and has a time in mind; has a general idea but lacks specifics in the plan; has a bizarre or unusual plan that sounds unreal or phony; or has no plan, says “I’ll think of something.”
Past behavior is also an indicator of future behavior. If someone has had a previous suicide attempt, they are at greater risk of a future attempt, especially if that attempt was of high lethality. If they have a close relative attempt or commit suicide, the odds of being a danger to self rise, as well.
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