Behavioral health workers are understandably distressed by the recent rise in the rates of suicide, suicide attempts, and reported suicidal ideation, including increases among teens and young adults, minorities, and those affected by the Covid-19 pandemic (Molock et al, 2023; Pathirathna et al, 2022; Akkas, 2023). While these statistics are alarming, a lot can be done to help individuals who are experiencing suicidal thoughts. Steps include recognizing who is at greater risk for suicide, assessing suicidal thoughts in a nonjudgmental, compassionate way, and safety planning to help provide people with alternative behaviors when they have suicidal impulses.
Suicidal thoughts and behaviors can affect anyone, regardless of age, race, or gender and must always be taken seriously. There are certain factors, though, which have been identified as putting individuals at a higher risk and to which we, as behavioral health workers, must give special attention and further assessment. The Centers for Disease Control and Prevention groups risk factors into four categories (CDC). There are risk factors:
- On the individual level, particularly if someone has a previous history of suicide attempts, chronic pain, mental illness, job loss or financial problems, substance use, or childhood trauma;
- Pertaining to one’s relationships with other people, including loss of a relationship, social isolation, and family history of suicide;
- On a community level, including living in a community with a cluster of suicides, being exposed to community violence, and experiencing discrimination or racism; and
- On a societal level, risk factors that predict higher suicide rates include people at risk having easy access to guns and living in a community where there is greater stigma associated with seeking help for mental illness.
Unfortunately, we cannot always prevent people from experiencing these risk factors. Therefore, we must be mindful of an individual’s community and familial situation as well as their personal experiences and history when thinking about who might be at greatest risk of suicide.
The most effective way to know whether someone is at current risk for suicide may be to ask them. Questions about suicidal thoughts can be valuable coming not just from clinical providers, but also, at times, from an individual’s friends, family, caregivers, care managers and more. Some people are afraid that asking about suicide can put the idea into someone’s mind. However, research has shown that this fear is unfounded and, in fact, that asking about suicide can in itself reduce suicidal ideation (Dazzi et al, 2014) and increase hopefulness that they may be able to get help. Being asked may also help the person who is feeling hopeless feel connected, which combats feelings of isolation.
How people ask about suicidal thoughts can be important. In a lot of contexts, providers are required to ask questions about suicide using a checklist, such as the Columbia Suicide Severity Rating Scale. Scales can be extremely valuable to make sure we gather needed information, but reading the questions off a form without connecting to the patient is more likely to lead to false negative responses, in which people deny suicidality even though they are experiencing it. The more questions can be asked in an empathic way, connecting with the person, acknowledging their struggles, and validating their feelings, the more helpful the questions will be. For people who work in the field, it can take practice asking these questions in order to increase comfort level.
When people seek mental health treatment, they are acknowledging that at least a part of them doesn’t want to be feeling the way they do. To people struggling with suicidal ideation, those thoughts can sometimes feel like a potential way out, if they feel they don’t have other ways to cope with their situation. Feeling validated and heard can be an important start to their gaining hope that there are better solutions to their problems than suicide.
Once someone has acknowledged suicidal thoughts or been deemed at risk of suicide, an important step towards helping them stay safe is safety planning. The most commonly used safety plan was developed by Stanley and Brown (2012). It aims to help people find substitutes for suicidal behavior. It starts with having a person recognize the triggers to when the safety plan would need to be implemented, and then moves on to help the person identify alternatives, whether on their own (e.g. engaging in a specific distracting or enjoyable activity), or by contacting other supports or professionals. When a person has planned out other options beforehand, they are less likely to choose suicide as their go-to option to relieve suffering during heightened moments of distress.
The safety plan also outlines how to decrease access to means (e.g., locking up medications, guns and blades). At Westchester Jewish Community Services (WJCS), we have added specific questions about accessing guns, in order to be more proactive in protecting people from guns, as they are the most lethal suicide method. We have also trained our clinicians on Counseling on Access to Lethal Means, in order to help navigate difficult conversations about access to guns. Once a safety plan is completed, it should be made accessible to the individual, and when possible, to others involved in their care as well.
Since mental illness is a risk factor for suicide, it could be argued that anyone who is in treatment for serious mental illness should create a safety plan. Even if someone is not reporting current suicidal thoughts, having a safety plan can help them know where to turn if those thoughts ever arise. Sometimes such a plan can be referred to as a crisis plan, helping them recognize tools they can use to cope with any dangerous or unhelpful urges, including not only suicide but also the urge to harm others or to use substances.
Just as it is important how we ask questions about suicide, how we create a safety plan is also crucial. Safety planning needs to be done collaboratively with the provider and individual. If someone is just told, “here are the things you should do to keep yourself safe,” they will feel much less buy-in and agency and be less likely to follow those recommendations. Instead, the person needs to feel like they are taking a much more active role in their care by collaboratively developing the plan. Stanley and Brown (2012) suggest asking individuals to identify the most helpful aspects of the plan in order to increase their motivation to use it. They also stress the need to identify any potential obstacles to using the plan, and to help the individual problem solve.
Unfortunately, safety plans are not a guarantee of protecting people against suicide. Studies have shown that they are effective in decreasing suicidal behaviors (Stanley et al, 2018), and in some settings, such as Emergency Departments, safety plans can increase people’s treatment engagement for follow up appointments and act as a stand-alone intervention. However, safety plans do not completely eliminate suicidal behaviors, and they do not decrease reported frequency of suicidal thoughts (Nuij et al, 2021), only behaviors. This could be because safety plans focus on providing people with alternative behaviors to suicide, but do not focus on providing alternative thoughts to suicidal or hopeless thoughts. Safety planning is a concrete, brief intervention and an important first step in keeping people safe. Other ongoing forms of mental health treatment must then follow. For example, at WJCS, we offer a comprehensive Dialectical Behavior Therapy (DBT) program. DBT focuses on helping people learn alternative ways of thinking and build meaningful skills in order to create what they feel is a life worth living, thereby decreasing suicidal thoughts.
Rachel F. Held, PhD, is Supervising Psychologist, Psychology Externship Coordinator, and Intensive Outpatient Program Coordinator at WJCS, the largest provider of licensed outpatient, community-based mental health services in Westchester County in New York. To learn more about WJCS, please visit WJCS.com.
References
Molock, S. D., Boyd, R. C., Alvarez, K., Cha, C., Denton, E.-g., Glenn, C. R., Katz, C. C., Mueller, A. S., Meca, A., Meza, J. I., Miranda, R., Ortin-Peralta, A., Polanco-Roman, L., Singer, J. B., Zullo, L., & Miller, A. B. (2023, March 13). Culturally Responsive Assessment of Suicidal Thoughts and Behaviors in Youth of Color. American Psychologist. Advance online publication.
Pathirathna, M.L., Nandasena, H.M.R.K.G., Atapattu, A.M.M.P. et al. Impact of the COVID-19 pandemic on suicidal attempts and death rates: a systematic review. BMC Psychiatry 22, 506 (2022). https://doi.org/10.1186/s12888-022-04158-w
Akkas, F. Youth Suicide Risk Increased Over Past Decade. 2023
CDC risk factors of suicide: https://www.cdc.gov/suicide/factors/index.html
Dazzi T, Gribble R, Wessely S, Fear NT. Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychol Med. 2014 Dec;44(16):3361-3. doi: 10.1017/S0033291714001299. Epub 2014 Jul 7. PMID: 24998511.
Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264.
Stanley B, Brown GK, Brenner LA, Galfalvy HC, Currier GW, Knox KL, Chaudhury SR, Bush AL, Green KL. Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department. JAMA Psychiatry. 2018 Sep 1;75(9):894-900. doi:10.1001/jamapsychiatry.2018.1776. PMID: 29998307; PMCID: PMC6142908.
Nuij C, van Ballegooijen W, de Beurs D, Juniar D, Erlangsen A, Portzky G, O’Connor RC, Smit JH, Kerkhof A, Riper H. Safety planning-type interventions for suicide prevention: meta-analysis. Br J Psychiatry. 2021 Aug;219(2):419-426. doi: 10.1192/bjp.2021.50. PMID: 35048835.
