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Key points
- Without care, suicide risk assessment can become very mechanical, leaving someone feeling unseen.
- Suicide risk assessment can be done with compassion and intention.
- Effective suicide prevention involves more than crisis intervention.
- Community level interventions are necessary in suicide prevention.
"Are you homicidal or suicidal?"
A standard question in an emergency room intake is not the most precise way to assess for suicidal ideation. What does it mean to "be" suicidal? Thoughts of suicide? Fantasies? Plans? Intent? An answer of "yes" can land a person in a stripped room with a chaperone awaiting a crisis screen. It's brave.
Crisis intervention saves lives. Yet, in emergency settings, common practice can feel quite mechanical and lacking in care. A study of emergency room medical professionals found that many carried attitudes of avoidance, rejection, hostility, and fear when faced with patients experiencing suicidal ideation (Sepri and Shipra, 2006).
I have walked with many through dark roads and taken some dark turns myself at times. I have hoped not to lose others or myself along the way. I am thankful to be alive.
Yet, in my lifetime, I have lost three friends to suicide. Each of these deaths took a real mark on my heart in a different way. When a person dies of an awful disease, it is not uncommon to hear people say, "There is no pain now."
While not everyone who dies by suicide lives with a mental health condition, mental illness is thought to play a role in 90 percent of cases (Friedman and Nestadt, 2015). Although most associate suicide with a diagnosis of depression, a chart review of 40,692 individuals who died by suicide found that psychotic disorders such as schizophrenia were most strongly linked to suicide (Song et al., 2020).
Mental health conditions can cause an immense level of emotional pain.
The pain is as real as any other, but there is hope. Mental illness is often treatable, yet a good number of people cannot access the treatment they need. Some of these people do not make it.
When someone survives a suicide attempt, they often echo renditions of the same concept: "I thought no one would care." In the interpersonal theory of suicide, the perception of being a burden is a key factor in suicidal ideation. This has been supported through examinations of suicide notes with a tragic finding that the greater a sense of burden one expressed, often the more lethal means one used (Joiner et al., 2002).
I have seen practitioners go to exceptional lengths to help someone feel heard and achieve the help they need. I myself have also benefited from compassion given by mental health providers and friends in my darkest moments. For this, I am grateful and inspired.
Still, as someone who has worked in systems of care, I have sometimes wondered how much "care" there is in the mental health system as a whole for those struggling. While individual clinicians often care deeply, compassion fatigue can flourish in crowded emergency rooms with limited resources and high stress. This seems particularly true for those facing the deepest of challenges, including those without family, the unhoused, individuals facing addictions, and those with the most serious mental illnesses.
The system is overwhelmed. "Beds" (or available spots) in psychiatric inpatient units are limited, and it is not uncommon for individuals to board in an emergency room for multiple days or to be transferred far away for inpatient care. Stays in hospitals are often short and can be aversive. An interview study found that many individuals hide their thoughts of suicide from clinicians, expressing fear of hospitalization as among the top reasons (Blanchard and Farber, 2020).
The mental health system often delivers beautiful services that spur recovery. Services like early intervention for psychosis, crisis phone lines, community support, psychiatry, and therapy can make all the difference. Yet, connection to these resources after a mental health crisis often involves a level of stability gained through an emergency room stay. If we are to bring a person through a challenge that can affect every aspect of their life, we have to do more than give them stability. We have to foster hope.
A research study investigating the lived experience of individuals who had survived a suicide attempt found that among the common themes listed were emotional pain, loneliness, and a need for love and belonging (Shamsaei et al., 2020). We are not all clinicians, but we can all show each other kindness to alleviate a small amount of pain.
This life we share is too precious and difficult not to give each other compassion. We never know how much someone is carrying. When someone dies by suicide, we are forced to acknowledge their hurt. When we see someone hurting, or they turn to us, we can be there, which may include advocacy or walking with them through the mazes to find the help they need.
I have promised myself that I will do what I can to show people genuine acknowledgment within my clinical work and in my relationships. To be there. This is something we can all do and something we all need.
Sometimes, the best way to help the person is to change the system.
We have to do that.
We have to care.
References
Blanchard, M., & Farber, B. A. (2020). “It is never okay to talk about suicide”: patients’ reasons for concealing suicidal ideation in psychotherapy. Psychotherapy Research, 30(1), 124-136.
Friedman, M. B., & Nestadt, P. S. (2015). Violence and mental illness: Suicide, not homicide, is the major problem. Huffington Post.
Joiner, T. E., Pettit, J. W., Walker, R. L., Voelz, Z. R., Cruz, J., Rudd, M. D., & Lester, D. (2002). Perceived burdensomeness and suicidality: Two studies on the suicide notes of those attempting and those completing suicide. Journal of Social and Clinical Psychology, 21(5), 531-545.
Sethi, S., & Shipra, U. (2006). Attitudes of clinicians in emergency room towards suicide. International journal of psychiatry in clinical practice, 10(3), 182-185.
Shamsaei, F., Yaghmaei, S., & Haghighi, M. (2020). Exploring the lived experiences of the suicide attempt survivors: a phenomenological approach. International journal of qualitative studies on health and well-being, 15(1), 1745478.
Song, Y., Rhee, S. J., Lee, H., Kim, M. J., Shin, D., & Ahn, Y. M. (2020). Comparison of suicide risk by mental illness: a retrospective review of 14-year electronic medical records. Journal of Korean medical science, 35(47).
