"I wish I were dead," is a commonly used phrase. The intent, however, is what determines the seriousness of this declaration. In an era in which suicide among the elderly is increasing, particularly among white males, caregivers need to understand ways in which to address intent, and to follow through on statements which are serious in nature. Unfortunately, many discussions of suicide in the elderly leave off or stop short of steps that caregivers need to take when suicide is hinted.
In previous issues I have pointed out that philosophers and ethicists have long debated without conclusion the right of someone to take his/her own life. A different perspective on suicide is raised, however, when one is a healthcare professional charged with the responsibility of "diagnosing and treating human responses to actual or potential health problems. " Moreover, few would disagree that suicide is a mental health problem.
Society's perspective has been that mental health and other healthcare workers are accountable for missing and/or not diagnosing suicidal potential. Therefore, as the philosophers and ethicists continue their debate, practitioners have a very real responsibility and need to be informed of ways in which to address suicidal hints and gestures.
A good place to start assessment is by debunking the notion that "people who talk about suicide never do it." Those who study suicide suggest that any/all suicidal gestures/statements must be taken seriously. Death by suicide is very highly correlated with statements and gestures which are of a suicidal nature. If someone is thinking enough about suicide to make a statement regarding it, that statement must be taken seriously.
Persons, however, need not make a statement per se to communicate suicidal intent. The most lethal situations are perhaps those in which someone's behavior makes us suspicious of his/her intent without him/her ever making such a statement. For example, someone who begins giving away cherished possessions after some very stressful period may be contemplating suicide: persons who are desperate and under severe stress, who suddenly seem to have resolved their dilemma without any actual change in the situation, may be contemplating suicide.
The question in either situation is "as a caregiver, what do 1 do?" In answer to this question, the response suggested is gleaned from so many sources used over the years, those both written and verbal, synthesized from ideas of teachers, colleagues, students, and mental health clinicians that it is impossible to adequately reference these ideas. An excellent sourcebook, however, is one by Hoff.'
First, it is important to clarify suicidal intent by inquiring about it and experts tell us our reluctance to inquire is more a reflection of our own fear than based on any findings that asking intent may suggest suicide to someone. Further, bringing someone's behavior into their consciousness will often help them clarify feelings: eg, "I am upset - but not that upset. "
"What do you mean by that? I'm worried you are thinking of harming yourself. Are you speaking of suicide?" These are all examples of ways in which clinicians can clarify intent. There is a small percentage of people who will deny suicide, although they do intend to take their life, but clinical practice suggests that the vast majority of clients will give an honest answer to such a statement of concern.
If the answer is "Yes" (and in my experience that is a small percentage of cases) there are several steps that clinicians need Io take. An honest expression of concern such as "I do not want you to take your life, and I will help with this troubling situation" is called for. because suicidal people most often feel alone and have "tunnel vision" that leads to only one solution - their suicide if their answer is affirmative.
Next, determine the plan and lethality of same; eg. "What do you plan to do?" In essence you must find out when, where, and how. If someone, for example, has a gun or a stockpile of sedatives, and is planning suicide soon or at an undetermined time, the situation is lethal, and that person should not be left alone.
Although some would disagree. 1 tend to err on the side of caution. A general plan and a means of suicide at hand are all the evidence I need to go to the next step. That step consists of staying with the person: lending strength and support, therefore preventing the institution of their plan: and calling for assistance.
A good resource is a local community mental health center, often supported by funds that mandate a 24-hour telephone crisis line. The step-by-step directions they give, usually accompanying the person to an emergency room, will be important to follow. If you are in a Healthcare facility, a mental health consultant is the next step. If none is on staff, your insistance on the need for an immediate mental health consultation is usually sufficient to obtain one.
Once you believe the situation is lethal, never leave the person alone. If necessary, take them with you as you make your plans and inquiries. Seeing the person admitted or placed in a situation where they may work through problems is the goal.
If depressed, the suicidal person's cognitive processes may be slowed, and hospital izati on allows them a "time out" to identify alternative aspects of the situation. If someone has thoughts of suicide, but no plan or wish to do so , that does not mean one abandons them; rather, care is also obtained, but on a less urgent basis.
One final thought, after discussing these steps with students, I sometimes have a few who see suicide behind every patient's statement. Although this may be more indicative of their own anxiety than of any real situation, I'd rather they be overly cautious than miss suicidal situations. Usually a few negative replies by patients are enough to put the situation in perspective.
The finality of suicide, as well as its increasing incidence with age, however, should make us all critical evaîuators of suicidal potential.
- 1. Hoff LA: People in Crisis: Understanding and Helping. Mento Park, Addison-Wesley, 1978.