How to Help the Suicidal Person to Choose Life: The Ethic of Care and Empathy as an Indispensable Tool for Intervention [1 ed.] 9781681085401, 9781681085418

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How to Help the Suicidal Person to Choose Life: The Ethic of Care and Empathy as an Indispensable Tool for Intervention Authored by Kathleen Stephany Faculty of Health Sciences, Douglas College,BC, Canada

 

How to Help the Suicidal Person to Choose Life: The Ethic of Care and Empathy as an Indispensable Tools for Intervention Author: Kathleen Stephany eISBN (Online): 978-1-68108-540-1 ISBN (Print): 978-1-68108-541-8 © 2017, Bentham eBooks imprint. Published by Bentham Science Publishers – Sharjah, UAE. All Rights Reserved. First published in 2017. 

   

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CONTENTS FOREWORD ........................................................................................................................................... i PREFACE ................................................................................................................................................ The Ethic of Care & Empathy ............................................................................................... Where My Interest in Suicide Prevention Began? .................................................................. Why this Book was Written? .................................................................................................. Learning from Other People’s Experiences ............................................................................ Who Should Read this Book? .................................................................................................

ii ii ii iii iii iii

ABOUT THE AUTHOR ......................................................................................................................... iv ACKNOWLEDGEMENTS .................................................................................................................... v CONFLICT OF INTEREST ......................................................................................................... v CHAPTER 1 THE IMPORTANCE OF TEACHING SUICIDAL PREVENTION STRATEGIES TO GATEKEEPERS .............................................................................................................................. LEARNING GUIDE ....................................................................................................................... After Completing this Chapter, the Reader Should be Able to: ............................................. INTRODUCTION .......................................................................................................................... Overview of Chapter 1 ............................................................................................................ INSTILLATION OF HOPE .......................................................................................................... SOME HARD FACTS ABOUT SUICIDE ................................................................................... THE MULTI-DIMENSIONAL FACTORS ASSOCIATED WITH SUICIDE ........................ SOCIAL STRESSORS & SUICIDE ............................................................................................. Social Stressors & Adverse Life Experiences ........................................................................ Social Stressors & Loss .......................................................................................................... CULTURAL ISSUES & SUICIDE ............................................................................................... Suicide & Socio-economic Status: .......................................................................................... 25 COUNTRIES WITH THE HIGHEST RATES OF SUICIDE (AS ADAPTED FROM PETR, 2015) .................................................................................................................................... 25. POLAND (16.6 per 100,000 people) ................................................................................ 24. UKRAINE (16.8 per 100,000 people) .............................................................................. 23. COMOROS (16.9 per 100,000 people) ............................................................................ 22. SUDAN (17.2 per 100,000 people) .................................................................................. 21. BHUTAN (17.8 per 100,000 people) ............................................................................... 20. ZIMBABWE (18.1 per 100,000 people) .......................................................................... 19. BELARUS (18.3 per 100,000 people) .............................................................................. 18. JAPAN (18.5 per 100,000 people) .................................................................................... 17. HUNGARY (19.1 per 100,000 people) ............................................................................ 16. UGANDA (19.5 per 100,000 people) ............................................................................... 15. RUSSIA FEDERATION (19.5 per 100,000 people) ........................................................ 14. TURKMENISTAN (19.6 per 100,000 people) ................................................................. 13. SOUTH SUDAN (19.8 per 100,000 people) .................................................................... 12. INDIA (21.1 per 100,000 people) ..................................................................................... 11. BURUNDI (23.1 per 100,000 people) .............................................................................. 10. KAZAKHSTAN (23.8 per 100,000 people) ..................................................................... 9. NEPAL (24.9 per 100,000 people) ..................................................................................... 8. UNITED REPUBLIC OF TANZANIA (24.9 per 100,000 people) ................................... 7. MOZAMBIQUE (27.4 per 100,000 people) ....................................................................... 6. SURINAME (27.8 per 100,000 people) .............................................................................

1 2 2 3 3 4 5 6 7 7 7 9 9 9 9 9 10 10 10 10 10 10 10 11 11 11 11 11 11 11 12 12 12 12

5. LITHUANIA (28.2 per 100,000 people) ............................................................................ 4. SRI LANKA (28.8 per 100,000 people) ............................................................................. 3. SOUTH KOREA (28.9 per 100,000 people) ...................................................................... 2. DEMOCRATIC PEOPLE”S REPUBLIC OF KOREA (38.5 per 100,000 people) ........... 1. GUYANA (44.2 per 100,000 people) ................................................................................. Suicide & Age ......................................................................................................................... Suicide & Gender .................................................................................................................... Suicide & Aboriginals ............................................................................................................. RELIGION & SUICIDE ................................................................................................................ THE IMPORTANCE OF TRAINING GATEKEEPERS .......................................................... Premise 1: The Training of Health Professionals in Suicide Risk & Therapeutic Intervention is Often Limited ...................................................................................................................... Premise 2: We Need to Do a Better Job of Teaching Suicide Prevention to Health Professionals ........................................................................................................................... Premise 3: People who are Feeling Suicidal Do Reach Out to Health Professionals for Help Premise 4: Teaching Gatekeepers How to Establish Therapeutic Rapport & to Offer Empathy May Help to Save Some Lives ................................................................................ THE ETHIC OF CARE AS THE THEORETICAL FOUNDATION ...................................... THE ETHIC OF CARE AND EMPATHY AS A TOOL FOR SUICIDE PREVENTION ..... The Importance of Training Gatekeepers in How to Care ...................................................... METHODOLOGY ......................................................................................................................... NARRATIVE CASE STUDY: ADMISSION TO A SECURE ROOM ..................................... Analysis of the Case Study ..................................................................................................... Theme Analysis ...................................................................................................................... Suggested Questions for Group Discussion ............................................................................ SOMETHING TO PONDER: THE IMPORTANCE OF SELF-COMPASSION ................... ETHICAL ISSUES THAT MAY ARISE WHEN CARING FOR THE SUICIDAL PERSON Suggested Question for Group Discussion ............................................................................. REFLECTING BACK ................................................................................................................... Summary of Key Points Covered in Chapter 1 .......................................................................

12 12 12 13 13 13 13 14 14 15

CHAPTER 2 CHANGING STIGMA, DISPELLING MYTHS AND ASSESSING RISK ............ LEARNING GUIDE ....................................................................................................................... After Completing this Chapter, the Reader Should be Able to: ............................................. Overview of Chapter 2 ............................................................................................................ STIGMA & HOW IT NEGATIVELY IMPACTS PEOPLE WHO SUFFER FROM MENTAL ILLNESS & SUICIDAL IDEATION ......................................................................... EDUCATION IS THE KEY TO CHANGING STIGMA ........................................................... LEARNING FROM THE LIVED EXPERIENCES OF BEING STIGMITIZED .................. Analysis of Their Lived Experiences ...................................................................................... Theme Analysis ...................................................................................................................... Questions ................................................................................................................................. EDUCATING OTHERS BY DISPELLING PRECONCEIVED ASSUMPTIONS ................. Presumed Assumption 1: You can’t stop a person from committing suicide once their mind is made up ............................................................................................................................... Presumed Assumption 2: Only depressed people kill themselves and other people are not at risk ........................................................................................................................................... Presumed Assumption 3: If you talk about suicide with someone who is thinking about it, you will push them over the edge and make them do it .......................................................... The following four questions are also useful when you suspect that someone is suicidal (as adapted from SAVE, 2015) ........................................................................

32 33 33 33

16 16 18 18 21 21 21 23 24 26 27 27 28 29 29 30 30

34 36 37 38 39 41 41 41 42 42 42

Presumed Assumption 4: If a person denies an intention of acting on their suicidal thoughts or plan, no further intervention is needed ............................................................................... THE LIMITATIONS OF SOME SUICIDE RISK ASSESSMENT TOOLS OR FRAMEWORKS ............................................................................................................................ INITIAL SCREENING: BECOME AWARE OF THE WARNING SIGNS OF SUICIDE ... Warning Signs: (as adapted from Fowler, 2011; Rudd et al., 2006) ...................................... LEARN HOW TO CONDUCT A THOROUGH & FOCUSED SUICIDE RISK ASSESSMENT ................................................................................................................................ Eleven Steps to a Focused Suicide Risk Assessment (as adapted from SuicideLine, 2016; PatientPlus, 2016; Perlman et al., 2011; Barker & Buchanan-Barker, 2005; Stephany, 2015) Step 1: Establish Rapport by Conveying Empathy ................................................................. Step 2: Ask Open-ended Questions ........................................................................................ Examples of Open-Ended Questions to Ask (as adapted from SuicideLine, 2016) ...... Step 3: Assess for Risk Factors ............................................................................................... Individual Risk Factors ................................................................................................. Socio-cultural Risk Factors ........................................................................................... Situational Risk Factors ................................................................................................ Step 4: Assess for Protective Factors ...................................................................................... Personal Protective Factors (as adapted from SuicideLine, 2016) .............................. Work Protective Factors (as adapted from SuicideLine, 2016) .................................... Family Protective Factors (as adapted from SuicideLine, 2016) ................................. Community Protective Factors (as adapted from SuicideLine, 2016) .......................... Step 5: Assess for Current Suicidal Thoughts ........................................................................ Useful Questions to ask to inquire about Suicidal Thoughts (as adapted from SuicideLine, 2016) ......................................................................................................... Step 6: Is There a Suicidal Plan? ............................................................................................ Questions that Assess for a Plan (as adapted from SuicideLine, 2016) ....................... Step 7: Is There Access to Means? ......................................................................................... Questions that Explore Access to Means (as adapted from SuicideLine, 2016) ........... Step 8: Is There Any Prior History of Suicidal Behavior? ..................................................... Step 9: Document all Findings ................................................................................................ Sample of Recommended Suicide Risk Assessment Documentation Topics (as adapted from Perlman et al., 2011) ............................................................................................ Step 10: Develop and Implement a Care Plan ........................................................................ Step 11: Engage in On-going Monitoring & Re-Assessment ................................................. Key Components of the Safety Plan (as adapted from Stanley and Brown, 2016; The National Suicide Prevention Line, 2013) ................................................................................ NARRATIVE CASE STUDY: WHEN A PSYCHIATRIST EXPERIENCES STIGMA ....... Analysis of the Case Study ..................................................................................................... Theme Analysis ...................................................................................................................... Questions ................................................................................................................................. SOMETHING TO PONDER: INCREASING SELF-AWARENESS TO REDUCE STIGMA Simple Ways to Increase Self-Awareness (as adapted from Change Management Coach, 2016) ....................................................................................................................................... REFLECTING BACK ................................................................................................................... Summary of Key Points Covered in Chapter 2 .......................................................................

43 43 44 45 45 45 46 46 47 47 47 48 48 48 48 49 49 49 49 49 49 49 50 50 50 50 51 51 52 52 53 54 54 55 55 56 57 57

CHAPTER 3 PREVENTING AND TREATING MENTAL ILLNESS & UNDERSTANDING THE MINDSET OF THE SUICIDAL PERSON ................................................................................. 60 LEARNING GUIDE ....................................................................................................................... 61 After Completing this Chapter, the Reader Should be Able to: ............................................. 61

Overview of Chapter 3 ............................................................................................................ THE IMPORTANCE OF EARLY DIAGNOSIS AND TREATMENT OF MENTAL ILLNESS & ADDICTIONS ........................................................................................................... Percentage of Hospital Admissions For Self-Harm (as adapted from the Canadian Institute for Health Information, 2011 as cited in Moore & Melrose, 2014, p. 511) ............................ Strategies to Address the Global Shortfall in Mental Health & Addiction Services: (as adapted from WHO, 2012; MHCC, 2012; Schmitz, et al., 2012) ........................................... PSYCHACHE AS A NECESSARY CONDITION FOR SUICIDE .......................................... PSYCHACHE & CONSTRICTION OF THOUGHT ................................................................ THE STRAIN THEORY AND PSYCHACHE ............................................................................ THE LIVED EXPERIENCE OF PSYCHACHE ........................................................................ Analysis of Peter’s Experience ............................................................................................... Theme Analysis ...................................................................................................................... MOVING THE SUICIDAL PERSON BEYOND A DEATH FOCUSED MIND SET ............ Empathy as Means to Foster Connection ................................................................................ Challenging a Patient’s Constricted Thought Patterns ........................................................... Helping The Suicidal Person to Change the Ending of Their Story: ...................................... A PSYCHOLOGICAL AUTOPSY: WHAT A SUICIDE NOTE CAN TEACH US ABOUT THE EXPERIENCE OF PSYCHACHE ...................................................................................... Analysis of Howard’s Suicide Note ........................................................................................ Theme Analysis ...................................................................................................................... SOMETHING TO PONDER: FOSTERING RESILIENCY ..................................................... REFLECTING BACK ................................................................................................................... Summary of Key Points Covered in Chapter 3 ....................................................................... CHAPTER 4 THE ETHIC OF CARE & EMPATHY AS A TOOL FOR HELPING THE SUICIDAL PERSON .............................................................................................................................. LEARNING GUIDE ....................................................................................................................... After completing this Chapter, the Reader Should be Able to: .............................................. Overview of Chapter 4 ............................................................................................................ THE ETHIC OF CARE AS THE WEB OF CONNECTION .................................................... EMPATHY AS A KEY COMPONENT OF THE ETHIC OF CARE ...................................... Offering Empathy as a Means to Help the Suicidal Person to Choose Life ........................... ENCOURAGING THE SUICIDAL PERSON TO CHOOSE LIFE BY UTILIZING COMPONENTS ASSOCIATED WITH THE ETHIC OF CARE & EMPATHY .................. The Ethic of Care & Empathy: The Importance of Establishing a Connection ...................... Advice from Suicidal Patients ....................................................................................... The Ethic of Care & Empathy: Fostering a Therapeutic Alliance &Trust ............................. When Trust is Sometimes Severed ................................................................................. Establishing Trust Must be the Foundation for Everything Else that Occurs .............. THE AESCHI WORKING GROUP: GUIDELINES FOR CLINICIANS (SOURCE: MICHEL, 2011, PP. 9 – 10). (NOTE THAT THE FOLLOWING POINTS HAVE BEEN SUMMARIZED) ............................................................................................................................. The Ethic of Care & Empathy: Offering Unconditional Positive Regard .............................. Strategies for Learning How to Practice Unconditional Positive Regard ................... The Ethic of Care & Empathy: Listening With Your Heart ................................................... Learn to Avoid Listening Stoppers ................................................................................ Qualities Demonstrated by Good Listeners (as adapted from Shafir, 2008) ................ The Ethic of Care & Empathy: Making Use of Presencing .................................................... Qualities of a Fully Present Person (as adapted from Walker, 2010, p. 80; Shafir, 2008; Stephany, 2015) ..................................................................................................

61 62 63 64 65 66 66 67 68 68 68 68 69 71 71 72 72 72 73 73 76 77 77 77 78 79 80 82 82 83 83 84 84 85 86 87 88 88 89 90 90

Presencing & Silence: Knowing When Not to Speak (as adapted from Shafir, 2008, p. 229) ............................................................................................................................... The Ethic of Care & Empathy: Learning how to be Compassionate ...................................... NARRATIVE CASE STUDY: AN ACT OF COMPASSION .................................................... Analysis of the Case Study ..................................................................................................... Theme Analysis ...................................................................................................................... Question .................................................................................................................................. A PSYCHOLOGICAL AUTOPSY: REVIEWING WHAT WENT WRONG IN ORDER TO LEARN HOW TO DO IT DIFFERENTLY (AS ADAPTED FROM STEPHANY, 2007) ..... Analysis of the Case Study ..................................................................................................... Theme Analysis ...................................................................................................................... MOVING BEYOND THE INITIAL SUICIDE CRISIS: THE ROLE OF COGNITIVE THERAPY ....................................................................................................................................... Cognitive Therapy: Moving the Patient Beyond their Initial Crisis ....................................... SIMULATION: MAKING USE OF EMPATHY TO HELP A SUICIDAL PATIENT .......... Objective One: Establish a Therapeutic Alliance ................................................................... Objective Two: Practice Skills that Covey Empathy .............................................................. Objective Three: Develop a Safety Plan ................................................................................. Summary of Safety Plan Goals: (as adapted from Stanley & Brown, 2016; The National Suicide Prevention Line, 2013) ............................................................................................... Simulation Confidentiality ...................................................................................................... Preparation for the Simulation ................................................................................................ Non-Verbal Communication Skills: (as adapted from Rosenberg, 2003; Walker, 2010) Verbal Communication Skills (as adapted from Brammer & MacDonald, 1999; Walker, 2010) ................................................................................................................ Scenario: ....................................................................................................................... Setting the Scene: .......................................................................................................... Role Play Part I: The Assessment Interview ........................................................................... Role Play Part II: Creating a Safety Plan ................................................................................ Simulation Suggestion ............................................................................................................ De-Brief & Learn .................................................................................................................... De-Briefing Strategies for Consideration ..................................................................... SOMETHING TO PONDER: MAKE EMPATHETIC RESPONSES A HABIT IN YOUR LIFE ................................................................................................................................................. Key Points on How to Journal to Evaluate Your Empathy Skills: (as adapted by Goldstein & Brooks, 2004; Stephany, 2006; Stephany, 2015) ................................................................ REFLECTING BACK ................................................................................................................... Summary of Key Points Covered in Chapter 4 ....................................................................... CHAPTER 5 STRATEGIES THAT PROMOTE THE EMOTIONAL WELL-BEING OF GATEKEEPERS ..................................................................................................................................... LEARNING GUIDE ....................................................................................................................... After Completing this Chapter, the Reader Should be Able to: ............................................. Overview of Chapter 5 ............................................................................................................ ADMITTING THE UNTHINKABLE: SUICIDE AS AN OCCUPATIONAL HAZARD ...... SUICIDE & DOCTORS ................................................................................................................. Contributing Factors to Physician Suicide .............................................................................. Obstacles to Treatment ........................................................................................................... Change the Stigma That Exits Within the Medical Community ............................................ SUICIDE & NURSES ..................................................................................................................... Nurse Suicide & The Role of Work Stress .............................................................................

91 91 92 93 93 94 94 96 96 97 98 100 100 101 101 101 101 102 102 102 103 103 103 106 108 108 108 109 110 110 110 112 113 113 113 114 114 115 116 116 117 117

Stigma Prevents Nurses from Getting Help ............................................................................ CARING FOR THE SUICIDAL PERSON & COMPASSION FATIGUE .............................. STRATEGIES THAT ENHANCE EMOTIONAL WELL-BEING .......................................... STRATEGY 1: REACH OUT FOR PROFESSIONAL HELP IF NEEDED ........................... Normalize the Experience of Getting Help ............................................................................. Access Critical Incident De-Briefing (CID) ........................................................................... STRATEGY 2: FOSTER SELF-COMPASSION ........................................................................ Reflective Journaling & Self-awareness ................................................................................. STRATEGY 3: MAKE CARE FOR THE CAREGIVER A PRIORITY ................................. Self-Care Plan A: Adopt ways that Enhance your Physical & Emotional Health .................. Begin by Conducting an Evaluation of Your Wellness ................................................. Set Realistic Goals for Yourself .................................................................................... Have Someone Make you Accountable ......................................................................... Self-Care Plan B: Strive for Work-Life Balance .................................................................... Self-Care Plan C: Foster Supportive Relationships with Others at Work .............................. Self-Care Plan D: Cultivate Gratitude .................................................................................... CONCLUSION & TAKE AWAY POINTS ................................................................................. REFLECTING BACK ................................................................................................................... Summary of Key Points Covered in Chapter 5 .......................................................................

118 118 120 120 120 122 122 123 124 125 125 125 125 126 127 127 128 130 130

REFERENCES ........................................................................................................................................ 132 GLOSSARY ............................................................................................................................................. 143 APPENDIX A: SAMPLE: CONFIDENTIALITY AGREEMENT FOR SIMULATION ............... 148 APPENDIX B: FURTHER RECOMMENDED READINGS ............................................................. 149 APPENDIX C: INFORMATION & RESOURCES FOR SUICIDE & CRISIS INTERVENTION

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APPENDIX D: COMMONLY USED SUICIDE RISK ASSESSMENT TOOLS ............................. 153 SUBJECT INDEX

.................................................................................................................................. 154

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FOREWORD I believe we are all, in one way or another, affected by suicide, be it the suicide of a patient, a client, or a loved one. I am constantly looking for resources and research that can provide an answer to how we can deliver better care to people who are at risk for suicide. As a practitioner educated, trained and practiced in three different continents, I am keenly aware that suicide is a worldwide phenomenon, affecting people from all cultures and countries. This knowledge underlies healthcare providers' search to mitigate the alarming increase in suicide and its disastrous toll on societies across the globe. At this time, awareness of mental health is increasing and there is an opportunity to re-focus and commit more resources towards stemming this terrible epidemic. Healthcare has evolved steadily over the years and with the rise of modern technology we have the ability to diagnose and treat individuals, even when the symptoms are many and varied. However, when it comes to caring for people at risk of suicide, our progress is limited. This book, How to Help the Suicidal Person to Choose Life: The Ethic of Care and Empathy as an Indispensable Tool for Intervention by Dr. Kathleen Stephany, provides unequivocal, current, evidence-based considerations on ways we can care for people at risk of suicide. It provides comprehensive and practical strategies for healthcare practitioners, mental health professionals, parents, and other family members who are striving to make a difference in the life of a person who may be at risk for suicide. For each reader, the goal of reading this book may be different. Whether it is to prevent the death of a loved one, improve patient outcomes and experience or provide the best possible professional care, I believe that anyone who reads this book will be equipped with strategies that could ultimately save a life.

Kofi Bonnie Clinical Nurse Specialist St. Paul’s Hospital, Vancouver Canada

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PREFACE “What is suicide anyway? How can we understand it and prevent it?” Shneidman, Suicidologist

The Ethic of Care & Empathy This book is the third book, or trilogy, in a series of textbooks published by Bentham Science that I have written that features the ethic of care as the theoretical premise (Stephany, 2012; Stephany, 2015). The ethic of care emphasizes the interconnectedness of all of life and values lived experience with specific emphasis on the important relationship between the caregiver and patient. The ethic of care involves the action of caring for and about others, demonstrating compassion and doing what we can to end human suffering (Stephany, 2012; Stephany, 2015). This current book is also the second book that features empathy as an important therapeutic tool (Stephany, 2015). Empathy is closely aligned with the ethic of care (Stephany, 2015). Empathy is the capacity to understand and to identify with the experiences felt by another person (Shafir, 2008; Stephany, 2015). In this current textbook, the ethic of care in conjunction with empathetic responses coming from caregivers are presented as a tool for suicide intervention.

Where My Interest in Suicide Prevention Began? My interest in the important topic of suicide prevention began when I was working as a Coroner in charge of Special Investigations for the Office of the Chief Coroner in the province of British Columbia (BC). A Coroner is a death investigator. A Coroner’s job is to identify the deceased and their cause of death (BC Coroner’s Service (BCCS), 2015). However, another integral role of the Coroner is to make recommendations to prevent death under similar circumstances based on the evidence gathered during the investigation (BCCS, 2015). One of my roles in this position as a Coroner was to lead investigations into deaths due to suicide. Over the course of time what became evident in my research was that many adults reached out to a health care professional shortly before taking their life, often within 72 hours prior to death (Stephany, 2007). As a result I began my journey to find out, what if anything, could the health professional have done differently, to help to change the suicidal person’s mind about wanting to die. The beginning of my inquiry came up with a surprising result. Many of these individuals (68 % of 118 cases over the course of a decade) had admitted to someone close to them, prior to taking their life, that they did not feel cared for by the professional they reached out to for help (Stephany, 2007). Some of these suicidal people also disclosed that they felt judged by the care provider (Stephany, 2007). This finding was consistent with the findings of other researchers (Bailey, 1994; Gairin et al., 2003; Pompili et al., 2005; Betz et al., 2013). Therefore, I decided to conduct further research into what health professionals were doing well and what they could do better to prevent death by suicide. What I discovered was that, even though people who are suicidal often reach out to health professionals for help before taking their life, there is evidence that we often do not adequately train practitioners in how to intervene in these situations (Feldman & Freedenthal, 2006; Schmitz, et al., 2012; Motto & Bostrom, 2014). In fact there are gaps in the curriculum for many health professionals in the area of suicide prevention (WHO, 2012). This book has been written to address some of those gaps in information and the application of knowledge. The content is aimed at teaching everyone who cares for suicidal people to better understand the mindset of the suicidal person and how to help them to choose life.

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Why this Book was Written? Why did I write this book? I wrote this book because what it proposes is important information for caregivers to know, especially if they want to help prevent some people from ending their lives through suicide. Traditionally there has been a greater focus in the literature on risk factors for suicide with less emphasis on strategies of intervention (Gairin et al., 2003; Betz et al., 2013; Pompili, 2015). We now know that the essential component of the suicidal person’s state of crisis is psychological and emotional. Therefore, we need to acknowledge and address those aspects of their experience especially if we want to gain their trust and help them (Shneidman, 1998; Pompili, 2015). In fact, approaches that focus on suicide prevention that do not address the despairing emotional mind set of the suicidal person, may not be as helpful as ones that do (Shneidman, 1998; Pompili, 2015).

Learning from Other People’s Experiences Throughout this book, I share heart felt stories. What these people had to tell me was extremely informative and can assist us in doing a better job of helping others to climb out of their psychological dungeon of despair. Useful information was derived from narrative case studies and psychological autopsies. Practice exercises and simulation were also included to help the care provider to practice how to be more empathetic. (Note that all the names of the people in this book and many details of the cases have been altered to preserve confidentiality).

Who Should Read this Book? This book is ideal for any student or practicing professional who is confronted with trying to help people who are suicidal. Family members and others who have lost someone close to them due to suicide may also experience a sense of solace in some of the contents of this book. The recommended readership for this book may include students or actual practitioners in the following disciplines and vocations. ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Medicine Psychiatry Nursing Psychiatric Nursing Psychology Counselling Teaching Social Work The Military The Police Force Paramedics Other first responders (e.g., Fire Fighters) Volunteers Outreach Workers Kathleen Stephany Full Time Nurse Educator in Faculty of Health Sciences Douglas College, BC Canada E-mail: [email protected]

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About the Author Dr. Kathleen Stephany PhD is a practicing registered nurse (RN) with the College of Registered Nurses in BC (CRNBC) and a Psychologist who is certified with the Canadian Counselling & Psychotherapy Association (CCPA). She is also a nurse educator, published author, ethicist, ethic of care theorist and suicidologist. Kathleen has conducted both quantitative and qualitative research on suicide. As a psychiatric nurse, clinician and Psychologist she has experience assessing persons for suicide risk. Kathleen also teaches suicide risk assessment and prevention to nursing students. She is a member of the International Association for Suicide Prevention (IASP) and a member of the Canadian Association for Suicide Prevention (CASP). Kathleen speaks publicly in both academic and non-academic venues about the important subject of suicide prevention. Kathleen obtained her doctorate in Counselling Psychology from Breyer State University in Alabama. The topic of her doctoral Dissertation was entitled, Suicide Intervention: The Importance of Care as a Therapeutic Imperative. She also previously earned a MA in Counselling Psychology from Simon Fraser University (SFU), a BA in Psychology from SFU, a BSN from the University of Victoria and a Diploma in Nursing from the British Columbia Institute of Technology (BCIT). In addition to being a member of IASP and CASP, Kathleen is a member of other professional associations. For example, Kathleen is a member of The Canadian Mental Health Association (CMHA), BC Branch, and a member of the Xia Eta Chapter of Sigma Theta Tau International, Honor Society of Nursing, and an associate member of the Western Northern Region of the Canadian Association of Schools of Nursing (WNRCASN). Kathleen Stephany is employed full-time as a Nurse Educator in the Bachelor of Science in Nursing (BSN) Program at Douglas College in Coquitlam, BC. She is also a motivational and inspirational speaker and a passionate gardener.

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ACKNOWLEDGEMENTS I would like to acknowledge all of the people who work with people suffering from suicidal ideation. Thank-you for your compassion, devotion and care. Your work is not easy but extremely important. I also want to thank all of the people who so willingly shared their experiences with me. Thank-you for helping me to better understand what it feels like to lose all hope and to not feel understood by others, but also sharing how important it is for us to acknowledge your pain and offer you hope. You have enlightened me and have made me a better practitioner. This book could not have been written without you. I want to extend a special thank-you to my husband, Dr. Harold Stephany for encouraging me to write this book even though the topic is not very uplifting. You constantly reminded me that this message was important and that it needed to be shared. I am grateful for your unending patience as you watched and waited while I hid away in my office for countless hours working on this project. Thank-you Bentham Science for publishing this book. I also wish to extend my sincere gratitude to those who made helpful suggestions on how to make this book even better.

CONFLICT OF INTEREST The author (editor) declares no conflict of interest, financial or otherwise.

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1

CHAPTER 1

The Importance of Teaching Suicidal Prevention Strategies to Gatekeepers Abstract: The purpose of this current book was to add to what is already scientifically and experientially known, about the important role that gatekeepers play in suicide prevention. A gatekeeper is defined as a person, who due to the type of work they are involved in, may come into contact with persons who are at risk of suicide. The therapeutic relationship between the gatekeeper and suicidal person was presented as key to helping the suicidal person. Instillation of hope was also promoted because, while persons who are suicidal are in the midst of their despair they cannot see clearly. They may therefore, benefit from a gatekeeper helping them to re-discover their hope. Some hard facts about suicide on a global level were reviewed. It was pointed out that suicide is a complex issue and never occurs in isolation. Therefore, taking into consideration relevant issues that either contribute to, or are associated with suicide were discussed, such as social stressors and cultural issues. Religion was identified as a potential protective factor against suicide. Reasons were given in support of doing more to train gatekeepers. The ethic of care was presented as the theoretical premise for this book and both the ethic of care and empathy were introduced as a tool for suicide prevention. Quantitative and qualitative research were acknowledged as important in enhancing what we know about suicide prevention. This current manuscript draws quite significantly from evidence based data that is quantitative and qualitative. Two modes of qualitative methodologies were utilized to specifically analyze the case studies presented in this book, the narrative case study approach and the psychological autopsy. In this current Chapter, key themes were identified from the narrative case study of a suicidal person who was admitted to the Emergency Room (ER). Placing a suicidal person is a secure room for a lengthy period of time may increase their sense of being alone, and perceived neglect from a gatekeeper may be interpreted by the suicidal person as a lack of care. It was advised that when caregivers do not act in empathetic ways, instead of being self-critical, they must strive to be more selfcompassionate. We were made aware of some of the ethical issues associated with caring for the suicidal person. For example, it was established that there is a risk of clinicians experiencing a violation of their moral agency, or their ability to act on their own moral beliefs.

Kathleen Stephany All rights reserved-© 2017 Bentham Science Publishers

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Keywords: Adverse life experiences, Autonomy, Beneficence, Culture, Emergency room, Empathy, Ethical dilemma, Ethic of care, Ethic of justice, Ethnicity, Ethics, Gatekeeper, Hope, Methodology, Moral agency, Moral dis-engagement, Moral residue, Narrative case study, Non-maleficence, Occupation, Philosophy, Psychological autopsy, Qualitative research, Quantitative study, Recovery models, Religion, Resiliency, Secure room, Self-compassion, Sexual prejudice, Social stressors, Spirituality, Suicide, Suicidology, Suicidologist, Transgender.

LEARNING GUIDE After Completing this Chapter, the Reader Should be Able to: ● ● ● ●

● ●

●

● ● ● ● ●

●

●

● ● ● ●

Define the terms suicide, suicidology and the role of the suicidologist. Explain how suicide differs from many other disease processes. Describe the function of a gatekeeper. Understand why conveying hope is important when trying to help a suicidal person. Be aware that suicide is still a leading cause of death in the developed world. Gain an understanding of some of the relevant issues that either contribute to, or are associated with suicide, such as the role that specific social stressors play in suicide. Be able to identify the 25 countries that have the highest suicide rates in the world along with some of the social factors that contribute to high suicide numbers. Discuss cultural aspects associated with suicide. Understand how religion sometimes acts as a protective factor against suicide. Describe the four key premises that support better training of gatekeepers. Appreciate that the ethic of care is the theoretical premise for this book. Explain why the ethic of care and empathy are an important tool for suicide prevention. Recognize the importance of both quantitative and qualitative research in enhancing what we know about suicide prevention. Gain an understanding of the qualitative methodologies utilized in this book, the narrative case study approach and the psychological autopsy. Explore themes from the Narrative Case Study: Admission to a Secure Room. Understand the importance of being more self-compassionate. Be aware of ethical issues associated with caring for the suicidal person. Understand that an ethical violation of a clinician’s moral agency may occur when caring for a suicidal person and may cause moral residue and moral disengagement.

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INTRODUCTION “Sorrow comes in great waves but it rolls over us and though it may almost smother us it leaves us on the spot and we know that if it is strong, we are stronger inasmuch as it passes and we remain.” Henry James, American Writer

This book is concerned with the topic of preventing suicide. Suicide is the act of a person choosing to end his/her life voluntarily and intentionally (MerriamWebster Dictionary, 2016). The subject matter of this textbook draws quite significantly from suicidology. Suicidology is the study of suicide, suicidal behavior and suicide prevention, and a suicidologist is someone who researches the subject of suicide (The Free Dictionary, 2016). It is important to note that suicide differs from many other disease processes in that its causes are multidimensional. Gunnell (2015), a suicidologist, asserts that there is a wide-range of factors that contribute to suicide. For example, suicide is the fatal outcome of a behavior, rather than a single disease process” (p. 155). Gunnell points out that, “suicidal behavior occurs in vulnerable individuals in the context of a range of different mental illnesses and social stresses and may be influenced by helpseeking behaviors and cultural attitudes” (p.155). Gunnell, therefore, subsequently recommends that prevention strategies focus on a wide range of areas. The purpose of this current book is to add to what is already scientifically and experientially known, about the important role that gatekeepers play in suicide prevention. A gatekeeper is a person, who due to the type of work they are involved in may come into contact with persons who are at risk of suicide (Ghoncheh, Koot & Kerkhof, 2014). The therapeutic relationship between the gatekeeper and suicidal person is presented as key to helping the suicidal person. Subsequently, this book teaches practical, therapeutic and hopeful prevention strategies for gatekeepers to implement. Overview of Chapter 1 This introductory Chapter introduces the notion of instillation of hope, followed by a brief overview of some of the hard facts about suicide. The multidimensional issues that either contribute to, or are associated with suicide are reviewed. For example, two specific social stressors are identified in relationship to suicide. The 25 countries that have the highest suicide rates in the world are presented along with some of the social factors that contribute to high suicide numbers. Cultural aspects associated with suicide are explored. Attitudes of various world religions toward suicide are presented and religion was identified as a potential protective factor against suicide. A comprehensive explanation is made as to why we need to be doing more to train gatekeepers. The ethic of care is

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presented as the theoretical premise for this book and both the ethic of care and empathy are put forward as a tool for suicide prevention. Two qualitative methodologies for case study analysis are introduced, the narrative case study and the psychological autopsy. A case study of a suicidal person’s experience in seclusion is analyzed and themes identified. Gatekeepers are admonished to be more self-compassionate. Emerging ethical challenges facing clinicians who work with suicidal persons is also discussed. INSTILLATION OF HOPE Often someone who is suicidal has lost all hope. (Shneidman, 1998). Hope is about having goals for the future and a belief that life can get better than it presently is (The Free Dictionary, 2016). Hopelessness is defined as having no hope, feeling despair and resignation (The Free Dictionary, 2016). It is the feeling that is expressed in the form of, “I have nothing to live for.” In fact, hopelessness is actually more highly correlated with suicidal thoughts than depression, and a person does not need to suffer from a mental illness to feel hopeless (Shneidman, 1998; Stephany, 2007). Recent loss or cumulating losses and/or psycho-social stressors can play a big role in someone giving up and contemplating suicide (Maltsberger & Buie, 1989; Shneidman, 1998; Pompili, 2015).

H.O.P.E HOLD ON, PAIN ENDS

Fig. (1.1). Picture of Hope. Source: www.ishafoundation.org/us

Fig. (1.1) illustrates a caption that emphasizes the importance of hope in life and the realization that emotional pain is not necessarily a permanent experience. There are therapeutic means to assist hopeless patients to learn how to replace emotional angst with hope (Brown, Wenzel & Rudd, 2011). However, people who are extremely distraught with their present circumstances may not understand that

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their situation may, and can, change for the better. Therefore, the instillation of hope coming from another person is of particular importance for people who are suicidal. For instance, while they are in the midst of their despair they cannot see clearly and they may need someone else to help them re-discover their particular type of hope (Shneidman, 1998; Stephany, 2007). SOME HARD FACTS ABOUT SUICIDE As illustrated by the World Health Organization (WHO) (2014) in Fig. (1.2), suicide kills. Suicide is a global issue (WHO, 2015). In fact someone in the world commits suicide every 40 seconds (WHO, 2014). “Suicide continues to be a leading cause of death in the developed world” (Motto & Bostrom, 2014, p. 828). Suicide deaths exceed deaths from homicides and wars combined (WHO, 2014). More than 800,000 people across the globe die each year from suicide and many others attempt suicide (WHO, 2015a). The countries with the highest rates of suicide will be reviewed later on in this Chapter. Age-standardized suicide rates (per 100 000 population), both sexes, 2012

Suicide rate (per 100 000 population) 15.0

Not applicable

0

The boundaries and names shown and the designation on this map do not imply the expression of any opinion whatsoever

Data Source: World Health Orgainzation

on the part of the World Health Organization concerning the legal status of any country, teritory, city or areas or of its authorities,

Map Production: Health Statistics and Information System (HSI) World Health Organization

or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps respresent approxiate border lines

for which there may not yet be full agreement.

850

17,00

3,400 Kilometres

World Health Organization c WHO 2014, All rights reserved.

Fig. (1.2). Global Suicide rates. Source: WHO, 2014.

The WHO (2014) estimates that for every person who commits suicide 20 others have attempted suicide. Suicide rates have increased by 60% in the past 50 years. In many countries the number of recorded suicide deaths are not completely

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accurate due to the fact that many deaths may be classified as accidental when in fact they were a suicide (Rockett, 2010). In Canada approximately 300 people die from suicide every 30 days (Statistics Canada, 2011). As stressed in Fig. (1.3) the cost of suicide far exceeds loss of life. There are economic consequences such as loss of years of productive living and human contribution to society. In Canada 70% of all suicides occur among working aged adults (age range of 30 – 34 years). The estimated cost in lost revenue due to suicide among this group is 6 Billion dollars (Centre for Suicide Prevention, 2015). The cost of suicide far exceeds loss of life. There are economic consequences such as loss of years of productive living and human contribution to society. Also, so many people who have lost someone to suicide suffer emotionally Fig. (1.3). The cost of suicide. Source: Centre for Suicide Prevention, 2015; Motto & Bostrom, 2014; WHO, 2014.

Loss of revenue is only one type of cost due to suicide. There is also a tremendous emotional cost. For example, so many people who have lost someone to suicide suffer psychologically (Motto & Bostrom, 2014; WHO, 2014). Fleischmann and De Leo (2014) point out that millions of people who have lost someone to suicide or who have someone close to them attempt suicide, are negatively impacted on a psychological level. These authors also remind us that suicide is preventable. Yet, the WHO (2014) in their report on preventing suicide, draws attention to the fact that there has hardly been any progress made in decreasing the numbers of suicide in the world in the past 40 years. The WHO (2014) recommends a more coordinated international effort to prevent death by suicide. THE MULTI-DIMENSIONAL FACTORS ASSOCIATED WITH SUICIDE Klott (2012) points out that, “Suicide is, perhaps, the ultimate individualized experience” (p. 1). In fact each suicidal act is specific to that individual (Klott, 2012; Shneidman, 1998). However, suicide is also a complex issue and never occurs in isolation. Therefore, taking into consideration relevant issues that either contribute to, or are associated with suicide is very important. Some of the issues that will be explored include specific social stressors, cultural components and the protective features associated with belonging to a religion. Note that suicide is also highly correlated with a diagnosis of mental illness. However, this important topic will not be discussed here because Chapter Three specifically covers the association between suicide and psychiatric disorders.

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SOCIAL STRESSORS & SUICIDE Social stressors collectively represent factors and/or situations that occur in society that have an impact on stress levels and a person’s ability to cope (The Urban Dictionary, 2017). “The review of the literature on psychosocial stressors and suicide attempts produces a very complex picture” (Baca-Garcia et al., 2007, p. 192). Not all social stressors lead to a suicide attempt. However, suicide attempts are highly correlated with two specific social stressors, adverse life experiences and loss (Mandell, 2009; Klott, 2012). Social Stressors & Adverse Life Experiences As emphasized in Fig. (1.4), one type of social stressor that does often lead to a suicide attempt is associated with adverse life experiences. As Baca-Garcia et al. (2007) point out, adverse life experiences are traumatic life experiences that may include early separation from parents, “childhood physical, sexual and emotional abuse, and physical and sexual abuse in adult life” (p. 194). Any or all of these adverse life experiences are significantly more frequent in persons who attempt suicide (Baca-Garcia et al., 2007). Fergusson, Beautrais & Horwood (2003) found that social stressors such as childhood adverse events or abuse may not only increase a person’s vulnerability to suicide and but may also substantially decrease their capacity for resiliency. Resiliency consists of the ability to cope in positive ways to the stress that occurs in one’s life (Brooks & Goldstein, 2003). A lack of resiliency can prove to be detrimental to someone who has experienced abuse because they are unable to perceive their circumstances in a hopeful manner (Fergusson et al., 2003). SUICIDE & ADVERSE LIFE EXPERIENCES: All life adverse experiences including early separation from parents, childhood physical, sexual and emotional abuse, and physical and sexual abuse in adult life are significantly more frequent in persons who attempt suicide Fig. (1.4). Suicide & adverse life experiences. Source: Baca-Garcia et al., 2007, p. 194.

Social Stressors & Loss As Fig. (1.5) points out, another type of social stressor that often leads to a suicide attempt is closely tied to the experience of loss. Some examples of loss that are associated with increased suicidality consist of, but are not limited to, loss of primary relationship, loss of health, loss of occupation and loss experienced by adolescents (Klott, 2012).

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Relationship losses are particularly troubling for many people. Humans are social creatures who yearn for social connection and intimacy. Without human connection “in our lives we can experience emotional and intellectual decay” (Klott, 2012, p. 17). Loss of a primary relationship through separation, divorce or death is also very stressful (Orbach, 2011). Feelings of loneliness, abandonment, rejection and isolation may abound (Klott, 2012; Orbach, 2011). Although both adult females and males are extremely vulnerable after the end of a significant relationship, persons who are most vulnerable to feeling hopeless are elderly men who have lost a spouse, especially if they have limited social support (Klott, 2012; Orbach, 2011; WHO, 2015; WHO 2015a). Elderly men often find it unbearable “facing the remaining years without . . . intimate connection” and for them suicide becomes a real option to end their loneliness (Klott, 2012, p. 16). Loss of health is associated with increased suicidality. Chronic illnesses significantly contributes to a person’s vulnerability to suicide and includes illnesses that incapacitate like: “Multiple Sclerosis, cancer of the brain, HIV/AIDS, renal failure, Parkinson’s or Huntington’s disease” (Klott, 2012, p. 16). The person who is experiencing a chronic illness feels a complete loss of control. They lose their sense of independence and autonomy. They often become dependent on others for help, which contributes to a loss of self-esteem and feelings of worthlessness (Orbach, 2011). Collateral issues associated with being diagnosed with a chronic illness include loss of financial security that leads to further stress and feelings of worthlessness (Klott, 2012; WHO, 2012; WHO 2015a). SUICIDE & LOSS: Suicide is often very closely tied to all forms of loss such as: loss of primary relationship, loss of health, loss of occupation and loss experienced by adolescents Fig. (1.5). Suicide & loss. Source: Klott, 2012.

Although “job loss and unemployment are devastating . . . (they) are not necessarily correlated to suicide” (Klott, 2012, p. 17). However, loss of an occupation is closely linked to suicide for very specific reasons. An occupation differs from a job, in that people who identify themselves with a profession often define their whole sense of who they are with what they do for a living. Their entire self-esteem is very closely and intimately aligned with their sense of performance (Klott, 2012). If their occupation is prematurely severed or they are fired they may experience unbearable damage to their self-image. Males who are Caucasian and 65 years or older are also at “an exceptionally elevated risk for

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suicide, and one of the contributors to that risk is retirement” (Klott, 2012, p. 17). When retirement occurs there is often a loss of identity and purpose for many men. Adolescents are also extremely vulnerable to loss. They often find the experience of rejection and aloneness as intolerable (Klott, 2012). They are likely to act impulsively after any recent loss, even after what seems to adults as a rather insignificant loss, like a failing grade in school, failure to pass a driving test, after a break-up or following a fight with a parent (Stephany, 2007). Bullying is also “significantly correlated with adolescent suicide as it triggers themes of abandonment, isolation, rejection, and devaluation” (Klott, 2012, p. 20). CULTURAL ISSUES & SUICIDE Suicide is closely tied to culture (WHO 2015a). Culture represents the beliefs and customs of particular groups in society and includes ethnicity (Stephany, 2012). Ethnicity traditionally is associated with a particular social group that shares a common culture, religion and language (Merriam-Webster Dictionary, 2017). However, culture is much more than just ethnicity and encompasses many factors that include but are not limited to, socio-economic status, age and gender. We will now briefly explore some of these aspects of culture in relation to suicidality. Suicide & Socio-economic Status: Most countries with high suicide rates are poor (Petr, 2015). In fact, 75% of the suicides that occur in the world occur with people living in lower or middle income families (WHO, 2015b). However, in wealthy countries three times as many men die of suicide as do women (WHO, 2015b). We will now identify the 25 countries with the highest suicide rates along with some specific factors that may contribute to those high rates. 25 COUNTRIES WITH THE HIGHEST RATES OF SUICIDE (AS ADAPTED FROM PETR, 2015) 25. POLAND (16.6 per 100,000 people) Causes of suicide in Poland are mostly unknown because of a lack of statistics. Poland has the highest disparity between suicides committed by men and women with three times as many males committing suicide as females. 24. UKRAINE (16.8 per 100,000 people) Ukraine has a high suicide rate and greater than 50% of all deaths due to suicide are in the military.

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23. COMOROS (16.9 per 100,000 people) Comoros is an African country and is known for its violent past, full of civil war, political coups and extreme poverty, all of which are thought to contribute to high suicide rates. 22. SUDAN (17.2 per 100,000 people) Sudan is one of the largest African countries. It is known for ethnic strife, increased crime, corruption, slavery and brutal punishments which are thought to be associated with higher numbers of suicide deaths. 21. BHUTAN (17.8 per 100,000 people) Citizens of Bhutan adhere to Tibetan Buddhism traditions. Discussion of suicide and ways to prevent it are not permitted in Bhutan. Yet, it is people of Nepalese origin who most often end their lives through suicide. Their reasons are not well known. 20. ZIMBABWE (18.1 per 100,000 people) Zimbabwe is another African country where people live in harsh conditions. HIV/AIDS and poverty are paramount. Suicide is seen as an option to escape such suffering, sadly even for children and youth. 19. BELARUS (18.3 per 100,000 people) Belarus is an Eastern European country bordering Russia. Two thousand people in this country commit suicide annually and suicide is highest in rural areas and in small towns. Alcohol misuse is thought to be a contributing factor. 18. JAPAN (18.5 per 100,000 people) Although Japan is a developed and wealthy nation, it has unusually high suicide rates. In fact, suicide is the leading cause of death in males 20 – 44 and is attributed to mental illness and social pressures to achieve. 17. HUNGARY (19.1 per 100,000 people) From 1950 – 2000 Hungary had the highest suicide rates in the world. Although their suicide rates have improved in the last 17 years, it is still quite high. Causes of suicide are unknown.

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16. UGANDA (19.5 per 100,000 people) Uganda is an Eastern African country with a good economy and living standards. The reasons for suicide are associated with depression, stress, relationship problems, unemployment, poor housing and poor health. 15. RUSSIA FEDERATION (19.5 per 100,000 people) In the late 1990s the suicide rate in Russia was twice the rate it is today at 40 per 1000,000. There has been a notable improvement. However, heavy alcohol use has been identified as a contributing factor to present day suicides in Russia. 14. TURKMENISTAN (19.6 per 100,000 people) Turkmenistan is a central Asian country where suicide consists of 2% of all deaths. Contributing factors are thought to be related to an economy that is not doing that well and extreme unemployment. 13. SOUTH SUDAN (19.8 per 100,000 people) South Sudan is a Northeastern African country that has been devastated by numerous conflicts and civil wars. The WHO points that people at high risk for suicide are those who have been displaced, are refugees, homeless, soldiers and war veterans. 12. INDIA (21.1 per 100,000 people) Apparently almost half of the suicides in India are related to family or health issues. Until 2014 suicide in India was illegal and persons who attempted suicide could be imprisoned for up to a year. 11. BURUNDI (23.1 per 100,000 people) Burundi is a Central African country and it is one of the poorest and least developed countries in the world. Hunger is paramount. War, corruption, lack of food, lack of education and poor health care are all thought to contribute to suicide. Men in Burundi commit suicide three times more often than women. 10. KAZAKHSTAN (23.8 per 100,000 people) Kazakhstan is a rather large country in Central Asia. Suicide is a large problem in youth and students in this country. Kazakhstan has the highest rate in the world of suicide in young women 15 – 19 years of age. Causes are unknown.

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9. NEPAL (24.9 per 100,000 people) Nepal is a mountainous country in South Asia. Recent trends have seen an increase in suicide in women. For instance, 20 of the 24.9 suicides per 100,000 in Nepal are women. Causes and/or contributing factors unknown. 8. UNITED REPUBLIC OF TANZANIA (24.9 per 100,000 people) The United Republic of Tanzania is an Eastern African country with 45 million residents. Poverty, hunger, violence, poor access to health services and high rates of HIV are thought to be contributing factors to suicide. 7. MOZAMBIQUE (27.4 per 100,000 people) Mozambique is a Southeastern African country. Residents in Mozambique have the shortest life span in the world. Poor access to health care and HIV/AIDS are thought to be a big factor in their high suicide rates. 6. SURINAME (27.8 per 100,000 people) Suriname is a South African country. Suicide in males is almost four times the rate it is for females. Major social and economic issues, poverty, domestic violence, alcohol abuse and extensive unemployment are all thought to contribute to high suicide rates. 5. LITHUANIA (28.2 per 100,000 people) Lithuania is located in Europe and has the highest suicide rate in Europe and has the fifth highest suicide rate in the world. Social and financial issues are thought to be the cause. 4. SRI LANKA (28.8 per 100,000 people) Sri Lanka is a South Asian country that gained its independence in 1948. Since that point in time suicide rates have been constantly increasing and the causes are unknown. 3. SOUTH KOREA (28.9 per 100,000 people) Although South Korea is known for its technological advancements, good education opportunities for its citizens and advanced health care, suicide rates are still very high. Social pressures and family discord are thought to be contributing factors.

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2. DEMOCRATIC PEOPLE”S REPUBLIC OF KOREA (38.5 per 100,000 people) North Korea has high suicide rates that are thought to be related to a restrictive environment, human rights violations, economic difficulties and stress. Oftentimes whole families have been known to commit suicide in order to avoid punishment by the regime. 1. GUYANA (44.2 per 100,000 people) Guyana is a country that is located in the Northeastern part of South America. Guyana has the highest suicide rates in the world. Their suicide rate is four times the global average. Rural poverty, alcohol misuse and easy access to means have all been identified as contributing factors to suicide in Guyana. Suicide & Age Suicide occurs across the lifespan but is highest in youth (WHO, 2015b). For example, suicide is the second leading cause of death in the age group of 15 – 29 year-olds and the leading cause of death for young women in the age range of 15 – 19 years of age (WHO, 2014). In Canada, suicide is the second leading cause of death in adolescents between the ages of 10 – 24, second only to death due to motor vehicle accidents. Suicide rates for children 10 - 14 years has actually increased in recent years (Centre for Suicide Prevention, 2017). Furthermore, research had revealed that a significant number of youth either contemplate, plan or attempt suicide without reaching out for help, and adolescent males are less likely to reach out for help than teenaged females (Centre for Suicide Prevention, 2017). The second largest number of deaths due to suicide on a global level occurs in the elderly (WHO, 2015a). Seniors are at high risk, especially men over the age of 65. As previously pointed out, loss plays a role in increased suicide in this group, such as, loss of significant relationships due to divorce or death, loss due to ill health and loss of identity due to retirement (Canadian Association for Suicide Prevention, (CASP) 2017). Suicide & Gender On a global level “suicide accounts for 50% of all violent deaths in men and 71% of women” (Fleischmann & De Leo, 2014, p. 290). Although women are more prone to threaten suicide, men are also more likely to commit suicide without warning and they tend to use more lethal means (Motto & Bostrom, 2014; WHO, 2015b; Moore & Melrose, 2014).

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Members of the Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) community often experience sexual prejudice from others. Sexual prejudice consists of negative attitudes toward sexual preferences that differ from heterosexuality and can have a negative psychological impact of persons of a sexual minority (Cramer et al., 2015). Members of sexual minority groups are known to be at an increased risk for suicide. For example, Gay and bisexual men have reported a lifetime prevalence of suicide attempts that are almost twice that of heterosexuals (The Parents and Families and Friends of Lesbians and Gays (PFLAG), 2015 as cited in Cramer et al., 2015). Lesbian and bisexual women have also reported lifetime prevalence of suicide attempts nearly twice the rate of heterosexuals (The Parents and Families and Friends of Lesbians and Gays (PFLAG), 2015 as cited in Cramer et al., 2015). Transgender refers to a person whose gender identity does not correspond to that person’s biological sex assigned at birth. Transgender persons also have a higher rate of suicide attempts than the general population. According to Grant et al. (2011) the estimated lifetime suicide attempts among persons who are from the transgender population range from 26% – 45% compared to less than 2 - 9% in the general population. Suicide & Aboriginals Suicide rates are high among aboriginals. For example, in Australia suicide rates for indigenous men (25 – 29 years of age) is the highest in the world (Fogarty, 2016). Some of the reasons for such high rates of suicide among young aboriginal men in Australia include, a high incidence of mental illness, alcohol and drug abuse, and decreased access to education and employment opportunities (Fogarty, 2016). Aboriginal people in Canada are also especially vulnerable to death by suicide and the rate of suicide among aboriginals is at least two times greater than in the rest of the Canadian population (Aboriginal Healing Foundation, 2009). Among aboriginal youth in Canada, greater than 30% of deaths are attributed to suicide (Aboriginal Healing Foundation, 2009). Some of the highest rates of suicide in Canada occur in the Inuit and in Nunavut (Khan, 2008). For example, Inuit suicide rates are 6 – 11 times the Canadian average, and in Nunavut 27% of all deaths are due to suicide (Khan, 2008). RELIGION & SUICIDE “The vast majority of the world’s population is affiliated with a religious belief structure, and each of the major faith traditions (in its true form) is strongly opposed to suicide” (Norko et al., 2017, p. 9). According to Wright (2010) Judaism, has always opposed suicide declaring that a person’s body is owned by God. Traditionally and historically Christianity has been intolerant of suicide,

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even though there is no scripture contained in the Bible that condemns the act of ending one’s life voluntarily. The assumption is that the commandment, “Thou shalt not kill” is justification enough for Christianity to condemn the act of suicide (Wright, 2010, p. 14). Beginning in the 6th century the Catholic Church refused to conduct a mass for a person who ended their life through suicide. However, in time, the Catholic faith softened its views toward suicide somewhat, solely for those who suffered from a mental illness (Wright, 2010). The Qur’an prohibits suicide and persons who are of the Muslim faith have lower rates of suicide when compared to other religions (Wright, 2010). “Hindu teachers strongly condemn suicide as the destruction of sacred life” (Norko et al., 2017, p.10). However, there are some exceptions to religious opposition to suicide, such as the burning death of a wife on her husband’s funeral bed (Bhugra, 2005 as cited in Norko et al., 2017). Suicide is also a recognized form of political protest in some Buddhist countries like Tibet and Vietnam (Worth, 2011). Suicide bombings are also encouraged by religious radicals under the promise of eternal salvation (Anees, 2006). What we now know is that an association with a religion sometimes offers protection against suicide. The literature has revealed the following set of protective effects of formally belonging to a religion: enhanced social network, social integration, a strong sense of belonging, a strong sense of community, and even fear of eternal condemnation (Norko et al., 2017; Wright, 2010). However, the most important feature of belonging to a formal religious group that offers protection against suicide has been identified to be due to social support and social networking (Norko et al., 2017). (See Fig. 1.6).

What we now know is that an association with a religion sometimes offers protection against suicide and the most important protective feature of belonging to a formal religious group has been identified to be due to social support and social networking Fig. (1.6). Religion and Protection against suicide. Source: (Norko et al., 2017).

THE IMPORTANCE OF TRAINING GATEKEEPERS As illustrated in Fig. (1.7), we need to ensure that gatekeepers who are confronted with persons who are suicidal are trained in how to best help them. That is a key focus of this book. The rationale for this book stems from four key premises which will be further explained in the dialogue that ensues. The first premise is concerned with the fact that the training of many gatekeepers, especially health professionals, in suicide risk and therapeutic intervention is often limited. Premise two points out that we need to be doing more to teach suicide prevention to health

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professionals. The third premise stresses the fact that many people who are suicidal do reach out to health professionals for help before committing suicide. A fourth premise presents the therapeutic relationship between the gatekeeper and suicidal person as key to helping the suicidal person. It proposes that teaching gatekeepers how to establish therapeutic rapport and offer empathy may help to save some lives.

We need to ensure that gatekeepers who are confronted with persons who are suicidal are trained in how to best help them Fig. (1.7). Key focus of this book. Source: Stephany, author.

Premise 1: The Training of Health Professionals in Suicide Risk & Therapeutic Intervention is Often Limited The first premise for this book concerns the fact that although mental health care providers are the gatekeepers who frequently assess and care for people who are suicidal, their training in suicide risk assessment and therapeutic intervention is often limited, and has been for several decades (Schmitz, et al., 2012). Ruth et al., (2009) point out that most students trained in graduate work in social work receive fewer than four hours of training in suicide assessment and less than 25% of social workers received no suicide training at all in their programs (Feldman & Freedenthal, 2006). Schmitz et al., (2012) call attention to the fact that physicians over all are not trained in suicide risk and intervention. If they do receive training in suicide risk they only receive an average of 3.6 hours. Recipients of this training reported that it was insufficient (Melton & Coverdale, 2009). Only the specific field of psychiatric medicine ensures “that their trainees are, at a minimum, exposed to the skills required to properly conduct a suicide risk assessment and address suicidality in treatment” (Schmitz et al., 2012, p. 295). Premise 2: We Need to Do a Better Job of Teaching Suicide Prevention to Health Professionals Premise two points out that we need to do a better job of teaching suicide prevention to health professionals. Many doctors and nurses feel uncomfortable about asking their patients questions about suicide. For example, after a thorough review of the literature, Pompili et al. (2015) found that the stigma, or prejudicial bias, toward patients who are suicidal is not due to actual prejudice or lack of care, but due to fear. Many health professionals feel uncomfortable with the subject of suicide and their formal training does not give them tools to adequately

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deal with suicidal patients. In fact Schmitz et al., (2012) asserts that “the training of mental health professionals in the assessment and management of suicidal patients has been, and remains woefully inadequate” (p. 293). Fig. (1.8), summarizes three reasons why we should be doing more to teach health professionals about suicide prevention. Many doctors and nurses feel uncomfortable about asking their patients questions about suicide

Increased awareness of suicide risk is not enough to prevent suicide We need to train helping professionals how to better care for the suicidal person

Fig. (1.8). The reasons why we should do more to teach suicide prevention to health professionals. Source: Pompili et al., 2015; Motto & Bostrom, 2014; Quinnet and Simpson, 2012.

Other research indicates that solely emphasizing increased awareness of suicide risk for doctors who treat suicidal patients, without also training them in therapeutic interventions is not enough to prevent suicides (Motto & Bostrom, 2014). For instance, a randomized controlled study that reviewed efforts to improve physicians’ skills in recognizing and assessing suicide risk, was unable to identify any specific treatment technique that had a significant aspect of prevention associated with it (Motto & Bostrom, 2014). Betz et al. (2013) investigated the attitudes and preparedness of health professionals in the ER toward people who presented with suicidal ideation. Their findings indicated that although many physicians and nurses self-reported that they felt confident in their assessment of suicide risk, they felt ill equipped in the areas of more advanced risk assessment. They even admitted to being at a complete loss in skills

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pertaining to counselling or referral to additional community supports. Quinnet and Simpson (2012) proposed that in order to prevent suicide we must not only provide better training for health professionals in suicide risk assessment, but also train them how to better care for the suicidal person. Premise 3: People who are Feeling Suicidal Do Reach Out to Health Professionals for Help The third premise for this textbook is based on the fact that even though we do not adequately train health professionals in suicide assessment and intervention, suicidal people do seek help from health professional gatekeepers before taking their life. For example, Luoma, Martin & Pearson (2002) reviewed 40 studies where rates of contact with primary care and mental health professionals occurred prior to a person taking their own life. Although their review was unable to determine to what degree contact with these professionals may have been able to prevent suicide, what was made evident was that the majority of people who die by suicide do reach out to primary care providers. In fact, about one third of people who died from suicide had contact with some sort of mental health services within the last year before death. Another 20% had been in contact with a mental health professional within a month of choosing to end their life (Luoma et al., 2002). The results of the work done by Luoma et al., 2002 was replicated by Gairin et al. (2003). Gairin et al. (2003) did a retrospective study and found that 39% of patients who ended their lives by suicide actually presented to the ER within a year prior to death and many had interfaced with the ER in months, weeks or days before ending their lives. My research revealed that many people committed suicide within 72 hours after reaching out for professional help, usually by presenting to the ER (Stephany, 2007). Similar findings have been noted by other researchers (Bajai et al., 2008; Betz et al., 2013; Motto & Bostrom, 2014; Cerel et al., 2016). In fact, a study by Cerel et al., (2016) examined attendance in the ER by patients who later died by either suicide or homicide. They found that 10% of them had attended an ER within six weeks prior to their death, and most of them presented to the ER in the month prior to death. Premise 4: Teaching Gatekeepers How to Establish Therapeutic Rapport & to Offer Empathy May Help to Save Some Lives As previously stressed, in order to do a better job of preventing suicide we need to provide better training for gatekeepers, especially health professionals. They need to be trained in suicide risk assessment, early identification of mental illnesses and how to better care for the suicidal person (Cutcliffe & Stevenson, 2007; Stephany, 2007). In fact, when training in all of these areas does occur, positive results in preventing suicides is the result (Fleischmann & De Leo, 2014; Schmitz et al.,

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2012; Vijayakumar, 2003). Chapter Two will cover risk assessment. Chapter Three will review the importance of early intervention for mental disorders and Chapter Four will teach empathy skills. However, this current discussion introduces the reader to the proposition that teaching gatekeepers how to establish therapeutic rapport and to offer empathy may help to save some lives. In fact, Perlman, Neufeld, Martin, Goy & Hirdes (2011) point out in Fig. (1.9), that any assessment of a person with suicidal thoughts must be person-centered. The therapeutic relationship should make active listening, respect, trust, genuineness and empathy a priority, and focus on the concerns presented by the person who is being assessed.

Any assessment of a person with suicidal thoughts must be person-centered. The therapeutic relationship should make active listening, respect, trust, genuineness, & empathy a priority

Fig. (1.9). Items that need to be focused upon during assessment of the suicidal person. Source: Perlman et al., 2011.

However a problem exists because establishing therapeutic rapport or offering empathy are very seldom included in the formal training of care provider gatekeepers (Wyman et al., 2008; Joiner Jr., et al., 2009; Vijayakumar; 2003). Teaching empathy is often excluded in the curriculum of medical schools. Sometimes the medical faculty who train doctors do not teach the importance of therapeutic communication techniques because these aspects of care are not

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considered as important as other physical assessment skills and diagnostics (Klitzman, 2008). Yet, there is considerable support in the literature for the role of the therapeutic relationship between the care giver and suicidal person as an important aspect of helping the person in crisis to choose life. Martin, Garske and Davis (2000) performed a meta-analysis of studies into the therapeutic relationship which resulted in the finding that empathy was central to a patient’s emotional progress and more highly correlated to emotional wellness than any specific therapeutic strategy. Paulson and Everal (2003) investigated adolescent’s perceptions of what was helpful when receiving psychotherapy for suicidal ideation. Their findings indicated that the following five aspects of therapy as most beneficial: enhanced understanding, communication, creative expression, therapeutic relationship and therapeutic strategies. The North Sydney Department of Health (2004) asserted that once suicide risk had been confirmed, establishing therapeutic rapport with a person as a crucial first task for the helping professional to prevent suicide. Others have come up with similar findings. The United Kingdom’s Royal College of Psychiatrists (2010) reviewed cases of self-harm and suicide to identify what if anything was helpful. They “concluded that understanding, empathy and nonjudgment as key to assessment and treatment of patients who have attempted suicide” (p. 141). Cutcliffe and Stevenson (2007) in their research into caring for the suicidal person found that a psychiatric nurse communicating a genuine sense that they did care about the person was an immensely valid indicator of a reduction in the person’s suicidal ideation. However, as demonstrated in Fig. (1.10), what was also extremely significant was that compassion and understanding was not enough to reduce the person’s suicidal ideation unless the suicidal person “felt” and received these empathetic qualities genuinely emanating from the nurse (Cutcliffe & Stevenson, 2007). Michel (2011) also points to the therapeutic relationship between patient and clinician, establishing trust and being empathetic, as crucial to helping the suicidal person through their emotional crisis. Compassion and understanding is not enough to reduce a person's suicidal ideation unless the suicidal person "feels" and receives these empathetic qualities genuinely emanating from the nurse Fig. (1.10). Necessary empathetic qualities. Source: Cutcliffe & Stevenson, 2007.

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THE ETHIC OF CARE AS THE THEORETICAL FOUNDATION “While the ethic of justice proceeds from the premise of equality – that everyone should be treated the same – an ethic of care rests in the premise of nonviolence – that no one should be hurt.” Carol Gilligan, Ethic of Care Theorist

The ethic of care is the theoretical premise for this book. Ethics is derived from philosophy and is concerned with ideal conduct (Stephany, 2012). The ethic of justice is traditionally associated with fairness and ensuring that everyone be treated equally. The ethic of care is more concerned with the practice of caring for and about others and has a strong affiliation with the practice of nursing (Gilligan, 1982; Watson, 2008; Stephany, 2012). The ethic of care is concerned with the caring relationship between the caregiver and the patient and the caregiver’s role in reducing human suffering. However, this explanation is a mere glimpse of what the ethic of care in action really entails. Held (2006) proposed that the ethic of care is both a practice and a value that cultivates in the care giver an attitude that builds trust and connectedness between people. That relationship of trust is especially important between the caregiver and the one being cared for, if healing is to occur (Stephany, 2012). Similarly Watson (2008) views the ethic of caring as a means to facilitate healing by honoring a person’s wholeness, by promoting forgiveness, and by encouraging a sense of community and responsibility for others. Caring in this capacity accepts people not only as they are now but focuses on the human capacity for growth and change. In this manner the ethic of care may offer hope to someone who currently feels hopeless (Watson, 2008; Stephany, 2012). THE ETHIC OF CARE AND EMPATHY AS A TOOL FOR SUICIDE PREVENTION In addition to the ethic of care being the theoretical premise for this book, it is also presented as a tool for suicide prevention in conjunction with empathy. I firmly believe that the ethic of care is a powerful tool for the helper who wants to help others. However, as Watson (2008) points out, one must never assume that knowledge of what consists of caring action is evident in every care provider’s practice. The Importance of Training Gatekeepers in How to Care Fig. (1.11) sheds light on an important point, that sometimes we need to teach some people in the helping professions how to better care for their patients with increased understanding and without judgment (Watson, 2008; Stephany, 2012; Stephany, 2015). This current book aims to do just that, to assist gatekeepers who

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are confronted with a suicidal person how to best offer that individual care and empathy.

Sometimes we need to teach some people in the helping professions how to better care for their patients with increased understanding and without judgment

Fig. (1.11). Training gatekeepers. Source: Watson, 2008; Stephany, 2012; Stephany, 2015.

The question can be posed, why is the ethic of care an important aspect of caring for the person who is suicidal? It is important because we know that the suicidal person is often very distraught and hopeless and that they are in need of feeling understood (Shneidman, 1998; Stephany, 2007; Stephany, 2015). The ethic of care can inspire and motivate the caregiver to want to understand what the suicidal person is experiencing, as well as to take action to do whatever is possible to reduce their emotional suffering. Empathy as a key component of the ethic of care consists of action by the caregiver to want to fully understand the experiences of another person (Stephany, 2015). Together, the ethic of care and empathy are both “seen as an active means to cultivate a form of motivated sensitivity to the experience of others” (Stephany, 2015, p. 7). In Fig. (1.12), the relationship between the ethic of care, empathy and suicide prevention are emphasized. The ethic of care promotes action by the caregiver to do what they can to help alleviate a person’s suffering and empathy motivates the helping professional to want to more fully understand the suicidal person’s experience (Stephany, 2015). The caregiver is inspired to enter into the other person’s space, even for a moment, in order to truly feel what they are feeling. By establishing this connection between human to human understanding is born. This is the essence of the ethic of care and empathy in action. This current discussion about the important role of the ethic of care and empathy is offered as a brief introduction to very rich concepts. Chapter Four of this textbook will more fully focus on the ethic of care and the importance of offering empathetic responses when assisting someone who is experiencing suicidal ideation. Chapter Four will also include simulation exercises to help to teach gatekeepers how to be more empathetic.

The Importance of Teaching

THE ETHIC OF CARE promotes action by the caregiver to do what they can to help alleviate the suicidal person's emotional suffering

How to Help the Suicidal Person to Choose Life 23

EMPATHY, as a cricial component of the ethic of care, motivates the helping professional to want to more fully understand the suicidal person's experience

Fig. (1.12). The ethic of care and empathy as a tool for suicide prevention. Source: Stephany, 2015.

METHODOLOGY All research, both quantitative and qualitative, have resulted in increased understanding of the complex notion of suicide and ways to prevent suicide, and both methods of inquiry are important (WHO, 2015; Pompili, 2015). However, because aspects of the subjective relationship between caregiver and suicidal person are the key focus of the case studies in this book, the methodologies for case analysis were chosen to be primarily qualitative in nature. Before presenting the two specific types of qualitative methods that were utilized, a brief comparison between quantitative and qualitative methods of research are presented. This brief review may prove to be beneficial for the non-academic reader. Quantitative research is concerned with the measuring and quantification of identified objective reality in order to draw inferences about the whole from the analysis of its parts. It is focused upon causes and effects (Myers, 2000). In quantitative research the researcher stands outside the phenomenon that is being studied. In contrast to quantitative inquiry, qualitative study consists of methods of scientific inquiry that are utilized to gain increased understanding of the experience of humans and to describe the essence of that experience. Qualitative methods are less concerned with causes and effects (Myers, 2000). In qualitative study the researcher can oftentimes become immersed with the subject of interest. Qualitative research aims “to discover meaning and understanding, rather than to verify truth or predict outcomes” (Myers, 2000, p. 2). The key method of discovery in qualitative study is to analyze cases in natural settings and deduce information through the process of inferring themes. Often qualitative data can be

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used to further enhance what is known objectively by quantitative means (Etherington, 2016). This current e-textbook draws quite significantly from evidence based data that is quantitative in nature as well as from qualitative sources. However, it is important to point out that traditionally there has been a greater emphasis in the literature on quantitative studies on suicide risk and less emphasis on qualitative strategies of intervention (Gairin et al., 2003; Betz et al., 2013; Pompili, 2015; Gunnell, 2015). Gunnell (2015) proposes that qualitative methods can help us to better understand a range of issues relevant to suicide prevention. One example is to explore why some people who are suicidal do not reach out for help. Another is to enquire how to better respond and treat people who are at risk of self-harm (Gunnell, 2015). Two specific modes of qualitative methodologies were utilized in this book to analyze the case studies that are presented, the narrative case study approach and the psychological autopsy. For persons who had experienced suicidal thoughts or attempted suicide, the narrative case study approach was used to study their lived emotional experiences. The narrative case study approach consists of systematically gathering data by analyzing a person’s story as told by them in order to identify themes and trends (Etherington, 2016). For cases that were studied retrospectively after a suicide had occurred, the psychological autopsy was utilized. A psychological autopsy consists of a retrospective investigation after a death has occurred with the goal of trying to re-trace the events of what happened to the deceased prior to death. The psychological autopsy may consist of gathering physical evidence, review of medical records and interviewing people who were involved with the person prior to death, including health professionals (The Free Dictionary, 2016). Before proceeding an important message is warranted. Some qualitative studies can be limited methodologically. This is especially true with psychological autopsies, because they rely so heavily on recalled memory, after the fact (Klott, 2012; Shneidman, 2004). But as Klott (2012) so poignantly points out, the bottom line is, “Studies on suicide are a challenge” (p. xi). A great deal can still be learned from psychological autopsies, especially about what may have been occurring in the mind of the person (Shneidman, 1998, Shneidman, 2004). NARRATIVE CASE STUDY: ADMISSION TO A SECURE ROOM We will now explore a narrative case study as told by an 18 year old woman whom we will refer to as Parma. Parma shares her humiliating experience after being admitted to an Emergency Room (ER) secure room after she attempted suicide. Note the picture of a sad woman in Fig. (1.13). It is symbolic of Parma’s experience of being in a secure room. Before proceeding with this case study, it is

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important to point out that it is not my intention to label or blame any actions of the caregivers who were involved. Rather, it is my hope that by closely examining what occurred in this and other cases in this textbook, other health professional gatekeepers who are faced with similar circumstances, may learn from what has transpired (Stephany, 2007; Stephany; 2015).

Fig. (1.13). Sad woman. Source: www.pixabay.com

I was admitted to the ER after a serious suicide attempt. I had been suffering from depression for more than three months. I had failed to graduate from high school due to missing so many of my classes because of my daily marijuana use. This made me feel like a total loser. My parents were especially disappointed in me and I hated myself. I had been a patient in the ER for three days and locked in what they called a secure room. This room was like a jail cell. The mattress was on the floor and all I was allowed to wear was a hospital gown. I felt really cold and alone. There was a sink and toilet in the room and a camera watching me day and night. How humiliating. Mostly the doctors and nurses came into the room briefly accompanied by a security guard and then they left soon afterwards. They hardly spoke to me. They gave me medications without telling me what they were for. My food was presented to me on paper plates and the forks and spoons were plastic. They didn’t even give me a plastic knife. After pleading with one of the nurses to let me out of this cold isolated room, she informed me that I had to stay put for now because I may hurt myself. She was quite abrupt with me. I felt like I was an annoyance. None of the nurses spoke to me very much at all and I wasn’t allowed any visitors, not that I would have wanted anyone to see me like this anyway. I would be ashamed. I felt so alone and sad. I was convinced that coming to the hospital was a mistake. I actually felt that I may have been better off dead.

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It was the change of shift and a new nurse, Gilbert, was assigned to take care of me. At the onset of his shift Gilbert came into the secure room to talk to me. Gilbert had the security guard stand outside the door instead of having them come inside the room like before. Gilbert explained that the security guard’s role was to ensure that I did not try and escape but that he didn’t need to listen to our conversation. No one else had told me why a security guard always accompanied the staff when they came to see me. Instantly, I felt a bit more respected but I was not convinced that this nurse would be any different than the others. Gilbert asked me how I was doing and I was quite abrupt with my response. I told him that I hated this place and that next time I would never come to the hospital for help. I told him how disappointed I was with the care I received and how I felt neglected, big time. This place or the people who were supposed to care for me did not seem helpful to me at all. Some of them were even annoyed to have to even attend to me. I told Gilbert that I felt punished for trying to hurt myself and felt worse about my situation than I did before I tried to kill myself. Gilbert did not say anything. I was sitting on the mattress on the floor and he kneeled down a bit so he could be at my level. He just waited and remained silent, which seemed kind of odd at first. Gilbert just stayed with me and listened to me, nodding from time to time. I rambled on and on and on, and then I started to cry. Gilbert remained quiet and just let me cry. After I stopped crying, Gilbert finally spoke again. He told me that he thought it must be terrible to feel the way I was feeling and that I had a right to be upset about the situation I was in. Gilbert told me that being in this room was a short term measure. I mumbled under my breath something to the effect of, “Are you kidding me, three days in a jail cell like this is short term?” Gilbert quietly chuckled a bit because I guess he heard what I had just said. He told me he would work on getting me out of this room, and that when I was ready he would like to come back and talk to me more, then he left. I told him that it would be good to be able to talk to someone. About an hour later Gilbert and the security guard moved me into a different room and I had a mental health worker assigned to sit with me and watch over me. I was in a real bed now with blankets. It may not seem like much but the move to a real room with a real bed helped me feel more cared for. Gilbert didn’t do much of anything that I can describe exactly, but somehow I felt like he didn’t judge me and that he did care for me a bit more than the others. Maybe it was just in my head, but he seemed different. Analysis of the Case Study “Seclusion and restraint aren’t treatment options: they are treatment failures.” United States Substance Abuse and Mental Health Services Two key themes surfaced from this narrative case study.

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Theme One: Leaving a suicidal person in a secure room for an extended period of time may increase their sense of being alone and worthless. Theme Two: Neglect or not spending time with a person who is suicidal may be interpreted by them as a lack of care. Theme Analysis Theme One: Placing Parma in an isolation room was to keep her safe from selfharm. However, research has demonstrated that keeping a suicidal person in a secure room for extended periods of time can increase their feeling of loneliness, worthlessness, hopelessness and suicidal tendencies (Cutcliffe & Stevenson, 2007; Mental Health Commission of Canada (MHCC), 2012). In a study by Kuosmanen, Makkonen, Lehtila and Salmine (2015), nurses who were asked to volunteer to spend time in a seclusion room reported experiencing increased anxiety and frustration. They also felt that the physical environment was inhumane. In fact, because of the negative experiences reported by patients in seclusion, in some jurisdictions seclusion room as a treatment method is completely avoided. For example, “seclusion and restraint have been virtually eliminated through the implementation of alternative approaches that are based on recovery principles and are sensitive to people’s past experiences of trauma” (MHCC, 2012, p. 34). Recovery models are strength based and encourage patient empowerment (MHCC, 2012). Recovery models in mental health treatment do not necessarily focus on full recovery from illness but emphasize productive ways that people with mental illness can lead productive lives. Theme Two: Neglect or not spending time with a person who is suicidal may be interpreted by them as a lack of care. Parma felt neglected by the large majority of her caregivers while she resided in the secure room. Dr. Kuhn (2003) points out that patients who report that they are not happy with the care that they received often admit that they did not feel understood or cared for. Patients who are suicidal are no different. In fact they interpret neglect or indifference emanating from a gatekeeper, like a nurse, doctor or other care giver, as a form of rejection. This perception of a lack of care may actually increase their sense of worthlessness and hopelessness (Shneidman, 1998; Stephany, 2007; Stephany 2015). Suggested Questions for Group Discussion 1. What other themes stood out for you from Parma’s story? 2. Is keeping someone safe from self-harm by placing them in a secure room ever justified? 3. What other strategies could have been employed to help Parma feel cared for?

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4. If you were Parma’s care giver, what would you have personally done differently to help Parma know that you were there to help her? .

SOMETHING TO COMPASSION

PONDER:

THE

IMPORTANCE

OF

SELF-

“Self-judgments, like all judgments, are tragic expressions of unmet needs.” Marshall Rosenberg, author of Nonviolent Communication: A Language of Life

Have you ever been in a situation when even though you really do care for and about another person, when you responded to their situation, you came across a bit harsh? Why does this happen? Wegela (2011) points out that our longing to help others and to show them that we care for them is a part of who we are as humans, but sometimes we communicate frustration or even demonstrate a hesitancy to help. We may respond with anger or hold back because of fear of being drawn into the other person’s suffering, or due to increased stress in our own life, or because we do not know exactly what to do or say (Wegela, 2011; Salzberg, 2004). Rosenberg (2003) advises that instead of scolding ourselves for not acting in empathetic ways or becoming angry with ourselves, we must be more self-compassionate. Self-compassion consists of telling ourselves that because we are human we sometimes make errors in judgment and we must be kind to ourselves and self-forgiving. Although we are encouraged to admit to ourselves to that we could have done better, first and foremost we must not be unduly hard on ourselves or be overcome with guilt or shame. These negative emotions will not help us to be more empathetic because we cannot give out to others what we ourselves do not possess (Wegela, 2011). Rosenberg so poignantly stresses that, “When we are intentionally violent toward ourselves, it is difficult to be genuinely compassionate toward others” (p. 129). Self-compassion can only be cultivated if we learn to take care of our own needs first (Rosenberg, 2003, Salzberg, 2004). The next time you become aware that you may have not acted in a caring way with someone who reached out to you for help, consider exploring some of the following questions through journaling or by talking it through, with someone you trust. 1. 2. 3. 4. 5. 6.

Maybe I am not at my best right now. Do I need to do more to take care of me? What is going on for me? Am I too stressed to care? Am I afraid and what am I scared about? I can choose to be self-forgiving. I can choose to be compassionate with myself.

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ETHICAL ISSUES THAT MAY ARISE WHEN CARING FOR THE SUICIDAL PERSON Ethical dilemmas are known to occur when caring for a person who is suicidal. In the health care setting, an ethical dilemma exists when there are two or more ethically defensible courses of action that can be taken but only one can play out in practice (Stephany, 2012). An example of an ethical dilemma would be a person’s right to choose to self-harm or to attempt suicide versus keeping them safe from self-harm. The action of allowing a person to choose for themselves is supported by the ethical principle of autonomy, which respects a person’s right to make decisions about their life (Wright & Leahey, 2005). Keeping a person safe from self-harm is supported by the ethical principles of beneficence and nonmaleficence. Beneficence is concerned with doing what will be beneficial to a patient (Oberle & Bouchal, 2009). Non-maleficence is an aspect of beneficence and is about our duty to do no harm, either intentionally or unintentionally (Stephany, 2012). Similarly, although commitment of a suicidal person under the Mental Health Act to keep them safe from self-harm, violates the ethical principle of autonomy, it can be justified by the principles of beneficence and nonmaleficence. Moral agency is one’s ability of a practitioner to act on one’s personal moral beliefs (Oberle & Bouchal, 2009). When a patient’s beliefs or actions conflict with a clinician’s, the care giver may experience a violation of their moral agency which may cause them stress. An example of a violation of a clinician’s moral agency occurs when a person’s choice to self-harm or to attempt suicide opposes a clinician’s view of the sanctity of life. If a clinician is constantly forced to oppose such a belief system when caring for the suicidal person, they may develop moral residue. Moral residue is the feeling of on-going remorse and guilt that may occur when practitioners are unable to act on their moral beliefs (Oberle & Bouchal, 2009). If moral residue remains undealt with moral disengagement may occur. Moral disengagement happens when a clinician distances themselves from all relational aspects of care and resorts to only performing tasks. Moral disengagement is not a therapeutic way to care for a person who is suicidal. Moral disengagement is also “not in alignment with the ethic of care but it does occur” (Stephany, 2012, p. 64). When and if, moral residue does happen the health care professional should look for ways to reconcile with what they are experiencing before resorting to moral disengagement. They can reach out for professional help, engage in reflective journaling, meditation or prayer (Stephany, 2012). Suggested Question for Group Discussion 1. In addition to what was suggested, can you think of other ways that a clinician

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who is experiencing moral residue can rectify what they are experiencing before they resort to moral disengagement? REFLECTING BACK Summary of Key Points Covered in Chapter 1 ●

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The purpose of this book is to add to what is already scientifically and experientially known about the important role that gatekeepers play in suicide prevention. Suicide differs from many other disease processes because its causes are multidimensional. Often someone who is suicidal has lost all hope and they may need someone else to help them to re-discover their particular type of hope. Some hard facts about suicide were presented such as the fact that someone in the world commits suicide every 40 seconds and that suicide continues to be the leading cause of death in the developed world. Suicide never occurs in complete isolation. Therefore, it is important to gain an understanding of some of the multi-dimensional contributing factors associated with suicide. Social stressors that were deemed to be closely associated with suicide are: adverse life experiences such as abuse and all forms of loss. The 25 countries that have the highest suicide rates in the world were identified along with and some of the social factors that contribute to high numbers of suicide. Suicide occurs across the lifespan but is highest in youth. The second largest number of deaths due to suicide on a global level occurs in the elderly. Although women are more prone to threaten suicide, men are more likely to commit suicide without warning. Members of sexual minority groups (e.g., members of the LGBTQ community) are known to be at an increased risk for suicide. Suicide rates are high among aboriginals. Although each of the world’s major faith traditions (in its true form) is strongly opposed to suicide, association with a religion sometimes offers protection against suicide. The following four key premises were presented as the reasons why we need to be doing a better job of teaching gatekeepers. 1. The training of many gatekeepers, especially health professionals in suicide risk assessment and intervention is often limited. 2. We need to do a better job of teaching suicide prevention to health professionals. 3. Many people who are suicidal do reach out to health professionals for help

The Importance of Teaching

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How to Help the Suicidal Person to Choose Life 31

before committing suicide. 4. Teaching gatekeepers how to establish therapeutic rapport and offer empathy may save some lives. The ethic of care was deemed to be the theoretical premise for this book. The ethic of care is concerned with the caring relationship between the caregiver and patient. The ethic of care and empathy were introduced as a strategy for suicide prevention. The ethic of care promotes action by the caregiver to do what they can to help alleviate the suicidal person’s emotional suffering. Empathy, which is concerned with identifying what another person is feeling, is a critical component of the ethic of care. Empathy motivates the helping professional to want to more fully understand the suicidal person’s experience. It was pointed out that both quantitative and qualitative research are important in enhancing what we know about suicide prevention and that this current work draws from both types of scientific inquiry. However, in this current book case study analysis was conducted by two qualitative methodologies, the narrative case study approach and the psychological autopsy. Two key themes were identified from the narrative case study of a suicidal person who was admitted to the Emergency Room (ER). Placing a suicidal person is a secure room for a lengthy period of time may increase their sense of being alone, and perceived neglect from a gatekeeper may be interpreted by the suicidal person as a lack of care. Questions for group discussion were proposed to review what could have been done differently to help the suicidal person feel cared for. Caregivers were encouraged to be more self-compassionate, especially when they believe that they may have acted in less than compassionate ways. Ethical dilemmas are known to occur when caring for a person who is suicidal. When a patient’s beliefs or actions conflict with a clinician’s, the care giver may experience a violation of their moral agency, which is their ability to act on their own moral belief system. Moral residue is the feeling of on-going remorse and guilt that may occur when practitioners are unable to act on their moral beliefs. If moral residue remains undealt with, moral disengagement may occur. Moral disengagement happens when a clinician distances themselves from all relational aspects of care and resorts to only performing tasks. When and if, moral residue does occur the health care professional should look for ways to reconcile with what they are experiencing before resorting to moral disengagement.

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How to Help the Suicidal Person to Choose Life, 2017, 32-59

CHAPTER 2

Changing Stigma, Dispelling Myths and Assessing Risk Abstract: Chapter two pointed out how stigma negatively impacts people who suffer from mental illness and/or suicidal ideation. Stigma can actually prevent patients from seeking the help that they need. What is alarming is that some of the most distressing stigma that people experience is perpetrated by health professionals. Health professionals who do engage in acts of stigmatization breach the very essence of what the ethic of care stands for. Educational endeavors need to be pursued in order to stop all discrimination. The lived experiences of two patients who presented to the emergency Room (ER) after a serious suicide attempt, was reviewed. Analysis revealed that their suicide attempts were not considered serious by staff and stigma likely played a role. No care plan or follow-up was arranged upon their discharge from the ER. Yet, research has demonstrated that the strongest indicator of a completed suicide is a previous attempt. Subsequently, caregivers were admonished to learn how to differentiate between a deliberate suicide attempt and other forms of self-harm. Dispelling preconceived assumptions about suicide that are not true was presented as another way to help to prevent suicide. It was also pointed out that some suicide risk assessment tools and/or frameworks are limited, and because the causes of suicide are multi-dimensional assessing suicide risk is not always a precise predictor of future outcomes. The warning signs of suicide were highlighted followed by a detailed 11 step process on how to conduct a thorough and focused suicide risk assessment. Key components of a Safety Plan was underscored. A narrative case study was presented as told by a Psychiatrist who was admitted to hospital after being diagnosed with depression, suicidal ideation and plan. Two key themes surfaced. There was a degree of personal shame experienced by the Psychiatrist associated with the notion of becoming depressed and suicidal. A patient’s experience of shame associated with having a mental illness can also be made worse when they feel judged by their caregivers. In short, a few simple strategies to increase gatekeepers’ self-awareness were highlighted as a means to dispel stigma.

Keywords: Access to means, Borderline personality disorder, Care plan, Compassion, Discrimination, Emergency room, Empathy, Ethic of care, Gatekeeper, Gesture, Journal, Lived experiences, Open-ended question, Parasuicidal gesture, Preconceived assumption, Protective factors, Rapport, Risk factors for suicide, Safety plan, Self-awareness, Stigma, Suicidal ideation, Suicidal plan, Suicidal thoughts, Suicide risk assessment, Suicide risk assessment tool, Warning signs of suicide. Kathleen Stephany All rights reserved-© 2017 Bentham Science Publishers

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LEARNING GUIDE After Completing this Chapter, the Reader Should be Able to: ● ●

●

● ● ●

● ● ● ●

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Describe what stigma is. Become aware how stigma by the general public and health professionals toward the mentally ill and the suicidal person, negatively affects them. Recognize that stigma from health professionals goes against empathy and the ethic of care. Understand how stigma also impedes suicide prevention. Be cognizant of the ways in which education can be used to end discrimination. Explore the lived experiences of two suicidal patients who experienced stigma from their caregivers. Differentiate between a deliberate suicide attempt and other forms of self-harm. Understand that the strongest risk for suicide is a previous attempt. Describe the four key preconceived assumptions about suicide that are not true. Become mindful of the limitations of some suicide risk assessment tools or frameworks. Become familiar with the warning signs of suicide. Learn how to conduct all of the 11 steps of a thorough and focused suicide risk assessment. Be able to describe the key components of a safety plan and when to use it. Explore themes from the Narrative Case Study: When a Psychiatrist Experiences Stigma. Learn some simple strategies to increase self-awareness.

Overview of Chapter 2 Chapter two begins by addressing the issue of stigma, how it negatively impacts people who suffer from mental illness and/or suicidal ideation, and how to change negative stereotypes through education. The lived experiences, as shared by two patients who felt judged after a suicide attempt, are presented and analyzed. Some common preconceived myths about suicide are dispelled. The warning signs of suicide are presented. Some of the problems associated with suicide risk assessment tools or frameworks are pointed out, followed by a step by step process of how to best conduct a thorough and focused suicide risk assessment. The importance of creating a safety plan is emphasized along with an overview of its key components. A narrative case study explores a Psychiatrist’s experience of stigma when he is admitted to hospital for depression and suicidal tendencies. In closing, a few simple strategies are suggested to help gatekeepers enhance selfawareness.

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STIGMA & HOW IT NEGATIVELY IMPACTS PEOPLE WHO SUFFER FROM MENTAL ILLNESS & SUICIDAL IDEATION Stigma is defined as an association of disgrace or public disapproval of something such as a behavior or condition (The Free Dictionary, 2016). The term, stigma also conveys a deep, shameful mark or fault related to being a member of a group that is devalued by societal norms (Hinshaw, 2009). People who suffer from mental illness are stigmatized by “members of the public, from friends, family and co-workers” (MHCC, 2012, p. 16). In a report written by the Surgeon General for the United States, stigma was declared the “most formidable obstacle to future progress in the area of mental illness and mental health” (Hinshaw, 2009, p. x). As Fig. (2.1) points out, we need to do more to stop the stigma.

Fig. (2.1). Image: Stop the Stigma. Source: www.pixabay.com.

People living with mental illness “often report that the experience of being stigmatized has a more devastating impact on them than the illness itself” (MHCC, 2012, p. 16). The fact is that people who suffer from mental illness face additional discrimination when they also exhibit suicidal ideation (Betz et al., 2013). The judgment and stigmatization of people who suffer from mental illness has also been noted to be an impediment to suicide prevention in society in general (WHO 2012; WHO, 2014). For example, “stigma may prevent people from seeking help and can become a barrier to accessing suicide prevention services including counselling” and post-intervention support (WHO, 2012, p. 11). Langille (2014 points out that in her opinion, “We’ve all grown up in a society that has taught us to stigmatize mental illness. Even though we don’t want to

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admit it, we all do it” (p. 35). Sadly, stigma also exists within the health professions. For example, the stigma toward persons who suffer from mental illness and/or suicidal thoughts is perpetrated by health professionals whose job it is to help them (Langille, 2014; Ross & Goldner, 2009; Betz et al., 2013; MHCC, 2012). As illustrated in Fig. (2.2), “Health-care providers may be aware that they should not perpetuate stigma, yet people who seek help for mental health concerns report that some of the most deeply felt stigma they experience comes from frontline health-care professionals” (Langille, 2014, p. 35).

People who seek help for mental health concerns report that some of the most deeply felt stigma they experience comes from front-line health-care professionals

Fig. (2.2). Stigma coming from health-care professionals. Source: Langille, 2014, p. 35.

Many health professionals also do not realize that their language and behaviors, if discriminatory or judgmental, are harmful (Langille, 2014). The following insulting labels have sometimes been used by health care professionals when referring to people with mental illness, “psycho, crazy, or frequent flyer” (Langille, 2014, p. 36). Other than through derogatory labelling, discrimination by health professionals occurs in other forms. For instance, sometimes physical symptoms experienced by a patient with mental illness are ignored and attributed to their mental illness. In other situations staff from a medical setting sometimes refuse to treat a person who has a medical problem who also suffers from a mental health issue (Langille, 2014). The medical problem is subsequently ignored. This is not acceptable. Not surprising is the fact that the implications of feeling judged by health professionals also has many negative emotional repercussions for the patient who is being judged. Suicidal patients who feel judged by the caregivers that they reach out to, may experience increased sadness, despair and feelings of worthlessness and hopelessness (Stephany, 2007; Betz et al., 2013). As Fig. (2.3) emphasizes, a belief that suicide prevention is ineffective and that medical resources are often wasted on persons who want to kill themselves has also been noted to inhibit treatment (Betz et al., 2013; Langille, 2014; Ross &

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Goldner, 2009). When health professionals judge people who suffer from mental illness or suicidal thoughts, they are acting without empathy and compassion (Stephany, 2015). They are going against many aspects of the ethic of care. How can we truly care for someone that we do not honor with respect? How do we facilitate healing, help them to feel hope or worthwhile, if we categorically depict them as less than deserving than others? As helping professionals we have to do better to genuinely convey that our capacity to care is without discrimination and unconditional, which is integral to the practice of the ethic of care. We will now explore ways to help to stop the stigma.

A belief that suicide prevention is ineffective and that medical resources are often wasted on persons who want to kill themselves has also been noted to inhibit treatment. When health professionals judge people who suffer from mental illness or suicidal thoughts, they are acting without empathy and compassion

Fig. (2.3). Discriminatory attitudes from health professionals. Source: Betz et al., 2013; Langille, 2014; Ross & Goldner, 20019, Stephany, 2015.

EDUCATION IS THE KEY TO CHANGING STIGMA “Education is the most powerful weapon you can use to change the world.” Nelson Mandela, Former President of South Africa

As Nelson Mandela’s quote so poignantly points out, education is the most powerful weapon for change, including transforming discrimination. We need to educate both the general public and gatekeepers in the health professions about the importance of stopping stigma toward people who suffer from mental illness

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and/or suicidal ideation. They need to be taught the facts that suffering from a mental disorder is not a choice, and that a mental disorder is a treatable illness. Recovery from mental illness is possible when the right treatment and supports are provided (MHCC, 2016). Making everyone aware of how stigma hurts is another effective educational strategy. People also need to understand that when discrimination is reduced, persons with mental illness and/or who are having thoughts of suicide, experience better health outcomes (MHCC, 2016). Another effective way to help change stigma is to listen to the lived experience of persons who have felt the negative effects of being discriminated against (MHCC, 2014). Fig. (2.4) is a brief summary of the key points that we need to teach to the general public and all gatekeepers, in order to stop the stigma. Key Points to Remember to Help Stop the Stigma

Having a mental disorder is not a choice, it is a treatable illness

Recovery from mental illness is possible when the right treatment and supports are provided

When discrimination is reduced, persons with mental illness and/or suicidal ideation experience better health outcomes

Make everyone aware of how stigma hurts

Listen to the stories as told by persons who have felt judged

Fig. (2.4). Points to remember to stop the stigma. Source: MHCC, 2012; MHCC, 2016.

LEARNING FROM STIGMITIZED

THE

LIVED

EXPERIENCES

OF

BEING

Stigma toward the mentally ill can be challenged and even changed, by the experience of empathy or truly relating to the experience of the person who is stigmatized. We can achieve this by listening to their stories (Corrigan et al., 2012). Let’s review what two patients reported as their experience when they presented to hospital with a suicidal attempt. Be forewarned that these particular negative experiences as shared by two patients, do not negate the fact that many health professionals do a great job of helping mental health patients who are suicidal (MHCC, 2012; WHO; 2012). However, we have to face the fact that we still need to change the stigma that does exist in the helping professions, and strive more diligently to foster more respect and acceptance (MHCC, 2016).

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Sarah: After everyone left the house in the morning I took an overdose of pills. I did not want anyone to find me and I wrote a note telling my family why I chose to end it all. But my mom came home early and unexpectedly to get something. She found me drowsy and in bed when I was supposed to be at school. I gave her the suicide note and when she read it she called 911. The paramedics arrived quite quickly and brought me to the hospital ER. They washed out my stomach and made me drink some stuff that was supposed to absorb the pills I had taken. I felt judged by the nurse who was looking after me. She was quite abrupt with me and her tone of voice was mean. She told me that I had brought this whole ordeal upon myself and that she had other patients with real medical issues that she needed to tend to. I felt like I was a waste of her time. She didn’t even ask me why I took the pills or what was going on for me. I felt ashamed and worthless. Parvinder: I was failing in school and I was very depressed. I slashed my wrist for the third time in one month and this time I did it really deeply because I wanted to do it right and end my life. I bled quite a bit from the slash that I made, and then I became really scared. So I went to the ER to get help. The nurse at the front desk was mean to me, even though I told her that I tried to kill myself. She said she was going to make me wait to see the doctor because it was my own fault that I was hurt. I was holding my wrist with a towel and the bleeding kept happening, but no one seemed to care. I waited four hours before someone asked me to come through the ER doors. The doctor took a look at my wrist and said he would have to put in stitches. He seemed like he was in a hurry. He put in freezing first and then sewed together the cut. The doctor then told the nurse to dress my wound. When the doctor left the room this nurse told me I could cover the wound myself because I was the one responsible for cutting myself in the first place. She left the dressing and tape on the table. After a few minutes the same nurse returned and told me I could go home. No one asked me why I had slashed my wrist and more deeply this time. They didn’t seem concerned that I actually wanted to die. They just blamed me for hurting myself. Analysis of Their Lived Experiences Three key themes surfaced from these stories. Theme One: In both cases the health professionals did not consider the person’s suicidal attempt as serious, and stigma most likely played a role. Theme Two: Both patients were judged as being responsible for their own injuries. Theme Three: No care plan was put in place upon discharge from the ER to ensure that these patients were safe. There also was no effort to ensure that they

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were followed-up by a mental health worker in the community for re-assessment. Theme Analysis Theme One: There was a lack of concern expressed by the caregivers in the ER about the seriousness of Sarah’s and Parvinder’s suicide attempts. Sarah had taken an overdose of pills and did not want to be discovered. That is a very clear sign that she intended on ending her life. Parvinder had cut his wrist quite deeply and this was not his first time. He even admitted that he was trying to kill himself. Caregivers need to learn how to differentiate between a deliberate suicide attempt and other forms of self-harm. For instance, some gatekeepers consider all self-harm attempts as mere gestures Fig. (2.5). Differentiating between a deliberate suicide attempt and other forms of self-harm. Source: Stephany, author.

As Fig. (2.5) points out, caregivers need to learn how to differentiate between a deliberate suicide attempt and other forms of self-harm. For instance, some gatekeepers consider all self-harm attempts as mere gestures. A parasuicidal gesture refers to an action of self-harm by a person. Some self-harm, such as slashing, may be due to reasons other than the person wanting to end their life. They may self-harm as an emotional release or for attention, especially if they suffer from a borderline personality disorder (Stephany, 2007). A person who suffers from a borderline personality disorder portrays “marked instability in emotion regulation, unstable interpersonal relationships, impulsivity, identity or self-image distortions, and unstable mood” (Pollard, Ray, Haase, 2014, p. 741). The following authors explain the importance of determining if an action of selfharm is an intention to end one’s life or if it is done for other reasons. Suicide is an intentional, self-inflicted act that results in death. The difficulty in distinguishing suicidal behaviors from purposeful self-harm is in determining the person’s intent. For example, was the intention of the behavior to end the person’s life, a call for help, or a means of temporary escape? Suicidal behaviors that do not result in death are considered “nonfatal,” or more commonly, “suicide attempts.” Self-harm is an intentional and often repetitive behavior that involves the infliction of harm to one’s body for purposes not socially condoned (excluding culturally accepted aesthetic modifications such as piercing) and without suicidal intent (Perlman, Neufeld, Martin, Goy, & Hirdes, 2011, p. 3)

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However, equating an actual suicide attempt to a mere gesture, without first of all examining the person’s intent, may result in a dismissive response from a health care professional and actually diminish the gravity of the suicide attempt (Freedenthal, 2014). This attitude may also impede efforts to keep the person safe from further self-harm and may even increase their feelings of hopelessness. (Freedenthal, 2014; Stephany, 2007). The term “gesture” has been determined to be partly responsible for this attitude because a gesture is defined as an action performed for show and not necessarily for effect (Oxford Dictionary, 2016; Freedenthal, 2014). Yet, as emphasized in Fig. (2.6), research has demonstrated that the “strongest risk factor for suicide is a previous episode of self-harm” (Gunnell, 2015, p. 155). Both of these patients should have been considered to be at high risk of a future suicide, assessed for suicide risk and have a care plan put in place before they were discharged from the ER (Stephany, 2007). Research has demonstrated that the strongest risk factor for suicide is a previous episode of self-harm

Fig. (2.6). Self-harm is the strongest risk factor for suicide. Source: Gunnell, 2015.

Theme Two: Both patients were judged as being responsible for their injuries and they were considered to be a nuisance. As previously mentioned, a belief that medical resources are wasted on people who attempt suicide may cause emotional harm (Betz et al., 2013; Ross & Goldner, 2009). Judging a person as responsible for their actions of self-harm in an actual suicide attempt can be very emotionally distressing for the person and may increase their feelings of sadness, despair, worthlessness and hopelessness and may put them at additional risk of another suicide attempt (Stephany, 2007; Betz et al., 2013). Furthermore, people who self-harm and receive poor hospital care are less likely to re-present to hospital for help when they self-harm again because of their negative experiences. This places them at further risk of a completed suicide (Gunnell, 2015). Theme Three: When these two patients were discharged from the ER, no care plan was put in place to ensure that they were safe. There was also no arrangements made to have them followed-up by a mental health worker in the community. In legal terms this lack of action to ensure their safety may be classified by some as somewhat irresponsible (Simon, 2002). The standard of care that is recommended is that a Safety Plan be put in place which is a written, prioritized list of coping strategies as well as people and numbers to call when a person feels they are unsafe (Stanley and Brown, 2016). Monitoring and re-

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How to Help the Suicidal Person to Choose Life 41

assessment of the person’s suicidal risk also needs to occur on an on-going basis in order to mitigate further risk (Perlman et al., 2011). It is worthy to note that people who have been discharged from hospital or the ER after a suicidal attempt, are at a high risk of committing suicide once released from hospital (Goldacre, Seagroatt & Hawton, 2008; Stephany, 2007). Questions 1. Were there any other themes that stood out for you from Sarah’s and Parvinder’s experience? 2. Can you make further suggestions on how to best approach attitudes by health professional gatekeepers that consist of judging the person who has made a suicide attempt? What strategies might prove enlightening and help to change these attitudes? EDUCATING OTHERS ASSUMPTIONS

BY

DISPELLING

PRECONCEIVED

In addition to stopping stigma, Fig. (2.7) emphasizes that dispelling preconceived assumptions about suicide that are not true, is another extremely important step in educating members of the public and gatekeepers.

Dispelling preconceived assumptions about suicide that are not true, is another important step in educating members of the public and gatekeepers

Fig. (2.7). Dispelling preconceived assumptions. Source: Stephany, author.

Presumed Assumption 1: You can’t stop a person from committing suicide once their mind is made up The above stated assumption is not true, although many people in the general public believe it to be accurate (Suicide Awareness Voices of Education (SAVE), 2015). Many nurses and doctors also have unsubstantiated fixed beliefs that suicide prevention is mostly ineffective in stopping someone from ending their life, but this assertion is not supported by the evidence (Betz et al., 2013). People who have suicidal thoughts or even the intent to act on a plan, and those who are extremely depressed and hopeless, often experience ambivalence about dying

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(SAVE, 2015). Someone who is suicidal does not necessarily want to die, they want their emotional pain to end (Shneidman, 1998). They frequently welcome a conversation about how they are feeling. They often feel so alone and somewhat ashamed about having thoughts of wanting to end their life, so when you ask them if they are suicidal, they may feel relieved that you care (Living Works Education, 2015; Stephany, 2007). Presumed Assumption 2: Only depressed people kill themselves and other people are not at risk This assumption is also not true. Suicidal thoughts can happen to anyone. For example, “people with or without mental illness, but who encounter psychosocial stressors, experience increased hopelessness and suicidal ideation” (Stephany, 2007, p. 19). Furthermore, the feeling of hopelessness is more highly correlated with suicide than depression (Shneidman, 1998). In fact, a person who is experiencing suicidal thoughts and is also depressed, may experience hopelessness, but a person who is hopeless does not necessarily have to be depressed (Shneidman, 1998 as cited in Stephany, 2007). Recent loss or an accumulation of losses, guilt, self-loathing and the feeling that there is no way out of a situation, are all associated with suicide, with or without a mental health diagnosis (Moore & Melrose, 2014; Stephany, 2007). Presumed Assumption 3: If you talk about suicide with someone who is thinking about it, you will push them over the edge and make them do it This is just not true (SAVE, 2015). You do not give a suicidal person ideas of carrying through with their plan when you talk to them about suicide. The opposite is true (SAVE, 2015). Bringing the subject matter up and asking them directly about how they are feeling is actually helpful (SAVE, 2015). Practice asking them questions like, “You sound kind of down and you have been saying things that make me worry about you. Are you having thoughts of suicide?” Most often they welcome the question because they are too afraid or ashamed to bring the topic up themselves (SAVE, 2015). The following four questions are also useful when you suspect that someone is suicidal (as adapted from SAVE, 2015) 1. 2. 3. 4.

“Do you ever feel so badly that you think of suicide?” “Do you have a plan to commit suicide?” “Have you thought you might actually go through with it?” “Have you thought about when you might do it?”

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How to Help the Suicidal Person to Choose Life 43

If the person seems to be in immediate danger, call 911, the Crisis Line or other suicide help lines. (Please refer to Appendix C for a comprehensive list of Information and Resource Centres for Suicide Help). Do your best to stay with the person and keep them safe from ways to harm themselves, until help is obtained (Living Works Education, 2015). Also, remember to tell them that you are staying with them because you care about them (Stephany, 2007). Presumed Assumption 4: If a person denies an intention of acting on their suicidal thoughts or plan, no further intervention is needed Even if they deny intention, you cannot be sure that they will not act on their suicidal thoughts or plan (Joiner Jr., 2010). Therefore, you need to always ensure that you do your best to direct them to help and further assessment. It is not your job to save them, even if you are a health practitioner. However, it is your role to do whatever you can do to keep them safe from harm to the best of your ability, and to get them to help (e.g., to be assessed by a mental health professional or a doctor in the ER) (Living Works Education, 2015). ASSESSING SUICIDE RISK IS NOT ALWAYS A PRECISE PREDICTOR OF FUTURE OUTCOMES: Unlike many diagnostic procedures that assess a relatively stable phenomenon, we do not yet possess a single test, or panel of tests that accurately identifies the emergence of a suicide crisis Fig. (2.8). Assessing suicide risk is not always a predictor of future outcomes. Source, Fowler, 2011.

THE LIMITATIONS OF SOME SUICIDE RISK ASSESSMENT TOOLS OR FRAMEWORKS Before embarking on how to conduct a focused and thorough suicide risk assessment, it is important to point out that there are limitations to some suicide risk assessment tools or frameworks. Suicide risk assessment tools (or frameworks) are designed to assess the presence of particular symptoms or circumstances that places a person on a scale of categorized risk for a completed suicide (e.g., high risk, moderate risk, low risk) (Wingate, Joiner, Walker, Rudd & Jobes, 2004). Some key problems with many suicide risk assessment tools is that they are just too complex, too extensive (such as over a hundred pages in length) and not user friendly (Wingate et al., 2004). As illustrated in Fig. (2.8), suicide risk assessment is neither simplistic nor uniform. Although assessing the degree of suicide risk is an important aspect of treatment of the suicidal person,

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unfortunately, unlike many diagnostic procedures that assess other relatively stable phenomenon, we do not yet possess a single test, or panel of tests that accurately identifies the emergence of a suicide crisis (Fowler, 2012). Another word of caution is needed when it comes to using suicide risk assessment tools or frameworks. As Simon (2002) points out, “Attempts to predict suicide produce many false-positive and false-negative results. Thus there is no professional standard of care for the prediction of suicide” (p. 340). No psychiatric expert would disagree with this assertion, yet what is necessary is that the psychiatrist or general practitioner gather as much information during suicide assessment of risk, to inform clinical intervention and management (Simon, 2002). Another caution is warranted, because the causes of suicide are multidimensional, any risk assessment tool or framework should only be used as one aspect of an overall assessment and is not totally predictive of degree of actual risk (See Fig. 2.9). It therefore, recommended, that all risk assessment frameworks be utilized in conjunction with a thorough examination of personal, interpersonal and social circumstances (Cutcliffe & Barker, 2004). Because the causes of suicide are MULTIDIMENSIONAL, any suicide risk assessment tool is only ONE aspect of an overall assessment and is not totally predictive of degree of actual risk. Therefore, all risk assessment frameworks must be utilized in conjunction with a thorough examination of PERSONAL, INTERPERSONAL and SOCIAL CIRCUMSANCES Fig. (2.9). Caution concerning the use of suicide risk assessment tools. Source: Cutcliffe & Barker, 2004.

INITIAL SCREENING: BECOME AWARE OF THE WARNING SIGNS OF SUICIDE For every gatekeeper it is important to first of all be aware of the warning signs that someone is thinking of suicide. Warning signs of suicide are somewhat elusive or sometimes overt messages that a person is in trouble (The MerriamWebster Dictionary, 2016). Many signs may not appear to be concerning to the observer, but when taken together they become quite concerning. You must also be aware that sometimes there are no warning signs. Some people commit suicide without any indication that they are distressed. Those who do not leave warning signs often suffer in silence, and it is not until after they take their life that the people in their lives are able to see the stressors, but now it is too late. The following is an illustration of some warning signs that places a person at risk for suicide. As the number of warning signs increases so does the risk.

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How to Help the Suicidal Person to Choose Life 45

Warning Signs: (as adapted from Fowler, 2011; Rudd et al., 2006)

(Associated with high to very high risk as the number of Warning Signs increases. Immediate or urgent referral to ER or mental health professional is needed) ● ● ● ● ● ● ● ● ● ● ● ● ●

Expresses no reason for living and/or having no purpose Giving prized possessions away Saying good-bye to people Sudden change in mood from sad or depressed to happy Experiencing anxiety, agitation Experiencing abnormal sleep (too much or too little) Withdrawing from family, friends and others Increased substance use or excessive use of substances Expressing feeling trapped with no way out Pre-occupation with death and dying Evidence of a suicide plan Seeking access to means Threatening to harm one’s self or end one’s life

LEARN HOW TO CONDUCT A THOROUGH & FOCUSED SUICIDE RISK ASSESSMENT After becoming aware of warning signs, gatekeepers, especially those in the health professions, also need to know how to conduct a thorough and focused suicide risk assessment. Health professionals are the type of gatekeeper who are in a key position to identify people who are at risk of suicide, yet many helping professionals do not treat suicidal people on a regular basis, so it is important that they still be able to conduct a suicide risk assessment when required to do so (Schmitz, 2012). A suicide risk assessment may focus on different aspects of risk, but the key goal is to ascertain that the person is indeed in trouble and in need of intervention and further management (Perlman et al., 2011). Based on a review of the literature and recommendations according to best practices, I have compiled 11 key steps to a focused suicide risk assessment as listed below. Eleven Steps to a Focused Suicide Risk Assessment (as adapted from SuicideLine, 2016; PatientPlus, 2016; Perlman et al., 2011; Barker & Buchanan-Barker, 2005; Stephany, 2015) 1. 2. 3. 4. 5. 6.

Establish rapport by conveying empathy Make use of open-ended questions Assess for risk factors Assess for protective factors Assess for suicidal thoughts Ascertaining if there is the presence of a suicidal plan

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Be aware of any access to means Be cognizant of any prior history of suicidal behavior Document all findings Develop and implement a care plan Engage in on-going monitoring & re-assessment

We will now examine each of the aforementioned risk assessment steps individually. Step 1: Establish Rapport by Conveying Empathy A comprehensive risk assessment begins with establishing rapport and conveying empathy to the person. First and foremost avoid judging them at all costs. Nothing shuts a person down faster than judgment (Stephany, 2015). (Refer to Fig. 2.10). During the interview process, ensure that you maintain eye contact, lean forward and use a quiet, calm, patient and soft voice (SuicideLine, 2016; Stephany, 2015). But in order to gain their trust you must also convey genuine empathy and communicate that you understand what they are going through. Without empathy there can be no trust. Without trust there will not be any rapport, and the person will likely not tell you very much at all. Subsequently your efforts to accurately assess their risk will be thwarted (Perlman et al., 2011; Stephany, 2015).

A comprehensive risk assessment begins with establishing rapport, trust and conveying empathy to the person. Without empathy there can be no trust, and without trust there will not be any rapport Fig. (2.10). Suicide risk assessment begins with establishing rapport & trust. Source: Perlman et al., 2011; Stephany, 2007.

Step 2: Ask Open-ended Questions When you are starting to conduct the interview you must try and get the person to tell you as much as possible about their present situation without having to draw it out from them. That is why it is really important to ask as many open-ended questions as you can. Arnold (2011) defines an open-ended question as one that cannot be answered with one word, such as “Fine,” Yes,” or No.” It is the type of question that helps the person to tell you their story (Stephany, 2015). Begin with questions that are supportive and ones that will gain their trust. Then gently lead the person to telling you what you need to know about their suicidality. Look for responses or words used that are negative in nature concerning their specific

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situation or view of the world. Some examples of what sort of questions to ask, are given below. Examples of Open-Ended Questions to Ask (as adapted from SuicideLine, 2016) “I am not here to judge you. I want to help you. I understand that you have been having a difficult time lately. Some of my other patients have told me that when they face a lot of stress they sometimes start thinking of hurting themselves. Can you tell me in your own words what has been going on for you lately and if you have any thoughts of suicide?” “I want you to know that I am here to help you and not to judge you. I have just read the chart and I understand that things have been so bad for you lately that you have been thinking thoughts that you would rather not be alive. Please tell me the circumstances that lead to you to feel the way that you now feel?” Step 3: Assess for Risk Factors You need to be familiar with the factors associated with risk for suicide. You also need to be able to ascertain whether or not the person is coping or not coping, with what is currently going on in their life. The list below identifies many key risk factors for suicide. It is not an exhaustive list, but it does zero in on three specific areas of a person’s life that should be assessed: individual factors, sociocultural factors and situational factors. Please be advised that a suicide risk assessment is not a onetime event. It is meant to be performed as often as needed because risk fluctuates as circumstances change (SuicideLine, 2016). (Note: For a List of some recommended and commonly used suicide risk assessment tools or frameworks please refer to Appendix D). Risk Factors for Suicide (Non-Exhaustive List) (as adapted from WHO, 2012; PatientPlus, 2016; Perlman et al., 2011) Individual Risk Factors ● ●

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Previous suicide attempt Past or present Psychiatric illness (People who suffer from a mental disorder have a 5 – 15 times higher risk for suicide than those without a mental disorder) Alcohol or drug abuse Hopelessness Sense of Social Isolation Lack of Social support Aggressive tendencies Impulsivity

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History of trauma or abuse Acute emotional distress Major physical or chronic illnesses, including chronic pain Family history of suicide Neurobiological factors

Socio-cultural Risk Factors ● ●

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Stigma associated with help-seeking behavior Barriers to accessing health care, especially mental health and substance abuse treatment Certain cultural and religious beliefs (for example, a belief that suicide is the noble or honorable thing to do) Exposure to suicidal behaviours, including through the media, and influence of others who have died by suicide

Situational Risk Factors ● ● ● ● ● ● ●

Job and financial losses Relational or social losses Easy access to lethal means Local clusters of suicide that have a contagious influence Stressful life events (such as bullying or relationship break-up) War veteran Institutionalized (e.g., prison)

Step 4: Assess for Protective Factors In addition to assessing suicide risk it is important to identify and foster protective factors that may reduce or mitigate the risk of suicide. Protective factors are socio-cultural, environmental and individual factors which may reduce a person’s vulnerability to suicidal behavior (WHO, 2012). Any plan of intervention should therefore, “identify ways to establish, enhance and sustain protective factors for suicide” (WHO, 2012, p. 16). Personal Protective Factors (as adapted from SuicideLine, 2016) ● ● ● ● ●

Ability to cope with stress Effective problem solving skills Self-understanding Sense of competency Spirituality or religious beliefs

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Work Protective Factors (as adapted from SuicideLine, 2016) ● ● ● ●

Supportive work environment Positive relationships with co-workers Opportunities for Professional Development Access to employee assistance

Family Protective Factors (as adapted from SuicideLine, 2016) ● ●

Close relationship with family Sense of belonging

Community Protective Factors (as adapted from SuicideLine, 2016) ● ●

Opportunities to become involved in community endeavors Affordable and accessible and supportive community services

Step 5: Assess for Current Suicidal Thoughts You need to determine if the person is currently having suicidal thoughts and how often they are occurring. Frequent thoughts of suicide increases the person’s risk (Perlman et al., 2011). The following are useful questions to ask. Useful Questions to ask to inquire about Suicidal Thoughts (as adapted from SuicideLine, 2016) “Are you presently having suicidal thoughts?” “When did these thoughts begin?” “How often are you having these thoughts?” “Are you able to control these thoughts?” “What has stopped you from acting on these thoughts?” Step 6: Is There a Suicidal Plan? If a person has a plan in place, is prepared to die, and has been organizing the affairs of their life, they are at serious risk of suicide (SuicideLine, 2016). You may want to consider asking the following questions. Questions that Assess for a Plan (as adapted from SuicideLine, 2016) “Have you made any plans to harm yourself?”

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“Have you planned a specific method and if yes, what is it?” “When would you do it?” “How often are you thinking of your plan?” Step 7: Is There Access to Means? You need to assess whether or not the person has any access to means. If they have developed a suicidal plan, have the access to means and intend to carry their plan out, they are in extreme danger of dying. You must also consider if the person’s line of work may give them access to easy means (e.g., police officer with access to fire arms or a health care provider with access to drugs (SuicideLine, 2016). Consider asking the following questions. Questions that Explore Access to Means (as adapted from SuicideLine, 2016) “Do you have access to any means to carry your plan out?” “If given the opportunity would you carry out your plan?” Step 8: Is There Any Prior History of Suicidal Behavior? It is important to be aware if the person has any history of a prior suicide attempt and any details of a prior attempt. As previously pointed out, the biggest predictor of suicide is a previous suicide attempt (Gunnell, 2015). Inquire if the previous attempt was serious. Did they intend on not being discovered? Have they been practicing to do it ‘right’ by cutting deeper and deeper? Step 9: Document all Findings It is imperative to document a comprehensive summary of all important findings because this summary will ultimately inform plans for safety, decision making and care planning. Some of the biggest pitfalls legally have been the lack of proper documentation of suicide risk. Simon (2002) reviewed a litany of psychiatric records in litigation and found that what usually passes for suicide risk documentation is something very inadequate like the following. “Patient denies homicidal ideation, suicidal ideation and contracts for safety.” “Patient denies suicidal ideation, intent or plan.” The above sort of documentation is very insufficient (Simon, 2002). As Fig. (2.11) emphasizes, the total reliance on checklists or questionnaires without an in

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depth interview and reviewing collateral information, has also sometimes proven to be problematic in court after a completed suicide (Simon, 2002). The total reliance on checklists or questionnaires without an in depth interview and reviewing collateral information, has also sometimes proven to be problematic in court after a completed suicide Fig. (2.11). The pitfalls of relying on checklists or questionnaires. Source: Simon, 2002.

The following is an indication of the areas that should be included in documentation. Sample of Recommended Suicide Risk Assessment Documentation Topics (as adapted from Perlman et al., 2011) Document ●

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The overall level of risk along with information that supports the degree of risk as well as any type of assessment tool that was utilized. Prior history of suicide attempt(s) and self-harming behavior. Details of all potentiating risk factors, warning signs and protective factors. The degree of suicide intent. The person’s feeling and reaction following suicidal behavior. Evidence of an escalation in potential lethality or self-harm or suicidal behaviours. Similarity of the person’s current circumstances to those surrounding previous suicide attempt(s) or self-harming behaviours. History of self-harm or suicidal behavior(s) among family or friends or significant loss of family or friends.

Step 10: Develop and Implement a Care Plan Once the person’s level of risk, including immediate risk, has been established, a specific course of intervention and a care plan should be developed and implemented (Perlman et al., 2011). The plan should be to support the person’s safety and recovery and take into account protective factors that may mitigate future danger of self-harm (SuicideLine, 2016). “When warning signs are present, immediate intervention includes engaging professional mental health services, crisis supports, and/or seeking emergency mental health services” (Perlman et al., 2011, p. 69). All care plans should ideally be multi-disciplinary and include the person’s family doctor as well as developed collaboratively with the person who

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is suicidal (PatientPlus, 2016). The plan must include short-term and long-term goals and specific steps to achieve these goals, as well as crisis management strategies and how to access services when a crisis occurs (PatientPlus, 2016). Step 11: Engage in On-going Monitoring & Re-Assessment “Monitoring and re-assessment is essential at any point of transition” (Perlman et al., 2011, p. 69). Be reminded that a suicide risk assessment process is on-going and not just a one-time event (Perlman et al., 2011). There should be brief rescreening for changes in level of risk; mitigation of immediate warning signs; and the advancement or engagement of protective factors (Perlman et al., 2011). As aforementioned, research has demonstrated that people who have been discharged from hospital after an admission due to suicidal ideation or attempt, are at a high risk of committing suicide after they are released from hospital (Goldacre, Seagroatt, & Hawton, 2008). The Safety Plan is a written, prioritized list of coping strategies and resources for reducing suicide risk. It is a prevention tool that is designed to help those who struggle with their suicidal thoughts with healthy coping, helps them to establish reasons for living and identify people to call when they are in crisis (Stanley & Brown, 2016). It places the responsibility on the person who is suicidal to take responsibility for thinking through how they can cope without resorting to self-harm, which helps them to take ownership for their safety and wellness (The National Suicide Prevention Line, 2013). The patient carries the plan with them and is instructed to refer to their plan when they become stressed. A copy is also to remain on the patient record. Key Components of the Safety Plan (as adapted from Stanley and Brown, 2016; The National Suicide Prevention Line, 2013) The following are some essential elements to explore that you may want to include in the development of your safety plan. 1. Ensure that your environment is safe: Have you thought of ways in which you might harm yourself? Work with your counsellor to develop a plan to limit your access to these means. 2. Recognize warning signs: What sorts of thoughts, images, moods, situations, and behaviors indicate to you that a crisis may be developing? Write these down in your own words. 3. Use your own coping strategies – without contacting another person: What are some things that you can do on your own to help you not to act on thoughts/urges to harm yourself? 4. Identify reasons for living: These serve as anchors to help the person feel connected to the goodness in life. 5. Socialize with others who may offer support as well as a distraction from

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the crisis: Make a list of people (with phone numbers) and social settings that may help take your mind off things. 6. Contact family members or friends who may help to resolve a crisis: Make a list of family members (with phone numbers) who are supportive and who you feel you can talk to when under stress. 7. Contact mental health professionals or agencies: List names, numbers and/or locations of clinicians, local emergency rooms, crisis hotlines & carry the Lifeline number with you (1-800-273-8255). NARRATIVE CASE STUDY: WHEN A PSYCHIATRIST EXPERIENCES STIGMA Let’s now explore the lived experience of a Psychiatrist, who was admitted to hospital after being diagnosed with depression, suicidal ideation and a plan. Be reminded that this story is told from the perspective of one specific patient, and does not in any way negate the good care that is often provided to many psychiatric patients. I have been practicing as a Psychiatrist for over 20 years now and I have always considered myself to be quite a compassionate doctor. I have also been the recipient of the health care system more than once in my life time because of various physical ailments, and for the most part, the care that I received, either as an outpatient or when hospitalized, was exceptional. However, I was not treated with the same respect when I was hospitalized for major depression and suicidal ideation. You see, after the sudden death of my wife in a car accident, I found myself becoming depressed. I knew the symptoms of depression all too well. I lost all interest in things I used to enjoy. I stopped attending hockey games and stopped listening to music. I lost a great deal of weight. Food did not interest me and I had a terrible time falling asleep at night and staying asleep. I even started drinking more than usual to try and help me sleep, which made me more depressed. I avoided my friends and family because I didn’t want them to see me like this. I kept working as a Psychiatrist because it felt easier to try and help others with their problems than facing my own. Work seemed like an escape. But then something bad happened. I made a serious medication error. That was a wake-up call. I knew that I needed to get help. I confided in a colleague of mine, a reputable Psychiatrist that I had gone to Medical school with, about my situation. I admitted to him that since I made the medication error I felt like a failure as a doctor and that I started having frequent thoughts of suicide. I had even created a well thought out plan on how to end my life. My colleague and treating Psychiatrist, informed me that I needed to be admitted to hospital for treatment of my depression and especially for safety reasons. I reluctantly agreed to be hospitalized but made him promise to admit me to a hospital where no one would

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know me, and that I be admitted without them knowing I was a Psychiatrist. He arranged it all for me. I became an inpatient in an acute adult Psychiatric ward and for the first time I experienced stigma and indifference. A few of the staff were nice to me, but so many others just ignored me or seemed annoyed when I asked for something. I was pretty much left alone most of the time. I didn’t receive any individual therapy. I was encouraged to go to groups but I didn’t feel ready. When one of the nurses noticed that I was in my room crying, she told me that I needed to stop feeling sorry for myself and to “snap out of it.” This nurse’s judgment made me feel increased embarrassment and shame. I felt that being in hospital was not therapeutic at all. I begged my Psychiatrist to discharge me. After much persuading, I was discharged on a safety plan, antidepressant medication and referred to private outpatient counselling. Being in the hospital was a horrible experience. I think stigma definitely played a role. Analysis of the Case Study Two key themes surfaced from this narrative case study. Theme One: There is often a degree of personal shame associated with the idea of becoming depressed and suicidal. Theme Two: A patient’s experience of the shame associated with having a mental illness is made worse when they feel judged by their caregivers. Theme Analysis Theme One: There is often a degree of personal shame experienced by a person when they are suffering from a mental illness and the Psychiatrist in this story felt it first hand, for himself. Many negative emotions may be associated with feeling shame. Brown’s (2013) research has revealed that feelings of shame may cause a person to feel worthless, and can even result in aggravating an existing depression, result in addiction and acts of aggression, or even suicide. Dr. Klitzman (2008) who is also a Psychiatrist wrote a book called, When Doctors Become Patients. In this book Dr. Klitzman tells his own story of what it felt like to become depressed. His sister died in one of the Towers at the World Trade Center, on September 11, 2001. Following her death, Dr. Klitzman became very depressed. This is what he shared in his writings. For the first time, I fully appreciated what my patients had to undergo, and how hard it is to put the experience of depression into words. It was hard to accept that I had a mental illness. I felt weak and ashamed, and began to appreciate, too, the embarrassment and stigma my patients felt. . . . I thought that my training as a psychiatrist would help, but it was quite the

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opposite. The experience forced me to cross the border from provider to patient, and taught me how much I did not know (Klitzman, 2008, pp. 3 4).

Theme Two: In the narrative case study that we reviewed, the Psychiatrist admitted that the shame that he felt was made worse when the felt judged by his nurse. He believed that stigma played a role in how he was treated. Other patients who suffer from mental illness have reported that they felt judged by their caregivers which made them feel increased despair and enhanced their feelings of worthlessness (Betz et al., 2013; Stephany, 2007). Questions 1. What other themes stood out for you from the Psychiatrist’s story? 2. Other than what is suggested in this Chapter, can you think of innovative ways to help eliminate the stigma toward the mentally ill within the helping professions? SOMETHING TO PONDER: INCREASING SELF-AWARENESS TO REDUCE STIGMA “Without reflection, we go blindly on our way, creating more unintended consequences, and failing to achieve anything useful.” Margaret Whealtley, American writer The question must be posed, when it comes to the behavior of helping professionals, “why does mental illness elicit a ‘switch off’ of compassion rather than a promotion of empathic responding, when empathy and support are so desperately needed?” (Hinshaw, 2009, p. iv). The answer to this complex question is not entirely known. The current literature does point to the fact that stigma in the helping professions does exist, but it does not examine the clear reasons why. Perhaps this is because the research that documents the negative attitudes of mental health professionals toward the mentally ill has only recently become a focus of stigma research (Schulze, 2009). Historically, the vast majority of previous research on mental health stigma has been primarily concerned with the attitudes of the general public (Schulze, 2007; Hinshaw, 2009). International researchers even found that three quarters of the studies of mental health stigma that were reviewed, the negative beliefs of mental health providers did not differ from those of the general population and were even more negative (Schulze, 2007). Regardless of the reasons for the negative attitudes toward those suffering from mental illness, there are ways to change these attitudes.

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In addition to education, examining our attitudes and increasing tolerance are key starting points to help end the stigma within the helping professions (Schulze, 2007). Examining our attitudes begins with self-awareness. Self-awareness is the ability to recognize your emotions, beliefs, values and attitudes. Goleman (2005) also describes self-awareness as the ability to self-reflect while feeling intense emotion without reacting to that emotion in the moment. When it comes to the issue of stigma, you need to become aware of any negative attitudes and/or behaviours that you may harbor toward the mentally ill or people who are suicidal. Awareness of your negative attitudes is the first step toward changing them.

Fig. (2.12). Journal writing to increase self-awareness. Source: www.pixabay.com.

Simple Ways to Increase Self-Awareness (as adapted from Change Management Coach, 2016) 1. In order to increase self-awareness consider keeping a journal of what you are feeling. (See Fig. 2.12). Document any attitudes you may harbor. Write about why you think you feel the way that you feel. Where did those attitudes come from? Are they based on fact or prejudice? Rationale: You cannot change what you are not aware of. Therefore, the more that you know about your own habits and presumed attitudes, the easier it is to challenge them. 2. Get frank feedback from people who you know and trust on how your less than desirable behavior is perceived by others. Rationale: Sometimes other people can act as a mirror for us so we can see what others see. Often the impetus to change your behavior only occurs after you become aware that it does indeed affect others in a negative way.

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REFLECTING BACK Summary of Key Points Covered in Chapter 2 ●

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Stigma is a shameful mark or fault related to being a member of a group that is devalued by societal norms. In this Chapter we learned how stigma toward the mentally ill, and those who are suicidal, negatively impacts them. Stigma may impede access to mental health services. It can also interfere with suicide prevention because it can stop people from seeking the help that they need, including counselling. People who seek help for mental health concerns report that some of the most deeply felt stigma that they experience comes from front-line health professionals. When health professionals stigmatize they are acting without empathy and compassion and their behavior contravenes the ethic of care. Education was identified as an important way to help stop stigma, and the following five ways were presented as important to remember. 1. Having a mental disorder is not a choice, it is a treatable illness. 2. Recovery from mental illness is possible when the right treatment and supports are provided. 3. We need to make gatekeepers aware of how stigma hurts. 4. When stigma is reduced, a person with a mental illness and/or suicidal ideation experiences better health outcomes. 5. We need to listen to the stories as told by persons who have felt judged. The following three themes were identified from analysis of two patients’ lived experiences. In both cases the health professionals did not consider the person’s suicidal attempt as serious, and stigma most likely played a role. Both patients were judged as being responsible for their own injuries. No care plan was put in place upon discharge from the ER to ensure that these patients were safe. There also was no effort to ensure that they were followed-up by a mental health worker in the community for re-assessment. Gatekeepers need to learn how to differentiate between a deliberate suicide attempt and other forms of self-harm. Research has demonstrated that the strongest indicator for suicide is a previous episode of self-harm. Educating others about the lack of truth of four preconceived assumptions about suicide were presented. 1. Contrary to what some people believe, you can sometimes stop a person from committing suicide once their mind is made up. Someone who is suicidal does not necessarily want to die, they want their emotional pain to end. 2. It is not true that only people who are depressed kill themselves. Suicidal

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thoughts can happen to anyone. 3. If you talk to someone who is thinking about suicide you will not push them over the edge and make them do it. In fact, bringing the subject matter up and asking directly about what they are feeling is actually helpful. 4. Even if a person denies an intention of acting on their suicidal thoughts or plan, you can never be sure that they will not carry through with it. Therefore, you must do your best to keep them safe and direct them to help. It was emphasized that there are limitations to some suicide risk assessment tools and frameworks. Some key problems that were identified is that some tools are just too complex, too extensive and not user friendly. It was also pointed out that although assessing the degree of suicide risk is an important aspect of treatment of the suicidal person, unfortunately, unlike many diagnostic procedures that assess other relatively stable phenomenon, we do not yet possess a single test, or panel of tests that accurately identifies the emergence of a suicide crisis. Warning signs were identified as somewhat elusive overt messages that someone is in trouble. It is a good idea to be aware of the type of warning signs that are often exhibited. However, sometimes people kill themselves without warning. The following 11 comprehensive steps on how to conduct a focused and thorough suicide risk assessment were presented. 1. Establish rapport by conveying empathy 2. Make use of open-ended questions 3. Assess for risk factors 4. Assess for protective factors 5. Assess for suicidal thoughts 6. Ascertaining if there is the presence of a suicidal plan 7. Be aware of any access to means 8. Be cognizant of any prior history of suicidal behavior 9. Document all findings 10. Develop and implement a care plan 11. Engage in on-going monitoring & re-assessment Research has demonstrated that people who have been discharged from hospital, after a suicide attempt are at a high risk of committing suicide. Therefore, a Safety Plan should ideally be in place for any suicidal person who has been discharged from hospital, released from the ER or is going on a day pass. The Safety Plan was defined as a written, prioritized list of coping strategies and resources for reducing suicide risk. Two key themes were identified from the narrative case study of a psychiatrist who was admitted to hospital with depression, suicidal ideation and a plan. There is often shame associated with the idea of becoming depressed and

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suicidal, and a patient’s experience of shame can be made worse if they feel judged by their caregivers. Two ways were recommended to increase self-awareness as a technique to help to reduce stigma. Keep a journal in order to become aware of any negative attitudes that you may harbor. Obtain constructive feedback from people that you know on how you may be acting in a less than desirable ways toward others.

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CHAPTER 3

Preventing and Treating Mental Illness & Understanding the Mindset of the Suicidal Person Abstract: Chapter three pointed out that there is a significant connection between suicide and a diagnosis of mental illness and/or addictions. In fact the risk of suicide in people who are suffering from a mental disorder is five to 15 times higher than for people without a co-existing mental disorder. The degree of suicide risk associated with some specific diagnoses was presented first, followed by strategies to address early diagnosis and treatment. We are made aware of the fact that the WHO recommends that every country develop a national strategy for suicide prevention that includes provisions for early diagnosis and treatment of persons suffering from mental illness. Six specific strategies were recommended to address the global shortfall in mental health and addictions services. Psychache, or a mindset of unbearable emotional pain was determined to be a necessary condition for suicide to happen. Constriction of thought often accompanies psychache. The Strain Theory of Suicide was used to explain how psychache is preceded by specific types of psychological stressors. These stressors actually pull a person in conflicting directions that contribute to their hopeless despair. The lived experience of a suicidal person was examined in order to gain a clearer appreciation of the degree of their psychological pain. The following three specific ways were proposed to help the suicidal person to move past a death focused mindset. Attempting to understand their psychological pain fosters connection through empathy. Challenging their constricted thought patterns may help them to choose a coping mechanism other than death, and so will assist them to change the ending of their story from death to life. As an aspect of a psychological autopsy, the contents of a suicide note was examined and two key premises surfaced. The suicide note left clues to the person’s experience of psychache. It also revealed their plea for understanding. In short, fostering resiliency was proposed as another way to help prevent suicide.

Keywords: Addictions, Affective disorders, Anxiety disorders, Behavior disorders, Constriction of thought, Empathy, Mental illness, Mental wellness, Narrative Action Theoretical Approach, Personality disorders, Psychache, Psychological autopsy, Psychological pain, Resiliency, Schizophrenia, Strain Theory of Suicide, Substance-related disorders, Suicide note, Understanding.

Kathleen Stephany All rights reserved-© 2017 Bentham Science Publishers

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LEARNING GUIDE After Completing this Chapter, the Reader Should be Able to: ●

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Be cognizant of the fact that there is a significant connection between suicide and a diagnosis of mental illness and/or addictions. Be able to identify the suicide risk associated with certain types of mental disorders. Be aware that the WHO recommends that every country develop a national strategy for suicide prevention that includes provisions for early diagnosis and treatment of persons suffering from mental illness. Realize that mental health is more than the absence of illness. Describe six strategies that are recommended to address the global shortfall in services for mental health and addictions. Define psychache. Be aware that psychache is a necessary condition for suicide. Describe what is meant by constriction of thought. Explain what the Strain Theory of Suicide proposes. Explore themes from the lived emotional experience of a person who is despondent. Become aware of three specific ways to help the suicidal person to move past a death focused mindset. Review the contents of an actual suicide note in order to identify themes. Give reasons why fostering resiliency can help prevent suicide.

Overview of Chapter 3 Fig. (3.1), is a word conundrum. It is meant to create a sense of curiosity about what lurks in the mind of the suicidal person. Chapter three attempts to address this important query. Is it depression? Is it hopelessness, a lack of joy in life, emotional angst or something else? The chapter begins by pointing out that there is a significant connection between suicide and a diagnosis of mental illness and addictions (Shneidman, 1998; Troister & Holden, 2010; Klott, 2012). The degree of suicide risk associated with some specific diagnoses is presented. Specific strategies are proposed to address early diagnosis and treatment of mental illness and addictions, and to promote increased mental wellness. Supportive rationale for these suggested policies is included (WHO, 2012; MHCC, 2012).

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Fig. (3.1). Image: Word Conundrum & suicide mindset. Source: www.pixabay.com.

Although the factors that contribute to someone having suicidal thoughts is multidimensional, in almost every case of suicidal ideation, with or without a diagnosis of mental illness or addictions, emotional pain or distorted psychological needs are paramount (Shneidman, 1993; Shneidman, 1998). Therefore, chapter three also explores the mindset of the suicidal person and identifies specific ways to help them. THE IMPORTANCE OF EARLY DIAGNOSIS AND TREATMENT OF MENTAL ILLNESS & ADDICTIONS Suicidal thoughts can happen to anyone, and suicide is more highly correlated with hopelessness than with depression (Shneidman, 1998 as cited in Stephany, 2007). However, there is a significant connection between suicide and a diagnosis of mental illness (Shneidman, 1998). In fact, the risk of suicide in people who are suffering from a mental disorder, is five to 15 times higher than for people without a co-existing mental disorder (PatientPlus, 2016). “It is estimated that 90% of people who die by suicide experience depression, another mental health illness, or a substance use disorder, all of which are potentially treatable” (Institute of Marriage and Family Canada, 2009 as cited in Moore & Melrose, 2014, pp. 509 – 510). “In Canada, in 2009 – 2010, approximately seven in ten hospitalizations for self-harm included a mental health diagnosis” (Moore & Melrose, 2014, p. 510). Therefore, prevention strategies need to focus on better management of underlying mental illnesses, especially early diagnosis and treatment (Shneidman, 1998; MHCC, 2012; Klott, 2012; Troister & Holden, 2010; Gunnell, 2015). The list that ensues breaks down the percentages of

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hospital admissions for self-harm in relation to specific psychiatric diagnoses. Note that people who suffer from affective disorders, such as depression or bipolar disorder, present with the highest percentage of self-harm resulting in hospitalization. It is also important to be aware that often people who are suicidal can experience symptoms of more than one mental disorder and may also be simultaneously abusing substances. Percentage of Hospital Admissions For Self-Harm (as adapted from the Canadian Institute for Health Information, 2011 as cited in Moore & Melrose, 2014, p. 511) Affective Disorders (e.g. major depression & bi-polar disorder) 23% Substance-related disorders 12% Anxiety disorders (including Post Traumatic Stress Disorder) 11% Disorders of personality and behavior 6% Schizophrenia 3% Multiple mental-health related diagnoses 14% “Mental and substance use disorders are proven risk factors for suicide” (WHO, 2012, p. 19). However, there is a global shortage of mental health professionals and inadequate service provisions, leaving these persons untreated and subsequently more vulnerable to death by suicide (WHO, 2012). What is so needed is that every country has a national strategy for suicide prevention that includes provisions for the early diagnosis and treatment of persons suffering from a mental disorder or addictions (WHO, 2012). (See Fig. 3.2). Note that Canada does not yet have a national strategy for suicide prevention (MHCC, 2012). The WHO recommends that every country develop a national strategy for suicide prevention that includes provisions for early diagnosis and treatment of persons suffering from mental illness Fig. (3.2). Every country needs a national strategy for suicide prevention. Source: WHO, 2012.

However, if we want to do a better job of preventing suicide we need to do more than just treat mental illness and addictions. We must adopt the goal of striving to achieve increased mental wellness for all members of society. As so poignantly

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stated by MHCC (2012), mental health is much more than just the absence of mental illness. Mental health is different from the absence of mental illness, and it is integral to our overall health. Mental health is a state of well-being in which the individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his own community . . . . Good mental health buffers us from the stresses and hardships that are part of life for us all, and can help to reduce the risk of developing mental health problems and illnesses (MHCC, 2012, p. 11).

Strategies to Address the Global Shortfall in Mental Health & Addiction Services: (as adapted from WHO, 2012; MHCC, 2012; Schmitz, et al., 2012) The following strategies are specific recommendations to address the global shortfall in mental health and addictions services and to promote increased mental wellness. 1. Emphasize the need to integrate mental health services into primary health care. Rationale: Oftentimes mental health services are isolated and not as easy to access as other physical aspects of health care. 2. Draw attention, when needed, to a lack of mental health services. Rationale: Admitting that a problem does exist in the delivery of some health care services is the first step toward changing it. 3. Promote mental health across the lifespan in homes, schools, and workplaces in order to prevent mental illness. Rationale: Reducing the incidence of mental illness begins with community efforts aimed at health promotion and health preventative efforts. 4. Highlight the need to regularly educate primary health providers, about key components of suicide prevention such as: identification, management, support and referral of suicidal individuals in communities. Rationale: The training of mental health gatekeepers who frequently assess and care for people who are suicidal is often limited. 5. Foster recovery and well-being for people of all ages living with mental health problems and illnesses. Rationale: The key to recovery is eliminating discrimination and helping people of all ages to access services that can assist them to function at a healthier level. 6. Provide access to the right combination of services, treatments and supports, when, and where people need them.

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Rationale: A full range of services needs to include preventative care, primary health care, community based care and specialized mental health services. The Strategies to address the global short fall in mental health services are summarized in Fig. (3.3).

Emphasize the need to integrate mental health services into primary health care Draw attention, when needed, to a lack of mental health services

Promote mental health across the lifespan

Highlight the need to regularly educate primary health providers, about key components of suicide prevention

Foster recovery and well-being for people of all ages living with mental health problems Provide access to the right combination of services, treatments and supports, when, and where people need them

Fig. (3.3). Specific strategies to address mental health and addictions. Source: WHO, 2012; MHCC, 2012; Schmitz, et al., 2012.

PSYCHACHE AS A NECESSARY CONDITION FOR SUICIDE Shneidman (1993) has long asserted that the causes of suicidal ideation, or thoughts of wanting to end one’s life, are complicated and non-linear. He stressed that suicidal thoughts can be related to a biochemical imbalance in the brain as proposed by psychiatrists. As some psychologists believe, suicidal ideation can also be triggered by rage toward oneself that is misdirected. Suicidal thoughts may also be associated with psychosocial stressors and/or recent loss (Shneidman, 1993; Shneidman, 1998). However, in addition to the many aspects that may affect a person’s inclination to want to end their life, what Shneidman’s work emphasized, was the fact that there is a key factor that must not be ignored when we are considering suicide prevention. That crucial component is the negative mindset of the suicidal person. “Those who are suicidal . . . often feel worthless with emotional impoverishment and loss of self-esteem” (Pompili, 2015, p. 227). Social isolation, and feelings of loneliness and hopelessness are also very prevalent (Cutcliffe & Stevenson, 2007; Shneidman, 1998). Shneidman (1993)

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referred to the desolate and severely emotional, psychological pain that is experienced by the suicidal person as “psychache.” According to Shneidman (1993) psychache consists of the “hurt, anguish, soreness, aching, psychological pain in the mind,” that the person finds intolerable (p. 145). Even though depression and/or hopelessness are strong predictors of suicide, Shneidman (1993) also insisted that neither one of these experiences in isolation is able to either account for, or predict suicide. As proposed by Shneidman (1993), psychache is a necessary condition for suicide to happen. Other researchers have tested Shneidman’s assertions and found similar results. For example, “depression, hopelessness and psychache are all statistical predictors of suicide ideation, suicide preparation and suicide motivation. Psychache, however, is consistently the strongest indicator of suicidality” (Troister & Holden, 2010, p. 692). (Refer to Fig. 3.4). Even though depression and/or hopelessness are strong predictors of suicide, psychache is a necessary condition for suicide to happen Fig. (3.4). Psychache and suicide. Source: Shneidman, 1993; Troister & Holden, 2010.

PSYCHACHE & CONSTRICTION OF THOUGHT Shneidman (1993) further explained that a person’s psychache, or their perception of their emotional pain, is so unbearable for them that their desire to end that pain through imminent death, is viewed by them as their only solution. Shneidman (1998) described this narrowing of thinking that is focused only on death, as constriction of thought. “In suicide, the diaphragm of the mind narrows and focuses on the single goal of escape, to the exclusion of all else – parents, spouse, children” (Shneidman, 1998, p. 60). Shneidman (1998) further explains that it is not that these other significant people in the suicidal person’s life do not matter, it is just that they no longer fit into the picture that only focusses on their death. No other solution to their pain is considered. Everything else is excluded (Shneidman, 1998). Shneidman (1998) describes constriction of thought as often characterized by the word, “only.” For example, phrases like the following are often included in their sentences. “The only way out.” “There is only one thing left to do.” “There is only way to get away from it all.” THE STRAIN THEORY AND PSYCHACHE What is worthy of noting is that although psychache is a major factor in suicide, Shneidman was unable to identify what exactly causes such emotional pain and

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hopelessness in the individual (Zhang, 2016). Zhang (2016) proposed that a Strain Theory of Suicide is able to explain that psychache and ensuing suicide is usually preceded by specific types of psychological stressors. These strains usually consist of two or more variables that, “pulls or pushes an individual in different directions, so as to make the individual frustrated, upset, angry,” or feel intense psychological pain (Zhang, 2016, p. 171). As Fig. (3.5) emphasizes, at least one of the following conflicting stressors must be present to constitute a psychological strain: conflicting cultural values; a discrepancy between a person’s goals and the reality of not being able to achieve them; comparing one’s status to that of another who is more successful; and a crisis accompanied by an inability to cope (Zhang, 2016). The person who is experiencing psychological strain seeks to find a solution to reduce or eliminate their stress. “The extreme solution for an unsolved strain is suicide” (Zhang, 2016, p. 171). THE STRAIN THEORY & TYPES OF STRESSORS THAT PRECEDE SUICIDE:

Conflicting cultural values

A discrepancy between a person’s goals and the reality of not being able to achieve them

Comparing one’s status to that of another who is more successful

A crisis accompanied by an inability to cope

Fig. (3.5). Strain theory and stressors. Source: Zhang, 2016.

THE LIVED EXPERIENCE OF PSYCHACHE A man, we will refer to as Peter, was admitted to hospital after a serious suicide attempt. What ensues is an excerpt from an interview between Peter and his Psychiatrist, where Peter describes what his experience of emotional pain was like for him.

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Peter:I am living in a personal hell. Everything is hopeless. My wife of 10 years left me and took our only child with her. She has also filed for divorce. I lost my job because of heavy drinking and soon I will be evicted from my apartment because I cannot pay my rent. I brought all of this onto myself. It is all my fault. Lately I have been in this dark place where I constantly think of dying. I kind of feel a bit of an emotional release now that I have decided what it is I must do. There is only one way for me to fix this whole mess. I have to die and I have a plan. I love my daughter but she is better off without me. My brother will be devastated by my death but he can’t make this better for me. I never deserved any of them in the first place. There definitely is only one way out of my emotional hell, and that is for me to end it all. Analysis of Peter’s Experience A key theme surfaced. Theme: Peter experienced psychache that was characterized by constriction of thought. Theme Analysis Theme: Peter’s experience of psychache was depicted by everything that Shneidman (1998) proposed. The focus of his thinking was narrow and constricted. He was pre-occupied with dying, and death was viewed by him, as the “only” solution to his problems. Even the child that he loves no longer fits into the picture. Peter’s experience was characterized by two variables that totally frustrated him and caused him to feel hopeless. Peter was in a crisis and he was unable to cope with his tragic predicament (Zhang, 2016). This was consistent with the Strain Theory of Suicide. MOVING THE SUICIDAL PERSON BEYOND A DEATH FOCUSED MIND SET Three specific ways to help the suicidal person move past a death focused mindset are proposed. Attempting to understand their psychological pain fosters connection through empathy. Challenging their constricted thought patterns may help them to choose a coping mechanism other than death (Shneidman, 1998; Pompili, 2015; Stephany, 2015). Assisting them to change the ending of their story from death to life is also beneficial (Stephany, 2007). Empathy as Means to Foster Connection Empathy acts as a means to foster connection with the suicidal person (Stephany, 2015). Shneidman (1998) explains that the person who is suicidal and who is

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experiencing psychache does not want to necessarily die. They so desperately want their psychological pain to end, yet they see death as their only option to ending that pain. He advises that if we truly want to help the person we must first seek to genuinely understand what it is like to be going through what they are experiencing. In this manner empathy acts as a means to connect with them and make them feel understood (Shneidman, 1998; Pompili, 2015; Stephany, 2015). I asked one of my patients who had experienced suicidal ideation in the past for advice on how a health professional could be more understanding and empathetic. Her response was, “Make my time with you all about me and listen to my story. Don’t judge me or try to fix anything. Don’t interrupt. Be quiet and just listen to me so that I will feel like I actually matter to you.” As Fig. (3.6) demonstrates, the most sincere forms of respect that we can show to another person, especially someone who is emotionally distraught, is to listen to what they have to say. Rosenberg (2003) when speaking about the power of empathy pointed out that when a person has been listened to and when they feel heard, they are often better able to see their world in a new way and go on. Problems that seemed “irremediable turn into relatively clear flowing streams when one is heard” (Rosenberg, 2003, p. 113). (Chapter Four will demonstrate specific strategies to cultivate empathy).

Fig. (3.6). Empathy & listening. Source: www.google.ca.

Challenging a Patient’s Constricted Thought Patterns A second way to help a suicidal person is to gently challenge the constriction of their thought patterns. The image in Fig. (3.7) is a tunnel which symbolizes the narrowed vision of the suicidal person who views death as their only option. In order to break the spell this constricted thought pattern has to be challenged.

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However, this process should only be undertaken by a highly trained and qualified health professional.

Fig. (3.7). Tunnel vision. Source: www.pixabay.com.

Take a few minutes to review the lived experience of psychache as revealed to us in the story about Peter. If Shneidman (1998) were given the opportunity to offer Peter counselling prior to his death he may have challenged Peter’s thought patterns in the following manner. Once he had ensured that he had acquired his patient’s trust, Shneidman (1998) would likely have generated a list of alternatives and present these choices to Peter. Shneidman would have likely posed the following type of questions to help to get Peter to open up his thinking. The whole idea is to get the Peter to explore even one option other than death by suicide. “You could join Alcoholics Anonymous (AA) to help you stop your drinking.” “You could arrange to stay with a friend for a short while if you get evicted from your home.” “You could apply for unemployment insurance (UI) or welfare to keep you going until you get a new job. UI will even offer to re-train you.” “You could reach out to your brother whom you speak so highly of. You told me he would be devastated if you died.” “You could arrange to see your daughter. You have told me how much you love her. She needs a father who is alive. If you end your life by suicide your daughter will be forever scarred. Do you want to do that to her?”

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Helping The Suicidal Person to Change the Ending of Their Story: “You must have control of the authorship of your own destiny. The pen that writes your life story must be held in your own hand.” Irene C. Kassorla, Author

A type of therapy that has been utilized to help a suicidal person to open the lens of their constricted thinking, and to choose life over death, is called the Narrative Action Theoretical Approach. With the Narrative Action Theoretical Approach the therapist encourages the person who is suicidal, to tell the story of why it is they have decided to end their life. They then encourage the person to change the ending to their story and to choose life. Active compassionate listening by the therapist, in conjunction with empathetic understanding, “conveys hope to the patient, that suicide is not the only alternative. Choosing life becomes a viable ending to their story” (Stephany, 2007, p. 58). A PSYCHOLOGICAL AUTOPSY: WHAT A SUICIDE NOTE CAN TEACH US ABOUT THE EXPERIENCE OF PSYCHACHE We will now review the contents of a suicide note left by a man, whom we will refer to as Howard. “The suicide note is a vehicle by which the decedent can have the last word. This mechanism allows the decedent to explain, to bring closure (or not), to assuage guilt, to dictate next steps, to control, to absolve or blame” (Shneidman, 2004, p. 12). The material contained in this particular suicide note was one aspect of a psychological autopsy that was conducted after Howard chose to end his life. Some background is needed to put the suicide note into context. Howard was a married, 55 year-old man, who suffered from bouts of depression during the course of his life. Howard had worked as a very successful engineer and he was also a respected member of his community. Howard had recently lost his job because the company that he worked for was sold. The new owners wanted to downsize and told Howard that he was too expensive to keep on. Howard was unable to find a new job that paid the equivalent to what he had earned previously. He became depressed, his depression grew worse, and because of feelings of profound hopelessness and shame, he refused to get professional help. I am in so much pain. I cannot endure it any longer. It is not just the loss of my job that has caused me to be so sad, it is the loss of being someone who mattered. I am no one now. I have no purpose. There is no point in going on. I cry and then I feel nothing. I feel like the sadness is drowning me and I cannot breathe. I look in the mirror. All I see a loser, someone others once admired. My face looks dark and empty. I am already dead inside. Please do not mourn me when I am gone. Isabelle, you will still have a good life without me. You are better off without me.

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You deserve to find someone else who you can admire. A real man, not a loser like me. I have made sure that there is lots of money in the bank. I just cannot do this anymore. Please do not hate me. I already hate myself beyond what I can explain. I just so desperately need to feel peace. I need to end this pain that is my hell. Death is my only refuge. Remember that I do love you. Analysis of Howard’s Suicide Note Two key themes surfaced. Theme One: The suicide note left clues to Howard’s experience of psychache. Theme Two: Howard was pleading for understanding. Theme Analysis Theme One: The descriptive words in the suicide note eluded to Howard’s experience of psychache. He spoke of how the sadness was drowning him and how he so desperately needed the intolerable pain to end. Constriction of thought was also evident toward the end of the note where he spoke of dying as his only refuge. Theme Two: In this note Howard somehow wants to be understood, especially by his wife. Not unlike other pleas seen in suicide notes, “he tells us how badly he hurts; asks us to understand his need for respite and peace of mind” (Shneidman, 2004, p. 8). SOMETHING TO PONDER: FOSTERING RESILIENCY What stood out for me about Howard’s story, was his feeling of not being good enough after he had lost his job. Howard’s self-esteem was very closely aligned with his career success. Like so many other people, losing his job caused him to experience an identity crisis accompanied by a feeling of worthlessness and a lack of resiliency. Resiliency was briefly introduced in Chapter one. Resiliency refers to a person’s optimistic set of assumptions about themselves that in turn influences their mindset, their responses to life’s stressors and their ability to cope in an affirmative manner to those stressors (Brooks & Goldstein, 2003). A resiliency mindset does not mean that a person is stress free, rather it refers to their capacity to cope in healthy ways when problems do arise (Brooks & Goldstein, 2003). Fig. (3.8) consists of a list of some of the characteristics of a resilient mindset.

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Characteristics of Resilience* Internal locus of control Strong self-esteem, self-efficiency Have personal goals Sense of meaningfulness Can use past successes to confront current challenges Can view stress as a challenge/way to get stronger Use humor, patience, tolerance, and optimism Can adapt to change Action-oriented approach Have strong relationships and ask for help Have faith

Fig. (3.8). Characteristics of Resilience. Source: www.google.ca.

If we want to do more to prevent suicide we have to do what we can to enhance people’s resiliency. Our patterns of thinking, either positive or negative, are formed as a part of our childhood and our interpersonal relationships. If our relationships to our significant others “permit flexibility and change, they represent the building blocks of positive scripts and should be repeated” (Brooks & Goldstein, 2003, p. 23). Children are also taught that mistakes are not failures, but opportunities to learn and grow (Goleman, 2005). This type of confident upbringing is conducive to promoting enhanced resiliency. However, if the way in which are taught to view ourselves in the world is negative, critical and self-defeating, we believe these negative scripts about ourselves as being our true nature. Errors in judgment are viewed as character flaws that cannot be changed (Goleman, 2005). “Negative scripts serve as powerful obstacles to a resilient lifestyle” (Brooks & Goldstein, 2003, p. 24). The good news is that negative scripts can be changed when the right help is given. REFLECTING BACK Summary of Key Points Covered in Chapter 3 ●

It was pointed out that there is a significant connection between suicide and a diagnosis of mental illness.

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In fact, the risk for suicide for people who are suffering from a mental disorder is five to 15 times higher than for people without a mental disorder. Prevention strategies need to focus on better management of underlying mental illnesses. The WHO recommends that every country develop a national strategy for suicide prevention. Mental health was identified as being much more than just the absence of mental illness. It consists in the ability of a person to cope with the normal stresses of life and to make a contribution to their community. Mental wellness is also known to buffer people from developing mental health problems. The following six strategies were recommended to address the global shortage of services for mental illness and addictions. 1. Emphasize the need to integrate mental health services into primary health care. 2. Draw attention to a lack of mental health services. 3. Promote mental health across the life span. 4. Highlight the need to regularly educate primary health providers, about the key components of suicide prevention. 5. Foster recovery and well-being for people of all ages. 6. Provide access to the right combination of services, treatments and supports where they are needed. Psychache was described as severe emotional and psychological pain that is experienced as intolerable by a person who is experiencing suicidal thoughts. Even though depression and/or hopelessness are strong predictors of suicide, psychache was identified as a necessary condition for suicide to happen. Constriction of thought that is narrow and focused only on death often accompanies psychache. The Strain Theory of Suicide identified that psychache and ensuing suicide, is usually preceded by specific types of psychological strains. The following types of stressors pushes and pulls a person in different directions and causes them severe distress. 1. Conflicting cultural values. 2. A discrepancy between a person’s goals and the reality of not achieving them. 3. Comparing one’s status to that of a more successful person. 4. A crisis accompanied by an inability to cope. The lived experience as shared by a suicidal person demonstrated how psychache is characterized by constriction of thought that views death as the only option. Three specific ways were proposed to help a person who possesses a death focused mindset.

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1. Attempting to understand their psychological pain fosters connection through empathy. 2. Challenging their constricted thought patterns may help them to choose a coping mechanism other than death. However it was pointed out that this strategy must only be used by a trained and qualified professional. 3. Assisting them to rewrite the ending of their story through the Narrative Theoretical Approach. A suicide note was identified as a vehicle by which the decedent can have a last word. The contents of an actual suicide note was examined and revealed two themes. 1. The suicide note left clues to the person’s experience of psychache. 2. The person was pleading with their loved one for understanding. Resiliency was described as a person’s optimistic set of assumptions about themselves that in turn influences their mindset, their responses to life’s stressors and their ability to cope. If we want to do more to prevent suicide we have to do more to enhance people’s resiliency.

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CHAPTER 4

The Ethic of Care & Empathy as a Tool for Helping the Suicidal Person Abstract: In chapter four we became aware that people who are experiencing suicidal thoughts feel especially alone in their experience. If we can help them to know that we genuinely care about them and their situation, we may be able to convince them that their life matters. This is the essence of the ethic of care in action. Empathic responses, in the form of validating another’s experience, can also save lives. Specifically, in the hopeless patient, increased hope is instilled if they feel understood and cared for by their physician or nurse. Explicit aspects of the ethic of care and empathy were identified as a means to help the suicidal person to choose life. These strategies include: establishing connection, fostering a therapeutic alliance, offering unconditional positive regard, heartfelt listening, presencing and compassion. It was pointed out that trust can sometimes be severed in the emergency room (ER) when someone presents with a suicide attempt. For example, suicidal persons are often not even considered as real patients because they are not injured or ill. Key aspects of The Guidelines for Clinicians developed by The Aeschi Working Group of suicidologists were reviewed. These guidelines emphasized the significance of the therapeutic alliance between the clinician and patient. They highlighted the importance of offering empathy and of being non-judgmental and placed the patient’s story as a priority over clinical expertise. We also learned that after a suicide attempt has occurred there is often a window where a patient can be reached. A touching narrative case study was reviewed where we discovered how a total stranger helped a suicidal youth through an act of compassion. A psychological autopsy followed this story and assisted us in gaining a retrospective view of what went wrong in the ER and why. Key themes emerged. The patient experienced the narrow constriction of thought associated with psychache. The ER physician admitted that she did not receive adequate training in suicide risk assessment. The patient reported that he did not feel cared for by the professionals in the ER, and prior to the patient being discharged no care plan was put in place to ensure that they would be safe. We learned that after the initial suicidal crisis has subsided, Cognitive Therapy may help the person to find a sense of purpose and meaning in their life. A dynamic simulation exercise was recommended to help gatekeepers practice being empathetic with a suicidal patient. The role play encouraged the use of both non-verbal and verbal empathic communication skills. At the end of the chapter, caregivers were encouraged to make empathy a habit through the act of journaling to increase self-awareness.

Keywords: Care plan, Clarification, Cognitive Therapy, Cognitive Behavioral Therapy, Cognitive re-structuring, Compassion, Connecting, Constriction of Kathleen Stephany All rights reserved-© 2017 Bentham Science Publishers

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thought, Coping cards, Empathy, Exquisite empathy, Journaling, Listening, Listening stoppers, Mindful listening, Non-verbal communication skills, Open-ended question, Para-phrasing, Presencing, Psychache, Role play, Safety Plan, Self-awareness, Simulation, The Aeschi Working Group, The ethic of care, The International Association for Suicide Prevention (IASP), Therapeutic alliance, Trust, Unconditional positive regard, Validation, Verbal communication skills.

LEARNING GUIDE After completing this Chapter, the Reader Should be Able to: ● ● ● ● ● ●

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Learn how the ethic of care and empathy can help the suicidal person. How the ethic of care promotes a web of connection. Define exquisite empathy. Explain how empathy helps a suicidal person to choose life. Compare helpful verbal responses with ones that are not helpful. Become familiar with specific components of the ethic of care and empathy that are beneficial to utilize when trying to help the suicidal person. Explain what often happens in the Emergency Room (ER) after a patient attempts suicide. Be able to summarize key aspects of The Aeschi Working Group of suicidologists’ Guidelines for Clinicians. Be aware that after suicide attempt there is often a window where patients can be reached. Explore themes from the Narrative Case Study: An Act of Compassion. Review the results of a psychological autopsy in order to learn what could have been done differently. Understand the importance of referring a patient to Cognitive Therapy after a suicidal crisis has subsided. Practice utilizing both non-verbal and verbal empathetic communication skills in a simulation role play. Make empathy a habit through journaling to increase self-awareness.

Overview of Chapter 4 All human beings, may experience vulnerabilities at some time during the course of their journey through life (Klitzman, 2008). When the trials and tribulations hit, many people will likely require a caring person or professional to assist them during such trying times. The suicidal person as one such individual in crisis, is especially in need of our care (Stephany, 2015). In Chapter Four the ethic of care and empathy are presented as the means to communicate to the suicidal person that we genuinely care for them and want to help them out of their place of hopeless despair. (See Fig. 4.1).

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All human beings may experience vulnerabilities at some time during the course of their journey through life. When the trials and tribulations hit, many people will likely require a caring person or professional to assist them during such trying times. The suicidal person as one such individual in crisis, is especially in need of our care Fig. (4.1). Caring for the suicidal person. Source: Klitzman, 2008; Stephany, 2015).

In this current chapter, specific components of the ethic of care and empathy are presented as an actual tool for suicide intervention. These include, establishing connection, fostering a therapeutic alliance, offering unconditional positive regard, heartfelt listening, presencing and compassion. Key aspects of The Aeschi Working Group of suicidologists’ Guidelines for Clinicians will be reviewed. A touching narrative case study is presented where we learn how a total stranger helped a suicidal girl through an act of compassion. A psychological autopsy follows this story and assists us in gaining a retrospective view of what went wrong in the emergency room (ER) and why. Near the end of the Chapter, Cognitive Therapy is recommended once a suicidal person’s initial crisis has subsided. A dynamic simulation exercise is then presented in two parts to help gatekeepers practice being empathetic with a suicidal patient. In closing, caregivers are encouraged to practice empathy in their daily round through the act of journaling to increase self-awareness. THE ETHIC OF CARE AS THE WEB OF CONNECTION The ethic of care is multi-dimensional and values our relationships to others, context, a sense of community and our interconnectedness (Gilligan, 1982; Noddings; 1984; Watson, 2008). The ethic of care also admonishes us to attend to the needs of all other persons, including those in our direct care as well as everyone else, even those we do not know (Noddings, 1984; Slote, 2007). In fact, caring for one another is not depicted as a nicety, it is portrayed as a necessity for the survival of all humans. For example, if we do not care about everyone we will not take moral action to help those who are in need, or to preserve life (Noddings, 1984; Slote, 2007). In fact the ethic of care promotes a web of connection that is inclusive of everyone and excludes no one (Gilligan, 1982; Stephany, 2012). In Fig. (4.2), a pair of caring hands embraces a mosaic globe that is symbolic of how the ethic of care in inclusive of everyone. It does not matter whether or not our belief system aligns with that of other people, or what their status is in life, or whether or not they have made good life choices. Everyone is worthy of our care because they are fellow human beings (Stephany, 2007). We know that people

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who are experiencing suicidal thoughts feel especially alone in their experience. The ethic of care encourages us to help the suicidal person to understand that we genuinely care about them, their situation and their psychological pain, and that we want to do whatever we can to help them (Stephany, 2015). (Refer to Fig. 4.3).

Fig. (4.2). Image: The Ethic of Care excludes no one. Source: www.pixabay.com.

The ethic of care encourages us to help the suicidal person to understand that we genuinely care about them, their situation and their psychological pain, and that we want to do whatever we can to help them Fig. (4.3). The Ethic of Care & the Suicidal Person. Source: Stephany, 2015.

EMPATHY AS A KEY COMPONENT OF THE ETHIC OF CARE Empathy is a key component of the ethic of care and consists of the ability to relate on an emotional level to the experience of another person and includes identifying with all emotions experienced by another person, either happy or sad (Stephany, 2015). “Virtually every approach to psychotherapy or counseling acknowledges the importance of empathy” (Walsh, 2008, p. 72). Although empathy is a complex multidimensional concept, the key is that it involves the action of a person attempting to understand the world from the patient’s perspective. An empathetic approach when providing care to patients has been associated with better patient outcomes (William & Stickley, 2010). For example,

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patients who feel empathy emanating from their care provider report decreased anxiety. Furthermore, a review of thousands of studies over the past 60 years discovered that better client outcomes are much more closely tied to specific attributes of the caregiver and less so with any specialized therapeutic techniques (Lambert & Simon, 2008). Those studies have identified empathetic responses as most important (Lambert & Simon, 2008). Carl Rogers, a well-known 20th century Psychologist, is credited as one of the key contributors to the definition of empathy as applied in therapy. The following excerpt is from one of Rogers’ original works and is a powerful explanation of what empathy consists of. The state of empathy, or being empathic, is to perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person, but without ever losing the “as if” condition. Thus it means to sense the hurt or the pleasure of another as he senses it and to perceive the causes thereof as he perceives them, but without ever losing the recognition that it is as if I were hurt or pleased and so forth. If this “as if” quality is lost, then the state is one of identification (Rogers, 1957, pp. 210 – 211).

Rogers emphasizes the importance of the caregiver never losing site of the fact that they must identify with the other person’s experience but that they remain somewhat separate from it. For example, if we get completely lost in another’s suffering we will not be able to help them. Today we refer to this therapeutic strategy as exquisite empathy, where the practitioner identifies with the patient’s feelings, but is also able to stay separate from their patient’s suffering. The caregiver intentionally chooses to remain in the present moment, and in doing so, does not take on their patient’s emotional pain (Kearney & Weininger, 2011). It takes conscious effort to learn how to develop exquisite empathy, most notably by practicing increased self-awareness. (Note that at the end of Chapter Four, selfawareness strategies will be re-introduced). Offering Empathy as a Means to Help the Suicidal Person to Choose Life Before proceeding, an important question is worthy of being repeated. What is the specific role of empathy in helping the suicidal person to choose life over death? Konrad (2011) proposes that empathic action in the form of validating another’s experience can save lives. Specifically, in the hopeless patient, increased hope is instilled if they feel understood and cared for by their physician or nurse (Williams & Stickley, 2010). However, the opposite is also true. Suicidal persons are very sensitive to rejection by their caregivers (Langille, 2014; Betz et al., 2013; Stephany, 2007). According to neurobiological research, a lack of empathetic responses from a care giver dehumanizes patients and makes them feel objectified (Reiss, 2010).

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The North Sydney Department of Health (2004) found that once a person has been assessed as at risk for suicide offering empathy was identified as a crucial task in helping to prevent a completed suicide. Pompili (2015) also points out that, because suicidal thoughts are closely tied to a feeling of hopelessness and isolation, one of the first steps in helping the suicidal person is to seek to identify with their pain. Orbach (2011) concurs with this assertion. They point to the practitioner’s capacity to empathize with the emotional anguish experienced by someone who is suicidal as a crucial one of the first step in helping them to feel that they are not alone (Orbach, 2011). Furthermore, Cutcliffe & Stevenson (2007) also found that when empathy was genuinely expressed by a nurse the person who was suicidal experienced a reduction in suicidal tendencies. How can we actually convey empathetic understanding to the suicidal person? As pointed out in Box 4.1, we can learn what sort of statements are helpful versus ones that are not helpful and learn to apply the more beneficial strategies in practice. Box 4.1. What is helpful versus what is not helpful. Source: Stephany, author.

HELPFULL

NOT HELPFULL

I can't imagine what it feels like to be in the situation that you are in.

Look, it can't be that bad, other people have it worse.

I am so sorry to hear that you are Everyone has a down day going through this. It must be very sometimes. This too shall pass. scary. There are other people who have been in your situation or even Tell me in your own words what happened to you that brought you worse and they didn't try and kill to this dark place that you are in. I themsleves. want to hear your story. You need to stop feeling so sorry Where do you hurt and how might I for yourself. help you?

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ENCOURAGING THE SUICIDAL PERSON TO CHOOSE LIFE BY UTILIZING COMPONENTS ASSOCIATED WITH THE ETHIC OF CARE & EMPATHY The following specific components associated with the ethic of care and empathy will now be reviewed as a means to help the suicidal person to choose life: establishing connection, fostering therapeutic alliance and trust, offering unconditional positive regard, listening with the heart, presencing and learning how to be compassionate. The Ethic of Care & Empathy: The Importance of Establishing a Connection “When we seek for connection, we restore the world to wholeness. Our seemingly separate lives become meaningful as we discover how truly necessary we are to each other.” Margaret Wheatley, American writer

Connecting is a term that is used in communication that refers to the ability of one person to relate to another person on a human and felt level. Both the ethic of care and empathy value and promote the healing capacity of truly being able to connect with other people. What people who are experiencing suicidal thoughts are so badly in need of is that feeling of being connected to others and to all of life (Stephany, 2015). Persons who are experiencing suicidal thoughts often feel that they are very alone in their experience. They do not believe that anyone can or even wants to understand their emotional pain (Allen, 2011). Bien (2008) explains this well. “Whenever we encounter some difficulty, whenever we find ourselves in a difficult emotional state, full of sadness we tend to feel more isolated and disconnected and what is so badly needed is connection” (Bien, 2008, p. 51). Yet, feeling connected to others in a world that is rapidly changing can sometimes be challenging. For example, in the 21st century when the bulk of interpersonal communication is now occurring more often through social media, human relations are becoming colder. Our communications with one another are also often hurried and impersonal (Ferrucci, 2006). In view of these facts, Walker (2010) admonishes us to put human connection above all else. I agree with her. As Maxwell (2007) points out, so many of us are able to communicate but so few of us know how to connect with another person. What is the key to connecting? To connect with other people you need to be able to relate to them as individuals (Maxwell, 2007). The way that you do that is to communicate with openness and sincerity. You demonstrate a genuine interest in what is going on for them in their life. To connect with another human being you also need to be able to go where they are, to focus on them and their experience

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and not on you. You have to convey that you believe in them and offer them hope (Maxwell, 2007). With hope you can help them see that the future can be different, that the ending to their story does not have to be suicide. “When you give people hope, you give them a future” (Maxwell, 2007, p. 119). Shafir (2008) reminds us that when patients are sharing their problems and their story with us they are also often sharing their wisdom. “When we pay full attention to someone, we are showing this person that he or she matters to us, that their dilemma matters to us” (Walker, 2010, p. 19). The following statements were made by patients who were experiencing suicidal thoughts after being asked the question, “What can your caregiver do to help you to feel more connected to them?” Advice from Suicidal Patients “Give me your full attention. I can tell if you are not really listening to me.” “Don’t be in a rush.” “Greet me with kindness. Show that you care in your voice.” “Be more gracious.” “Be approachable.” “Demonstrate warmth.” “Show me that you are interested in knowing what is going on for me.” “Please don’t tell me how busy you are or talk about what a bad day you are having. This is not about you.” “Listen, just listen.” “Please do not stand at the foot of the stretcher or bed. Sit down and be personable.” The Ethic of Care & Empathy: Fostering a Therapeutic Alliance &Trust “Establishing a therapeutic alliance requires a meeting of minds, and it is no small feat for a clinician to achieve this connection with a patient who is in a suicidal state of mind.” Jon G. Allen, Suicidologist & Member of The Aeschi Working Group

Michel (2011) describes the therapeutic alliance as the basis of a therapeutic process where the patient and care giver become collaborators in helping to heal mental illness and emotional distress. It is a partnership of sorts (Michel, 2011).

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The therapeutic relationship between a physician and patient has long been known to be key to the healing process (Larson & Yao, 2005). The ethic of care places tremendous emphasis on the importance of the therapeutic alliance and trust between the caregiver and the one receiving care (Watson, 2008; Stephany, 2012). Furthermore, empathy can only occur when trust has been established between the caregiver and the recipient of that care. “Creating trust within a therapeutic relationship means being aware of the needs of patients, attentive and responsive to those needs, and accepting and present in the moment for them” (Shafir, 2008, p. 216). Talking to someone that the suicidal person trusts, may help them. For example, a person who is suicidal is often very ambivalent about their feelings. Talking it through with someone they have established trust and rapport with may help them to feel cared for (Stephany, 2007). Yet, trust is not a given, it must be earned (Stephany, 2015). When Trust is Sometimes Severed However, before we discuss ways to establish and maintain trust, we must first of all draw attention to how trust is sometimes severed from the onset of a suicidal person’s encounter with a care provider. For example, as emphasized in Fig (4.4), when a person presents to the ER with a suicide attempt they are often not even considered as real patients because they are not injured or ill (Michel, 2011a). Subsequently, little attention is paid to them and they may even be “treated with sarcasm, even disgust. . . . Clinical decisions about management of such cases must usually be made in minutes, often in the absence of a full clinical picture – let alone an exploration of the patient’s inner experience” (Michel, 2011a, p. 5). The patient is then admitted to psychiatry as a means to get them out of the way (Michel, 2011a). Trust is completely absent (Michel, 2011a). When a person presents to the ER with a suicide attempt they are often not even considered as real patients because they are not injured or ill Subsequently, little attention is paid to them and they are treated with sarcasm, even disgust Fig. (4.4). How patients are sometimes treated in the ER. Source: Michel, 2011a, p. 5.

Establishing Trust Must be the Foundation for Everything Else that Occurs “Addressing suicide in the clinical encounter with a suicidal patient requires a different therapeutic approach” (Michel, 2011a, p. 6). Establishing a trusting relationship between caregiver and patient must form the foundation for everything else that occurs. The patient must be the center of all that happens and they need to be treated as the one who is the expert of their own experience (Michel, 2011a).

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The Aeschi Working Group of suicidologists is based in Switzerland and associated with the International Association for Suicide Prevention (IASP). The Aeschi Working Group consists of highly qualified professionals who focus on the therapeutic approach to the suicidal patient and offers new helpful strategies for health professionals (IASP, 2016). The Aeschi Working Group have worked very strenuously to study the experiences of suicidal persons. For example, The Aeschi Working Group have conducted extensive research over the course of more than a decade and they have developed guidelines for clinicians to help to foster a therapeutic alliance and trust (Michel, 2011). As demonstrated in Fig. (4.5), the suicidal person’s story is the starting place for assessment and intervention, not the expert’s diagnosis. This is in stark contrast to the medical model where the clinician is the expert (Michel, 2011). We will now review key elements of The Aeschi Working Group’s guidelines for clinicians, which among other things, emphasizes the importance of the therapeutic alliance between the clinician and patient, establishing trust and offering empathy. The suicidal person’s story is the starting place for assessment and intervention, not the expert’s diagnosis. This is in stark contrast to the medical model where the clinician is the expert Fig. (4.5). Guidelines for Clinicians. Source: Michel, 2011.

THE AESCHI WORKING GROUP: GUIDELINES FOR CLINICIANS (SOURCE: MICHEL, 2011, PP. 9 – 10). (NOTE THAT THE FOLLOWING POINTS HAVE BEEN SUMMARIZED) 1. The key goal of the practitioner must consist of reaching a shared understanding of the patient’s experience of suicidality. Understanding of the psychiatric diagnosis is a crucial component of the assessment interview and must be taken into consideration for planning and intervention. However, the examination of the patient’s mental state must not be first, it must follow the patient’s story. 2. The clinician needs to understand that most people who are suicidal are in emotional pain and have lost all self-respect. These patients are very vulnerable and are prone to closing up. However, after a suicide attempt there is often a “window” where patients can be reached. At this point in time they may be open to talk about their thoughts and feelings related to their emotional crisis, especially if the clinician is willing to explore the meaning of the suicidal act for the person. (See Fig. 4.6). 3. The interviewer’s attitude must be void of judgment and instead be supportive which involves listening to the person. The patient is the expert of their

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experience and empathy is important if the patient is to be motivated to be compliant with future treatment goals. 4. A suicidal crisis has a history. Therefore the clinician needs to aim to understand the circumstances leading up to the present situation. The interviewer should encourage the person to talk about their experience in their own words and encourage the use of “I” statements. 5. New models are needed to help the clinician and patient have a shared understanding of the patient’s suicidality. Patients must not be is viewed as objects but as persons that have had good reasons that resulted in self-harm (such as wanting to escape from unbearable emotional pain). Models that understand suicide actions as goal directed and related to life or career issues may prove useful to practice. 6. The key goal should be to engage the patient in the therapeutic relationship, at the onset. In a critical moment in the patient’s life the meaningful discourse with another person can be the turning point where life-orientated goals can be reestablished. This will require that the clinician be able to empathize with the person’s inner most experience and to understand their suicidal urges.

After a suicide attempt there is often a “window” where patients can be reached. At this point in time they may be open to talk about their thoughts and feelings related to their emotional crisis, especially if the clinician is willing to explore the meaning of the suicidal act for the person Fig. (4.6). The window of reaching the suicidal person. Source: Michel, 2011, p. 9.

The Ethic of Care & Empathy: Offering Unconditional Positive Regard As Michel (2011) so clearly articulated in The Aeschi Working Group’s Guidelines for Clinicians who are working with suicidal persons, it is extremely important that a clinician avoid judging the person. I believe that what Michel (2011) was alluding to is an action associated with the ethic of care and empathy that we refer to as unconditional positive regard. “When unconditional positive regard is practiced, there are no conditions or obstacles to your ability to care for another person. You do not judge a person as unworthy of care based on their conduct. Everyone is deserving of being cared for and about, regardless of their behavior or what they have done (Rogers, 1959; Stephany, 2012). Although the notion of offering care to everyone irrespective of their behavior or status in life is the ideal to be practiced, it is often not what occurs in real life. Judging others occurs instead. Recall that Michel (2011a) pointed out how often patients who

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present to the ER with suicidal ideation or attempt are treated with judgment. Being judged in this way can make the suicidal person feel even more hopeless and worthless (Stephany, 2007; Stephany, 2015). Most of us think of ourselves as accepting of others; but closer examination may discover that prejudices, biases, and fears prevent us from accepting all people as they are, without condition. This is a key factor in accepting others: we do it without setting conditions on the relationship (Schmidt, 2002, p. 15).

Strategies for Learning How to Practice Unconditional Positive Regard There are three key strategies that I recommend to nursing students to utilize in order for them to learn how to offer genuine unconditional positive regard. As a start, make unconditional positive regard a conscious choice. Secondly, imagine that the patient is someone in your life, past or present that is very dear to you. A third means is to remind yourself that your patient is human and just like you. Strategy One: Make Unconditional Positive Regard a Conscious Choice As emphasized in Fig. (4.7), offering unconditional positive regard instead of judging someone is a conscious choice that we make. It is not our place to judge others. We should make it our goal to listen to their whole story, and then we might not be so quick to judge them. Offering unconditional positive regard instead of judging someone is a conscious choice that we make Fig. (4.7). Offering unconditional positive regard is a choice. Source: Stephany, author.

Regardless of where another person’s actions have lead them, they are still people first, who are deserving of our respect and care. That does not mean that there are no consequences when a person has done something that is harmful, but it is not our place as caregivers to be the jury and judge. It is our place to take care of the person and to offer them the best care we can give. I also explain, how judging a person is never helpful it only causes them to close off and may even reinforce their own false beliefs that they are worthless. Strategy Two: Imagine that Your Patient is someone in Your Life Another method to practice unconditional positive regard is to imagine that the

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person that you are caring for is someone in your life that you love very dearly either from your past or present. If you use this strategy you will be less likely to judge that person. You will also be more willing to offer them the care that they so desperately need and deserve. My nursing students consistently report back to me that this approach really does work. Strategy Three: Remind yourself that Your Patient is Human Just Like You A third useful tactic that helps us not to judge another person comes from Chopra’s (2005) advice. Chopra (2005) advises that to avoid judging we must remind ourselves that just like us the other person has people in their lives that love them. Just like us they have experienced joy and have suffered. Just like us they will someday die. Just like us, they deserve to be respected and cared for (Chopra, 2005). The Ethic of Care & Empathy: Listening With Your Heart Any time a patient shares something personal about their history, I tell them, “It’s a privilege to know this about you.” Jeff Lewis, Nurse Practitioner (as cited in Walker, 2010, p. 43)

Establishing a connection, a trusting therapeutic alliance and offering unconditional positive regard, are crucial first steps in offering the suicidal person help. What naturally follows is learning how to genuinely listen to what the person has to say. As previously pointed out, we need to listen to the person’s story if we want to help them (Michel, 2011). All gatekeepers, but especially health professionals, need to be able to accept the suicidal patient “as an individual with a very unique and personal history. The patient’s very personal and rich inner world should be the focus of the early exploratory phase of treatment” (Michel, 2011, p. 18). Listening with your full attention and with heartfelt interest to the suicidal person’s story is not always easy to do, but it is what is so badly needed (Stephany, 2007; Stephany, 2015). Learn to Avoid Listening Stoppers However, although we may have good intentions of wanting to listen to our patients we sometimes close people off with what we do incorrectly. For example, we offer solutions to another person’s problems but that is not necessarily helpful. As Siegel (2001), a surgeon and author, so poignantly advises fellow physicians, “Don’t ever forget the power of listening and the strength that it takes to be there – not curing, but caring. The world is in need of listeners” (p. 118). However, even with the best of intentions we want to do something for our patients, do anything but listen. Shafir (2008) refers to specific actions called listening

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stoppers as hindrances that interfere with our ability to connect with others. As demonstrated in Fig. (4.8) it is important to remember to never give advice and not to invalidate another’s experience. Giving advice, although well-meaning, puts the responsibility for success or failure on the caregiver and can disempower the patient (Shafir, 2008). Invalidating another’s experience is also not helpful. Do not say something like, “It will get better tomorrow.” or “We all have bad days.” Statements like these actually deny the person’s reality and can make it worse for them. These statements can also contribute to a greater disconnect and increase the person’s feelings of loneliness (Shafir, 2008; Stephany, 2015). Listening Stopper:

• Never Give Advice

Making it Worse:

• Do not invalidate what the person is experiencing

Fig. (4.8). Listening stopper and making it worse. Source: Shafir, 2008.

There is an assumption that good listening takes more time. It doesn’t take more time. It takes different skills (Shafir, 2008). What do good listeners do differently? In order to explore the answer to this question, Shafir questioned a group of caregivers that she was lecturing to. She asked that the attendees raise their hand if they could remember a time when they really felt heard by another person at least once in their lives. Only a few people raised their hands and of those who did, they referred to a grand-parent or therapist as the only good listeners. These same people also described four unique qualities that made a conversation with that person special and sometimes even life enhancing (Shafir, 2008). The qualities that good listeners demonstrated are summarized below. Qualities Demonstrated by Good Listeners (as adapted from Shafir, 2008) 1. 2. 3. 4.

They sustained our attention over time. They heard and saw the whole message, not just part of it. They made us feel valued and respected, no matter what we were saying. They listened to themselves too. They were self-aware.

Fig. (4.9) challenges you to recall a time when you felt really listened to. What is it that the other person did to make you feel heard? What can be learned from this experience? How can you be more like them in your own way of interacting with others?

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Can you recall a time when you really felt listened to? What did the other person do to make you feel that they were truely listening? Fig. (4.9). Recalling being listened to. Source: Stephany, author.

The Ethic of Care & Empathy: Making Use of Presencing “When you give someone your total attention, you are creating a bubble of comfort, a little pocket of safety.” Reverend Patricia Ellen, Portland, Maine

Presencing as another crucial component of the ethic of care and empathy in action. It involves the act of being fully present and in the moment with a person and offering them your full attention (Stephany, 2012; Stephany, 2015). Presencing is closely aligned with listening with the heart. It consists of sending a person kind and caring thoughts while listening to what they have to say (Stephany, 2012). Walker (2010) points out that, there is “power in our mere presence when we simply make time to be there” (p. 79). Presencing is also practiced best in silence (Stephany, 2012). In fact Shafir (2008) refers to presencing as a form of generous, attentive silence that allows the person to have the time that they need to organize their thoughts. It also enables them to communicate their concerns. Mindful listening is closely aligned with presencing and is concerned with making time stand still. Mindful listening entails actively listening without anything distracting you from being in that very moment with the other person (Salzberg, 2004). Listed below are some crucial qualities that emanate from a fully present person whose only goal is to pay full attention to the other person. Qualities of a Fully Present Person (as adapted from Walker, 2010, p. 80; Shafir, 2008; Stephany, 2015) ● ● ● ● ●

● ●

Be totally present. Make the other person feel respected. Pat attention to the other person’s strengths. Show an interest and be curious about them and their circumstances. Look for hidden themes. In other words pay as much attention to what is said as to what is left out. Be open to knowing that there is no one right way to face loss or pain. If at all possible stay silent and just listen.

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There are also specific strategies to help you to stay silent and to be fully present with another person. The following method is very effective means to determine when not to speak and easy to apply. When interacting with a person who is experiencing suicidal thoughts, ask yourself the following four questions before proceeding to say a word. Presencing & Silence: Knowing When Not to Speak (as adapted from Shafir, 2008, p. 229) Before uttering a word ask yourself the following four questions. 1. 2. 3. 4.

“Is what I am about to say kind?” “Is what I am about to say true?” “Is it even necessary?” “Will it be an improvement or help more than silence?”

If your answer to all four questions is a resounding “YES” then speak, otherwise if there is even one “NO” just watch, wait and listen. Your patient will fill in the silence, if not with words than with an expression of emotion. Either way, if you remain silent and just listen, the other person will likely feel respected and understood (Shafir, 2008). The Ethic of Care & Empathy: Learning how to be Compassionate “The purpose of human life is to serve, and to show compassion and the will to help others.” Albert Schweitzer, Theologian, Philosopher and Physician

The ethic of care and empathy are both concerned with learning how to be compassionate with others. The modern day Philosopher, Slote (2007) who is the author of the book entitled, The Ethics of Care and Empathy, proposed that empathy is the primary mechanism of ethical caring, benevolence and compassion. Whereas empathy consists of the action of truly identifying with another’s experience, either happy or sad, compassion, is the action of solely identifying with the suffering of another person (Stephany, 2015). To be able to respond with compassion to another person’s anguish we have to be able and willing to understand their circumstances. We need to take the time to try and understand what has occurred to bring them to their current situation of despair (Salzberg, 2004). Once again, I cannot stress it often enough that listening to the person’s story must be the priority. As formerly pointed out, we may be prone to judge them if we only see their current circumstances without obtaining the background knowledge of how they got where they currently are. Therefore, compassion can only occur if we take into consideration the context of what has

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transpired. Walker (2010) explains how the act of compassion works in a very practical but heartfelt way. “When we comfort someone, we need to begin with the understanding that even if their concern doesn’t seem to us to be the ‘real’ issue or the ‘problem,’ we need to respect the reality of their pain, and tune in through their eyes to how their situation is impacting them” (Walker, 2010, p. 51). Salzburg (2004) explains how gaining a clearer understanding of what someone has experienced may help to convert judging into empathy. Have you ever had the experience of feeling resentful toward someone and then having an insight into what in their history might have caused them to behave in a certain way? Suddenly you can see the conditions that gave rise to that situation, not simply the end result of those conditions (Salzburg, 2004, p. 139).

When we identify with another person’s suffering we also need to look for a way to help alleviate their suffering. This is the essence of the ethic of care (Stephany, 2012; Stephany, 2015). Yet, compassion must consist of more than just seeking to lessen another’s suffering. In order for compassion to be effective, we have to be strong enough to notice and acknowledge the other person’s vulnerability, and not be afraid to go there because it makes us feel uncomfortable (Brown, 2012). To be vulnerable takes courage yet there is a great deal to be gained through the act of allowing ourselves to be vulnerable. For example, the more we allow ourselves to be comfortable with our own emotions, the better we become at not ignoring or minimizing strong emotions when they occur in others (Brooks & Goldstein, 2004). Let’s explore a narrative case study where an act of compassion emanating from a total stranger, named Jennifer, helped a young girl called, Susan. NARRATIVE CASE STUDY: AN ACT OF COMPASSION Jennifer is a retired registered nurse. She was walking her golden retriever, Max, on their usual route on a sunny August evening. Their walk consisted of crossing a bridge over the highway. As they approached the bridge Jennifer couldn’t help but notice a young girl with her head in her hands, leaning over the bridge railing and looking down onto the traffic below. Something about this young person’s demeanor made Jennifer feel uneasy. “Are you okay?” Jennifer asked. The young girl did not move. Jennifer persisted. “Are you okay?” Still no response. Thinking that the young girl might not have heard her, Jennifer placed her hand gently on the back of the youth’s shoulder and raised her voice. “Are you okay?” This time the youth jumped as if she was startled and looked up at Jennifer. Jennifer could see that the young girl had been crying. Jennifer decided to try and help in some way and asked,“Can we go somewhere and talk? I know there is a bench across the bridge where it is quieter.” The youth did not speak. Jennifer then gently

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grasped the young girl’s hand in hers and they proceeded to walk over the bridge with Max. Jennifer led Susan and her dog to the park bench under a tree. Jennifer sat down on the bench with Max at her side and the young woman sat next to her. The youth was now crying even more than before. Huge tears streamed down her face accompanied by quiet sobs. Jennifer felt overwhelmed by the site of this youth’s distress. “What is your name?” The youth responded ever so quietly. “Susan, Susan is my name.” Jennifer reached out for Susan’s hand once again, but this time Susan pulled her hand away. Jennifer did not feel rejected by this action and continued to try and help. “You seem so very sad. Can I do anything at all to help you?” Susan responded with, “I don’t know. I don’t think so. I am in trouble and I can’t see any way out. You stopped me just before I was going to jump. I was ready to do it. My mind was made up.” “But you didn’t jump,” Jennifer pointed out. “You are still here.” Silence followed. After a long pause, Susan looked up and she noticed that Jennifer had tears in her eyes. “Why are you crying?” asked Susan. Wiping away her tears, Jennifer responded with, “I feel so badly that you want to die. That makes me feel very sad.” Another long pause ensued. Jennifer, still with tears in her eyes asked Susan one last question, “Will you let me help you?” This time Susan reached for Jennifer’s hand and quietly replied, “Yes.” Analysis of the Case Study Three key themes were identified from this narrative case study: Theme One: Susan experienced the narrow constriction of thought associated with psychache. Theme Two: Jennifer, by identifying with Susan’s suffering demonstrated compassion. Theme Three: Susan felt understood by Jennifer. Theme Analysis Theme One: Susan experienced the narrow constriction of thought associated with psychache (Shneidman, 1998). Psychache refers to the unbearable emotional pain experienced by someone who is suicidal. The constriction of thought associated with that psychological pain is so terrible that the person views death as their only solution (Shneidman, 1998). Susan was so solely focused on the act of her imminent intent on ending her life that she did not notice anything around her, not even Jennifer’s calling out to her. However, when Jennifer placed her hand on Susan’s shoulder, Susan was startled. This startling effect actually forced Susan to momentarily awaken from her trance like state.

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Theme Two: Jennifer felt sad when she listened to Susan’s story and even shed tears. By identifying with Susan’s suffering Jennifer demonstrated compassion. It took courage for Jennifer to approach a total stranger. She risked being rejected, insulted or ignored. However, Jennifer felt that she needed to approach this young girl because she sensed that this youth needed her help. Theme Three: Susan felt understood by Jennifer. When someone reaches out to a person who is in need and connects with them on a human level, that person will often feel relieved. Everyone needs to be heard and treated with warmth and to feel understood and accepted (Ferrucci, 2006). A person who is suicidal is no different. They are especially in need of nonjudgment and acceptance (Michel, 2011a). Question 1. Would you have had the courage to approach a total stranger if you thought they needed your help? Why or why not? A PSYCHOLOGICAL AUTOPSY: REVIEWING WHAT WENT WRONG IN ORDER TO LEARN HOW TO DO IT DIFFERENTLY (AS ADAPTED FROM STEPHANY, 2007) A great deal can be learned by conducting a psychological autopsy and reexamining the sequence of events and circumstances that precede suicide (Shneidman, 2004). The following story has been adapted from Stephany (2007). This particular story was part of a psychological autopsy that was conducted by the Coroner after Jim chose to end his life. It must be reiterated that the causes of suicide are multi-factorial (Shneidman, 1998). There is no intent to blame any of the caregivers who were involved in this case. Instead, it is my intense desire that other health professionals who work in the Emergency Room (ER), who are faced with a similar situation may learn from the review of this specific case (Stephany, 2007; Stephany; 2015). Jim had been on a small disability pension because of a serious old back injury that he sustained in a car accident. The disability pension was not very large and Jim was poor at managing his money. Jim had recently been evicted from his rooming house for not paying his rent. Jim did not have any prior history of any mental illness, but he had been known to smoke cannabis on occasion. Jim had now become homeless for the first time in his life. Because of his recent state of affairs Jim was referred by the disability pension personnel to a social worker at the local Community Human Resources Centre. Jim went to see his assigned social worker after spending a week living on the street. He was not coping with being homeless. He was really hoping that the social worker could arrange for

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some temporary housing for him. Jim informed his social worker that he felt hopeless concerning his situation and that he wanted to end his life. He told the social worker that he had already taken an overdose of pills a few days ago and that he was surprised that he was still alive. He admitted to her that he had another suicidal plan. The social worker was so concerned about Jim’s safety that she arranged for him to be assessed at the local ER for possible admission to hospital. Jim arrived to the ER by ambulance and waited in the waiting room for six hours before he was assessed by the ER doctor. Jim told the ER doctor that he had attempted suicide recently, that he still wanted to end his life and that he had a new plan. Nevertheless, Jim was released from the hospital onto the street that same evening. Prior to discharge from hospital, a safety plan was not put in place and no arrangements were made for Jim to be referred to a shelter. A body was found the next morning on a street bench by a traffic officer. The body was identified in the morgue as being Jim. An autopsy revealed the cause of death to be from suicide. As part of the psychological autopsy, the Coroner interviewed the ER Physician and asked her why she discharged Jim from the ER even though he had recently attempted suicide and admitted to another suicidal plan. The doctor stated that there were no psychiatric beds available. The social worker in the community was also interviewed and she informed the Coroner that she had called ahead and spoken to the ER doctor about her concerns for Jim’s safety. She was surprised when she received a voice mail message from Jim, sometime later that evening, where he informed her that he was going to end his life. He said that even though she seemed to care for him, no one at the hospital seemed to “give a dam.” When questioned by the Coroner as to what she said and did to try and help Jim, the social worker stated that she did her best to listen to his concerns. She told him that she wanted to help him and tried to instill in him a sense of hope that things could get better. In spite of her efforts, Jim continued to talk about wanting to die. That was why she referred Jim to the hospital ER. The social worker informed the Coroner that it is proper procedure for a health professional to refer someone who is at high risk of suicide to the ER. The social worker did not listen to her voice mail messages until the next day. Her voice mail recording was ceased by the Coroner as evidence. The Coroner conducted a second interview with the ER physician and allowed her to listen to the saved voice mail message. The doctor was visibly upset by what she heard. She stated that she had no idea that she appeared uncaring to Jim and that was never her intention. The ER physician admitted that she did not think that Jim was at risk of killing himself. She also disclosed to the Coroner that she was not very skilled at suicide risk assessment because that sort of training was not included in the curriculum when she was in medical school. The Doctor suggested that a Coroner’s investigation was very important. So often doctors and nurses do not hear about a patient they have

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treated for suicidal tendencies actually committing suicide. They just assume that the patient is doing alright after they are discharged because they do not see them in the ER again. Analysis of the Case Study Although the outcome may have been the same, there is some benefit in reviewing the circumstances in this case to see what could have been done differently. The following four key themes were apparent. Theme One: There is evidence to indicate that Jim experienced the narrow constriction of thought associated with psychache. Theme Two: The ER doctor freely admitted that she did not receive adequate training in suicide risk assessment and she therefore did not think that Jim was at high risk of suicide. Theme Three: Jim admitted that he did not feel cared for by the professionals in the ER. Theme Four: A care plan was not put in place and a Safety Plan was not created to ensure that Jim would be safe before he was discharged from hospital. Theme Analysis As you read through the following analysis, keep in mind that a lack of training of health professionals in suicide risk assessment and therapeutic intervention is an embedded theme. Theme One: There is evidence that Jim possessed the constriction of thought associated with psychache. As aforementioned psychache refers to the unbearable emotional pain experienced by someone who is suicidal. Their desire to end their psychological pain is so intense that they view death as their only solution (Shneidman, 1998). Theme Two: The ER doctor freely admitted that she did not think that Jim was at high risk of suicide. She also disclosed that she did not receive adequate training in suicide risk assessment. Yet Jim had recently made a serious attempt at ending his life, therefore he was at high risk of a completed suicide. Research has also demonstrated that the strongest indicator that a person is at risk of a completed suicide is a previous suicide attempt (Gunnell, 2015). The ER doctor may have been more concerned about ensuring Jim’s safety if she was aware of this crucial information. Although ER doctors and other first line health professionals are frequently confronted with caring for people who are suicidal, their training in

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suicide risk assessment and therapeutic intervention is either limited or nonexistent (Schmitz et al., 2012; WHO, 2012). Theme Three: Jim communicated that he did not feel cared for by the professionals in the ER. The ER doctor may have acted differently with the patient if she had received formal training in offering empathy. What we now know is that empathy as a skill set is very seldom included in the curriculum of training health care gatekeepers (Wyman et al., 2008; Joiner et al., 2009; Vijayakumar, 2003). Yet, establishing therapeutic rapport with persons suffering from suicidal thoughts and offering them empathy is an important first step in helping them to feel cared for and understood (Perlman et al., 2011). The literature also clearly points out, that the role of the therapeutic relationship between the caregiver and the suicidal person is crucial in helping them to choose life over death (Martin et al., 2000; The United Kingdom Royal College of Psychiatrists, 2010; Cutcliffe & Stevenson, 2007). Theme Four: Before Jim was discharged from the ER a care plan was not put in place, nor was a Safety Plan created to ensure that he was safe. When a person is deemed to be at a high level of risk for suicide, a care plan should be developed and implemented (Perlman, 2011). The plan should include ways to ensure that the patient is kept safe, include a plan for their recovery, and take into consideration protective factors to lessen the risk of future harm (SuicideLine, 2016). Prior to discharging a suicidal person from the ER a Safety Plan should also ideally be developed. As aforementioned, a Safety Plan is a prevention tool. It is designed to help those who struggle with their suicidal thoughts to adopt healthy ways of coping, assists them in establishing reasons for living, and specifically identifies people to call when they are in crisis (Stanley & Brown, 2016). MOVING BEYOND THE INITIAL SUICIDE CRISIS: THE ROLE OF COGNITIVE THERAPY This Chapter was written with the goal of assisting all types of gatekeepers to utilize the ethic of care and empathy as a means to help a suicidal person to choose life. We know that if a helping gatekeeper spends time genuinely listening to a suicidal patient’s story, the caregiver is more likely to have a positive caring attitude toward the patient, and the patient is more likely to feel understood (Michel, 2011). Upon further reflection, it is all well and good to listen to the person’s suicidal story, to foster a meaningful alliance, and to offer acts of empathy. These are helpful starting points to anchor of person to life in their moment of crisis (Michel 2011a; Jobes, 2011). However, more needs to happen after the initial suicidal emergency has occurred to help the person to find purpose

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in going on with their life. As the sign in Fig. (4.10) clearly indicates, we must do our best to help the suicidal person to change their narrative from one of despair to one of hope after the initial crisis has passed. This objective can best be achieved if the patient is referred for further professional help in the form of cognitive therapy (Brown, Wenzel & Rudd, 2011).

Fig. (4.10). Hope versus despair. Source: www.pixabay.com.

Cognitive Therapy: Moving the Patient Beyond their Initial Crisis Therefore, in the ensuing discussion, Cognitive Therapy is recommended as a strategy to help the suicidal person to move beyond their current predicament. As Fig. (4.11) emphasizes, although it is beyond the scope of this present book to delve into therapy in any depth, the merits of Cognitive Therapy in relation to changing the negative mindset of the suicidal person is worth introducing. Although it is beyond the scope of this present book to delve into therapy in any depth, the merits of Cognitive Therapy in relation to changing the mindset of the suicidal person is worth introducing Fig. (4.11). The merits of Cognitive Therapy. Source: Stephany, author.

Cognitive Therapy, also referred to as Cognitive Behavioral Therapy, is a form of treatment that consists of helping a person to change the way that they think. “The way that you think about events in your life profoundly influences the way that you feel about them; change the way that you think and this will in turn, change the way you feel” (Neenan & Dryden, 2002, p. ix). This is the essence of Cognitive Therapy. Cognitive Therapy has a proven track record in assisting the suicidal person. Cognitive Therapy involves “interventions that target

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hopelessness as well as other vulnerabilities that mitigate suicide risk” (Brown, Wenzel & Rudd, 2011, p. 273). Cognitive Therapy, “specifically adapted for suicidal patients, is based on the premise that suicidal patients lack important cognitive, behavioral, and affective coping skills or fail to use them during a suicidal crisis” (Wenzel, Brown & Beck, 2000, as cited in Brown et al., 2011, p. 274). Cognitive Therapy is the means to help the suicidal person to move beyond where they are to a course that will help them to move forward. The following excerpt explains the importance of this necessary course of action. At the end of the therapeutic day, the once suicidal patient must ultimately come to realize a fundamental sense of purpose and meaning in life. . . . (A) new course, an alternative path, must be charted to avert the otherwise potentially terminal outcome of the suicidal patient’s journey. Such a course must invariably include certain features that are necessary to make any life worth living: re-establishing life-orientated goals, meaningful work, love, play, and an emerging sense of purpose, a viable sense of self, and the ability to manage previously life-threatening pain and despair (Jobes, 2011, pp. 381 – 382).

Cognitive Therapy does not necessarily offer any quick solutions to rectify or eliminate the problems that are experienced by the individual. However, it does emphasize that sustained effort and commitment can result in the successful outcome of changing one’s automatic negative thinking processes into ones that are healthy, more positive and life enhancing (Neenan & Dryden, 2002). One of the first goals of cognitive strategies consist of assisting the suicidal person to identify their negative thoughts and beliefs and how those cognitions affect their feelings and influence their suicidal tendencies (Brown et. al., 2011). This process consists of making use of cognitive-restructuring. Cognitive re-structuring consists of having a helping professional challenge automatic negative thoughts that are not necessarily true with actual facts (Neenan & Dryden, 2002). For instance, cognitive re-structuring is used to help the patient to gain a better understanding of the core beliefs that were active at the time of their suicidal crisis. They are then challenged to explore the automatic thoughts and beliefs that are not necessarily true, but that have kept the person fixated on suicide as the only solution (Brown et al., 2011). An example of cognitive re-structuring may include something like the following. The statement and belief, “My family would be better off if I were dead,” is challenged with a truth statement such as, “That simply is not true, your whole family will be emotionally devastated if you choose to end your life and you will leave them in a financial crisis.” Another very useful Cognitive Therapy strategy that is beneficial to employ with the recovering suicidal person is that of creating Coping Cards (Wenzel et al., 2009 as cited in Brown et al., 2011). Coping Cards are developed when a person

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is no longer in a crisis and contain adaptive coping statements that patients can consult during a time of future distress (Brown et al., 2011). One type of coping card that is utilized for a person who experienced a suicidal crisis is to write a suicide core belief on one side of the card and on the opposite side, write a more truthful and life supporting statement (Brown et al., 2011). One example would be to have the patient write on one side, “I am all alone in the world.” On the opposite side, they could write something to the effect of, “I can name at least five people in my life who do care very much about me.” Because this Chapter has been focused primarily on the topic of how the ethic of care and empathetic strategies can be applied in the clinical setting, to help the suicidal person to choose life, it is only fitting that we be reminded that the same focus holds true when Cognitive Therapy (CT) is undertaken. “Perhaps the most important skill for CT clinicians who work with suicidal patients is the ability to understand and empathize with their experiences, while at the same time coaching them to address their problems in a systematic way” (Brown et al., 2011, p. 290). (See Fig. 4.12). Perhaps the most important skill for CT clinicians who work with suicidal patients is the ability to understand and empathize with their experiences while at the same time coaching them to address their problems in a systematic way Fig. (4.12). The most Important Skill for Cognitive Therapists. Source: Brown et al., 2011, p. 290.

SIMULATION: MAKING USE OF EMPATHY TO HELP A SUICIDAL PATIENT This specific simulation is designed to help gatekeepers to use empathetic responses when they are assessing a person who is suicidal. The simulation exercise is divided into two parts. The first part of the simulation exercise is concerned with assessing a person who is suicidal. The second simulation activity is a role play on helping a suicidal person to develop a Safety Plan. The simulation was designed with the following three key objectives in mind. Objective One: Establish a Therapeutic Alliance To establish a therapeutic alliance and trust with the suicidal patient. Rationale: “The importance of establishing a strong relationship with the suicidal patient cannot be overstated. Even the best therapeutic techniques are of little value when an adequate relationship has not been formed with the patient” (Rudd, 2006, p. 19.

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Objective Two: Practice Skills that Covey Empathy To practice using both non-verbal and verbal communications skills that convey empathy. Rationale: The second goal is to get the patient to tell their story. You must not be too eager to diagnose and treat them or act in a hurried fashion. The most important therapeutic activity is “creating an atmosphere of support whereas the patient feels comfortable enough to fully describe how things have evolved in their life . . . where suicide has become a viable option for coping with unbearable suffering” (Jobes & Ballard, 2011, p. 57). Objective Three: Develop a Safety Plan To practice helping a person who is having suicidal thoughts develop a Safety Plan. For a sample Safety Plan please visit: www.comh.ca/publications/resources/ pub_cwst/cwst.pdf or http://suicidepreventionlifeline.org/wp-content/uploads/ 2016/08/Brown_StanleySafetyPlanTemplate.pdf Rationale: The third objective is to get the patient who experiencing suicidal thoughts to develop a Safety Plan. As previously explained, a Safety Plan is a written care plan that is developed by the suicidal person with the assistance of the caregiver. The Safety Plan usually consists of several parts that can be tackled in any order, and some Safety Plans are shorter than others (Stanley & Brown, 2016). Summary of Safety Plan Goals: (as adapted from Stanley & Brown, 2016; The National Suicide Prevention Line, 2013) ●

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Often the first task of a Safety Plan is to help the individual to ensure that their environment is safe and that they do not have any ready access to a way to selfharm. A second aim may to assist them to identify warning signs that they are headed for a crisis usually follows. A third goal may include encouraging the person to identify coping strategies that they can utilize when they are headed toward a crisis. A fourth strategy is to help the person to identify reasons for living. A fifth aim is to have them make a list of the people or organizations that they can call (including specific phone numbers) when they are in trouble.

Simulation Confidentiality What occurs in simulation needs to remain confidential. The learning session should not be shared with people outside of the simulation setting. The goal of

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simulation is to ensure that the practice session occurs in a safe environment where the participants can feel free to make an error without causing harm to an actual person (Pagano & Greiner, 2009). (Please refer to the sample Simulation Confidentiality Form in Appendix A). Preparation for the Simulation In order to be adequately prepared for the simulation it would be a good idea to review Chapter Four’s ethic of care and empathy strategies. Some of the following non-verbal & verbal communication skills should also be rehearsed. Non-Verbal Communication Skills: (as adapted from Rosenberg, 2003; Walker, 2010) ●

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Avoid smiling: Smiling may convey a lack of understanding especially if the person is very emotionally distressed. Make eye contact: Eye contact demonstrates that you are present and interested in the other person. (Be aware that some cultures find it offensive to make eye contact. e.g., First Nations). Be on their level: Sit if they are sitting. Being at the other person’s level conveys that there is no hierarchy of power over them. Lean slightly forward: This action conveys the unspoken message that you care and that that you are listening. When silence occurs remain quiet and just listen: Silence may help the patient sort through their feelings and it is best to let them do the talking. Avoid distractors: Do not look at your phone, fidget, look at your watch or day dream. That is rude behavior and conveys the message that you do not care. Occasionally nod: Nodding communicates that you are listening and in agreement with what the other person is sharing.

Verbal Communication Skills (as adapted from Brammer & MacDonald, 1999; Walker, 2010) ●

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Clarification: This is a communication strategy that involves the process of trying to understand what may appear vague or confusing. It may consist of summarizing what was said, or directly conveying that you do not quite understand what the intended message was. You may wish to say something like, “I’m not clear as to what you just said. Can you help me to better understand what you meant?” Validation: This technique consists of identifying with the feeling that the person is experiencing. It is a way to reassure the other person that you understand the essence of their experience. Example: “That must have been very frightening for you.”

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Para-phrasing: This strategy consists of re-stating the person’s basic message in your own words. The purpose is for the helper to test that they actually do understand what the intended message was. Ask open-ended questions: An open ended question is one that cannot be answered with one word, such as “Fine,” Yes,” or No.” It is the type of question that helps the person to tell you their story. You may want to say something like, “I am here to help and I am interested in understanding how you came to be in this situation.”

Scenario: Two actors are needed. One person will act as the health professional and the other will be the patient. The patient is a 28 year old man who is very emotionally distraught and has admitted that he is suicidal. The patient called 911 and informed them that he wanted to kill himself. This action resulted in the patient being brought by paramedics to the local Emergency Room (ER) for assessment. The role of the observers in the simulation setting is to pay close attention to everything that transpires in order to look for evidence of empathetic responses, non-verbally and verbally. Setting the Scene: The scene takes place in the interview room in the ER. The health professional can pretend to be a nurse, doctor, social worker or counsellor. The patient is sitting on a chair. He is gazing at the floor and is very sad. Role Play Part I: The Assessment Interview The scene begins with the health professional (HP) entering the interview room to assess the patient (PT) and to obtain a history. The health professional sits down in the chair across from the patient. The health professional purposely remains silent for a few moments before proceeding to introduce themselves. HP: Makes eye contact and speaks in a soft kind voice. “Hello, my name is (. . . .) I understand that you are here because you have been having thoughts of suicide, is that correct?” PT:“Yes” HP:“I am here because I care about you.” PT: Responds with anger. “Why do you care? You don’t know anything about me.”

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HP:“I understand that it may seem hard to believe that I care about you, but I do. That is why I am here.” PT: Feeling remorseful. “Sorry about that, I just hate myself and can’t imagine anyone feeling anything for me, especially a stranger.” HP:“I do care about what has been going on for you, and I want to do my best to help you. How can I help you?” PT:“I don’t know how you can help.” HP:“I understand that you were brought to the ER by paramedics after you called 911. Perhaps a good place to begin, is if you tell me in your own words, what lead you to make that phone call. I want to hear your story.” PT: Hesitates and then begins to tell his story. “My wife left me 2 months ago because I lost my job and because of my problem drinking. She took our little boy with her. I have lost everything that matters to me. I am lonely and broke and about to get evicted from my place. I am feeling very hopeless.” HP: Offers empathy. “It sounds like you have been through a lot lately. I can’t imagine how hard that must be for you.” PT:“It has been terrible. I feel like such a loser. I just want to die.” HP: Seeks to clarify. “It sounds like you have been thinking about dying as a way out of your situation. Have you been having thoughts of suicide?” PT:“Yes I have. Killing myself is my only way out of this mess.” HP:“That must be awfully scary for you to feel that way. Can you tell me a bit more about what lead you to this place? I want to understand so I can help you. I want to hear your story.” PT:“Are you sure you want to know what has been going on for me? It is not a very happy story and I ashamed to admit to some of it.” HP: Offers unconditional positive regard. Uses a soft caring voice and leans slightly forward. “I am not here to judge you, no matter what. I want to help you and the best way for me to help you is to first of all to understand.” PT:“Well if I am truthful my problems didn’t just start 2 months ago. They started when I was a teenager. My Dad was a heavy drinker and when he got drunk he got mean. He used to beat me a lot. I ran away from home when I was 17 and did odd jobs to survive, mostly in construction. I also started drinking right away, not

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a lot at first but over time my drinking became a problem. I met my wife at a coffee shop where she worked as a waitress, when I was 22. She was the best thing that happened to me. She disliked the drinking so I cut it way back and she agreed to marry me. That was the best day of my life. I could hardly believe that this woman loved me and for a few years life seemed pretty good. Three years ago we even had a son, and he is the love of my life. But now I have ruined everything. I wish I were dead.” (PT is crying now.) HP: Remains silent and allows PT to process what he is feeling. PT: Continues to cry. HP: After some time has passed HP proceeds to clarify. “I can sense your sadness and that you are in a very terrible place. I also get the feeling that you think that you don’t deserve to be alive because you believe that you have let your wife and son down. Is that correct.” PT: Still crying. “Yes.” HP: Checking to see if HP has a suicidal plan. “I am going to ask you some very difficult questions and I am only asking them because I care about you, and not because I am judging you. Do you have a plan to kill yourself and if you do, will you try and act on your plan?” PT:“I do have a plan and it is to take a bunch of pills with alcohol.” HP:“Do you intend on acting on your plan?” PT:“Not right now. That is why I called 911. There is a small part of me that is scared to die. I guess I am a loser and a coward too.” HP: Conveying hope. “I am glad that you called 911 and that you are here now so we can help you. I think that perhaps you called 911 because there is a small part of you that believes that your life is still worth living. But we will need to keep you here in hospital for a little while to help you to sort through your situation, and to help you to feel more hopeful.” PT:“Do you really think you can help me?” HP:“We will do our best to help you.” PT: The patient looks relieved. “Thank-you.”

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Role Play Part II: Creating a Safety Plan This scene occurs two days after the patient (PT) has been admitted to hospital. The same health professional (HP) has been working with the patient for two days and there is evidence that trust and rapport has been built between them. The health professional approaches the patient to help him to develop a Safety Plan. HP: The HP approaches the patient in a kind manner and sits down beside the patient in the chair adjacent to his hospital bed. “Good morning. I am looking after you again today for 12 hours.” PT: The patient makes slight eye contact with the HP and smiles a little bit. “I am glad that it is you and not someone else. I feel that I can trust you.” HP:“I am glad that you are okay with me taking care of you again. I just want to check in first to see how you are doing? How are you feeling this morning?” PT: Patient lacks emotional expression on his face. “Okay I guess.” HP:“Are you still sad?” PT:“Not sad so much, but I feel really tired and kind of numb.” HP: Validates the patient’s experience and then moves on to conduct a brief assessment of current suicide and homicide ideation. “It is okay to feel tired and a bit numb. You have been through a lot lately. I have to ask you a few other questions as a part of my safety assessment. How about your thoughts? Have you had any recent thoughts of wanting to harm yourself or anyone else?” PT:“No thoughts of suicide yet today. But I never have had thoughts of wanting to hurt other people, only myself.” HP:“I understand, but sometimes people experience both types of thoughts, so I just need to make sure that I know where you are with all of this.” PT:“I am doing okay right now and I am not thinking of suicide right now.” HP: Offers validation before proceeding. “That is a good thing. This morning I thought we could work together to help you to develop a Safety Plan. Do you know what a Safety Plan is?” PT:“No I don’t. What is it?” HP: The caregiver shows the patient the Safety Plan form and begins to explain what it consists of. “I have the form right here with me. A Safety Plan is a plan

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that you can refer to when you feel like you are getting to that dark place you were in when you wanted to kill yourself. It is plan to help you not to self-harm, and instead it will help you to identify ways to cope and to stay focused on life. Does that make sense?” PT:“It makes some sense to me, but does it work?” HP:“Yes, it does, for the most part, if the person is willing to use it. In my opinion I think everyone should develop something similar because life can throw some difficult situations our way when we least expect it. In fact, I have developed a safety for myself that I keep in my bedroom drawer.” PT:“Wow, if you have one, and you are the caregiver, than I want to do one too.” HP:“Good. You can complete it in stages if you wish. Can I go over it with you so you can get started?” PT: Looking somewhat eager. “Yes.” HP:“I think a good place to begin is for you to complete the first page, which consists of identifying ways of coping when you feel stressed as well as reasons for living. Would you be willing to do that with my help?” PT:“Yes, but what if I don’t have any reasons for living?” HP:“That is why I am here. I can help you with that part first if you like.” PT:“Yes, please.” HP:“Try and think of just one reason for living.” PT: The patient looks perplexed and spends a few minutes thinking. HP: The caregiver remains silent and allows the patient to process his thoughts and feelings. PT:“My son, I guess.” HP: The caregiver offers validation. “Yes, your son, you spoke so fondly of him. You told me how much you love him.” PT:“But aren’t I a burden as his Dad? I am not coping right now. Wouldn’t he be better off if I died? Wouldn’t he be better off without me?” HP: Caregiver asks permission to use some reality therapy. “I am not hear to

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judge how you feel, a lot of people who are suicidal think that their loved ones would be better off without them. But I think this is a good time to help you to see things a bit differently, perhaps from the perspective of your son. Is that okay if I tell you more?” PT:“Yes.” HP:“Can you imagine what might be worse than having a Dad who is not coping?” PT: The patient looks at the caregiver with curiosity. “No, what is worse?” HP:“Not having a Dad at all and knowing that your Dad chose to end his own life. That could negatively impact your son on an emotional level for his entire life.” PT:“Oh my, I never thought of it like that before. I don’t want to hurt my son. That is definitely a reason for living.” HP:“Can you think of any other reasons for living?” PT:“I suppose that I can think of other reasons but not right now. I am feeling tired and a bit overwhelmed. Can we take a break for a bit? But can you leave the form with me so I can think about my answers more? I want to take some time to do this. I think it could help.” HP:“Of course, try and get some rest. I can check in with you a bit later.” The caregiver then leaves the room to give the patient a break. Simulation Suggestion The simulation can stop here or you can proceed with exploring the other parts of the Safety Plan and allow the person playing the role of the patient to get creative in their responses, while the person acting as the caregiver practices being empathetic. De-Brief & Learn Spend at least 15 – 20 minutes to de-brief. The simulation facilitator may choose to take the lead and de-brief the whole group or begin by de-briefing the key actors first. De-Briefing Strategies for Consideration ●

Give the key actors an opportunity to share with the group how they felt during

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the session. Ask them to be as specific as possible. Encourage all of those who were observing to give feedback concerning what they observed. What messages did the actor’s body language convey and were the non-verbal messages congruent with what was said? What actions by the caregiver appeared to convey empathy? Were any of the actions awkward or did they in anyway convey disinterest? Have the actors and the observers make suggestions as to what could have been done differently to demonstrate empathy and care.

SOMETHING TO PONDER: MAKE EMPATHETIC RESPONSES A HABIT IN YOUR LIFE “We are what we repeatedly do. Excellence, then is not an act, but a habit.” Will Durant, American author and historian

If we want to become empathetic practitioners in our work with people who suffer from suicidal ideation, we need to make empathy a part of our way of being. Yet, to accomplish this feat requires determination, practice and effort on our part (Stephany, 2015). Evidence demonstrates that if we want to cultivate a change in behavior we must practice that new skill until it becomes a habit (Goldstein & Brooks, 2004). How do you go about making empathy a habit? You do so by practicing self-awareness through journaling. As pointed out in Chapter Two, self-awareness is the ability to reflect on what you are feeling in the midst of experiencing strong emotions without acting on those emotions (Goleman, 2005). I encourage you to practice actual acts of empathy on a daily basis with those in your immediate family and friend circle and to write in a journal about your experiences. Keeping a journal will help you to become more self-aware and also assist you in keeping track of your progress. (Refer to Fig. 4.13).

Fig. (4.13). Journaling to increase self-awareness. Source: www.pixabay.com.

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Key Points on How to Journal to Evaluate Your Empathy Skills: (as adapted by Goldstein & Brooks, 2004; Stephany, 2006; Stephany, 2015) ●

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Write about what you did well and include what you could do better next time. However, a word of caution is warranted. Do not judge yourself if you do not live up to your expectations of how you want to be or act. Rather, be selfcompassionate, and use what didn’t work as a learning opportunity of how to do it differently when given another chance. Often times, error is our greatest teacher. (See Fig. 4.14). Ask yourself the following types of questions. Did I spend time really listening to the other person? Was I pre-occupied with something else? If so, how can I avoid doing that next time? When someone said something that I did not agree with, did I try to understand the other person’s point of view, or did I become defensive? When someone did or said something that I deemed to be wrong, did I demonstrate unconditional positive regard or was I quick to judge? When someone shares their painful story or situation with me did I emanate genuine care or pity them with sympathy? How might I do better next time? Do not judge yourself if you do not live up to your expectations of how you want to be or act. Rather, be self-compassionate and use what didn’t work as a learning opportunity of how to do it differently when given another chance. Often times, error is our greatest teacher

Fig. (4.14). Oftentimes Error is our greatest teacher. Source: Stephany, author.

REFLECTING BACK Summary of Key Points Covered in Chapter 4 ●

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The ethic of care promotes a web of connection that is inclusive of everyone and excludes no one. We know that people who are experiencing suicidal thoughts feel especially alone in their experience. If we can help them to know that we genuinely care about them and their situation, we may be able to convince them that their life matters. This is the essence of the ethic of care in action. Empathic action in the form of validating another’s experience can save lives. In the hopeless patient offering hope instillation may assist them to feel understood and cared for by their physician or nurse. While offering empathy the caregiver should strive to identify with the other person’s experience. However, they must also remain somewhat separate from

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it. For example, if the helper gets completely lost in another’s suffering they will not be able to help the other person. Today we refer to this therapeutic strategy as exquisite empathy, where the practitioner identifies with the patient’s feelings but is also able to stay separate from their patient’s suffering. When setting out to validate another person’s experience we learned what sorts of statements are helpful versus ones that are not. Specific elements associated with the ethic of care and empathy were presented as a means to help the suicidal person to choose life: establishing connection, fostering therapeutic alliance and trust, offering unconditional positive regard, listening with the heart, presencing and learning how to be compassionate. It was pointed out that trust can sometimes be severed in the emergency room (ER) when someone presents with a suicide attempt. The suicidal patient is sometimes not even considered a real patient because they are not injured or ill. Key aspects of The Aeschi Working Group Guidelines for clinicians were also reviewed in summary form. These guidelines emphasized the significance of the therapeutic alliance between the clinician and patient. They highlighted the importance of offering empathy and being non-judgmental and they placed the patient’s story as a priority over clinical expertise. After a suicide attempt there is often a window where patients can be reached. At this time the patient may be open to talk about their thoughts and feelings especially if the clinician is willing to explore the meaning of the suicidal act for the person. A touching narrative case study was presented where we learned how a total stranger helped a suicidal youth through an act of compassion. A psychological autopsy assisted us in gaining a retrospective view of what went wrong in the emergency room (ER) and why. Key themes emerged. The patient experienced the narrow constriction of thought associated with psychache. The ER physician admitted that she did not receive adequate training in suicide risk assessment. The patient reported that he did not feel cared for by the professionals in the ER. Prior to the patient being discharged a care plan or Safety Plan were not completed to help keep the patient safe. Due to the fact that people who suffer from suicidal thoughts still need help to find a sense of purpose and meaning in life after their initial crisis has subsided, Cognitive Therapy was recommended. A dynamic simulation exercise was presented in two parts to help gatekeepers practice being empathetic with a suicidal patient. The role play encouraged the use of both non-verbal and verbal communication skills and practiced assisting a patient to develop a Safety Plan. At the end of the Chapter caregivers were encouraged to make empathy a habit through the act of journaling to increase self-awareness.

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CHAPTER 5

Strategies that Promote the Emotional Well-being of Gatekeepers Abstract: Chapter five begins by pointing out that suicide can be an occupational hazard in the caring professions. For example, physicians are twice as likely to commit suicide when compared to members of the general population. Contributing factors to physician suicide include but are not limited to: heavy work-loads, bullying, unreasonable expectations, stigma and perfectionism. Stigma associated with a diagnosis of mental illness, the dread of being judged, or fear of losing one’s license to practice, all play a role in doctors refusing to get the help that they need. Studies have also demonstrated that there is high prevalence of suicide among nurses, higher than that of the general public. Ready access to means, mental illness, substance abuse, work related stress and even work place bullying were cited as some of the contributing factors to nurse suicide. Stigma toward mental illness was identified as a key factor in nurses not seeking professional help. It was pointed out that due to the fact that caring for the suicidal person can be stressful there is a real risk of gatekeepers developing compassion fatigue. Compassion fatigue was defined followed by an overview of some of the causal factors and symptoms associated with it. If compassion fatigue is to be prevented or effectively treated when it does occur, additional coping strategies need to be adopted and utilized. Therefore, the following approaches were recommended: encouraging gatekeepers to reach out for professional help; fostering self-compassion; and implementing strategies that promote self-care. In conclusion, some take away points from the book were highlighted.

Keywords: doctor suicide, mental illness, depression, substance misuse, stress, nurse suicide, Neonatal Intensive Care Unit (NICU), burn out, stigma, compassion fatigue, vicarious traumatization, critical incident de-briefing (CID), post-traumatic stress disorder (PTSD), depression, self-care, self-compassion, self-awareness, journaling, physical health, emotional health, work-life balance, gratitude.

Kathleen Stephany All rights reserved-© 2017 Bentham Science Publishers

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LEARNING GUIDE After Completing this Chapter, the Reader Should be Able to: ●

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Be cognizant of the fact that people who work in the caring professions are themselves at risk of suicide especially doctors and nurses. Be able to identify some of the key contributing factors to physician and nurse suicides. Describe some of the reasons why doctors and nurses are reluctant to reach out for help. Be aware that gatekeepers are at risk of developing compassion fatigue. Define compassion fatigue and vicarious traumatization and describe the similarities and differences between the two. List some of the key symptoms associated with compassion fatigue. Identify strategies that promote self-care. Summarize a few key take away points from the book.

Overview of Chapter 5 As Fig. (5.1) demonstrates, it is not selfish to love and take care of yourself, it is a priority, especially if you are a caregiver. As Schmidt (2002) points out, “Helpful persons sometimes spend so much time and energy caring for others that they risk neglecting themselves” (p. 83). Yet a helper who does not take care of themselves first over time will become too tired to care for others (Florio, 2010). Therefore, chapter five is concerned with promoting the well-being of gatekeepers. The discussion begins by pointing out a difficult truth that many people in the caring professions are themselves at risk of suicide, especially doctors and nurses. Key contributing factors to physician and nurse suicides and obstacles that impede their willingness to get help, are explored. Due to the fact that caring for the suicidal person can be stressful there is also a real risk of gatekeepers developing compassion fatigue. Compassion fatigue is defined followed by an overview of some causal factors that may lead to its development. A list of some of the actual symptoms associated with compassion fatigue are also included in the discussion. In order to prevent compassion fatigue or to treat it when it does occur, strategies are recommended. These approaches include: encouraging gatekeepers to reach out for professional help, fostering selfcompassion and suggesting specific ways to encourage self-care. The chapter ends with take-away points highlighted from the book.

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Fig. (5.1). Taking care of yourself is a priority. Source: www.recoveryexperts.com.

ADMITTING THE UNTHINKABLE: SUICIDE AS AN OCCUPATIONAL HAZARD Although it is a difficult topic to talk about, those in the caring professions are themselves at risk of suicide. For instance, suicide in the medically related professions such as: medicine, nursing, pharmacy and dentistry are on the increase when compared with data from the general population (Keith et al., 2011). There is also evidence that stress, depression and suicide are common among physicians and nurses (Rakatansky, 2016; Alderson, Parent-Rocheleau & Mishara, 2015). Although, it is beyond the scope of this chapter to explore the contributing factors related to all health professionals and suicide, some key contributing factors to physician and nurse suicides will be reviewed. SUICIDE & DOCTORS Doctors are people first, they are therefore, as susceptible to emotional difficulties like anyone else. Furthermore, being a physician is itself a stressful occupation and can sometimes lead to substance misuse, mental illness and suicide (Klitzman, 2007; Vogel, 2016; Rakatansky, 2016). In fact, “suicide is now considered an occupational hazard for physicians. About 400 doctors take their own life in the United States annually” (Picard, 2015, p. A15). Physicians are also twice as likely to commit suicide when compared to members of the general population (Milne, 2001). There is also a higher incidence of suicide among

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women doctors when compared to males (Rakatansky, 2016). Rakatansky (2016) estimated that the actual number of physician deaths due to suicide could be higher than the statistics indicated, based on the fact that many death certificates in the United States do not list the actual cause of death. In many jurisdictions in Canada statistics on actual physician suicides are not even kept (Milne, 2001). Contributing Factors to Physician Suicide Contributing factors to physician suicide include but are not limited to: heavy work-loads, bullying, unreasonable expectations, stigma and perfectionism (Picard, 2015; Vogel, 2016; Milne, 2001). (Refer to Fig. 5.2). The stressors that may lead to suicide begin in medical school. Medical students and residents are especially at risk due to the amount of pressure they face. What is even more alarming is that during medical school, “bullying and psychological harassment are commonplace, and so is stigma toward mental illness” (Picard, 2015, p. A15). Medical school is often associated with this macho attitude that medical students need to be toughened, and those who can’t take the pressure are weak and unfit for the job (Picard, 2015). In fact, expressing any form of emotion is regarded as an impediment to success (Korenblum, 2015). Another issue for medical students and residents includes uncertainty about the future. Doctors can no longer assume that they will be living a life of privilege once they graduate from medical school (Picard, 2015). This is especially true when student debt is extremely high due to years spent in school before they are gainfully employed as a doctor. Contributing factors to physician suicide include but are not limited to: heavy work-loads, bullying, unreasonable expectations, stigma and perfectionism Fig. (5.2). Contributing Factors to physician suicide. Source: Picard. 2015; Vogel, 2016; Milne, 2001.

Perfectionism is another known risk factor for suicide among physicians. “Increasingly, research is showing that so-called super-performers (such as those attracted to medical school) are particularly vulnerable” to mental illness and suicide because of the extreme pressure that they place upon themselves to excel (Picard, 2015, p. A15). The culture of medicine “rewards workaholics, demands perfection and glorifies self-sacrifice” (Vogel, 2016, p. 1213). Some older doctors even ridicule the newer generation of medical school graduates. They openly refer to these younger doctors as weak, especially if they do not want to put in the long and exhaustive overtime hours that has been expected of the older medical community (Picard, 2015).

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Obstacles to Treatment There are considerable obstacles that inhibit doctors from coming forward and getting the assistance that they need. For example, even though mental illness and depression play a significant role in physician suicide, large numbers of doctors refuse to get treated. In fact, only 25 percent of doctors who suffer from a mental illness will seek help (Vogel, 2016). Of those that do get treated, many selfprescribe anti-depressants or get a physician colleague to write them a prescription without a formal psychiatric assessment being done (Vogel, 2016; Klitzman, 2008). One reason that doctors do not get treated for a mental illness, is that they are afraid of being judged as weak. There is a large degree of shame and guilt associated with coming out and admitting that you are not coping (Vogel, 2016). Subsequently, many doctors do a good job of hiding their symptoms. In addition to the apprehension of being judged, doctors also have a real fear of losing their license to practice if they openly admit that they have a mental health problem (Rakatansky, 2016). Rakatansky (2016) proposes that licensing boards should not penalize doctors for admitting that they have a mental illness. Licensing bodies should also ensure that physicians can be re-instated once their symptoms have been adequately treated (Rakatansky, 2016). Although, no doctor should practice if they are unfit either physically or mentally, there still needs to be a willingness to demonstrate that a doctor will be able to return to work again once they are well enough (Rakatansky, 2016). Change the Stigma That Exits Within the Medical Community In the past when doctors killed themselves it was kept quiet, now there is at least a dialogue about the problem of physician suicide (Picard, 2015). However, merely talking about the fact that suicide among doctors occurs is not good enough. We need to change the stigma that exists within the medical community. (Refer to Fig. 5.3) A good place to start is to normalize the fact that doctors are human beings who are under considerable stress and pressure, and that it is okay for them to admit that they need help (Vogel, 2016). Early diagnosis and treatment of mental illness also needs to occur (Vogel, 2016). CHANGE THE STIGMA WITHIN THE MEDICAL COMMUNITY: We have to normalize the fact that doctors are human beings, who are under considerable stress and pressure, and that it is okay for them to admit that they need help. Early dignosis and treatment of a mental illness also needs to occur Fig. (5.3). Change the stigma within the Medical Community. Source: Vogel, 2016.

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SUICIDE & NURSES Studies have demonstrated that there is high prevalence of suicide among nurses, higher than that of the general public (Alderson et al., 2015). Alderson et al. (2015) also point out that the research that explores the prevalence of nurse suicides has been extremely inadequate over the course of the past two decades. Nevertheless, when existing research did compare nurses with others in the health-related occupations, nurses, (both male and female) stood out as being at considerable increased risk of suicide (Skegg, Firth, Gray & Cox, 2010). Alderson et al. identified the following specific factors that contributed to an increase risk of suicide in nurses: “nurses’ knowledge of and access to medications that could be taken to complete suicide, mental illness (particularly depression), stress, occupational stress, smoking and substance abuse” (Alderson et al., 2015, p. 91).

Fig. (5.4). Nursing as a profession can be stressful. Source: www.pixabay.com.

Nurse Suicide & The Role of Work Stress Fig. (5.4) is a picture of a nurse caring for a premature new born in a Neonatal Intensive Care Unit (NICU). This picture is symbolic of the fact that nursing as a profession can be stressful (Alderson et al., 2015). Although the causes of nurse suicide are multi-factorial, work related stress is definitely a contributing factor because the work that nurses do taxes both their physical and emotional resources (Alderson et al., 2015). For instance, nurses often work long hours which includes rotating shifts and they are often pressured into doing over time. Nurses are also constantly exposed to human suffering which takes its emotional toll (Florio, 2010). In fact, the literature named the following specific factors related to working conditions that negatively impacts nurses and contributes to suicide: very heavy work-loads, inadequate coping, interpersonal conflicts, work place aggression and lack of support by immediate supervisors (Alderson et al., 2015).

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Leymann & Gustafsson (2014) also identified a direct association between bullying in the work place and nurse suicide. Stigma Prevents Nurses from Getting Help If we want to be able to prevent more suicide deaths among nurses we need to do more to change a culture within the profession of nursing that stigmatizes nurses who are mentally ill (Ross & Goldner, 2009). For example, as Fig. (5.5) emphasizes stigma toward mental illness prevents nurses from getting the help that they need. For example, Ross & Goldner (2009) did a review of the literature that identified stigma toward mental illness within the nursing profession. They found that large numbers of nurses held stereotypical views of people who suffer from mental illness. Many nurses readily admitted that they believed that mental illness is due to weakness of character or a lack of will. Nurses were also very prone to judge other nurses who suffered from mental illness. Even nurses who suffer from a mental illness judged themselves (Ross & Goldner, 2009).

Stigma toward mental illness plays a role in preventing nurses from getting the help that they need. Nurses are also very prone to judge other nurses who suffer from

mental illness. Even nurses who suffer from a mental illness judge themselves

Fig. (5.5). Stigma by Nurses. Source: Ross & Goldner, 2009.

CARING FOR THE SUICIDAL PERSON & COMPASSION FATIGUE “The expectation that we can be immersed in suffering and loss daily and not be affected or be touched by it, is as unrealistic as expecting to walk through water without getting wet.” Rachel Naomi Remen MD, author and teacher of alternative medicine

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Caring for the suicidal person can be stressful. A person who is suicidal is in an emotional crisis. They may have already attempted to kill themselves and perhaps more than once (Michel, 2011). When the suicidal patient shares their story a gatekeeper may become emotionally traumatized by the details of the degree of suffering and loss experienced by their patient (Florio, 2010). Being repetitively exposed to these stories can also have a cumulative emotional effect on a helping professional which places them at risk of developing compassion fatigue (Jarvis, 2009, Florio, 2010). Compassion fatigue occurs when people are exposed to suffering on a regular basis, suffering such as trauma, death, loss and emotional pain. Over time exposure to constant suffering can result in helping professionals disconnecting emotionally from those in their care as a means to cope. Florio (2010) is quick to point out that compassion fatigue is not a pathological condition like a “mental illness, but is considered a natural behavioral and emotional response that results from helping or desiring to help another person suffering from trauma or pain” (p. 7). However, when compassion fatigue sets in your capacity to actually help becomes eroded and inevitably results in the lack of capacity or interest in being empathetic with other people (Figley, 2002). Some of the symptoms of compassion fatigue include, but are not limited to: disturbed sleep with intrusive thoughts during sleep or while awake; feeling sad or resorting to angry outbursts without any real reason; feeling overwhelmed; emotional withdrawal from patients; difficulties with personal relationships; no longer caring about, or for others; and feeling hopeless (Mathieu, 2012; Stephany, 2015; Jarvis, 2009). (Refer to Box 5.1). Box 5.1. Symptoms of compassion fatigue. Source: Mathieu, 2012; Stephany, 2015; Jarvis, 2009.

SOME OF THE SYMPTOMS OF COMPASSION FATIGUE: Disturbed sleep with intrusive thoughts during slepp or while awake Feeling sad or resorting to angry outbursts without any real reason Feeling overwhelmed

Emotional withdrawal from patients Difficulties with personal relationships No longer caring about, or for others Feeling Hopeless

Vicarious traumatization is very similar to compassion fatigue. It is defined as “the cumulative transformative effects upon therapists resulting from empathic engagement with traumatized clients” (McCann & Perlman, 1990 as cited in

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Kearney & Weininger, 2009, p. 112). However, although compassion fatigue and vicarious traumatization are similar, they differ in one key way. Whereas compassion fatigue can occur from exposure to any type of suffering, vicarious traumatization is more closely related to continual exposure to patients who have specifically experienced some sort of trauma (Mathieu, 2012). STRATEGIES THAT ENHANCE EMOTIONAL WELL-BEING If compassion fatigue is to be prevented or effectively treated when it does occur, healthy coping strategies need to be adopted and utilized that enhance emotional well-being. These approaches include: 1) encouraging gatekeepers to reach out for professional help, 2) fostering self-compassion and 3) making self-care a priority (Mathieu, 2012; Schmidt, 2002; Florio, 2010; Stephany, 2015). We will explore each of these three regimes more fully. STRATEGY 1: REACH OUT FOR PROFESSIONAL HELP IF NEEDED “The ability to hear our own feelings and needs and to empathize with them can free us from depression.” Marshall Rosenberg, author and founder of Non-violent Communication

One way to prevent compassion fatigue is to be aware that it can occur (Jarvis, 2009). However, if you find yourself experiencing some of the symptoms of compassion fatigue you may require professional help (Florio, 2010). Reaching out to a therapist is an excellent way to help you to sort through what is going on for you. It can “help ease some of the burdens of professional and personal issues and is an excellent way to manage stress and anxiety” (Florio, 2010, p. 42). Normalize the Experience of Getting Help Therapy works and Fig. (5.6) depicts a picture of a therapist seeking guidance from another therapist. We need to make it normal for all health professionals to believe that it is okay to ask for professional help when they need it. I do my very best to normalize the experience of nurses seeking assistance from a trained professional by explain to my nursing students how therapists are trained. Psychologists in training learn that because our work is emotionally exhausting at times, seeking help from another trained therapist is highly recommended. We are taught that therapy is just as important for the therapist as it is for our patients (Macran & Shapiro, 1998). For example, when I was in graduate school and preparing to become a Counselling Psychologist, it was a mandatory requirement that all of us students receive therapy each week. On-going therapy for training Psychologists was a required part of the curriculum.

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Fig. (5.6). Therapy should be normalized. Source: www.pixabay.com.

It is also not an uncommon practice for practicing Psychologists and other helpers in the counselling field to self-refer to therapy, especially if they are feeling negatively impacted by their work or experiencing stress in their personal lives (Macran & Shapiro, 1998; Gimmer, 2015). Gimmer (2015) points out that, “Personal therapy for therapists is widely undertaken and highly valued by many therapists from diverse approaches. Many regard therapy as being of great benefit both personally and professionally” (p. 265). (Refer to Fig. 5.7). Personal therapy for therapists is widely undertaken and highly valued by many therapists from diverse approaches. Many regard it as being of great benefit both personally and professionally Fig. (5.7). Personal therapy & therapists. Source: Gimmer, 2015.

I also try to normalize the experience of reaching out for help by openly encouraging my nursing students to seek guidance at the end of a difficult day in the clinical setting. My nursing students sometimes report that just listening to a suicidal person’s story can cause them to become extremely emotionally distraught. When a student nurse does admit that they are being negatively impacted by what they are exposed to in clinical practice, I ensure that they are immediately de-briefed. We explore the feelings experienced by the student nurse

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and how to best deal with those feelings (Mathieu, 2012; Stephany, 2015). I then assist the student nurse to develop a personal plan of self-care that includes connecting with supports. I also openly encourage them to attend counselling sessions that are freely offered at the college. Access Critical Incident De-Briefing (CID) Many employment venues offer critical incident debriefing (CID) when a worker is exposed to circumstances in the work environment that may cause them emotional distress. Critical incident de-briefing (CID) is a formal process where a trained counsellor debriefs workers who have been exposed to traumatic situations that are outside of the normal realm of human experiences (Mathieu, 2012). CID can be very helpful for gatekeepers. For example, having a patient either attempt suicide or commit suicide may warrant CID. Ideally, CID should occur as soon as possible after the event and be conducted by a professional trained in CID (Mathieu, 2012). The goal of CID is not to spend too much time going over the details of the incident because that may cause re-traumatization. The objective is to help the person to process their feelings and any other negative emotional consequences of being exposed to a trauma. If symptoms progress to signs of post-traumatic stress disorder or depression, then further professional assistance may be required (Stephany, 2015). Post-traumatic stress disorder (PTSD) occurs after exposure to an event that is outside the realm of normal human experience (e.g., war, violence, rape, abuse, disaster). Some of the symptoms of PTSD include hyperarousal, re-experiencing of the trauma, avoidance of anything associated with the disturbing memory, trouble in relationships, mood swings and even symptoms of depression (Andrews, Brewin, Rose, & Kirk, 2000). Depression is characterized by some of the following symptoms: depressed mood, low energy, loss of interest in activities normally enjoyed, change of appetite, sleep disturbances (e.g., sleeping too much or too little), and negative thought processes which may include thoughts of suicide (Kozy & Varcarolis, 2014). STRATEGY 2: FOSTER SELF-COMPASSION Caring for myself is not self-indulgence, it is self-preservation.” Audre Lorde, African-American writer and civil rights activist

Being self-compassionate involves the action of being self-forgiving and avoiding self-judging, especially when you think you have not measured up to your own, or other’s expectations. At the end of Chapter One I encouraged gatekeepers to be self-compassionate, especially if they felt that they may have acted without demonstrating empathy. This current Chapter re-introduces the

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important strategy because as Fig. (5.8) points out, caregivers who develop compassion fatigue often resort to feelings of self-blame and a real sense that they are letting those people down who depend on them for support. They also may feel like they are a failure professionally (Jarvis, 2009; Florio, 2010). Those who develop compassion fatigue often resort to feelings of selfblame and a real sense that they are letting those people down who depend on them for support. They also may feel like they are a failure professionally Fig. (5.8). Compassion fatigue & self-blame. Source: Jarvis, 2009; Florio, 2010.

Rosenberg (2003) stresses the importance of reminding ourselves that helpers are especially in need of love and care. Health professionals need to be cognizant of the fact that all judging impedes personal growth including judging ourselves (Stephany, 2012a). We need to learn to forgive ourselves for being human and not only look for the good in others, but also look for the good in ourselves (Salzberg, 2004). Reflective Journaling & Self-awareness Practicing self-awareness through journaling has been recommended several times in this book. These strategies are recommended once again as a good way to become acquainted with your feelings, especially if you are being self-critical or experiencing self-loathing (Goleman, 2005). Reflective journaling increases selfawareness and all change begins with being aware that change is needed (Goleman, 2005). Studies have even demonstrated that reflective journal writing may actually help prevent compassion fatigue. The rationale is that writing reflectively about your experiences and thoughts assists you to acknowledge that you are being affected by what has been happening in your practice, and that it is okay to feel unnerved or exhausted (Mathieu, 2012; Jarvis, 2009). When journaling you may want to write about what you have learned or are currently learning. Rosenberg (2003) when referring to self-compassion eludes to the process of empathetically holding “both the parts of ourselves – the self that regrets a past action and the self that took the action in the first place. The process of mourning and self-forgiveness frees us in the direction of learning and growing” (p. 134). This process better enables us to let go of fear, guilt, shame and a sense of obligation (Brown, 2013). We are then freed to start again with a fresh perspective and with no negativity holding us back. We are able to look at ourselves, not with contempt but with the compassion that we so deserve (Rosenberg, 2003). (Refer to Fig. 5.9).

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The process of mourning and self-forgiveness frees us in the direction of learning and growing. This process better enables us to let go of fear, guilt, shame and a sense of obligation. We are then freed to start again with a fresh perspective and with no negativity holding us back. We are able to look at ourselves, not with contempt but with the compassion that we so deserve Fig. (5.9). Source: Rosenberg, 2003; Brown, 2013.

STRATEGY 3: MAKE CARE FOR THE CAREGIVER A PRIORITY “Although it is virtually impossible to avoid compassion stress altogether, the helping professional can use several precautions to prevent the stress of caregiving from escalating to higher levels of stress, such as . . . compassion fatigue.” Christine Florio, author of the book, Burnout & Compassion Fatigue

Schmidt (2002) points out that helping professionals routinely encourage their clients or patients to take care of themselves, but they do not necessarily practice what they preach. The fact is, helping professionals often spend so much time caring for others that they neglect their own health and well-being (Schmidt, 2002). Yet, as Fig. (5.10) points out, you can’t really do a good job of taking care of others if you don’t take care of yourself. Caregivers can learn how to make self-care a priority in some of the following ways: adopt ways that enhance your physical and emotional health; strive for work-life balance; foster supportive relationships at work; and cultivate gratitude.

Fig. (5.10). Take Care of yourself first. Source: www.quotehd.com.

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Self-Care Plan A: Adopt ways that Enhance your Physical & Emotional Health Health professionals and all gatekeepers need to ensure that they remain fit to practice which consists of making their physical and emotional health a priority. Yet too often the opposite is the reality. Busy work schedules often lead to poor eating habits, lack of exercise, sleep difficulties, over consumption of alcohol, and over the counter drug use (Florio, 2010). Furthermore, less than desirable life style habits that compromise your overall health can decrease your ability to cope with all types of stress. Poor life style choices can also put you at increased risk of developing compassion fatigue (Mathieu, 2012). Begin by Conducting an Evaluation of Your Wellness A good place to start to make better health choices should ideally consist of doing an evaluation of where you currently are because all change in behavior begins with self-awareness (Goleman, 2005). It is time to get the journal out again. Ask yourself a series of questions and be honest with yourself. “What am I doing well?” “What am I neglecting?” “What could I do better?” “What needs to change?” “What will it take for me to begin to move toward making those changes?” “What is my first priority?” Set Realistic Goals for Yourself Setting unrealistic goals sets you up for failure. Therefore, you need to set realistic and achievable health enhancing goals for yourself if you are going to succeed. I suggest that you make a list of what you would like to achieve and then embark on one priority at a time. When you have made one change a habit move onto to the next goal. Remind yourself that success in small steps increases your belief that change is possible, and motivates you to continue on your journey of wellness (Stephany, 2012a). Have Someone Make you Accountable Often we need to rely on someone close to us to help us to stay on track with our health goals. What I suggest is that you reach out to someone you trust and form a

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partnership to keep you on track with your plan. When you do not feel like carrying through with a strategy, the other person in the partnership holds you accountable to your prior commitment. Remember that it usually takes about 21 days before an activity becomes a habit (Stephany, 2006; Stephany 2012a). Listed below are some strategies that you may want to consider to improve your overall health. Strategies to Improve your Overall Health: (as adapted from Stephany, 2015, pp. 165 – 166). ● ● ● ● ● ●

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Exercise on a regular basis and remember that walking is free Get enough sleep Eat healthier Drink more water Keep alcohol consumption to a minimum Begin your day by reading something positive like a daily devotional or a list of affirmations Avoid spending time with negative people Replace negative self-talk with positive affirmations Spend time in nature Make time to do the things that you enjoy

Self-Care Plan B: Strive for Work-Life Balance “Don’t confuse having a career with having a life.” Hillary Rodham Clinton, Former USA Secretary of State

If you are going to be able to stay physically and emotional healthy you need to strive for work-life balance. Many of us caregivers view the work that we do for a living as extremely important. We take pride in knowing that we make a difference in the lives of others through our vocation. However, we need to remind ourselves that our work is not our whole life. Leisure time, time spent with family and friends and time to do the sort of activities that bring us joy are not luxuries they are necessities for our overall wellbeing. Kearney and Weininger (2009) so clearly advise that all caregivers “need times of retreat, times from work and time to immerse ourselves in whatever is most deeply meaningful for us” (p. 123). Mihaly Csikszentmihalyi (1990) is the author of the book, Flow: The Psychology of Optimal Experience. His studies have revealed that pleasure, in and of itself is not what brings us happiness, it is being in the flow while immersed in something that we truly enjoy that leads to blissfulness. For example, when we are involved in an activity that we feel passionate about and that requires our full attention, we lose all concept of time because we are in the flow. Nothing else seems to matter. This is what gives our lives meaning (Csikszentmihalyi, 1990). I

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challenge you to consider making time to do some of the activities that bring you joy. Recently I did an inventory of what I used to love to do and realized that I had stopped playing the piano even though I loved playing it. I had stopped playing simply because I was busy with so many other things and it didn’t seem like a priority. I began playing the piano again and I purposely set aside time each week to play the piano. I also have stuck to my commitment. Playing the piano is now considered my time. I can’t even explain how wonderful this experience has been for me. I only wish I had made this change sooner. Self-Care Plan C: Foster Supportive Relationships with Others at Work As a helping professional chances are that you work very closely with other caring people who are compassionate in nature. If this is the case, self-care begins by fostering supportive relationships with other caring professionals that you work with. For example, according to Kearney & Weininger (2009) self-care is not only about stress management and emotional damage control. It is also “about finding ways of remembering and staying connected in the workplace with the wholeness that is already there?”(p. 109). By developing a good working relationship with others in the same helping work environment, you have a built in support network. Leaning on one another for emotional support may result in a healthy venue to openly express frustrations, process emotional responses and vent feelings in a safe environment (Florio, 2010). It can also facilitate opportunities to receive feedback from another professional in the same field of work on how to best regain focus (Florio, 2010). Furthermore, the more that you practice leaning on each other for support at work, especially when in crisis, the more likely that this process will become an integral part of your work place climate (Florio, 2010). Self-Care Plan D: Cultivate Gratitude “Acknowledging the good that you already have in your life is the foundation for all abundances.” Eckhart Tolle, author

I encourage you to consider cultivating gratitude as a means to enhance your emotional well-being. Gratitude is defined as the positive experience of being purposely thankful for the benefits in one’s life (Karshdan, Uswatte & Julian, 2005). As Fig. (5.11) emphasizes, there are many benefits to the practice of gratitude. For example, research has demonstrated that gratitude has a positive effect on the everyday functioning of the person who expresses it on a regular basis (Karshdan et al., 2005). It has also been established that gratitude as a personality trait is strongly linked to positive mental health (Wood, Joseph & Linley, 2007). In fact, “Multiple studies now suggest that people who feel more

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gratitude are much more likely to have higher levels of happiness and lower levels of depression and stress” (Wood et al., 2007, p. 18).

It is has been established that gratitude as a personality trait is strongly linked to positive mental health. In fact, Multiple studies now suggest that people who feel more gratitude are much more likely to have higher levels of happiness and lower levels of depression and stress Fig. (5.11). The benefits of gratitude. Source: Wood et al., 2007.

Gratitude has transformed my life in a positive way. It has been two decades since I embarked on a journey of giving thanks. Every day I record what I was thankful for in a journal. Since undertaking this endeavor, my life has never been the same. Even though I have encountered trials and tribulations and even serious health challenges in the past few years, gratitude has helped me to focus on the many blessings in my life. In fact, when “I am confronted with a troubling issue, I force myself to give thanks even more. What inevitably occurs is that my sadness or anxiety lifts and is replaced with perfectly peaceful joy” (Stephany, 2012a, p. 18). The problems themselves do not disappear but my ability to cope with them is enhanced. I teach my nursing students to focus on the goodness in life as a strategy to help them deal with what they are exposed to in the clinical setting. My nursing students are assigned to take care of patients who are mentally ill, suffering from addictions and who are suicidal. Oftentimes they become very distraught by the stories that they hear. In addition to de-briefing and offering them support, I also do a check-in with each student just before they leave the hospital. I ask them to pick an activity that they can do when they go home that will help to connect them to the goodness in life. They come up with ideas such as: hug my child; take my dog for a walk; talk to my mom; read something positive; listen to relaxing music; talk to a friend and so forth. My nursing students consistently report back to me that connecting with the goodness in life helps them to focus more fully on what is going well in their life. It also increases their ability to cope with their clinical work. CONCLUSION & TAKE AWAY POINTS “Never give up, for that is just the place and time that the tide will turn.” Harriet Beecher Stowe, American author

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In closing I will briefly highlight a few take away points that I would like every reader to remember from this book. We can do a better job of caring for the suicidal person. We need to be reminded that the essential component of a suicidal person’s crisis is emotional, therefore strategies for prevention need to ensure that they do not neglect this essential component. Preventing mental illness accompanied by early treatment is imperative if we are to save more lives. Establishing a therapeutic alliance of trust between the caregiver and patient is crucial, and so is making the suicidal person’s story a priority. The ethic of care and empathy are an active means to communicate to our patients that we genuinely care for them and that we want to help them out of their place of hopelessness and despair. After the initial crisis has passed, the suicidal person also should be referred for further help in the form of Cognitive Therapy. They need therapy to help change their negative mind set, to improve their coping and to establish a purpose for going on with their life. Taking care of people who are suicidal can be stressful for helpers. Therefore, strategies that promote the wellbeing of gatekeepers need to be adopted. We also must not forget to acknowledge the tremendous work of all suicidologists and gatekeepers, whose primary goal is to do whatever they can to prevent further deaths by suicide. As a final note, I would like to share a poem that was given to me by a patient. I think the message clearly articulates the role of the helper and reminds us of what we are here to do. WHAT WE ARE HERE FOR We are here to listen . . . not to work miracles. We are here to help people discover what they are feeling . . . not to make feelings go away. We are here to help people identify their options . . . not to decide for them what they should do. We are here to help people discover their own strength . . . not to rescue them and leave them still vulnerable. We are here to help people discover they can help themselves . . . not to take responsibility for them. We are here to help people learn to choose . . . not to make it unnecessary for them to make difficult choices. We are here to provide support for changes. Author Unknown

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REFLECTING BACK Summary of Key Points Covered in Chapter 5 ●

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It was pointed out that many people in the caring professions are themselves at risk of suicide. In fact, suicide is now considered an occupational hazard for physicians. Doctors are twice as likely to commit suicide when compared to members of the general population. Contributing factors to physician suicide include but are not limited to: heavy work-loads, bullying, unreasonable expectations, stigma and perfectionism. Key obstacles to doctors getting help include: stigma toward mental illness within their own physician population; the fear of being judged as weak; and fear of losing their license to practice. If we are to make headway toward changing the stigma toward mental illness among the physician population, we need to normalize the fact that doctors are human beings. Early diagnosis and treatment of a mental illness also needs to occur. Studies have demonstrated that there is high prevalence of suicide among nurses, higher than that of the general public. Ready access to means, mental illness, substance abuse, work related stress and even work place bullying were cited as some of the contributing factors to nurse suicide. Stigma toward mental illness within the profession of nursing was identified as a key factor in nurses not seeking professional help. It was pointed out that due to the fact that caring for the suicidal person can be stressful there is a real risk of a gatekeepers developing compassion fatigue. Compassion fatigue occurs when people are exposed to suffering on a regular basis. Over time exposure to constant suffering can result in helping professionals disconnecting emotionally from those in their care as a means to cope. Symptoms associated with compassion fatigue, include, but are not limited to: disturbed sleep with intrusive thoughts while awake or during sleep; feeling sad or resorting to angry outbursts without any real reason; feeling overwhelmed; emotional withdrawal from patients; difficulties with personal relationships; no longer caring about, or for others; and feeling hopeless. Vicarious traumatization is very similar to compassion fatigue. It is defined as the cumulative transformative effects upon therapists resulting from empathic engagement with traumatized clients. However, although compassion fatigue and vicarious traumatization are similar, they differ in one key way. Compassion fatigue can occur from exposure to any type of suffering, but vicarious traumatization is more closely related to

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continual exposure to patients who have specifically experienced some sort of trauma. If compassion fatigue is to be prevented or effectively treated when it does occur, additional coping strategies need to be adopted and utilized such as 1) encouraging gatekeepers to reach out for professional help; 2) fostering selfcompassion; and 3) suggesting ways for caregivers to make their wellbeing a priority. We need to help gatekeepers reach out for professional help by normalizing this experience. We should encourage gatekeepers to attend critical incident de-briefling (CID) if it is available. CID is a formal process where a trained counsellor debriefs workers who have been exposed to traumatic situations that are outside of the normal realm of human experiences. Caregivers were inspired to be more self-compassionate. Being self-compassionate involves the action of being self-forgiving and avoiding self-judging, especially when you think you have not measured up to your own, or other’s expectations. Practicing self-awareness through journaling was recommended as a way to sort through your feelings if you are feeling self-critical. Gatekeepers were urged to make care for the caregiver a priority in the following ways: adopt strategies that enhance one’s physical and emotional health; strive for work-life balance; foster supportive relationships at work; and cultivate gratitude. In conclusion a few take way points from the book were highlighted. We need can do a better job of caring for the suicidal person. Remember that the suicidal person’s crisis is an emotional one. Preventing mental illness accompanied by early treatment is important. The therapeutic alliance of trust between the caregiver and patient is crucial. We have to make the suicidal person’s story a priority. The ethic of care and empathy are an active means to communicate to our patients that we care about them enough to want to help them out of their despair. After the initial crisis has passed, the suicidal person needs to be referred for further help. We have to be grateful for the work and commitment of all suicidologists and gatekeepers. ❍ ❍ ❍ ❍ ❍ ❍

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GLOSSARY adverse life experiences are traumatic life experiences that may include early separation from parents, childhood physical, sexual and emotional abuse, and physical and sexual abuse in adult life. autonomy is an ethical principle which respects a person’s right to make decisions about their life. beneficence is an ethical principle that is concerned with doing what will be beneficial to a patient. borderline personality disorder is characterized as a marked instability in emotion regulation, unstable interpersonal relationships, impulsivity, identity or self-image distortions, and unstable mood. clarification is a communication technique that involves the process of making clearer what may appear vague. It may consist of directly asking the other person to explain what they meant. Cognitive Therapy, also referred to as Cognitive Behavioral Therapy, is a form of treatment that consists of helping a person to change the way that they think. It is based on the premise that the way that we think about events in our life profoundly influences the way that we feel about them. If we can change the way that we think, this will in turn, change the way that we feel. cognitive re-structuring consists of a process of having a helping professional challenge negative automatic thought processes that are not necessarily true with actual facts. compassion is closely aligned with empathy and is concerned with identifying with the suffering of others. compassion fatigue occurs when people are exposed to suffering on a regular basis, suffering such as trauma, death, loss and emotional pain. Over time exposure to constant suffering can result in helping professionals disconnecting emotionally from those in their care as a means to cope. This is the essence of compassion fatigue. connecting is a term that is used in communication that refers to the ability to meet another person on a human level and to relate to them as individuals. It helps someone to feel understood. constriction of thought refers to the narrowing or tunneling of the focus of attention on death by the suicidal person as the only way out of their psychological pain. coping cards are developed when a person is no longer in a crisis and contain adaptive coping statements that patients can consult during a time of future distress. Coroner is the title given to certain death investigators. In addition to identifying the deceased and a cause of death, an integral role of the Coroner is to gather facts concerning the circumstances leading up to an unexpected sudden and unnatural death. An additional purpose of a Coroner is to make recommendations when appropriate to prevent a death under similar circumstances. critical incident de-briefing (CID) is a formal process where a trained counsellor debriefs workers who have been exposed to traumatic situations that are outside of the normal realm of human experience.

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culture represents the beliefs and customs of particular groups in society and consists of much more than ethnicity. Culture includes ethnicity but also encompasses age, socioeconomic status, gender, and religion. depression is characterized by some of the following symptoms: depressed mood, low energy, loss of interest in activities normally enjoyed, change of appetite, sleep disturbances, and negative thought processes including thoughts of suicide. empathy is the ability to be able to identify with and to understand, the experiences of another person and includes both positive and negative experiences. ethnicity traditionally is associated with a particular social group that shares a common culture, religion and language. ethics is derived from philosophy and is concerned with the study of ideal conduct. ethic of care is associated with the caring relationships between people and their interconnectedness. It is concerned with the action of caring for others and doing what we can to end human suffering and discrimination against all minorities. ethic of justice is concerned with fairness and treating everyone equally. ethical dilemma is said to occur when there are two or more ethically defensible courses of action that can be taken but only one can play out in practice. exquisite empathy is a type of empathy that encourages professional boundaries. The practitioner identifies with the patient’s feelings but is also able to stay separate from their suffering by choosing to remain in the present moment. gatekeeper is a person who because of their specific line of work may come into contact with people who are suffering from suicide ideation. gesture refers to an action performed for show and not necessarily for effect. gratitude is the positive experience of being purposely thankful for the benefits in one’s life. hope is about having goals for the future and a belief that life can get better than it presently is. hopelessness is associated with having no hope, feeling despair and resignation that nothing will change. hope instillation is a process of helping others to re-discover their sense of hope. It is of particular importance for people who are suicidal because they often have lost all hope. listening stoppers are hindrances that interfere with our ability to connect with the other person. Interrupting the other person is an example of a listening stopper. mindful listening is concerned with making time stand still. It entails actively listening without anything distracting you from being in that very moment with the other person. moral agency is one’s ability to act on one’s personal moral beliefs. moral disengagement happens when a clinician who is experiencing moral residue, distances themselves from all relational aspects of care and resorts to only performing tasks. moral residue is the feeling of on-going remorse and guilt that may occur when nurses are unable to act on their moral beliefs. Narrative Action Theoretical Approach is a type of therapeutic technique where the therapist encourages the person who is suicidal to tell the story of why it is they have decided to end their life. They are then encouraged to change the ending to their story and to choose life instead of death.

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narrative case study is a form of qualitative research. It consists of systematically gathering data by analyzing a person’s story as told by them in order to identify themes and trends. non-maleficence is an aspect of the ethical principle of beneficence and is about our duty to do no harm, either intentionally or unintentionally. open-ended question is one that cannot be answered with one word, such as “Fine,” Yes,” or No.” It is the type of question that helps the person to tell you their story. para-phrasing is a communication technique that consists of re-stating the person’s basic message in your own words. The purpose of para-phrasing is for the helper to see if they actually do understand what the intended message was. parasuicidal gesture refers to an action of self-harm by a person. Equating an actual suicide attempt to a mere gesture may result in a dismissive response and actually diminish the gravity of the suicide attempt. philosophy is the study of ideas concerning knowledge and what is true and the overall nature and meaning of life. post-traumatic stress disorder (PTSD) occurs after exposure to an event that is outside the realm of normal human experience. Some of the symptoms of PTSD include hyperarousal, re-experiencing of the trauma, avoidance of anything associated with the disturbing memory, trouble in relationships, mood swings and even symptoms of depression. presencing is the act of being fully present and in the moment with a person and offering them your full attention. It also entails sending the person kind and caring thoughts and is best done in silence. protective factors are socio-cultural, environmental and individual factors which may reduce a person’s vulnerability to suicidal behavior. psychache is a term that refers to a person’s unbearable emotional pain. It was a term developed by a world re-known 20th century suicidologist, Edwin Shneidman. psychological autopsy consists of a retrospective investigation after a death has occurred. The goal is to try and re-trace the events that happened to the deceased prior to death. The process may consist of gathering physical evidence, review of medical records and interviewing people who were involved with the person prior to death. qualitative study is a method of scientific inquiry that is utilized to gain increased understanding of the experience of humans and to describe the essence of that experience. Qualitative research aims to discover meaning and understanding rather than to verify truth or predict outcomes. quantitative research consists of the measuring and quantification of identified objective reality. The goal is to draw inferences about the whole from the analysis of its parts and quantitative studies are concerned with causes and effects. In quantitative research the researcher stands outside the phenomenon that is being studied. recovery models in mental health treatment do not necessarily focus on full recovery from illness but emphasize ways that people with mental illness can lead productive lives. Recovery models are strength based and encourage patient empowerment. resiliency refers to a person’s optimistic set of assumptions about themselves that in turn influence their mindset, their responses to life’s stressors and their ability to cope in an affirmative manner to those stressors.

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Safety Plan is a prevention tool that is designed to help those who struggle with their suicidal thoughts. It promotes healthy coping, assists the person in establishing reasons for living and to specifically identify people to call when they are in crisis. self-awareness is the ability to recognize your emotions, beliefs, values and attitudes and to know your strengths and weaknesses. It also entails being aware of strong feelings without reacting to those feelings. self-compassion consists of telling ourselves that because we are human we sometimes make errors in judgment and we must be more self-forgiving. sexual prejudice consists of negative attitudes toward sexual preferences that differ from heterosexuality. social stressors collectively represent factors and/or situations that occur in society that have an impact on a person’s stress levels and ability to cope. stigma is defined as an association of disgrace or public disapproval of something such as a behavior or condition. Strain Theory of Suicide explains how psychache and ensuing suicide is usually preceded by specific types of psychological strains. These stressors usually consist of two or more variables that pulls or pushes an individual in different directions. suicidal ideation refers to a person experiencing thoughts of suicide. suicide is the act of a person choosing to end their life voluntarily and intentionally. suicide note is a vehicle by which the decedent can have the last word. suicide risk assessment tools are designed to assess the presence of particular symptoms or circumstances that places a person on a scale of categorized risk for a completed suicide (e.g., high risk, moderate risk, low risk). suicidology is the study of suicide, suicidal behavior and suicide prevention. suicidologist is someone who studies suicide. The Aeschi Working Group is a group of suicidologists who are based in Switzerland and associated with the International Association for Suicide Prevention (IASP). This group of highly qualified professionals focuses on the therapeutic approach and offers new helpful strategies for health professionals to adopt to prevent suicide. therapeutic alliance is the basis of a therapeutic process where the patient and care giver become collaborators in helping to heal mental illness and emotional distress. It is like a partnership. transgender refers to a person whose gender identity does not correspond to that person’s biological sex assigned at birth. unconditional positive regard in practice consists of there being no conditions or obstacles to your ability to care for another person. Everyone is deserving of being cared for regardless of their behavior. validation is a communication technique that consists of identifying with the feeling that the other person is experiencing. It may be in the form of offering reassurance that you understand the essence of their experience. vicarious traumatization is very similar to compassion fatigue. It occurs due to the cumulative transformative effects upon therapists from empathic engagement with traumatized clients. warning signs of suicide are somewhat elusive or sometimes overt messages that a person is in trouble. Many warning signs may not appear to be concerning to the

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observer but when taken together they become quite concerning. You must also be aware that sometimes there are no warning signs of suicide.

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APPENDIX A: Sample: Confidentiality Agreement for Simulation Faculty of Health Sciences(as adapted from Douglas College Simulations Lab) Welcome to our Faculty of Health Sciences Simulation Centre. The simulation lab is a learning environment whereby students and faculty actively engage in simulated clinical scenarios to enhance psychomotor, assessment, communication and critical thinking skills pertinent to clinical practice. The simulation lab is a learning environment which promotes professionalism and an expectation that all students and faculty adhere to professional practice. This includes treating everyone with respect, valuing the opinions of others, and fostering a collegial and supportive learning environment. It is also an expectation that all simulation experiences be kept confidential with respect to scenario information, student performance, and debriefing discussions. All students are to adhere to confidentiality by ensuring that no discussions of students actions are to take place outside the simulation lab, this includes any information shared during debriefing sessions. This confidentiality agreement is in keeping with our school of Nursing’s Policy, which expects academic integrity, honesty and ethical conduct of all students. As a student participating within the simulation lab, I understand that the information and shared experiences of all students be kept confidential and that any violation of confidentiality is unethical and may result in disciplinary action according to our school’s Academic Honesty policy.

Student Signature: ____________________________ Month____ Day____ Year____

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APPENDIX B: Further Recommended Readings Colucci, E., & Lester, D. (Eds.), (2013). Suicide and culture: Understanding the context. UK: Hogrefe Publishing. Cutcliffe, J. R., & Stevenson, C. (2007). Care of the suicidal person. USA: Churchill Livingstone Elsevier. De Leo, D., Cimitan, A., Dyregrov, K., Grad, O., & Andriessen, K. (Eds.), (2014). Bereavement after traumatic death: Helping survivors. UK: Hogrefe Publishing. Gorski, T. T. (2010). Straight talk about suicide: Finding a compelling reason to live. USA: Herald House/Independence Press. Hawton, K., & van Herringer, K. (Eds.), (2002). The international handbook of suicide and attempted suicide. UK: Wiley. Henden, J. (2008). Preventing suicide: The solution focused approach. UK: Wiley. Klott, J. (2012). Suicide & psychological pain: Prevention that works. USA: Publishing Media. Kolf, J. C. (2002). Standing in the shadows: Help and encouragement for suicide survivors. USA: Baker Book House. Michel, K., & Jobes, D. A. (Eds). Building a therapeutic alliance with the suicidal patient. Washington DC: American Psychological Association. Perlman, C.M., Neufeld, E., Martin, L., Goy, M., & Hirdes, J. P. (2011). Suicide risk assessment inventory: A resource guide for Canadian health care organizations. Canada: Ontario Hospital Association & Canadian Safety Institute. Michel, K., & Maillart, A. G. (2015). ASSIP – Attempted suicide short intervention program. UK: Hogrefe Publishing. Shneidman, E. S. (2004). Autopsy of a suicidal mind. UK: Oxford University Press. Slote, M. (2007). The ethics of care and empathy. New York: Routledge Taylor & Francis Group. Stephany, K. (2015). Cultivating empathy: Inspiring health professionals to communicate more effectively. United Arab Emirates: Bentham Science Publishing. Simon Fraser University (SFU) Centre for Applied Research in Mental Health & Addiction (CARMHA). (2016). Hope & healing: A practical guide for survivors of suicide. The complete booklet can be downloaded from: www.health.gov.bc.ca/mhd or www.carmha.ca Van Bergan, D. D., Montesinos, A. H., & Schouler-Ocak, M. (2015). Suicidal behavior of

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immigrants and Ethnic minorities. UK: Hegrefe Publishing. World Health Organization (WHO) (2012) Public health for action for the prevention of suicide: A framework. Geneva Switzerland: WHO Library Cataloguing-in-Publication Data.

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APPENDIX C: Information & Resources for Suicide & Crisis Intervention International Association for Suicide Prevention (IASP) Email: [email protected] www.isap.info IASP Resources & Crisis Centres To find a Crisis Centre in your area of the World please visit the link below and select your continent and/or region www.iasp.info/resources/Crisis_Centres/

Some Additional Resources: Canadian Association for Suicide Prevention/Association canadienne pour la prevention du suicide (CASP/ACPS) Winnipeg, Manitoba, Canada Telephone: (204) 784-4073 www.suicideprevention.ca Crisis Intervention & Suicide Prevention Centre of British Columbia (Canada) https://crisiscentre.bc.ca 24 Hour Crisis Help Anywhere in BC: 1-800-SUICIDE or 1-800-784-2433 (In different languages) Vancouver: 604-872-3311 Sunshine Coast/Sea to Sky: 1-866-661-3311 Mental Health Support Line: 604-872-1234 Seniors Direct Line: 604-872-1234 On-Line Chat Service for Youth: www.YouthInBC.com (noon – 1 AM) Online Chat Service for Adults: www.CrisisCentreChat.ca (noon – 1 AM)

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Centre for Suicide Prevention (CSP) (Alberta, Canada) Telephone: 1-(403) 245-3900 Email: [email protected] www.suicideinfo.ca Reason to Live Manitoba, Canada Linked with Manitoba’s Suicide Line www.reasontolive.ca National Centre for Suicide Research and Prevention (NSSF) (Oslo, Norway) Telephone: +47 22 92 34 73 Email: nssf-post (at) medisin.uio.no www.med.uio.no/ipsy/ssff Suicide Prevention Resource Center (SPRC) Washington, DC & Waltham, MA, USA Telephone: 877-438-7772 Email: [email protected] www.sprc.org American Association of Suicidology (AAS) Washington, DC, USA Telephone: +1 (202) 237-2280 Email: [email protected] www.suicidology.org Irish Association of Suicidology (IAS) Dublin, Ireland Telephone: +01 667 4900 Email: [email protected] www.ias.ie Suicide Prevention Australia (SPA) Sydney, NSW Telephone: +61 2 9223 3333 Email: [email protected] www.suicidepreventionaust.org Suicide Prevention Information New Zealand (SPINZ) Telephone: (09) 623 4813 Email: [email protected] www.spinz.org.nz

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APPENDIX D: Commonly Used Suicide Risk Assessment Tools The following is a list of a few commonly used suicide risk assessments tools that assess either symptoms (e.g., hopelessness) or resilience factors (e.g., reasons for living), or both (Perlman et al., 2011). This is by no means an exhaustive list. However, these tools, and others, have been recommended by Perlman et al. (2011) after a review of the literature and interviews with experts. A brief statement as to what the scale measures is included. Perlman et al. (2011) strongly advises training prior to utilizing any scales for suicide assessment. Beck Hopelessness Scale (BHS) (Beck & Steer, 1988) Measures “negative attitudes about one’s future and perceived inability to avert negative life occurrences” (Perlman et al., 2011, p. 39). Beck Scale for Suicide Ideation (BSS) (Beck, Kovacs & Weissman, 1979) Measures “the current and immediate intensity of attitudes, behaviors and plans for suicide related behavior with the intent to end life among psychiatric patients” (Perlman et al., 2011, p. 40). Geriatric Suicide Ideation Scale (GSS) (Heisel & Flett, 2006) “(I)s a multidimensional measure of suicide-related ideation developed for use with older adults” (Perlman et al., 2011, p. 42). Nurses’ Global Assessment of Suicide Risk (NGASR) (Cutcliffe & Barker, 2004) The NGASR “is a nursing assessment tool used to identify psychological stressors that are reported to be strongly linked with suicide” (Perlman et al., 2011, p. 47). Reasons for Living Inventory (RFL) (Linehan, Goodstien, Nielson & Chiles, 1983) The RFL “assesses potential protective factors among persons who report ideation of suicide. It may be used to explore differences in the reasons for living among individuals who engage in suicide-related behaviours and those who do not” (Perlman et al., 2011, p. 48). SAD PERSONS and Sad PERSONAS Scales (Patterson, Dohn & Bird, 1983) This scale “is a simple mnemonic to assess major suicide-related risk factors” (Perlman et al., 2011, p. 49). Scale for Impact of Suicidality – Management, Assessment and Planning of Care (SISMAP) (Nelson, Johnston & Shrivastava, 2010) This scale “Is a comprehensive suicide assessment tool to aid in the prediction of suicide risk, as well as the development of a care and management plan” (Perlman et al., 2011, p. 51).

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SUBJECT INDEX A Aboriginal healing foundation 14 Addictions 54, 60, 61, 62, 63, 65, 74, 128 Addressing suicide 84 Address suicidality 16 Adolescents 7, 8, 9, 13 Aeschi working group 76, 77, 78, 83, 85, 86 of suicidologists 76, 85 guidelines for clinicians 85, 86 Affective disorders 60, 63 Alcoholics anonymous (AA) 70 Analysis of howard’s suicide note 72 Angry outbursts 119, 130 Anxiety disorders 60, 63 Approaches 27, 79, 88, 94, 112, 113, 120, 121 empathetic 79 therapeutic 84, 85 Assumptions 15, 41, 42, 72, 75, 89 preconceived 32, 33, 41, 57 Australia suicide rates for indigenous 14

B Behavior disorders 60 Beliefs 4, 9, 29, 31, 35, 36, 40, 48, 56, 99, 100, 125 patient’s 29, 31 religious 48 suicide core 100 Borderline personality disorder 32, 39 portrays 39 Burn out 112

C Canada statistics on actual physician suicides 115 Canadian association for suicide prevention 13 Care 19, 20, 21, 27, 29, 31, 76, 80, 82, 83, 84, 86, 88, 90, 91 & empathy 76, 82, 83, 86, 88, 90, 91 giver 20, 21, 27, 29, 31, 83 giver dehumanizes patients 80

role 21 theorist 21 Care provider 19, 21, 84 gatekeepers 19 practice 21 Career 72, 86 issues 86 success 72 Caring 77, 78, 91, 112, 113, 114, 130 ethical 91 person 77, 78 professions 112, 113, 114, 130 Cause of death 2, 5, 10, 13, 30, 95 Clinician distances 29, 31 Cognitive 76, 98, 99 behavioral therapy 98 re-structuring 76, 99 Cognitive therapy (CT) 76, 77, 78, 97, 98, 99, 100, 111, 129 Cognitive therapy in relation 98 Cognizant 33, 46, 58, 61, 113, 123 Collateral information 51 Committing suicide 16, 31, 41, 52, 57, 58, 96 Compassion 20, 32, 36, 55, 57, 76, 77, 78, 91, 92, 111, 123, 124 act of 76, 77, 78, 92, 111 Compassion and understanding 20 Compassion fatigue 112, 113, 119, 120, 123, 124, 125, 130, 131 developing 112, 113, 119, 125, 130 symptoms of 119, 120 Component, essential 129 Connection 22, 60, 61, 62, 68, 73, 75, 76, 77, 78, 82, 83, 88, 110, 111 establishing 76, 78, 82, 111 significant 60, 61, 62, 73 Conscious choices 87 Constriction 60, 61, 66, 68, 72, 74, 93, 96, 111 narrow 76, 93, 96, 111 of thought 60, 61, 66, 68, 72, 74, 93, 96 Contact, eye 46, 102, 103, 106 Contributing factors 10, 11, 12, 13, 112, 113, 114, 115, 117, 130 to physician suicide 112, 115, 130

Kathleen Stephany All rights reserved-© 2017 Bentham Science Publishers

Subject Index

Contribution, human 6 Convey empathy 101, 109 Coping cards 77, 99, 100 Coping strategies 40, 52, 58, 101, 112, 131 healthy 120 Crisis 20, 51, 52, 53, 67, 68, 74, 77, 78, 85, 86, 97, 100, 101, 111, 119, 127, 129, 131 emotional 20, 85, 86, 119 initial 78, 98, 111, 129, 131 suicidal person’s 129, 131 Critical incident debriefing (CID) 112, 122, 131 CT clinicians 100 Cultural 9, 67, 74 issues & suicide 9 values 67, 74 Current suicidal thoughts 49

D Death, physician 115 Decedent 71, 75 Depth interview 51 Diagnostic procedures 43, 44, 58 Direction of learning 123, 124 Disability pension 94 personnel 94 Disease processes 2, 3, 30 Disorders of personality and behavior 63

E Early diagnosis and treatment 60, 61, 62, 63, 116, 130 of mental illness 62, 116 Economic consequences 6 Educating members 41 Emergency, initial suicidal 1, 2, 24, 31, 32, 76, 77, 78, 94, 97, 111 room 1, 2, 24, 31, 32, 76, 77, 78, 94, 111 Emotional 7, 119, 130 abuse 7 withdrawal 119, 130 Empathetic 80, 100, 103, 109 practitioners 109 responses 80, 100, 103, 109 identified 80

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Empathic 76, 80, 110, 119, 130 action 80, 110 engagement 119, 130 responses 76 Empathy 77, 80, 111 exquisite 77, 80, 111 making 109 practice 78 Empathy acts 68, 69 Empathy Skills 110 Empathy strategies 102 Empathy value 82 Establish rapport by conveying empathy 45, 46, 58 Etherington 24 Ethical challenges 4 Ethical dilemmas 2, 29, 31 Ethical issues 1, 2, 29 Ethical principles 29 Ethical violation 2 Ethnicity 2, 9 Expectations 110, 118, 122, 131 unreasonable 112, 115, 130 Experience 7, 8, 9, 14, 22, 23, 27, 29, 31, 32, 34, 35, 37, 40, 42, 54, 55, 57, 66, 67, 72, 76, 79, 80, 82, 84, 85, 86, 89, 91, 92, 100, 102, 106, 109, 110, 120, 121, 122, 123, 127, 131 human 122, 131 negative 27, 37, 40 Experience hopelessness 42 Experience of psychache 71 Experience vulnerabilities 77, 78 Expert’s diagnoses 85

F Factors 2, 3, 7, 9, 12, 30, 47, 48, 62, 66, 112, 113, 117 causal 112, 113 individual 47, 48 social 2, 3, 30 Family history of suicide 48 Feeling hopeless 8, 119, 130 Feeling suicidal 18 Free dictionary 3, 4, 24, 34 Fully present person 90

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G General population 14, 55, 112, 114, 130 Gestures 32, 39, 40 parasuicidal 32, 39 Goal, person’s 67, 74 Good listeners 89 Group 6, 9, 13, 15, 34, 54, 57, 85, 89, 108 formal religious 15 Growth, personal 123

H Health 7, 8, 15, 18, 20, 25, 30, 41, 64, 69, 81, 95, 103, 106, 112, 124, 125, 126, 131 emotional 112, 124, 125, 131 Health care 11, 12, 29, 31, 40, 48, 64, 65 accessing 48 advanced 12 poor 11 primary 65 Health-care 35 professionals 35 front-line 35 Health care 53, 64 services 64 system 53 Health outcomes, better 37, 57 Health professional(s) (HP) 15, 16, 17, 18, 24, 25, 30, 32, 33, 35, 36, 37, 38, 43, 45, 53, 55, 57, 63, 69, 70, 85, 88, 94, 95, 96, 103, 104, 105, 106, 107, 108, 114, 120, 123, 125 in suicide risk 16 stigmatize 57 Helpful 17, 21, 22, 36, 37, 45, 55, 56, 97, 113, 119, 124, 127, 130 persons 113 gatekeeper 97 professional chances 127 professionals 17, 36, 45, 55, 124 professionals disconnecting 119, 130 professions 21, 22, 37, 55, 56 work environment 127 Heterosexuals 14 Highest suicide rates 2, 3, 9, 10, 12, 13, 30 High risk 41, 52, 58, 95, 96 of committing suicide 41, 52, 58

Kathleen Stephany

of suicide 95, 96 High suicide numbers 2, 3 Hospital 40, 63 admissions 63 care, poor 40 Hospitalizations 62, 63 Howard’s 72 experience of psychache 72 suicide note 72

I Illnesses, chronic 8, 48 Information and resource centres for suicide help 43 Initial suicide crisis 97 International association for suicide prevention (IASP) 77, 85 Interpersonal and social circumsances 44 Interpersonal communication 82 Interpersonal relationships 39, 73 unstable 39 Intervention 15, 16, 17, 18, 24, 30, 43, 45, 48, 51, 85, 96, 97, 98 therapeutic 15, 16, 17, 96, 97 Intrusive thoughts 119, 130 Inuit suicide rates 14

J Journaling 28, 76, 77, 78, 109, 111, 112, 123, 131

K Key 1, 22, 26, 31, 32, 33, 38, 45, 52, 54, 58, 68, 72, 76, 85, 86, 93, 96, 108, 111 actors 108 components 22, 32, 33, 52, 79 goal 45, 85, 86 themes 1, 26, 31, 32, 38, 54, 58, 68, 72, 76, 93, 96, 111

L Lesbian, gay, bisexual, transgender and queer (LGBTQ) 14

Subject Index

Life experiences, adverse 2, 7, 30 Lifespan 13, 30, 64, 65 Limitations 33, 43, 58 Listening stoppers 77, 88 Lithuania 12 Lived 24, 32, 33, 37, 38, 53, 60, 61, 70, 74 emotional experiences 24, 61 experiences 32, 33, 37, 38, 53, 60, 70, 74 Living works education 42, 43 Loss 6, 7, 8 of health 7, 8 of life 6 of occupation 7, 8 of primary relationship 7, 8 of years 6

M Males committing suicide 9 Medical community 115, 116 model 85 problem 35 school 19, 53, 95, 115 Medication errors 53 Mental disorder 18, 19, 26, 37, 47, 57, 60, 62, 63, 74 Mental health 16, 17, 18, 27, 34, 35, 37, 43, 45, 48, 51, 53, 55, 57, 61, 62, 63, 64, 65, 74 care providers 16 commission of Canada (MHCC) 27, 34, 35, 37, 61, 62, 63, 64 gatekeepers 64 professionals 17, 18, 53, 55, 63 services 18, 26, 51, 57, 64, 65, 74 stigma 55 worker 26, 39, 40, 57 Mental illness 3, 4, 6, 10, 14, 15, 18, 27, 32, 33, 34, 35, 36, 37, 42, 54, 55, 57, 60, 61, 62, 63, 64, 73, 74, 83, 94, 112, 114, 115, 116, 117, 118, 119, 129, 130, 131 & addictions 62 & suicidal ideation 34 elicit 55

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judge 118 Mental wellness 60, 61, 63, 64, 74 increased 61, 63, 64 Mindful listening 77, 90 Moral 1, 2, 29, 30, 31 agency 1, 2, 29, 31 beliefs, personal 29 disengagement 2, 29, 30, 31 dis-engagement 2 residue 2, 29, 30, 31 Mozambique 12 Multiple studies 127, 128

N Narrative 2, 24, 26, 32, 33, 53, 54, 60, 71, 76, 77, 78, 92, 93, 111 action theoretical approach 60, 71 case study 2, 24, 26, 32, 33, 53, 54, 76, 77, 78, 92, 93, 111 National 52, 60, 63, 74, 101 strategy 60, 63, 74 suicide prevention line 52, 101 Necessary empathetic qualities 20 Negative scripts 73 Neonatal Intensive Care Unit (NICU) 112, 117 Non-maleficence 2, 29 Non-verbal communication skills 77, 102 Nurse(s) 16, 17, 20, 25, 26, 27, 38, 41, 54, 55, 76, 80, 81, 95, 103, 110, 112, 113, 114, 117, 118, 120, 121, 122, 130 caring 117 stigmatizes 118 student 121, 122 suicides 112, 113, 114, 117, 118, 130 Nursing students 87, 88, 120, 121, 128

O Occupational hazard 112, 114, 130 Offer empathy may help 18 Offering empathetic responses 22 Offering unconditional positive regard 76, 78, 82, 86, 87, 88, 111

P Parvinder’s suicide 39

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Personal 68, 120 hell 68 issues 120 Personality 60, 63, 127, 128 disorders 60, 63 trait 127, 128 Personal 32, 48, 54, 119, 121, 122, 130 plan 122 protective factors 48 relationships 119, 130 shame, degree of 32, 54 therapy 121 therapy for therapists 121 Person 7, 8, 20, 21, 22, 24, 38, 39, 41, 43, 47, 48, 51, 57, 58, 65, 72, 75, 87, 88, 89, 90, 91, 92, 97, 102, 108 denies 43, 58 playing 108 ability 7 actions 87 demeanor, young 92 family doctor 51 feelings 51, 89 inclination 65 levels 51, 102 life 39, 47 optimistic set 72, 75 problems 88 safety 51 space 22 story 24, 88, 91 strengths 90 suicidal 38, 57 suicidal ideation 20 suicidal risk 41 suicidal story 97 vulnerability 7, 8, 48, 92 wholeness 21 wanting 39 Perspective 79, 123, 124 fresh 123, 124 patient’s 79 Peter’s 68 experience 68 experience of psychache 68 Physical health 112

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Physician(s) 16, 17, 76, 80, 84, 91, 95, 110, 111, 112, 113, 114, 115, 116, 130 population 130 suicide 112, 115, 116, 130 Post-traumatic stress disorder (PTSD) 112, 122 Preconceived assumption 32, 33, 41, 57 Presumed assumption 41, 42, 43 Preventative care 65 Prevention strategies 3, 62, 74 Primary 7, 8, 18, 64, 65, 74 care providers 18 health providers 64, 65, 74 relationship 7, 8 Professional gatekeepers 25, 41 Protective factors 2, 32, 45, 48, 51, 52, 58, 97 Psychache 60, 61, 65, 66, 67, 68, 69, 70, 71, 72, 74, 75, 76, 77, 93, 96, 111 experienced 68 lived experience of 67, 70 person’s 66 person’s experience of 60, 75 Psychiatrist 33, 53 experiences Stigma 33, 53 experience of stigma 33 Psychological 1, 2, 4, 24, 31, 60, 66, 68, 69, 71, 74, 75, 76, 77, 78, 79, 93, 94, 95, 96, 111 autopsy 1, 2, 4, 24, 31, 60, 71, 76, 77, 78, 94, 95, 111 pain 60, 66, 68, 69, 74, 75, 79, 93, 96 Psychologists 65, 120, 121

Q Qualitative 1, 2, 4, 23, 24, 31 methodologies 1, 2, 4, 24, 31 methods 23, 24 research 1, 2, 23, 31 study 23, 24 Qualities, empathetic 20 Quantitative study 2

R Recommended suicide risk assessment documentation topics 51

Subject Index

Recovery models 2, 27 Religion & suicide 14 Resiliency, fostering 60, 61, 72 Resources, medical 35, 40 Risk 1, 3, 9, 24, 40, 41, 42, 44, 45, 46, 47, 48, 49, 51, 52, 60, 62, 64, 74, 81, 95, 96, 97, 112, 113, 114, 115, 117, 119, 130 person’s 49 real 112, 113, 130 Risk assessment 19, 30, 44, 46 comprehensive 46 frameworks 44 Risk factors 32, 40, 45, 47, 58, 63, 115 strongest 40 Role play 76, 77, 100, 103, 106, 111

S Safety Plan 32, 33, 40, 52, 54, 58, 77, 95, 96, 97, 100, 101, 106, 108, 111 Sample of recommended suicide risk assessment documentation topics 51 Sarah 38, 39, 41 Sarcasm 84 Schizophrenia 60, 63 Seclusion 4, 26, 27 Secure room 1, 2, 24, 25, 26, 27, 31 Security guard 25, 26 Self-awareness 32, 33, 56, 59, 76, 77, 78, 109, 111, 112, 123, 125, 131 Self-blame 123 Self-care 112, 113, 122, 124, 125, 126, 127 plan 125, 126, 127 Self-compassion 2, 28, 112, 113, 120, 122, 123, 131 fostering 112, 113, 120, 131 Self-forgiveness frees 123, 124 Self-harm 20, 24, 27, 29, 32, 33, 39, 40, 51, 52, 57, 62, 63, 86, 101, 107 action of 39, 40 previous episode of 40 Separation, early 7 Services 34, 64, 65, 74 accessing suicide prevention 34 right combination of 64, 65, 74 Sexual abuse 7 Shneidman’s work 65

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Shortfall, global 60, 61, 64 Simulation exercises 22, 76, 78, 100, 111 dynamic 76, 78, 111 Skills 16, 17, 19, 76, 77, 89, 100, 102, 109, 111 important 100 teach empathy 19 verbal communication 77, 102, 111 verbal empathetic communication 77 verbal empathic communication 76 Sleep, disturbed 119, 130 Social networking 15 Social stressors 1, 2, 3, 6, 7, 30 Social stressors & adverse life experiences 7 Social stressors & suicide 7 Social support 15, 47 Social worker 16, 94, 95, 103 Stigma 16, 32, 33, 34, 35, 36, 37, 38, 41, 48, 54, 55, 56, 57, 59, 112, 115, 116, 118, 130 distressing 32 experienced 33, 54 hurts 37, 57 prevents nurses 118 Stigmatization 32, 34 Stopped playing 127 Strain(s) 60, 61, 67, 68, 74 psychological 67, 74 theory of suicide 60, 61, 67, 68, 74 Stranger, total 76, 78, 92, 94 Strategies 85, 100 empathetic 100 helpful 85 Street 94, 95 Stress 7, 8, 11, 13, 28, 29, 47, 48, 53, 64, 67, 72, 91, 112, 114, 116, 117, 120, 121, 123, 124, 125, 128, 130 considerable 116 Stressors 44, 60, 67, 72, 74, 75, 115 life’s 72, 75 Substance 62, 63, 112, 114 misuse 112, 114 -related disorders 60, 63 use disorders 62, 63 Suicidal 4, 6, 19, 24, 27, 32, 33, 35, 36, 41, 42, 43, 45, 49, 50, 52, 58, 62, 65, 74, 76, 79, 81, 82, 83, 85, 86, 91, 96, 97, 99, 101, 105, 110, 111

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act 6, 85, 86, 111 plan 32, 45, 49, 50, 58, 95, 105 state 83 tendencies 27, 33, 81, 96, 99 thoughts 4, 19, 32, 35, 36, 41, 42, 43, 45, 49, 52, 58, 62, 65, 74, 76, 79, 81, 82, 83, 91, 97, 101, 110, 111 experienced 24 youth 76, 111 Suicidal behavior 3, 39, 46, 48, 50, 51, 58 distinguishing 39 prior history of 46, 50, 58 Suicidal crisis 76, 77, 86, 99, 100 initial 76 Suicidal ideation 17, 20, 22, 32, 33, 34, 37, 42, 50, 52, 53, 58, 62, 65, 69, 87, 109 Suicidality 9, 46, 66, 85 increased 7, 8, 86 patient’s 86 Suicidal patient 97, 99, 119 shares 119 journey 99 story 97 Suicidal person 4, 22, 23, 31, 66, 68, 84, 85, 88, 121, 129, 131 & compassion fatigue 118 move past 68 experience 4, 22, 23, 31 life 66 story 85, 88, 121, 129, 131 trusts 84 Suicide 2, 3, 6, 9, 13, 14, 15, 16, 18, 32, 33, 39, 43, 44, 86, 39, 40, 41, 44, 47, 50, 57, 58, 63, 96, 112, 114, 117 Suicide deaths 5, 10, 118 recorded 5 Suicide experience depression 62 Suicide help 43 Suicide ideation 66 Suicide intent 51 Suicide intervention 78 Suicide mindset 62 Suicide motivation 66 Suicide note 38, 60, 61, 71, 72, 75 actual 61, 75 Suicide plan 45 Suicide preparation 66

Kathleen Stephany

Suicide prevention 1, 2, 3, 4, 6, 13, 15, 16, 17, 21, 22, 23, 24, 30, 31, 33, 34, 35, 36, 41, 57, 60, 61, 63, 64, 65, 74, 85 key components of 64, 65, 74 teach 15, 17 teaching 16, 30 Suicide rates 5, 9, 10, 11, 12, 13, 14, 30 high 9, 10, 12, 13 Suicide rates for children 13 Suicide risk 15, 16, 17, 18, 20, 24, 32, 33, 40, 43, 44, 45, 46, 47, 48, 50, 52, 58, 60, 61, 76, 95, 96, 97, 99, 111 degree of 43, 58, 60, 61 increased awareness of 17 mitigate 99 reducing 52, 58 & Therapeutic Intervention 16 assessment 16, 17, 18, 32, 33, 43, 45, 46, 47, 58, 76, 95, 96, 97, 111 assessment process 52 assessment tools 32, 33, 43, 44, 47, 58 documentation 50 Suicide training 16 Suicidologist & member 83 Suicidologists 2, 3, 76, 77, 78, 85, 129, 131 Suicidology 2, 3

T Teaching 16, 18, 19, 30, 31 empathy 19 gatekeepers 16, 18, 19, 30, 31 Theoretical premise 1, 2, 4, 21, 31 Therapeutic 1, 3, 16, 19, 20, 76, 77, 78, 80, 83, 84, 85, 86, 88, 97, 100, 111, 129, 131 alliance 76, 77, 78, 83, 84, 85, 88, 100, 111 alliance of trust 129, 131 rapport, establishing 19, 20, 97 relationship 1, 3, 16, 19, 20, 84, 86, 97 strategy 20, 80, 111 Thought patterns, constricted 60, 68, 69, 75 Time 1, 9, 11, 12, 13, 14, 15, 26, 27, 31, 38, 47, 54, 60, 62, 69, 74, 77, 78, 85, 86, 88, 89, 90, 91, 92, 97, 99, 100, 105, 108, 110, 111, 113, 117, 119, 120, 122, 123, 124, 125, 126, 127, 128, 130 caring 124

Subject Index

coaching 100 exposure 119, 130 suicide rates 12 Total reliance 50, 51 Train 1, 3, 17, 18 gatekeepers 1, 3 Training 2, 15, 16, 17, 18, 21, 22, 30, 54, 64, 76, 95, 96, 97, 111, 120 better 2, 18 gatekeepers 15, 21, 22 health care gatekeepers 97 of health professionals in suicide risk 16 Transgender 2, 14 Trauma 27, 48, 119, 120, 122, 131 Tribulations 77, 78, 128 Trust 19, 20, 21, 28, 46, 56, 70, 76, 77, 82, 84, 85, 100, 106, 111, 125, 129, 131 establishing 20, 84, 85 patient’s 70

U Unconditional positive regard 77, 86, 87, 104, 110

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Understanding 21, 22, 23, 71, 81 empathetic 71, 81 increased 21, 22, 23 Unemployment insurance (UI) 70

V Verbal responses, helpful 77 Vicarious traumatization 112, 113, 119, 120, 130

W Warning signs 32, 33, 44, 45, 51, 52, 58, 101 of suicide 32, 33, 44 Work 112, 115, 117, 124, 126, 131 -life balance 112, 124, 126, 131 -loads, heavy 112, 115, 117 Worthlessness 8, 27, 35, 40, 55, 72