This page contains suicide prevention and education resources
Find the PDF titled Coping With Suicidal Thoughts, here (includes a safety plan)
Measures for clinicians:
- The Columbia Suicide Risk Assessment C-SSRS Lifeline Version 2014 pdf document here and here
The text below is from https://www.goodtherapy.org/learn-about-therapy/issues/suicide and is posted here for posterity.
People diagnosed with schizophrenia have a higher rate of suicidal ideation during periods of remission, and those diagnosed with serious medical illnesses such as AIDS or cancer are more likely to experience suicidal ideation if they also have a psychiatric condition. Suicidal ideation and behavior have been found to be most prevalent in people who are coping with mood issues such as bipolar while also dealing with substance or alcohol abuse.
Psychological issues that might lead one to experience thoughts of suicide include, but are not limited to:
- Eating and food issues
- Body image issues
- Posttraumatic stress/trauma
- Social anxiety
CONDITIONS ASSOCIATED WITH SUICIDAL IDEATION
The Diagnostic and Statistical Manual (DSM) lists many psychiatric conditions that may lead to or result from suicidal ideation and behavior. Not all individuals with one or more of these conditions will experience suicidal ideation or behavior, but having one or more of these conditions has been shown to increase one’s risk of suicidal ideation.
- Adjustment disorder: A psychological response to identifiable stressor(s) that can lead to significant behavioral or emotional symptoms.
- Anorexia nervosa: An eating disorder characterized by the inability to maintain a healthy body weight and an extreme fear of gaining weight due to a distorted self-image.
- Bipolar: A mood condition defined by one or more episodes of abnormally elevated energy levels with or without one or more depressive episodes.
- Body dysmorphia: A psychological condition characterized by excessive concern and preoccupation with a perceived defect in physical features.
- Borderline personality: A personality condition characterized by a prolonged disturbance of personality function, defined by depth and variability of moods.
- Dissociative identity disorder: A psychological condition in which multiple and distinct personalities are present.
- Gender dysphoria: The mental distress that occurs when one’s gender identity does not align with the gender assigned at birth; in other words, gender dysphoria can be described as distress experienced as a result of being in the wrong body.
- Major depressive disorder: A condition characterized by an all-encompassing low mood with low self-esteem and social isolation.
- Panic: A form of anxiety characterized by severe and recurring panic attacks.
- Posttraumatic stress (PTSD): A condition that may develop after exposure to an event that results in psychological trauma.
- Schizophrenia: A serious mental health condition characterized by disintegrating thought processes and perceptions of reality and diminishing emotional responsiveness.
- Social anxiety: A form of anxiety in which social situations cause an individual to experience significant fear and distress that may lead to an impaired ability to function.
All of these are real options that can help, treatments. From: https://afsp.org/about-suicide/preventing-suicide/
The treatment that works
This article by Lisa Firestone Ph.D. is for the mental health professional, and patient, with a reminder that there are treatments that are proven to work.
One of the first methods designed as an intervention that targeted suicide directly was Dialectical Behavioral Therapy (DBT), which was developed by Marsha Linehan. DBT was originally developed to treat women with personality disorders, who engaged in suicidal behavior. One of the core elements of DBT is teaching skills that help the person to regulate and tolerate their emotions. This is extremely important, as suicidal individuals are a diverse population with one thing in common: they have trouble labeling, tolerating and regulating their emotions. What Dr. Linehan found in her research is that receiving DBT greatly reduced the likelihood of suicidal behaviors.
If we see suicide risk as a skills deficit problem, we can focus treatment on helping people to develop the skills they need to stay alive. Once this is accomplished, there will likely be other psychological issues to address to help these individuals to feel better, but addressing the “underlying disorders” alone won’t necessarily work to prevent people from taking their lives. The number one goal of the therapist should be to help keep the suicidal person alive, so they can then benefit from treatment for their other difficulties. By focusing intervention on helping the person build the skills that help them stay alive, the therapist has time to work on the other psychological troubles they’re facing.
Because suicidality is a unique condition requiring a unique and targeted treatment, there was even consideration of making it a separate category in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders(DSM-5), rather than regarding it as a symptom of other mental health disorders. When we look at suicide as the focus of treatment, we are better able to target the skills deficit from which suicidal people suffer. We can better teach healthy strategies for staying alive and collaborate with the client, sharing the responsibility for his or her survival.
Another therapy that takes a targeted approach is Cognitive Behavioral Therapy for suicidal patients (CBT), developed by Aaron Beck and Gregory Brown. This model draws upon some of the basic skills-training aspects of DBT. One important element they add could be described as state-dependent learning. Previous research had demonstrated that suicide attempters can learn skills in a non-activated state, but when they are triggered, they can’t access these skills. Therefore, the final step Dr. Beck and Dr. Brown added in therapy involves inducing the suicidal state in session and essentially testing the person’s ability to implement the skills they have learned, when in the suicidal mode. The therapist is there to if it is necessary to help the person through the induced suicidal state. However, the goal is for the person to demonstrate their ability to calm themselves down when triggered and survive on their own. Therapy continues until they can do this on their own.
Dr. David Rudd, a lead researcher in the area of suicide has recently developed a specialized time-limited CBT approach to treat suicidal military personnel. Last month, I saw Dr. Rudd present at the 2013 American Psychological Association Convention, where he described his 12-session intervention program for those who’ve made past suicide attempts. This intervention targets suicide as a skills deficit that requires specific training to overcome. His model sees preventing suicide as a shared responsibility between patient and therapist. The treatment helps people learn tools to develop their ability to notice and label their emotions, as they get activated into the suicidal state. They develop personalized strategies to calm themselves and keep themselves safe. Dr. Rudd says that when a person is suicidal, they are in a state of over-arousal, which is why the inability to sleep is one of the main immediate warning signs for suicide. This CBT approach has been implemented in the military, and data is showing that it reduces the reattempt rate by 50 percent.
For people who are concerned about a friend, relative or co-worker who may be at risk for suicide, there is a strong message of hope in the fact that there are now several good, effective treatments available to help suicidal people learn the skills to stay alive. These new discoveries, paired with new methods of outreach, have made me increasingly optimistic about our ability to help save lives. New technologies are even helping in this mission with our National Suicide Prevention Lifeline providing e-cards that allow you to reach out to suicidal people. These e-cards are scripted with messages designed by a specialist in the field and can be personally modified by the sender. A “Hope Kit” app is in development, which would allow people coping with suicidal thoughts to have access on their mobile device to things they can do to calm down their feelings. There are websites listing warning signs and helper tasks that can help any of us save another person’s life. There is also the National Suicide Prevention Lifeline, available 24/7, where people can call to get help (1-800-273-8255). They have added an online chat feature as well.
Almost every suicidal person is ambivalent about his or her suicide. What we can do as friends, relatives, co-workers or acquaintances is reach out, show that we care and help these people get to the help they need to stay alive.
The text below is from https://www.speakingofsuicide.com/2013/07/22/therapists-who-do-not-panic/ and posted here for posterity.
Finding a Panic-Free Therapist
There are ways to figure out if a therapist is one who will shy away from treating suicidal clients or overreact when they do. Here are some tips about areas to look out for:
Look for a therapist who states that suicidal crises are an area that they treat. Therapist-finder sites like Psychology Today, HelpPRO, and GoodTherapy.org allow therapists to list the problem areas in which they have expertise. If a therapist has not checked off the site’s category for suicidal thoughts, then the therapist may lack the experience, education, or interest necessary to work with suicidal clients.
Therapist’s Acceptance of Suicidal Clients
When you call to make an appointment, ask if they accept clients in a suicidal crisis. If the therapist immediately says “no,” then you are spared the heartache of going for an appointment, sharing exquisitely personal information about yourself, and being turned away afterward.
Even if the therapist says they accept suicidal clients as new clients, still pay special attention to their response. Do they qualify in any way their willingness to work with suicidal clients?
Therapist’s Training in Suicide Prevention
You might ask what training they have received on assessing a client’s risk for suicide and working with suicidal clients. Most graduate school programs do not require training in suicide assessment or intervention, and most therapists report having received scant, if any, training in the area.
Therapist’s Ability to Talk Openly about Suicide
In early sessions, make note of whether your therapist asks you about any possible suicidal thoughts – or, if you have already brought up the topic, whether they delve more deeply into your thoughts of suicide. Some therapists avoid bringing up suicide, out of fear that it will give clients the idea. Others may have personal experiences or attitudes about suicide that make them hesitate to introduce the topic.
Therapist’s Ability to Listen Fully about Suicide
Along with asking about your suicidal thoughts, a therapist needs to listen. Does your therapist give you the space to tell your story? Do they gain an understanding of why you think about dying by suicide, and why the thoughts may or may not make sense to you? Do they respond with empathy rather than advice or judgment?
Some therapists ask a mental checklist of questions to assess the risk that you will make an attempt. Those questions are important. Equally important, if not more important, is offering you the space to tell your story, to be heard, and to be understood.
Therapists who Specialize in Suicide Prevention
Keep in mind that there is a difference between a therapist who works with suicidal clients and a therapist who specializes in working with suicidal clients. It is not necessary for a therapist to specialize in suicide prevention to be competent, well trained and experienced in working effectively with suicidal clients.
If you do seek a specialist in suicide prevention, look for someone who has published research or clinical articles about suicide, participated in a suicide-related professional conference, used the CAMS approach (Collaborative Assessment and Management of Suicidality), or undergone specialized clinical training in suicide prevention. Specialists also are likely to belong to a suicide-specific professional group such as the American Association of Suicidology.
The information below is from https://www.speakingofsuicide.com/resources/ shared here for posterity. Please make sure to visit https://www.speakingofsuicide.com/ for additional and more updated information.
If you are in danger of acting on suicidal thoughts or are in any other life-threatening crisis, please call emergency services in your area (9-1-1 in the U.S.) or go to your nearest hospital emergency room.
Hotlines in the U.S.
All hotlines listed below are free and confidential.
The National Suicide Prevention Lifeline is open 24 hours a day, every day.
Services are also available for veterans, and for Spanish speakers.
866-488-7386 – a hotline for LGBT youth
This is a hotline for transgender people. The volunteers and staff are themselves transgender.
U.S.: (877) 565-8860
Canada: (877) 330-6366
Crisis Text Line – 741-741
According to Crisis Text Line’s web site, if you text 741-741, you can receive a text from a trained crisis counselor within minutes.
This information is from the group’s web site:
- You text 741741 when in crisis. Anywhere, anytime.
- A live, trained crisis counselor receives the text and responds quickly.
- The crisis counselor helps the teen move from a hot moment to a cool calm to stay safe and healthy using effective active listening and suggested referrals – all through text message using CTL’s secure platform.
Online Chat and Email
Note that the Samaritans international website states that people who send an email typically receive a response within 12 hours. The site also notes that names are immediately removed from emails, and emails are deleted after 30 days.
The National Suicide Prevention Lifeline also has chat available, 24 hours a day. To use the service, go to chat.suicidepreventionlifeline.org/GetHelp/LifelineChat.aspx.
This site contains lists with dozens of sites, in addition to the sites above, where a suicidal individual can discuss their problems via instant messaging, chat rooms, email, text, and online support groups. The site is ideal for someone who does not want to talk with someone on the phone about their suicidal thoughts. It offers healthy options for receiving help. (I say “healthy,” because unfortunately danger lurks on many Internet sites, where “pro-suicide” folks actually encourage suicide.)
The Trevor Project, which reaches out to LGBT youth, provides instant-messaging chat on Mondays and Fridays, from 4 p.m. to 10 p.m. Eastern standard time.
Other Online Resources
Here you will find an impassioned and persuasive plea, as well as information resources for help, coping with challenges faced by suicidal individuals, relevant books, and useful web sites.
This online handbook provides information and food for thought for suicidal individuals, with material addressing what to do when suicidal, how to make sense of suicidal thoughts, and ways to decrease suicidal thoughts and prevent more suicidal episodes. (Sponsored by Simon Fraser University in Canada.)
This site, a project of the National Suicide Prevention Lifeline, contains personal accounts of people who have seriously considered suicide or attempted suicide. The people come from all walks of life – gay and straight, military and not, teen and adult, and so on – and though their suffering has been great, their survival is inspiring.
This website contains a wealth of information for people who think about dying by suicide or who have made an attempt or had such thoughts in the past. The Resources page is rather exhaustive, and I highly recommend it. It provides a list not only of crisis hotlines, but also of various creative projects aimed at spreading information about the suicidal experience.
This page by the Samaritans provides advice on how to help someone you care about who may be considering suicide.
This booklet by the VA is geared toward family members of veterans who survived a suicide attempt, but the information largely is applicable to all attempt survivors and their families. The guide contains good advice on talking with children about a suicide attempt of a family member, separated by age groups: 4-8 year olds; 9-13 year olds; 14-18 year olds.
Verbal signs, physical changes, new behaviors, and triggering events linked to suicide are described here. (Sponsored by the Samaritans.)
This booklet begins with information about the practical logistics immediately following a suicide, including details about a possible autopsy, cleaning of the home if the suicide occurred there, organ donation – and more. The second part of this booklet addresses the emotional aftermath of suicide bereavement, including common reactions to the suicide of a loved one, as well as the process of grieving.
This site contains abundant information about the experience of losing a loved one to suicide. It includes a blog, recommended books, memorials for people who died by suicide, and a community forum. The site states, “In our forum, survivors can contact others with similar losses, share their stories and discuss the many facets of healing from loss by suicide. It operates like a 24/7 support group, with a team of trained moderators and a mental health clinician who contributes regularly.”
This blog for survivors of suicide loss is authored by Franklin Cook. His father died by suicide almost 30 years ago, and since then he has served as a voice for suicide loss survivors in numerous national roles. A highlight of his blog is the Survivor Outlook section, which features first-person accounts of other suicide loss survivors. The Grief After Suicide blog also contains numerous other resources, including lists of suicide loss survivor websites, support groups, online discussion forums and chat rooms.
This Facebook group describes itself as “a suicide grief support group for spouses-partners who have been through loss of a husband/wife, fiance, boyfriend/girlfriend, or life partner to suicide.” (SOLOS stands for Survivors of Loved Ones to Suicide.)
Of all the online guides to surviving the suicide of a loved one, this may be the most comprehensive. Written by a man whose wife died by suicide, the guide includes information on the “emotional rollercoaster” that follows a suicide, myths and facts about suicide, suggestions for coping, narratives from other survivors, and inspirational words for surviving, coping, and healing after the loss of a loved one to suicide. (Sponsored by the American Association of Suicidology.)
This Facebook page is geared toward everyone affected in some form or other by suicide or mental illness. Yet the people who seem to follow it most passionately are people who have lost a loved one to suicide, hence its inclusion here as a resource for suicide loss survivors. The page’s administrator Barb Hildebrand is tireless in her advocacy and compassion for people touched, in any way, by suicide. Because of the page’s popularity, you can comment on a post or photo and usually watch the discussion grow in just minutes. As of March 2017, more than 150,000 people were following the page.
Lists of Support Groups for Suicide Loss Survivors
This site, sponsored by the American Association for Suicidology, and this site, sponsored by the American Foundation for Suicide Prevention, both provide directories for support groups nationwide for people who have lost a loved one to suicide. Some support groups are led by a mental health professional, while others are led by participants themselves.
The American Foundation for Suicide Prevention trains people who have survived a suicide loss to reach out to others newly bereaved by suicide. The volunteers will visit new survivors and offer peer support, at the survivor’s request. Click here to request an in-person or remote visit
For Mental Health Professionals
There is a wealth of information available – too much to list here – for mental health professionals who want to learn more about risk assessment, intervention, psychotherapy, and legal risk management with individuals at risk for suicide. Here I provide a brief list of key books:
By A. Wenzel, PhD, G.K. Brown, PhD, & A.T. Beck, MD
Cognitive therapy (also called cognitive behavioral therapy, or CBT) is one of only a few treatments that has demonstrated effectiveness in reducing suicide risk and attempts. This book describes in specific detail the cognitive therapy techniques that have helped reduced suicide attempts.
By Shawn C. Shea, MD
This book should be required reading not only for students, but also for mental health professionals at all levels of experience. As I explain in a separate post, it describes techniques to help assess a person’s suicidal thoughts and intent. It also provides extensive information, in a highly readable, non-academic style, about suicide, its stigma, and its possible causes, while also delving into the specifics of suicide risk documentation and decision making.
By R.I. Simon, MD
The author may well be the foremost authority on the legal aspects of psychotherapy with suicidal clients, in particular the risk for malpractice lawsuits following a client’s suicide. He provides good, sound advice in this bookfor managing suicide risk and providing competent care. He states his positions forthrightly; in fact, he approaches sacrilege when criticizing commonly held notions in suicide risk assessment. For example, he asserts that suicide risk assessment forms encourage clinical lassitude and increase malpractice risk. And he argues that clinicians are practicing unethically when they do not provide after-hours coverage for emergencies and instead refer a patient to call 911 or go to an emergency room in the event of an emergency. All the while, he bases his arguments on prior legal cases and case histories.
By Edwin Shneidman, PhD
In this book, the author (considered the “grandfather” of modern suicidology) focuses on psychological pain as the cause of suicide. Of course, this seems obvious, but in reality, much of the literature about suicide over the last few decades has focused on biological, sociological, and psychiatric risk factors for suicide, looking at statistics instead of individuals’ personal accounts of their pain. Shneidman elucidates this pain intensely, and argues that the only way to really prevent a person’s suicide is to fundamentally understand that person’s pain and to help reduce it.
By M. David Rudd, PhD, Thomas Joiner, PhD, and M. Hasan Rajab, PhD
Cognitive behavioral therapy has demonstrated effectiveness at treating depression and suicidality. This bookdescribes, in extensive detail, one CBT approach to helping suicidal clients. Topics go beyond the standard fare of theory, risk factors, and risk assessment. The material has immediate relevance to clinical practice, with information on crisis intervention, symptom management, cognitive restructuring (the book titles this section “Changing the suicidal belief system and building a philosophy for living”), and skills training.
By Thomas Joiner, PhD
This book by a renowned suicidologist, whose father died by suicide, describes the author’s prominent theory of suicide causation, the Interpersonal-Psychological Theory of Suicide. Joiner provides evidence that key characteristics must co-exist for a person to die by suicide: 1) They perceive that they are a burden to their loved ones; 2) They experience, or perceive they experience, extreme alienation; and 3) They have become habituated in some way to physical pain or life-threatening situations, making suicide seem less frightening and formidable to them. The first two factors combine to create a desire for death, and the habituation to pain or danger enables the ability to die by suicide.
The AAS website contains material of interest to everyone on the suicide-related spectrum: professionals, survivors, crisis workers, employers, friends and loved ones, and suicidal people themselves. Geared more toward research and statistics than some sites, it still has material accessible to everyone. Especially valuable is the information on postvention (what to do after a suicide), suicide loss survivor groups, and warning signs for suicide.
Like the AAS site (above), this site offers information for everyone affected, in any way, by suicide. It also has much information about research findings, and contains a rich section on advocacy efforts and opportunities in the field of suicide prevention.
At the SAVE site, you can find an array of information for both professionals and the lay public, including a depression symptom checklist, online resources, reading lists, and more.
This is the go-to site for all sorts of information on suicide and its prevention. Especially useful to practitioners is its Best Practices Registry, which provides a list and descriptions of evidence-based practices in suicide prevention and intervention.
This site offers information geared toward suicide prevention in lesbian, gay, bisexual, and transgender youth. Educators, parents, mental health professionals, and youth themselves can find meaningful help here. In particular, the site offers extensive resources to youth; see the section above, “For Immediate Help with Suicidal Thoughts.”
The text below is from https://www.psychologytoday.com/us/blog/think-act-be/201809/what-happens-when-you-mention-suicide-in-therapy posted here for posterity and educational purposes
What happens when you mention suicide in therapy
A person might also be ashamed of her suicidal thoughts, believing they represent a personal failing on her part, when in fact they’re a fairly common response to intense distress. If she doesn’t feel free to be open about these thoughts in therapy, she may have no place to discuss them. Most disturbingly, choosing not to seek treatment for this reason could prevent a person from getting the help she needs, thereby increasing the risk for acting on the suicidal thoughts. Clinicians generally consider it a positive sign when a patient discloses thoughts of wanting to die; it’s much more concerning when a suicidal person says nothing, and thus remains at higher risk.
While the specifics will vary among mental health professionals, the standard approach for discussing suicide includes asking about:
- Thoughts of wanting to die or thinking one would be better off dead (called “passive suicidal ideation”)
- Thoughts of actually harming or killing oneself
- A desire to kill oneself
- A plan for killing oneself
- Steps a person has taken to prepare for suicide (e.g., giving away belongings)
- Ready access to the means of suicide (e.g., owning a gun)
Obviously the later steps represent a more serious level of risk; many more people will have had passing thoughts of not wanting to be around anymore versus actually formulating a suicide plan. In addition, the clinician will ask about reasons not to take one’s life, such as, “I could never do that to my children.”
The severity of the risk will determine the course of action. A high level of danger for the person might require hospitalization to ensure their safety. When the clinician concludes that there is no emergency, they will likely develop a safety plan (Stanley & Brown, 2012) with their patient. The plan will include ways for the person to manage suicidal thoughts and impulses, arranged as a series of steps:
- Step 1: The first step is identifying the warning signs — thoughts, feelings, behaviors, or situations — that increase the risk for suicide. For example, a person might recognize the thought, “I’d be better off dead.” The presence of warning signs leads to Step 2.
- Step 2: The next step is to use coping strategies that don’t require contacting anyone else, such as listening to relaxing music or exercising. The advantage of these approaches is that they’re always available, in principle. If they’re not sufficient to defuse the potential crisis, it’s on to Step 3.
- Step 3: The third step is to contact people who can provide distraction and relief — not necessarily people to confide in about the suicidality, but people the person enjoys being with. The plan will include a list of people’s names and their contact information, as well as social settings that can provide distraction (e.g., going to the mall).
- Step 4: If needed, Step 4 involves contacting a friend or family member specifically to ask for help. This step is more intensive than the previous one, because it involves disclosing one’s thoughts of suicide. The safety plan will include the names and contact information for multiple people the individual could contact.
- Step 5: The fifth step is to contact professionals or agencies, including one’s psychiatrist or other mental health professional, if applicable. It can also include local urgent care services and 24-hour treatment facilities, as well as the National Suicide Prevention Lifeline (800-273-TALK ) for those in the U.S.
It’s also important to keep the environment as safe as possible, like not having easy access to the means of suicide (e.g., a stockpile of potentially lethal medication). Finally, the plan will list what is most important to the person — what makes life worth living.
Many clinicians may have been trained (like I was initially) to obtain a signed “safety contract” or “no-suicide contract” from the patient, which in essence is a “promise” from the patient not to attempt suicide. However, these contracts obviously aren’t enforceable, and there is minimal evidence that they lower the risk for suicide. As Stanley and Brown (2012) point out, these contracts also don’t include a plan for how the person will reduce their chances of hurting themselves. Moreover, they can interfere with the therapy relationship, especially if the patient feels coerced into signing the contract. Patients might also suspect — perhaps rightly — that the contract is more about protecting the therapist than the patient.
In contrast, formulating a safety plan together can strengthen the bond between the therapist and patient, as they collaborate toward a shared goal of keeping the patient safe so the work of healing can continue. It’s also an empowering approach, as it includes the patient in planning and decision-making at a time when the person is particularly vulnerable and may fear an automatic loss of freedom and autonomy by mentioning the word “suicide.”
Mental health professionals should be trained in how to respond confidently and compassionately when a person says they’ve thought of suicide. The response should include a collaborative discussion to determine the level of risk, and the development of a plan for safety.