Management of suicidal behavior

Earlier in this module, it had been stated that the majority of suicides can be averted through timely intervention. Very often, a person contemplated and attempts suicide, when all other possible channels have dried out. The person goes through severe emotional distress, while contemplating the act. Individuals who are predisposed to the
risk factors go through a long turbulent period of planning the ‘how’ and ‘when’ of their act. Very often there occurs a triggering incident when such a person is pushed to the edge of life.

The time to intervene is this time of contemplation. The best strategies are the ‘talktherapy’ (where the suicidal person is encouraged to ventilate the deep emotional stress) and ‘active listening’. Through these processes the person is enabled to explore other options suitable to overcome his problems and look at life in a different perspective.

‘Active empathetic listening’ and catharsis are the bases of suicidal support services as befriending and counselling.

Listening Skills

It is important for people to have the opportunity to explore difficult feelings. Being listened to in confidence and accepted without prejudice can alleviate general distress, despair and suicidal feelings.

Often being listened to is enough to help someone through a time of distress. Even just showing that you are there for them and that they are going through a distressing time can itself be a comfort.

You are a good listener if you:
 Always try to give people your undivided attention.
 Let them sit in silence and collect their thoughts if they needed to.
 Question them gently, tactfully and without intruding.
 Encourage them to tell their story in their own words and in their own time.
 Refrain from offering advice based on your own experience.
 Always try and see their point of view even though you may not agree with it.

Befriending

Befriending literally means being a friend for a person in distress. It is different from counselling. Befriending is offered by trained volunteers unlike counselling which is more professional being offered by qualified personnel.

Befrienders listen to people who are lonely, despairing or considering suicide. They don’t judge them, don’t tell them what to do. Instead, they listen. Listening can make the difference between life and death. People who feel suicidal are so often focused on a particular problem or pain that they find it difficult to see a way forward. Talking openly to a befriender in a safe and confidential environment can help. By listening to a suicidal person, a befriender helps him listen to himself.

Befrienders worldwide

According to WHO, there are around 1 million suicides every year and for every suicide, there are approximately 20 attempted suicides. There are also many others who may not be suicidal, but urgently need access to appropriate emotional support services.

WHO stipulates that policies and services should include reducing the number of people who develop mental health problems and eliminating stigma associated with mental or emotional problems and also provide effective interventions to all in need. Volunteers services play a crucial role in all of these.

Befrienders Worldwide is a network of over 400 volunteer centres in 39 countries, across 6 continents. These centres provide help to those in need of emotional support.

Befriender’s India is the member body of Befriender’s Worldwide in India. The member centres of BI are spread across India and situated in Chennai, Ahmedabad, Kolkata, Kochi, Mumbai and Navi Mumbai, New Delhi,Puduchery and Secunderabad . All these centres offer volunteer befriending through personal/telephonic/postal interaction.

Befriending takes place when a suicidal person interacts with a volunteer – through visits, telephone or letters. During befriending, callers get a chance to ventilate their feelings to the volunteer who will give them undivided attention. The caller can contact the centre freely, they are not required to give volunteers either contributions or gratitude.

The aim of befriending is to support callers as they face their difficulties and to share their pain by demonstrating acceptance, empathy and care.

The essential nature of befriending is love – in its simplest and purest form. It is this love that heals and restores to callers their dignity, confidence and self-esteem. A volunteer responds to a suicidal person as a friend, on an equal level, with unconditional, uncritical acceptance and respect.

Befriending does not limit callers’ freedom. Callers are offered simple emotional support and remain free to make their own decisions, reject help, break contact and even move on with their decisions about ending life.

Befriending is not forced. Volunteers do not intrude on the person who have sought Centre’s help. A person who contacted once is not sought after.

What Befriending is not: Befriending is not counselling, neither is it a substitute for medical treatment or specialised help.

Unfortunately, there are no agreed upon, set procedures for handling a suicidal or potentially suicidal individual. However, counselling services must be responsive to the needs of the suicidal individual. The identification, assessment and treatment of the suicidal individuals call for the consideration of many important variables. Suicidal individuals have a range of needs from information to counselling to medication. Combinations of brief supportive counselling and medications to treat depression and other behaviours are often indicated.

When a person is experiencing suicidal thoughts (ideation) it is important to initiate immediate management procedures. This will include an assessment (eg: level of ambivalence, impulsivity, rigidity and means lethality), enlisting support, varying levels of contracting and family involvement, as well as counselling. Management of the suicidal person also might include pharmacological or inpatient treatment.

Suicide crisis management should not be a solitary event. It is often essential that other health agencies be involved and in some cases even the authorities should be notified.
Counsellors with large case loads will need to be particularly aware of their ability to effectively deal with a suicide crisis. In addition, knowledge of ethical codes and regional
laws regarding the involvement of third parties is important.

 Collaboration between counsellors and health care professionals in the prevention of suicide is critical. Counsellors, psychologists, social workers, psychiatric nurses, psychiatrists, and physicians need to work collaboratively and cooperatively in providing community information regarding the nature of suicide and in establishing linkages between service centres and mental health and medical treatment plans.

During a suicidal crisis, it is important for the counsellor to:
 Be calm and supportive;
 Be non-judgmental;
 Encourage self-disclosure;
 Acknowledge suicide as a choice, but not ‘normalize’ suicide as a choice;
 Actively listen and positively reinforce self-care;
 Keep the counselling process focussed in the here and now;
 Avoid in-depth counselling until the crisis abates;
 Call upon others to help assess the potential for self-harm;
 Ask questions about lethality;
 Remove lethal means;
 Make effective crisis management decisions.

To elaborate on this last point, effective decision-making during a suicide Crisis is a function of a predetermined plan for various types of individuals, risk factors, and levels of potential harm. Counsellors working with specific populations or settings can develop suicide management plans for their respective groups, situations, or contexts.

For example counsellors managing an outpatient crisis with a child should have a clear management plan that will likely differ from a residential or inpatient intervention with an
adult where emergency nursing staff or physicians are immediately available. Clearly defined suicide management plans not only provide quality care, but also include referral
sources and ensure that no one gets lost in the system of care.

Although there is little evidence about the utility of contracts, many counsellors favour contracting with potentially suicidal individuals since a contract may have potential benefits. However, if a suicide attempt occurs, all channels of communication between the counselling staff, health professionals, the family, and victim need to be open and efficient. Practicing suicide attempt response drills can increase the confidence of all counsellors dealing with a suicide crisis.

It is critical that the counsellor establish a relationship with the potential suicidal individual that includes a degree of faith and trust in the counsellor. The potentially suicidal individual
must feel free to share information and be confident that the counsellor is willing to handle the crisis. Essentially, the counsellor needs to ensure the individual’s safety while attempting to de-escalate the crisis.

Prevention of Suicides

Since the causes of suicides are multiple. There is no single solution that can prevent all suicides. The prevention programmes need to be tailored for different age, sex, cause  and setting. Some of the known and established strategies that would help prevent suicides are :

Early identification of those with suicidal behaviours and ideations and providing timely intervention.

 Providing social and crisis support mechanisms for people and communities in distress and at risk.
 Implementing effective life skills programmes in all education institutions along with teacher and parent training.
 Provision of mental health services and training of professionals with skills to recognize and manage people with mental health problems (especially depression and alcohol with screening)
 Expanding and strengthening counselling services across institutions (eg: workplaces, hospitals etc)
 Limiting easy availability of drugs and organo phosphorous compounds, dispensing medicines in smaller quantities, child proof containers for all medicinal bottles, community storage of lethal pesticides and bold warning and labels etc.
 Promoting manufacture of less lethal pesticides and banning all lethal pesticides from routine availability.
 Improving care and support for those with past suicidal attempts. Domestic violence and alcohol problems.
 Setting up programmes in all workplaces, focussing on early recognition of suicidal behaviours among employees.

 Better media reporting practices like not giving undue focus on celebrity suicides, reporting on those who have coped efficiently, information on help lines and counselling agencies, effective coping methods, early recognition of people etc.
 Measures to destigmatize and decriminalise suicides so that survivors come forward to receive help.
 Improving trauma care practices in hospitals and first aid skills for families and general practitioners.
 Surveillance and research to delineate risk factors and causes to formulate, implement and evaluate suicide prevention and control.