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Schizophrenia: Practical Strategies for Relapses & Reducing Symptoms
10 CEUs Schizophrenia: Practical Strategies for Relapses & Reducing Symptoms

Section 26
Strategies for Dealing with Suicidality in Schizophrenic Clients

Question 26 | Answer Booklet | Table of Contents | Schizophrenia CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, & MFT CEU

Efficiency in Suicide Assessments : Results of this study offer a more concise and usable list of potential risk factors for suicidality among clients with schizophrenia. Until recently, clinicians were forced to consider a dizzying array of precursors to suicidal behavior. As reflected in the following statement by the APA (1997), the possible risk factors can ultimately make assessment of suicidality difficult, if not confusing: “being male, white, single, socially isolated, depressed or hopeless, unemployed, or chemically dependent and having a significant recent loss, personal history of suicide attempts, or family history of suicide…. being young, being within the first 6 years of initial hospitalization, having high IQ, high aspirations, a high level of premorbid scholastic achievement, a chronic and deteriorating course, or an awareness of loss of functional abilities…. the presence of command auditory hallucinations to kill oneself, and recent discharge from the hospital, (p. 45)”

Results such as those outlined in this study indicate a narrower list of primarily qualitative factors (i.e., depressed mood and recent psychosocial Stressors) that counselors should consider as primary indicators of potential suicide risk.

Awareness of Suicidality in Schizophrenia: It is vital for counselors to recognize the commonality of suicide attempts among clients with schizophrenia. Between 60% and 80% of clients with schizophrenia have suicidal ideation (Drake, Gates, Whitaker, & Cotton, 1985), an estimated 18% to 55% will attempt suicide (Black & Fisher, 1992; Roy, 1986), and between 10% and 15% will commit suicide (APA, 1997; Caldwell & Gottesman, 1990). Consistent with other research, this study found a high occurrence of suicidal ideation and attempts in clients with schizophrenia. Therefore, counselors must always consider the possibility of suicidality when treating these clients. Moreover, in contrast to clients without psychotic disorders, these clients had strong intent to harm themselves, and their attempts were serious (usually requiring emergency medical attention). Thus, reality confirms that developing an emergency safety plan for crisis situations may help counselors respond quickly and effectively when confronted with a suicidal psychotic client. For example, having phone numbers of emergency care facilities and having established a solid relationship with an attending psychiatrist can increase efficiency during a potentially disorganizing situation such as this.

Efficacy in Conceptualizing Suicidality
Because current emotional state and recent psychosocial Stressors rather than demographic or past clinical characteristics were associated with suicidality, perhaps counselors should use a stress-diathesis model when conceptualizing risk of suicide with clients who have schizophrenia (Blumenthal & Kupfer, 1990). This model might help counselors both empathize with and better conceptualize the case of such clients. A stress-diathesis model of suicidality proposes that certain clients have less resilience when coping with problems in living and that certain changes in psychological states or environmental conditions increase vulnerability to extreme negative emotional states. Consistent with psychotic clients' risk of suicidality, perhaps the following is a commonly occurring scenario. A stressful condition (e.g., increased psychotic symptoms or loss of a spouse, boyfriend, or girlfriend) results in increased psychological vulnerability. The client attempts to cope with this heightened vulnerability. If executive functioning is sufficiently impaired (as is often the case in schizophrenia), then the client's past repertoire of coping mechanisms is ineffective, or they have no ability to psychologically accommodate the new Stressor. A predominant negative emotional syndrome ensues (i.e., severe depression), and this overwhelming syndrome disrupts the individual's biopsychosocial system (e.g., less circulating serotonin, thoughts of hopelessness, feelings of helplessness, increased depression, and eventual social withdrawal), which culminates in more extreme psychological vulnerability. An acute awareness of this vicious cycle and its emotional consequences is perhaps the "final straw," resulting in suicidal ideation and intent. Finally, the client seeks an "escape" from his or her illness and its psychosocial consequences by attempting suicide (Schwartz, 2000; Schwartz & Petersen, 1999).

Counselor Training in and Use of Ongoing Assessment of Suicidality
Findings similar to those described in this study emphasize a definite need for training in and use of ongoing assessment during the counseling process. As reported by Harkavy-Friedman et al. (1999), most suicidal clients had clear ideation and intent to harm themselves before engaging in suicidal behaviors. Counseling professionals must continually assess clients' biopsychosocial functioning whether or not current suicidality is present. Ongoing assessment may have preventive functions that are crucial to clients' health and safety. As Harkavy-Friedman et al. (1999) stated, "this study supports the need for prospective evaluation of suicidal behavior and its associated risk factors; it also supports the need for ongoing biopsychosocial assessments and interventions" (p. 1278). The developmental and holistic philosophy of counseling professionals (Ginter, 1999) allows for a unique ability to perform this critical function. However, counselors must be trained in assessment and evaluation skills, especially regarding crisis interventions. For example, counselors must know suicide assessment techniques and instruments, specifically those tailored to the counseling professions (e.g., The Suicide Assessment Checklist; Rogers, Alexander, & Subich, 1994). Counseling professionals should also understand the characteristics of effective crisis workers. Multicultural issues in crisis intervention and specific crisis intervention models should also be studied when working with clients in this vulnerable population (Gilliland & James, 1997). In particular, counselors need experience in skills related to assessing the severity of the problem, defining the problem, ensuring client safety, providing support, examining alternatives to crisis-induced behaviors, and making specific action plans for client or professional interventions when working with clients who have schizophrenia.

When suicidality is detected, counselors should identify clients' intent, plan, and means of completion, if possible. This standard technique can clarify the severity of clients' desire to harm themselves. Intent describes clients' actual desire to kill themselves, rather than a wish to escape from their psychological pain. Apian is defined as a concrete and achievable way to carry out their intent. Means of completion refers to the availability of resources (e.g., a gun) and the clients' ability (e.g., problem-solving ability and energy level) to carry out the plan. Depending on the severity of suicidality (i.e., combination of thoughts, intent, plan, and means of completion), various degrees of intervention can be attempted. Generally, the "least restrictive environment," that is, the most noninvasive intervention necessary, should be used to achieve a safe and effective outcome. Often, increasing the number of outpatient visits and accessing social support networks may be helpful during these vulnerable periods. If more intensive interventions are deemed necessary or clients are unwilling to cooperate with reasonable and voluntary evaluation, an inpatient admission should be considered (APA, 1997). Clients at high risk for suicide (based on the criteria previously outlined) should be considered for immediate hospitalization, and suicide precautions should be instituted. This includes effective use of psychotropic medications, a supportive and empathic counseling approach, and mobilization of social support networks (e.g., family and friends). During such periods, supportive counseling (i.e., an empathic, calm, moderately directive approach) can be very beneficial (APA, 1997). Please note that counselors should have training and supervision in diagnosis (Hohenshil, 1996; Seligman, 1999) because the findings of this study may not generalize to clients without schizophrenia.

Preventive Interventions: Because counselors are "front-line" professionals who have ongoing contact with clients, many are often in a unique position to prevent the exacerbation of symptoms that may ultimately lead to suicidality. These preventive measures may include referral to a physician for medication evaluation or changes. This type of referral is particularly indicated with schizophrenic clients who are decompensating psychologically. To preempt the stress-diathesis cycle previously described, counseling professionals should consider referring psychotic clients for a psychiatric evaluation if either depressive or heightened psychotic symptoms are evident. Perhaps an antidepressant medication is necessary to forestall a major depressive episode (Buelow, Hebert, & Buelow, 2000), or possibly an increase in antipsychotic medications is warranted to reduce stress-inducing psychotic symptoms. As Buelow et al. (2000) explained, three of the primary clinical situations that call for a referral to a psychiatrist include evidence of severe psychotic behaviors, current suicidal ideation, or severe depression with a history of suicide attempts. All three of these criteria were present and intercorrelated in the sample of suicidal clients investigated by Harkavy-Friedman et al. (1999). According to the National Alliance for the Mentally Ill (1998), only 62% of clients with schizophrenia receive the appropriate dose of antipsychotic medications when new or exacerbated symptoms are reported. Only 29% of these clients are administered an appropriate continuous dose of antipsychotic medications. Slightly more than 45% of clients with schizophrenia receive antidepressant medication after reporting depressive symptoms. It is therefore vital for continued safety (and possibly for survival) that counselors advocate for client needs in this area.

Coping With Completed Suicides: Given the large proportion of clients with schizophrenia who commit suicide, counseling professionals should also be prepared to cope personally with this potentially devastating circumstance. The impact of client suicide can have severe and long-term consequences for counselors, and several authors (e.g., Bongar, 1993; Juhnke, 1994) have reported that completed suicide is the type of crisis most frequently encountered by counseling professionals. As Foster and McAdams (1999) described, the profession of counseling is often a dissonance-producing experience. This experience is compounded when treating clients with more severe disturbances for whom the prognosis is poor and progress is slow Because counselors are routinely treating clients with more severe disturbances in clinics, agencies, hospitals, and training facilities, it is important to recognize that roping with completed suicide may be a professional reality. Thus, personal preparation through reading, supervision, and development of a structured plan that incorporates reflection, catharsis, and rehabilitation may be invaluable. A counseling professional can never be fully prepared to manage every circumstance related to client suicidality, but with knowledge and experience, clinical expertise develops, after which self-efficacy can slowly evolve.
- Schwartz, Robert C.; Suicidality in Schizophrenia: Implications for the Counseling Profession;  Journal of Counseling & Development; Fall2000; Vol. 78 Issue 4

Personal Reflection Exercise #12
The preceding section contained information about strategies for dealing with schizophrenic clients. Write three case study examples regarding how you might use the content of this section in your practice.

What is meant by a stress-diathesis model of suicidality? Record the letter of the correct answer the Answer Booklet.

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