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Section 9
Suicide Contagion

CEU Question 9 | CE Test | Table of Contents | Bipolar
Counselor CEUs, Social Worker CEUs, Psychologist CEs, MFT CEUs

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On the last track, we presented three temperamental disturbances and how these affect a client’s vulnerability for bipolar disorder.  These temperaments are hyperthymic, cyclothymic, and dysthymic.

On this track, we will examine steps I take to prevent a client’s suicide.  These steps are establishing a family history, reviewing a checklist of risk factors, and giving advice to the client’s family.

3 Steps for Preventing a Client's Suicide

1. Family and Personal History
See how my steps compare with yours. The first step I take to prevent a client’s suicide is to establish a client’s history of suicidal attempts or thoughts. Often, if they have made a suicide attempt, this puts them at greater risk for trying it again.  Also, if there is a family history of suicide or attempts at suicide, this can also increase a client’s potential for committing suicide.  If the client has expressed a family or personal history of suicide or suicide attempts, I monitor their behavior much more closely. 

For example, Christopher, age 31, related that his mother had committed suicide when Christopher was a young boy.  Because of this, I put this "Suicide Questionnaire" to him to better assess his feelings when I believed that he was at a point in his cycles in which he could become suicidal. 

Technique:  Suicide Questionnaire
You might consider asking your depressive client these same questions if you believe that he or she has become a greater risk to him or herself, especially if the client has become more withdrawn than usual:
1. Do you feel hopeless about life, or sometimes feel like life is too painful to continue living?
2. Are you suffering from constant worry, anxiety attacks, and/or the inability to sit still?
3. Are you fearful of the future, and do you have episodes of pacing?
4. What are your reasons for living at this point?
5. Do you have any thoughts of dying or ending your life?
6. Do you have a suicidal plan?
7. Do you have the means to carry it out?
These questions are designed not only to engage the client, but to also help them examine themselves and their lives. I find that these questions have often forced a suicidal client to truly confront their decision instead of calmly resigning to it.

2. Risk Factors
Second, I assess the client’s potential for suicide with a checklist of risk factors.  Have you, like I, found that many bipolar clients are more at risk at different points in their lives than at others? 

Most notably, I have found that manic-depressive clients are more likely to attempt suicide when they are recovering from depression rather than when they are severely depressed. This stems from the fact that the client still feels the same helplessness and worthlessness they did when they were severely depressed, but because they have more energy recovering from depression, they are more likely to act on these impulses. 

Checklist of Risk Factors
My checklist of risk factors includes the following:
1. Depression accompanied by severe anxiety, agitation, or rage.
2. Previous suicide attempt.
3. Family history of suicide or suicide attempts.
4. Anniversary of a family member’s suicide.
5. Statements about wanting to die or being tired of living.
6. Giving away possessions, paying off debts, or updating a will.
7. Physical or emotional illness.
8. Loss of a spouse, child or close friend, particularly if unexpected and sudden.
9. Excessive use of alcohol or drugs.
10. A sense of hopelessness and helplessness.

Technique:  Journal
Joanne, age 45, had previously attempted suicide.  The previous attempt had occurred while she was recovering from a depressive episode.  Because I knew that this particular characteristic was a high risk factor for Joanne, I monitored her cycles carefully. When I found that Joanne had begun to recover from a crippling depressive episode, I suggested she try keeping a Journal.  I asked Joanne to find a notebook that she really liked for whatever reason. 

I then asked her to set about 20 to 30 minutes aside each day and find a secluded but comfortable location. I then told her to write about whatever was on her mind without worrying about spelling or grammar. I also asked her to focus on her emotions and thoughts.

3 Questions for Suicidal Clients

Once she was done, I asked Joanne to review what she wrote and ask herself,
a. "Why do I have these thoughts?"
b. "Should I consult my therapist about anything I wrote?" and
c. "Are any of my thoughts geared towards harming myself?" 
Often, I have found that clients who can see their suicidal thoughts on paper and face their decision are more likely to consult a therapist.

3. Advice to Family
In addition to personal and family history and monitoring risk factors, the third step I take in preventing a client’s suicide is to talk to the client’s family about what to do in case their loved one should be at risk for suicide or is making threats of suicide.

Sofia was a 26 year old bipolar client of mine whose family was extremely supportive and involved with her therapy and healing. Because Sofia had made suicide attempts in the past, I gave her family advice on what to do at high-risk times. I have taken these suggestions from the preventative measures that the National DMDA recommends in the case of a suicide threat. 

Suggestions for Preventative Measures
You might consider giving these suggestions to the family of a client who might be a potential suicide risk.
1. Take seriously the person’s condition.
2. Stay calm, but don’t under-react.
3. Involve other people. Don’t try to handle the crisis alone or jeopardize your own health or safety. Call 911, if necessary,
4. Contact the person’s psychiatrist, therapist, crisis intervention team, or others who are trained to help.
5. Express concern. Let the person talk about suicidal thoughts without loved ones appearing to convey shock and condemnation. Give concrete examples of what leads you to believe the person is close to suicide. If this understanding is conveyed to the patient, then he or she may feel less guilty about possessing such suicidal thoughts.
6. Listen attentively.  Maintain eye contact.  Use body language, such as moving close to the person or holding his or her hand, if it is appropriate.
7. Ask direct questions.  Inquire whether the person has a specific plan for suicide.  Determine, if possible, what method of suicide the person is thinking about.
8. Acknowledge the person’s feelings. Be empathetic, not judgmental. Do not relieve the person of responsibility for his or her actions, however.
9. Reassure. Stress that suicide is a permanent solution to temporary problems. Insist that the problem can be helped, even if past attempts have failed. Provide realistic hope. Remind the person that things can get better if the right help is made available. Stress that you will help them
find effective treatment.
10. Don’t worry about confidentiality. Confidentiality is secondary to a life-and-death situation. Don’t hesitate to speak with the person’s doctor in order to protect that person.
11. Do not leave the person alone, if possible, until you are sure that he or she is in the hands of competent professionals.
By giving these guidelines to Sofia’s family, they can be more prepared to aid Sofia should she start to express suicidal thoughts.

Are you treating a client currently who is at risk for suicide?  Would it be beneficial to replay this track to review the content to assess if you are missing any of these criteria for suicide in your sessions?

On this track, we discussed steps I take to prevent a client’s suicide: establishing a family history, reviewing a checklist of risk factors, and giving advice to the client’s family.

On the next track, we will examine the role childhood and upbringing play in a bipolar client’s life:  characteristics of functions and dysfunctional families; types of dysfunctional families; and family communication.

Peer-Reviewed Journal Article References:
Alloy, L. B., Urošević, S., Abramson, L. Y., Jager-Hyman, S., Nusslock, R., Whitehouse, W. G., & Hogan, M. (2012). Progression along the bipolar spectrum: A longitudinal study of predictors of conversion from bipolar spectrum conditions to bipolar I and II disorders. Journal of Abnormal Psychology, 121(1), 16–27.

Gilkes, M., Perich, T., & Meade, T. (2019). Predictors of self-stigma in bipolar disorder: Depression, mania, and perceived cognitive function. Stigma and Health, 4(3), 330–336.

Ma-Kellams, C., Baek, J. H., & Or, F. (2018). Suicide contagion in response to widely publicized celebrity deaths: The roles of depressed affect, death-thought accessibility, and attitudes. Psychology of Popular Media Culture, 7(2), 164–170.

Swartz-Vanetik, M., Zeevin, M., & Barak, Y. (2018). Scope and characteristics of suicide attempts among manic patients with bipolar disorder. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(6), 489–492.

Online Continuing Education QUESTION 9
What are three steps to take in preventing a client’s suicide? To select and enter your answer go to CE Test.


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