Warning Signs 

When a person is feeling suicidal, there are usually warning signs present.  These may include: 

Making statements such as:

         “I wish I were dead.”

         “I wish I had never been born.”

        “All of my problems will end soon.”

         “No one can help me now.”

         “I just can’t take it anymore.”

        “Everyone would be better off without me.”

This list was compiled from the following sources: Canadian Mental Health Association, 2006; Living Works, 1999 & Mayo Clinic 2006. It is important that clinicians be aware of these signs and monitor clients for them. 

Screening 

Because of fear, many people feel uncomfortable talking about suicide.  However, because suicide attempts and rates are higher among persons experiencing problems with gambling, it is important to ask every client explicitly if they have been thinking about suicide, whether the above warning signs are there or not.  “Raising the question of suicide shows that you are taking the person seriously and responding to the potential of her or his distress” (San Francisco Suicide Prevention, 2006). 

If a person indicates that they have been thinking of suicide, you should ask them if they have a plan, if they have thought about how or when they would do it and if they have the means to.  It is more important to ask “how” and “when” than to ask “why” because these questions help you to determine if the person is at risk.  (San Francisco Suicide Prevention, 2006).  In addition, because the rate of suicide among people who have previous attempts is 40 times greater, you also want to ask the person if there have been any prior attempts (Living Works, 1999).    When asking these questions it is important that you listen attentively and without judgment. 

Figure 2:  How to screen for suicidality.

Responding

If you ask the above questions and determine that the person is at risk, it is now time to take action: 

• Remain calm.
• Listen attentively and without judgment.
• Take the person seriously.
• Do not minimize the person’s feelings.
• Express empathy and concern.
• Ensure the person has the number for the local crisis telephone support line: http://www.suicideinfo.ca/
• Don’t promise confidentiality. You will not be able to keep your discussions with the client confidential if you know they are planning to commit suicide.
• Ensure that the person does not have access to weapons or dangerous medications.
• Draw on support from trusted and supportive family and friends.
• Refer to physician.
• Refer to mental health services.
• Make a Contract:  A contract can be a verbal or written agreement to not engage in any self-harming behaviour. 

    When making a contract:

• Be specific about what the agreement and the plan is:  For example, “I am making a commitment that I will not harm myself for the next two days.”
• When setting a timeframe, make sure to be realistic.  The purpose to is address immediate harm so a contract of a few hours or a few days can be helpful.
• Ask the person to repeat the commitment to you.  This way, you know that the person understands what he or she is agreeing to.
• Ensure you come up with an emergency plan, in case the person is no longer able to keep their commitment.  This can include the person calling a family member, friend, or crisis line or going to his or her local hospital emergency department.

This list was compiled from the following sources: Canadian Mental Health Association, 2006; Depression and Bipolar Support Alliance, 2006; Living Works, 1999; San Francisco Suicide Prevention, 2006.

If someone is threatening suicide and are not willing to make any of the above commitments, contact someone who can help:  911, person’s doctor, police or a crisis intervention team.  (Depression and Bipolar Support Alliance, 2006).

Having an understanding of suicide is the best way to prevent it.  Both the Canadian Mental Health Association (www.cmha.ca) as well as Distress Centres Ontario (www.dcontario.org) offer excellent workshops on suicide prevention.

Cultural Considerations

Culture can have an influence on: 

• “health, healing and wellness belief systems”
• “how illness, disease and their causes are perceived”
• “the behaviours of (a person who is) seeking health care and their attitude toward health care providers”

(Office of Minority Health, 2006)

 As a result, it is important to keep the following in mind when addressing issues related to suicide: 

• Understand the role of families and the community in supporting people affected by suicide. 
• Maintain respect for the beliefs and values of people.
• Be aware of individual spiritual beliefs and practices.
• Become educated about behaviours that are shaped by culture. 
• Understand and accept the need for ritual and customs in coping and dealing with difficult situations.
• People vary in their responses to and expressions of distress and loss.
• Stigma is a concern for many when it comes to issues relate to mental health.
• There is diversity around healing and help seeking.
• Our values and beliefs are shaped by more than just our culture, so be cautious not to make stereotypes based on knowledge of general characteristics of a group. (Project Liberty, 2006)

You can educate yourself on some of the above recommendations by forming working alliances with people from diverse backgrounds, speaking with spiritual leaders or community members, attending workshops related to different cultures and/or diversity, reading about other cultures or attending cultural events or festivals.

Working with Family and Friends

“The loss of a loved one by suicide is often shocking, painful and unexpected.  The grief that ensues can be intense, complex and long term.”  (American Association of Suicidology, 2004)  Offering support to someone who has lost a family member or friend to suicide, is very important:  

• Let your genuine concern and caring show.
• Be available to listen.
• Reassure the person that they did everything they could. 

Validating the person’s feelings and making recommendations around coping is also very important: 

• Intense emotions are normal.
• It is common for people to feel shame, guilt, anger, fear, despair and confusion.
• Healing takes time so be patient with yourself.
• Do what’s right for you.
• Keep asking “why” until you no longer need to.
• Do not isolate yourself.
• Seek out supportive people who are willing to listen and be there for you.
• Seek professional help.
• Join a survivors support group.

(Suicide Awareness Voices of Education, 2006)

Clinician Self-Care 

If someone is determined to end their life, there may be little that can be done to stop them.  As a result, therapists sometimes are faced with the challenge of losing a client to suicide.  What little literature there is on this topic suggests, “therapists react to suicide in two ways.  As humans, they may face grief, guilt, loss and anger, not very different from that experienced by others left behind:  simply, they react as humans who have lost another with whom they have had a close relationship.  But therapists also have to deal with the death in terms of their special role in that person’s life.”  (Soderlund, 2006)   

As a professional, it is very common to experience some or all of the following: 

• Self-doubt about your professional capabilities.
• Ideas that others, such as family members or coworkers are blaming you.
• Anxiety about the professional consequences.
• Anger at the client.
• Feelings of blame, responsibility or inadequacy.
• A desire to avoid working with suicidal clients.

(Soderlund, 2006) 

Losing a client to suicide can be very difficult to deal with, therefore, it is imperative that you seek support for yourself. 

“Therapist survivors of suicide are unanimous that formal and informal consultation with colleagues is one of the most important and helpful actions to take as soon after the suicide as possible…  It is a way of bringing a close to the shock of the death and dissecting the feelings you may have, however inappropriate you think they might be.”  (Soderlund,2006)  

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