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Treating the self-destructive patient is a difficult and often stressful responsibility. The clinician not only must assess the patient's risk of suicide and recommend appropriate therapy but also must confront the underlying question of who is ultimately responsible if the patient commits suicide. Additionally, because of a mistaken belief that all suicide attempts or gestures are purposeful and manipulative, many clinicians have strong negative reactions toward suicidal patients, which further complicates clinical decision making.
Although self-destructive behavior can occur in various settings, emergency department clinicians bear an increased responsibility for self-destructive patients, because the suicide rate in users of psychiatric emergency services is 10 times greater than that in the general population (Hillard, 1983). By following the principles of intervention presented in this chapter, you can ensure that all reasonable treatment options for the suicidal patient have been explored.
Self-destructive patients fall into one of three categories: those who have suicidal thoughts but do not try to kill themselves, those who attempt suicide for attention or retaliation but do not intend to kill themselves (suicide gesture), and those who attempt suicide with the intention of fatal consequences. Patients in all diagnostic groups-including those with schizophrenia, depression, mania, and personality disorders-may have suicidal thoughts or make suicide gestures or attempts. In addition, alcohol or drug use can precipitate self-destructive behavior.
Your first priority when presented with a self-destructive patient is to ensure the patient's safety. This can be accomplished by:
After taking steps to ensure the patient's safety, conduct a mental status examination to determine the patient's suicide risk. A patient is more likely to commit suicide if he exhibits any of the following symptoms:
A patient's suicidal feelings can range from fleeting ideas to serious intentions. When assessing the patient's thoughts about suicide, do not immediately discuss the self-destructive behavior, especially if the patient appears unprepared to face his suicidal thoughts. Hillard (1983) suggests this gradual line of questioning:
Your immediate concern when caring for a patient who has attempted suicide should be to assess and treat the patient's physical condition. Obviously, the type of suicide attempt (such as drug overdose, wrist laceration, gunshot wound, or hanging) will dictate the necessary treatment.
When the patient has made a suicide gesture, ensure that (he patient has not minimized the problem (for instance, the patient may have swallowed 50 aspirin tablets but state that he took 10). The physical examination also helps determine if the patient has used alcohol or drugs. Assess the patient's heart rate and rhythm, pulse rate, temperature, blood pressure, pupil size, reflexes, gait, and level of consciousness.
You will need a laboratory evaluation if you suspect the patient has an underlying medical complication. The type of suicide attempt determines which laboratory studies you should request. An alcohol and drug screen should be part of the diagnostic analysis because the patient may deny or minimize the amount ingested.
The differential diagnosis for self-destructive behavior encompasses all major psychiatric illnesses. These conditions include schizophrenia, major depressive disorder, mania, delirium, alcohol or drug withdrawal or intoxication, dementia, and personality disorders.
Interpersonal intervention can be more effective if you keep in mind the possible reasons for suicidal behavior. Underlying motives for self-destructive actions include release from unbearable tension, impulsive response to delusional thinking or command hallucinations, revenge or retaliation toward another person, desire to join a deceased loved one, or religious or political beliefs (Hanke, 1984). Suicide also can be an act of desperation—what appears to be the only solution for a person who feels hopeless or trapped, without a future, alone in the face of overwhelming difficulties.
Your primary intervention goal is to determine the risk of suicide. Although no systematic method for assessing ultimate risk has been established, several clinical indicators of high suicide risk have been identified (see Clinical indicators of high suicide risk). Remember. however, that these risk factors are not of equal weight; a patient who is psychotic, intoxicated, divorced, widowed, separated, older than age 65, or living alone is at a higher risk for suicide.
| CLINICAL INDICATORS OF HIGH SUICIDE RISK | |
| The following indicators, if they occur in clusters, suggest an increased risk of suicide: | |
| Epidemiological risk factors | |
| · | Separated, divorced, widowed |
| · | Over age 45 |
| · | Male |
| · | White |
| · | Recent losses (loved one, health, money, job) |
| · | Protestant |
| · | Spring, tell |
| Historical data | |
| · | Family or personal history of suicidal behavior |
| · | Previous suicide attempts |
| Concurrent medical conditions | |
| · | Chronic or terminal illness |
| · | Chronic pain |
| · | Severe, persistent insomnia |
| · | Hypochondriasis |
| Concurrent psychopathology | |
| · | Poor impulse control |
| · | Poor reality testing |
| · | Psychosis or impaired brain function |
| · | Depression |
| · | Drug or alcohol abuse |
| · | Personality disorders (borderline, paranoid) |
| Suicidal behavior | |
| · | Lethal method and means |
| · | Serious, persistent intent |
| · | Will or serious note written |
| · | High-risk environment (lives alone, has no social supports) |
| Source: Hanke, 1984, p. 99. Adapted with permission of the publisher. | |
When evaluating a patient's suicide risk, consider these factors:
A patient who minimizes or denies the risk of death is difficult to assess. The patient may try to convince you that the self-destructive behavior was unintentional. This attitude, common among alcohol and drug abusers, suggests a continued high risk for suicide. Be especially alert when a patient feels reborn after surviving an overdose, coma, or other brush with death. Such a patient may feel elated, claiming that the near-fatal episode has erased his unhappy past. But the patient's elation usually is short-lived – and he again becomes suicidal-when he returns to reality and must face the disappointments of everyday life.
When evaluating a suicidal patient, remain objective, non-judgmental, and caring. Under no circumstances should you reprimand or belittle the patient, treat the patient with indifference, or minimize the need for intervention. Because a suicidal patient is unusually sensitive to rejection, treat seriously all self-destructive behavior and thoughts, even if you realize early in the interview that the patient did not intend a fatal outcome and was only trying to get attention.
Other staff members also must treat a suicidal patient seriously. The suicidal patient as manipulative and willful creator of his own problems is a common misperception among many staff members, who may resent caring for the patient when "we have really sick patients who need help." They may use the term suicide gesture derogatively to characterize the seriousness of the patient's intent, yet many patients who make repeated gestures do eventually kill themselves. Staff members must accept that the suicide gesture or attempt may represent a complete breakdown of the patient's coping mechanisms. Although this behavior appears willful, the patient may be depleted of all psychological resources and incapable of a healthier response. Hostility and rejection by the staff will increase the patient's sense of loneliness and hopelessness, intensifying or prolonging his suicidal impulse.
To lower the patient's suicide risk, try to ascertain the reasons for the self-destructive thoughts or behavior and help the patient explore alternative ways to deal with the perceived crisis. Recognize that the suicide attempt or gesture is an active effort by the patient to stop unbearable anguish. Thus, you can defuse the situation by being supportive and caring. If the patient's sense of despair and loneliness can be decreased, he may gain renewed hope of establishing an emotional rapport with others.
To help a highly suicidal person, involve others (supportive relatives, friends, or colleagues), assure the patient that he will be helped, and try to do what the patient wants done (such as referring him to social services for housing, reuniting him with a significant other, or providing relief from symptoms. If that cannot be accomplished, at least move in the direction of the patient's desired goals (Schneidman, 1980).
Be prepared to spend several hours with a self-destructive patient during the initial session. A hurried, harried interview, in which the primary goal is to discharge the patient as quickly as possible, only reaffirms the patient's sense of worthlessness and rejection. A group session that includes the patient, yourself, and other involved staff members is an effective initial intervention. Be sure to introduce all staff members to the patient before the session begins.
The session should be supportive, with staff members showing empathy. Try to see the world through the patient's eyes. Self-destructive behavior commonly is precipitated by rejection from a lover, spouse, parent, or child. However, the patient's survival suggests ambivalence toward suicide and a desire to live. Instilling hope is the first step in shifting the patient's attitude away from death and toward life.
Offering food and tending to the patient's comfort during the session can help develop a therapeutic alliance. For instance, you might ask the patient, "What can we do for you now?" In answering this question, the patient may divulge the reason for his self-destructive behavior.
When possible, precede interventions by informing the patient, "I'm going to help you now by..." or "The next thing we're going to do for you is...." Using such phrases to announce even routine interventions may help the patient begin to feel accepted, appreciated, and valued. Another helpful intervention is to inquire about and then emphasize the patient's past accomplishments on the job, in a marriage, or during outpatient treatment or hospitalizations. For a patient with repetitive self-destructive behavior, point out that he overcame hopelessness and worthlessness in the past and was able to resume his life. Similarly, if the suicidal behavior results from rejection, note that the patient overcame past rejections and was able to establish other positive relationships.
Explain to the patient that self-destructive behavior is rage directed toward oneself. The patient usually is unaware that he is punishing himself because of anger at someone else. Once the patient understands this, he can begin to develop more constructive ways to channel anger and disappointment.
With the patient's permission, contact family members or friends and request their participation in treatment. Their support and care may enhance the patient's feelings of being wanted and appreciated and ease any feelings of rejection. In addition, family members can provide clinical information that will be helpful in treating the patient. Use discretion when mobilizing such support, however. If relatives or friends are ambivalent or angry, they can exacerbate the patient's feelings of hopelessness and rejection. In such situations, you may choose not to involve them.
Certain patients create difficulty for the clinician because their behavior prevents the establishment of a therapeutic alliance. Meyerson et al. (1976) describe five types of patients who pose special problems for the clinician.
The depressed patient feels worthless, guilty, and helpless. If your approach is too kindly and solicitous, the patient's guilt and shame may intensify, preventing the patient from discussing how bad he feels. Thus, the best approach is to conduct yourself as a concerned, albeit neutral, professional. Actively explore the specific details of the patient's self-criticism, anger, and suicidal thoughts and plans, assessing the depth of the patient's depression while trying to appreciate the painfulness of his emotions.
The angry patient may engender further rejection because of immature behavior. You can easily feel trapped in a power struggle with a provocative patient or become angry at the patient for not cooperating. If such a situation goes unchecked, the interview rapidly becomes an extension of the patient's hostile struggle with authority, the angry patient skillfully frustrating your attempts to understand the problem and establish a therapeutic rapport. To overcome these problems, first recognize that your anger at the patient is a response to the patient's displaced anger at another person. Such recognition will allow you to focus on the conflict that prompted the suicide threat. For instance, you might say to the patient, "You must be very angry at someone," which should encourage the patient to discuss the actual target of his anger.
The manipulative patient usually tries to prevent you from understanding the situation, perhaps insisting on being hospitalized or not being hospitalized while avoiding any discussion of problems during the interview. An inexperienced clinician may feel compelled to bar the door when such a patient expresses a desire to be in the hospital. This manipulative and demanding behavior, however, provides insight into the patient's way of relating to others and may be a factor in the suicidal crisis. To avoid being manipulated, tell the patient firmly and directly that appropriate treatment decisions cannot be made without sufficient information. The patient may continue to push his demands with such comments as. "Before I can tell you anything, you must promise that...." Instead of giving in to these demands, ask the patient about other situations in which his needs have not been met by others. This approach refocuses the interview on the patient's life and allows discussion of how unsatisfied demands may have led to the patient’s suicidal thoughts or behavior.
A patient may admit to thinking frequently about suicide but deny any intention of carrying out the thought, usually responding with "I think about it, but not really" or "I think about it, but I would never do it. I'm too religious." When interviewing such a patient, ask specific questions that can reveal the patient's intentions, such as whether the patient has made out a will or given away valuables. Conduct a complete mental status examination to assess the patient’s suicide risk. A patient who is fully oriented, not psychotic, and without a history of impulsive or suicidal behavior is a low suicide risk (Myerson et al., 1976). Of special concern is the chronically ill, typically elderly patient who wishes "to be allowed to die." Filled with despair, feeling isolated and abandoned, the patient usually is asking the hidden question "Does anyone still care about me?" (Myerson et al, 1976). Although the suicide risk is low in such a patient, you must respond to his concerns in a professional and caring manner.
If a patient telephones a hospital or clinic with suicidal threats, ask for the person's name and address and encourage him to come in for an evaluation. A patient who gives truthful information will probably come for help. At serious risk for suicide, however, is the person who refuses an evaluation, especially if he provides evidence of previous self-destructive behavior, has slurred speech, or demonstrates an altered state of consciousness. With such a patient, try to have the call traced by asking a colleague to notify the telephone company on another line, and then inform the police. Although a therapeutic alliance is difficult to establish with such callers, always identify yourself and tell the patient where you can be reached if the call is disconnected. Such information may give the person hope that this is not the last contact he will have.
Psychotic and agitated behavior in a self-destructive patient can be controlled by rapid tranquilization with a neuroleptic medication. Recommended drugs and dosages include haloperidol (Haldol), 10 mg concentrate or 5 mg I.M. every 30 to 60 minutes, or thiothixene (Navane), 20 mg concentrate or 10 mg I.M. every 30 to 60 minutes. For a patient who is not psychotic but extremely anxious and restless, administer 5 to 10 mg of diazepam (Valium) orally or 2 to 4 mg oflorazepam (Ativan) I.M. every 1 to 2 hours. A discharged patient should not be given more than a 1-day supply of medication. Obviously, you must be extremely careful when administering medication to a patient who has attempted suicide with a drug overdose.
If you do not address the suicidal patient's hopelessness and depression, the patient will remain at risk for suicide. You can help the patient to understand and cope with depression more successfully by following these guidelines:
Other appropriate patient-teaching interventions for the suicidal patient include those listed here:
Consider admitting a self-destructive patient to the hospital if any of the following criteria apply:
Under most circumstances, consider a self-destructive patient ready for discharge if all of the following criteria apply:
If the patient is in ongoing therapy, contact the therapist for a follow-up appointment with the patient the next day. If the patient is not in therapy, arrange for the patient to meet with a therapist within 24 hours, informing the patient of the therapist's name and the time of the appointment. Finally, encourage family members or friends to stay with the patient at all times.
State laws permit involuntary commitment of a person who is demonstrably suicidal, although you should petition for commitment only after the patient refuses voluntary hospitalization. If the patient refuses treatment and cannot be detained legally, contact the patient's family members or friends to alert them to the patient’s suicidal behavior.
When treating a self-destructive patient, you can be held liable for professional negligence if you fail to identify the suicide risk, do not try to detain a suicidal person, or prescribe medication are later used by the patient to attempt suicide. Thorough documentation of the patient's history, examination, and treatment plan are the best protection against charges of negligence.