Liz Wolf

Suicidal Behavior and Treatment

“Death is sometimes chosen as the only alternative by people who feel deeply alone and

ashamed, yet are profoundly loved and respected” (McKeon, 53).

Research on suicide and suicidal behavior is scarce and according to McKeon,

“we do not have research that inpatient treatment is effective, let alone under what

circumstances hospitalization might be effective” (McKeon, 1). But one thing has been

seen as a constant; very closely after inpatient discharge, for acute care of suicide, the

patient is at high risk for suicidal behavior. “Most suicides occur within the first month of

discharge” (McKeon, 36). Clinicians who treat suicidal individuals have to have various

expertise and aptitudes in; assessment, treatment planning, crisis management, and

knowing state law and regulations.

I am going to use an analogy to make suicide comparable to something that more

people know and talk about, once you go from thinking about killing yourself to taking

the action you have crossed the imaginary line and there is no going back you have

desensitized yourself to death, it is like once you have crossed that imaginary line of

being a social drinker to an alcoholic there is no going back you will always be an

alcoholic.

In my opinion suicide is a trifold disorder biological, psychological, and

environment. The neuropsychiatric theory on suicide has strong evidence, from identical

twin studies, that genetics have a strong influence in suicide behavior. This theory also

states that along with genetics playing a role that psychological and environmental

components play in as well, “the genetic contribution to suicide presumably acts by

creating a biological vulnerability, which then interacts with environmental factors to

intensify risk” (McKeon, 26). There are a few psychological theories one of which is by

Edwin Shneidman who states that suicidal individuals have a reason for their actions its

to escape the intolerable psychological pain. “Cognitive constriction was a common

characteristic of all suicidal individuals. Suicidal people have “tunnel vision” and don’t

see alternatives to suicide as solutions for ending their pain” (McKeon, 28). Beck points

out that suicidal people have an over general memory, a type of autobiographical memory

that emphases that persons life history, and leans to remember their life in a general way

and the events are distorted to be depressing and hopeless. Linehan’s model says,

“Suicidal persons frequently experience strong emotions; they respond

emotionally to a wide variety of cues and their responses are intense. They have

difficulty tolerating this emotional distress without resorting to behaviors that help

them escape or moderate these intense and painful emotions” (McKeon, 29).

Joiner points out a very important fact, before the suicidal act is to ensue two things must

exist before; desire to die and capacity to follow through. Then Joiner points out why

people want to kill themselves. There are seven common reasons besides mental illness;

the feelings of hopelessness, helplessness, being a burden, psychological pain, despair,

don’t want to be conscious anymore. If people didn’t feel these emotions they probably

wouldn’t want to die, they just want the unbearable pain to go away. With every attempt

there is always ambivalence, “no matter how high the risk for an individual, no matter

how deep and realistic the clinicians level of concerns, there is always hope” (McKeon,

15).

As sad as it is the number one mistake made by clinicians is not doing a thorough

evaluation at intake with a solid suicide risk assessment, Suicide Assessment (C-CASA)

and the Suicide Severity Rating Scale (CSSRS).

Most clinicians don’t even do a suicide risk assessment due to the fact that it is

uncomfortable. And even when clinicians do a suicide risk assessment and the patient is

seeing them because of a suicide attempt clinicians often make the error of treating them

for the underlying condition, when the attention should be placed on how suicide risk will

be assessed, managed, and treated. “It is important for therapists to treat the suicidal

behaviors, thoughts, or desires directly” (McKeon, 31). Treating the underlying

conditions doesn’t prevent suicidal behavior from occurring again; it doesn’t give the

patient any tools to use in defense against the urges to engage in the behavior.

Treating suicidal patients is a multimodal treatment plan; there have been no

studies that show that one form of treatment is more effective than another because every

study has used a variety of treatment models. The three most common combinations of

treatments are; medication management, short-term CBT focused on suicidal thoughts,

and DBT long term. The most effective medication in preventing suicide according to

scientific evidence is Lithium; this medication is usually used for Bipolar patients or

Major Depression patients that are treatment resistant. Another medication that has had

good results in preventing suicide in patients with Schizophrenia and Schizoaffective

Disorder is Clozapine, these patients were “less likely to attempt suicide or be

hospitalized for suicide risk” (McKeon, 39). Before starting DBT doing a short-term 12

week cognitive behavioral therapy sessions will help symptoms of depressions, anxiety,

problem solve, distress tolerance, and distorted burdensome. After the 12-week therapy

attending a long term DBT sessions will help in preventing suicide. To this day the best

noted treatment for suicidal behavior is Dialectal Behavior Therapy and it is for people

who have attempted suicide multiple times. Clinicians will want to examine the patient’s

social withdrawal, isolation, and why the patient feels that they are a burden. The goal is

to instill an awareness of belonging and presence of meaningful social connections.

The goal in therapy for suicidal behavior is to ease pain, make the intolerable a

little more tolerable and maybe one day tolerable, and problem solve. In DBT one of the

skills they teach is mindfulness, it is the core of the theory, “cultivation of mindfulness

stands in direct opposition to the desire to die by suicide" (McKeon, 60). The reason

being that suicidal people want to end consciousness/ attentiveness, mindfulness is a skill

that requires you to perceive everything you experience in life “enhances conscious

awareness” (McKeon, 60). Distress tolerance skills can help a suicidal person in a crisis

to stay alive with the use of distraction tools long enough to solve the problems that are

causing the pain. The second part of distress tolerance is radical acceptance. Emotional

regulation skills can help the patient alter their actions based on emotions through

behavior adjustment. The last DBT skill is interpersonal effectiveness where the patient

integrates all parts of the therapy and uses assertiveness and does what is efficient for

them.

In both CBT and DBT homework assignments are useful and effective. Diary

cards help the suicidal person have knowledge of what leads up to their suicidal behavior,

what their triggers are for acting out. The diary cards are done everyday and have on

them suicidal ideation and if they acted in suicidal behaviors.

References

McKeon, R. (2009). Suicidal behavior. Ashland, OH: Hogrefe.