Suicide Attempt Survivor Support: A Critical Unmet Need

Montgomery County has a serious problem with suicide, losing over one-hundred residents yearly.  It is probably less well-known that the county has a much bigger problem with non-fatal suicide attempts, all of which raise the individual’s life time suicide risk, and many of which subsequently become fatal attempts.

There is little data on the incidence of suicide attempts, an act in which a person with intent to die acts on a plan using potentially lethal means.  Many attempts occur without coming to anyone’s attention. Those that do usually are as a result of a need for medical treatment, self-reporting by the individual in seeking help, or when there has been an intervention.

Depending on age and gender, the ratio of suicide attempts to fatalities varies widely. Youths make more attempts than adults, men make considerably fewer attempts then women, elders tend to die on their first attempt.  Lethality of means, particularly firearms, accounts for these disparities.

Individuals with serious mental illness, especially schizophrenia, bipolar disorder, and major depression, attempt suicide more frequently than those without these conditions.  Alcohol abuse and dependence figure highly in suicide attempts. Imminent and actual suicide attempts account for a significant number of voluntary and involuntary psychiatric hospitalizations.

We could go on, but suffice it to say that focusing suicide prevention on individuals who have made a suicide attempt would likely save a lot of lives, enhance the recovery prospects and duration of those who may re-traumatize themselves when beset by even passing suicidal thoughts, and free up ERs and psychiatric hospitals to address other needs.

In 2012, the Action Alliance, a national suicide prevention coalition, identified support for attempt survivors as a priority for focus in the revised National Strategy for Suicide Prevention (NSSP).  This led to a national Suicide Attempt Survivors Task Force to help forge a path for stopping suicide attempts and deaths by engaging and supporting people with lived experience of a suicidal crisis.

In 2014, the Pennsylvania Adult Suicide Prevention Plan included an objective (9.1) to “identify all suicide strategies and services that respond to and care for individuals affected in the aftermath of a suicide attempt…and promote awareness of these resources.”  This state plan will presumably motivate the implementation of aftercare resources for suicide attempt survivors at the county level.

 

There are few suicide attempt support groups anywhere.  A 12-step based “Suicide Anonymous” group met for several years in Norristown, but ceased when its leader moved out-of-state.  At present, the only such support resource that we know of anywhere near Montgomery County is a “Suicide Anonymous” group in Burlington County, NJ:

Rise Above/R.I.T.E. Center

Twin Oaks Community Services

693 Main Street Building C

Lumberton, NJ 08048

1st Floor, Center Door

Group and Skype: 7:00pm 2nd and 4th Thursdays

Skype Only: 1st, 3rd, and 5th Thursdays

 

So why such a paucity of support groups in a major metropolitan area that probably has support groups for every other malady known to humanity?  Liability for self-injury or fatalities among group participants is often cited.  This probably would not apply to a peer-led group and has not proved insurmountable in the few provider-based groups around the country.  Bigger problems are stigma and finding peer facilitators.  (It is likely that there are a number of Certified Peer Specialists who have “lived experienced” of a suicide attempt as well as group facilitation skills.[i])  Indifference toward the needs of attempt survivors is an issue.  Perhaps those affected by recurrent episodes of acute suicidality will at some point step up.

 

Repeatedly hospitalizing those who make or almost make suicide attempts may be more part of the problem than part of the solution.  Clearly inpatient care may be indicated for stabilization and safety but there is no evidence of any long-term preventive value.  Moreover, the first 30 days after discharge from a psychiatric facility are a very high risk period for suicide.  Many readmissions within 30 days of discharge involve suicidal behavior.

 

Here are some on-line information resources on this topic:

 

 

 

[i] See “Peer Specialists can Prevent Suicide” Behavioral Healthcare, September 30, 2010 at http://www.behavioral.net/article/peer-specialists-can-prevent-suicides

The Nature of Suicide Threats

by Tony Salvatore, M.A.

The term “suicide threat” brings to mind an anguished “cry for help” by someone at imminent risk of suicide.  This may be the case and warrants immediate crisis intervention when it is.  However, there are suicide threats that are less a “cry for help” than an effort to bypass the established channels to get it.  This second form of suicide threat is usually devoid of any imminent risk.  Both variations are frequently encountered by emergency responders and behavioral health staff.

 

Basically, a suicide threat is a type of “suicide communication” and the common signal of potential suicide risk.  It is “any interpersonal action, verbal or nonverbal, without a direct self-injurious component, that a reasonable person might interpret as…communicating that suicidal behavior might occur in the near future” (Silverman et al., 2007).   Suicide threats may convey definite suicidal intent, involve no suicidal intent, or be unclear as to suicidal intent (Silverman et al., 2007).

 

A suicide threat may not always be a reflection of suicidal ideation involving any thought of death.  However, any suicide threat connotes the possibility of pending more active and possibly harmful suicidal behavior so it must be taken seriously.  At the very least this should involve screening the individual for signs of suicide risk, a specific suicide plan, and intent.  When these factors are present a voluntary or involuntary psychiatric evaluation may be in order.

 

A suicide threat grabs most people’s attention, particularly if those it is directed at care about the person voicing the threat or have some responsibility for her or his well-being.  This gives suicide threats the power to provoke a response whether or not suicidal intent is actually present.  Suicide threats get a gatekeeper’s full attention and can immediately open doors.  This feature has not been lost on substance abusers and others who wish to elude contact with the criminal justice system or expedite admission to an inpatient treatment setting.

 

While we must take a suicide threat at face value as a sign of potential suicide risk, it would be helpful to know when this is actually so.  It has been suggested that the nature of a threat may indicate if it is accompanied by intent.  Consider these two threats:

 

“I am going to kill myself tonight by [insert lethal means].”

“I will kill myself tonight if I have to go back to jail.”

 

The first is an unconditional statement of intent with a plan comprising a definite timeframe and means.  The second also gives a timeframe, but it is conditional and “sets the terms” under which “intent” may become effective.  The first is a “non-contingent suicide threat” which is passive and does not include any demands; the second is a “contingent suicide threat” which may be dramatic and predicated on secondary gain to the individual (Lambert, 2002).

 

Whereas emergency responders, crisis center and ER staff, and facility admissions personnel have probably heard both types of suicide threats, it is likely that they more often hear threats that are conditional in nature.  This is borne out by the research.  Those who make contingent suicide threats are more likely to have diagnoses of substance dependence and also to be at low risk of suicide (Lambert, 2002).  On the other hand, those making non-contingent threats are more likely to be characterized by severe depression rather than substance dependence, and also to be at high risk of suicide.

 

The nature of the suicide threat may give some indication of the nature of the suicidality and, correspondingly, the level of suicide risk that may be present.  Non-contingent threats tend to be associated with acute suicidality; contingent threats are more often linked to what has been called chronic suicidality.  It is hoped that further research may provide screening and assessment tools that can validly distinguish each type of suicide threat.