06 Suicide Management

Resources

Karl A. Slaikeu, Crisis Intervention: A Handbook for Practice and Research, Second Edition, Allyn and Bacon, 1990
Thomas C. Barrett, Youth in Crisis: Seeking solutions to Self-Destructive Behavior, 1987
Unknown, When Death is Sought, Chapter I, The Epidemiology of Suicide, found on the Metanoia Communications web page.
Magellan Behavioral Health, Clinical Practice Guidelines for Assessing and Managing the Suicidal Patient, 2000

THE EPIDEMIOLOGY OF SUICIDE

“The psychoanalytic theories of suicide prove, perhaps, only what was already obvious: that the processes which lead a man to take his own life are at least as complex and difficult as those by which he continues to live. The theories help untangle the intricacy of motive and define the deep ambiguity of the wish to die but say little about what it means to be suicidal, and how it feels.” – A. Alvarez, The Savage God

Suicide is the eighth leading cause of death in the United States. Based on the assumption that suicide is not a rational choice, society has long sought to prevent or discourage the practice. In fact, society has generally regarded a suicide attempt as a plea for help or an indication of a need for psychological intervention.

Suicide in the General Population

Overall, 2.9 percent of the adult population attempts suicide, and the suicide rate in the general population over a lifetime of 70 years is approximately one percent. Studies of suicide attempters suggest that one percent to two percent complete suicide within a year after the initial attempt, with another one percent committing suicide in each following year. Suicide is especially prevalent among the young and the elderly. It is the third leading cause of death for individuals 15 to 24 years of age. Over the last 30 years, the suicide rate in this age group has increased dramatically. Among younger people who attempt suicide, between 0.1 percent and 10 percent will eventually commit suicide.

Such tragic statistics are further magnified when one considers that between 100 and 120 attempts occur for every completion. Moreover, an examination of suicide is not sufficient to reveal the self-destructive path that many young people are taking. In order to bring the picture into clearer focus, drug abuse, unwanted pregnancies and runaways should also be considered. These behaviors are also self-destructive to varying degrees and can be placed on a continuum, with suicide the ultimate self-destructive act.

While suicide is a leading cause of death, there is no evidence that screening the general population for suicide risk is effective in reducing suicide rates. Even when a risk factor or suicidal intent is detected, there is weak evidence that interventions effectively reduce suicide rates. The assumption that must be made from this evidence is that our traditional methods of addressing the issue of suicide are in some way flawed. With this construct in mind, this protocol is oriented toward the use of two innovations: 1) the use of prevention, rather than identification, as the focus of intervention, and 2) the focus on cognitive technology as the basis for intervention.

Motives for self injury behavior

Motives for suicide tend to get equated with causality in the folk wisdom models such as “disappointments in love explain suicidal lovers”. The public information media are prone to use the causality model in reporting suicide phenomena and interpreting research. The deficiency of this thinking is the tendency to equate correlations with cause & effect and to ignore contributing factors such as stress or predisposing factors of psychological vulnerabilities that together enhance the impulse to act in a self injurious way. Popular use of causality models tends to yield over simplified explanations. On the other hand, the more sophisticated interpretations are harder to apply to practical prevention efforts.

In scientific writing there is also the tendency to over simplify by a narrowed focus of attention as in the Durckheimian and Freudian ideas of sociology and psychoanalysis respectively. The current suicidology literature is replete with studies that identify increased rates with unemployment, religious observance, divorce, status integration, etc., reflecting the sociology of suicide. The opposite also exists in the form of studies of significant loss, strict child rearing, parental conflicts, endogenous depression, conflicts, loss of hope, etc. reflecting the psychology of unique individual motivations.

Making sense of suicide continues to be difficult for the survivors, the public, and the suicidologist. What is sought are explanations that rely on premises of necessary and sufficient causation to distinguish between those that do and most that do not injure themselves given apparently equivalent motives.

Stephens (1983) contrasts sociological and psychological methods in the vocabulary of motives for completed suicide as manifested in suicide notes. The comparison is between “interpersonal activity that is oriented towards making sense to the self and to others…” versus “internal pushes toward actions that views motives as well springs to behavior”. From a sociological perspective she argues successfully that both victims and non victims develop motive vocabularies that provide acceptable explanations. She documents her position by comparing studies of suicide notes in the suicidology literature with her own survey on what kind of situation ‘justified’ suicide. Stephens concludes that there is evidence for a shared language of ‘suicide talk’, which effectively serves to justify the self injury action to the victim and their survivors. The victims see themselves as heroic or at least rational in their motives.

Jean Bachelor (1980) has proposed the model that suicide denotes “all behavior that seeks and finds solutions to existential problems by making an attempt on the life of the subject”. Bachelor ignores the perspective of the victim who may assume that there will be a continuation of the self after a point of termination. In this, both Bachelor and the victims share the view that suicide is simply another problem solving action. They can do this because there is implied agreement about the mental state of death that Shneidman calls cessation. The victims tend to expect some form of continuation of the self after termination. Parenthetically, the problem solving motives seem to assume a life after death, which may be relevant for younger suicides who are less able to believe in a world without themselves continuing to exist. The explanation dissolves into the inability of individuals to experience death and the necessarily incomplete and unique notions most individuals entertain about the meanings of death for themselves.

Bachelor provides a profound and useful clarification of concepts. He views suicidal action as problem solving behavior that is oriented to accomplishing some objective, in his phrase ‘in order to …’ He also contrasts this with a larger purpose, a ‘because’. Bachelor starts with a typology of suicidal actions. These are hostility, escape, oblative (sacrificial), & Ludic (game in the sense of chance or trial by ordeal). He explicitly denies that the typology equals cause or motives. The meanings of the types are instead strategic simulations that allow a logical, if not rational, solution for the victim to achieve a unique end.

The ‘in order to’ objectives are future oriented, while the ‘because’ objectives are retrospective rationales. Bachelor illustrates with the example of a person opening an umbrella ‘in order’ to prevent getting wet ‘because’ the person dislikes wearing wet clothes. The ‘because’ focuses on the kind of victims and the situations that are prone to suicide. Bachelor who is a social philosopher presents clear formulations that provide heuristic concepts to the suicidologist.

Martin (1984) confirms the old wisdom that religious practice reduces the likelihood of suicidal deaths in the US based on 1972-1978 rates and church attendance.

Adams (1981) reports two studies. The first compares college students with intact families to those where one or both parents died before the students were 16 and a second group of students where parents were divorced or separated. A subsequent review of suicidal behavior for all subjects provided the basis for comparison. He found more suicidal ideation and attempts in students whose parents have died or were separated than those with intact families. The second study sought out victims of attempted suicides and compared them to controls. Parental loss was found to be greater in the attempted suicide group. Both studies looked at details of family stability, which differentiated suicidal and non suicidal subjects.

Motivations for suicidal death remain unique and inexplicable varying with age, sex, degree of intention to die, lethality of methods, and estimated risk for death. The efforts to develop a generalized motive for suicide remains disappointing. Even so more knowledge is accumulating including the awareness that classical explanations do not hold up under empirical scrutiny.

Research has not yielded a consensus among suicidologists about the necessary and sufficient reason to explain suicidal motivations. There seems to be a cacophony of models, meanings, and methods, no one of which commands enough confidence to yield universal adoption among suicidologist, while the gatekeepers continue to provide minimal effort for high risk populations. We can, however, extrapolate some variables from the literature for later discussion.

• justifying stories – people who commit suicide seem to need to justify to themselves, if not to others, the fact that they have taken their own life. To do so, they must create a story that is logical, if not rational. These stories seem to include two facets: they do this in order to … and because ….
• problem solving – it seems that when problem solving skills fail, taking one’s own life becomes a legitimate method for solving the unsolvable.
• continuation – its seems for many, most particularly the young, that there is a belief that somehow life will continue after suicide.
• lack of parental support – it seems that those who have lost their parents before the age of 16, either through death or divorce, are more prone to take their own lives.
• religious practices – the belief in something more powerful seems to have an impact on the decision to take one’s own life.

Cognitive Aspects [emphasis added]

Suicide is generally described as the intentional taking of one’s own life. For the individual who commits suicide, the act usually represents a solution to a problem or life circumstance that the individual fears will only become worse. Believing that their suffering will continue or intensify, suicidal individuals can envision no option but death. As articulated by a prominent suicidologist, the common stimulus to suicide is intolerable psychological pain. Suicide represents an escape or release from that pain.

Alvarez describes how it feels to be suicidal as follows: the logic of suicide is different. It is like the unanswerable logic of a nightmare, or like the science-fiction fantasy of being projected suddenly into another dimension: everything makes sense and follows its own strict rules; yet at the same time, everything is also different, perverted, upside down. Once a man decides to take his own life he enters a shut-off, impregnable but wholly convincing world where every detail fits and each incident reinforces his decision.

Contrary to popular opinion, suicide is not usually a reaction to an acute problem or crisis in one’s life or even to a terminal illness. Single events do not cause someone to commit suicide. Instead, certain personal characteristics are associated with a higher risk of attempting or committing suicide. The way in which an individual copes with problems over the course of his or her life usually indicates whether the person is emotionally predisposed to suicide. Depression, defined by symptoms of hopelessness and helplessness, is the most prevalent condition among individuals who commit suicide.

Hopelessness is the common factor that links depression and suicide in the general population. In fact, hopelessness is a better predictor of completed suicide than depression alone. Feelings of hopelessness and helplessness interact with the perception of psychological pain and the individual’s sense that his or her current suffering is inescapable.

The inner logic of suicide is embedded in the core beliefs about oneself, others and future prospects. Suicide seems like a logical course if you see yourself as worthless and helpless, if you believe that others see this as well, and finally, you understand that there is no hope for improvement in the future. It is not what you experience that determines your fate, but how you interpret that experience. People who become depressed do so, not because of a traumatic loss of a loved on or some important object, but because they interpret this experience as being personal, permanent and pervasive. The definitive characteristic of this kind of depression is helplessness and hopelessness. People who interpret these same events as impersonal, temporary and affecting only one part of their lives are much more resilient and do not follow the logic of suicide as an answer. The definitive characteristic of their depression is sadness, which passes.

In general, individuals who attempt suicide differ from those who complete suicide. Suicide attempters are likely to be female and generally attempt suicide by taking an overdose of medication. Suicide completers, by contrast, are more often male and tend to use more lethal means. Approximately 40 percent of people who commit suicide have made previous suicide attempts. Thoughts about suicide, referred to as ‘suicidal ideation’, are an important risk factor for suicide. However, many individuals experience suicidal ideation but never commit or attempt suicide.

Cultural Influences

If we are ever to understand our youth’s self-destructive actions, we must attempt to understand as much as possible about the social environment that helps shape that behavior. While many researchers make lists of such factors as family issues, school environments, mobility, modern music and television and the like as ‘reasons’ for a child’s distress, these are really symptoms of societal weaknesses and not the causes, any more than religious affiliation, rather than belief, is a deterrent. The causes are in the way our society thinks. Somewhere over the past fifty years, we have moved away from ‘rugged individualism’, which was a meme [idea, phrase] with the complex equivalence of a belief that each person both had the capability and the opportunity to achieve, to the meme of ‘victim’ with the complex equivalence that people will use you, ‘you can’t fight city hall’, and we are all simply being exploited and oppressed by someone else. Of course, this is an oversimplification. ‘Rugged individualism’ or self reliance was modified, for example, by a reliance on God and religion.

Nonetheless, the results of this meme change are not simply the increase in certain negative events, such as divorce, but the interpretation of those events in catastrophic terms. Children of divorce are a priori considered to be ‘damaged’ victims who will probably never recover. While divorce has increased in modern life, the death of a parent has substantially decreased. Yet the interpretation of that death is very different. Death was a normal experience one hundred years ago. Death today is considered to be a tragedy, and is interpreted as such. The child managers in this culture treat the death or loss of a parent through divorce as ‘unnatural’ and therefore support the notion in the child’s mind that s/he has been victimized.

When children begin to appraise the world and their place in it, they are embedded in a culture that sees life as a tragedy and tragedy as catastrophic. Unless the child is raised in an unusual family that supports the notion that s/he can achieve regardless of, or despite, the circumstances in which s/he find him/herself, such ‘victim’ memes set the table for the experience of pain and suffering.

Risk Factors for Suicide

Because of the maladaptive cognitive triad [negative core beliefs about self, others and future prospects] of people who become clinically depressed, depression is a critical risk factor for completed suicides. Depression is present in 50 percent of all suicides, and those suffering from depression are at 25 times greater risk for suicide than the general population. Older persons with depression are more likely to commit suicide than younger persons who are depressed. Studies indicate that the risk of depression is not related to race, education, or income. Instead it is related to how we frame what we experience.

Things turn out best for those who make the best of the way things turn out. – Art Linkletter

And conversely, those people who make the worst of the way things turn out have severe problems in living; sometimes unbearably so. If one is to imaging a program to manage the risk factors for suicide, one would need to pay close attention to the attitudes of people about themselves, others and their future. Such attitudes are not always clear, but there are certain inferences that can be made from the child’s self talk and an understanding of ‘cognitive errors’ that permit the constant reinforcement of core beliefs through the observations and judgements made about everyday events.

It should be apparent that not everyone who has a maladaptive triad and cognitive errors is prone to suicide. It would seem that risk for suicide involves two components – a lifetime attitude of seeing oneself as an object and a series of incidents that make one feel ‘painted into a corner’ from which there is no escape – causing interminable pain and suffering.

It is an evident consequence of being self-aware that if one has some conception of one’s own nature, then one must also have some conception of the nature of things other than oneself, i.e. of the world. Thus, the very existence of a moral order, self-awareness, and therefore human being, depends on the making of some distinction between ‘objective’ (things that are not an intrinsic part of the self) and ‘subjective’ (things that are an intrinsic part of the self) [Hallowell, ‘Orientations for the Self’, 1955]. However, as a consequence of this skill and the ability to ‘imagine’, human beings are able to view themselves as both subject and object.

The consequences of this skill has some psychological downside. Often when we view ourselves as the object, we are subjectively viewing ourselves as the ‘victim’ of some act by others. This negative way of thinking about ourselves has profound effect on the way we think about self and others. If our tendency is to think of ourselves as the subject [e.g., the actor in the scenario], we tend to think positively. The object thinking of self, as not intrinsically a part of the self, is a paradox of immense proportion. As a being who is not intrinsically ‘there’, we become a ‘thing’, with no control over our circumstances. When we think of ourselves as the object or recipient in the scenario, we tend to think negatively, hopelessly and helplessly. This is based on the epigenetic rule that we have a bias toward our own actions and against the actions of others. If you ask a child why s/he hit someone, s/he is likely to make the excuse that the other person did something [external reason]. If you as the child why the other person might do such a thing, s/he is likely to say something like, because s/he is a nasty person [internal reason].

Thus, when we consistently see ourselves as the subject, we tend to be optimistic about ourselves and generally think positive thoughts. But, when we consistently see ourselves as the object, it seems that we become the equivalent of the other and lose our positive self-bias – we blame ourselves.

Now we can make the basic cognitive error of attribution, which states that if I am explaining my own actions [I am the subject], the reasons for the actions are generally seen as external. However, if I am explaining the actions of another [myself as object], the reasons are generally seen as internal. By viewing myself as the object, I not only see things negatively, but I am biased to identify these negatives as being my own fault.

Pain and Suffering

For some people, uncontrolled pain is an important contributing factor for suicide and suicidal ideation.

Suffering represents a more global phenomenon of psychic distress. While suffering is often associated with pain, it also occurs independently. Different kinds of physical symptoms, such as difficulty breathing, can lead to suffering. Suffering may also arise from diverse social factors such as isolation, loss, and despair.

The International Association for the Study of Pain defines pain as follows:

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage… Pain is always subjective… It is unquestionably a sensation in a part or parts of the body but it is also always unpleasant and therefore an emotional experience.

This definition reflects a distinction between pain and nociception. Nociception refers to activity produced in the nervous system in response to potentially damaging (‘noxious’) stimuli. Pain is the person’s perception of nociception. A person’s pain reflects both the activity of his or her nervous system, and psychological, personal, and physiological factors.

Different types of pain vary both in the way they affect people and in their responsiveness to treatment. Acute pain, which is of limited duration, may arise from injury or as a result of a surgical procedure. Chronic pain is pain that persists well beyond the normal course of healing of a disease or injury or, most typically, is associated with chronic or progressive diseases. Pain may be constant, or it may occur as a result of activity. The characteristics of pain such as severity, quality (e.g., burning or stabbing), time course (continuous or intermittent), and location are important in assessing the nature of the pain. Severity of pain may be less important than the patient’s perception of pain and the fear of anticipated pain.

Pain is terribly real and immediately present for the person in pain, but can be less apparent to observers. This divergence can lead to a sense of isolation on the part of the person in pain, and to inadequate responses by others in alleviating pain. If so inclined, the person can interpret these experiences stoically or catastrophically.

Chronic pain has been defined as “pain that persists a month beyond the usual course of an acute disease or a reasonable time for an injury to heal or that is associated with a chronic pathological process that causes continuous pain or pain [that] recurs at intervals for months or years.” Chronic pain may be caused by a patient’s chronic or progressive disease, or by prolonged dysfunction of the nervous system. Although chronic pain may be severe and debilitating, a patient in chronic pain may not display the objective signs associated with acute pain. Chronic pain may therefore be less visible, adding to the burden individuals face in coping with the pain in their daily activities and relationships with others.

Both pain and other physical symptoms directly diminish a person’s quality of life. Apart from the experience of pain or discomfort itself, pain and other symptoms of serious illness may severely limit a person’s activities, denying some patients the capacity to engage in the activities of daily living most important to their sense of well-being and self.

Suffering is a more global experience of impaired quality of life. As defined by one physician, suffering is “the state of severe distress associated with events that threaten the intactness of the person”. The threat might be to the person’s existence or integrity, to maintaining his or her role in the family or in society, or to his or her sense of self and identity. While pain and suffering are often associated, minor pain can occur without causing suffering, and suffering can occur in the absence of physical pain. Suffering, as an interpretation, may arise from many experiences, including physical incapacity, social isolation, fear, the death of a loved one, or frustration of a cherished goal.

Even more so than with pain, an individual’s experience of suffering reflects his or her unique psychological and personal characteristics. Suffering is in effect the experience of severe psychological pain, arising from medical or personal causes. Because the experience of suffering is subjective, people are often unaware of the causes or extent of another person’s suffering. Ultimately, suffering is a distinctly human, not a medical, condition.

Again, we are brought to the element of cognitive interaction with life events to determine potentially suicidal outcome. Pain may be great or small, but the interpretation of the ‘noxious stimulus’ is what creates suffering. Whether that stimuli is physical or psychological pain is almost irrelevant; it is the interpretation of that pain and the circumstance that matter. If the pain is seen as personal, permanent and pervasive it is likely to cause hopelessness and helplessness and lead to the logic of suicide. In terms of managing suicide, this focus on ‘inner logic’ will be an important component.

THE INTERVENTION PROCESS FOR SUICIDE

If one accepts that the way an individual copes with problems over the course of his or her life usually indicates whether the person is emotionally predisposed to suicide, it follows that one needs to pay attention to how children cope with problems as a first step in identifying those children who are most likely to be prone to suicide when the second factor – seemingly obdurate ‘crisis’ – occurs.

It is not to great a leap to suggest, that as one identifies children with a propensity to see themselves as objects, interventions to change this perception would provide a preventative shield to future difficulty. Thus, an initial intervention could include both an ‘early warning system’ that identifies ‘victim’ attitudes and an early intervention system that changes these attitudes.

Early Warning System

As mentioned earlier, one of the major ‘clues’ to a person’s core beliefs comes from his/her internal dialogue or self talk. Technique #01, Perceiving Reflex Thoughts gives specific information as to how to help a child catch and attend to this self talk. However, as an early warning system, family members, preschool and school teacher, and peers are in a perfect position to hear the self talk of children, particularly at times when problems in living occur. Thus, teaching family members, teachers and peers how to listen and what to listen for, would provide substantial gain.

A second area for sensitivity is that of peer rejection or neglect. Whether instigated by the individual child or by the group, the power of peer rejection is enormous. Adults must recognize this power and not take instances of peer rejection lightly. Sociometric measure of peer acceptance are available and can be implemented with relative ease in educational settings.

It must be acknowledged by parents and teachers alike that they contribute to the attitudes the child selects for his/her core beliefs. Thus, the early warning process not only must sensitize adults to listen to the self talk of children, but to begin to ‘catch’ their own as well. Where the adults in the child ecosystem catch themselves initiating and/or maintaining negative object and victim thoughts, they may well need to seek helpful intervention for themselves, if not for the sake themselves, for the sake of the children.

The interactive quality of communication, which is the basis for thought, is nowhere more apparent than with the creation of a family or school culture. Communication includes the conveyance of information far beyond the use of words, although the words themselves are very telling. But the conveyance of information requires both a sender and receiver, and the message that is received is not always the message that was intended to be sent. The NeuroLinguistic Programming field starts with a supposition that ‘The meaning of your communication is the response it evokes’. This is a powerful construct. Too often adults, when communicating to children, assume that they are sending a clear message to the child, despite a response that indicates just the opposite. The corollary to this suppositions is, of course, that it is the sender’s responsibility to get the message to the child. It is not the child’s responsibility to ‘figure it out’ . The ‘burden of proof’ in the conveyance of information is on the sender.

Having outlined an early warning system process, we will later need to address how to train parents, teachers and peers in how to listen effectively and what to listen for, but we will hold that for the moment and move on the question of what will we do with the information received.

Early Intervention Process

Since we have an interactive problem area, we will need to address both sides of the ‘coin’. We will need to help children have more positive, resilient thoughts and we will need to help adults convey and maintain these more resilient thoughts. We can do so on three different levels, prevention, development and remediation. On the prevention level, we can begin by concerning ourselves with cultural analysis and restructuring. Since families and schools represent the major cultural components that a child is likely to participate in, both family and school cultures can be addressed. However, addressing these cultures, though simple, is not easy. What is meant by this is that the process is simple to devise and implement, but that the acceptance by adults and the retraining of the child managers is a complex problem. To understand this, we need to have some understanding about how individuals form a ‘theory of meaning’ about who they are and how they fit into the world.

“One of the deepest problems in cognitive science is that of understanding how people make sense of the vast amount of raw data constantly bombarding them from the environment” [Hofstadter, 1995]. How do perceptions occur and formulate conceptions? Out of the many sensations the mind seeks to find an orderly process by which to make sense of the world. Perceptions, however, may be influenced by belief, goals, and external context. This implies that there is a top-down process along with the bottom-up process of the senses. In order for raw data to be shaped into a coherent whole, such data must go through a process of filtering and organization, yielding a structured representation that can be used by the mind for any number of purposes. Representations then are the conclusions drawn from sensations.

What Hofstadter describes is a perceptual process that begins in a pure bottom-up manner but that is gradually invaded by increasing amounts of top-down influence. Another term for ‘bottom-up’ is thus ‘data-driven’; and ‘top-down’ corresponds to ‘theory-driven’. As the theory or schema becomes valued [given emotional content], it become increasingly difficult to displace.

The question that is raised is, at what point does the balance of learning become theory driven rather than data driven, since it is at this point that the data based management of information becomes contaminated by past experience. Another way of describing this question is at what age does the child develop a ‘theory of meaning’ about self, other and future prospects, which drives future learning? Psychologists seem to vary on any definitive age, but it is suggested that at age four or five, the child has a naive understanding of the world and his/her place in it and that perhaps over the next three or four years, this theory of meaning is quite malleable. After that, the child become increasingly resistant to changing his/her theory of meaning since this changes one’s self, although change is always possible if sufficient novel information is introduced or if the child is habituated to new information while the energy for analysis is drained. The latter aspect is true because all propositions are considered to be true until the person expends energy on analysis.

With this brief construct for the development of self in hand, it becomes apparent that adults are much more likely to resist changing their own thoughts than children are. And yet, adults are the standard bearers of the prevalent culture and the child’s data collection results in collections of information conveyed by adults, filtered only by a naive theory of meaning and the ambiguity of communication.

But adult change is possible, and even probable, if the adults have a real motivation to help the child. The typical cognitive factors of awareness, attendance, analysis, alternatives and adaptation is followed in the development of a cultural restructuring. First the child managers must become aware of and attend to the predominant memes of the culture they convey. Second, they must attend to these memes to keep them in consciousness so that they then can be analyzed for distortions and utility. Next, the process includes finding alternative memes that meet the goals, preferences of the child managers, and finally, there is an adaptation through habituation to these new memes.

The new culture will send new messages about how to think of self, others and future prospects that are more subject [within the control of the child] oriented and therefore make the child more resilient to unexpected or traumatic life incidents.

This level of prevention, however, may not be sufficient to overcome the prior learning and theory of meaning, and it may require the development of greater levels of novel and utile information. A developmental curriculum, oriented for example, toward emotional literacy, may be helpful in supplying such information. Howard Gardner identifies five main emotional literacy domains:

• Knowing one’s emotions. Self awareness – recognizing a feeling as it happens – is the keystone of emotional intelligence.
• Managing emotions. Handling feelings so they are appropriate is an ability that builds on self-awareness.
• Motivating oneself. Emotional self-control – delaying gratification and stifling impulsiveness – underlies accomplishment of every sort.
• Recognizing emotions in others. Empathy is a fundamental people skill. People who are more attuned to the subtle social signals that indicate what others need or want ae better able to respond appropriately.
• Handling relationships. The art of relationships is, in large part, skill in managing the emotions in others.

Probably the best known emotional literacy curriculum is the PATHS curriculum but other curriculae are also available for use in public schools as a developmental intervention to increase a child’s subject oriented core beliefs and as a result, his/her resiliency.

Another core curriculum that may be considered is the Interpersonal Cognitive Problem Solving Curriculum that can be taught to children as young as four years old and teaches children ‘how’ to think. In the process such problem solving skills erode the belief that s/he cannot effect change through his/her own efforts. If we recall that suicide has been seen as a method of problem solving, the ICPS solution might be preferable.

Finally, there is the level of intervention that is remedial. This is a clinical approach that differs only in degree of intensity, not of type, from the prevention and developmental interventions and is composed of two levels: 1) cognitive error correction, and 2) cognitive reconstruction. Again, the differences between the two approaches are a matter of degree rather than type. Cognitive error correction addresses the ‘self talk’ aspects that reflect the core beliefs and cognitive restructuring addresses the core beliefs more directly.

CRISIS INTERVENTION

While no program of intervention should be organized around crisis management, all programs need to consider what happens when a crisis occurs. The following approach differs dramatically from the traditional mental health approaches that are oriented toward taking responsibility for the potential suicide victim on the understanding that they are not rational and therefore not able to make appropriate decisions for themselves. Such an approach, of course, sends a message that reinforces much of the negative belief about self, others and future prospects that leads the person to this point in the first place. This approach, based on the work of Karl A.. Slaikeu, provides a different message entirely. The message conveyed throughout the process is oriented to restoring the person to power, as a subject acting in his/her own behalf.

PSYCHOLOGICAL FIRST AID

Psychological first aid, as developed by Slaikeu, is based on the concept of crisis as an essential building block in any structured understanding of human growth and development. Too often we think of crises as the unusual, mostly negative events that bring disruption to ‘normal’ life. The implication is that an ideal world would be one without crisis. Crisis theory, however, takes a different perspective and is based on the idea that crises and major life transitions – similar in their components and varying only in degree and intensity – are the stuff of which life is made. This whole concept at once sets the stage for a thought process that is entirely different than the catastrophic approaches of traditional methodology.

Slaikeu describes psychological first aid as a helping process aimed at assisting a person to move past an unsettling event so that the probability of debilitating effects [e.g., emotional scars, physical harm] is minimized, and the probability of growth [e.g., new skills, new outlook on life, more options] is maximized.

The focus is immediately shifted from prevention of the act of suicide to the future growth and development of the individual. Crisis is a time when ‘everything is on the line’. Previous means of coping and managing problems break down in the face of new threats and challenges. The potential for good or bad outcomes lies in the disorganization and disequilibrium of crisis. A wealth of clinical data suggests that some form of reorganization will begin in a matter of weeks after the onset of crisis. The reorganization may be toward growth and positive development or toward psychological impairment or even death.

“An examination of the history of psychiatric patients shows that, during certain of these crisis periods, the individual seems to have dealt with his problems in a maladjusted manner and to have emerged less healthy than he had been before the crisis”
[Caplan, 1964].

How the child will emerge from this crisis of potential suicide is at least, in part, dependent upon how the crisis is managed.

THE SEMANTIC ROOTS OF CRISIS

The semantic analysis of the word crisis reveals concepts that are rich in psychological meaning. The Chinese term for crisis [weiji] is composed of two characters that signify danger and opportunity occurring at the same time. The English word is based on the Greek krinein meaning to decide. Derivations of the Greek word indicate that crisis is a time of decision, judgement, as well as a turning point during which there will be a change for better or worse.

A crisis is a temporary state of upset and disorganization, characterized chiefly by an individual’s inability to cope with a particular situation using customary methods of problem solving, and by the potential for a radically positive or negative outcome.

A crisis state is time limited, is usually touched off by some precipitating event, can be expected to follow sequential stages, and has the potential for resolution toward higher or lower levels of functioning.

How a person perceives the crisis event, especially how the event fits in with the person’s existing frame of reference about life, makes the situation critical.

At certain times in the crisis state , people are ready for new ways to explain the data and to understand what has happened or is happening. This vulnerability, suggestibility or reduced defensiveness is what produces the opportunity for change.

THE PROCESS

Psychological First Aid

Time: Minutes to Hours

Goal: Reestablishing immediate coping

• provide support: assumes that people should not be left alone as they bear extraordinary burdens.
• reduce lethality: take measures to minimize destructive possibilities and to defuse the situation.
• link to helping resources: Rather than try to solve the whole problem immediately, pinpoint critical needs and then make appropriate referral.

Place: Anywhere – but if you can, move the person into a calm area away from stimuli.

Procedure: There are five [05] steps:

• Tune in
• Get the picture
• Explore possibilities
• Assist in taking action
• Follow up

Step Number One MAKE PSYCHOLOGICAL CONTACT

Tune in – empathic listening is a precondition for any helping activity.

• invite the person to talk
• articulate the obvious – I can see you are very upset or angry
• communicate concern.
• listen for what happened [facts]
• listen for the person’s reaction to the events [thoughts & feelings]
• use reflective statements so the person knows you have really heard what they said
• physically touch or hold
• maintain a calm, controlled manner

The first objective for making psychological contact is for the person to feel heard, accepted, understood and supported, which in turn leads to a reduction of the intensity of the emotions. Psychological contact serves to reduce the pain of being alone during a crisis. By recognizing and legitimizing feelings of anger, hurt, fear, etc. the helper reduces emotional intensity. The person’s energy may then be redirected toward doing something about the situation.

Step Number Two EXAMINE THE DIMENSIONS OF THE PROBLEM

Ask questions that focus on three [03] areas:

• immediate past – what were the events leading up to the crisis?[ specially the specific event that triggered the crises]

  Try to get information about the person’s BASIC functioning prior to the crisis [See Chart at the end].
  Why did problem solving break down now? Has anything like this ever happened before?

• present – Who, what, when, where, how? Have the person tell the story.

  Listen for BASIC functioning.
  How does the person feel right now – about the events?
  Is the person on alcohol or drugs?
  What is the impact on family life and friendships? Explore possible lethality. Who is the most significant person who might be called upon to help?

• immediate future – What are the likely future difficulties that might be impacted?

The main objective is to work toward an ordering of the person’s needs within two categories: 1) issues that need to be addressed immediately; and 2) issues that can be postponed. An important role for the helper is to assist in this sorting out process. This information gathering phase can have an immediate benefit for the person and also both of you in planning next steps.

Step Number Three EXPLORE POSSIBLE SOLUTIONS

• The helper takes a step-by-step approach, asking first about what has been tried already, then getting the person in crisis to generate alternatives, followed by the helper adding other possibilities.
• It may be important to coach some people to even consider the idea that a possible solution exists.
• Make room for untried prematurely rejected options, and guide the person in fully considering them.
• Examine obstacles to implementation. Take the responsibility to address these issues before a plan is implemented.
• If agreement on a solution between you and the person in crisis has not occurred there is need to talk further about the parameters of the problem, solutions, and/or a match between the two.
• Sometimes it is important to separate the crisis into components and to deal with one at a time.
• Part of the solution may include implementing the person’s social network; find a significant person who can help.

How an individual responds to a precipitating event and later works through the crisis experience depends on his or her material, personal and social resources.
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A poorly handled crisis or transition can lead to subsequent disorganization and ‘mental illness’.

Step Number Four Take Action

• The objective is very limited, no more than taking the best next step given the situation; implementing the agreed upon immediate solutions(s) aimed at dealing with the immediate need(s).
• Depending upon two major factors [lethality and capability] the helper takes either a facilitative or directive stance.
• The facilitative stance is one in which (1) the helper and person in crisis talk about the situation, but (2) the person takes major responsibility for any action. Further, (3) any contract regarding action is a matter involving only the helper and the person. Facilitative approaches may range from active listening to advice.
• The directive stance is different. Though the (1) talk is again between the helper and the person in crisis, the (2) action part may include the helper as well as the client. Similarly, the (3) contract for action might involve others. Directive action ranges from actively mobilizing resources to controlling actions.

Step Number Five Follow up

The last component involves getting information and setting up a procedure to check progress.

• the objective is first and foremost to complete the loop, to determine whether or not goals have been met; 1) support provided, 2) reducing lethality, and 3) making linkage to resources. If the immediate needs have been met by one of the agreed upon immediate solutions, followed by concrete action steps, and if linkage for later needs has been accomplished, then the process is complete.
• If the above issues have not been met, then the helper goes back to exploring the dimensions of the problem and reexamines the situation as it presently stands.

CONCLUSIONS

The intense personal costs – both physical and psychological – of tragedy is all too familiar to mental health practitioners. The idea that poor resolution of life crisis can lead to long range psychic damage is one of the cornerstones of crisis theory. In order to diminish this potential damage, two responses are supplied. The first is to create a more resilient person – one who is capable of framing tragedy in its most positive light. The second is to recognize that no matter how well prepared we are, certain situations or circumstances may exceed our coping capacity, and when this happens, we will need someone who will restore out capacity, not usurp it. In the context of public health, prevention can take three forms:

• primary prevention aims to reduce the incidence of disorders and the interventions oriented toward cultural restructuring and developmental curriculum would fit this category;
• secondary prevention aims to minimize the harmful effects of events that have already occurred – psychological first aid is a secondary prevention, since it is a process that takes place after critical life events have occurred
• tertiary prevention aims to repair damage long after its original onset. In this context, the remedial response is the tertiary effort.

The intent of this booklet is to establish a framework for the management of suicide with children and adolescents. However, the implementation strategies will require another document that examines the community response and the role of schools in such a response.

The school may be the most logical place for a comprehensive suicide management and intervention effort because it is the common element that all communities share, regardless of their size, and all children must attend. Every state has laws that mandate school attendance and, it is fair to say that, with the exception of the home, children spend more time in schools than any other place.

The logic behind a school suicide intervention effort is strengthened when the resources of school systems are considered. Schools generally maintain a high professional to student ratio, and, in most situations, schools have access to individuals with training in counseling and guidance. In addition, students themselves are key resources in the suicide intervention process. Obviously, schools provide the most common opportunity for large numbers of youngsters to interact on a day-to-day basis.

Schools are in a strong position to establish and maintain key liaison functions. All schools have formal communication channels with parents or guardians and open communication with families is of utmost importance in dealing with the potentially suicidal youngster. Most schools also maintain some degree of communication with various key community resources such as social service agencies, police departments and mental health centers.

The degree to which a school system can undertake a comprehensive suicide intervention effort is contingent on the commitment of the school and the community toward the effort.

BASIC PERSONALITY PROFILE CBP#06-001

Modality/
System Variables/Subsystems
Behavioral Patterns of work, play, leisure, exercise, diet [eating and drinking habits] sexual behavior, sleeping habits, use of drugs and tobacco; presence of any of the following: suicidal, homicidal or aggressive acts.

Customary methods of coping with stress.
Affective Feelings about any of above behaviors; presence of feelings such as anxiety, anger, joy, sadness, etc.; appropriate affect to life circumstances. Are feelings expressed or hidden?
Somatic General physical functioning, health.
Interpersonal Nature of relationships with family, friends, neighbors and peers; interpersonal strengths and difficulties; number of friends, frequency of contact with friends and acquaintances; role taken with various intimates [passive, independent, leader, co-equal]; conflict resolution style [assertive, aggressive, withdrawn]’ basic interpersonal style [congenial, suspicious, manipulative, exploitive, submissive, dependent.
Cognitive Mental pictures about past or future; self image; life goals and reasons for their validity; religious beliefs; philosophy of life; presence of any of the following: catastrophizing, overgeneralizing, delusions, hallucinations, irrational self talk, rationalization, paranoid ideation; general [positive/negative] attitude toward life.