1. Copyright © 2014. F.A. Davis Company The Suicidal Client Chapter 17

2. Copyright © 2014. F.A. Davis Company Introduction Suicide is not a diagnosis or a disorder; it is a behavior. More than 90 percent of suicides are by individuals who have a diagnosed mental disorder.

3. Copyright © 2014. F.A. Davis Company Historical Perspectives In ancient Greece, suicide was an offense against the state, and individuals who committed suicide were denied burial in community sites. In the culture of the imperial Roman army, individuals sometimes resorted to suicide to escape humiliation or abuse. In the Middle Ages, suicide was viewed as a selfish or criminal act.

4. Copyright © 2014. F.A. Davis Company During the Renaissance, the view became more philosophical, and intellectuals could discuss suicide more freely. Most philosophers of the 17th and 18th centuries condemned suicide, but some individuals began to associate suicide with mental illness. Historical Perspectives (cont.)

5. Copyright © 2014. F.A. Davis Company Suicide was illegal in England until 1961, and only in 1993 was it decriminalized in Ireland. Most religions consider suicide a sin against God. Historical Perspectives (cont.)

6. Copyright © 2014. F.A. Davis Company Epidemiological Factors Suicide is: – The third leading cause of death among Americans 15 to 24 years of age – The fourth leading cause of death for ages 25 to 44 – The eighth leading cause of death for ages 45 to 64 National Center for Health Statistics

7. Copyright © 2014. F.A. Davis Company Facts and Fables About Suicide 1. Which is a misconception about suicide? A.Eight out of ten individuals who commit suicide give warnings about their intentions. B.Most suicidal individuals are very ambivalent about their feelings about suicide. C.Most individuals commit suicide by taking an overdose of drugs. D.Initial mood improvement can precipitate suicide.

8. Copyright © 2014. F.A. Davis Company Correct answer: C – It is a misconception that individuals usually commit suicide by taking an overdose of drugs. Gunshot wounds are the leading cause of death among suicide victims. Facts and Fables About Suicide (cont.)

9. Copyright © 2014. F.A. Davis Company Risk Factors Marital status – The suicide rate for single persons is twice that of married persons. Gender – Women attempt suicide more often, but more men succeed. – Men commonly choose more lethal methods than women.

10. Copyright © 2014. F.A. Davis Company Age – Risk of suicide increases with age, particularly among men. – White men older than 80 years are at the greatest risk of all age/gender/race groups. Risk Factors (cont.)

11. Copyright © 2014. F.A. Davis Company Religion – Affiliation with a religious group decreases risk of suicide. Catholics have lower rates than Protestants or Jews. Socioeconomic Status – Individuals in the very highest and lowest social classes have higher suicide rates than those in the middle class. Ethnicity – Whites are at highest risk for suicide followed by Native Americans, African Americans, Hispanic Americans, and Asian Americans. Risk Factors (cont.)

12. Copyright © 2014. F.A. Davis Company Other Risk Factors – Psychiatric illness. Mood and substance use disorders are the most common psychiatric illnesses that precede suicide. Other psychiatric disorders that account for suicidal behavior include: Schizophrenia Personality disorders Anxiety disorders – Severe insomnia is associated with increased risk of suicide. Risk Factors (cont.)

13. Copyright © 2014. F.A. Davis Company Other Risk Factors (cont.) – Use of alcohol and barbiturates – Psychosis with command hallucinations – Affliction with a chronic, painful, or disabling illness – Family history of suicide – Homosexual individuals have a higher risk of suicide than their heterosexual counterparts. Risk Factors (cont.)

14. Copyright © 2014. F.A. Davis Company Other Risk Factors (cont.) – Having attempted suicide previously increases the risk of a subsequent attempt. About half of those who ultimately commit suicide have a history of a previous attempt. – Loss of a loved one through death or separation – Lack of employment or increased financial burden Risk Factors (cont.)

15. Copyright © 2014. F.A. Davis Company Predisposing Factors: Theories of Suicide Psychological Theories – Anger turned inward – Hopelessness – Desperation and guilt – History of aggression and violence – Shame and humiliation – Developmental stressors

16. Copyright © 2014. F.A. Davis Company Sociological Theory – Durkheim’s three social categories of suicide: Egoistic suicide Altruistic suicide Anomic suicide Predisposing Factors: Theories of Suicide (cont.)

17. Copyright © 2014. F.A. Davis Company Biological Theories – Genetics – Neurochemical factors Predisposing Factors: Theories of Suicide (cont.)

18. Copyright © 2014. F.A. Davis Company Nursing Process: Assessment Demographics – Age – Gender – Ethnicity – Martial status – Socioeconomic status – Occupation – Lethality and availability of method – Religion – Family history of suicide

19. Copyright © 2014. F.A. Davis Company Presenting Symptoms/Medical-Psychiatric Diagnosis Suicidal Ideas or Acts – Seriousness of intent – Plan – Means – Verbal and behavioral clues Interpersonal Support System Nursing Process: Assessment (cont.)

20. Copyright © 2014. F.A. Davis Company Analysis of the Suicidal Crisis – The precipitating stressor – Relevant history – Life-stage issues Psychiatric/Medical/Family History Coping Strategies Nursing Process: Assessment (cont.)

21. Copyright © 2014. F.A. Davis Company Nursing Process: Diagnosis/Outcome Identification Nursing diagnoses for the suicidal client may include: – Risk for suicide – Hopelessness

22. Copyright © 2014. F.A. Davis Company Nursing Process: Planning/Implementation 2.The nurse is caring for an actively suicidal client on the psychiatric unit. What is the nurse’s priority intervention? A.Discuss strategies for the management of anxiety, anger, and frustration. B.Provide opportunities for increasing the client’s self- worth, morale, and control. C.Place client on suicide precautions with one-to-one observation. D.Explore experiences that affirm self-worth and self- efficacy.

23. Copyright © 2014. F.A. Davis Company Correct answer: C – Placing the client on suicide precautions with one-to- one observation provides a safe environment for an actively suicidal client. Maintaining client safety should always be a priority nursing intervention. Nursing Process: Planning/Implementation (cont.)

24. Copyright © 2014. F.A. Davis Company Guidelines for treatment of the suicidal client on an outpatient basis: – Do not leave the person alone. – Establish a no-suicide contract with the client. – Enlist the help of family or friends. – Schedule frequent appointments. – Establish rapport and promote a trusting relationship. Nursing Process: Planning/Implementation (cont.)

25. Copyright © 2014. F.A. Davis Company Guidelines for treatment of the suicidal client on an outpatient basis (cont.) – Be direct and talk matter-of-factly about suicide. – Discuss the current crisis situation in the client’s life. – Identify areas of self-control. – Give antidepressant medications. Nursing Process: Planning/Implementation (cont.)

26. Copyright © 2014. F.A. Davis Company Crisis counseling with the suicidal client: – Focus on the current crisis and how it can be alleviated. – Note client’s reactivity to the crisis and how it can be changed. – Work toward restoration of the client’s self-worth, status, morale, and control. Introduce alternatives to suicide. – Rehearse more positive ways of thinking. Nursing Process: Planning/Implementation (cont.)

27. Copyright © 2014. F.A. Davis Company Crisis counseling with the suicidal client (cont.): – Identify experiences and actions that affirm self- worth and self-efficacy. – Encourage movement toward the new reality. – Be available for ongoing therapeutic support and growth. Nursing Process: Planning/Implementation (cont.)

28. Copyright © 2014. F.A. Davis Company 3.A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. At this time, which is the most appropriate nursing intervention for this client? A.Provide the client with a safe and structured environment. B.Isolate the client from all stressful situations that may precipitate a suicide attempt. C.Observe the client continuously to prevent self-harm. D.Assist the client to develop more effective coping mechanisms. Nursing Process: Planning/Implementation (cont.)

29. Copyright © 2014. F.A. Davis Company Correct answer: D – Assisting the client to develop more effective coping mechanisms is a nursing intervention that can and should be implemented in outpatient settings as ongoing follow-up. Nursing Process: Planning/Implementation (cont.)

30. Copyright © 2014. F.A. Davis Company Information for Family and Friends of the Suicidal Client Take any hint of suicide seriously. Do not keep secrets. Be a good listener. Express feelings of personal worth to the client. Know about suicide intervention resources. Restrict access to firearms or other means of self- harm. Nursing Process: Planning/Implementation (cont.)

31. Copyright © 2014. F.A. Davis Company Information for Family and Friends of the Suicidal Client (cont.) Acknowledge and accept the person’s feelings. Provide a feeling of hopefulness. Do not leave him or her alone. Show love and encouragement. Seek professional help. Remove children from the home. Do not judge or show anger toward the person or provoke guilt in him or her. Nursing Process: Planning/Implementation (cont.)

32. Copyright © 2014. F.A. Davis Company Interventions With Family and Friends of Suicide Victims Encourage the person to talk about the suicide. Discourage blaming and scapegoating. Listen to feelings of guilt and self-persecution. Talk about personal relationships with the victim. Recognize differences in styles of grieving. Assist with development of adaptive coping strategies. Identify resources that provide support. Nursing Process: Planning/Implementation (cont.)