Suicide Awareness Workshop How do we identify those most at risk and what can we do to prevent life

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Suicide Awareness WorkshopHow do we identify
those most at risk and what can we do to prevent
life harming behaviours
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• Workshop Aims
• To inform YMCA staff members of common signs of
  potentially suicidal behaviour
• Suggest interventions which may prevent suicidal
  / self harming behaviours from manifesting
  themselves in a fatal event

• To achieve these aims we need to
• Increase our awareness of this topic
• Understand what might be causing this behaviour
• Discuss local interventions that will support
• an individual at risk
• Understand the YMCAs role within successful
  prevention
• interventions

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Definitions

• Suicide
• Parasuicide / Deliberate Self-harm
• Suicide Prevention

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Suicide

• Is the result of an act deliberately initiated
  and performed by a person in the full knowledge
  or expectation of its fatal outcome.
• (The World Health Report 2001)

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• Parasuicide
• Non-fatal act
• Initiated deliberately
• In the knowledge that it may cause physical harm
  or even death
• Includes a range of acts with varying degrees of
  suicidal intent
• A majority of cases involve an overdose of
  medication or drugs, often in combination with
  alcohol

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• Self Harm
• Self Harm is deliberate injury to ones own
  body. This may be aimed at relieving otherwise
  unbearable emotions or sensations
• Self harm is generally a social taboo and is
  often (not always) associated with mental
  illnesses such as bipolar disorder, depression,
  anorexia, with a history of trauma and abuse or
  with mental traits such as perfectionism.

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Suicide Prevention

• Suicide prevention aims to reduce the prevalence
  of factors that increase the likelihood of
  suicidal behaviour, i.e. risk factors
• Suicide prevention also aims to increase the
  prevalence of factors that decrease the
  likelihood of suicidal behaviour, i.e. protective
  factors
• Suicide prevention aims to alleviate the distress
  caused to family and friends following a death by
  suicide (sometimes called postvention based on
  the notion that support following suicide can be
  a form of prevention for the bereaved)

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Patterns of Suicide in Ireland

• Task
• Circulate around the room and look at the
  various graphs of suicide / para suicide
  statistics in a N.I ROI context take the
  analysis sheet and jot down these trends and
  comment on any similarities / differences in
  existence.
• Think about any reasons that may be shaping
  these patterns with particular reference to
• Age
• Gender
• Geography
• N.I / ROI
• Method

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Possible Reasons In Younger People Alcohol and
drug abuse Family Problems Sexual and Physical
Abuse Hormonal Changes / Puberty Social
Interaction problems Early Relationship
problems Media Pressure / body image Accepting
Sexuality
In Older People Loss of loved one Physical pain
or illness Depression Living alone Retirement
worries Financial worries Divorce Certain
Professions e.g. farmers / medical
Geography Isolation, access to trees / remote
places / alternatively cities are associated
with higher crime, drug abuse etc.
Males / Females Males tend to favour more lethal
methods, more risk taking behaviour traits,
changing roles of males in the workplace
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• Risk Factors Warning Signs

Risk factors are stressful events, situations or
conditions that may increase the likelihood of a
person completing a suicide, they may be present
at birth or may develop through life Warning
signs are changes in a persons behaviour,
thoughts, physical appearance feelings,and in
what they are saying which are considered unusual
for that person and out of character, they are
very similar to the signs of depression.
In groups of three or more can you think of a
possible list of suicide risk factors / suicide
warning signs use the following headings to
assist you? Risk Factors Long term factors,
Short term precipitating factors,
sociodemographic factors Warning Signs
behaviour, physical signs, thoughts. Suicide
specific actions, feelings, verbal signs
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Selected Prevention Outcomes

• Reduced repetition of deliberate self-harm
• Increased involvement of GPs in caring for people
  following deliberate self-harm
• Improved understanding of suicidal behaviour
  among health care staff
• Improved development of a language to discuss
  issues related to suicide
• Protocols of response to suicidal behaviour
  developed in all schools
• Reduced suicide rate
• Increased availability of appropriate support
  services following suicide

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The Pattern of Suicidal BehaviourSuicideParasu
icide
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EU Total Population Suicide Rates per
100,000 Age-Standardised Source WHO site, May
10th. 2004
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THE PROBLEM contd.
EU Youth Suicide Rates per 100,000
population Source WHO site, May 10th. 2004
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Suicide, RTAs Undetermined Deaths , 1980 2002
(numbers in RoI) Note 2001-2002 data provisional
Central Statistics Office Data
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Irish Male and Female Rate of Suicide, 1980
2002 (RoI)
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Youth Suicide Ratio, 1980 2002 (RoI)
3-year moving averages
National Suicide Review Group
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Health board suicide rates, 1997-2001
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Irish Male Suicide Rate, 1980 - 2001
3-year moving averages
National Suicide Research Foundation
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Suicide rates among young Irish men, 1997-2001,
Annual rate per 100,000
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Irish Female Suicide Rate by Age, 1980 - 2001
3-year moving averages
National Suicide Research Foundation
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SuicideWhat is your impression?

• Dispelling the myths

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People who talk about suicide never attempt or
commit suicide

• Up to 80 of those who take their own lives will
  have talked about it to some significant other,
  parent, friend, counsellor or doctor in the
  months and weeks before the event. Talking about
  suicide can be a plea for help and must be taken
  seriously

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A promise to keep a note unopened and unread
should always be kept

• When the potential for harm, or actual harm, is
  disclosed confidentiality cannot be maintained
• A sealed note with the request for the note not
  to be opened is a very strong indicator that
  something is seriously wrong
• A sealed note is a late sign in the progression
  towards suicide

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If a person attempts suicide and survives, they
will never make a further attempt

• A suicide attempt is regarded can be an indicator
  of further attempts. It is likely that the level
  of danger will increase with each further attempt
• An estimated 10 make a further attempt within
  one year
• In that time, approximately 1 go on to die by
  suicide
• A previous suicide attempt is a very high risk
  factor for subsequent suicide

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People who threaten suicide are only attention
seeking

• All suicide attempts must be treated seriously
• Do not dismiss a suicide attempt as simply being
  attention seeking

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Attempted or completed suicides happen without
warning

• Looking back after someone dies by suicide,
  warning signs or indicators are often recognised.
  There is a greater need to make people aware of
  the warning signs or indicators and of how to
  respond if concerned.

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Once a person is intent on suicide, there is no
way of stopping them

• Some suicides can be prevented
• Suicidal crises are sometimes pass very quickly
• Suicide is a permanent solution to what is
  usually a temporary problem
• Immediate help might involve staying, listening,
  encouraging, planning for the future
• Long term help might involve counselling and / or
  another appropriate intervention
• The majority who die by suicide appear to have
  been ambivalent

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Talking of suicide or asking someone if they feel
suicidal will encourage suicide attempts

• Talking about suicide does not instil suicidal
  thoughts
• People who feel suicidal need to express their
  feelings in order to get help to manage them
• Talking about feelings is a first step in
  overcoming a crisis
• Crises must be managed carefully

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Suicide is painless

• Many suicides methods are very painful
• Fictional portrayals of suicide do not usually
  include the reality of pain
• Suicide bereavement can be very painful

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Depressed self-destructive behaviour are very
rare in young people

• Both are common in adolescents
• Depression may manifest itself among adolescents
  in a different way to adults
• Depression is common in children and adults
• Self-destructive behaviour is most likely to be
  first shown in adolescence
• Parasuicide is most common in 15 25 year olds

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All suicidal people are depressed

• While clinical depression is a contributing
  factor in many suicides, it need not be present
  for suicide to be attempted or completed
• Suicide rates are high in other psychiatric
  illnesses such as schizophrenia, anxiety states
  and anorexia nervosa
• Suicide occurs when there is no evidence of any
  diagnosable mental illness

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Marked, sudden improvement in mental state
following a suicidal crisis or depressive period,
signifies that the suicide risk is over

• The opposite may be true
• In the three months following an attempt, a young
  person is at most risk of completing suicide?
• An improvement may imply that the person has
  resolved to kill him or herself and is content in
  having finalised a decision
• Beware of spurious clinical improvements where
  underlying problems are not resolved

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Once a person is suicidal, they will be suicidal
forever

• Most people who are feeling suicidal, will only
  feel that way for a limited period in their lives
• Given proper support and assistance, they will
  probably recover and continue to lead meaningful
  and happy lives, unhindered by suicidal thoughts

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The only effective intervention is professional
psychotherapists with expertise in this area

• All who interact with suicidal people can help
  through emotional support and encouragement
• Social support is one of the strongest factors in
  protecting against suicidal behaviour
• Psychotherapeutic interventions rely heavily on
  the support network of family and friends

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Some people are always suicidal

• Nobody is suicidal all the time
• The risk of suicide for an individual varies from
  time to time
• The level of suicide risk should be assessed
  regularly in cases where risk has detected

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Finally..

• No matter how well intentioned, alert and
  diligent people's efforts may be, there is no
  way of preventing all suicides from occurring

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Suggested Models of Suicidal Behaviour for
Discussion
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Model of Suicidal Behaviour
environment
High risk
Biological / Genetic Vulnerability
National Suicide Review Group
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Physical and Cultural Environment

• Access to guns
• Ability to swim
• Tall buildings
• (Un)acceptability of suicide (e.g. Islam /
  Hungary)
• Civil or religious sanction

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Associated Risk Factors Psychological

• Hopelessness
• Poor problem-solving
• Dichotomous thinking
• Impaired memory function
• Etc.

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Negative Social Forces

• Poor social regulation / integration
• Religious values
• Materialistic values
• Gender roles
• Family break-up
• Urbanisation
• Work practices
• Unemployment
• Social expectation

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Mental Illness

• Depression
• Schizophrenia
• Alcohol disorder
• Etc.

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Biological / Genetic Vulnerability

• Impaired serotonin function
• Twin / family studies
• Aggressivity / impulsivity
• Executive reasoning

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Motives for Suicide

• Revenge
• Guilt
• Cry for help
• Self-punishment
• Coping with problems
• Escape
• Resolution

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Schneidman The Ten Commonalities of Suicide

• The common purpose of suicide is to seek a
  solution.
• The common goal of suicide is cessation of
  consciousness.
• The common stimulus in suicide is intolerable
  pain.
• The common stressor in suicide is frustrated
  psychological needs.
• The common emotion in suicide is hopelessness
  helplessness

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Schneidman The Ten Commonalities of Suicide

• The common cognitive state in suicide is
  ambivalence.
• The common perpetual state in suicide is
  constriction.
• The common action in suicide is egression.
• The common interpersonal act in suicide is
  communication of intention.
• The common consistency in suicide is with
  lifelong coping patterns.

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Individual Warning Signs and Suggested Responses
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Individual Warning Signs

• Change in mood
• Stress or grief about a significant loss
• Withdrawal from relationships
• Physical symptoms with emotional cause
• High Risk Behaviours
• Physical Appearance

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Individual Warning Signs

• Expressing feelings of failure/ hopelessness
• Expressing feelings of low self-esteem
• Inability to find solutions to problems
• Preoccupation with a known suicide

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Individual Warning Signs

• Writing about suicide
•       Speaking about suicide
•        Listening to songs with suicidal
  theme      
•        Threats and statements of intent
•        Giving away treasured possessions
• Tidying up affairs

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Responding at an Individual Level

• Two basic communication skills used in the
  helping process
• Attending
• Active Listening

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Attending

• Giving the person your full attention FLOWER
• Face the person
• Lean forward
• Open posture
• Watch the person
• Eye contact
• Relax

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Active ListeningDos Donts

• Show interest
• Be warm and supportive
• Pay attention
• Ask for clarification
• Allow time
• Be silent
• Be empathetic

• Argue
• Interrupt
• Make value judgements
• Give advice
• Find the solution
• Burden the person
• Give out platitudes

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How to ask about suicide

• You seem very unhappy, are you thinking about
  ending your life?
• Do you ever wish you could go to sleep and never
  wake up?
• Are you thinking about killing yourself?

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How serious are the suicidal ideas?

• Plan
• Have you made any plans to end your life?
• Method
• Do you have an idea of how you are going
• to do it?
• Do you have tablets, a gun, or another way?
• When
• Have you decided when you plan to end your
  life?

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How to encourage the person to get help

• Focus on the persons positive strengths how
  have earlier problems been resolved?
• Who could the person rely on in bad times? Is
  there anyone who might help?
• Explore alternatives to suicide
• I will help you to get help
• Youre not alone and help is available
• Lets talk to someone who can help

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Seven Steps for Helping

• Take all threats seriously.
• Ask the person to tell you what is wrong.
• Offer Support.
• Remove anything that could be lethal.
• Dont leave the suicidal person alone.
• Be positive and emphasize choices.
• Get professional help.

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Suicide Bereavement Issues and Response
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Suicide Bereavement Issues

• Definition of terms
• Bereavement is the process after death during
  which an individual learns to adjust to the loss.
  
• Grief is the emotional response to that loss.
• Mourning refers to the expression of grief.
• Counselling is an opportunity to explore a way of
  living without the deceased more resourcefully in
  a safe environment

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Stages of Grief

• Numbness
• Shock
• Disbelief
• Denial
• Alarm
• Panic
• Fear
• Pangs of Grief
• Anger

• Yearning and Searching
• Guilt
• Idealisation
• Hopelessness
• Apathy
• Despair
• Realisation
• Acceptance

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Influences on Grief

• Antecedents of Grief
• Childhood experience
• Their own experience of death and grief
• Their relationship with the deceased
• Concurrent determinants
• 1.The age of the person who died
• 2.The type of personality
• 3.Socio cultural factors
• 4. The mode of death terminal illness/suicide
• Subsequent Determinants
• Amount of support
• Other stresses in ones life

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Pathological Grief Reactions

• Chronic Grief
• Can occur when the bereaved continue to
  experience the immediate pain of loss months and
  even years later.
• When they are unable to move on in the grieving
  process
• Usually occurs when ambivalent relationship with
  the deceased existed.
• Masked grief
• Grief reaction masked by development of physical
  or somatic symptoms which appear to bereaved
  person to be unrelated to loss.
• Symptoms often replicate those experienced by the
  deceased.
• Exaggerated grief
• Grief reaction is excessive and intense (over the
  top )
• May develop into a serious Psychiatric illness
  e.g. depression or anxiety

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4 Tasks of Mourning

• The tasks of mourning are
• To accept the reality of the loss
• To experience pain and grief
• To adjust to a new environment in which the
  deceased is missing
• To relocate the deceased emotionally and move on
  with life
• (Worden, 1991)

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Whats Helped Others?

• Visiting the grave
• Rearranging and storing the belongings of the
  deceased
• Writing about shared experiences with family and
  friends
• Writing a letter to the deceased
• Allowing themselves to be angry but accepting
  that you love the person who died
• Meeting and talking with others with similar
  experiences

• Spending time planning the funeral
• Learning to mourn
• Acknowledging all feelings
• Talking honestly and openly with family and
  friends- telling the truth
• Having a regular chat and check up with a
  doctor
• Reviewing pictures and mementoes

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Suggestions for the Bereaved I

• Know you can survive. You may not think so but
  you can.
• Struggle with why it happened until you no
  longer need to know Why or until you are
  satisfied with partial answers.
• Know that you may feel overwhelmed by the
  intensity of your feelings but all your feelings
  are normal.
• Anger, guilt, confusion and forgetfulness are
  common responses. You are not crazy you are in
  mourning.
• Be aware that you may feel inappropriate anger at
  the person, the world, at God, at yourself. Its
  okay to express it.
• You may feel guilty for what you think you did or
  did not do, Guilt can turn into regret through
  forgiveness.

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Suggestions for the Bereaved II

• Having suicidal thoughts is common. It does not
  mean you will act on these thoughts.
• Remember to take one moment or one day at a time.
• Find a good listener with whom you can share.
  Call someone if you need to talk.
• Dont be afraid to cry, tears are healing.
• Give yourself time to heal.
• Remember the choice was not yours. No one is the
  sole influence in anothers life.
• Expect setbacks, Emotions can turn like a tidal
  wave but you may only be experiencing a remnant
  of grief, an unfinished piece.

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Suggestions for the Bereaved III

• Try to put off major decisions.
• Give yourself permission to get professional
  help.
• Be aware of the pain of family and friends.
• Be patient with yourself and with others who may
  not understand.
• Set your own limits and learn to say no.
• Steer clear of people who want to tell you what
  or how to feel.
• Know that there are support groups that can be
  helpful such as, the Samaritans, or Survivors of
  Suicide Support Groups. If not ask a professional
  to help start one.

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Suggestions for the Bereaved IV

• Call on your personal faith, if you have any, to
  help you through.
• It is common to experience physical reactions to
  your grief, e.g. Headache, loss of appetite,
  inability to sleep.
• The willingness to laugh with others and at
  yourself is healing.
• Wear out your questions, anger, guilt, or other
  feelings until you can let them go. Letting go
  doesnt mean forgetting.
• Know that you will never be the same again, but
  you can survive and even go beyond just
  surviving.
• Be kind and good to yourself.
• From Suicide and its aftermath Ed. E.J. Dunne
  JL Macintosh K. Dunne W.W.Norton

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Supports
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Statutory support services

• General practitioner
• Accident Emergency Dept
• Psychological services
• Adult psychiatric services
• Child and adolescent psychiatric services
• Addiction counsellors

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Voluntary services

• Samaritans
• Grow
• Mental Health Ireland
• Aware
• Schizophrenia Ireland
• Alcoholics Anonymous
• Rape crisis centre
• Bodywhys
• Bereavement counselling
• Suicide bereavement support group

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SELF-CARE

• Take Care of Yourself
• Share your experience and emotions with
  colleagues and/or partners
• Take part in or organise a debriefing session
• Resist coping with alcohol, drugs or cigarettes
• Reduce stress levels through
• Exercise, hot baths, family events, etc.
• Seek professional help if required

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The Way Forward - Ideas?

• National Council will look at the existing
  Dealing with Suicide policy and try an include
  some points focused upon suicide preventative
  approaches raised today.
• National Council could coordinate the delivery of
  the accredited ASIST training course on a
  regional basis to ensure that each Local
  Association had a key staff member trained in
  this area.
• National Council could coordinate the delivery of
  self harm / self injury training workshops to key
  staff from the YMCA movement
• National Council could display a list of key
  suicide awareness information web sites on the
  home web page.
• National Council will draft a set of guidelines
  of how to best respond to a suicide risk / self
  harm incident or suicidal event.
• National Council will suggest a list of external
  contacts that a personal relationship between the
  YMCA and them should be forged.
• National Council will establish links with the
  research based organisations and provide up to
  date intervention ideas for locally based staff.

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• Human understanding is the most effective weapon
  against suicide
• Dr. Edwin Schneidman