management of suicidal client

1. Presenter : Keerthi Mohanan

2. INTRODUCTION
Self destructive behavior include
 Direct: any form of suicidal activity, such as
suicide ideation, threats, attempts and
completed suicide. The intent of this behavior is
death and the person is aware of the desired
behavior.
 Indirect : any activity that is harmful to person’s
wellbeing and potentially may result in death.
The person may be unaware of this potential
and may deny it if conforted.

3. EPIDEMIOLOGY OF SUICIDE
 According to the WHO 2012 estimates, 8
lakh people globally die by suicide every year
which amounts to a suicide death every 40 s.
Suicide attempts are thought to be at least
25 times the suicide death rates.

6. SUICIDAL BEHAVIOUR
 Suicidal gestures
 Suicide threats
 Suicide attempts
 Completed suicide

7. SUICIDAL BEHAVIOUR
 Suicidal gestures
It is a suicide attempt directed towards the
goal of receiving attention rather than actual
destruction of the self
 Suicide threat
It may be veiled but usually occurs before
overt suicidal activity takes place

8. SUICIDAL BEHAVIOUR
 Suicide attempt
 Any self directed actions taken by the
individual that will lead to death if not
interrupted

9. COMPLETED SUICIDE
 It is the death from self inflicted injury,
poisoning or suffocation where there is
evidence that the decent intended to kill
himself or herself.

10. TYPES OF SUICIDE
Egoistic suicide
 Response of the
individual who feels
separate and apart
from the mainstream
from the society.

11. TYPES OF SUICIDE
Altruistic suicide
 It is the opposite of egoistic
suicide
 The individual is excessively
integrated into the group
 The individual will sacrifice
his/her life for the group

12. TYPES OF SUICIDE
Anomic suicide
 It occurs in response to
changes
that occur in an individual ‘s
life
that disrupt feelings of
relatedness
to the group
eg: Loss of job, divorce

13. RISK FACTORS
Marital status
 Single persons is twice that of married
persons
 Divorced ,separated, or widowed persons
have rates four to five times greater than
those of the married
Gender
 Women attempt suicide more, but men
succeed more often

14. RISK FACTORS
Age
 The rates rise sharply
during
Adolescence
 Peak between 40 and 50
years,
Off until age 65

15. RISK FACTORS
Religion
 Depressed men and women who consider
themselves affiliated with a religion are less
likely to attempt suicide than their non-
religious counterparts
Socio economic status
 Individuals in the very highest and lower
social classes have higher suicide rates than
those in the middle classes

16. PREDISPOSING FACTORS
Psychiatric disorder
 Major depression and bipolar disorder
 Substance abuse
 Schizophrenia
 Personality disorder
 Anxiety disorder
 Eating disorders
 Conduct disorders in adoslecent

17. PREDISPOSING FACTORS
Familial history
 History of suicide
 Family stress
 Genetic factors
Biochemical factors
 Reduced serotonin function
Personality traits & disorders
 Four aspects-hostility, impulsivity, depression
and hopelessness

18. PREDISPOSING FACTORS
 Psychosocial factors & physical illness
 Factors like loss, lack of social support
negative life events and chronic physical
illness.
 Lives alone, unemployed.
 Suicide rate among recently discharged
general hospital patients is almost three
times higher than in general population.

19. RISK FACTORS FOR SUICIDE IN SPECIAL
POPULATION
 Hospitalized depressed pateint’s
 high level of anxiety
 First week of admission
 First month after discharge
 Elderly pateint’s
 Death of loved one’s
 Patient’s with alcoholism
 Lose of dear ones
 Substance use
 Late in course of illness

20. RISK FACTORS FOR SUICIDE IN SPECIAL
POPULATION
 Depressed adolescent
 Loss of significant relationship
 Co-morbid substance use
 Prior suicide attempt
 Family history of major depression
 Previous anti depressant treatment
 History of legal problems

21. FACTORS IN THE ASSESSMENT OF SELF
DESTRUCTIVE PATIENT
Assessing circumstances of an attempt
 Precipitating humiliating life event
 Preparatory action- suicide note, giving away priced
possession
 Use of violent method or more legal drugs

22. FACTORS IN THE ASSESSMENT OF SELF
DESTRUCTIVE PATIENT
suicide risk can be assess by using an
assessment scale. One such scale is called
the SAD PERSONS Scale, which identifies
risk factors for suicide as follows:
 Sex (male)
 Age younger than 19 or older than 50 years
of age
 Depression (severe enough to be considered
clinically significant)

23. FACTORS IN THE ASSESSMENT OF SELF
DESTRUCTIVE PATIENT
 Previous suicide attempt or received mental-health
services of any kind
 Excessive alcohol or other drug use
 Rational thinking lost
 Separated, divorced, or widowed (or other ending
of significant relationship)
 Organized suicide plan or serious attempt
 No or little social support
 Sickness or chronic medical illness

24. PRESENTING SYMPTOMS
 Hopelessness
 Decreased mood
 Agitation & restlessness
 Persistent insomnia
 Weight loss
 Suicidal thoughts & plans

25. PROTECTIVE FACTORS AGAINST SUICIDE
 Ability to cope with stress
 Effective and appropriate clinical care
 Support for help seeking
 Restricted access to lethal methods
 Cultural and religious belief that discourage
 Ongoing sense of hope in adversity

26. NURSING DIAGNOSIS
 High risk for self mutilation
 Non- compliance
 Potential for self directed violence
 Altered nutrition
 Ineffective individual coping
 Self esteem disturbances

27. ASSESSMENT
Demographics-age, gender, marital status,
economy…
Suicidal ideas or acts
How serious is the intend? Behavioral and verbal
clues.
Does he have a plan? If so, does he have the means?
How lethal are the means?
Has the individual ever attempted suicide?

28. CONTD…
Interpersonal support system
• Does the individual have support persons on
whom he can rely during crisis situation?
Analysis of suicidal crisis
• Precipitating stressor-loss, relationship
problems, role changes, physical illness
• Relevant history- failures and rejections in
life
• Development stage issues

29. CONTD…
Psychiatric medical and family history
 Previous psychiatric treatment for depression,
alcoholism or for previous suicidal attempts
 Chronic debilitating terminal illness
 History of depression or suicide in family
Copying strategies
• How has he handled previous crisis situations
• How does this situation differ from previous one

30. RISK FACTORS
• Previous suicide attempt
• Mental disorders
• Substance abuse disorder
• Family history of suicide
• Hopelessness
• Impulsive and aggressive tendencies
• Loss of any kind
• Isolation
• Debilitating physical illness

31. LEVELS OF RISK
 no suicidal ideation
 some ideation, no plan
 ideation, vague plan, low on lethality, wouldn't
do it
 ideation, plan specific and lethal, wouldn't do
it
 ideation, plan specific and lethal, will do it
 None -
 Mild -
 Moderate
 Severe -
 Extreme -

32. HIGHEST RISK GROUP
 Suicidal ideation
 A plan
 High lethality
 Few inhibitors
 Low self-control

33. LEVEL 1- RISK GROUP
Details
• Person states she/he is feeling suicidal
• No suicide plan developed
• Person not in immediate danger.
Mental health
• May or may not have received counseling in
the past.
• May or may not have received mental illness
diagnoses/treatment.

34. LEVEL 1- RISK GROUP
Precipitating event
• Recent crisis or string of crises.
Person’s disposition
• Primary need seems to be someone to talk
to who will listen.
• Person is open to and active in developing a
positive plan of action.
• Person has a basic support system
available.

35. LEVEL 1 - RISK GROUP
Intervention
• Explore primary issues.
• Discuss short and long term plans of
actions.
• Contract with person to fulfill positive plan of
action
• Contract with person to reach out for help
again if the suicidal feelings return.

36. LEVEL 2
Details
• Person states she/he is feeling suicidal.
• They have a plan.
• Means to carry out the plan are available but not
readily accessible.
• Means are available but not immediately lethal.
Intent is not immediate.
Mental health
• May have family history of suicide and/or mental
illness.
• May have chronic mental illness diagnosis.

37. LEVEL 2 - RISK GROUP
Precipitating event
• Likely feels that negative life events have been
ongoing for years.
• May resist idea of "here and now.“
Person’s disposition
• Person may seem uncertain about prospect of
future happiness/wellness.
• Person still willing to reach for help and develop
a positive plan of action

38. LEVEL 2 - RISK GROUP
Intervention
• Explore primary issue.
• Discuss short and long term plans of action,
including the possibility of mental health
assessment.
• Contract with person to fulfill a positive plan
of action.
• Contract with person to reach out for help
again if the suicidal feelings return.

39. LEVEL 3 - RISK GROUP
Details
• Person states she/he is feeling suicidal.
• Plan developed
• Intent is immediate or within near future.
• Means are lethal and accessible.
• Likely to have attempted before, and has probably felt
suicidal for a long period of time.
Mental health
• Presence of chronic mental illness is likely, whether
or not it's been diagnosed.
• Likely has family history of mental illness/suicide.

40. LEVEL 3 - RISK GROUP
Precipitating event
• Recent crisis likely in addition to ongoing
crisis/distress
Person’s disposition
• Person stated intent to die.
• Resistance to open communication/
alternatives.
• Disillusioned with helping system, strong
feelings of hopelessness and diminished fear in
the face of death.
• You believe the person will harm themselves

41. LEVEL 3 - RISK GROUP
Intervention
 Contract with person to seek immediate
assistance from a mental health professional
-- follow up to make sure this was done.
 Contract with person to reach out for help
again if suicidal feelings return.

42. LETHALITY
 Shotgun to head-99%
 Cyanide-97%
 Gunshot of head-97%
 Shotgun to chest-96.4%
• Explosives-96.4%
• Hit by train-96.2%
• Jump from height-93.4%
• Gunshot of chest-89.5%
• Hanging-89.5%

43. HOW TO INTERVENE?
Ask client directly
• Have you thought about harming yourself in any
way? If so, what is your plan? Do you have a any
mean to carry out this plan?
Create a safe environment for the client
• Remove all potentially harmful objects from
client’s access-sharps objects, straps, belt,
glass items, alcohol.
• Supervise closely during meals and medication
administration

44. HOW TO INTERVENE?
Contract
• Formulate a short term verbal or written
contract that the client will not harm self.
• When time is up, make another, and so forth
• Secure a promise that the client will seek out
staff when feeling suicidal

45. HOW TO INTERVENE?
Observation
• Maintain close observation of the client.
• Provide one to one contact, constant visual
observation, or every 15 minute checks.
• Place in a room close to nurses station, do not assign
private room
• Accompany whenever necessary
• Make rounds at frequent , irregular intervals
especially at night, towards early morning, at change
of shift, or other predictable busy times for staff.

46. HOW TO INTERVENE?
Information for family and friends
• Be a good listener, be supportive. Let them know that
you are there for them and are willing to help them.
• Stress on the importance of that person in your life
• Express concern for the individuals, acknowledge the
pain and hopelessness and encourage to ventilate
• Stay with them. Do not leave them alone
• Show love and encouragement. Hold them. Touch
them and hug them. Allow them to cry

47. HOW TO INTERVENE?
• Remove any items from the home with which
the person may harm himself or herself
• Help them seek professional help
• Do not-judge them, show anger towards
them, provoke guilt in them, discount their
feelings or tell them to snap out of it.
• Take any hint of suicide seriously. Anyone
expressing suicidal feelings needs immediate
attention.

48. CONTD..
• Do not keep secrets, if a suicidal person
requests you to keep promise, do not make
that promise.
• They are ambivalent about dying, and
suicidal behavior is a cry for help. It is the
part of the person that wants to stay alive
that tells you about it. Get help for the person
and for you.

49. HIGH RISK FOR SELF MUTILATION
 Ask the client directly “Have you thought of
harming yourself in anyway ? If so what do
you plan ?
 Create a safe environment for the client
 Make rounds at frequent, irregular intervals
 Develop a contract with a patient
 Provide close one to one observation

50. HIGH RISK FOR SELF MUTILATION
 Remove all potentially
dangerous objects
 Provide prescribed
medications
 Identify cues triggers
that precede self
mutilation behaviour

51. HIGH RISK FOR MUTILATION
 Help patient explore
feelings related to these
events
 Reinforce adaptive
behaviour
 Identify positive
consequences of
adaptive behaviour

52. POTENTIAL FOR SELF DIRECTED VIOLENCE
 Observe closely
 Remove harmful objects
 Provide basic physiologic needs
 Monitor medications
 Identify patients strength

53. POTENTIAL FOR SELF DIRECTED VIOLENCE
 Encourage to participate activities he/she
likes
 Foster healthy IPR
 Assist patient to recognize coping
mechanisms
 Reward healthy coping

54. INEFFECTIVE COPING
 Invite patient to talk
 Encourage ventilation of feelings
 Communicate, concern, empathy, calm
control
 Ask about precipitating factor
 Obtain patient perception of stress

55. INEFFECTIVE COPING
 Assess supports, resources,& usual coping
 Prioritize needs & what coping have been
tried
 Suggest alternative coping & assist in
implementing
 Reinforce adaptive behaviour

56. SELF ESTEEM DISTURBANCE
 Confirm the patient ‘s identity
 Provide supportive measures to decrease
panic
 Set limits on inappropriate behaviour
 Work with whatever ego strengths the patient
possess
 Assist to describe & express feelings,
thoughts

57. SELF ESTEEM DISTURBANCE
 Help in identifying strengths, weaknesses
 Respond empathetically
 Identify stressors & patient’s appraisal of
them
 Clarify faulty beliefs & cognitive distortions
 Evaluate advantages & disturbances of
current coping

58. SELF ESTEEM DISTURBANCES
 Encourage patient to formulate a new goal
 Help patient to clearly define the change to
be made
 Use role rehearsal, role modelling to
practice new behaviour
 Provide opportunity for patient to experience
success

59. LEGAL ASPECT IN SUICIDE
 As per IPC
 Section 309- attempt to suicide can lead to
one year imprisonment and fine
 Section 306- abetment to suicide lead to ten
years of imprisonment

60. SUICIDE PREVENTION STRATEGIES
 Decreases availability of lethal weapons
 Limitations on sale and availibility if alcohol &
drugs.
 Increased public and professional awareness
about depression and suicide.
 Less attention and reinforcement of suicide
behavior in media.
 Community based crisis intervention clinics
 Campaign to decrease stigma associated with
psychiatric care.

61. CONCLUSION
 Suicide assessment should be done
continuously during in-patient at the hospital
either at admission, home or any change in
medication or other treatments
 If you think a friend or family member is
considering suicide, you might be afraid to
bring up the subject. But talking openly about
suicidal thoughts and feelings can save a life.

62. REFERENCES
 Stuart, Principles And Practice of
Psychiatric Nursing, 10th edition, 1987,
Mosby, St. Louis, Page.no.323-339
 Mary Townsend, Psychiatric Mental Health
Nursing, 5 th. edition, 2000, Davis company,
Philadelphia, Page. No: 265-271
 http://informahealthcare.com/doi/abs/10.3109
/00048674.2011.590465 DOA 16/02/2014