Healthcare professionals can play a pivotal role in identifying patients who might be at risk for suicide, and in providing these patients with the resources they need to cope.
“I can’t believe I didn’t see the signs.”
“I just wish there’s something I could have done.”
“I should have been there for them.”
Friends, loved ones, colleagues and even acquaintances commonly share such regrets when they’ve just lost someone to suicide.
And we hear these types of sentiments far too frequently.
One person dies by suicide every 40 seconds, according to the World Health Organization (WHO). In 2018, the Centers for Disease Control and Prevention (CDC) cited suicide as the 10th leading cause in the United States.
WHO also estimates that “for each adult who died by suicide, there may have been more than 20 others attempting suicide.”
The COVID-19 crisis certainly won’t help contain these numbers, and some mental health experts caution that we could see a rise in suicide rates stemming from the devastating impact of the coronavirus.
Healthcare professionals, however, can play a vital role in identifying patients who might at risk for suicide, cultivating relationships with these patients and providing them with the necessary support and resources.
Identifying those at risk
The state of being suicidal can be thought of as an assembly line, says Pamela Garber, LMHC, a New York-based psychotherapist and owner of Grand Central Counseling Group.
“The earlier levels on the assembly line can have different signs than the later stages.”
Healthcare professionals who have an ongoing professional relationship with a patient have the best chance at recognizing when and if that patient is at risk, she says, noting that signs typically stem from differences in a person’s typical conduct.
“Under all circumstances, the first line of defense is establishing enough rapport to engage the patient in talking. If the patient seems to be at high risk … and the goal is taking the legal steps available for prevention, there can still be an opportunity for communication with the healthcare professional if the relationship has longevity or connection.”
Still, identifying real risk is often out of the realm of dedicated professionals and loved ones, says Garber. This is true even when an individual displays some of the textbook signs—changes in mood, giving away belongings, displaying frivolousness with money, suddenly feeling at peace after crisis, or verbalizing hopelessness or the recent loss of a loved one, for example.
Of course, signs of suicidal ideation can be difficult for even seasoned professionals to detect.
“This is because thoughtfully planned suicide takes time and effort,” says Patti Ashley, PhD, LPC, a Boulder, Colo.-based psychotherapist, author and speaker. “Someone who has a serious intention to commit suicide might not mention it all, because they don’t want to be stopped.”
As such, clinicians must pay close attention to less obvious cues, family history, support systems and other factors, says Ashley.
For example, increased use of alcohol or drugs, anxious feelings, sleeping too little or too might be subtle signs that a patient is feeling suicidal.
“If a client reports one or more of these over a period of time, clinicians can assess risk by asking if they have ever thought of suicide. And if so, do they have a plan to carry it out? If they have a thought-out plan, then this would be considered a high-risk patient, and safety precautions should be put in place.”
Family history is a factor to consider as well, says Ashley, noting that individuals with one or more family members who have committed suicide pose a higher risk.
“It’s also important to note that any other family history, such as alcoholism or substance use, schizophrenia or other psychotic disorders might lead to a greater risk of suicide,” she says, adding that children who have experienced bullying or harassment are also at higher risk.
Providing a safe space
Of course, current pandemic conditions have added a degree of difficulty in administering care for all types of patients.
The nature of this crisis means more healthcare systems are relying on telehealth services to connect with patients. The effectiveness of remote therapy for patients at risk of suicide, however, all depends on the patient and therapist, and can also vary based on the circumstances at hand, such as immediate crisis or physiological changes, says Garber.
Remote therapy, she says, eliminates the need to deal with the logistics associated with office visits—traffic, waiting room back-ups, for example—and the immediacy it affords makes telehealth potentially ideal for patients at risk for suicide.
“But in some cases, being remote may interfere with getting an accurate [risk] assessment,” says Garber.
“Some people might actually open up and reveal more candid details about their level of risk in a remote setting where they are on their own turf. Others may mask more.”
Whether done in-person or via remote therapy, effective risk assessments ultimately hinge on knowing the patient, says Garber.
“And, even then, this task is delicate, risky and subjective, no matter how educated or experienced the professional. People only show you what they want you to see, and reading them is never 100 percent objective.”
In an effort to help patients feel comfortable opening up, “it’s crucial to give patients permission to feel whatever feelings they might be feeling,” adds Ashley.
“Trying to talk someone out of feelings can actually make them worse. All feelings are OK, but all behavior isn’t. When a client has a safe space to express all feelings without shame or judgment, it can be a tremendous protective factor in preventing suicide.”
This type of empathy is key to effective treatment, Ashley continues, noting that clients who feel a sustained connection with an empathetic listener also feel a sense of “unconditional positive regard, which helps to build self-compassion and resilience.”
“Paying attention to feelings and finding healthy outlets to express them takes compassion, connection, curiosity and courage. Clinicians provide a safe space to guide clients through feelings in the hopes of getting them to a better emotional state.”
At least one mental health professional should also be part of the care team in clinical settings, says KaRae’ Powers-Carey, PhD, a core faculty member in Walden University’s MS in Clinical Mental Health Counseling program.
“The licensed mental health professional can provide screenings, administer appropriate assessments, mitigate suicide risks and meet any other healthcare needs,” says Powers-Carey. “A visit with a mental health professional at routine medical appointments should be a standard practice at every outpatient visit and before discharge from an inpatient hospital stay.”
Indeed, screening for suicide risk is an essential part of any healthcare visit, adds Jasleen Chhatwal, MD, chief medical officer at Tucson, Ariz.-based residential treatment center Sierra Tucson.
“This can be done with two-to-six question screening tools that ask about any recent or current thoughts of death, dying or suicide. [And] screening for risk factors such as asking about early life trauma in the form of an Adverse Childhood Experience scale helps to add context,” says Chhatwal, adding that healthcare providers throughout the enterprise should receive appropriate training on suicide risk, for patients’ benefit as well as their own.
“Providing education about suicide and its risk factors to healthcare providers at every level of the organization, and providing training on ways to reduce stigma, can go a long way in creating a safe space for our patients (as well as staff) to be able to reach out for support.”
- World Health Organization, 2016. Accessed July 26, 2020. [https://www.who.int/mental_health/prevention/suicide/suicideprevent/en/]
- Centers for Disease Control and Prevention, 2018. Accessed July 27, 2020. [https://www.cdc.gov/injury/wisqars/fatal.html]
- U.S. News & World Report, 2020. Accessed July 27, 2020. [https://www.usnews.com/news/healthiest-communities/articles/2020-05-22/experts-warn-of-a-surge-of-suicides-tied-to-the-coronavirus-pandemic]
Caring for the Caregivers
Healthcare professionals have long been among the occupational groups most at risk for anxiety, post-traumatic stress disorder, depression and even suicide.
These same healthcare workers have been on the frontlines since Day One of the coronavirus pandemic—caring for patients in overwhelming numbers and seeing trauma, despair and death on a daily basis.
COVID-19’s adverse impact on healthcare workers’ well-being has been well-documented. Programs and initiatives are emerging, however, to provide these professionals with the tools and resources they need to cope during COVID-19 and beyond.
For example, Tucson, Ariz.-based residential treatment center Sierra Tucson has launched the Healthcare Heroes Trauma Recovery program, a mental health initiative designed to provide care for physicians, nurses and other frontline healthcare workers under the strain caused by the coronavirus pandemic.
Introduced in May, the new program offers residential trauma treatment for nurses, physicians, healthcare technicians, social workers, respiratory therapists, psychologists, hospital administrators and others whose careers involving caring for others, especially in the midst of COVID-19.
Sierra Tucson has launched three program tiers for healthcare providers on its 160-acre campus, such as a five-day “renew and heal” option focused on promoting recovery and revitalization, and a 30-day trauma healing program geared toward healthcare workers who might have had prior trauma and are now experiencing increased symptoms as a result of their work during COVID-19.
On the other side of the country, meanwhile, the Medical Society of the State of New York has launched the MSSNY Peer to Peer (P2P) program, designed to provide colleagues the opportunity to connect with trained peer supporters to confidentially discuss work, school, family or financial stressors, as well as the additional strain caused by the coronavirus pandemic.
“We believe that the MSSNY P2P program is the first such program to assist physicians, residents and medical students developed by a statewide physician association,” says Charles Rothberg, MD, chair of the MSSNY physician wellness and resiliency committee.
“In a typical scenario, a physician or student contacts the program via a confidential telephone helpline or email (1-844-P2P-PEER [844-727-7337] or P2P@mssny.org). Stressors—personal, professional or in combination—taxing an individual’s normal coping mechanisms are often the trigger,” says Rothberg.
“The program is designed to lend a supportive ear to the peer in order to help the peer regain perspective. It is not treatment, it’s a one-time discussion with a colleague that may validate a physician’s feelings, but it might include some discussion of additional resources available to them.”
- Occupational Health & Safety, 2020. Accessed July 29, 2020. [https://ohsonline.com/articles/2020/05/19/healthcare-workers-suffer-from-ptsd-and-burnout-during-covid19.aspx]