Suicide: Understanding the risk factors

As a therapist working alongside inpatient psychiatric hospitals, it has been important to me to try and understand the risk factors associated with suicide. I wanted to write my thoughts on suicide prevention in order to contribute to the ongoing conversation regarding what we, as therapists, can do to try and prevent this often unnecessary loss of life.

Factors associated with suicide

Traditionally, a large number of studies relating to suicide focused primarily on mental health, however, under 30% of people who die by suicide were seen by mental health services in the last year of their lives (National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, 2016). It is apparent that, although mental illness plays a significant role, it is essential to take other factors into consideration when attempting to understand suicidal behaviour.

There are many factors associated with suicide and these can include demographics, social and cultural factors, biological factors, physical illness, mental illness, deliberate self-harm and personality factors. Therefore, when we are conducting our assessments, and during our continuing work with our clients, it is essential to keep all these factors in mind. I find it helpful to understand that some of the risk factors are fixed, which can include previous attempts, abuse, relatives who have taken their lives, anniversaries etc. Whereas, some of the risk factors are fluid and can include feelings of hopelessness, self-harm, access to means of suicide, revengeful feelings, isolating oneself from friends and family, change or stopping medication or illegal drugs. There are many risk factors and I have listed some of the key ones that I often find myself keeping my eyes and ears open for:

Demographics, society and community
Different areas, cultures and societies bring different pressures, access to help and the differing stigma associated with talking about mental health and suicide. One study highlighted that: ‘Men from the lowest social class, living in the most deprived areas, are up to ten times more likely to end their lives by suicide than those in the highest social class from the most affluent areas’ (Wylie C, 2012).

Physical health
A person’s physical health is often overlooked when conducting risk assessments, chronic pain, chronic obstructive pulmonary disease, cancer, spine disorders and stroke may increase the risk factors. During assessment and ongoing therapy, it can be important and helpful to talk through their feelings surrounding any physical illness.

Mental illness
As mentioned previously, studies suggest that just under 30% of people who took their own lives had been seen by mental health services in the previous year. This does not mean that 70% did not have any form of mental illness, many will have been undiagnosed, or be historic, or have not been able to access help. It is interesting to note that although depression can be a major contributing factor to those who have taken their lives, there is an increased risk associated with those who have been diagnosed with an eating disorder, ADHD and early dementia.

Relationships
The breakdown of significant relationships, whether it is a long-term marriage or a short term relationship, can increase the risk of feelings of hopelessness, lower the person’s self-esteem and make them more vulnerable.

Deliberate self-harm
Studies indicate that people who struggle with deliberate self-harm are subject to higher risk of suicide. It is important, however, to understand that many people who do harm themselves do not wish to end their lives.

Personality and individual factors
There are a number of personality traits and individual factors that can contribute to an increased risk and some of these can include:

• Perfectionism
• Impulsivity
• Hopelessness
• Issues with problem-solving
• Low self-esteem
• Unhelpful thinking styles such as all or nothing thinking, catastrophising, jumping to conclusions

Protective factors

When conducting risk assessments, in addition to looking out for the risk factors, I am also trying to identify the person’s protective factors and some of these include:

• Hopefulness
• Religion
• Strong coping and problem-solving skills
• Responsibility, for example family or pets
• Receiving good Care
• Strong social support network

Asking about suicide

As psychotherapists, we are likely to meet people who have previously thought about suicide or are actively thinking about it. Talking to the person about their suicidal thoughts can provide a much needed sense of relief for many who are in distress. By realising that talking about the topic does not mean you will give them the idea to do it, it is important to know what kind of questions to ask in order to help understand how they are feeling and to help assess their risk levels. From already keeping in mind the risk factors, which may have provided me with specific information about the person’s risk levels, I may feel it necessary to ask more direct questions, which may include, do you really want to die, or do you want the pain to go away?

One aspect of working with vulnerable clients, that is important to me, is that if any therapist is going to open up a potentially emotive and difficult conversation around suicidal feelings, they need to be confident in knowing the appropriate steps to be taken afterwards if necessary. This, perhaps, is to refer on to the most appropriate person or service or to follow a specific policy or protocol within the organisation in which they work.

Conclusion

For me, one of the most important aspects of my job is to help assess risk levels and to know when and how to help someone who is at possible risk of suicide. Being able to conduct a thorough risk assessment at an initial consultation is essential, knowing some of the risk factors are fixed and some are fluid and realising that we need to constantly revisit our risk assessments throughout our work is just as important. The other vital aspect is what to do if you feel someone is at risk. Professional supervision is an essential part of our work, it provides a space to reflect, however, there are times when we must think and act in the moment. If you work in an organisation, is there a suicide prevention policy? If you work independently do you know who to refer to, how to refer and what level of communication and follow up is required?  In my practice I often ensure there is close communication with all those involved in the client’s care essentially the client’s GP, their consultant psychiatrist and any other healthcare professional. If I feel the person is at risk, I will always communicate with the client about my intentions and what I am going to do. If I feel it necessary to speak with their GP or family member, I will tell the client my intentions and work through their feelings surrounding this. It is paramount to be upfront and honest with the client about your actions.

Lastly, for any therapist who has suffered the loss of a client due to suicide, it is important to take care of yourself, talk in supervision about your feelings and trust in your professional relationship with your supervisor, and potentially consider reengaging with your own personal therapy. The impact of suicide can be devasting for all involved; the family, friends, work colleagues, class friends and also all those included in the person’s care, so I thoroughly welcome further research, training and ongoing conversations relating to this difficult topic.

For immediate help with suicidal thoughts:

In an emergency, call: 999

NHS (England), call: 111

NHS Direct (Wales), call: 0845 46 47

The Samaritans 24-hour helpline, call: 116 123