Suicide Crisis Or Self-harm: Intervention

The World Health Organization (WHO) indicates that suicide is the leading cause of violent death worldwide; even higher than the murders and deaths due to war. Since 2016, the number of suicides in many European countries has doubled compared to deaths from road accidents. This is one of the reasons why we have decided to dedicate this article to how to intervene in the suicide or self-harm crisis.

Suicide is also the second leading cause of unnatural death between the ages of 15 and 25. It seems that this gesture, and all the psychopathology that accompanies it, must be considered an epidemic that never ceases to threaten public health and people’s well-being.

In the field of psychotherapy, intervention in the suicide or self-harm crisis is fundamental from the first session.

The countless myths and prejudices about suicide and the fear of a hypothetical – and even empirically refuted – “boomerang effect” mean that suicide rarely appears in the headlines and on the news. As a result, the knowledge of many people on the subject is scarce and superficial.

The suicide crisis and the first session

It is important to emphasize that talking about suicide does not increase the chances of the person taking this path. Don’t be afraid to ask specific questions about any suicidal thoughts or self-harming behaviors.

Assessment tools such as the BDI-II (Beck, Steer, Brown, Sanz & Vázquez, 2011), in fact, pose explicit questions not only about suicidal intent; they also try to determine the level of risk.

For therapists, therefore, the BDI-II is configured as a standardized measurement tool, thanks to which it is possible to evaluate freely, without fear of reinforcing these ideas.

The evaluation must be comprehensive. It must take into account factors such as social and environmental support, the presence of any medical pathologies, the previous and family history of psychopathology, any previous suicide attempts and exploration of the suicide act (method used, planning, intentionality…).

Starting from these elements, it is possible to evaluate the need for hospitalization. However, sometimes hospitalization is not always possible or suicide attempts are not so urgent. So it will be necessary to analyze the situation in a 50-minute session and motivate its follow-up.

Alternative behaviors and stimulating control

Intervention in a suicide crisis must take into account the number of psychotherapy sessions. Psychological therapy is usually organized through weekly appointments.

If during the first session, the psychotherapist realizes that the patient is showing suicidal ideas, the sessions will need to be rescheduled and increased to at least two per week. In this way, the patient will only have to face two or three days without therapeutic support.

Similarly, the patient should not be expected to possess coping strategies that he can develop in moments of suicide crisis. Until this level is reached with a greater degree of autonomy, it would be advisable to work on the therapeutic relationship two days a week, introducing tasks to be performed.

In a first session it is not possible to expect correct emotional management from the patient. Therefore, the goal is not to prevent suicidal or self-harming thoughts, but to draw up a list of alternative behaviors to put into practice when malaise increases.

These types of behaviors can be: showering, listening to some music, reading, going for a walk, talking to a friend or loved one about something different, etc.

Even if they seem trivial actions, forcing the person to leave the house and establishing stimulus control with behaviors incompatible with suicide – such as talking to a friend – can be decisive when it comes to preventing the person from engaging in self-harming actions.

It is important to list these alternative behaviors during the first session and, the next time, to check if they have been put into practice. If the client refers to a suicide crisis in which they did not use these alternatives, it would be interesting to consider why.

Finding a reason to live in the face of a suicide crisis

After the first session, it is necessary to proceed with a cognitive restructuring, to identify a reason why it is worth living.

However, given that the first session will be insufficient to establish an adequate and effective dialogue, a simple list can be proposed, possibly with photographs, which motivate alternative behaviors to suicide.

The purpose of the reasons to live list is to ensure that the customer always has it at hand to use in critical moments. That is, when negative thoughts take over and the positive sides of life are forgotten.

This and other measures must always be accompanied by a well-planned evaluation, which gives the therapist clues as to the quantity and quality of possible items to be included in the list.

To facilitate the use of this method, there are applications such as Prevensuic, with tools such as “Reasons to live” or “Photos of my life” which may be relevant during the session.

Non-suicide contract: is it valid?

The non-suicide contract between the patient and the therapist is valid until the next session. For example, the client must undertake not to commit suicide within the next 3 days, ie when the next session will take place. At that point, the contract will be signed again to renew its validity.

The signing of the contract will be diluted with the passing of the sessions, and perhaps, in the meantime, suicidal thoughts will be less and less recurrent.

From the first session, therefore, activities can be carried out that provide the patient with resources against suicidal ideation. Making lists to evaluate the suicide crisis shows that it is taken seriously and can initiate a fruitful therapeutic collaboration.

This connection will be central to the development of the therapy and to the improvement of the client’s mood. The tasks carried out in subsequent sessions will have to be more specific and incisive.

However, offering alternative behaviors, signing a no-suicide contract and using the tools of positive psychology are very effective actions to help a person who sees suicide as the only option.