34. 应对自杀意图
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以下英文内容先直译，再根据信雅达原则进行调整，然后进一步调整为更符合中文习惯的表达方式。最后再根据文中内容进一步阐述知识点。所有内容都用markdown格式的代码呈现：
34 Responding to suicidal intentions
Crisis telephone counselling services frequently get calls from people who are contemplating suicide and sometimes callers have already overdosed on prescribed medication before ringing for help. Also face-to-face counsellors will inevitably be confronted at times by people who have suicidal thoughts or tendencies. Most, it not all, counsellors are anxious when counselling such people, and working with them is inevitably stressful.
ETHICAL ISSUES 1 here are ethical issues involved when dealing with a pei’son who is contemplating suicide, and before choosing strategies that are acceptable to you, as a counsellor, you may need to clarify your own values with regard to suicide. As counsellors, it is desirable that, if possible, we do not impose our own values on the people who seek help. However, we do need to be congruent and genuine, so each of us needs to do whatever is necessary’ to satisfy7 our own conscience. In addition, we need to be aware of any legal obligations and the legal implications of our actions. We must remember that we owe a duty of care to every7 person who seeks our help and that we need to respect the policies of the agency for which we work. If there are internal conflicts for us when dealing with a pei’son who is contemplating suicide, then we need to resolve these for both our own wellbeing and theirs.
Counsellors have a duty of care to those who seek their help
Does a person have the right to take their own life if they choose to do so? Your answer to this question may differ from Olli’s, and our answers may differ from those of a pei’son who seeks our help. We suggest that you discuss this question in depth with your training group if you are in one, or with your supervisor, so that you have a clear idea of your own attitudes and beliefs regarding suicide and of your supervisor’s expectations. You will then be better equipped to help a person who has suicidal thoughts. We recognise that some counsellors believe that a person has the right to kill themselves if, after careful consideration, they choose to do so. However, most counsellors strongly oppose this view and believe that firm intervention is justifiable and necessary7 to prevent suicide from occurring. Many counsellors believe that a person who is contemplating suicide may be temporarily emotionally disturbed and not capable of making a rational decision at that time. This belief is reinforced by experiences with people who were suicidal and then later have thanked the counsellor, because they have found new meaning and satisfaction in their lives. Consequently, most counsellors believe that a counsellor s duty of care justifies the need for firm intervention, involuntary hospitalisation and subsequent psychiatric treatment where other options fail. Clearly, there are duty of care issues involved because suicide involves a one-way journey, and people who have suicidal thoughts need to be taken seriously. Remember that people who repeatedly make suicide attempts often succeed in killing themselves eventually. Their cry for help needs to be heard before it is too late.
REASONS FOR CONTEMPLATING SUICIDE People who are considering suicide broadly fall into four categories, although three of these overlap to some extent. The first category comprises people whose quality of life is terrible, and who see little or no possibility7 for improvement. Included in this category are people who are chronically ill, in chronic pain, seriously disabled and/or in extreme poverty’ with little possibility7 of changing their situations. Such people are often severely depressed and are seriously at risk of ending their lives because they can see little reason for living. This is particularly so if they are alone and do not have adequate social support. The second category7 includes people who have experienced a recent trauma. These people are very much at risk around their time of crisis. Included in this category are people who have suffered losses such as those described in Chapter 32. fhe third category comprises people who use suicidal talk or suicidal behaviour as a last resort in an attempt to get others to hear or respond to their pain. Sometimes their goal is to manipulate the behaviour of others. They are still genuinely at risk, but their motivation is different. They often have considerable ambivalence towards dying and may not really want to die. Some people in this categoiy are openly manipulative and, for example, might say to a spouse who has left them, ‘Come back to me or 1 will kill myself. I he fourth categoiy includes people who are having a psychotic episode and may be hearing voices that tell them to kill themselves. Clearly, these people need urgent psychiatric help.
The first step in helping is to try to understand the person s current thinking
We have drawn up a list of possible reasons why a person might contemplate or talk about the possibility of suicide. As you read the list you may wish to think about whether there might be other reasons which have not been included. Possible reasons include: • because they despair of their situation and are unable to see an alternative solution to their problems, which seem to them to be unsolvable, intolerable and inescapable • because they are emotionally disturbed, are afraid that they may commit suicide and want to be stopped • to make a statement • as a way of hurting others; an ultimate expression of anger • to make a last-ditch effort to draw attention to a seemingly impossible situation, when other methods have failed to manipulate someone else because they have positively decided to commit suicide, want to do it and want other people to understand the reasons for the proposed action to be in contact with another human being prior to, or while, dying to say 'Goodbye’, as preparation for death because they are having a psychotic episode and are hearing voices telling them to kill themselves.
ASSESSMENT OF RISK OF SUICIDE Anyone who says that life is not worth living may be at some level of risk. However, many people who have no intention of killing themselves experience times when they despair and start to question die value of their lives. A difficulty for counsellors is to determine the level of risk for a particular person. It is here that experience can be helpful in estimating level of risk, in deciding whether action needs to be taken or not, and in choosing the action to take, if action is needed. Consequently, new counsellors need to consult with their supervisors.
When assessing the level of risk it can be helpful to consult with your supervisor
There are some factors that are commonly considered in the relevant literature to be useful in determining level of risk (see the further reading suggested at the end of this chapter). A number of risk factors will now be discussed. GENDER AND ETHNICITY Although women attempt suicide more often than men, males are associated with higher risk. This is because males are more often successful in completing suicide than females. In particular, in Australia, Aboriginal males are associated with high risk. AGE Suicide is more likely to occur in the young and the old, with the risk being higher in people up to the age of 18 years and above 45. INTENSE OR FREQUENT THOUGHTS OF SUICIDE Whenever a person thinks of suicide it is wise to assume that there is some level of risk. However, if the thoughts are persistent or strong with little ambivalence, risk is increased.
WARNING SIGNALS People who commit suicide have often given out warning signals over a period of time. Unfortunately, sometimes these are disregarded because they may have been given many times and been seen incorrectly as threats that will not be carried out.
HAVING A SUICIDE PLAN If a realistic plan for committing suicide has been developed, then clearly the person has moved beyond vague thoughts that life is not worth living and there is a real risk that the plan may be carried out.
CHOICE OF A LETHAL METHOD Some methods of committing suicide are more likely to reach completion than Others because they are quick or provide little opportunity for withdrawal if the person concerned has a change of mind as death approaches. Examples are when a person uses a gun or jumps off a high building.
AVAILABILITY OF METHOD Risk is higher if the person already has the means to carry out the plan. For example, if a person has a loaded gun, or enough pills to cause death, then the plan may be carried out.
DIFFICULTY OF RESCUE Risk is increased in cases where it would be difficult for others to intervene and prevent the suicide attempt. Examples are where a person is in an isolated place, when the location is unknown or when someone has climbed a structure, making it difficult for others to follow.
BEING ALONE AND HAVING LACK OF SUPPORT People who are alone, single or separated, and believe that no one cares for them, are vulnerable to depression and suicidal thoughts and action. It may also be easier for them to cany out a suicidal plan without interference.
PREVIOUS ATTEMPTS Previous attempts are an indication of increased risk. This is particularly so if the attempts have been frequent, are recent and have been serious.
A FRIEND OR FAMILY MEMBER HAS DIED OR COMPLETED SUICIDE Risk of suicide is increased where a family member, close friend, colleague or peer has completed suicide. Additionally there may be risk where a loved one or pet has died.
LISTENING TO SONGS ABOUT DEATH Some people, particularly the younger members of society, tend to listen obsessively to songs about death, dying and suicide. This increases risk.
DEPRESSION People who are depressed, feel hopeless, helpless or in despair are at risk. Phis is particularly so with severe depression where there may be symptoms such as loss of sleep or an eating disturbance.
PSYCHIATRIC HISTORY Psychiatric illness or history is another indication of increased risk.
LOSS OF RATIONAL THINKING Loss of rational thinking can occur for a variety of reasons. People who have been traumatised, are under the influence of alcohol or drugs, are suffering from dementia or have a psychiatric disorder may not be capable of thinking rationally. They therefore present increased risk and there are clear duties of care for the counsellor.
UNEXPLAINED IMPROVEMENT Someone who has been exhibiting severely depressed feelings with suicidal thoughts and then suddenly changes to display a calmness and sense of satisfaction for no recognisable reason may be at Very high risk. The person may have completed preparations for suicide and have a sense of relief at the thought of their planned escape from acute emotional pain. By convincing the counsellor that everything is now OK, they may effectively mislead the counsellor so that preventative action is not taken.
GIVING AWAY POSSESSIONS AND FINALISING AFFAIRS Behaviours such as giving away personal possessions, making a new will or terminating a lease may be an indication that the person is preparing for suicide and at high risk.
MEDICAL PROBLEMS Medical problems that severely interfere with quality of life, are painful or are life threatening increase the risk of suicide. Chronic illness with little perceived hope of a cure or respite may increase a person s desire to terminate life. Here, there are both values and duty of care issues, as some people firmly believe that voluntary7 euthanasia is morally justifiable while others strongly disagree.
SUBSTANCE ABUSE Excessive use of alcohol or drugs, both illegal and legally prescribed, raises the suicide risk. Certainly, alcohol or other substance abuse is associated with completed suicides.
RELATIONSHIP PROBLEMS People who believe that they are locked in to highly dysfunctional relationships and cannot leave are at increased risk. Similarly, there may be risks for people whose relationships are breaking up, who are separating or separated, and for those who are going through the process of divorce. When relationships change through, for example, remarriage, moving into a new stepfamily, having a new child in the family or children leaving the family, there may be an increased risk.
CHANGES IN LIFESTYLE OR ROUTINE Many people find it difficult to adjust to changes in their lifestyle or routine, so times of change can precipitate suicidal thoughts and increased risk. Examples are when a person changes job, school or their place of residence. This may be particularly relevant when a person moves to a new locality and may lose access to long-term friends.
FINANCIAL PROBLEMS Issues involving poverty, unemployment and financial difficulties, where the person concerned is depressed and feeling helpless to change the situation, lead to an increased risk. Important examples are bankruptcy and cases where a person loses a business or home.
TRAUMA AND ABUSE Traumatic events and the experience of abuse or perceived abuse, in both the past and the present, may contribute to suicide risk. I his includes emotional, physical, sexual and social abuse.
LOSS All losses of importance contribute to suicide risk. Examples include loss of a significant relationship, job, employment opportunities, business, home, possessions, self-esteem and loss of role. People who experience failure either at work or academically, or believe that they have failed others, are likely to suffer loss of self-esteem. The risk factors that have been discussed are included in Figure 34.1. 1 his may be photocopied for personal use and used as an aid in identifying risk factors when counselling people with suicidal thoughts or tendencies. However, it must be remembered that there is no precise formula for assessing risk, because we human beings are each unique, possessing our own individual qualities. All talk of suicide needs to be taken seriously and appropriate help sought where necessary.
COUNSELLING STRATEGIES Perhaps the biggest problem for a new counsellor when seeking to help a person troubled by suicidal thoughts is the counsellor’s own anxiety. Sometimes new counsellors will tty to deflect a person away from suicidal talk rather than encouraging them to bring their self-destructive thoughts out into the open and deal with them appropriately. Unfortunately, such avoidance of the issue may increase the likelihood of a suicide attempt.
Figure 34.1 Assessment of suicide risk Risk factors - tick boxes where risk is indicated □ Gender □ Age □ Ethnic background□ Medical problems □ intense and/or frequent thoughts of suicide □ Warning signals given out over a period of time □ Has a suicide plan □ Choice of a lethal method □ Availability of method □ Difficulty of rescue □ Is isolated or alone □ Lack of support□ Significant life-changing events □ Change in lifestyle and/or routine □ Change in job, school or house locality □ Previous suicide attempts □ A friend, peer, colleague or family member has completed suicide □ Listening obsessively to songs about death, dying or suicide □ Death of loved one, friend or pet □ Depression □ Psychiatric illness or history □ Loss of rational thinking □ Unexplained improvement □ Giving away possessions □ F inalising affairs □ Relationship highly dysfunctional □ Relationship break up, separation or divorce □ Relationship changes - remarriage, new stepfamily, addition of new child, children leaving family □ Relationship worries -■ fear of losing a family member or partner or that someone is not coping □ Alcohol and/or drug abuse □ Financial problems □ Socioeconomic situation □ Trauma □ Abuse or perceived abuse — emotional, physical, sexual or social abuse in the past or the present □ Loss of employment or employment opportunities □ Loss of business, home or possessions □ Loss of self-esteem — feeling a failure at work or academically — or belief that others have been let down □ Loss of role □ Other factors not listed
BRING SUICIDAL THOUGHTS INTO THE OPEN Whenever counselling a depressed or anxious person, counsellors need to look for the smallest clues that might suggest that the person may be contemplating suicide. People are often reluctant to say "I would like to kill myself. They tend instead to be less specific and to make statements such as ' 1 don’t enjoy life anymore’ or ‘I’m fed up with living.' When a person makes a statement such as this, it is sensible for the counsellor to be direct, and ask them, ‘Are you thinking of killing yourself?' In this way, suicidal thoughts are brought out into the open and can be dealt with appropriately. We need to remember that a significant proportion of people are at some times in their lives ambivalent about wanting to live and that many consider the possibility of committing suicide before rejecting it.
It can be advantageous to be direct when exploring suicidal thoughts
DEAL WITH YOUR OWN FEELINGS You will be a very’ unusual person indeed if you don't become emotionally tense when a person tells you that they are thinking of killing themselves. As a counsellor, allow yourself to experience your feelings and then you will be able to decide what to do about them. It is likely that these feelings may result from you giving yourself unhelpful messages such as those listed in Table 34.1. If so, you can give yourself new messages, after discarding the self-destructive messages that may be contributing to your tension. Table 34.1 presents some typical self-destructive and alternative helpful self statements for the situation. Challenge your self-destructive thoughts, and if your feelings of tension don’t subside, consult your supervisor.
COUNSELLING SKILLS I he micro-skills that have been learnt previously, together with an appropriate counselling relationship, are the basic tools for helping a person who is contemplating suicide. We suggest that initially it is important to concentrate on building a relationship with the person, so that when trust has been established they can talk openly about their feelings and intentions. The counsellor might invite them to do this by saying, ‘I am concerned for your safety and wellbeing, and it is important for me to understand fully how and why you feel the way you do.' By taking this approach the person is likely to recognise that the counsellor is joining with them in the exploration of their feelings, thoughts and options, rather than working in opposition to them.
The counselling relationship can be a valuable resource when confronting suicidal thoughts
FOCUS ON THE PERSON'S AMBIVALENCE We recognise that each individual counsellor needs to make a decision for themselves about how to counsel a suicidal person. Some counsellors prefer a direct
Table 34.1 Comparison between self-destructive and helpful self-statements for counsellors seeking to help people with suicidal thoughts SELF-DESTRUCTIVE STATEMENTHELPFUL SELF-STATEMENT 1 am personally responsible if this person completed suicide.Sadly in the long term, no one can stop this person from killing themselves if they firmly decide to do that. Ultimately it will be their choice. 1 should stay with the person until they no longer have suicidal thoughts.It's impossible for me to watch over the person 2.4 hours a day. In the long term they have to be responsible for themselves. However, if 1 wish, and am able, 1 can take steps to arrange appropriate psychiatric supervision. 1 have the power to change this persons mind if 1 am skilful enough. OR 1 must persuade this person not to suicide.1 don't have the power to change someone else's mind, ThW most 1 can do is to help them explore the issues involved, and then take any other action available to me. I'm not as well qualified as other counsellors.1 am me, with my skills and limitations. If 1 am able to refer this person on to someone more qualified 1 will, and in the meantime I II do my best. If 1 am incompetent 1 will be to blame for this person's death.It's unrealistic for me to expect to be a perfect counsellor in such a stressful situation. 1 cannot take responsibility for their decision. 1 can only do what 1 am capable of doing. 1 must Live up to the person's expectations.1 do not need to live up to the person's expectations. 1 can't cope.1 can cope provided that i set realistic expectations for myself. approach where they will try to convince the person that they should not kill themselves, and for some people this may be the best approach. However, in our view this is not always the best approach because it puts the counsellor in opposition to the person. We think that usually it is more useful to focus on building a relationship with the person and then exploring their ambivalence — 'Should I kill myself or not?1 Most, if not all, people with suicidal thoughts have some degree of ambivalence towards dying. If a person was 100 per cent convinced that they wanted to kill themselves, they probably wouldn't be talking to a counsellor; they would just go ahead with their suicide plan. We have found that focusing on the person-to- person counselling relationship while exploring the person's ambivalence is often the key to the successful counselling of those who are contemplating suicide. EXPLORING THE PERSON'S OPTIONS As explained in Chapter 25, when a person chooses between two alternatives they lose one of the options and may also have to pay a price for the chosen option. By choosing suicide, a person loses life, contact with others and the opportunity to communicate with others about their pain. In addition they lose hope, if they had any, for a better future. The cost of dying is likely to include fear of the unknown and for some religious people fear of being punished for killing themselves. We think that in many situations it can be advantageous to make a person who is contemplating suicide aware of their ambivalence, and to help them to look at the consequences, costs and pay-offs of dying and of living. Although at some stage we may decide that duty of care requires the use of firm intervention, in the first instance we try to avoid directly pressuring the person to stay alive and instead help in the exploration of their options. In this way the person is likely to feel understood, has the opportunity'’ to work through their pain and may feel sufficiently valued to enable them to reconsider their decision.
By joining with the person, they are free to explore both the 41 want to die1 part of self and the opposite polarity, with the counsellor walking alongside during the exploration.
A person needs to fully explore their self-destructive thoughts in order to be able to change them
THE DIRECT APPROACH The direct approach is to try to persuade the person who is contemplating suicide that living is the best option. This approach is not usually our first preference because it sets up a struggle between the person who is saying ‘I want to die’ and the counsellor who is saying ‘I want you to live’. There is then heavy pressure on the counsellor to convince the person of the rightness of living, and this may be difficult as the counsellor and the person are in opposition rather than joining together. Even so, this approach can be successful with some people. There is no universal 'right way’ to go. Every’ person is unique and so is every’ counsellor. Each counsellor needs to choose an approach that seems right for them and for the person who is seeking their help. If a counsellor concentrates on establishing and maintaining a sound person-to-person counselling relationship, then they optimise the chances of success. Where this approach is not successful, duty of care requires the counsellor to take action, in consultation with their supervisor, to ensure the person’s safety and wellbeing.
DEALING WITH DEPRESSION AND ANGER People who are contemplating suicide are usually in deep depression, and depression, as explained in Chapter 31, is often due to repressed anger. Sometimes a person who is contemplating suicide may be turning anger, which could be appropriately directed at others, inward and towards themselves. It may be useful to ask the question 'Who are you angry with?’ If the person replies by saying 'Myself, you can agree that that is obvious and consistent with wanting to suicide. You might say, ‘You are so angry with yourself that you want to punish yourself by killing yourself.’ 1 his reframe of suicide as self-punishment rather than escape may be useful in some cases in helping to produce change. You could then ask, ‘After yourself, who are you most angry with?’ If by doing this you can help the person to verbalise their anger and direct it away from themselves and onto some other person or persons, their depression and suicidal thoughts may moderate. However, it is important to remember that as a counsellor it is important to do your best to ensure that the person who seeks your help is not a danger to others.
LOOKING FOR THE TRIGGER Another way of entering a person’s world is to find out what triggered off the suicidal thoughts today. Very often a single event is the trigger and this trigger can sometimes give important clues about the person’s intentions. For example, is the person’s intention pa illy to punish someone who has angered or hurt them? If so, it might be useful to explore the issues involved.
CONTRACTING After working through the relevant issues with a person who has been troubled by suicidal thoughts, many counsellors encourage the person to sign a contract to agree that if strong suicidal thoughts return they will not kill themselves before coming back for counselling. Although we ourselves do not use written contracts, we do negotiate with such people to obtain a verbal agreement about what action they will take if strong suicidal thoughts recur. We explore alternatives with them regarding the help they might seek if they start to feel tempted again to commit suicide. We ask them who is the first person they would try to contact, and if that person wasn’t available who else could they contact, or where would they go for help, in seeking a verbal agreement we rely on the strength of the counselling relationship, making it clear that the person is important to us and that we believe that we can trust them to honour the agreement.
RECOGNISE YOUR LIMITATIONS Don’t forget that it is unrealistic, unfortunately, to expect that a person will necessarily decide to stay alive. Although you may be able, if you choose, to take measures to ensure that the person stays alive in the short term, in the long term, if they are determined to kill themselves, they are likely to succeed. However, as counselling progresses you will need to decide, in consultation with your supervisor, whether direct action to prevent suicide is warranted and necessary. This decision is a heavy one and is certain to be influenced by your own values and those of the agency that employs you. There are some cases where the decision to intervene is clear. It would, for example, be unethical and irresponsible to allow someone who was psychologically disturbed due to a temporary psychiatric condition or a sudden trauma to kill themselves without determined and positive action being taken to stop them. A person who is seriously contemplating suicide is likely to need ongoing psychotherapy from a skilled professional, so be prepared to refer appropriately. 1 he eventual wellbeing of such a person depends on them being able to make significant changes to their thinking and way of living, and this is unlikely to be achieved in one counselling session.
In some cases our duty of care demands firm direct action
Learning summary People who make repeated suicide attempts often succeed m killing themselves. Suicidal people include those who are locked into miserable lives, those who have recently experienced trauma, and those who want to manipulate others. When counselling a suicidal person, it is important to deal with your own feelings as a counsellor and to challenge any irrational beliefs you may have. When counselling a person who is contemplating suicide, focus on the counselling relationship using the normal counselling micro-skills: » find out what triggered the suicidal thoughts » bring the persons anger into focus » hook into the person's ambivalence if that can be useful » explore the person's options and particularly the costs of dying » use a more direct confrontational approach if you think that it is more likely to be effective » decide what direct action is warranted and necessary to prevent suicide » whenever possible, refer to suitably qualified professionals.
Further reading Duffy, D. & Ryan, T. (eds) 2004, Xew Approaches to Preventing Suicide: A Manual for Practitioners, Jessica Kingsley, London. Henden, J. 2008, Preventing Suicide: The Solution Focused Approach, Wiley, Chichester. Reeves, A. 2010, Counselling Suicidal Clients, SAGE. London.