ResourceSheet#1:CoreCompetenciesfortheAssessmentandManagement ofIndividualsatRiskforSuicide

Thefollowingcorecompetenciesweredevelopedbyexpertsinclinicalsuicidologytoserveasthefoundationfor coursesonassessingandmanagingsuiciderisk,forbothgraduatestudentsandexperiencedmentalhealth professionals.Thecompetenciesreflectcurrentempiricalevidenceandexpertopinion. Thecompetenciesarenotintendedtoserveasastandardofcareforpsychologicalormedicaltreatment.Core competenciesrelatedtospecifictreatmentinterventionshavenotbeendeveloped.

WorkingwithIndividualsatRiskforSuicide:AttitudesandApproach
1. Manageonesownreactionstosuicide a. b. c. d. 2. Becomeselfawareofemotionalreactions,attitudes,andbeliefsrelatedtosuicide Understandtheimpactontheclientofcliniciansemotionalreactions,attitudes,beliefs,orlackof understandingculturalimplications Tolerateandregulateonesemotionalreactionstosuicide Obtainprofessionalassistanceifneeded

Reconcilethedifference(andpotentialconflict)betweenthecliniciansgoaltopreventsuicideandthe clientsgoaltoeliminatepsychologicalpainviasuicidalbehavior a. b. c. d. e. f. g. Understandthatsuicidalthinkingandbehaviormakessensetotheclientwhenviewedinthecontextof hisorherhistory,vulnerabilities,andcircumstances Acceptthataclientmaybesuicidalandvalidatethedepthoftheclientsstrongfeelingsanddesiretobe freeofpain Understandthefunctionalorusefulpurposeofsuicidalitytotheclient Understandthatmostsuicidalindividualssufferfromastateofmentalpainoranguishandalossofself respect Maintainanonjudgmentalandsupportivestance Voiceauthenticconcernandtruedesiretohelptheclient Vieweachclientasanindividualwithhisorherownuniquesetofissuesandcircumstancesandsomeone theclinicianseekstounderstandthoroughlywithintheclientsownminiculture(familyandcommunity context)ratherthanasastereotypicsuicidalpatient

3.

Maintainacollaborative,nonadversarialstance a. b. c. Listenthoroughlytoattainasharedunderstandingofclientssuicidalityandgoals Communicatetoclientsthathelpingthemresolvetheirproblem(s)isparamount Obtaininformedconsent

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d. e. f. g. 4.

Createanatmosphereinwhichtheclientfeelssafeinsharinginformationabouthisorhersuicidal thoughts,behaviors,andplans Sharewhatyouknowaboutthesuicidalstateofmind;beempathictothesuicidalwish Begenuineandexpresstotheclientwhyitisimportantthatthepersoncontinuetolive Workwiththeclientanddonotabandonhimorher

Makearealisticassessmentofonesabilityandtimetoassessandcareforasuicidalclient,aswellasthe roleforwhichoneisbestsuited

UnderstandingSuicide
5. 6. 7. 8. Definebasictermsrelatedtosuicidality Befamiliarwithsuiciderelatedstatistics Describethephenomenologyofsuicide Demonstrateunderstandingofriskandprotectivefactors

CollectingAccurateAssessmentInformation
9. Integrateariskassessmentforsuicidalityearlyoninaclinicalinterview,regardlessofthesettinginwhich theinterviewoccurs,andcontinuetocollectassessmentinformationonanongoingbasis

10. Elicitriskandprotectivefactors 11. Elicitsuicideideation,intent,plans,andrelatedbehaviors 12. Elicitothersignsofsuiciderisk 13. Obtainrecordsandinformationfromcollateralsourcesasappropriate

FormulationofRisk
14. Makeaclinicaljudgmentoftheriskthataclientwillattemptorcompletesuicideintheshortandlongterm a. b. c. Integrateandprioritizealltheinformationthathasbeencollected Assessacuteriskofsuicide Assesschronicorongoingriskofsuicide

15. Writethejudgmentandtherationaleintheclientsrecord

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TreatmentandServicesPlanning
16. Collaborativelydevelopacrisisresponseplanthatassuressafetyandconveysthemessagethattheclients safetyisnotnegotiable 17. Developawrittentreatmentandservicesplanthataddressestheclientsimmediate,acute,andcontinuing suicideideationandriskforsuicidebehavior a. b. c. d. Addressriskandprotectivefactorsthatareamenabletochange Specifythesettingandfrequencyofinterventionsforspecificperiodsoftime:immediate,acute, continuingcare,maintenanceofresolvedsuicidality Identifyarangeoftreatmentalternatives Developtheplancollaborativelywiththeclient,familymembers,andsignificantothers

18. Coordinateandworkcollaborativelywithothertreatmentandserviceprovidersinaninterdisciplinary teamapproach

ManagementofCare
19. Developpoliciesandproceduresforfollowingclientscloselyincludingtakingreasonablestepstobe proactive a. b. c. d. e. f. g. h. Motivateandsupportclientsingettingthemtoareferralsourceortotheirnexttreatment/intervention session Engageincollaborativeproblemsolvingwiththeclienttoaddressbarriersinadheringtotheplanandto revisetheplanasnecessarysessionbysession Assurethattheclient,family,significantothers,andothercareprovidersarefollowingthroughonagreed uponactions Assesstheoutcomeofeachreferral Developandimplementfollowupproceduresforallmissedappointments Beavailablebetweenappointments Arrangeforclinicalcoveragewhentherapistisunavailable Assurecontinuityofcareandfollowupcontactwithallsuicidalclientswhohaveendedtreatment

20. Followprinciplesofcrisismanagement a. b. c. d. e. Takeaproblemsolvingapproach Maintainamatteroffactdemeanor Perceivecrisesasopportunitiesforgrowth Knowthatcrisesareshortlived Neitherpunishnorreinforcesuicidalbehavior.

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Documentation
21. Documentthefollowingitemsrelatedtosuicidality a. b. c. d. e. f. g. Completeassessmentinformationrelatedtobiopsychosocialculturalconsiderations Formulationandstatementofsuiciderisk,includingrationale Suicidespecifictreatmentplanthatjustifiesoutpatientcareortheneedforinpatienthospitalization Howsuicideriskandcrisesaretobemanaged Interactionsandconsultationswithprofessionalcolleagues Treatmentprogressandoutcomes Dispositionandterminationinformation

LegalandRegulatoryIssues
22. UnderstandStatelawspertainingtosuicide. 23. Understandlegalchallengesthataredifficulttodefendagainstasaresultofpoororincomplete documentation 24. ProtectclientrecordsandrightstoprivacyandconfidentialityfollowingTheHealthInsurancePortability andAccountabilityActof1996thatwentintoeffectApril15,2003.

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ResourceSheet#2:TheLanguageofSuicide
ThedefinitionsofsuicideideationandsuicidalbehaviorprovidedinthisresourcesheetarefromtheColumbiaSuicide SeverityRatingScale(CSSRS)
*

SuicidalIdeation
Wishtobedead Thepersonhaswishedtobedeadornotaliveanymore,orwishedtofallasleepandnotwakeup.Wishtobe deadalsoisreferredtoasmorbidruminationsandisdistinguishedfromsuicidalthoughtsprimarilybytheintent (i.e.nothoughtsoftakingonesownlife).Forexample,IwishIwerenotaround,deadornothere. Aclarifyingquestionregardingintentisneededtodifferentiatebetweenawishtobedeadandsuicideideation. Forexample,youmayask,Yousaythatyouvehadthoughtsofbeingdead,haveyouhadthoughtsoftakingyour ownlife? Nonspecificactivesuicidalthoughts Thepersonhasgeneralnonspecificthoughtsofwantingtoendhisorherlife(diebysuicide)withoutthoughtsof waystokilloneself(associatedmethods),intent,orplan.Forexample,Ivethoughtaboutkillingmyself.Thisis incontrasttothenexttypeofsuicideideationinwhichtheindividualmentionsamethodofkillingoneself. Activesuicidalideationwithanymethod,butwithoutplanandwithoutintenttoact Thepersonhasthoughtsofsuicideandhasthoughtofatleastonemethod.Thepersondoesnothaveaspecific planwithdetailsoftime,placeormethodworkedout.Forexample,IthoughtabouttakinganoverdosebutI nevermadeaspecificplanastowhenwhereorhowIwouldactuallydoit..andIwouldnevergothroughwithit. Activesuicidalideationwithsomeintenttoact,withoutspecificplan Apersonhasactivesuicidalthoughtsofkillingoneselfandreportshavingsomeintenttoactonsuchthoughts. Activesuicidalideationwithspecificplanandintent Thepersonhasthoughtsofkillingoneself,detailsof planfullyorpartiallyworkedout,andhassomeintenttocarry itout.
*

ColumbiaSuicideSeverityRatingScale(CSSRS)developedbyPosner,K.;Brent,D.;Lucas,C.;Gould,M.;Stanley,B.;Brown,G.;Fisher,P.;Zelazny, J.;Burke,A.;Oquendo,M.;Mann,J..DefinitionsofbehavioralsuicidaleventsinthisscalearebasedonthoseusedinTheColumbiaSuicideHistory Form,developedbyJohnMann,MDandMariaOquendo,MD,ConteCenterfortheNeuroscienceofMentalDisorders(CCNMD),NewYorkState PsychiatricInstitute,1051RiversideDrive,NewYork,NY,10032.(OquendoM.A.,HalberstamB.&MannJ.J,Riskfactorsforsuicidalbehavior:utility andlimitationsofresearchinstruments.InM.B.First[Ed.]StandardizedEvaluationinClinicalPractice,pp.103130,2003.)ForreprintsoftheC SSRScontactKellyPosner,Ph.D.,NewYorkStatePsychiatricInstitute,1051RiversideDrive,NewYork,NewYork,10032;inquiriescontact posnerk@childpsych.columbia.edu

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SuicidalBehavior
ActualAttempt: Apersoncarriesoutapotentiallyselfinjuriousactwithatleastsomewishtodie,asaresultofact.Theintent doesnothavetobe100%.Ifthereisanyintentordesiretodieassociatedwiththeact,thenitcanbeconsidered anactualsuicideattempt.Theredoesnothavetobeanyinjuryorharm,justthepotentialforinjuryorharm.For example,ifpersonpullsthetriggerwhileagunisinhisorhermouthbutthegunisbrokensonoinjuryresults,this isconsideredanattempt. Inferringintent:Evenifanindividualdeniesintentordesiretodie,itmaybeinferredclinicallyfromthebehavior orcircumstances.Forexample,itcanbeinferredthatahighlylethalact(e.g.,gunshottohead,jumpingfroma windowofahighfloor/storyofabuilding)thatisclearlynotanaccident,isasuicideattempt.Inaddition,if someonedeniesintenttodie,buttheythoughtthatwhattheydidcouldbelethal,intentmaybeinferred. InterruptedAttempt(bysomeoneorsomething) Apersonisinterrupted(byanoutsidecircumstance)fromstartingthepotentiallyselfinjuriousact.Ifnotforthe interruption,anactualattemptwouldhaveoccurred.Forexample:1.)Personhaspillsinhandbutisstoppedfrom ingesting.Oncetheyingestanypills,thisbecomesanattemptratherthananinterruptedattempt.2.)Personhas gunpointedtowardself,gunistakenawaybysomeoneelse,orissomehowpreventedfrompullingtrigger.Once theypullthetrigger,evenifthegunfailstofire,itisanattempt.3.)Personispoisedtojump,butisgrabbedand takendownfromledge.4.)Personhasnoosearoundneckbuthasnotyetstartedtohangbecauseheorsheis stoppedfromdoingso. AbortedAttempt(byself) Apersonbeginstotakestepstowardmakingasuicideattempt,butstopsbeforeheorsheactuallyengagesinthe selfdestructivebehavior.Examplesaresimilartointerruptedattempts,exceptthattheindividualstopshimor herself,insteadofbeingstoppedbysomeoneorsomethingelse. Preparatoryactsorbehavior Actsorpreparationtowardsimminentlymakingasuicideattempt.Thiscanincludeanythingbeyonda verbalizationorthought,suchasassemblingaspecificmethod(e.g.buyingpills,purchasingagun)orpreparingfor onesdeathbysuicide(e.g.givingthingsaway,writingasuicidenote)Preparationinvolvesbehaviorinanticipation oftakingoneslifebutnotassociatedwiththeplanitself(e.g.writingletterstolovedones,writingawill,making financialarrangements,etc) Rehearsal Rehearsalisimplementingthestepsofaplanforsuicideshortofmakingasuicideattempt(e.g.,puttingarope aroundonesneckorputtingaloadedguntooneshead). CompletedSuicideorDeathbySuicide Deathfrominjury,includingpoisoningorsuffocation,wherethereisevidencethattheinjurywasselfinflictedand intendedtocausedeath. Thetermcommittedsuicideisdiscouragedbecauseitconnotestheequivalencyofacrimeorsin.

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AdditionalTerms
Suicidality Suicideideationorbehaviorsasdescribedabove. Deliberateselfharm(DSH) DSHisintentionalselfinjuriousbehaviorwherethereisnoevidenceofintenttodie.DSHincludesvarious methodsbywhichindividualsinjurethemselves,suchasselflaceration,selfbattering,takingoverdoses,or exhibitingdeliberaterecklessness.TheintentofDSHisvariableandcanincludesuchthingsasemotionregulation, anger,revenge,andthedesiretoinfluencethebehaviorofothers. Unintentionalinjury(accident) Fatalornonfatalinjuresthatwereunplannedandnotintendedtohappen. Suicidegesture Thewordgestureisnotrecommendedlanguagebecauseitimplieslowintentwhen,infact,thereisroutinely insufficientdatatosupportsuchasassessment.Itismorehelpfultorefertospecificbehaviordescribedinthis resourcesheet. Suicidethreat Anyverbalornonverbalinterpersonalaction,stoppingshortofadirectlyselfharmact,whichcommunicatesor suggeststhatthepersonwishestodieormayattemptsuicide.Theintentofthepersonmakingthethreatcannot bedetermineduntilathoroughassessmentiscompleted.

Suicidology:Thescientificstudyofsuicideandsuicidalbehavior
Prevention Interventionsdesignedtostopsuicideattemptsorcompletionsfromoccurringbyfocusingeffortsonatrisk individuals,environmentalsafeguards,and/ortheavailabilityoflethalmethods. InterventionorTreatment Thecareofsuicidalpeoplebylicensedmentalhealthcaregivers,healthcareproviders,andothercaregiverswith individuallytailoredstrategiesdesignedtochangethethoughts,behaviors,mood,environment,orbiologyof individualsandhelpthemidentifyandsatisfytheirneedswithoutengaginginselfdestructivebehaviors. Postvention Thistermisusedtodescribeactionstakenafterasuicidehasoccurredlargelytohelpsurvivorssuchasfamily, friends,andcoworkerscopewiththelossofalovedone.

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Survivors
Thetermsurvivorsoriginallyreferredtopeoplewhohadlostalovedonetosuicide.However,itisnowusedto meanbothsuicideattemptsurvivorsandthosewhohavelostalovedonetosuicide.Itisimportanttoclarifytheuse ofthistermwhendiscussingorwritingaboutsuicide. SuicideAttemptSurvivorsorSurvivorsofaSuicideAttempt(SOSA) Individualswhohavesurvivedapriorsuicideattempt. SuicideSurvivors Familymembersandsignificantotherswhohavelostalovedoneduetosuicide.

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ResourceSheet#3:SuicideRelatedStatistics
Deathbysuicide 1
In2005:32,637peopleintheU.S.diedbysuicide.Thisis1.3%ofalldeaths.Thisistheequivalentofone persondyingbysuicideeverysixteenminutesandhasthesamedeathtollasajetlinerfullofpeoplecrashing everytwodays. Suicideisthe3rdleadingcauseofdeathamongAmericansbetweentheagesof1524andthesecondleading causeofdeathamongthosebetweentheagesof2534. Suicideisthe11thleadingcauseofdeathoverall.

Suicideattempts(estimated)
In2005,anestimated816,000peopleintheU.S.attemptedsuicide(usingaratioof25attemptsforeach1 completedsuicide).2 Note:Estimatesoftheratioofsuicideattemptstosuicidedeathsrangefrom200:1foryouthsto3:1for elders.Thevariationishighlydependentonthelethalityofmethodused. Amongadults(1854)respondingtoanationalsurveyin20012003,0.6%reportedhavingattemptedsuicide inthepast12months.3 Amongcollegestudentsrespondingtoalargesurveyin2000,1.5%ofstudentsreportedhavingattempted suicideduringthepast12months.4 Amongstudentsingrades912respondingtoasurveyin2005,8.4%(10.8%offemalesand6%ofmales) reportedhavingattemptedsuicideinthepast12months.5

Suicideideation(estimated)
Foradults(1854)respondingtoanationalsurveyin20012003,3.3%reportedhavingseriouslyconsidered suicideinthepast12months.4 Amongadultsaged18orolderwhoexperiencedapastyearmajordepressiveepisode,56.3percentthought, duringtheirworstormostrecentepisode,thatitwouldbebetteriftheyweredead,40.3percentthought aboutcommittingsuicide,14.5percentmadeasuicideplan,and10.4percentmadeasuicideattempt.6 Forcollegestudents,9.5%ofstudentsrespondingtolargesurveyreportedhavingseriouslyconsidered suicideduringthepast12months.5 Forstudentsingrades912,14.5%(18.7%forfemalesand10.3%formales)reportedthattheyseriously consideredsuicideduringthepast12months.Theprevalenceofsuicidalthoughtswashighestamong Hispanicfemales(21.1%).7

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Survivors(estimated)2
Survivors:eachsuicidedeathaffectsintimatelyatleast6otherpeople.2Manyconsiderthisestimatetobe conservative.

Methodofsuicide1
Firearms:52% Suffocation/hanging:22% Poisoning:18% Cut/pierce:2% Other:6%

Suicideandmentalillness
NinetypercentofsuicidesintheUnitedStatesareassociatedwithadiagnosablementalillness,substance usedisorder,orboth.8Childrenandyoungerteenswhodiebysuicidearemuchlesslikelytohavethese disorders. Fiftypercentofthosewhodiebysuicidewereafflictedwithmajordepression,andthesuiciderateofpeople withmajordepressioniseighttimesthatofthegeneralpopulation.9

Gender,Ethnic,andAgeDifferencesinSuicidalBehaviors10
Malesarefourtimesaslikelytodiebysuicideasfemales,althoughfemalesarethreetimesaslikelyasmales tomakeanonfatalsuicideattempt. WhiteAmericansaremorelikelytodiebysuicide(rate=12.3/100,000)thannonwhiteAmericans(rate= 5.5/100,000). ElderwhitemaleshavethehighestsuicideratesintheU.S.Thedeathrateofsuicideforwhitemales65+ yearsoldis32.6/100,000.ThedemographicgroupwiththelowestrateisAfricanAmericanwomen(rate= 1.8/100,000) Amongyouth(ages1524),AmericanIndian/AlaskanNativemaleshavethehighestratesofsuicide (32.5/100,000);Hispanicfemaleshavethehighestratesofsuicideattempts.

Youth(ages1019)1

Variationbyage.Thesuiciderateincreasesfromlatechildhood/earlyadolescence(10to14years)tolater adolescence(15to19years).Thesearehighlysignificantdifferences. o The2005suicideratewas1.89formales1014yearsofage;itwas12.39morethansixtimes higherformales1519yearsofage. o The2005suicideratewas0.67forfemales1014yearsofage;itwas3.0241/2timeshigherfor females1519yearsofage.

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Variationbyrace/ethnicity. o Among1519yearoldmales,the2005suiciderates(per100,000)were: 24.14forAmericanIndian/AlaskanNatives 13.24forWhites 7.20forBlacks 4.81forAsian/PacificIslanders. o Amongfemalesinthisagegroup,therateswere: 14.86forAmericanIndian/AlaskanNatives 3.13forWhites 3.11forAsian/PacificIslanders 1.43forBlacks

Variationovertime(20002005). o Therehasbeenmuchmediaattentiontochangesinyouthsuiciderates,particularlyinrelationto thecontroversyconcerningtheefficacyandsafetyofantidepressantmedicationsforthetreatment ofdepressivedisordersinchildrenandadolescents.Althoughyouthsuicidecontinuestobea nationaltragedyandtheratesarefartoohigh,theoverallratesformales10to19years,and females10to19yearswerelowerin2005than2004. o The2005suicideratewasatorbelowthe6yearaverageformales1014yearsofage,males1519 yearsofage,andfemales1014yearsofage. o The2005suicideratewashigherthanthe6yearaverageforfemales1519yearsofage.However, itwasstillmeaningfullylowerthanthe2004rate.Therewere355suicidedeathsamong1519year oldfemalesintheUnitedStatesin2004and310suicidedeathsforthisgroupin2005.

NationalCenterforInjuryPreventionandControlandtheCentersforDiseaseControl.(2008).Webbasedinjurystatisticsquery andreportingsystem(WISQARS).Retrievedmultipledatesin2007and2008,fromwww.cdc.gov/ncipc/wisqars

AmericanAssociationofSuicidology.(2008).USASuicide:2005OfficialFinalData.RetrievedApril7,2008,from http://mypage.iusb.edu/~jmcintos/usa2005summary.htm Kessler,R.,etal.(2005).Trendsinsuicideideation,plans,gestures,andattemptsintheUnitedStates,19901992.TheJournalof theAmericanMedicalAssociation(JAMA),293(20),24872495.

SuicidePreventionResourceCenter.(2004).Promotingmentalhealthandpreventingsuicideincollegeanduniversitysettings. Newton,MA:EducationDevelopmentCenter,Inc. Eaton,D.K.,etal.(2006)YouthriskbehaviorsurveillanceUnitedStates,2005.MMWRSurveillanceSummaries,55(SS5) RetrievedApril7,2008,fromhttp://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf

SAMHSAsOfficeofAppliedStudies.(2006).Suicidalthoughts,suicideattempts,majordepressiveepisode,andsubstanceuse amongadults.TheOASReport,34.Retrievedfromhttp://oas.samhsa.gov/2k6/suicide/suicide.pdf Eaton,D.K.,etal.(2008)YouthriskbehaviorsurveillanceUnitedStates,2007.MMWRSurveillanceSummaries,57(SS04) RetrievedApril7,2008,fromhttp://www.cdc.gov/mmwr/preview/mmwrhtml/ss5704a1.htm?s_cid=ss5704a1_e Jacobs,D.,Brewer,M.,andKleinBenheim,M.(1999).Suicideassessment:Anoverviewandrecommendedprotocol.InD.Jacobs (Ed.),TheHarvardMedical Schoolguide tosuicide assessmentand intervention.SanFrancisco:JosseyBass.

SubstanceAbuseandMentalHealthServicesAdministration.(2001).NationalStrategyforSuicidePrevention(Goal1).Rockville, MD:UnitedStatesPublicHealthService.

10

CentersforDiseaseControlandPrevention.(2004).Suicide:Factsheet.Retrievedfrom www.cdc.gov/ncipc/factsheets/suifacts.htm

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ResourceSheet#4:SuicidePreventionResourcesandReferences
CrisisLines
NationalSuicidePreventionLifeline1800273TALK(8255) TheNationalSuicidePreventionLifelineisa24hour,tollfreesuicidepreventionserviceavailabletoanyonein suicidalcrisis1-800-273-TALK (8255).Callersareroutedtotheclosestpossiblecrisiscenter.Withover120 crisiscentersacrossthecountry,themissionistoprovideimmediateassistancetoanyoneseekingmentalhealth services.Callersmaydiscussthemselvesorsomeonetheycareabout.Callsarefreeandconfidential.TheLifeline isnotaresourceforpractitionersinprovidingcare. VeteransAffairs(VA)SuicideHotline1800273TALK(8255)andpress"1"toreachtheVAhotline Toensureveteranswithemotionalcriseshaveroundtheclockaccesstotrainedprofessionals,theDepartmentof VeteransAffairs(VA)hasbegunoperationofanationalsuicidepreventionhotlineforveterans.Tooperatethe nationalhotline,VAispartneringwiththeSubstanceAbuseandMentalHealthServicesAdministrationofthe DepartmentofHealthandHumanServices(HHS)andtheNationalSuicidePreventionLifeline.Veteranscancall1 800273TALK(8255)andpress"1"toreachtheVAhotline,whichisstaffedbymentalhealthprofessionalsin Canandaigua,N.Y.whoworkcloselywithVAmentalhealthprovidersinthecallerslocalareatorespondtocallers needs. TheTrevorHelpline8664UTrevor8664887386 TheTrevorHelplineistheonlynationalcrisisandsuicidepreventionhelplineforgay,lesbian,bisexual,transgender andquestioningyouth.TheHelplineisafreeandconfidentialservicethatoffershopeandtrainedcounselorsto talkto,24/7.

Organizationsdedicatedtosuicideresearch,trainingandeducation,prevention,andissuesrelatedto survivors
AmericanAssociationofSuicidology(AAS):www.suicidology.org ThegoaloftheAmericanAssociationofSuicidology(AAS)istounderstandandpreventsuicide.Foundedin1968 byEdwinS.Shneidman,Ph.D.,AASpromotesresearch,publicawarenessprograms,publiceducation,andtraining forprofessionalsandvolunteers.Inaddition,AASservesasanationalclearinghouseforinformationonsuicide. ThemembershipofAASincludesmentalhealthandpublichealthprofessionals,researchers,suicideprevention andcrisisinterventioncenters,schooldistricts,crisiscentervolunteers,survivorsofsuicideandavarietyoflay personswhohaveaninterestinsuicideprevention. AASsAnnualConferenceforresearchers,clinicians,survivors,schoolpersonnel,volunteers,andothermental healthprofessionalsincludespresentationsandworkshopsonlatestresearchfindings.AASpublishesSuicideand LifeThreateningBehavior,aquarterlypeerreviewedjournalforcliniciansandresearchers.Alistofnotable referencesinsuicidologyarelistedonthewebsite.

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TheResearchDivisionofAASisdedicatedtoadvancingknowledgeaboutsuicidalbehaviorthroughresearch. Activitiesofthisdivisioninclude: SelectedresearchpaperspresentedattheAASannualmeetingareavailablefordownloading. ConsultationNetworkTaskforce(CNT)hasbeencreatedtohelpresearchersatalllevelsofexperiencein theirresearchendeavors,forexample,relatedtoprogramevaluation,outcomemeasures,methodology, findingdatasources,questionsabouttheoreticalapproachestothestudyofsuicide,prevention,and postvention.TheCNTisopentoallmembersofAAS. TheClinicalDivisionofAASisdedicatedtopreventingandinterveninginsuicidalbehaviorthroughthesharingof clinicalexpertiseandexperience.Recentprojectsinclude: RecommendationsforInpatientsandResidentialPatientsKnowntobeatElevatedRiskforSuicide Jail/CustodySuicide:ACompendiumofSuicidePreventionStandardsandResources TheCrisisCentersDivisionofAASsupportstheworkofcrisiscentersandhotlinesthroughtraining,educationand certification. AASlistservisanonlinediscussionforumforclinicians,researchers,educators.Tosubscribegoto http://listserve.apa.org/archives/suicidology.html.Suicidologyarchivesmayalsobeviewedandsearchedatthis location. AmericanFoundationforSuicidePrevention(AFSP):www.afsp.org TheAmericanFoundationforSuicidePrevention(AFSP)isdedicatedtoadvancingourknowledgeofsuicideand ourabilitytopreventit.TheFoundationsactivitiesinclude: Supportingresearchprojectsthroughgrantstohelpfurthertheunderstandingandtreatmentof depressionandthepreventionofsuicide Providinginformationandeducationaboutdepressionandsuicide Promotingprofessionaleducationfortherecognitionandtreatmentofdepressedandsuicidalindividuals Publicizingthemagnitudeoftheproblemsofdepressionandsuicideandtheneedforresearch, preventionandtreatment Supportingprogramsforsuicidesurvivortreatment,researchandeducation TheFoundationpublishesscientificarticlesonsuicideintheLifesaversnewsletterpublishedquarterlyand availableonthewebsite.AFSPfundsresearchstudiesandconductsworkshopsandconferencesthroughoutthe country. CentersforDiseaseControlandPrevention(CDC)http://www.cdc.gov TheCDCisoneofthemajoroperatingcomponentsoftheDepartmentofHealthandHumanServices.Itsmission istopromotehealthandqualityoflifebypreventingandcontrollingdisease,injury,anddisability.WithinCDC,the NationalCenterforInjuryPreventionandControlandtheNationalCenterforHealthStatisticsprovideessential informationtosupportsuicideprevention. GlendonAssociation:www.glendon.org TheGlendonAssociationisa501(c)(3)nonprofitwhosemissionistosavelivesandhelppeoplecreatemore meaningfullivesbyaddressingthesocialproblemsofsuicide,violence,childabuseandtroubledinterpersonal relationships,throughresearch,publiceducationandprofessionaltraining.Glendonproduceseducationalfilms,

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forbothprofessionalandpublicaudiences,addressingtopicssuchassuicideprevention,parenting,andcouple relationships.Publicationsincludebooks,articles,andcomplimentarybrochures.Glendonstafftravelnationally andinternationallytoconducttrainings.PsychologicalAssessmentResources,Inc.(www.parinc.com)distributes thefollowingassessmentinstrumentsdevelopedbyGlendonstaff:FAST(FirestoneAssessmentofSelfDestructive Thoughts);FASI(FirestoneAssessmentofSuicideIntent);andFAVT(FirestoneAssessmentofViolentThoughts). FormoreinformationcontactJinaCarvalhoat18006635281orJina@glendon.org. InternationalAssociationforSuicidePrevention(IASP)http://www.med.uio.no/iasp/ IASPisdedicatedtopreventingsuicidalbehavior,toalleviateitseffects,andtoprovideaforumforacademicians, mentalhealthprofessionals,crisisworkers,volunteersandsuicidesurvivors. NationalInstituteofMentalHealth,SuicideResearchConsortium: http://www.nimh.nih.gov/suicideresearch/consortium.cfm ComprisedprimarilyofNIMHscientistsacrosstheInstitutewhoalsoadministerresearchgrants,theConsortium: CoordinatesprogramdevelopmentinsuicideresearchacrosstheInstitute Identifiesgapsinthescientificknowledgebaseonsuicideacrossthelifespan StimulatesandmonitorsNIMHsponsoredresearchonsuicide Keepsabreastofscientificdevelopmentsinsuicidologyandpublicpolicyissuesrelatedtosuicide surveillance Preventionandtreatment Disseminatessciencebasedinformationonsuicidologytothepublic,media,andpolicymakers. NationalOrganizationforPeopleofColorAgainstSuicide(NOPCAS):www.nopcas.org TheNationalOrganizationforPeopleofColorAgainstSuicide(NOPCAS)supportsthedevelopmentofinnovative researchtoidentifytheuniquefactorsinminoritycommunitiesthatcontributetosuicide;andcommunitybased strategiestopreventsuicideandtheassociatedproblemsofviolenceanddepression.Suicideresources,research, articles,andpublicationsareavailableontheNOPCASwebsite. SubstanceAbuseandMentalHealthServices/CenterforMentalHealthServices(SAMHSA/CMHS) http://mentalhealth.samhsa.gov/cmhs/default.asp TheCenterforMentalHealthServicesistheFederalagencywithintheU.S.SubstanceAbuseandMentalHealth ServicesAdministrationthatleadsnationaleffortstoimprovepreventionandmentalhealthtreatmentservicesfor allAmericans.SAMHSA/CMHSpursuesitsmissionbyhelpingStatesimproveandincreasethequalityandrangeof treatment,rehabilitation,andsupportservicesforpeoplewithmentalhealthproblems,theirfamilies,and communities.CMHSprogramsandactivitiesinclude: TheJedFoundationhttp://www.jedfoundation.org TheJedFoundationisthenationsleadingorganizationworkingtopreventsuicideandpromotementalhealth amongcollegestudents.Weareguidedbyanexpertboardofmentalhealthprofessionalsinoureffortstoidentify theunderlyingcausesofsuicideandproduceeffectiveprevention,awarenessandinterventionprograms. TheSuicidePreventionActionNetwork(SPANUSA)http://www.spanusa.org/

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SPANUSAisa501(c)(3)organizationdedicatedtopreventingsuicidethroughpubliceducationandawareness, communityactionandfederal,stateandlocalgrassrootsadvocacy.Theorganizationwasfoundedin1996by GeraldandElsieWeyrauchofMarietta,Georgia,survivorsofthesuicideoftheir34yearoldphysiciandaughter, Terri.Theirgoalwastocreateawayforsurvivorsofsuicidethosewhohavelostsomeonetosuicideto transformtheirgriefintopositiveactiontopreventfuturetragediestoraiseawareness,buildpoliticalwill,and takeactionwithregardtocreating,advancing,implementing,andevaluatinganationalstrategytoaddresssuicide inournation. SPANUSAsmissionistoleveragegrassrootssupportamongsuicidesurvivors(thosewhohavelostalovedoneto suicideandthosewhohaveattemptedsuicide)andotherstoadvancepublicpoliciesthathelppreventsuicide. SPANUSA'sprojectsareguidedbyitsfourunderlyinggoalpriorities: Advancingpublicpolicy, Organizingcommunities, Engagingsurvivors,and Promotingtheapplicationofbestpracticesinsuicideprevention. SuicidePreventionResourceCenter(SPRC):www.sprc.org TheSuicidePreventionResourceCenter(SPRC)supportssuicidepreventionwiththebestofscience,skillsand practice.TheCenterprovidespreventionsupport,training,andinformationalmaterialstostrengthensuicide preventionnetworksandadvancetheNationalStrategyforSuicidePrevention.Fundedthroughacooperative agreementbetweentheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)andtheEducation DevelopmentCenter,Inc.,(EDC),theSPRCworksincollaborationwithmanypartnerorganizationstoadvance suicideprevention. SPRCLibraryCatalogisasearchabledatabaseoftheSPRClibrarycollectionandcontainsadetailedrecordforeach resource.Aprofessionallibrarianselectsresourcesfromavarietyofsourcessuchaspublishedworks,peer reviewedresearch,curricula,andwebbasedresources.TheresourcescontainedintheSPRClibrarypromote suicidepreventionefforts,fosterpreventionnetworks,andprovideinformationonthescopeofthesuicide problem. ResearchNewsBriefssectionoftheSPRCwebsiteprovidessummariesofcurrentresearchinsuicidology,selected fortheirgeneralinterestandrelevancetosuicideprevention. SPARK.Subscriberstothiselectronicnewsletterreceiveaweeklyenewslettercontainingannouncements,the newsheadlinesandsummaries,summariesofthelatestresearch,andfundingnews. SPRCTrainingInstituteTheSPRCTrainingInstituteprovidesaneverexpandingarrayofcurriculadesignedtobuild capacityforsuicidepreventioninstate,tribal,local,andcommunitybasedorganizations.Thesehighquality curriculareflecttheemphasisontrainingfoundintheNationalStrategyforSuicidePrevention,andinthatspirit, areprovidedatthelowestcostpossibletoindividualsandcommunitiesacrossthecountry.Pleasecontactusat info@sprc.org.Coursesincludethefollowing: AssessingandManagingSuicideRisk:CoreCompetenciesforMentalHealthProfessionals StrategicPlanningforSuicidePrevention:Thismultidayworkshopisdesignedforsuicideprevention coalitionsandplanninggroups.Usingapublichealthapproach,thecoursecoverstopicssuchas:

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accessingandusingdata;evidencebasedpractices;creatingaframeworkforevaluation;actionplanning; andworkinginpartnerships.SPRCpartnerswiththeSuicidePreventionActionNetwork(SPANUSA)to disseminatethecourse. WebbasedSeminars:SPRCResearchtoPracticewebinarsfosterdialogueonsuicideandsuicide preventionamongpractitioners,researchers,andothersworkinginthefield.Recordingsoftheseperiodic webbasedseminars,aswellassupplementarymaterialsfromeachsession,canbeaccessedonline. OnlineWorkshops:Fourselfpacedonlineworkshopsareavailablefreeofcharge.Eachworkshopfocuses onyouthsuicidepreventionbutmuchofthecontentisapplicabletosuicideacrossthelifespan. Continuingeducationcreditsareavailable.

Journals
Muchoftheprimarysuicideresearchispublishedinthefollowingjournals: ArchivesofGenPsychiatry JournalofConsultingandClinicalPsychology AmericanJournalofPsychiatry JournalofClinicalChildandAdolescentPsychology AmericanAcademyofChildandAdolescentPsychiatry SuicideandLifeThreateningBehavior,theofficialjournaloftheAmericanAssociationofSuicidology TheJournalofCrisisInterventionandSuicidePrevention,publishedundertheAuspicesofthe InternationalAssociationforSuicidePrevention(IASP) ArchivesofSuicideResearch,publishedundertheAuspicesoftheInternationalAcademyforSuicide Research

Otherresources
ResourcesforFamilies Ellis,T.E.,&Newman,C.F.(1996).Appendix:Guideforconcernedfamilymembersandfriends.In ChoosingtoLive:HowtoDefeatSuicideThroughCognitiveTherapy.(pp.169181).Oakland,CA:New HarbingerPublications,Inc. Woolis,R.(1992).WhenSomeoneYouLoveHasaMentalIllness.NewYork,NY:PenguinPutnam,Inc. SAMHSAsNationalMentalHealthInformationCenter Afteranattempt:Aguidefortakingcareofyourfamilymemberaftertreatmentinthe emergencydepartment,http://mentalhealth.samhsa.gov/publications/allpubs/SVP0159/ Afteranattempt:Aguidefortakingcareofyourselfafteryourtreatmentintheemergency department,http://mentalhealth.samhsa.gov/publications/allpubs/SVP0157/

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UnderstandingSuicidefromthePerspectiveofConsumersandSuicideAttemptSurvivors FirstNationalConferenceforSurvivorsofSuicideAttempts,HealthCareProfessionals,andClergyand Laity.OnOct.1921,2005,over100participantsmetinMemphis,TN,fortheFirstNationalConference forSurvivorsofSuicideAttempts(SOSAs),HealthCareProfessionals,andClergyandLaity.Asummaryof theconferencereportmaybefoundontheSPRCwebsiteathttp://www.sprc.org/library/SOSAconf.pdf LifelineServiceandOutreachStrategiesSuggestedbySuicideAttemptSurvivors;FinalReportofthe AttemptSurvivorAdvisorySummitMeetingandIndividualInterviews.Eightattemptsurvivorsattended thesummitmeetinginNewYorkCityonJanuary16,2007.Fourotherattemptsurvivorswhowereunable toattendthemeetingcontributedtheirsuggestionsduringindividualindepthphoneinterviews conductedbetweenJanuary25andFebruary1,2007.Thereportoftheseinterviewsmaybefoundonthe NationalSuicidePreventionLifelineNetwork(Lifeline)websiteat http://www.suicidepreventionlifeline.org/media/pdf/NSPLSOSA_Report73107_FINAL.pdf Ameetingheldwith26preventionprofessionals,healthcareproviders,researchers,policymakers,and consumerswithpersonalexperienceinsuicideinAnnapolis,MarylandonNovember2829,2007.A reportofthismeetingisbeingpreparedandmaybeobtainedbycontactingtheOfficeofConsumer Affairs,SAMHSACenterforMentalHealthServicesat http://mentalhealth.samhsa.gov/consumersurvivor/about.asp NationalConsensusStatementonMentalHealthRecovery,producedataDecember,2004,meetingof morethan110expertpanelists:consumers,familymembers,providers,researchers,publicofficials,and others.ThefullstatementcanbefoundonSAMSHAsWebsite, http://mentalhealth.samhsa.gov/publications/allpubs/sma054129/

References
ThefollowingarereferencestothebodyofliteraturethatundergirdstheAMSRcurriculum. WorkingwithIndividualsatRiskforSuicide:AttitudesandApproach Brown,G.K.,Steer,R.A.,Henriques,G.R.,&Beck,A.T.(2005).Theinternalstrugglebetweenwishtolive andwishtodie:Ariskfactorforsuicide.AmericanJournalofPsychiatry,172,19771979. Chiles,J.A.,&Strosahl,K.D.(1995).Examineyourattitudes:affective,ethical,andlegalissuesinthe treatmentofthesuicidalpatient;Thecliniciansattitudeandbehavior:themediumisthemessage.InThe SuicidalPatient:PrinciplesofAssessment,Treatment,andCaseManagement.Washington,D.C.:American PsychiatricPress,Inc. Chu,J.A.(1999).TraumaandSuicide.InD.Jacobs(Ed.).TheHarvardMedicalSchoolGuidetoSuicide AssessmentandIntervention.(pp.332354).SanFrancisco,CA:JosseyBassPublishing. Ellis,T.E.(2004).Collaborationandaselfhelporientationintherapywithsuicidalclients.Journalof ContemporaryPsychotherapy,34,4157. Hendin,H.,Haas,A.P.,Maltsberger,J.T.,Koestner,B.,&Szanto,K.(2006)Problemsinpsychotherapywith suicidalpatients.AmericanJournalofPsychiatry,163(1),p.6772.

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Jobes,D.A.(2000).Collaboratingtopreventsuicide:Aclinicalresearchperspective.SuicideandLife ThreateningBehavior,30(1),817. Jobes,D.A.,&Drozd,J.F.(2004).TheCAMSapproachtoworkingwithsuicidalpatients.Journalof ContemporaryPsychotherapy,34(1),7385. Jobes,D.A.,&Mann,R.E.(1999).Reasonsforlivingvs.reasonsfordying:Examiningtheinternaldebate ofsuicide.SuicideandLifeThreateningBehavior,29,97104. Kovacs,M.,&Beck,A.T.(1977).Thewishtodieandthewishtoliveinattemptedsuicides.Journalof ClinicalPsychology,33,361365. Linehan,M.M.(1993).RelationshipStrategies.InCognitiveBehavioralTreatmentofBorderline PersonalityDisorder.(pp.514519).NewYork,NY:TheGuilfordPress. Maltsberger,J.T.,&Buie,D.H.(1974).Countertransferencehateinthetreatmentofsuicidalpatients. ArchivesofGeneralPsychiatry,30(5),625633. Maltsberger,J.T.(2001).Treatingthesuicidalpatient.AnnalsoftheNewYorkAcademyofSciences,932, 158168. Maltsberger,M.K.,Jobes,D.A.,Leenaars,A.A.,Orbach,I.,Sadler,K.,Pascal,D.,Young,R.A.,&Valach,L. (2002).Discoveringthetruthinattemptedsuicide.AmericanJournalofPsychotherapy,56(3),424437. Norcross,J.C.(Ed.).(2001).Empiricallysupportedtherapyrelationships:SummaryreportoftheDivision 29TaskForce.Psychotherapy,38(4). Orbach,I.(2001).Therapeuticempathywiththesuicidalwish:Principlesoftherapywithsuicidal individuals.AmericanJournalofPsychotherapy,55(2),166184. Shea,S.(2002).Beforetheinterviewbegins:Overcomingthetabooagainsttalkingaboutsuicide.InThe PracticalArtofSuicideAssessment:AGuideforMentalHealthProfessionalsandSubstanceAbuse Counselor.(pp.109123).Hoboken,NJ:JohnWiley&Sons. Shneidman,E.S.(1985).Definitionofsuicide.NewYork:JohnWileyandSons. Werth,J.L.(2002).Incorporatingendoflifeissuesintopsychologycourses.TeachingofPsychology,29 (2),106111. Werth,J.L.(2001).U.S.involuntarymentalhealthcommitmentstatutes:requirementsforpersons perceivedtobeapotentialharmtoself.SuicideandLifeThreateningBehavior,31(3),348357. Werth,J.L.,&Holdwick,D.J.(2000).Aprimeronrationalsuicideandotherformsofhasteneddeath.The CounselingPsychologist,28(4),511539.

Specialsectiononculturalcompetency: Barnes,D.H.(2004).CulturalCompetency.InNationalOrganizationforPeopleofColorAgainstSuicide (NOPCAS)TaskForceReporttoSPRCpostedonwww.nopcas.org.

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Constantine,M.G.&Sue,D.W.(2005)StrategiesforbuildingmulticulturalcompetenceinMentalhealth andeducationalsettings.JohnWileyandSons,Inc. Goldston,D.B.,Molock,S.D.,Whitbeck,L.B.,Murakami,J.L.,Zayas,L.H.,&Hall,G.C.N.(2008).Cultural considerationsinadolescentsuicidepreventionandpsychologicaltreatment.AmericanPsychologist, 63(1),1431. Griner,D.&Smith,T.B.(2006).Culturallyadaptedmentalhealthinterventions:Ametaanalyticreview. Psychotherapy:Theory,Research,Practice,Training,43(4),531548. Hwang,W.(2006).Thepsychotherapyadaptationandmodificationframework:ApplicationstoAsian Americans.AmericanPsychologist,61(7),702715. InstituteofMedicine(2003).Unequaltreatment:Confrontingracialandethnicdisparitiesinhealthcare, TheNationalAcademiesPress,Washington,DC. Leach,M.M.(2006).Culturaldiversityandsuicide:Ethnic,religious,gender,andsexualorientation perspectives.NewYork:TheHaworthPress,Inc. Martin,M(2002).SavingOurLastNerve:TheBlackWomansPathtoMentalHealth,HiltonPublishing Company,Munster,IN Munoz,R.,Primm,A.,Ananth,J.,&Ruiz,P(2007).Lifeincolor:CultureinAmericanPsychiatry,Hilton PublishingCompany,Chicago,Illinois Sue,S.(2006).Culturalcompetency:Fromphilosophytoresearchandpractice.JournalofCommunity Psychology,34(2),237245. Whaley,A.L.&David,K.E.(2007)Culturalcompetenceandevidencebasedpracticeinmentalhealth services:Acomplementaryperspective.AmericanPsychologist,62(6),563574. Firstnationalconferenceforsurvivorsofsuicideattempts,health`careprofessionals,andclergyandlaity: Summaryofworkgroupreportshttp://www.sprc.org/library/SOSAconf.pdf Lifelineserviceandoutreachstrategiessuggestedbysuicideattemptsurvivors. http://www.suicidepreventionlifeline.org/media/pdf/NSPLSOSA_Report73107_FINAL.pdf

UnderstandingSuicide InstituteofMedicine.(2002).ReducingSuicide:ANationalImperative.(pp.69216).Washington,D.C.: TheNationalAcademiesPress. Jacobs,D.&Brewer,M.(2004).AmericanPsychiatricAssociationpracticeguidelinesprovides recommendationsforassessingandtreatingpatientswithsuicidalbehaviors.PsychiatricAnnals,34(5), 373380. Joiner,T.E.(2006).WhyPeopleDiebySuicide.Boston,MA:HarvardUniversityPress. Linehan,M.M.,&Laffaw,J.A.(1982).Suicidalbehaviorsamongclientsatanoutpatientpsychologyclinic vs.thegeneralpopulation.SuicideandLifeThreateningBehavior,12,234239.

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Linehan,M.M.(1986).SuicidalPeople:OnePopulationorTwo?AnnalsoftheNewYorkAcademyof Sciences,487,1633. Luoma,J.B.,Martin,C.E.,&Pearson,J.L.(2002).ContactwithMentalHealthandPrimaryCareProviders before Suicide:AReviewoftheEvidence.AmJPsychiatry159:909916. Maris,R.W.,Berman,A.L.,&Silverman,M.M.(2000).PartII:SociodemographicandEpidemiologic Issues.InComprehensiveTextbookofSuicidology.(pp.126308).NewYork,NY:TheGuilfordPress. O'Carroll,P.W.,Berman,A.L.,Maris,R.W.,Moscicki,E.K.,Tanney,B.L.,&Silverman,M.M.(1996). BeyondtheTowerofBabel:Anomenclatureforsuicidology.SuicideandLifeThreateningBehavior,26(3), 237252. Shneidman,E.S.(1996).Commonalitiesofsuicide.InTheSuicidalMind.(pp.129137).London:Oxford UniversityPress. Styron,W.(1992).DarknessVisible:AMemoirofMadness.NewYork,NY:VintagePublisher. Wise,T.L.(2003).WakingUp:ClimbingThroughtheDarkness.Oxnard,CA:PathfinderPublishingof California.

Statistics CentersforDiseaseControlandPrevention(CDC)http://www.cdc.gov/ Typesuicideinthesearchwindowtoobtainpublicationsandfactsheets. Typesuicidestatisticsinthesearchwindowtoobtainsourcesforcurrentdatarelatedtosuicide. NationalCenterforInjuryPreventionandControl(NCIPC)http://www.cdc.gov/ncipc/ WISQARS(WebbasedInjuryStatisticsQueryandReportingSystem)isaninteractivedatabasesystemthat providescustomizedreportsofinjuryrelateddata(brokendownbyage,gender,race/ethnicity,state, etc.)thatmaybeaccessedatthefollowingurl:http://www.cdc.gov/ncipc/wisqars/default.htm OnlinecustomizedsearchespresentU.S.injurymortalitydataandnationalestimatesofnonfatalinjuries treatedinU.S.hospitalemergencydepartments. NationalViolentDeathReportingSystem(NVDRS)http://www.cdc.gov/ncipc/profiles/nvdrs/default.htm In2002CDCreceivedfundingtoestablishtheNVDRStocollectdataonviolentdeathsfromavarietyof sources,includingdeathcertificates,policereports,medicalexaminerandcoronerreports,andcrime laboratories.Individually,thesesourcesprovidefragmenteddatathatexplainviolenceonlyinanarrow context.Together,thesesourcesofferamorecomprehensivepictureofthecircumstancessurroundinga homicideorsuicide.Asaresult,NVDRSprovidesinsightintotheoptimalpointsforintervention,thus improvingviolencepreventionefforts.

CollectingAccurateAssessmentInformation AmericanAcademyofChildandAdolescentPsychiatry.(2001).Practiceparameterfortheassessmentand treatmentofchildrenandadolescentswithsuicidalbehavior.JournaloftheAmericanAcademyofChild& AdolescentPsychiatry,40(Suppl.7),24S50S.

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Bongar,B.,Maris,R.W.,Berman,A.L.,&Litman,R.E.(1998).Chapter1:OutpatientStandardsofCare andtheSuicidalPatient.InB.Bongar,A.L.Berman,R.W.Maris,M.M.Silverman,E.Haris,&W.L. Packman(Eds.).RiskManagementwithSuicidalPatients.(pp.433).NewYork,NY:TheGuilfordPress. Brown,G.K.(2002).AReviewofSuicideAssessmentMeasuresforInterventionResearchwithAdultsand OlderAdults.TechnicalreportsubmittedtoNIMHunderContractNo.263MH914950.Bethesda,MD: NationalInstituteofMentalHealth.http://www.nimh.nih.gov/suicideresearch/adultsuicide.pdf Brown,L.M,Bongar,B.,&ClearyK.M.(2004).Aprofileofpsychologistsviewsofcriticalriskfactorsfor completedsuicideinolderadults.ProfessionalPsychology:ResearchandPractice,31(1). Goldston,D.B.(2003).MeasuringSuicidalBehaviorandRiskinChildrenandAdolescents.Washington, D.C.:AmericanPsychologicalAssociation.[Note:Muchoftheinformationinthisbookisalsoavailable throughtheNIMHwebpublisheddocument:AssessmentofSuicidalBehaviorsandRiskamongChildren andAdolescentsbyDavidB.Goldston.(2000)TechnicalReportsubmittedtoNIMHundercontract263 MD909995.Acriticaloverviewofinstrumentsusedtoassesssuicidalityinyouth. http://www.nimh.nih.gov/suicideresearch/measures.pdf] Jobes,D.A.,Eyman,J.R.,&Yufit,R.I.(1995).Howcliniciansassesssuicideriskinadolescentsandadults. CrisisInterventionandTimeLimitedTreatment,2,112. Range,L.M.(2005).Thefamilyofinstrumentsthatassesssuiciderisk.JournalofPsychopathologyand BehavioralAssessment,27,133140. Rudd,M.D.,Joiner,T.E.Jr.,Jobes,D.A.,&King,C.A.(1999).Theoutpatienttreatmentofsuicidality:An integrationofscienceandrecognitionofitslimitations.ProfessionalPsychology:Research&Practice,30 (5),437446. Shea,S.(2004).TheDelicateArtofElicitingSuicidalIdeation.PsychiatricAnnals,34(5),374400.

FormulationofRisk AmericanAcademyofChildandAdolescentPsychiatry.(2001).Practiceparameterfortheassessmentand treatmentofchildrenandadolescentswithsuicidalbehavior.JournaloftheAmericanAcademyofChild& AdolescentPsychiatry,40(Suppl.7),24S50S. Jacobs,D.,&Brewer,M.(2004).AmericanPsychiatricAssociationpracticeguidelinesprovides recommendationsforassessingandtreatingpatientswithsuicidalbehaviors.PsychiatricAnnals,34(5), 373380. Joiner,T.E.Jr.,Walker,R.L.,Rudd,M.D.,&Jobes,D.A.(1999).Scientizingandroutinizingtheassessment ofsuicidalityinoutpatientpractice.ProfessionalPsychology:Research&Practice,30(5),447453. Shea,S.(2002).Puttingitalltogether:Safeandeffectivedecisionmaking.InThePracticalArtofSuicide Assessment:AGuideforMentalHealthProfessionalsandSubstanceAbuseCounselors.(pp.191247). Hoboken,NJ:JohnWiley&Sons.

TreatmentandServicesPlanning

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Baldessarini,R.J.,Tondo,L.,&Hennen,J.(1999).Effectsoflithiumtreatmentanditsdiscontinuationon suicidalbehaviorinbipolarmanicdepressivedisorders.JournalofClinicalPsychiatry,60(Suppl.2),7784. Berman,A.L.,Jobes,D.A,&Silverman,M.M.(2005).AdolescentSuicide:AssessmentandIntervention (2nded.).Washington,D.C.:AmericanPsychologicalAssociation. Brown,G.K.,TenHave,T.,Henriques,G.R.,Xie,S.X.,Hollander,J.E.,&Beck,A.T.(2005).Cognitive therapyforthepreventionofsuicideattempts:Arandomizedcontrolledtrial.JournaloftheAmerican MedicalAssociation,294(5),p.563570.Abstractat: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16 077050&query_hl=1 Ellis,T.E.(2001).Psychotherapywithsuicidalpatients.InD.Lester(Ed.).SuicidePrevention:Resourcesfor theMillennium.(pp.129152).AnnArbor,MI:SheridanBooks. Guthrie,E.,Kapur,N.,MackwayJones,K.,ChewGraham,C.,Moorey,J.,Mendel,E.,etal.(2001). Randomisedcontrolledtrialofbriefpsychologicalinterventionafterdeliberateselfpoisoning.BMJ, 323(7305),135138. Jacobs,D.G.(Ed.).(1999).Appendix:Guidelinesforidentification,assessment,andtreatmentplanningfor suicidality.InTheHarvardMedicalSchoolGuidetoSuicideAssessmentandIntervention.(pp.579582). SanFrancisco,CA:JosseyBass. Jobes,D.A.,Wong,S.A.,Conrad,A.,Drozd,J.F.,&NealWalden,T.(2005).TheCollaborativeassessment andmanagementofsuicidalityvs.treatmentasusual:Aretrospectivestudywithsuicidaloutpatients. SuicideandLifeThreateningBehavior,35,483497. LinehanMM,ComtoisKA,MurrayAM,BrownMZ,GallopRJ,etal.(2006).Twoyearrandomized controlledtrialandfollowupofdialecticalbehaviortherapyvstherapybyexpertsforsuicidalbehaviors andborderlinepersonalitydisorder.ArchivesofGeneralPsychiatry,63(7),p.757766.Abstractat http://archpsyc.amaassn.org/cgi/content/abstract/63/7/757 Litts,D.A.,Radke,A.Q.,Silverman,M.M.(Eds.).(2008).SuicidePreventionEffortsforIndividualswith SeriousMentalIllness:RolesfortheStateMentalHealthAuthority.Washington,D.C.National AssociationofStateMentalHealthProgramDirectors/ SuicidePreventionResourceCenter.(http://www.sprc.org/library/SeriousMI.pdf) Meltzer,H.Y.(1999).Suicideandschizophrenia:ClozapineandtheInterSePTstudy.International Clozaril/LeponexSuicidePreventionTrial.JournalofClinicalPsychiatry,60(Suppl.12),4750. Meltzer,H.Y.,Alphs,L.,Altamura,C.,Kerwin,R.,Chouinard,G.,Green,A.,etal.(2001).Effectofclozapine onthereductionofsuicidalityinschizophreniaandschizoaffectivedisorder.Paperpresentedatthe AmericanCollegeofNeoropsychopharmacologyAnnualMeeting,Kona,Hawaii. Motto,J.A.,&Bostrom,A.G.(2001).Arandomizedcontrolledtrialofpostcrisissuicideprevention. PsychiatricServices,52(6),828833. Neimeyer,R.,Maltsberger,J.,&Leenaars,A.(1994).TreatmentofSuicidalPeople.NewYork,NY:Brunner Routledge,Inc.

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Simon,R.I.(2004).Collaborativetreatment.InAssessingandManagingSuicideRisk:Guidelinesfor ClinicallyBasedRiskManagement.(pp.105124).Washington,D.C.AmericanPsychiatricPublishing,Inc.

ManagementofCare Chiles,J.A.,&Strosahl,K.D.(1995).Chapter7:CrisisandCaseManagementwithRecurrentSuicidal Behavior.IntheSuicidalPatient:PrinciplesofAssessment,Treatment,andCaseManagement. Washington,D.C.:AmericanPsychiatricPress,Inc. Jobes,D.A.(2006).ManagingSuicidalRisk:ACollaborativeApproach.NewYork:TheGuilfordPress.

Documentation Bongar,B.,Maris,R.W.,Berman,A.L.,&Litman,R.E.(1998).Chapter1:OutpatientStandardsofCare andtheSuicidalPatient.InB.Bongar,A.L.Berman,R.W.Maris,M.M.Silverman,E.Haris,&W.L. Packman(Eds.).RiskManagementwithSuicidalPatients.(pp.433).NewYork,NY:TheGuilfordPress. Shea,S.(2002).AppendixA:Howtodocumentasuicideassessment.InThePracticalArtofSuicide Assessment:AGuideforMentalHealthProfessionalsandSubstanceAbuseCounselors.(pp.249285). Hoboken,NJ:JohnWiley&Sons.

LegalandRegulatoryIssues Bongar,B.(2002).LegalPerspectives.InTheSuicidalPatient:ClinicalandLegalStandardsofCare(2nded., pp.3980).Washington,D.C.:AmericanPsychologicalAssociation. Simon,R.I.(2004).AssessingandManagingSuicideRisk:GuidelinesforClinicallyBasedRiskManagement. Washington,D.C.:AmericanPsychiatricPublishing,Inc. Werth,JL.(2001).U.S.involuntarymentalhealthcommitmentstatutes:requirementsforpersons perceivedtobeapotentialharmtoself.SuicideandLifeThreateningBehavior,31(3),348357.Abstract at:http://www.ncbi.nlm.nih.gov/pubmed/11577919 SummaryofStateStatutesonInvoluntaryOutpatientCommitmentBazelonCenterforMentalHealth Law,June2004http://www.bazelon.org/issues/commitment/moreresources/iocchart.html

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ResourceSheet#5 SectionI:ClinicallyRelevantRiskandProtectiveFactors
Thissectionidentifiestheriskandprotectivefactorsthataremostsalientfortheclinicalassessmentandmanagement ofsuiciderisk.

RiskFactors:
Riskfactorsaretraits,attributes,characteristics,orothervariablesthatareassociatedwithsuicideorsuicidal behaviors.Thepresenceofriskfactorsisassociatedwithanincreasedriskforsuicideorsuicidalbehaviors.

Suicidality
Previoussuicideattempt
Multipleattempts=higherrisk Especiallywithintent,evidencedbyspecificplans andpreparatorybehaviors

MentalHealth
Mentaldisorders
Mooddisorder:depressiveorbipolardisorder Psychoticdisorder:schizophrenia Alcohol/drugabuse/dependence ClusterBpersonalitydisorder(antisocial/borderline) Conductdisorder Bulimia/anorexia Anxietydisorder/PTSD Impairedmentalstatus,particularlythoughtdisorder Psychicpain:hurt,anguish,misery.Notethisisnotstressor physicalpain Perceivedburdensomeness Stress:generalfeelingofbeingpressuredoroverwhelmed Agitation:emotionalurgency;feelingthatyouneedtotake action;notirritation;notannoyance Hopelessness:expectationthatthingswillnotgetbetterno matterwhatyoudo Selfhate:generalfeelingofdislikingyourself;noself esteem;noselfrespect Depressedmood Anxiety/panic Anger Anhedonia Impulsivity Poorrealitytesting Sleepdisturbances Commandhallucinations Intoxication Aggressivetendenciesorhistoryofviolentbehavior Recklessness Dischargefrompsychiatrichospitalization Changeintherapist Changeintreatmentapproach/medication

Suicideideationorbehaviors

Contextual/Interpersonal
Socialisolation Exposuretosuicidalbehavior
Mediaexposure Localclusters(e.g.,school) Historyofphysicalorsexualabuse Familyhistoryofmentaldisorder,drugabuse, suicide Chaoticfamilyhistory(e.g.,separationordivorce, changeincaretaker,changeinlivingsituationor residence)

Mentalstatus/stateofmind/behavior

Developmental/familyhistory

Victimofbullying Discriminationrelatedtobeinglesbian,gay, bisexual,transgender(adolescentsuicidal behavior) Accessto,orfamiliaritywith,lethalmeans

Firearms Medications

Stressors/Precipitants
Triggeringeventsleadingtoshame,humiliation, ordespair
Foryouth:lossofrelationship,legal/disciplinary problems/incarceration,conflict Foradults:lossofrelationship,financialorhealth statusrealoranticipated;legalordisciplinary problems/incarceration;unemployment Pain Centralnervoussystemdisorders,including traumaticbraininjury

Changeintreatment

Severephysicalillness,impairment,orpain

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ProtectiveFactors:
Protectivefactorsaretraits,attributes,characteristics,orothervariablesthatareassociatedwithlessenedriskfor suicideorsuicidalbehaviorsacrossthelifespan. Clinicalcare
Effectivecareformental,physical,andsubstanceabusedisorders Positivetherapeuticrelationships Easyaccesstoavarietyofclinicalinterventionsandsupportforhelpseekingindividuals

Family&communitysupport
Strongconnectionstofamilyandcommunitysupport Responsibilitytochildrenandbelovedpets Supportthroughongoingmedicalandmentalhealthrelationships

Resilience Copingskills Frustrationtoleranceandemotionregulation Culturalandreligiousbeliefsthataffirmlifeanddiscouragesuicide

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ResourceSheet#5 SectionII:OtherRiskFactors
Thissectionprovidesamoreglobaloverviewofsuicideriskfactors,endingwithtwoexercisestobecompletedbefore thestartoftheworkshop.Thediscussionofmoreclinicallysalientfactorsismuchmoregeneralthanthechartin SectionIabove.

Overviewofepidemiology
Everyyearapproximately30,000peoplediebysuicideintheUnitedStates.Approximately650,000peopleyearlyreceive emergencytreatmentafterattemptingsuicide.ItisthethirdleadingcauseofdeathamongAmericanyouthsandthe eleventhforAmericansofallages. Overthelast100yearssuicideshaveoutnumberedhomicidesbyatleast3to2. Theratesofsuicideareexceptionallyhighamongcertainpopulationsandtheratesamongworkingagedadultsarerising. Inalmostallindustrializedcountries,men75yearsofageandolderhavethehighestsuiciderateamongallagegroups.In theU.S.,thisdistinctionistrueonlyforWhitemales.TherateofsuicideamongAmericanIndiansandAlaskaNatives (AI/AN)oftheUnitedStatesisabout1.7timestherateofthenationasawhole;youthsuicideratesarehighestforthis racialgroup.Suicideratesforjailinmatesare9timesgreaterthanthatofthegeneralpopulationand15timeshigherfor menalone.Younghomosexualorbisexualmalesareatgreaterriskthanheterosexualsforsuicideattempts,butfindings arelessclearregardingsuicidecompletion. Over90percentofsuicidesintheUnitedStatesareassociatedwithmentalillnessand/oralcoholandsubstanceabuse. Yetisimportanttorememberthatasmanyas10percentofpeoplewhocompletesuicidedonothaveanyknown psychiatricdiagnosis.Thispercentageappearshigherinsomepopulations,especiallyyoungerteens. Psychological,biological,socialandculturalfactorsallhaveasignificantimpactontheriskofsuicide.Whileriskfactors areoftendiscussedindividually,theneedforanintegratedunderstandingismostimportant.

Psychologicalfactors
Psychiatricdisorder Thevastmajorityofindividuals(over90%)whodiebysuicidesufferfromdiagnosablepsychiatricdisorders.Almostall psychiatricdisorders,includingalcoholandsubstancedisordersareassociatedwithanincreasedriskofsuicide. Suicidemostcommonlyisassociatedwithadiagnosisofdepression.Recentresearchhasincreasinglyestablishedanxiety disordersandborderlinepersonalitydisorderassignificantlyelevatingsuiciderisk.Comorbidityofpsychiatricdisorders and/orsubstanceabusefurtherincreasessuiciderisk.About90percentofsuicidesareassociatedwithmentalillness,but over95percentofthoseafflictedneverevenattemptsuicide. Alcoholabuse AboutonefourthofallcompletedsuicidesintheU.S.areindividualswithalcoholusedisorders.Alcoholintoxicationis indicatedinasmanyas64percentofsuicideattempts.Alcoholorsubstanceusedisorder,conductdisorder,and impulsivity/sensationseekingoftencooccurandrepresentparticularsuicideriskforyouth. Hopelessness Hopelessnessisrelatedtosuicidalityacrossage,diagnoses,andseverityofdisorder.Hopelessnessisacritical,modifiable riskfactorforreducingsuicide.Effectivetreatmentsexistforreducinghopelessness.

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Biologicalfactors
Dysregulationofthehypothalamicpituitaryadrenal(HPA)axis DysregulationoftheHPAaxisappearsassociatedwithsuicidalityacrosspsychiatricdiagnoses.SuchHPAaxisdysfunction oftendevelopsfollowingadversedevelopmentalexperiencesandtraumaticorchronicstress. Reducedserotonergicandalterednoradrenergicfunction Lowlevelsofserotoninand/oritsmetabolitehavebeenfoundinthebrainsandcerebrospinalfluidofserioussuicide attemptersandthosewhocompletesuicide.Studiessuggestthatimpairedserotoninfunctionspecificallyinfluences suicidalityviaincreasedimpulsiveaggression. Geneticinfluences Studiesfindevidenceofgeneticinfluencesonsuicidalityviafamilialaggregationofsuicide,highsuicideratesamong adopteeswhosebiologicalfamilieshaveelevatedrates,andhighconcordanceofsuicideamongidenticalvs.fraternal twins.

Childhoodtrauma
Childhoodtrauma,especiallychildsexualabuse,hasemergedasastrongandindependentriskfactorforsuicidalbehavior inadolescentsandadults.Ofthemanytypesofchildhoodtrauma,childhoodsexualabuseisthestrongestandmost independentriskfactorforsuicideattempts,accountingfor9to20percentofsuicideattempts. Exposuretochildhoodtraumacanaffectthedevelopingbrainwithpotentiallylifelongalterationsinthephysiological stressresponsesystemandcognitivedevelopment(aswellaspsychologicalandbehavioraleffects).

SocialandCulturalFactors
Familialfactors Arelativewhohasattemptedorcompletedsuicidecanserveasabehavioralmodelforanotherfamilymember;orcan signalageneticorbiochemicalvulnerabilitytosuicide. Parentalpsychopathology(suchasdepression,substanceabuse,oradmissiontopsychiatrichospital)isassociatedwith increasedriskforsuicide. Familyhistoryofsexualabuseandfamilydiscordareassociatedwithincreasedriskforsuicide. Contagion Thecopycateffectisthetermusedtodescribethephenomenonofwhathappenswhenahighlypublicizedsuicidal actiondescribedindetailstimulatesotherstoengageinthesameorsimilarbehavior.Contagionunderliesclustersof suicide. Perceptionofsuicide Culturestronglyinfluenceshowindividualsviewsuicide.Culturalvaluesandsocialstructureslargelydeterminethetype anddegreeofbothstressorsandsupport,availabilityoflethalmeans,accesstotreatment,andsocialprescriptionsor proscriptionsconcerningsuicidalbehavior.Culturesvaryintheirstigmaagainstsuicide,mentalhealthtreatment,andin theinfrastructureformonitoringdeathbysuicide,renderingcrossculturalcomparisonsofsuicidalbehaviordifficult.

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RiskFactors:associatedwithanincreasedoccurrenceofsuicidalbehavior1

Sociocultural
Historyoffamilyviolence:childhoodtrauma Familyhistoryofalcoholism Socialisolation:loworlackofsocialsupportand senseofisolation Exposuretosuicidalbehavior:familyhistoryof suicide Exposuretosuicidethroughthemedia Stigmaassociatedwithhelpseekingbehavior Barrierstoaccessinghealthcare,especiallymental healthservicesandsubstanceabusetreatment Certainculturalandreligiousbeliefs(e.g.,suicideis anobleresolutionofapersonaldilemma) Societalbreakdown Bullying Beingbullied Familyconflicts

Environmental
Easyaccesstolethalweapons:accesstoafirearm Unemploymentorfinancialloss Relationalorsocialloss Localclustersofsuicidethathaveacontagious influence Frequentmobility

Demographics
Malegender(forcompletions) Femalegender(fornonfatalattempts) Olderage Whiterace NativeAmerican(youth)

ThelistofriskandprotectivefactorsisinadditiontothoselistedinSectionI.Itisneitheracompletelistnorprioritizedinanyorder.
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PreworkshopExercise
PartA:Refertothechartsaboveandcircleriskfactorsandunderlineprotectivefactorsdescribedinthe followingcasestudies
Penny Pennyis12yearsold.Hercocaineaddictedfatherwalkedoutwhenshewas5,onlyweeksafterherbrotherwasbornand diagnosedashavingcerebralpalsy,nevertobeseenagain.Asasingleparent,Pennysmotherwasoverwhelmedwiththe demandsofattendingtoherbrothersneeds;Pennyfrequentlywasthrustintoasurrogateparentroleinordertohelpher mothermerelycope.Occasionallybabysitterswerehiredtoalleviatehermothersstress.Onebabysitter,amiddleaged womanandafriendofthemother,hadateenagesonwho,wheneverhecould,sexuallyabusedPenny.Pennywassworn tosecrecylestsomemoreintolerablefateweretobefallherorherbrother. Pennywithdrewintoherself.Abrightstudentatfirst,herschoolperformancefalteredandshehaddifficultyconcentrating. Shecomplainedofdysmenorrhea.Sheincreasinglythrewtempertantrumsandwasoppositionaltowardhermotherand teachers.Moreoften,shesimplywouldavoidschool.Twice,unbeknownsttoanyone,shetriedadifferentkindof withdrawal,toyingwithsomeofhermotherssleepingpills,takingafewtotestouthowlongshewouldsleep, Threedayspriortoherarrivalintheemergencyroom,Pennywatchedatelevisionmovieaboutsexualabuseandthewalls cametumblingdown.Pennysrage,fear,andsenseofworthlessnesstearfullypouredouttohermother,alongwithher storyofabuse.Withhermothersdisbelief,therenowemergedinPennyapanicthatherabusersthreatsnowwouldbe enacted.Heranxietysimplyoverwhelmedher.Shefoundthe.22caliberhandgunhermotherhadhiddenintherearofher nightstandandpulledthetrigger. PR PRsfirsthospitaladmissionwasattheageof12.Diagnosedashavingamajordepression,hewasadmittedwithahistory ofschoolvandalismandstealing,eneuresis(12times/week),andmorbidobesity.Atadmissionheadmittedtoincreasing suicideideation.Hewashospitalizedfor7monthswithmajortreatmentfocibeinghisbodyimage,anxietyandanger management,andsocialwithdrawal. Hissecondhospitalizationoccurredattheageof17.Broughttothehospitalbyhismotherforepisodesofangryoutburst, paranoia(hefearedhewasbeingwatchedthroughholesintheirapartmentwall),selfcutting(xsonarmsinhonorof thosewhohadturnedagainsthim)andsymptomsofvisualhallucinations,hewasinvoluntarilyadmitted.Afterfourdays hewasdischargedwithanAxisIdiagnosis:Adjustmentdisorderwithmixeddisturbancesofemotionandconductandan AxisIIdiagnosis:BorderlinePersonalityDisorder. PRhadbeenunemployedforsixmonthsandhadgivenuplookingforwork.Hereportedlyranoutofmarijuanathreedays agoandsaidhewasgoingcrazy.Duringhishighschoolyearshereportedlydealtdrugsandwasdependenton amphetamines.HecurrentlywastakingDepakoteandZoloft.

PartB:HighlightriskandprotectivefactorsinPreworkshopReadingResourceSheet#6:ThePhenomenology ofSuicide:FirstPersonNarratives

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ResourceSheet#6:ThePhenomenologyofSuicide FirstPersonNarratives
Phenomenologyofsuicide,theexperienceofsuicidefromaclientsperspective
Developmentalhistory.Clientnarrativesandpsychologicalautopsystudiesrevealthatsuicidedoes nothaveasimplecause.Itistheculminationoflifeeventsandhasadevelopmentalhistory. Psychicpain.Thementalanguishcalledpsychicpainmaybeanoverarchingdescriptionofthe experiential/phenomenologicalstatethatleadsanindividualtoseekdeaththroughsuicideasan escape.

FromVoicesofSuicide:LearningfromThoseWhoLive
ADVDavailablefromTheGlendonAssociation(http://www.glendon.org/index.html) Kevin,talkingabouthissuicideattempt: September24,2000rollsaround.Idecidethisisit.TomorrowImgoingtoendmylife.Iwasreadyto go.Iwasjustgone.Itwasover.Iknewwhatwasgoingtohappen.Imgoingtogotothebridge.Im goingtojump.Itsjustthatsimple.Thatsit.Theresnoifs,ands,orbuts.Itsdone. IwentouttotheGoldenGateBridge.OnthebusIbegantocrysoftlyintheback.Thebuswaspacked.On thebusIbeganthinking:IfonepersoncomesuptomeandsaysAreyouOK?Illturnaround.Ifone personcomesuptomeandasksifanythingswrong,Iwilltellthemeverything. IgotoutattheparkinglotandIthought:Kevin,turnaround.Getonthebusagain.Goback.ThenIheard voices:Youmustdie.Youmustdie. SoIwalkedontothespan.Imusthavebeentherefortyminutes.Andonceagain,Ithought:Oneperson hastocomeuptomeandsay,AreyouOK?Oneperson.Anybody.AwomanwasapproachingmeandI thought:Oh,thankGod.ThankyouGod.Shehadsunglassesonandanaccent.Shecameupandshe said:Willyoutakemypicture?Itookherpictureaboutfivetimes.Isaid:Nobodycaresaftersheleft.I turnedaround,backeduptotherailingnexttotheroadway,ran,andcatapultedmyselfoverwithmy armsThesplitsecondIhitfreefall,Ithought:OhmyGod.Idontwanttodie.WhatdidIjustdo?Iwas wideawake.Thevoicesweregone.Iwasrighttherefacingultimatedeath. Kevintalkingabouthisrecovery: WhenIgotbetterinmylastcyclein2005,Ijuststarteddoingthelittlethings.Istartedbrushingmy teeth.IshavedmybeardthatIhadgrownthreeinches.Itookashowereveryday.Andallthosethings seemsmallbutIhadtostartatbabystepstogetbetter.Today,unlikeinthepast,whereIwasnt followingaroutine,unlikethepastwhereIusedtonottakemymedicationsomedaysandthentakeit otherdays,unlikethepastwhereIwouldtellmypsychiatristandtherapistliestogetthemtoleaveme

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alone,Imcompletelyhonestintherapyabouteverythingthatsbotheringme.Itakemymedicationdaily atthesametimeeveryday. Ivehadsymptoms,obviously,andthatsgoingtohappenprobablyfortherestofmylife,asIunderstand it.Ivehaddepressionsbutinsteadofthemlastingaweek,twoweeks,oramonth,theylastfifteen minutesorlessbecauseIactivelyworktogetoutofthedepression.So,whenIfeelthatcomingon,andI knowitsclinical,IlltellMarge,mywife,Hey,Imgoingtoneedsomeonetotalktorightnow.OrIllget up,andgetdressed,andgoonaruntoreleasesomeendorphinsintomybraintofeelbetter.AndifI becomemanic,thefirstpersontonoticeitisme,insteadofeveryonearoundme.Isitdownandkindof meditate,slowingdownmythoughts.

FromDarknessVisible
ByWilliamStyron,copyright1990byWilliamStyron.UsedbypermissionofRandomHouse,Inc. WhatIhadbeguntodiscoveristhat,mysteriouslyandinwaysthataretotallyremotefromnormal experience,thegraydrizzleofhorrorinducedbydepressiontakesonthequalityofphysicalpain.Butitis notanimmediatelyidentifiablepain,likethatofabrokenlimb.Itmaybemoreaccuratetosaythat despair,owingtosomeeviltrickplayeduponthesickbrainbytheinhabitingpsyche,comestoresemble thediabolicaldiscomfortofbeingimprisonedinafiercelyoverheatedroom.Andbecausenobreezestirs thiscaldron,becausethereisnoescapefromthissmotheringconfinement,itisentirelynaturalthatthe victimbeginstothinkceaselesslyofoblivion AndsoWilliamStryron,awardwinningwriter,describeshisexperiencewithdepressionultimatelyleading tosuicidalideationandbehavior.Thefollowingpassagesareexcerptedfromhisbookandtobeusedfor instructionalpurposesinthetrainingofmentalhealthprofessionalsworkingwithindividualsatriskfor suicide. InParisonachillyeveninglateinOctoberof1985,Ifirstbecamefullyawarethatthestrugglewiththe disorderinmymind,astrugglewhichhadengagedmeforseveralmonths,mighthaveafataloutcome. OnlydaysbeforeIhadconcludedthatIwassufferingfromaseriousdepressiveillness,andwas flounderinghelplessinmyeffortstodealwithit.AsIdrovepastHotelWashington,ahotelIhadnotseen innearly35yearsIrecalledmystaytheresomanyyearsbeforewhenIwrotemyfirstnovelandwasa youngcelebrity,causingmetofeelthatIhadcomefatallyfullcircle.IrecallsayingtomyselfthatwhenI leftParisforNewYorkthenextmorningitwouldbeamatterofforever.Iwasshakenbythecertainty withwhichIacceptedtheideathatIwouldneverseeFranceagain,justasIwouldneverrecapturea luciditythatwasslippingawayfrommewithterrifyingspeed. Ifthepainwerereadilydescribablemostofthecountlesssufferersfromthisancientafflictionwouldhave beenabletoconfidentlydepictfortheirfriendsandlovedones(eventheirphysicians)someoftheactual dimensionsoftheirtorment,andperhapselicitacomprehensionthathasbeengenerallylackingdueto thebasicinabilityofhealthypeopletoimagineaformoftormentsoalientoeverydayexperience.For myself,thepainismostcloselyconnectedtodrowningorsuffocation,buteventheseimagesareoffthe mark.

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Neverletitbedoubtedthatdepression,initsextremeform,ismadness.Themadnessresultsfroman aberrantbiochemicalprocess.Ithasbeenestablishedwithreasonablecertainty(afterstrongresistance frommanypsychiatrists,andnotallthatlongago)thatsuchmadnessischemicallyinducedamidthe neurotransmittersofthebrain,probablyastheresultofsystemicstress,whichcausesadepletionofthe chemicalsnorepinephrineandserotonin,andtheincreaseofahormone,cortical.Withallthisupheavalin thebraintissues,thealternatedrenchinganddeprivation,itisnowonderthatthemindbeginstofeel aggrieved,stricken,andthemuddiedthoughtprocessesregisterthedistressofanorganinconvulsion. Sometimes,thoughnotveryoften,suchadisturbedmindwillturntoviolentthoughtsregardingothers. Butwiththeirmindsturnedagonizinglyinward,peoplewithdepressionareusuallydangerousonlyto themselves. Loss,inallofitsmanifestationsisthetouchstoneofdepressionintheprogressofthediseaseand,most likely,initsorigin.AtalaterdateIwouldgraduallybepersuadedthatdevastatinglossinchildhood figuredasaprobablygenesisofmyowndisorder;meanwhile,asImonitoredmyretrogradecondition,I feltlossateveryhand.Lossofselfesteemisacelebratedsymptom,andmyownsenseofselfhadallbut disappeared,alongwithanyselfreliance.Thislosscanquicklydegenerateintodependence,andfrom dependenceintoinfantiledread.Onedreadsthelossofallthings,allpeoplecloseanddear.Thereisan acutefearofabandonment.Beingaloneinthehouse,evenforamoment,causedmeexquisitepanicand trepidation.Mylossesmountedandproliferated.Thereisnodoubtthatasonenearsthepenultimate depthsofdepression,whichistosayjustbeforethestagewhenonebeginstoactoutonessuicide insteadofbeingamerecontemplatorofitthatacutesenseoflossisconnectedwithaknowledgeoflife slippingawayatacceleratedspeed. Itishopelessnessevenmorethanpainthatcrushesthesoul.Sothedecisionmakingofdailylifeinvolves not,asinnormalaffairs,shiftingfromoneannoyingsituationtoanotherlessannoyingorfrom discomforttorelativecomfortforfromboredomtoactivitybutmovingfrompaintopain.With depression,youbecomethewalkingwounded.Thesuffererfromdepressionisthrustintothemost intolerablesocialandfamilysituationsandtherehemust,despitetheanguishdevouringhisbrain, presentapleasantface,trytouttersmalltalk,beresponsivetoquestions,andknowinglynodandfrown andGodhelphim,evensmile. AfterIhadreturnedtohealthandwasabletoreflectonthepast,Ibegantoseeclearlyhowdepression hadclungclosetotheouteredgesofmylifeforyears.Suicidehasbeenapersistentthemeinmybooks. Myfatherbattledthegorgonformuchofhislifetime,andhadbeenhospitalizedinmyboyhoodaftera despondentspiralingdownwardthatinretrospectIsawgreatlyresembledmine.ButImpersuadedthat anevenmoresignificantfactorwasthedeathofmymotherwhenIwasthirteen. Forthosewhohavedweltindepressionsdarkwood,andknownitsinexplicableagony,theirreturnfrom theabyssisnotunliketheascentofthepoet,trudgingupwardandoutofhellsblackdepthsandatlast emergingintowhathesawastheshiningworld.There,whoeverhasbeenrestoredtohealthhas almostalwaysbeenrestoredtothecapacityforserenityandjoy,andthismaybeindemnityenoughfor havingenduredthedespairbeyonddespair.

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FromWakingUp:ClimbingThroughtheDarkness
ByTerryL.Wise(www.TerryWise.com) Theseexcerptshavebeenreprintedwiththeconsentofthepublisher,PathfinderPublishing,Inc.,120 SouthHoughtonRoad,Tucson,Arizona85648,andaretobeusedforinstructionalpurposesinthetraining ofmentalhealthprofessionalsworkingwithindividualsatriskforsuicide. TerryWisestruestorytoldinnarrativeformisofloveandpainandincludesherdialoguewithatherapist whowaswillingtostickwithherandhelpputherbrokenhearttogetheragain.Terrytriedtokillherselfbut survived. Thefollowingpassagesareexcerptedfromherbook. March2000 Ivehadunbelievableanxietyforweeks,Iadmitted...Ivetriedtokeepthingsundercontrol.Ihate havinganxietyattacksandtalkingabouthowtheyfeelonlyexacerbatestheangst,Iexplained,already feelingtheresurgenceofpalpitationsinmychest. Anxietyandloneliness.EvenwhenImwithpeople,Ifeelalone...ExceptfortheyearsKurtwashealthy, Iveprobablyfeltlikethismostofmylife. Ifinallydecidedtobravemymostprivate,definingcharacterflaw.Itshardtotellyou...ThetruthisthatI amaloser. TheyseetheimageIvecreatedthatImmorepopularandgroundedthanIreallyam...Ireallyfeelthat Iwasbornwithsomethinginsideofmethatmakesmealoser. IthinkIfirstnoticeditsomewherearound10yearsold. Iminnatelyamalcontent.Igetboredoruninterestedinthingssoquickly.Itsreallyhardformetofind anythingoranyonethatIenjoyforanylengthoftime...Ivespentamajorityofmylifeboredand unhappy...Ivealwaysfeltlikedyingwasbetterthanliving. Icantrememberexactlywhenitbeganbut,Idistinctlyrememberbeinginthefourthgrade,walking acrosstheschoolfield,scuffingmyheelsthroughthegrass,thinkinghowIcouldntwaituntilthiswas overlife,thatis. December2000 IclosedthebookIhadstudiedonassistedsuicideandpouredwhatremainedofthemorphineintoa glass,wonderingifIcouldspeedilygulpdownthethicksyrupasinstructed. Ibegananothercount:60dosesofmorphine,200Percosets,andalargeglassofgin.Aplasticbaglaynext tomypillow...Whatwasthecorrectamount?Whatwastoomuch?Toolittle?ShouldIusetheplastic bag?...Intheeventofadrugmiscalculation,sealingitovermyheadbeforeIwentunconsciouswould ensuresuffocation.Itwasa100percentsuretythatIwouldneveragainopenmyeyes.ButhowcouldI mercilesslyallowmyfamilytodiscovermeinascenemorefittingforahorrormovie?Thehideoussight ofmylifelessface,shrinkwrappedinsideaplasticbag,wouldbeapermanentimagereplayedintheir
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mindsforever...Ultimately,bynotfactoringinthebag,Idecidedtotakethe10%chancethatanoverdose wouldfail. ThiswasnotthefirsttimeIhadgonethroughtheprocessionoflayingoutthenecessaryaccoutrements. However,thiswasthefirsttimeIhadmeticulouslycoveredeverylastdetail.Iputmymailonhold, cleanedouttherefrigeratorandtidieduptheclosets.Iprepaidallofmybillsandmadesurethedonot resuscitatedirectivesofmyhealthcareproxycouldbeeasilylocated.IworetheconsolingfabricofKurts jeansandhisfavoritetshirtthatIhadsaved...Ihadbecomereclusiveenoughsincethefuneraltocover myabsencewithobscurereferencesthatIwasgoingoutoftownforafewdays.Myneedtogetaway fromthedifficultatmosphereoftheholidayseasonwasunderstandable.Everyonewouldbetoo distractedbytheirownholidayengagementstogiveasecondthoughttomywhereabouts. ...Hourspassed...Itsstrangetolookbackonwhatwasgoingthroughmymind...Mythoughts,whichwere ordinarilytooactiveformetobear,vacillatedbetweenhostinganunfamiliarblanknessandracingwith unrelentingconcerns.Itwasanadrenalinerushofclarityandcatatoniainoneaninexplicable combinationofemotionlessfear. Iwaspreoccupiedwiththeminutiae.Myfocuswaslargelyonlogisticsandminimizingthe aftermath...ShouldIdrinktheentirejugofmorphineandskipthePercosets?ShouldIcrushthepillsor justleavethemintabletform?ShouldIjustgoaheadandtakeeverything,despitetheriskofvomitingthe fataldose?...IfIwasdoomedtowakeup,whatkindofbraindamagewouldIsustain?...Rivalingasoneof mymostacutefearswastheterrorofwakingupinrestraints,confinedtoapsychiatricward.WouldIlose myfreedomandindependence? ...Istruggledwiththeobsessivecycleofconcernsabouttheimpactonothers. WhowouldnoticeIwasnotheardfromindays?...WhatwouldIhavedonetothemoncetheycaughtthe indelible,firstglimpseofmymotionlessfeet?Shamefully,Iadmitthatintheend,myinclinationto prioritizethefeelingsofothersmeantshittome.Allthatreallymatteredwastofinishthejoband overcomemyfearthatIwouldwakeupandlivetobeheldaccountableformyactions. ...However,afterlivinginthehellofovertwodecadesofexhaustivecontemplation,forthefirsttimein mylife,Istoodonthethresholdofdeathsdoorwiththenumbnessofafirmresolve...ThefinalthingI recallwasswallowingthelastfistfulofPercosets.Ididnotmakeasuicideattempt.Ikilledmyself.

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