THE SUICIDAL CLIENT

Introduction: Suicide is not a diagnosis or a disorder; it is a behavior. Suicide (Latin suicidium,

from sui caedere, "to kill oneself") is the act of a human being intentionally causing his or her
own death. Suicide is often committed out of despair, or attributed to some underlying mental
disorder which includes depression, bipolar disorder, schizophrenia, alcoholism and drug
abuse.Financial difficulties, interpersonal relationships and other undesirable situations play a
significant role.

The Judeo- Christian belief has been that life is a gift from god and that taking it is a gift from
God and that taking it is strictly forbidden (Carroll- Ghosh, Victor, & Bourgeois, 2003). A
recent, and more secular, view has influenced how some individuals view suicide in our society.
Growing support for an individual’s right to choose death over pain has been evidenced. Some
individuals are striving to advance the cause of physician- assisted suicides for the terminally ill.
Approximately 95 percent of all persons who commit or attempt suicide have a diagnosed mental
disorder (Sadock & Sadock, 2003).
Definition of Suicide: According to Durkheim, suicide refers to “every case of death resulting
directly or indirectly from a positive or negative death performed by the victim himself and
which strives to produce this result.”
Epidemiological Factors: Approximately 30,000 persons in the United States end their lives
each year by suicide. These statistics have established suicide as the third leading cause of death
(behind accidents and homicide) among young Americans ages 15 to 24 years, the fifth leading
cause of death for ages 25 to 44, and the eighth leading cause of death for individuals age 45 to
64 (National Center for Health Statistics, 2004). Many more people attempt suicide than succeed,
and countless others seriously contemplate the act without carrying it out. Suicide has become a
major health care problem in the United States today.

Risk Factors:
Marital Status: The suicide rate for single persons is twice that of married persons, Divorced,
separated, or widowed persons have rates four to five times greater than those of the married
(Tondo and Baldessarini, 2001).
Gender: Women attempt suicide more, but men succeed more often. Successful suicides number
about 70 percent for men and 30 percent for women tend to overdose; men use more lethal
means such as firearms. In the United States, from 1070 to 2002, annual suicide rates per
100,000 rose from 16.8 to 17.9 in men, but decreased from 6.6 to 4.3 in women (National Center
for Health Statistics, 2004).
Age: Suicide risk and age are positively correlated. This is particularly true with men. Although
rates among women remain fairly constant throughout life, rates among men show a higher age
correlation. The rates rise sharply during adolescence, peak between 40 and 50, and levels off
until age 65, when it rises again for the remaining years (National Center for Health Statistics,
2004).
 The suicide rate among young people ages 15 to 19 peaked in 1990 at 11.1 per 100,000 and
declined to 7.4 per 100,000 in 2002 (National Center for Health Statistics, 2004). Several factors
put adolescents at risk for suicide, including impulsive and high-risk behaviors, untreated mood
disorders (e.g., firearms), and substance abuse. The use of firearms, which accounts for about 49
percent of cases, is the most common method of completed suicide in children and adolescents
Religion: Historically, suicide rates among Roman Catholic populations have been lower thn
rates among Protestants and Jews (Sadock & Sadock, 2003). In a recent study published in the
American Journal of Psychiatry, depressed men and women who consider themselves affiliated
with a religion are less likely to attempt suicide than their non- religious counterparts (Dervic et
al., 2004).
Socioeconomic status: Individuals in the very highest and lowest social classes have higher
suicide rates than those in the middle classes (Sadock & Sadock, 2003). With regard to
occupation, suicide rates are higher among physicians, musicians, dentists, law enforcement
officers, lawyers, and insurance agents.
Ethnicity: With regard to ethnicity, most studies demonstrate that whites are at highest risk for
suicide, followed by Native Americans, African Americans, Hispanic Americans, and Asian
Americans (Caroll-Ghosh, Victor, & Burgeois, 2003).
Other Risk Factors: Individuals with mood disorders (major depression and bipolar disorder) are
far more likely to commit suicide than those in any other psychiatric or medical risk group.
Sadock & Sadock (2003) report, “Almost 95 percent of all people who commit or attempt suicide
have a diagnosed mental disorder. Depressive disorders account for 80 percent of this figure.”
Other psychiatric disorders that may account for suicidal behavior include psychoactive
substance abuse disorders, schizophrenia, personality disorders, and anxiety disorders (Tondo &
Baldessarini, 2001).
Theories of Suicide

1. Psychological Theories:
Anger Turned Inward. Freud (1957) believed that suicide was a response to the intense
self- hatred that an individual possessed. The anger had originated toward a love object but
was ultimately turned inward against the self. Freud believed that suicide occurred as a result
of an earlier repressed desire to kill someone else. He interpreted suicide to be an aggressive
act toward the self that often was really directed toward others.
Hopelessness. Carol- Ghosh, Victor, And Bourgeois (2003) identify hopelessness as a
central underlying factor in the predisposition to suicide. Beck and associates (1990) also
found a high correlation between hopelessness and suicide.
Desperation and Guilt. Hendin (1991) identified desperation, as another important factor in
suicide. With desperation, an individual feels helpless to change, but he or she also feels that
life is impossible without such change. Guilt and self-recrimination are other aspects of
desperation.
 History of Aggression and Violence. Some studies have indicated that violent behavior
often goes hand – in –hand with suicidal behavior (Caroll- Ghosh, Victor, & Bourgeois,
2003). These studies correlate the suicidal behavior in violent individuals to conscious rage,
therefore citing rage as an important psychological factor underlying the suicidal behavior
(Hendin,1991).
Shame and Humiliation. Some individuals have viewed suicide as a “face-saving”
mechanism- a way to prevent public humiliation following a social defeat such as a sudden
loss of status or income. Often these individuals are too embarrassed to seek treatment or
other support systems.
Developmental Stressors. Rich, Warsadt, and Nemiroff (1991) have associated
developmental level with certain life stressors and their correlation to suicide. The stressors
of conflict, separation, and rejection are associated with suicidal behavior in adolescence and
early adulthood. The principal stressor associated with suicidal behavior in the 40 to 60 year
old group is economic problems. Medical illness plays an increasingly significant role after
age 60 and becomes the leading predisposing factor to suicidal behavior in individuals older
than age 80.
Sociological Theory:
Durkheim (1951) studied the individual’s interaction with the society in which he or she
lived. He believed that the more cohesive the society, and the more that the individual felt an
integrated part of the society; the less likely he or she was to commit suicide. Durkheim
described three categories of suicide:
Egoistic suicide is the response of the individual who feels separate and apart from the
mainstream of society. Integration is lacking and the individual does not feel a part of any
cohesive group (such as a family or a church).
Altruistic suicide is the opposite of egoistic suicide. The individual who is prone to altruistic
suicide is excessively integrated into the group. The group is often governed by cultural,
religious, or political ties, and allegiance is so strong that the individual will sacrifice his or
her life for the group.
Anomic suicide occurs in response to changes that occur in an individual’s life (e.g., divorce,
loss of job) that disrupt feelings of relatedness to the group. An interruption in the customary
norms of behavior instills feelings of “separateness,” and fears of being without support from
the formerly cohesive group.
Biological Theories:
Genetics. Twin studies have shown a much higher concordance rate for monozygotic twins
than for tryptophan hydroxylase, with results indicating significant association to suicidality
(Abbar et al., 2001). These results suggest a possible existence of genetic predisposition
toward suicidal behavior.
Neurochemical Factors. A number of studies have been conducted to determine if there is a
correlation between neurochemical functioning in the central nervous system (CNS) and
 suicidal behavior. Some studies have revealed a deficiency of serotonin (measured as a
decrease in the levels of 5- hydroxyindole acetic acid of the cerebrospinal fluid) in depressed
clients who attempted suicide (Sadock & Sadock, 2003). Some changes in the noradrenergic
system of suicide victims have also been reported.

Classification of suicide

Self-harm

Self-harm is not a suicide attempt; however, initially self-harm was erroneously classified as a
suicide attempt. There is a non-causal correlation between self-harm and suicide; both are most
commonly a joint effect of depression.

Euthanasia and assisted suicide

Euthanasia machine invented by Dr. Philip Nitschke, on display at Science Museum, London.

Individuals who wish to end their own lives may enlist the assistance of another person to
achieve death. The other person, usually a family member or physician, may help carry out the
act if the individual lacks the physical capacity to do so even with the supplied means. Assisted
suicide is a contentious moral and political issue in many countries, as seen in the scandal
surrounding Dr. Jack Kevorkian, a medical practitioner who supported euthanasia, was found to
have helped patients end their own lives, and was sentenced to prison time.

Murder–suicide

A murder–suicide is an act in which an individual kills one or more other persons immediately
before or at the same time as him or herself.

The motivation for the murder in murder–suicide can be purely criminal in nature or be
perceived by the perpetrator as an act of care for loved ones in the context of severe depression.

Suicide attack

A suicide attack is when an attacker perpetrates an act of violence against others, typically to
achieve a military or political goal, that results in his or her own death as well. Suicide bombings
are often regarded as an act of terrorism. Historical examples include the assassination of Czar
Alexander II and the in-part successful kamikaze attacks by Japanese air pilots during the Second
World War.

Mass suicide

Some suicides are done under peer pressure or as a group. Mass suicides can take place with as
few as two people, in a "suicide pact", or with a larger number of people. An example is the mass
suicide that took place by members of the Peoples Temple, an American cult led by Jim Jones in
Guyana in 1978.
Suicide pact

A suicide pact describes the suicides of two or more individuals in an agreed-upon plan. The
plan may be to die together, or separately and closely timed. Suicide pacts are generally distinct
from mass suicide. The latter refers to incidents in which a larger number of people kill
themselves together for the same ideological reason, often within a religious, political, military
or paramilitary context. Suicide pacts, on the other hand, usually involve small groups of people
(such as married or romantic partners, family members, or friends) whose motivations are
intensely personal and individual.

Metaphorical suicide

The metaphorical sense of "willful destruction of one's self-interest", for example political
suicide.

Causes

A number of factors are associated with the risk of suicide including: mental illness, drug
addiction, and socio-economic factors. While external circumstances, such as a traumatic event,
may trigger suicide it does not seem to be an independent cause. Thus suicides are more likely to
occur during periods of socioeconomic, family and individual crisis.

Mental illness

Mental disorders are frequently present at the time of suicide with estimates from 87%to 98%
When broken down into type mood disorders are present in 30%, substance abuse in 18%,
schizophrenia in 14%, and personality disorders in 13.0% of suicides. About 5% of people with
schizophrenia die of suicide. Depression, one of the most commonly diagnosed psychiatric
disorders is being diagnosed in increasing numbers in various segments of the population
worldwide, and is often a precipitating factor in suicide. Depression in the United States alone
affects 17.6 million Americans each year or 1 in 6 people. Within the next twenty years
depression is expected to become the second leading cause of disability worldwide and the
leading cause in high-income nations, including the United States.

In approximately 75% of completed suicides the individuals had seen a physician within the
prior year before their death, 45%-66% within the prior month. Approximately 33% - 41% of
those who completed suicide had contact with mental health services in the prior year, 20%
within the prior month.

Substance abuse

Substance abuse is the second most common cause of suicide after mood disorders. Both chronic
substance misuse as well as acute substance abuse is associated with an increased risk of suicide.
This is attributed to the intoxicating and disinhibiting effects of many psychoactive substances;
when combined with personal grief such as bereavement the risk of suicide is greatly increased.
More than 50% of suicides are related to alcohol or drug use. Up to 25% of drug addicts and
alcoholics commit suicide. In adolescents the figure is higher with alcohol or drug misuse
playing a role in up to 70% of suicides. It has been recommended that all drug addicts or
alcoholics are investigated for suicidal thoughts due to the high risk of suicide.

Misuse of drugs such as cocaine have a high correlation with suicide. Suicide is most likely to
occur during the "crash" or withdrawal phase of cocaine in chronic abusers. Polysubstance
misuse has been found to more often result in suicide in younger adults whereas suicide from
alcoholism is more common in older adults. In San Diego it was found that 30% of suicides in
people under the age of 30 had used cocaine. In New York City during a crack epidemic one in
five people who committed suicide were found to have recently consumed cocaine. The "come
down" or withdrawal phase from cocaine can result in intense depressive symptoms coupled with
other distressing mental effects which serve to increase the risk of suicide. It has been found that
drinking 6 drinks or more per day results in a sixfold increased risk of suicide.

Alcohol misuse is associated with a number of mental health disorders, and alcoholics have a
very high suicide rate. High rates of major depressive disorder occur in heavy drinkers and those
who abuse alcohol. Controversy has previously surrounded whether those who abused alcohol
who developed major depressive disorder were self medicating (which may be true in some
cases) but recent research has now concluded that chronic excessive alcohol intake itself directly
causes the development of major depressive disorder in a significant number of alcohol abusers.

Cigarette smoking

There have been various studies done showing a positive link between smoking, suicidal ideation
and suicide attempts. In a study conducted among nurses, those smoking between 1-24 cigarettes
per day had twice the suicide risk; 25 cigarettes or more, 4 times the suicide risk, than those who
had never smokedIn a study of 300,000 male U.S. Army soldiers, a definitive link between
suicide and smoking was observed with those smoking over a pack a day having twice the
suicide rate of non-smokers.

Problem gambling

Problem gambling is often associated with increased suicidal ideation and attempts compared to
the general population.

Early onset of problem gambling increases the lifetime risk of suicide.[48] However, gambling-
related suicide attempts are usually made by older people with problem gambling.[49] Both
comorbid substance use and comorbid mental disorders increase the risk of suicide in people
with problem gamblingA 2010 Australian hospital study found that 17% of suicidal patients
admitted to the Alfred Hospital's emergency department was a problem gambler.

Biological

Genetics has an effect on suicide risk accounting for 30–50% of the variance Much of this
relationship acts through the heritability of mental illness
Judicial suicide

A person who has committed a crime may commit suicide to avoid prosecution and disgrace,
such as in murder–suicides. Nazi leader Hermann Göring, a high-ranked Nazi and head of the
Luftwaffe, committed suicide with cyanide capsules rather than be hanged after his conviction at
the Nuremberg Trials. Some school shootings, including the Virginia Tech massacre, concluded
with the perpetrator committing suicide.

Suicide as an escape

In situations where continuing to live is intolerable, some people use suicide as a means of
escape. Some inmates in Nazi concentration camps are known to have killed themselves by
delibertely touching the electrified fences.

According to a report by Tata Institute of Social Sciences in Mumbai, 150,000 debt-ridden

farmers in India have committed suicide in the past decade.

Other factors

Socio-economic factors such as unemployment, poverty, homelessness, and discrimination may

trigger suicidal thoughts. Poverty may not be a direct cause but it can increase the risk of suicide,
as it is a major risk group for depression. Advocacy of suicide has sometimes been cited as a
contributing factor.

Suicide Prevention

The view that suicide cannot be prevented is commonly held even among health professionals.
Many beliefs may explain this negative attitude. Chief among these is that suicide is a personal
matter that should be left for the individual to decide. Another belief is that suicide cannot be
prevented because its major determinants are social and environmental factors such as
unemployment over which an individual has relatively little control. However, for the
overwhelming majority who engage in suicidal behaviour, there is a probably an appropriate
alternative resolution of the precipitating problems. Suicide is often a permanent solution to a
temporary problem.

Mrazek and Haggerty's framework classified suicide prevention intervention as universal,

selective or indicated on the basis of how their target groups are defined. Universal interventions
target whole populations with the aim of favorably shifting proximal or distal risk factors across
the entire population. Selective interventions target subgroups whose members are not yet
manifesting suicidal behaviour but exhibit risk factors that predispose them to do so in the future.
Indicated interventions are designed for people already beginning to exhibit suicidal thoughts or
behaviour.

India grapples with infectious diseases, malnutrition, infant and maternal mortality and other
major health problems and hence, suicide is accorded low priority in the competition for meager
resources. The mental health services are inadequate for the needs of the country. For a
population of over a billion, there are only about 3,500 psychiatrists. Rapid urbanization,
industrialization and emerging family systems are resulting in social upheaval and distress. The
diminishing traditional support systems leave people vulnerable to suicidal behavior. Hence,
there is an emerging need for external emotional support. The enormity of the problem combined
with the paucity of mental health service has led to the emergence of NGOs in the field of
suicide prevention.

The primary aim of these NGOs is to provide support to suicidal individuals by befriending
them. Often these centers function as an entry point for those needing professional services.
Apart from befriending suicidal individuals, the NGOs have also undertaken education of
gatekeepers, raising awareness in the public and media and some intervention programmes.
However, there are certain limitations in the activities of the NGOs. There is a wide variability in
the expertise of their volunteers and in the services they provide. Quality control measures are
inadequate and the majority of their endeavors are not evaluated.

The World Health Organization's (WHO's) suicide prevention multisite intervention study on
suicidal behaviors (SUPRE-MISS), an intervention study, has revealed that it is possible to
reduce suicide mortality through brief, low-cost intervention in developing countries.

There is an urgent need to develop a national plan for suicide prevention in India. The priority
areas are reducing the availability of and access to pesticide, reducing alcohol availability and
consumption, promoting responsible media reporting of suicide and related issues, promoting
and supporting NGOs, improving the capacity of primary care workers and specialist mental
health services and providing support to those bereaved by suicide and training gatekeepers like
teachers, police officers and practitioners of alternative system of medicine and faith healers.
Above all, decriminalising attempted suicide is an urgent need if any suicide prevention strategy
is to succeed in the prevailing system in India.

10 th September - World Suicide Prevention Day: The World Suicide Prevention Day was
formally announced on 10 th September, 2003. Each year the International Association for
Suicide Prevention (IASP) in collaboration with WHO uses this day to call attention to suicide as
a leading cause of premature and preventable death. The theme for the year 2007 is " Suicide
Prevention-Across the Life Span". It calls attention to the fact that suicide occurs at all ages and
that suicide prevention and intervention strategies may be adapted to meet the needs of different
age groups. It is hoped that the theme will focus on vulnerable, ignored and stigmatized groups
and also draw together researchers, clinicians, societies, politicians, policy makers, volunteers
and survivors in a concerted action.

APPLICATION OF THE NURSING PROCESS WITH THE SUICIDAL CLIENT

Assessment:
The following items should be considered when conducting a suicidal assessment:
demographics, presenting symptoms/medical-psychiatric diagnosis, suicidal ideas or acts,
interpersonal support system, analysis of the suicidal crisis, psychiatric/medical/family
 history, and coping strategies. The Surgeon General, in his “Call to Action to Prevent
Suicide.” Speaks of risk factors and protective factors (U.S Public Health Services, 1999).
Risk factors are associated with a greater potential for suicide and suicidal behavior, whereas
protective factors are associated with reduced potential for suicide. These risk and protective
factors are given below in tables presents some additional guidelines for determining the
degree of suicide potential.

Suicide Risk Factors and Protective Factors

RISK FACTORS PROTECTIVE FACTORS

• Previous suicide attempt • Effective and appropriate clinical care
• Mental disorders-particularly mood for mental, physical, and substance abuse
disorders such as depression and bipolar disorders
disorder • Easy access to a variety of clinical
• Co-occurring mental and alcohol and interventions and support for help seeking
substance abuse disorders • Restricted access to highly lethal
• Family history of suicide methods of suicide
• Hopelessness • Family and community support
• Impulsive and/or aggressive tendencies • Support from ongoing medical and
• Barriers to accessing mental health mental health care relationships
treatment • Learned skills in problem solving,
• Relational, social, work, or financial loss conflict resolution, and nonviolent handling
• Physical illness of disputes
• Influence of significant people-family • Cultural and religious beliefs that
members, celebrities, peers who have died discourage suicide and support self-
by suicide- both through direct personal preservation instincts.
contact or inappropriate media
representations
• Cultural and religious beliefs-for instance,
the belief that suicide is a noble resolution
of a personal dilemma
• Isolation, a feeling of being cut off from
other people

Assessing the degree of Suicidal Risk:

INTENSITY OF RISK
BEHAVIOR LOW MODERATE HIGH
Anxiety Mild Moderate High or panic
Depression Mild Moderate Severe
Isolation,withdrawl Some feeling of Some feeling of Hopelessness,
isolation; no helplessness, helplessness,
withdrawal hopelessness, and withdrawn, and self-
withdrawal deprecating
Daily functioning Fairly good in most Moderately good in Not good in any
activities some activities activities
Resources Several Some Few or none
Coping strategies Generally Some that are Predominantly
being used constructive constructive destructive
significant others
Psychiatric help in None, or positive Yes, and moderately Negative view of
past attitude toward satisfied with results help received
Lifestyle Stable Moderately stable Unstable
Alcohol or drug use Infrequently to Frequently to excess Continual abuse
excess
Previous suicide None, or of low One or more of Multiple attempts of
attempts lethality moderate lethality high lethality
Disorientation; None Some Marked
disorganization
Hostility Little or none Some Marked
Suicidal plan Vague, fleeting Frequently thoughts, Frequent or constant
thoughts but no plan occasional ideas thought with a
about a plan specific plan

Demographics:
The following demographics are assessed:
Age. Suicide is highest in persons older than 50. Adolescents are also at high risk.
Gender. Males are at high risk than females.
Ethnicity. Caucasians are at higher risk than are Native Americans, who are at higher risk
than African Americans.
Marital status. Single, divorced, and widowed are at higher risk than married.
Socioeconomic Status. Individuals in the highest and lowest socioeconomic classes are
higher risk than those in the middle classes.
Occupation. Professional health care personnel and business executive are at highest risk.
Method. Use of firearms presents a significantly higher risk than overdose of substances.
Religion. Individuals who are not affiliated with any religious group are at higher risk than
those who have this type of affiliation.
Family History. Higher risk if individual has family history of suicide.
Presenting Symptoms/Medical- Psychiatric Diagnosis:
 Assessment data must be gathered regarding any psychiatric or physical condition for which
the client is being treated. Mood disorders (major depression and bipolar disorders) are the
most common disorders that precede suicide. Individuals with substance use disorders are
also at high risk. Other psychiatric disorders in which suicide may be a risk include anxiety
disorders, schizophrenia, and borderline and antisocial personality disorders (Tondo &
Baldessarini, 2001).
Suicidal Ideas or Acts: How serious is the intent? Does the person have a plan? If so, does
he or she have the means? How lethal are the means? Has the individual ever attempted
suicide before? These are all questions that must be answered by the person conducting the
suicidal assessment.
Individuals may leave both behavioral and verbal clues as to the intent of their act.
Examples of behavioral clues include giving away prized possessions, getting financial
affairs in order, writing suicide notes, or sudden lifts in mood.
Verbal clues may be both direct and indirect. Examples of direct statements include “I want
to die” or “I’m going to kill myself.” Examples of indirect statements include “This is the last
time you’ll see me,” “I won’t be around much longer for the doctor to have to worry about,”
or “I don’t have anything worth living for anyone.”
Interpersonal Support System:
Does the individual have support persons on whom he or she can rely during a crisis
situation? Lack of a meaningful network of satisfactory relationships may implicate an
individual at high risk for suicide during an emotional crisis.
Analysis of the Suicidal Crisis:
The precipitating Stressor. Adverse life events in combination with other risk factors such
as depression may lead to suicide (NIMH,2002). Life stresses accompanied by an increase in
emotional disturbance include the loss of a loved person either by death or by divorce,
problems in major relationships, changes in roles, or serious physical illness.
Relevant History. Has the individual experienced numerous failures or rejections that would
increase his or her vulnerability for a dysfunctional response to the current situation?
Life –Stage Issues. The ability to tolerate losses and disappointments is often compromised
if those losses an disappointments occur during various stages of life in which the individual
struggles with developmental issues (e.g., adolescence, midlife).
Psychiatric/Medical/Family History: The individual should be assessed with regard to
previous psychiatric treatment for depression, alcoholism, or for previous suicide attempts.
Medical history should be obtained to determine presence of chronic, debilitating, or terminal
illness. Is there a history of depressive disorder in the family, and has a close relative
committed suicide in the past?
Coping Strategies: How has the individual handled previous crisis situations? How does this
situation differ from previous ones?
 Diagnosis/ Outcome Identification
Nursing diagnoses for the suicidal client may include the following:
1. Risk for suicide related to feelings of hopelessness and desperation.
2. Hopelessness related to absence of support systems and perception of worthlessness.
The following criteria may be used for measurement of outcomes in the care of the suicidal
client.
The client:
1. Has experienced no physical harm to self.
2. Sets realistic goals for self.
3. Expresses some optimistic and hope for the future.
Planning/ Implementation:
Below table provides a plan of care for the hospitalized suicidal client.
CARE PLAN FOR THE SUICIDAL CLIENT:
Nursing diagnosis: Risk for Suicide
Related to: Feelings of hopelessness and description

Outcome Nursing Interventions Rationales

Criteria
Client will not 1. Ask client directly: “Have you 1. The risk of suicide is
harm self. plan to do? Do you have the means to greatly increased if the
carry out this plan?” client has developed a plan
and execute the plan.
2. Create a safe environment for the 2. Client safety is a
client. Remove all potentially harmful nursing priority.
objects from client’s access (sharp
objects, straps, belts, ties, glass items,
alcohol). Supervise closely during
meals and medication administration.

3. Formulate a short –term verbal 3. A degree of the

or written contract that the client will
not harm self. When time is up, make
another, and so forth. Secure a
promise that the client will seek out
staff when feeling suicidal.
responsibility for his or her
safety is given to the
client. Increased feelings
of self-worth may be
experienced when client
feels accepted
unconditionally regardless
 of thoughts or behavior.
4. Maintain close observation of 4. Close observation is
client. Depending on level of suicide necessary to ensure that
precaution, provide one-to-one client does not harm self in
contract, constant visual observation, any way. Being alert for
or every 15 minute checks. Place in suicidal escape attempts
room close to nurse’s station; do not facilitates being able to
assign to private room. Accompany to prevent or interrupt
off unit activities if attendance is harmful behavior.
indicated. May need to accompany to
bathroom.
5. Maintain special care in 5. Prevents saving up to
administration of medications. overdose or discarding and
not taking.
6. Encourage client to express 6. Depression and
honest feelings, including anger. suicidal behaviors may be
Provide hostility release if needed. viewed as anger turned
inward
On the self. If this anger can
be verbalized in a
nonthreatening environment,
the client may be able to
eventually resolve these
feelings.

Nursing diagnosis: Hopelessness

Related to: Absence of support systems and perception of worthlessness
Evidenced By: verbal cues; decreased affect; lack of initiative; suicidal ideas or attempts

Outcome criteria Nursing Intervention Rationales

Client will 1.Identify stressors in client’s life that 1.Important to identify
verbalize a precipitated current crisis. causative or contributing
measure of hope factors in order to plan
and acceptance of appropriate assistance.
life and situations
over which he or 2.Determine coping behaviors 2.It is important to identify
she has no previously used and client’s perception client’s strengths and
control. of effectiveness then and now. encourage their use in current
crisis situation.

3.Encourage client to explore and 3.Identification of feelings

verbalize feelings and perceptions. underlying behaviors helps
client to begin process of
taking control of own life.
 4.Help client identify areas of life 4. The client’s emotional
situation that are under own control. condition may interfere with
ability to problem solve.
Assistance may be required
to perceive the benefits and
consequences of available
alternatives accurately.

5.Identify sources that client may use 5.Client should be made

after discharge when crisis occur or
feelings of hopelessness and possible
suicidal ideation prevail.
aware of local suicide
hotlines or other local
support services from whom
he or she may seek assistance
following discharge from
hospital. A concrete plan
provides hope in the face of
crisis situation.

Intervention with the Suicidal Client Following Discharge (or Outpatient Suicidal
Client):
In some instances, it may be determined that suicidal intent is low and that hospitalization is
not required. Instead, the client with suicidal ideation may be treated in an outpatient setting.
Guidelines for treatment of the suicidal client on an outpatient basis include the following:
1. The person should not be left alone. Arrangements must be made for the client to stay
with family or friends. If this is not possible, hospitalization should be reconsidered.
2. Establish a no-suicide contract with the client. Formulate a written contract that the
client will not harm himself or herself in a stated period of time. For example, the
client writes, “I will not harm myself in any way between now and the time of our
next counseling session,” or “I will call the suicide hotline (or go to the emergency
room) if I start to feel like harming myself.” When the time period of this short-term
contract has lapsed, a new contract is negotiated.
3. Enlist the help of family or friends to ensure that the home environment is safe from
dangerous items, such as firearms or stockpiled drugs. Give support persons the
telephone number of counselor is not available.
4. Appointments may need to be scheduled daily or every other day at first until the
immediate suicidal crisis has subsided.
5. Establish rapport and promote a trusting relationship. It is important for the suicide
counselor to become a key person in the client’s support system at this time.
 6. Be direct. Talk openly and matter-of-factly about suicide. Listen actively and
encourage expression of feelings, including anger. Accept the client’s feelings in a
nonjudgmental manner.
7. Discuss the current crisis situation in the client’s life. Use the problem-solving
approach.
8. Help the client identify areas of life situation that are within his or her control and
those that client does not have the ability to control. Discuss feelings associated with
these control over his or her life situation in order to perceive a measure of self-worth.
9. The physician may prescribe antidepressants for an individual who is experiencing
suicidal depression. It is wise to prescribe no more than a 3 day supply of the
medication with no refills. The prescription can then be renewed at the client’s next
counseling session.
10. Macnab (1993) suggests the following steps in crisis counseling with the suicidal
client:
a) Focus on the current crisis and how it can be alleviated. Identify the client’s
appraisals of how things are, and how things will be. Note how these appraisals
change in changing contexts.
b) Note the client’s reactivity to crisis and how this can be changed. Discuss strategies
and procedures for the management of anxiety, anger and frustration.
c) Work toward restoration of the client’s self-worth, status, morale, and control.
Introduce alternatives to suicide.
d) Rehearse cognitive reconstruction –more positive ways of thinking about the self,
events, the past, the present, and the future.
e) Identify experiences and actions that affirm self-worth and self-efficacy.
f) Encourage movement toward the new reality, with the coping skills required to
manage adaptively.
Information for family and friends of the Suicidal Client:
The following suggestions are made for family and friends of an individual who is suicidal:
1. Take any hint of suicide seriously. Anyone expressing suicidal feelings needs immediate
attention.
2. Do not keep secrets. If a suicidal person says, “Promise you won’t tell anyone,” do not make
that promise. Suicidal individuals are ambivalent about dying, and suicidal behavior is a cry
for help. It is the part of the person that wants to stay alive that tells you about it. Get help
for the person and for you. 1-800-SUICIDE is a national hotline that is available 24 hours a
day.
3. The centers for Disease Control(CDC, 2002) offer the following suggestions for families and
friends of suicidal persons:
a) Be a good listener. If people express suicidal thoughts or feel depressed, hopeless,
or worthless, be supportive. Let them know you are there for them and are willing to
help them seek professional help.
b) Many people find it awkward to put into words how another person’s life is
important for their own well-being, but it is important to stress that the person’s life is
important to you and to in which the person’s suicide would be devastating to you and to
others.
c) Express concern for individuals who express thoughts about committing suicide.
The individual may be withdrawn and reluctant to discuss what he or she is thinking.
Acknowledge the person’s pain and feelings of hopelessness, and encourage the
individual to talk to someone else if he or she does not feel comfortable talking with
you.
d) Familiarize yourself with suicide intervention sources, such as mental health
centers and suicide hotlines.
e) Ensure that access to firearms or other means of self-harm is restricted.
4. The Mental Health Sanctuary (2004) offers the following tips:
a) Acknowledge and accept their feelings and be an active listener.
b) Try to give them hope and remind them that what they are feeling is temporary.
c) Stay with them. Do not leave them alone. Go to where they are, if necessary.
d) Show love and encouragement. Hold them, hug them, and touch them. Allow
them to cry and express anger.
e) Help them seek professional help.
f) Remove any items from the home with which the person may harm himself or herself.
g) If there are children present, try to remove them from the home. Perhaps another
friend or relative can assist by taking them to their home. This type of situation can be
extremely traumatic for children.
Intervention with Families and Friends of Suicide Victims:
Suicide of a family member can induce a whole gamut of feelings in the survivors. Macnab
(1993) identifies the following symptoms, which may be evident following the suicide of a loved
one.
1. A sense of guilt and responsibility
2. Anger, resentment, and rage that can never find its “object”
3. A heightened sense of emotionality, helplessness, failure, and despair
4. A recurring self-searching: “If only I had done something,” If only I had not done
something,” If only I had not done something,” “If only…….”
5. A sense of confusion and search for an explanation: “Why did this happen?” “What does it
mean?” “What could have stopped it?” “What will people think?”
6. A sense of inner injury. The family feels wounded. They do not know how they will ever
over it and get on with life.
7. A severe strain is placed on relationships. A sense of impatience, irritability, and anger exists
between family members.
8. A heightened vulnerability to illness and disease exists with this added burden of emotional
stress.
Strategies for assisting survivors of suicide victims include:
1. Encourage the clients to talk about the suicide, each responding to the other’s viewpoints,
and reconstructing of events. Share memories.
2. Be aware of any blaming or scapegoating of specific family members. Discuss how each
person fits into the family situation, both before and after the suicide.
3. Listen to feelings of guilt and self-persecution. Gently move the individuals toward the
reality of the situation.
4. Encourage the family members to discuss individual relationships with the lost loved one.
Focus on both positive and negative aspects of the relationships. Gradually, point out the
irrationality of any idealized concepts of the decreased person. The family must be able
to recognize both positive and negative aspects about the person before grief can be
resolved.
5. No two people grieve in the same way. It may appear that some family members are “getting
over” the grief faster than others. All family members must be made to understand that if
this occurs, it is not because they “care less,” just that they “grieve differently.” Variables
that enter into this phenomenon include individual past experiences, personal relationship
with the deceased person, and individual temperament and coping abilities.
6. Recognize how the suicide has caused disorganization in family coping. Reassess
interpersonal relationships in the context of the event. Discuss coping strategies that have
been successful in times of stress in the past, and work to reestablish these within the
family. Identify new adaptive coping strategies that can be incorporated.
7. Identify resources that provide support: religious beliefs and spiritual counselors, close
friends and relatives, survivors of suicide support groups.
Evaluation:
Evaluation of the suicidal client is an ongoing process accomplished through continuous
reassessment of the client, as well as determination of goal achievement. Once the immediate
crisis has been resolved, extended psychotherapy may be indicated. The long-term goals of
individual or group psychotherapy for the suicidal client would be for him or her to:
1. Develop and maintain a more positive self-concept.
2. Learn more effective ways to express feelings to others.
3. Achieve successful interpersonal relationships.
4. Feel accepted by others and achieve a sense of belonging.

A suicidal person feels worthless and hopeless. These goals serve to instill a sense of self-worth,
while offering a measure of hope and a meaning for living.