The suicidal thoughts Are undoubtedly the most serious psychopathological alteration that exists, since they seriously put the risk of the life of the person who suffers them.
In addition, dealing with these types of aspects is usually very complex and should always be emphasized with great delicacy, professionalism and rigor, since a bad approach Of suicidal thoughts can bring devastating and irreversible consequences.
In this article we will explain how this Kind of thoughts And what aspects should be taken into account in order to achieve this.
Evaluation of suicidal thinking
Knowing how to identify a suicide risk is a requirement that all mental health professionals must know.
As we have seen, the motivations, intentions and attitudes of a suicidal thinking can be very diverse, therefore it is important to evaluate To the patient properly to be able to detect its presence.
The objective of the evaluation is to estimate the risk of suicide in order to immediately implement the intervention plan that guarantees the safety of The life of the patient.
This evaluation should be done through a clinical interview, which will identify the specific factors, signs and symptoms that can Increase or decrease the risk of suicide. It must have four sections:
1. Psychopathological exploration
The appearance and general behavior of the patient (appearance, hygiene, clothing, expression, etc.), level of contact, level of Consciousness, alterations of attention and alterations of the memory.
Speech and language should also be explored, the speed of motor movements, State of mind And affectivity, the Suicidal impulses and the level of tolerance to frustrations.
In this way, one should not be afraid to ask directly for ideas of suicide if there are indications that they may exist, and the Responses provided by the patient taking into account the form and content of their thinking.
In the case of suicidal thoughts, the role of the patient should be explored (active or passive), their motives, their Suicide, the plans of suicide that it has and its degree of elaboration.
2. Assessment of risk factors
Those factors that may indicate an increased risk of suicidal thoughts and behaviors should be evaluated.
These are: chronic medical illnesses, advanced age, male sex, existence of a mental illness (above all Major depression , Alcoholism, schizophrenia , Y Borderline personality disorder ), Previous suicide attempts and Difficulty sleeping .
Other aspects such as being single, not having a job, having recently been discharged from hospital, Impulsive features , Chronic stress, wounds in the body, death or loss of loved ones make increase the risk of suicide.
3. Protection Factors
However, other factors can reduce the likelihood of suicidal thoughts and behaviors, these are:
The feeling of personal and self esteem , Have significant relationships and activities, be religious, be a woman and be pregnant, have a network Social support, have a good social integration, have a flexible style of thinking, have children and have control.
4. High Suicide Profile
The people most likely to commit suicide have the following characteristics:
They suffer from depression or a major psychiatric disorder, are over 45 years old, are separated, divorced or widowed, are retired or unemployed, Have chronic medical illnesses, personality disorder, have previously attempted suicide, have had alcoholism, and have had little Psychosocial support.
Treatment of suicidal thoughts
In the first place, it should be taken into account that in those cases that the patient's safety can not be guaranteed, the patient must be admitted to a hospital To initiate treatment under control.
Subsequently, most serious suicidal thoughts require pharmacological treatment.
When choosing the drug should take into account the mental disorder underlying the idea of suicide.
Most are usually diagnosed with major depression, so they are usually treated with antidepressants.
In cases where suicidal thoughts are accompanied by large impulsive features or psychotic symptoms, they should be administered Antipsychotics Atypical.
The rest of the patients are usually treated with Benzodiazepines . Also, in very severe depressions or with psychotic symptoms, therapy Electroconvulsive therapy is often an effective technique.
As far as psychological therapy is concerned, the role that the therapist acquires is fundamental for the proper approach to suicidal thoughts.
The main foundations that the therapist must have are:
Activity : The therapist must be active so that the patient feels that something is happening. This aspect is fundamental to restore Patient the feeling that he is important.
Authority The therapist must assume authority and lead the patient on a temporary basis. A patient with suicidal thoughts will find himself in a situation In which he is not able to find solutions, so the therapist must guide him in an empathic way.
Involvement of others People close to the patient will be key to helping you rebuild your feelings of self-esteem and self-confidence .
Likewise, to treat suicidal thoughts the following objectives must be achieved:
- Reduce the unbearable psychological pain experienced by the patient through the understanding and Empathic listening .
- Take into account the frustration of psychological needs and accept them as real.
- Give the subject an opportunity to manifest his situation and understand that for him the solution is suicide.
- Provide emotional support.
- Recognize the symptoms of hopelessness and not combat them with pessimistic expressions.
- Look for positive alternatives to the patient's possible ambivalence.
- Always be alert to the messages of intent to commit suicide.
To achieve these goals, the therapist can perform the following psychological interventions:
1. Work the"tunnel vision"
The patient has a narrow and rigid view of reality on all its negative aspects, a fact that causes only one solution, suicide.
Therefore, it is important to show them that there are other options. To do this, self-registrations will be made and work will be done:
Test the truthfulness of your thoughts in order to value your certainty and not automatically accept them.
Provide a system of beliefs or alternative schemes that offers explanations and visions different from yours.
Educate the patient to understand the emotional and situational nature of their cognitive distortions and their thoughts of suicide.
2. Negotiate for a delay
The therapist must have built a good relationship with the patient that allows him to delay his suicidal behavior. In this way, the tension of suicide It will decrease without having to perform it, and the therapist will gain time to work with the patient in a calmer environment.
3. Working with cognitive factors
People with suicidal thoughts have a negative view of themselves, the world and the future, so these three spheres must be worked to obtain More neutral thoughts .
To do this you can use:
Cognitive techniques Detection of thought, problem solving , Understatement, advantages and disadvantages and exaggeration or paradox of thoughts.
Behavioral techniques Programming of activities, assessment of dominion and pleasure, gradual assignment of tasks, Social skills training Y assertiveness , Role play therapy and behavioral testing.
What is suicide?
The word suicide Proceeds etymologically from Latin and means, literally, to kill itself.
For its part, the Dictionary of the Royal Spanish Academy Defines suicide as"the act or conduct that damages or destroys the agent himself"and To commit suicide as"the act of voluntarily taking life away."
With these three definitions we are not learning anything that we do not know, to commit suicide means to take life voluntarily, intentionally and Planned.
Currently, both the diagnostic manual ICD-10 As the DSM-IV Do not include suicide as a mental disorder, however, it does include Suicidal thoughts in different psychopathologies such as Depressions , in some personality disorders or in the schizophrenia .
However, it would be a mistake to think that all suicidal thoughts are identical and respond to the same situation.
Obviously, a person who thinks of death or the idea of suicide will not be the same as a person who has reflected on his own suicide, Has designed a plan to carry it out and is totally focused on ending his or her life.
In the eyes of all, the first suicidal thought will seem less light and less likely to consummate suicide, and the second will alarm us Much more and we will interpret it as more dangerous and alarming.
However, the complexity of this type of thinking is not based on a simple specificity of its seriousness, reason why many authors have tried Organize them into different groups.
It is not the purpose of this article to review the entire literature on the various classifications of suicidal thoughts as there have been many Authors who have made their proposals and theories of categorization.
However, in order to clarify a bit the complexity of these types of thoughts and to obtain a broader view when dealing with them, it seems to me Interesting to comment on the different classifications made by León Fuentes in 1996.
This author very aptly indicated that thoughts and suicidal behaviors could be classified as follows:
1. According to its etiology
Not all suicidal thoughts are based on the same bases, according to the origin can be divided into 4 different types:
Psychotic When the thought of death is constituted by delirium and psychotic cognitions.
Neurotics When they are caused by a mental illness that distorts rational thought, without it becoming delusional.
Psychodisplásticos When the person suffers a psychopathic personality alteration and assaults himself.
Philosophical When suicidal thinking is caused by a feeling of existential void or depressive states.
2. According to his intentionality
It should be borne in mind that, even though a suicidal thought holds the idea of dying, it can have a myriad of intentions.
Intention to die When thinking is based on conducting a behavior that ends life and gets death.
Escape from an unsustainable situation : When suicidal thinking aims to get out of a situation that produces high levels of discomfort, through death.
Risk behaviors When suicidal behavior is subject to risky thoughts and dangerous activities.
Intentionality When what is desired is suicide in itself, not death.
Suicide as a rematch When the act of committing suicide aims to emotionally harm someone.
Suicide by existential balance When suicidal thinking appears after making an assessment of the advantages and disadvantages of doing so.
3. According to the results obtained
A suicidal thought can have different effects.
- Consummate suicide When suicide is attempted and achieved.
- Frustrated suicide When suicidal behavior is achieved but the goal of dying is not achieved.
- Suicide attempt When attempting to carry out suicidal behavior but is not achieved.
- Idea of Suicide When you think of suicide but it does not take place.
- Idea of death When one thinks of death but not in the act of committing suicide.
4. According to severity
According to the seriousness of the suicidal thought can be classified as fatal if the suicide has been consumed, very serious if the suicide has not been consummated but Has put (or can put) the patient's life in high danger, and is mild when suicidal thinking does not imply a self-political act.
6. According to the attitude
Finally, the person with suicidal thinking can adopt an active attitude towards killing or a passive attitude.
So we see that suicidal thoughts can be of many types, they may have different origins, of different modalities, and with intentions and Attitudes.
That is why, although all suicidal thoughts have aspects in common, it is important to evaluate them in detail before intervening.
References
Appleby L. Prevention of suicide in psychiatric patients. In: K Hawton, K van Heeringen, eds. The international handbook of suicide and attempted suicide. Chichester: Wiley & Sons Publishers, 2000.
Brodsky BS, Malone KM, Ellis SP, et al. Characteristics of borderline personality disorder associated with suicidal behavior. American Journal of Psychiatry, 1997; 154: 1715-1719.
Goldstein RB, Black DW, Nasrallah MA, Winokur MD. The prediction of suicide. Archives of General Psychiatry, 1991; 48: 418-422
Mehlum L. Suicidal behavior and personality disorder. Current Opinion in Psychiatry, 2001; 14 (2): 131-135.
NSW Department of Health. Circular 98/31 Policy guidelines for the management of patients with possible suicidal behavior for NSW Health staff and staff in private hospital facilities, May 1998. Note: The policy was being revised at the time of preparation of this framework.
Rudd MD, Rajab MH, Dahm PF. Problem solving appraisal in suicide ideators and attempters. American Journal of Orthopsychiatry, 1994; 64: 136-149. Cited in: H Hawton, K. van Heeringen K, eds. The international handbook of suicide and attempted suicide. Chichester: Wiley & Sons Publishers, 2000.