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HealthMarch 03, 2021

Chocolates and tissues: Let’s talk about the “S” word

By: Lenore Cortez, MSN, RNC
Suicide. There, I said it. That word that people are so afraid to utter or talk about, is one that is heard very frequently by mental health nurses.

I take it as part of my duty to educate others about suicide, the signs, and symptoms and how you can help a person who is thinking about ending their life.

Why am I writing about this now? There have recently been two community deaths that I have become aware of through family and friends. One of these was an adolescent and one was an adult. In each case, the community is in shock. The parents of the adolescent said their son was happy and showed no signs of distress. The article announcing the death of the adult reported what a wonderful educator this man had been and how much he gave to his students and the community in which he lived. What happened in the lives of these two individuals that were so bad that the only solution they could find was death? Their families may never know the complete story.

Suicide terminology

Suicide has risen 35% since 1999 (National Alliance on Mental Illness [NAMI], 2021) and is now the 10th leading cause of death (Centers for Disease Control and Prevention [CDC], 2020). In trying to help others, there are several terms you need to understand to determine the level of suicidality of a person in crisis.

Suicidal ideation means the person is thinking about suicide. There are some people who live with suicidal thoughts all the time but have no intention of acting upon them. Other people have begun to formulate a plan for how they will act upon their suicidal thoughts. This is called suicidal intent. The most critical level is when a person has suicidal thoughts, intent and the means to follow through with the plan. This is an emergency situation. If you determine that a person has this highest level of suicidal ideation they need immediate help. Call 911 or take them to the nearest Emergency Room.

Parasuicide happens when a person self-harms or inflicts a wound that does not end up in suicide. This could be in the form of cutting or a non-lethal drug overdose. This is often considered a cry for help and may lead to an actual suicide. Copy-cat suicides can occur after the death of a person in the community or a celebrity figure. It is very important for news media to control the way the event is shared with the public because if the death is glamorized then there can be vulnerable people who see suicide as a way to emulate the celebrity and get attention (Vitelli, 2016).

Suicide risk factors

One of the primary parts of taking care of patients is to perform a complete head-to-toe assessment. This includes asking questions about a person’s emotional well-being. One of the concerns that my nursing students have voiced in the clinical setting is fear that if they ask a patient about suicidal thinking it will put the thought into that person’s head. This is a myth. I always explain to my students that this is not possible. In fact, in most cases, a person who is having suicidal thoughts will feel a sense of relief to be asked and offered support. Asking a patient if they are feeling suicidal should be part of every nursing assessment. There are certain factors that may contribute to a person having a higher risk for suicidal tendencies. These include:

  • A family history of suicide – this may play into the way a person reacts to stressors. They may see it as “Well, my father completed suicide and he was not weak, so I will follow in his shoes.”
  • Substance use – the use of substances can increase the mood swings that can cause suicidal ideation.
  • Intoxication – According to NAMI (2021), one in three people who are successful in suicide are intoxicated at the time of their death.
  • Access to firearms – the top three means of suicide are firearms, suffocation (hanging), and poisoning (CDC, 2020).
  • A serious or chronic medical illness or mental illness – 46% who die by suicide have been diagnosed with a mental illness (NAMI, 2021)
  • Gender – 78% are male. Women are more likely to attempt suicide, but men are 4x more likely to die (NAMI, 2021) due to the use of more deadly means, most often firearms.
  • A history of trauma or abuse
  • Prolonged stress
  • A recent tragedy or loss – elderly people, age 85 and older, have the highest suicide rate. Loss of independence (giving up a driver’s license), death of spouse and/or friends, health/memory issues, financial stressors, and loneliness are top reasons (Mendoza, 2020).

Recognizing suicide signs and symptoms

In nursing and in education we are in the position to make a difference. We share our knowledge with others. We become close to our patients and students. If we are good at our jobs they come to trust and respect us. They will listen to us if we listen to them. We need to know how to recognize the symptoms of suicidal thinking. Mayo Clinic (2021) offers a list of things to look for:

  • Changes in the person’s mood. This could be exhibited as highs one day and lows the next.
  • Talking about death. “I wish I was dead” or pondering “I wonder what people would do if I was no longer around?”
  • Giving away possessions.
  • Pattern changes in eating, sleeping, and normal routines.
  • Increased use of drugs or alcohol.
  • Obtaining the means to kill oneself.
  • Withdrawing from friends and family. This is especially noticeable if the person is normally very outgoing.
  • Not finding enjoyment in previously enjoyed activities, such as quitting sports or skipping classes.
  • Saying goodbye to people.

How we can help one another

“Preventing suicide is the responsibility of the whole community. Everyone plays a part in suicide prevention”. (NAMI-CONNECT, 2021, p. 1). Ask the difficult questions and then LISTEN. One of the most helpful therapeutic communication skills is to be silent. We are often quick to fill empty pauses or to ask closed-ended questions. Time should be allowed so that the person in crisis can gather their thoughts and respond honestly. Our observations should include looking at the congruence between body language and spoken language. People who are feeling suicidal can be very good at masking their pain and saying everything is okay. Do they look you in the eye when saying they are okay? Do they fidget while telling you they are fine? Any mention of suicidal thoughts should be taken seriously, even if you know the person frequently reports suicidality but has never made an actual attempt.

Allowing the person to talk about how they feel, their triggers and determining a course of action is the best way to support the person. Remember that the person is in crisis. The pain they are feeling is very real to them. Do not judge them. Be in the moment with them so they feel safe. Some people get very embarrassed to be having feelings of self-harm. It can be against their culture or religious beliefs, thus adding to the turmoil they are experiencing. When I talk to anyone in crisis, be it a patient, student or co-worker, I am sure to ask questions about when these feelings began, what might have triggered them, if they have ever felt this way before and I ALWAYS ask if they have a specific plan.

Reducing the stigma of suicide includes changing the way we describe it. Instead of saying that a person “committed suicide”, which sounds like they have committed a mortal sin, use the words “suicided” or “died by suicide” or “took their own life.” Many people are simply afraid to say the word suicide. Talk about it. Share information and resources. The more we hear the word the less scary it becomes.

If someone you know needs resources the National Suicide Prevention Helpline is available 24 hours per day, seven days per week at 800-273-TALK (8255). Another option is the Crisis Text Line. Simply type HOME to 741741, within the United States and Canada, to be connected to a crisis counselor. Our university has a student counseling center so we have the option of either referring students or walking them to the clinic. In the case of imminent danger call 911.

Our counseling center offers suicide intervention training (QPR Training) to everyone on campus. QPR stands for “Question, Persuade, and Refer” (QPR Institute, n.d., para 2). The QPR technique originated in 1995. The QPR Institute came into being in 1999 as a way of providing emergency mental health training, much the way CPR is used for cardiac emergencies. The website for the QPR Institute is https://qprinstitute.com/about-qpr and their phone number is (888) 726-7926.

Suicide is preventable. Research has shown that many people who attempt suicide are ambivalent about life versus death and intervention can make a difference in saving their life. (NAMI-CONNECT, 2021). Treatment is available for mental illness and substance abuse. Assessment, treatment and community resources are key in the prevention of suicide. It is estimated that the suicide of one person can affect 115 people, from those closest to the deceased to people in the community (teachers, clergy, police officers, nurses, doctors), and to people who hear about the death via media (Sandler, 2018). I previously wrote about the ripple effect in reference to reducing stigma one person at a time. This time the ripple effect refers to how the death of one person can affect many other people.

Learning to talk about the “S” word is the first step towards saving lives. Join me in being a person who cares. I listen, will you?

Ready for part 6 of chocolates and tissues? Read Chocolates and tissues: Nursing is a work of heart now.

Missed parts 1 through 4 of chocolates and tissues? Read them now:

Lenore Cortez, MSN, RNC
Expert Insights Contributor for Wolters Kluwer, Nursing Education
  1. Centers for Disease Control and Prevention. (2020). Suicide and Self-Harm Injury. Centers for Disease Control and Prevention. Retrieved January 13, 2021 from https://www.cdc.gov/nchs/fastats/suicide.htm.
  2. Mayo Clinic. (2021). Suicide and suicidal thoughts. Mayo Clinic. Retrieved January 13, 2021 from https://www.mayoclinic.org/diseases-conditions/suicide/symptoms-causes/syc-20378048.
  3. Mendoza, M. A. (2020). Why do elderly commit suicide? Psychology Today. https://www.psychologytoday.com/us/blog/understanding-grief/202001/why-do-the-elderly-commit-suicide.
  4. National Alliance on Mental Illness – CONNECT. (2021). Community-based approach of our suicide prevention training program model. NAMI-CONNECT. https://theconnectprogram.org/about-us/community-based-approach-of-our-suicide-prevention-program-model/.
  5. National Alliance on Mental Illness. (2021). Risk of suicide. NAMI. Retrieved January 13, 2021 from https://www.nami.org/About-Mental-Illness/Common-with-Mental-Illness/Risk-of-Suicide.
  6. QPR Institute. (n.d.). What is QPR? QPR Institute. https://qprinstitute.com/about-qpr.
  7. Sandler, E. P. (2018). The ripple effect of suicide. NAMI Blog. https://nami.org/Blogs/NAMI-Blog/September-2018/The-Ripple-Effect-of-Suicide.
  8. Vitelli, R. (2016). Can celebrity suicides lead to copy-cat deaths? Psychology Today. https://www.psychologytoday.com/us/blog/media-spotlight/201605/can-celebrity-suicides-lead-copycat-deaths.
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