242

Treatment of suicidal people falls into two major categories: treatment after suicide has been attempted and suicide prevention. Treatment may also be beneficial to relatives and friends of those who commit or attempt to commit suicide. Their feelings of loss, guilt, or anger after a suicide fatality or attempt can be intense (Kramer et al., 2015), but the discussion here is limited to the treatment afforded suicidal people themselves.

After a suicide attempt, most victims need medical care. Close to one-half million people in the United States are admitted to a hospital each year for injuries resulting from efforts to harm themselves (AFSP, 2014). Some are left with severe injuries, brain damage, or other medical problems. Once the physical damage is treated, psychotherapy or drug therapy may begin, on either an inpatient or outpatient basis.

Unfortunately, even after trying to kill themselves, many suicidal people fail to receive systematic follow-up care (Stanley et al., 2015). In some cases, health care professionals are at fault for this lack of follow-up. In others, the person who has attempted suicide refuses therapy. According to one review, the average number of therapy sessions attended by teenagers who receive follow-up care is 8; around 18 percent of such teens stop treatment against their therapists’ advice (Spirito et al., 2011).

The goals of therapy for those who have attempted suicide are to keep the individuals alive, reduce their psychological pain, help them achieve a nonsuicidal state of mind, provide them with hope, and guide them to develop better ways of handling stress (Rudd & Brown, 2011). Various therapies have been employed, including drug, psychodynamic, cognitive-behavioral, group, and family therapies (Baldessarini & Tondo, 2011, 2007; Spirito et al., 2011). Research indicates that cognitive-behavioral therapy may be particularly helpful (Rudd et al., 2015; Brown et al., 2011, 2010). This approach focuses largely on the painful thoughts, sense of hopelessness, dichotomous thinking, poor coping skills, weak problem-solving abilities, and other cognitive and behavioral features that characterize suicidal people.

During the past 60 years, emphasis around the world has shifted from suicide treatment to suicide prevention. In some respects this change is most appropriate: the last opportunity to keep many potential suicide victims alive comes before their first attempt.

The first suicide prevention program in the United States was founded in Los Angeles in 1955; the first in England, called the Samaritans, was started in 1953. There are now hundreds of suicide prevention centers in the United States and England. In addition, many of today’s mental health centers, hospital emergency rooms, pastoral counseling centers, and poison control centers include suicide prevention programs among their services.

243

There are also hundreds of suicide hotlines, 24-hour-a-day telephone services, in the United States. Callers reach a counselor, typically a paraprofessional—a person trained in counseling but without a formal degree—who provides services under the supervision of a mental health professional.

Suicide prevention programs and hotlines respond to suicidal people as individuals in crisis—that is, under great stress, unable to cope, feeling threatened or hurt, and interpreting their situations as unchangeable. Thus the programs offer crisis intervention: they try to help suicidal people see their situations more accurately, make better decisions, act more constructively, and overcome their crises (Lester, 2011). Because crises can occur at any time, the centers advertise their hotlines and also welcome people who walk in without appointments (see MindTech).

244

Some prevention centers and hotlines reach out to particular suicidal populations. The Trevor Lifeline, for example, is a nationwide, around-the-clock hotline available for LGBTQ (lesbian, gay, bisexual, transgender, and questioning) teenagers who are thinking about suicide. This hotline is one of several services offered by the Trevor Foundation, a wide-reaching organization dedicated to providing support, guidance, and information and promoting acceptance of LGBTQ teens.

The public sometimes confuses suicide prevention centers and hotlines with online chat rooms and forums (message boards) to which some suicidal people turn. However, chat rooms and forums operate quite differently, and in fact, most of them do not seek out suicidal people or try to prevent suicide. Typically, these sites are not prepared to deal with suicidal people, do not offer face-to-face support, do not involve professionals or paraprofessionals, and do not have ways of keeping out inappropriate users.

Today, suicide prevention takes place not only at prevention centers and hotlines but also in therapists’ offices. Suicide experts encourage all therapists to look for and address signs of suicidal thinking in their clients, regardless of the broad reasons that the clients are seeking treatment (McGlothlin, 2008). With this in mind, a number of guidelines have been developed to help therapists effectively uncover, assess, prevent, and treat suicidal thinking and behavior in their daily work (de Beurs et al., 2015; Van Orden et al., 2008; Shneidman & Farberow, 1968).

Although specific techniques vary from therapist to therapist and from prevention center to prevention center, the approach developed originally by the Los Angeles Suicide Prevention Center continues to reflect the goals and techniques of many clinicians and organizations. During the initial contact at the center, the counselor has several tasks:

Establish a Positive Relationship As callers must trust counselors in order to confide in them and follow their suggestions, counselors try to set a positive and comfortable tone for the discussion. They convey that they are listening, understanding, interested, nonjudgmental, and available.

Understand and Clarify the Problem Counselors first try to understand the full scope of the caller’s crisis and then help the person see the crisis in clear and constructive terms. In particular, they try to help callers see the central issues and the transient nature of their crises and recognize the alternatives to suicide.

Assess Suicide Potential Crisis workers at the Los Angeles Suicide Prevention Center fill out a questionnaire, often called a lethality scale, to estimate the caller’s potential for suicide. It helps them determine the degree of stress the caller is under, the caller’s relevant personality characteristics, how detailed the suicide plan is, the severity of symptoms, and the coping resources available to the caller.

Assess and Mobilize the Caller’s Resources Although they may view themselves as ineffectual, helpless, and alone, people who are suicidal usually have many strengths and resources, including relatives and friends. It is the counselor’s job to recognize, point out, and activate those resources.

Formulate a Plan Together the crisis worker and caller develop a plan of action. In essence, they are agreeing on a way out of the crisis, an alternative to suicidal action. Most plans include a series of follow-up counseling sessions over the next few days or weeks, either in person at the center or by phone. Each plan also requires the caller to take certain actions and make certain changes in his or her personal life. Counselors usually negotiate a no-suicide contract with the caller—a promise not to attempt suicide, or at least a promise to reestablish contact if the caller again considers suicide. Although such contracts are popular, their effectiveness has been called into question (Rudd et al., 2006). In addition, if callers are in the midst of a suicide attempt, counselors try to find out their whereabouts and get medical help to them immediately.

245

Although crisis intervention may be sufficient treatment for some suicidal people, longer-term therapy is needed for most (Lester et al., 2007). If a crisis intervention center does not offer this kind of therapy, its counselors will refer the clients elsewhere.

Yet another way to help prevent suicide may be to reduce the public’s access to common means of suicide (Anestis & Anestis, 2015; Lester, 2011). In 1960, for example, around 12 of every 100,000 people in Britain killed themselves by inhaling coal gas (which contains carbon monoxide). In the 1960s, Britain replaced coal gas with natural gas (which contains no carbon monoxide) as an energy source, and by the mid-1970s the rate of coal gas suicide fell to 0 (Maris, 2001). In fact, England’s overall rate of suicide dropped as well. On the other hand, the Netherlands’ drop in gas-induced suicides was compensated for by an increase in other methods, particularly drug overdoses.

Similarly, ever since Canada passed a law in the 1990s restricting the availability of and access to certain firearms, there has been a decrease in firearm suicides across the country (Leenaars, 2007). Some studies suggest that this decrease has not been displaced by increases in other kinds of suicides; other studies, however, have found an increase in the use of other suicide methods (Caron et al., 2008). Thus, although many clinicians hope that measures such as gun control, safer medications, better bridge barriers, and car emission controls will lower suicide rates, there is no guarantee that they will.

It is difficult for researchers to measure the effectiveness of suicide prevention programs (Sanburn, 2013; Lester, 2011). There are many kinds of programs, each with its own procedures and each serving populations that vary in number, age, and the like. Communities with high suicide risk factors, such as a high elderly population or economic problems, may continue to have higher suicide rates than other communities regardless of the effectiveness of their local prevention centers.

Do suicide prevention centers reduce the number of suicides in a community? Clinical researchers do not know (Sanburn, 2013). Studies comparing local suicide rates before and after the establishment of community prevention centers have yielded different findings. Some find a decline in a community’s suicide rates, others no change, and still others an increase (De Leo & Evans, 2004; Leenaars & Lester, 2004). Of course, even an increase may represent a positive impact, if it is lower than the larger society’s overall increase in suicidal behavior.

Do suicidal people contact prevention centers? Apparently only a small percentage do (Sanburn, 2013). Moreover, the typical caller to an urban prevention center appears to be young, African American, and female, whereas the greatest number of suicides are committed by older white men (Maris, 2001). A key problem is that people who are suicidal do not necessarily admit to or talk about their feelings in discussions with others, even professionals (Stolberg et al., 2002).

Prevention programs do seem to reduce the number of suicides among those high-risk people who do call. One study identified 8,000 high-risk individuals who contacted the Los Angeles Suicide Prevention Center (Farberow & Litman, 1970). Approximately 2 percent of these callers later committed suicide, compared with the 6 percent suicide rate usually found in similar high-risk groups. Clearly, centers need to be more visible and available to people who are thinking of suicide. The growing number of advertisements and announcements on the Web, television, radio, and billboards indicate movement in this direction.

246

Many theorists have called for more effective public education about suicide as the ultimate form of prevention, and a number of suicide education programs have emerged. Most of these programs take place in schools and concentrate on students and their teachers (Joshi et al., 2015; Schilling et al., 2014). There are also a growing number of online sites that provide education about suicide—targeting troubled persons, their family members, and friends (Lai et al., 2014). These offerings agree with the following statement by Shneidman: