Support networks are an extremely important protective factor in working with people who are suicidal. Support networks are first, internally, our beliefs, attitudes and strengths, and then externally the people in our lives who we can rely on for emotional support; finally, it’s the community agencies that you rely on for more intensive, or emergency support.
This post reviews some of the material from the Resources section of the CPR Risk Assessment as well.
There are a few ways you can record your support network. One is with a simple list, on which you write the three support network categories, Internal, External and Peripheral.
Internal resources are the things inside a person that help them defeat suicidal thinking. They include:
- Having future hopes and dreams
- A belief that suicide is wrong
- A relationship with God or a religion that believes suicide is wrong
- Fear of suicide and death
- A belief that a person should be responsible for their family
While these characteristics are unlikely to be changed while talking to someone who is suicide, it is helpful to recognize them.
Ego strength is the term for an internal coping strategy referring to your ability to consistently understand the world realistically and to use that understanding to get your wants and needs met.
External resources are the people in our daily life who can provide emotional support. Examples include:
- Close friends
- Pets (people often underestimate the benefits that pets can have on our emotional and mental health)
- Significant other/partner
Often suicidal individuals experience a form of tunnel vision where they find themselves unable to notice the resources in their lives. Therefore it may take some questioning. Examples of questions to help flesh out a person’s resources include:
“Who in your life do you turn to when you need someone to talk to?”
“Who is going to miss you if you die?”
“If something really amazing or really terrible happened, who’s the first person you would call?”
The next part of the resources section is the Peripheral resources. These are individuals we may not see in our daily lives but who are there to provide us with additional support in times of need. Examples include:
- Helplines and crisis lines
- Therapists, counsellors, social workers
- Teachers (if a student)
- Clergy (if religious)
Sometimes people without any family, people who have been isolated or people who have experienced an addiction or other life situation that causes a personality change find themselves without any external resources, and in those situations the peripheral resources will become more important as a way of providing emotional support while a person works to build up their external resources.
If a person has few or no external or peripheral resources, that is one risk factor. A person with 3 risk factors (a current plan, a previous history of exposure to suicide and few or no resources) is HIGH risk on the CPR Model. It’s important that all of us (whether in a state of good or poor emotional health) work to build up our support network so we can be more resilient in the face of negativity.
Suicide risk factors are those characteristics a person may possess that can increase their suicide risk on a “macro level.” Merely having these things indicates a person may be at an increased risk of suicide over their lifetime, but does not indicate that they are going to kill themselves soon, or even at all.
Suicide Risk Factors
- Gender – Men are at an increased risk of dying by suicide, although women attempt suicide more frequently. This is because men tend to use more lethal methods such as firearm and hanging while women tend to use overdosing. This trend is changing however, see our section on Suicide Statistics.
- Age – Above 30 years of age there is a direct correlation between age and risk of dying by suicide
- Abusing alcohol or drugs – Drugs and alcohol reduce a person’s inhibitions and increase their impulsiveness, which can make them take actions they wouldn’t do while sober. Additionally, chronic use of drugs can produce a change in personality that mirrors a personality disorder. This is known as substance-induced mood disorder (and in its more severe form substance-induced psychosis.)
- Personal History of mental health issues – As has been stated elsewhere, up to 90% of those who die by suicide have a mental health issue. This does not mean that feeling suicidal means you have an illness, only that those who die by suicide often have one that is not being treated effectively. With proper treatment, suicide risk is sharply decreased in those with mental health issues. See our Suicide Myths #4.
- Family History (of abuse, and of suicide) – A family history of abuse can make it difficult for someone to cope, and the symptoms associated with post-traumatic stress can raise suicide risk. By seeking therapy for victims of abuse they can learn to work through the feelings created by these experiences and seek healthier outlets than suicide. A family history of suicide (knowing someone in your family died by suicide) increases suicide risk and therefore is itself a risk factor.
One mnemonic that can be used to help remember suicide risk factors is the SAD PERSONS scale. This scale is a summary of a number of elements associated with suicide risk. The SAD PERSONS elements include:
- Previous Attempts
- Ethanol / Other Drug Use
- Rational Thinking Loss
- Social Support Lacking
- Organized Plan
- No Spouse
As you can see this scale includes both variables unlikely to change quickly (sex, marital status, and mental health status) and also some items that may (rational thinking loss, organized plan.) Items that are indicative of a more well-developed suicide plan are more correctly termed suicide warning signs.
Suicide Warning Signs
Suicide warning signs, as opposed to risk factors, are immediate signs that someone is preparing for a suicide attempt. These should be taken seriously, and an open dialogue should be established. Never underestimate the accuracy of a “gut feeling” or instinct in determining suicide risk. You know the person you’re worried about personally, and even if you can’t consciously identify the change in their behaviour, you’re subconsciously picking up on the change.
Warning signs that a suicide is imminent include the following:
- Giving away personal or prized possessions
- Getting final affairs in order (e.g. last will and testament)
- Someone who is normally very upset is experiencing a sudden peace – This can be because they’ve finally made the decision to die
- Stockpiling medication, purchasing other implements of suicide (rope, firearm)
- Showing interest in family member’s plans (searching for time alone)
It’s important that if you notice these signs and you’re worried, that you take immediate action. Sit down with the suicidal person and have the conversation. Use the word “suicide.” Remember that no one person is responsible for the actions of another.
The opposite of risk factors are protective factors. These are things that help reduce our suicide risk and keep us safe. Protective factors, like risk factors and warning signs can come and go; one day, week, or month we may have a number of protective factors but as our life changes we may lose some of them. It’s important that we stay vigilant to ensure we have as many protective factors as we can.
Protective factors include:
- A strong support network
- Competent mental health care (counsellor, therapist, primary-care physician)\
- Proper medication management
- Life-skills (including problem-solving) so that a suicidal person’s first instinct when confronted with an issue isn’t suicide
- Internal attributes including resilience and hope
- A belief that suicide is wrong (while not judging the rightness or wrongness of this belief, it does reduce suicide risk)
- Religion – Those who are religious tend to report lower rates of suicidality. This is thought to be partially because of religious proscription of suicide and also because of the sense of community that churches and religion provides
Remember, what one person considers a protective factor, another may not. So it’s important when talking to someone who is feeling suicidal and determining protective factors that you make sure they are actually protective factors for the person in question.
Many suicide risk assessments reduce the results into three broad categories: Low, Medium and High Risk. It’s important to realize that no one assessment can predict with great (or even necessarily “good”) accuracy when someone will attempt suicide.
Most tools that exist now return high rates of self-positives, but clinical judgement and referral to qualified mental health professionals can help make sure the most accurate judgment possible. Regardless of the rating a person is assigned, they may still suicide.
For instance, using the CPR Model, someone who has a current detailed suicide plan, no previous exposure to suicide, and a wife and children may be rated as “Low Risk”, but may shoot themselves the next day.
On the other-hand someone who is “High Risk” may never go on to kill themselves if they get the support that they need. When in doubt, seek help.