Learning Objectives
By the end of this section, you will be able to:
- Describe how self-harm can be related to mental illness
- Outline the challenges in dealing with attempted suicide in clients with a mental health problem
- Plan nursing care for a client who is contemplating suicide
- Define nonsuicidal self-injury and the approaches used to care for clients who may self-injure
Depression and suicide are deeply intertwined and represent significant public health challenges. Depression is a leading cause of disability worldwide, affecting more than 280 million people, and is a major risk factor for suicide (World Health Organization, 2023). Suicide is not a normal response to stress, but is most commonly driven by a mental disorder, such as depression or a substance use problem (American Psychiatric Association, 2022; NIMH, 2020b).
The term suicidal ideation refers to thoughts, fantasies, or preoccupations with suicide. It can range from fleeting thoughts of ending one’s life to detailed plans, with specific details on the timing or execution. Suicidal ideation is often considered a symptom or manifestation of an underlying psychiatric condition, such as depression, though it can also occur in the absence of a diagnosable mental health condition. The severity can vary significantly from person to person and it can exist on a spectrum that ranges from passive thoughts about being dead to active thoughts about how to carry out the detailed plan for suicide (Harmer et al., 2023). It is crucial for health-care providers, including nurses, to conduct a thorough risk assessment when suicidal ideation is present.
A lethality assessment refers to the structured evaluation of the risk factors associated with a person’s potential for engaging in a life-threatening behavior, such as suicide. This assessment aims to gauge the immediacy and severity of the risk to help determine the appropriate level of intervention or treatment required. Several factors are typically examined during a lethality assessment, including the presence of a detailed plan, the availability of means, the availability to carry out the plan (e.g., weapons or drugs), previous suicide attempts or violent behavior, current mental state, and other situational factors, such as social support and recent life events (Minnesota Department of Health, 2019).
Health-care providers, including nurses, often use standardized instruments like the Columbia-Suicide Severity Rating Scale (C-SSRS), the SAD PERSONS Scale, or other clinical interview protocols to guide the lethality assessment. Such assessments are vital in determining the immediate next steps, such as hospitalization, close monitoring, or outpatient treatment, as they help to identify individuals who are at higher risk and therefore require more intensive interventions (Andreotti et al., 2020).
Unfolding Case Study
Depression: Part 3
See Depression: Part 2 for a review of the client data.
| PMH | The client indicates that he has a plan to suffocate himself in the bed sheets in the hospital. He declines to come out of his room and continues to appear withdrawn and tearful. |
Self-Harm and Mental Illness
Often referred to as self-injury or self-mutilation, self-harm is a behavior that involves deliberately causing harm to one’s own body as a way to cope with emotional distress or regain a sense of control (Klonsky et al., 2014). Self-harm does not necessarily indicate a desire to end one’s life; instead, it often serves as a maladaptive coping mechanism for overwhelming feelings or situations (Elena-Rodica et al., 2023). It is, however, a significant risk factor for suicide, particularly when associated with mental disorders (Harris et al., 2019). Many mental health conditions can be associated with self-harm, including, but not limited to, borderline personality disorder, depression, anxiety disorders, and eating disorders (American Psychiatric Association, 2022). In many instances, individuals who self-harm may be attempting to manage intolerable emotional pain or regulate their emotions, express self-directed anger, distract themselves from emotional distress, or communicate their emotional state to others (Elena-Rodica et al., 2023).
Identifying signs and symptoms of self-harm is vital for health-care providers because it enables timely intervention and treatment planning. Physical signs often include visible cuts, burns, or bruises, frequently observed on wrists, arms, thighs, or other less noticeable body parts (Elena-Rodica et al., 2023). Behavioral indicators may include social isolation, wearing long sleeves or pants even in warm weather to conceal injuries, and the unexplained possession of sharp objects like knives or razors (Clarke et al., 2019). Emotional symptoms can involve increased emotional instability, impulsivity, and verbal expressions of hopelessness or overwhelming stress (Klonsky et al., 2014). Further, nurses may notice evasiveness or dishonesty when questioned about the source of injuries, along with frequent episodes of “minor accidents” that could serve as a facade for self-harm activities (Klonsky et al., 2014). Multiple visits to health-care facilities for the treatment of ambiguous physical injuries may also serve as a red flag (Plener et al., 2015). Early recognition of these signs is crucial for initiating comprehensive care, which may include risk assessments, psychotherapy, and medication management for underlying mental health conditions (Klonsky et al., 2014).
Suicide and Mental Health Problems
Suicide is a significant public health issue often linked to mental health problems. According to the WHO, more than 700,000 people die by suicide every year worldwide. Suicide is the fourth leading cause of death among individuals between the ages of fifteen and twenty-nine (World Health Organization, 2021). In the United States alone, in 2022, nearly 50,000 people died by suicide, close to four times as many males as females (Centers for Disease Control and Prevention [CDC], 2023).
A substantial proportion of individuals who die by suicide have a diagnosed mental disorder. Mental health conditions, such as depression, bipolar disorder, schizophrenia, and anxiety disorders, significantly increase the risk of suicidal thoughts and behaviors (NIMH, 2020b). Substance use disorders are also strongly associated with an increased risk of suicide, as are certain personality disorders, particularly borderline personality disorder (American Psychiatric Association, 2022).
Several factors can heighten the risk of suicide among people with mental health problems, including feelings of hopelessness, social isolation, poor adherence to treatment, high levels of impulsivity and aggression, and previous suicide attempts (American Psychiatric Association, 2022). Comprehensive mental health services, including assessment, diagnosis, and treatment, are essential to suicide prevention. Interventions often involve psychotherapy, medication management, and strengthening social support. Additionally, immediate crisis intervention is vital for individuals expressing suicidal thoughts or demonstrating suicidal behaviors. The National Suicide Prevention Lifeline is available at 1-800-273-TALK and the Suicide and Crisis Lifeline is available at 988 (NIMH, 2020b).
Methods Used in Suicide
Understanding the various methods of suicide is a critical aspect of suicide prevention and risk assessment in health-care settings. The most common methods of suicide vary by region and gender but generally include hanging, self-poisoning (including drug overdose), and firearms (Stone et al., 2018). In the United States, firearms are the most commonly used method of suicide, particularly among men (CDC, 2020). Hanging is the most frequently used method worldwide, especially in countries where firearms are less accessible. Self-poisoning, which includes overdose of medications or ingestion of toxic substances, is more common among women (Stone et al., 2018).
Health-care providers, including nurses, must be aware of these methods when assessing suicide risk. Access to lethal means can increase the risk of a suicide attempt being fatal, so a crucial part of a safety plan may involve working with clients and families to limit access to these means (Sidwell et al., 2023). Safety, empathy, and providing resources for help should always be the primary focus of such conversations (NIMH, 2020b).
Conversations about suicide with clients are a delicate yet essential task that health-care providers must navigate skillfully. Open and empathetic dialogue can serve as a powerful tool for risk assessment and therapeutic intervention. Conducting conversations with a nonjudgmental approach, employing open-ended questions, and actively listening to the client’s narrative are all techniques that may allow the client to feel comfortable enough to share sensitive information (Slade & Sergent, 2020). Providers should aim to uncover the depth of the individual’s suicidal ideation, including the existence of a plan, a means, and a timeline, as these factors significantly correlate with imminent risk (Weber et al., 2017). Clients should not only be asked about their thoughts of dying but also about their reasons for living; exploring the ambivalence between the wish to die and the wish to live can be a crucial element in a safety plan (Minnesota Department of Health, 2019). Failure to assess or inadequate assessment of suicide risk can have severe consequences, including possible legal repercussions for the health-care provider (Pinals, 2019).
Cultural Context
Cultural Perspectives on Suicide
Cultural norms and beliefs significantly influence attitudes toward mental health and suicide. Different cultures may interpret suicide differently, with some viewing it as a sin, a crime, a symptom of mental illness, or even an honorable act (Clay, 2018). For instance, in some cultures, suicide has historically been viewed as an honorable way to atone for failure or to preserve the dignity of one’s family. On the other hand, in some cultures, suicide is typically perceived as a tragic outcome of untreated mental illness (Steele et al., 2018). In indigenous communities, high rates of suicide are often understood in the context of historical trauma and ongoing systemic inequities (Connors, 2021). Therefore, understanding the cultural nuances is crucial for health-care providers in implementing effective prevention strategies and delivering sensitive care.
Many cultures and religions have strong stigmas and taboos surrounding suicide, which can prevent individuals from seeking help when experiencing suicidal thoughts. This stigma can be exacerbated by a lack of understanding or misconceptions about mental health (National Alliance on Mental Illness, n.d.). Religion can have a protective or risk-enhancing role, depending on its teachings and the individual’s relationship with their faith. In the Catholic religion, the act of suicide is considered a sin, adding another layer of stigma and complicating prevention efforts (Adamiak & Dohnalik, 2023). In some Islamic cultures, suicide is considered a sin and is highly stigmatized, making it difficult for individuals to seek assistance due to fear of social ostracization. Similarly, in some African and Caribbean communities, mental health issues may be attributed to spiritual or moral shortcomings, limiting the use of formal mental health-care services (Gearing & Alonzo, 2018). In some Chinese cultures, the concept of maintaining social standing can deter people from talking openly about mental health challenges (Yin et al., 2020). Understanding these dynamics can help health-care providers tailor their approaches to suicide prevention (Ariapooran et al., 2018).
Providing culturally competent care is essential in addressing suicide risk. This care includes understanding cultural influences on suicide, reducing stigma, and providing culturally appropriate treatment and intervention strategies (American Psychological Association, 2017). CBT can be adapted to incorporate cultural elements and rituals important to the individual, such as incorporating prayer for clients from highly religious backgrounds (de Abreu Costa & Moreira-Almeida, 2022). Engaging with religious and community leaders can help to diminish stigma and encourage more people to seek help (Minot, 2023).
Suicide Risks in Care Settings
Suicide risk within health-care settings is a critical issue that requires immediate attention from health-care professionals. The risk is not confined to psychiatric units but extends to emergency departments, medical-surgical floors, and even outpatient settings (King et al., 2017). Identifying and managing suicide risk involves comprehensive screening, vigilant observation, and strategic intervention. The Columbia-Suicide Severity Rating Scale (C-SSRS) is commonly used to assess the immediate risk of suicide among clients (Bjureberg et al., 2022). Assessment tools are not foolproof, however, and require accompanying clinical judgment and ongoing assessment.
Environmental safety measures are also crucial. Monitoring protocols, like one-on-one observation or frequent safety checks, can further mitigate risk (Quinlivan et al., 2016).
Effective communication among health-care team members is essential to maintain a high level of vigilance. Handoffs between staff should include detailed information about the client’s mental state, triggers, and coping mechanisms. Staff should also be trained in crisis intervention techniques to address acute episodes of suicidal ideation (SAMHSA, 2020a). The transition periods during admission and after discharge are times of elevated risk and require comprehensive risk assessment, safety planning, effective handoff communication, and follow-up procedures (Chammas et al., 2022).
All health-care providers must be trained adequately to recognize the signs of suicidal ideation, conduct risk assessments, provide immediate crisis intervention, and refer clients to appropriate mental health services. Collaboration and communication among health-care providers, clients, and their families is also crucial. Furthermore, integrating suicide prevention strategies into the wider health-care system, such as incorporating regular suicide risk screenings into routine care, implementing safety planning, and providing post-discharge follow-up, can help reduce suicide risk (American Psychological Association, 2019). Nurses should be skilled at identifying suicide risk factors. The SAD PERSONS Scale is a widely used clinical tool designed to assess suicide risk. The acronym stands for Sex, Age, Depression, Previous attempt, Ethanol use, Rational thinking loss, Social supports lacking, Organized plan, No spouse, and Sickness. Each factor is assigned a score, usually either 0 or 1, and the total score is used to estimate the risk level for suicide. The SAD PERSONS Scale offers the advantages of being quick and straightforward, making it a useful tool for busy health-care settings, such as emergency departments (Katz et al., 2017). After a suicide in a hospital, postvention strategies, including debriefing and support for affected staff and clients, are essential to promote healing and prevent further suicides (Andriessen et al., 2017).
Link to Learning
The Zero Suicide Institute’s mission is to decrease the incidence of suicide in clients under the care of a health-care provider. Their website provides information for implementation in clinics and practices.
Preventing Suicide in Care Settings
Preventing suicides in health-care settings requires a multifaceted approach encompassing self-awareness, risk assessment, environmental safety, staff training, and continuous client monitoring. Regular screening for suicide risk, as part of routine care, is essential, especially for clients with known mental health disorders, a history of suicidal behavior, or other risk factors (Chammas et al., 2022).
Self-awareness plays a critical role in suicide prevention within health-care settings. Being cognizant of one’s own biases, emotions, and knowledge gaps can directly influence the care provided to at-risk clients and may even impact outcomes. Health-care providers may hold conscious or unconscious biases related to suicide and mental health that could affect their judgment or interaction with clients. Being self-aware enables health-care professionals to recognize these biases and work toward mitigating their effects (Knaak et al., 2017). Providers must be aware of their emotional reactions when dealing with suicidal clients. Emotional responses like fear, discomfort, or frustration can impair clinical judgment and interfere with effective communication (Weber et al., 2017). Maintaining appropriate professional boundaries is crucial. Emotional involvement may cloud clinical judgment, whereas detachment may result in lack of empathy. Self-awareness assists in balancing empathy with professionalism (Banerjee et al., 2020). Providers should also recognize the emotional toll that managing high-risk clients can take and engage in appropriate self-care strategies, including debriefing sessions and consultations with peers or mental health professionals (SAMHSA, 2021).
Environmental safety measures can prevent suicides. These measures can include limiting access to means of suicide, such as certain medications or medical equipment that could be used for self-harm, and designing inpatient units with reduced opportunities for hanging or jumping (Chammas et al., 2022). Staff training is another key aspect of prevention. Staff should be trained to recognize signs of suicidal ideations, such as verbal or written expressions of suicidal thoughts, behavioral cues like withdrawal or agitation, and emotional indicators like severe anxiety or hopelessness (Zalsman et al., 2016).
Continuous client monitoring is a key component of effective suicide risk management within health-care settings. The level of monitoring should be aligned with the individual client’s risk level to ensure that adequate safety measures are in place. Those identified as high risk often require continuous one-to-one observation to ensure their immediate safety. This could include constant visual observation, sometimes even during personal activities like showering, to minimize any opportunity for self-harm. Those at moderate or lower risk may not require constant monitoring but should be subject to regular and frequent checks. The frequency of these checks should be based on a structured risk assessment and modified as the client’s condition changes (Shekelle et al., 2019).
Health-care providers must be vigilant for changes in behavior, affect, or verbal statements that may signify an increased risk of suicide. New or heightened expressions of hopelessness, agitation, or withdrawal should trigger an immediate reassessment of the level of monitoring required (Quinlivan et al., 2016). Thorough documentation of all observations and any changes in behavior is crucial for both ongoing care and legal considerations. Documentation should be detailed, contemporaneous, and communicated clearly during handoffs between staff members (Harmer et al., 2023). Suicide risk may change over time. Frequent reassessments help reduce risk, especially after any significant event like a familial crisis, change in medical condition, or adjustment in medication (National Action Alliance for Suicide Prevention, 2019).
Physician-Assisted Suicide
Physician-assisted suicide is a contentious issue that has implications for nursing practice. A physician provides a terminally ill client with the means, such as a prescription for lethal medication, to end their own life (Emanuel et al., 2016). The laws governing this action are different in each state. Nurses may find themselves in situations where they must navigate the ethical and legal challenges associated with this practice. The American Nurses Association (ANA) states that nurses should not participate in assisted suicide, even in jurisdictions where it is legal, because it is inconsistent with the ethical principles and standards of the nursing profession (ANA Center for Ethics and Human Rights, 2019). This statement does not mean that nurses should abandon clients who are considering or have chosen this path, however. Nurses are still obligated to provide compassionate, nonjudgmental care and respect the client’s autonomy while maintaining a focus on alleviating suffering (ANA Center for Ethics and Human Rights, 2019).
Planning Nursing Care for a Suicidal Client
Planning nursing care for suicidal clients necessitates a meticulous, comprehensive, and systematic approach. The immediate priority involves ensuring the client’s safety. The nurse should initiate suicide precautions. One suicide precaution includes maintaining a safe environment by removing items that could be used for self-harm or suicide, such as sharp objects, cords, and certain medications (Pinals, 2019). Regular and meticulous client monitoring is also a crucial aspect of suicide precautions, with clients being checked at frequent, unpredictable intervals to prevent any potential suicide attempts (Bowers et al., 2015). Ensuring that clients are not left alone and have someone to talk to can help alleviate feelings of isolation, which often accompany suicidal ideation.
Communication with suicidal clients also plays a critical role in nursing care planning (Falcone & Timmons-Mitchell, 2018). Develop a therapeutic relationship that encourages the client to express their feelings and thoughts openly. It is often a relief for clients to talk openly about their thoughts, and this also decreases isolation. This connection allows for a better understanding of the client’s emotional state and suicidal ideation, which can guide the implementation of appropriate nursing interventions. The nurse should never be reluctant to ask the client if they are contemplating suicide or self-harm because asking a client if they are suicidal will not put the thought into their head. If the client answers that they are, then the nurse has to ask which method of harm the client is contemplating so the nurse can carry out a risk assessment of the client and initiate protective precautions as necessary.
Providing crisis information to a suicidal client in a health-care setting is a critical and sensitive task. It is crucial to ensure that the information is accurate, easily understandable, and actionable. Make sure to provide numbers for emergency services and crisis hotlines, such as the Suicide and Crisis Lifeline at 988 (988 Suicide & Crisis Lifeline, 2022). It is important to assist the client in developing a personalized safety plan that includes identifying warning signs, coping strategies, and emergency contacts. Educating family members or close friends about the signs of suicide and how to offer support is essential in reducing suicide risk. In addition, integrating family members into the care plan helps create a supportive environment for the client during their recovery. Managing suicidal clients takes a multidisciplinary team approach. A team consisting of psychiatrists, psychologists, social workers, and nursing staff can provide holistic care that addresses a client’s physical and mental health needs (Moscardini et al., 2020).
Nonsuicidal Self-Injury
Self-harm, more formally referred to as nonsuicidal self-injury (NSSI), is a behavior involving deliberate self-inflicted harm that is not intended to result in death. NSSI usually presents as skin cutting, burning, or severe scratching, and is often associated with a desire to cope with distressing emotions or to communicate emotional pain to others (Grandclerc et al., 2016).
The complex nature of NSSI necessitates a multifaceted approach to management and prevention. For example, interventions may focus on teaching alternative coping strategies and emotional regulation skills and facilitating supportive interpersonal relationships (Timberlake et al., 2019). NSSI is a serious concern due to its association with an increased risk of future suicide attempts. Therefore, health-care providers must be attentive and proactive in recognizing and addressing this behavior (Grandclerc et al., 2016).
Types of Self-Harm
Self-harm refers to a variety of behaviors that individuals engage in with the intent of deliberately causing harm to themselves. These behaviors can be categorized into several types based on the method of self-injury (National Alliance on Mental Illness, 2020b). Cutting or scratching the skin is the most common form of self-harm. This form of self-harm typically involves using sharp objects like knives, razors, or even the individual’s fingernails to inflict superficial to moderate injuries, primarily on the arms, legs, and torso (Mayo Clinic, 2023). Another type of self-harm is burning, which involves applying heat or friction to the skin to cause damage. For example, individuals may use lighters, matches, hot metals, or even heated objects like a hair straightener or an iron (Cipriano et al., 2017). Other forms of self-harm include self-hitting, such as punching oneself or banging one’s head against a wall; self-poisoning or overdosing, which involves ingesting toxic substances or taking an excessive dose of medication; and interference with wound healing, where individuals deliberately prevent their wounds from healing normally (National Alliance on Mental Illness, 2020b).
While these types of self-harm may not be intended to result in suicide, they are often associated with severe emotional distress and mental health conditions such as depression, anxiety, and borderline personality disorder (Victor & Klonsky, 2014). These behaviors are a cry for help and indicate deep emotional pain. Individuals who self-harm often struggle with intense feelings of sadness, self-loathing, emptiness, or frustration, and they may have difficulty regulating, expressing, or understanding their feelings. Hence, health-care providers must recognize and address these behaviors promptly. Recovery is possible with professional help, and it often involves treating any underlying mental health conditions, improving emotional regulation skills, and developing healthier coping mechanisms (Mayo Clinic, 2023).
Link to Learning
The Substance Abuse and Mental Health Services Administration has provided a list of examples of self-harm that may be used by a mental health client.
Addressing Nonsuicidal Self-Injury in Care Settings
Clients admitted for other health issues may engage in NSSI while in the health-care facility. Staff should be trained to identify signs of NSSI and assess the level of risk, including the likelihood of escalation (Cipriano et al., 2017). Once identified, immediate steps should be taken to ensure the client’s safety. This may include removing objects that could be used for self-injury and considering relocation to a more closely monitored setting (Witt et al., 2021). Open, nonjudgmental communication is essential for building trust. Clients should feel understood rather than stigmatized (Witt et al., 2021). The nursing staff should continuously monitor the client’s mental and emotional state because changes may require adjustments to the treatment plan. Managing NSSI in health-care settings involves a multidimensional approach that considers immediate safety concerns, long-term treatment options, and the emotional well-being of both clients and health-care providers (Zhang et al., 2023).
Relationship between NSSI and Suicide Attempts
Understanding the relationship between NSSI and suicide attempts is important for effective prevention and intervention strategies. To be clear, MSSI refers to deliberate self-harm without suicidal intent, such as cutting or burning oneself, and is primarily used as a coping mechanism for emotional distress or to feel a sense of control (Zhang et al., 2023). In contrast, suicide attempts involve self-harming behaviors undertaken with the intent to end one’s life (World Health Organization, 2021). NSSI can be distinguished from suicide attempts by differences in intent, lethality, and frequency. NSSI is often repetitive and episodic, with no intention to die, whereas suicide attempts are usually less frequent but with higher lethality and intent to die (Zhang et al., 2023).
Still, individuals engaging in NSSI are at a higher risk of later suicide attempts, making NSSI a significant predictor of suicidal behavior (Chesin et al., 2017). Both NSSI and suicidal behaviors are indicators of severe emotional distress and mental health issues. Therefore, the presence of either behavior warrants immediate attention from health-care providers, who should employ a comprehensive approach to address the underlying issues contributing to these behaviors (Zhang et al., 2023).
Clinical Judgment Measurement Model
Importance of Clinical Judgment in NSSI
Accurate clinical judgment is crucial in identifying and managing NSSI. It guides recognizing and analyzing cues during initial evaluation and diagnosis and shapes the treatment approach and ongoing monitoring. Conversely, failure to exercise sound clinical judgment can result in a lack of recognition of NSSI, an incomplete understanding of the client’s situation, ineffective treatment strategies, and potentially serious health consequences. Properly assessing the severity and frequency of NSSI behaviors enables clinicians to make informed decisions about immediate interventions and long-term treatment plans. It is imperative for the health-care provider to ask the client direct questions related to self-harm potential. Therefore, improving clinical judgment in this area is vital for ensuring the best possible outcomes for individuals who self-harm (“Self-Harm: Assessment, Management and Preventing Recurrence,” 2022).