Suicide Response Part 1 Workbook

1 © 4 Mental Health Ltd. 2021Workbook v1.2

Suicide Response Part 1 Workbook

Important: Safety Protocol

We take the wellbeing and emotional safety of all our training participants very seriously. The trainers have a key role in supporting participants during the training.

If you are reading this booklet while on the training course, and the material brings up uncomfortable or distressing feelings, please speak to one of the trainers.

Many of us have been touched by suicide or self-harm in some way, whether through celebrities or public figures, or people from our own communities, colleagues, friends, family or perhaps even ourselves. We know how important it is to talk about things and seek timely support.

If you are reading this booklet after the training, and the subject matter makes you feel at all unsettled or distressed, please seek appropriate support as soon as possible.

“We wish we could reach everyone who is thinking that life isn’t worth living and help them to see that their suicidal thoughts and feelings are a sign that they need to change something in their life, not to end their life.” Dr Alys Cole-King, Director 4 Mental Health

Emotional distress, self-harm and suicide tragically still affect far too many lives. The responsibility for people at risk of suicide is often seen to lie with specialist mental health services, while others are wary of getting involved. At 4 Mental Health, we believe that everyone can potentially help someone in distress or with suicidal thoughts. Compassionate help from a colleague, friend, health provider, care giver, or even a complete stranger can make a real difference to someone who is in distress and considering suicide.

Every person lost to suicide is a tragedy affecting families, friends, colleagues and the wider community. The majority of people who end their lives by suicide are not in touch with mental health services around the time of their death. However, they almost always have had contact with someone. Every contact a suicidal individual has with another person is a potential opportunity to intervene and prevent that individual from going on to harm themselves or die by suicide.

Suicide is not the inevitable outcome of suicidal thoughts. Most people who have suicidal thoughts are ambivalent about dying but may be unable to imagine other potential solutions. With the right support people can find their way through a suicidal crisis and recover. Many people in distress report that they don’t know where to seek support and find it hard to believe that anyone cares about their suffering. They are often reluctant to talk about their suicidal thoughts.

The Connecting with People training aims to increase understanding and compassion and reduce the stigma associated with talking about suicide. The training is designed to develop the confidence and ability to engage in a compassionate and effective way with people who are experiencing emotional distress, having suicidal thoughts or following self-harm.

The Connecting with People training programme and resources have been developed to be as easy to use and accessible as possible. We believe that everyone has the capacity to help and to do so safely. We have developed our training and materials using the very latest research and with the help of an international group of experts, including academics, health care providers and suicide prevention charities. We have also worked closely with people (and their carers) who themselves have experience of self-harm, suicidal thoughts, suicide attempts and bereavement by suicide.


Throughout the session it will be possible to post questions to the training team and a named person will be allocated to collate these. At the beginning of the event we will explain how questions can be submitted. We will do our best to respond to questions at various points during the event, however If the number of questions is too great then we may not be able to respond to all of them.

Exercise 1: Triage Story in the Accident and Emergency Department

• Who might those in Emergency Departments unconsciously select to treat first?

• What are some of the reasons for stigma associated with suicide and self-harm?

• What are the barriers to a patient disclosing their suicidal thoughts?

• How can we overcome these barriers during a suicide risk assessment?

Extra Notes:

Questions and Exercises


Nature of the suicidal thoughts

Rare

Mild

Gradually develop

Momentary

No wish to die

Coping well with emotional pain

Easy to ignore/little

Frequent

Intense

Instantly present

Long lasting

Wish to die

Not coping at all with emotional pain

Intrusive/distressing

1. Frequency

2. Intensity

3. Speed of Onset

4. Persistence

5. Wish to Die

6. Ability to cope with emotional pain

7. Intrusiveness and distress

PLEASE NOTE: This should be used only by someone who has had appropriate training in its use and only as part of a full clinical assessment or within an ongoing therapeutic relationship

8. Hope

9. Alternatives toSuicide

10. Method

11. Time

12. Place

13. Means

14. Practical arrangements

15. Chance of discovery

16. Resistibility

Perception of the future

Degree of planning on suicidal act

Degree of preparation

Ability to resist thoughts of suicide

There is hope

There may be an alternative

No idea how

No idea when

No idea where

Has not obtained the means

No arrangements made

No steps to prevent discovery

Has specifically obtained the means and may have enacted elements

Arrangements made (e.g. funeral, pets)

Care taken to prevent discovery

Knows exactly how

Knows exactly when

Knows exactly where

The future is totally hopeless

There is no alternative

Easy not to act on thoughts

Feels no option but to act on thoughts

Exercise 2: Understanding The Continuum of Suicidal Thoughts (Cole-King & Platt 2021)

Details as appropriate






Use of the Continuum

Use the Continuum to capture the ‘here and now’. Use the free text box under each section to give additional details. For example, if there have been any recent changes in suicidal thoughts, such as more frequent, getting stronger, or more persistent. Also note down if feelings such as hopelessness, ability to cope with emotional plain or ability to resist suicidal thoughts have resulted from (or been exacerbated by) any disinhibiting factors such as substance use or an excess of alcohol consumption.

Exercise 2a. Understanding the Continuum of Suicidal Thoughts

General Discussion Notes:

Exercise 2b. Understanding the Continuum of Suicidal Thoughts

In this exercise you will be thinking about how the Continuum relates to and supports what you do

1. Going forward how do you see it supporting your conversations and consultations?

2. What part would it play in your assessments of people in distress?

3. How do you see the Continuum supporting and enhancing your referrals for people in distress with suicidal thinking? (or simply in discussing cases).


Exercise 3: Demographic Risk Factors

Demographic and Social Personal Background Clinical Factors in History Mental State Examination and Suicidal Thoughts Warning Signs

Age alone not risk factor interaction with other factors related to age of person e.g. loss, illness, painMen (3:1) 25-64yrs & >75yrsNon-disclosure extent distress or suicidal thoughts; Inability ask for/accept support or late help-seekingImpact work stressRedundancy/Unemployment Threat or actual job losslong term unemployedMarital status; separated> 1st year after separation > divorced > widowed > single > married; married women >single womenEthnic/Cultural Trauma: Experience or perception of intergenerational trauma, discrimination and/or inequality and/or feeling marginalised on basis of ethnicity or cultureInsecure/Temporary visa status (immigrant, asylum seeker or refugee) LGBTQI+.

Family History:Suicide and mental illness, particularly alcoholism and Bipolar Affective Disorder.Occupational risk:High/ low economic status; Sudden loss of status.Job strain: high demand, low control, low social support, job insecurity.Extended ‘working awayfrom home’ or isolation and/or access lethal means.Mining/Construction workers; Transport industry (truck drivers), Farmers; Pharmacists, Dentists, First Responders, Veterinary surgeons, Female health and social care esp nurses doctors: Drs esp. anaesthetists)Suicide BereavementFeels close to someone who died by suicide family or non- kin; Exposure suicidal behaviour others (family, peers, favourite celebrity)

ANY Mental Illness: Esp if repeated relapses; recent MH admission or discharge from a mental health inpatient unit/ hostel/day care 1st 72hrs Recent relapse in mental illness; Depressive symptoms: nihilism, anhedonia, insomnia, self-neglect; severe anxiety/panic, PTSD, depersonalisationPrimary care: incr. frequency appointments and/or several changes to medication, increasing requests for scripts.Medication:Prescribed and OTC (consider weekly scripts). Beware Dr ‘shopping’;N.B. Consider additive effect different medication.Perinatal period esp if new or persistent expressions of incompetency as a mother or feelings of estrangement from babyASD: maskingordifficultyexpressing thoughts/feelings

Negative thoughts,Hopelessness: Perception of the future persistently negative;Esp. worrying if only able to see 1-2hoursfuture.‘nothingtolivefor’.Helplessness,guilt,‘I’maburden’;Highdegreeemotionalpain or agitation.Feeling‘overwhelmed’;Feels trapped/ unable to escape ‘entrapment’;Disconnected ’thwartedbelongingness’;Sudden and unexplained change in personality/mental state, e.g. calmness following agitation;Shame or humiliation especially ifsevereand/orifinconflictwithunderlying religious or spiritual beliefs;

Inability to generate any optimism Unable to distract from negative or suicidal thinking

Acute or Chronic Life Event: Loss event: attachment or key relationship; recently bereaved loss of role e.g. leaving armed forces; cyberbullying/bullying/ hate crime; being a carer; domestic abuse/domestic violence; sexual/ physical abuse;debt/financialworries;moving home, insecure tenancy; criminal justice system - any involvement incl impending court caseesp.first-timeoffenders)Childhood no memory of being special to any adult when a child; Care leaver

Traits and Cognition: Lower distress tolerance or difficultyproblemsolvinge.g.rigid thinking or low IQDiagnosis of a personality disorder - should not be a diagnosis of exclusion• Impulsivity/ Recklessness• Aggression• Lability of mood• Increased risk taking• Fearlessness about death Insight: Early stage of illness/Previous high functioning and fear of deterioration

Self-harm or suicide attempts Suicide risk x 50-100 times after self-harm (regardless of intent, includes cutting). Beware previous high suicide intent attempt (esp. hanging); Recent increasing suicide intent or escalation of self-harm if repeated self-harmBeware method can change from low lethality method to a high lethality methodSome people unaware of medical lethality of given a method (important for means restriction/safety planning

Suicidal Ideas and Plans: High variability suicidal thoughts; Recent worsening in thoughtsVerbal cues, giving away prized possessions;Especially if pervasive and compelling;Suicide plans/preparations Mental or practical rehearsal of suicide attempt;Visualising suicide attempt or their body after death.‘AcquiredCapability’

Social disconnectedness• Perception lack social

support/noconfidants• Social isolation/living alone

incl living rural / remote area

• Withdrawing from relationships.

• Major relationship instability

Substance use:• Alcohol and/or illicit drug

use; long history drinking or high-level dependency

• Poly drug useEsp. if precipitated: • Recent loss e.g.

relationship loss• New relapse after a period

of abstinence.• Also consider potential to

act whilst intoxicated or if binge drinking

Chronic Medical Illness/ Pain: (1 in 10 suicides); life-limiting condition, functional disability; cancer; dialysis; gastrointestinal disease; cardiovascular disease. Post-cerebral trauma. male patients with GU disease. Tinnitus, MS neurological illnessEpilepsy (especially early onset); dementia; delirium; cluster headaches. Repeatedly seeking specialist referrals (looking for hope)Distressing side effects or adverse drug reactions e.g. akathisia

‘Affairs in order’ e.g will preparation‘Saying goodbye’ notes, social media posts, texts, videos, emails. Use of suicide promoting websites;High perceived lethality of method chosen and no potential for rescue/ reduced treatment

Psychotic symptomsEsp. if distressing: persecutory or nihilistic delusions, command hallucinations esp. if perceived as omnipotent (pervasive)

Access to Lethal Means: (e.g. firearms, ‘frequently used locations’); consider access due to profession or hobbies, ordering medication online ‘Stockpiling’ medication


Understanding evidence based risk factors and red and warning signs

When looking at and identifying risk factors we need to understand the significance of these and also how to respond. This exercise and session explores this a bit further and is introducing clarity on the weighting of demographic risk factors as opposed to others, the significance of red flags and warning signs and the consideration of a mitigation approach to risk factors once identified.

Note: An absence of risk factors does not assume that there is an absence of risk – remember what the Continuum might show you about someone’s level of distress. However, once risk factors are identified then actions/mitigation may be able to be taken in response to these.

Notes:


Think about:

1. How will the classification support your response to a patient?

2. How will the detail from the classification support you making referrals to other services?

3. How can the process of assessing someone at risk of suicide be used as an opportunity for a ther-apeutic intervention?

See the next page for the full Classification which includes the detailed clinical descriptors and suggested additional interventions to be done in conjunction with your ‘treatment as usual’ Management Plan. This is what supports us having a common understanding, common language and a consistent approach to pa-tients in distress and/or with suicidal thoughts.

Exercise 4: Understanding Classification of Suicidal Thoughts™

Classification of Suicidal Thoughts (Cole-King 2010, Cole-King and Platt 2021)

Characteristics Passive Active In danger In danger and Imminent

Nature of thoughts

Perception of future

Planning

Preparation

Ability to resist

Safe triage andResponses to consider

This is the element of the SAFETool which is populated by completing the compassionate questioning of a patient using the Continuum


This should only be used by someone who has received appropriate training from a licensed Connecting with People trainer. It is designed to support a compassionate clinical assessment and not intended to replace usual judgement.

Passive Active In Danger In Danger and Imminent

Nature of suicidal thoughts

Infrequent, mild, slow onset (e.g. lasting seconds/minutes)To escape a distressing situationEasy to ignoreCauses little distress

Conscious awareness Increasing in frequency, intensity or persistenceStarting to have difficultyingeneratingpositive future thoughts

Increasing distress

Frequent, persistent, intense, becoming compellingStart to focus on suicide to exclusion of more optimistic thoughtsVery hard to generate any positive future thoughts

Frequent, persistent, intense, compellingImpossible to generate any positive future thoughtsUnable to distract from thoughts of suicideUnable to entertain any other thoughtsPowerful and compelling

Perception of future

Lifeisdifficultbutknowthey have a futureHopes situation will resolveCoping with the emotional pain

LifeisverydifficultFutureisdifficultHard to see an end to their situationMay still have some hope and is coping with the emotional pain

Life is a struggle.Struggling to see a future Unable to see an end to their situation.Little or no hope.Emotional pain almost unbearable.Starting to disconnect from life and futureMay be giving away possessions

Life is impossibleNo futureSuicide is only option.Unable to see beyond todayExtreme hopelessness Emotional pain totally unbearable unless they feel relief at taking the decision to end their lifeDisconnection from life and future

Degree of planning of suicidal act

Suicide is not an option, no planning

Conscious thoughts of suicide but as suicide is not an option, no planning

Conscious thoughts of suicide and planning started though not completeConsideration/research of potential methods

Planning completeLikely to have chosen a potentially, or perceived as, lethal methodMay have a date and venue etc. with no/little expectation of discovery


None, as suicide is not an option.

Conscious thoughts of suicide but as suicide is not an option, no preparation

Preparation started Seeking means Sorting out affairs

Means obtainedAffairs in order


Suicide is not an option and/or thoughts are very easy to resist

Absolute belief that they will not act on thoughts

Able to resist thoughts Unsure about ability to resist thoughts of suicide and fears for their own safety

Unable to resist thoughts of suicide


Passive Active In Danger In Danger and Imminent

Possible Response

Establish relationship and rapport/Provide compassion. Review strengths and protective factors eg hope, reasons for living, supportCo-produce an immediate Safety Plan including agreed actions, coping strategies and people to contactRemove/mitigate access to means of harming themselves/ending their lifeIdentify triggers and plan responsesReview wellbeing and maximise emotional and social supportDocument NHS, Voluntary/third sector. Signpost StayingSafe.net Consider onward referral if clinically appropriateOther as required

Establish relationship and rapport/Provide compassion. Review strengths and protective factors eg hope, reasons for living, supportCo-produce an immediate Safety Plan including agreed actions, coping strategies and people to contactRemove/mitigate access to means of harming themselves/ending their lifeIdentify triggers and plan responsesReview wellbeing and maximise emotional and social supportDocument NHS, Voluntary/third sector. Signpost StayingSafe.net Consider onward referral if clinically appropriateOther as required

Triage/assess if safe to review later that day/next day HOWEVER may need to consider onward referralEstablish relationship and rapport. Provide compassion and share hope. If possible Start to uncover reasons for living and share distress reducing strategies to help alleviate distress Co-produce a robust Safety Plan including reasons for living, agreed actions and people to contact. Remove/mitigate access to means of harming themselves/ending their lifeIdentify distress triggers and rehearse robust responses - document in Safety PlanMaximise protective factors (social support). Suggest they stay with family or friends - agree a safe locationReview wellbeing and maximise emotional and social supportDocument NHS, Voluntary/third sector organisations as sources of support. Show how to use StayingSafe.net Consider onward referral if clinically appropriate - discuss with appropriate colleagues as neededEngageinbenefitsof disclosing suicidal thoughts to key supporter(s)Other as required

Potential immediate risk of suicide without interventions to maintain safety. Urgent intervention required. Ensure they remain safe and compassionately supported during and between assessment(s)Establish relationship and rapport. Provide compassion and share hope. If possible start to uncover reasons for living and if not possible consider sharing distress reducing strategies to help alleviate distress Initiate a robust Safety Plan (if possible) including reasons for living, agreed actions and people to contactNeed to remove, or if not possible, mitigate against access to means of ending their life. Start to identify triggers and plan helpful responses to help alleviate emotional painImmediate discussion to initiate referral into specialist mental health services. Show how to use StayingSafe.netIf patient is unknown to practitioner immediate referral essential for extended assessment and planning. Show how to use StayingSafe.netEngage in benefits of disclosing suicidal thoughts to key supporter(s)Consider breaking confidentiality if it is necessary in order to preserve lifeOther as required


Exercise 5: How will the Classification Support Effective Referral and Triage?

Think about the:

• Language Terminology

• Structure of Questioning (Continuum)

• ‘Red Flags’

Notes:

Exercise 6: What are people’s reasons for living? Such as reminders

Notes:


Safety Plans – StayingSafe.net and SAFEToolSafety planning is not a ‘one size fits all’. We need a more sophisticated approach which ensures that the nature and quality of a Safety Plan is matched to the needs of a person in distress. It also should take into account the capability and role of the person who is supporting someone to produce a safety plan. 4 Mental Health has three levels of Safety Plan within the Connecting with People programmes, as outlined below:Self-help Safety plan via Suicide Awareness (Community and Professionals) ModuleStayingSafe.net offers a ‘self-help’ Safety Plan:

• To make safety planning available and accessible to people in the community, for use before formal help-seeking

• Designed as a safe and accessible self-help guided process.

Supported Safety Plans via Suicide Response Part 1 / Suicide Response for Primary Care ModuleThere appears to be a correlation between the quality of Safety Plans and their effectiveness. Gamarra (2015) showed that high quality safety plans were associated with fewer psychiatric hospitalisations among veterans, and were more likely to be completed and detailed while also specific and person-centred. Lower quality safety plans tended to be too generic, missing out key sections, such as removal or mitigation of means and ‘means safety’ or internal coping skills, and included general statements such as ‘read’, instead of specifically identifying exactly what to read (e.g. the name of a book or magazine). It is for this reason that the Supported Safety Plan, designed to be developed during a triage or brief assessment, encourages personalisation and the co-production of a bespoke, ‘immediate’ Safety Plan, with detailed guidance for the supporter.

Enhanced Safety Plans via Suicide Response Part 2 ModuleProfessionals working in specialist services, GPs offering enhanced clinical care and expert third sector volunteers (charity and voluntary sector or NGOs) will be able to use their specialist skills to maximise the opportunity to co-produce a detailed and bespoke ‘longer term’, or Enhanced, Safety Plan. This will also involve supporting the person in distress to start to identify their distress triggers.

Once triggers have been identified, the trained supporter will collaborate with the person in distress to co-produce a list of potential ways to remove or avoid such triggers, or to mitigate them if removal/avoidance not possible. This may involve the development of clear contingency plans, such as defining exact coping strategies and their duration while also considering the use of identified sources of social, emotional and emergency support. The focus on identifying and minimising the negative impact of distress triggers should help the person in distress to avoid crisis in the future. Additionally, the person in distress will have explored ways to have more self-agency and access to resources to deal with future stressors, and be able to navigate a mental health crisis, characterised by severe distress and suicidal thoughts, more safely.

ReferencesGamarra, J.M.; Luciano, M.T.; Gradus, J.L.; Wiltsey Stirman, S. Assessing variability and implementation fidelity of suicide prevention safety planning in a regional VA healthcare system. Crisis 2015, 36, 433–439.

12. Safety Planning


Exercise 7: Co-producing a Supported Safety Plan with a Case Study

Please read the case study and then in your small groups start to construct a safety plan for the person

Thinking about reasons for living, reminders, family, friends, confidants, resources and services - activities, actions and plans for the future…

Case study 1: Patient Case Study - Stephen James aged 15

IntroductionStephen James has been referred to you as an emergency via his GP. His mum attends with him. Stephen is aged 15 and lives with his parents and younger sisters aged 9 and 11.

Presenting complaint Low mood, recent episode of self-harm/suicide attempt.

Current problemsLast month, Stephen’s mum was retrieving clothes to wash from his bedroom and whilst doing so she found a suicide note. It was addressed to her and Stephen’s dad and it apologised for any hurt saying “I think you’d be better off without me”. When his mum spoke to Stephen about the note, he confided that he’d taken an overdose of four paracetamol after writing it but then made himself sick and didn’t tell anyone.

Over the last few months, Stephen has become increasingly irritable and withdrawn, and is now well behind with his course work. The difference in Stephen has been so noticeable that his form teacher contacted his parents a few weeks ago to express her concerns about the changes she’s noticed. Stephen has a couple of close friends but says that he’s too busy to see them. He’s also given up his hobbies including cutting down on the number of Friday football training sessions and Saturday matches he attends, and has recently dropped out of his local youth club although he’d previously enjoyed attending every Wednesday evening..

Relevant past psychiatric and family historyStephen has a past history of cutting his arm which started about six months after his maternal grandmother’s death when he was aged 12. Stephen was very close to his grandmother and her loss caused him to experience intense grief. He didn’t feel that he could confide in anyone and so began using self-harm as a way of coping with his emptiness.

Five years before his grandmother’s death, his maternal uncle ended his life by suicide and Stephen’s mum was severely affected. She’s been treated for recurrent depressive episodes ever since.

Relevant personal history

Stephen had a happy childhood until his uncle died by suicide precipitating his mum’s serious depressive illness and an alcohol problem. His father also developed an alcohol problem around this time and his parents temporarily split up when Stephen was 10. Prior to the marriage breakdown, his father had occasionally been verbally abusive to the whole family when intoxicated which eventually precipitated his leaving the family home. Neither parent has any forensic history.

Stephen and his siblings stayed with their mum but he had to move to a new primary school where he suffered bullying until he began secondary school. By this time, the history of bullying had affected his confidence and as a result he found it difficult to make friends. His parents managed a reconciliation last year and the situation at home is now much better; neither parent is drinking to excess and Stephen’s father is no longer abusive to the family.

Current social circumstances

Stephen and his family now live in a rented house and although there are debt problems, his mum and dad are receiving debt advice and trying to improve their budgeting. His parents lack confidence in general, and whilst they love their children, they find it difficult to identify and express their feelings. Due to a lack of space in the house, there is no room for a dining table so they tend to eat ‘on the hoof’ and subsequently don’t have a lot of time together as a family unit.


Safety Plan for Stephen James Case Study (Supported Plan)

Supported Safety Plan Parental Aspects of Safety Plan

Getting Through Right Now

keep a handy reminder of the people and things you love or things which help you get through tough times

Safe Environment

removal/mitigation of access to means and ask patient to identify/avoid triggers such as alcohol or drugs including benzodiazepines for example

Activities to Lift Your Mood

If you are becoming distressed or thinking about harming yourself

Calming Activities


Distracting Activities

Identify things that distract you when you are distressed or thinking about harming yourself

General Support or Distraction

names and contact details of supportive family, friends, confidants and others

Specific Suicide Prevention Support

list who you can talk to if you are distressed or thinking about self-harm or suicide

Professional Support

Emergency Contacts

Personal commitment to Safety Plan


Case Study 2 - Bill Smith aged 52

Please read the scenario below and use the information to complete SAFETool Triage as if you were assessing Bill in your usual role

You assess Bill as an emergency. He is with his daughter. He is a cleaner for a large national company. Back injury 18 months ago, rarely uses healthcare apart from attending GP surgery for 3 monthly painkiller prescription review. Last appointment was informed they would not increase his medication any further.

Presenting complaintSuicidal thoughts for the past month; worse for 1 week, much worse for last 2 days.

History of presenting complaint

• 1 week ago – started feeling more hopeless, suicidal thoughts became more frequent, intense, harder to push away, and he began ruminating about his uncle’s suicide. “I was wanting to join him”.

• Last night Bill wrote the first line of a suicide note and searched for suicide-promoting websites but a Samaritans link appeared on the search engine. He called them: “It calmed me down and helped a bit”.

• This morning Bill found the suicide note he’d started to write. He panicked and phoned his daughter who set up today’s urgent appointment

Accompanying symptoms

3/12 Low mood – feels worse first thing in the morning but mood lifts in the afternoon.

3/12 Poor sleep – unable to drop off, waking early 5.00-5.30am for 2/12 (usually wakes up 7.00).

3/12 Appetite reduced and has lost weight and dropped a belt size.

1/12 Motivation down, ‘can’t be bothered’, unable to enjoy life, starting to feel hopeless.

1/12 Ability to enjoy life impaired but still able to enjoy seeing grandchildren (aged six and nine) once a week when they visit after dance class. But for the past month has “no patience when they play up”.

Recent life events and stressors

• Reconciliation with 2nd wife, (after several years apart) failed six months ago. Wife now wants a divorce.

• She left him partly due to their ongoing arguments and issues relating to his long-term drinking.

• His soon to be ex-wife was his best friend and he now feels he has no one to confide in.

• His employer is undertaking a review of employees and he is worried about redundancy.

• Bill is worried about his finances and mounting debts.

• Bill lives alone in a rented flat. He’s worried that he might lose the tenancy due to rent arrears.

Mental state examination Appearance and behaviourDishevelled, unshaven, poor eye contact. Initially distressed and hard to build rapport- became calmer.

SpeechInitially some delay in answering

Mood Practitioner’s view – He appeared depressed. Bill’s view – “Pretty bad”.

Details of suicidal thoughts (Continuum and Classification)

• Bill’s suicidal thoughts were occurring a few times a week, now most days (especially if he spots his pile of unpaid bills).

• They are getting more intense, take about 30 seconds to develop and usually persist for several minutes.

• Today Bill tells you he doesn’t actually want to die, saying “I can’t do to my family what my uncle did to me…..I can’t do that to my sister, kids and grandkids. He said his grandkids are “my reason to get up in the morning”.


• Bill is coping with his emotional pain, but the suicidal thoughts are starting to “get to me”.

• Last 2 days suicidal thoughts more intrusive, harder to ignore, lasting about 10 mins and cause him distress.

• Feels hopeless, “a burden” and is increasingly guilty that he is “letting my family down”.

• The future looks “very difficult” if he loses his job, but Bill wants help rather than to end his life.

• Bill has vaguely considered various ways to end his life, including how he could obtain a necessary amount of medication, but he has not thought through a fully detailed plan.

• He has not yet made any arrangements or preparation for after his death, though he says he has thought a little about how to get his finances in order and how to reconcile with some members of his family that he has not seen for many years.

• Most of the time it is easy to resist the suicidal thoughts. he can see an alternative to taking his life to get harder.

Relevant background history

Age 5: Younger brother tragically drowned, both parents developed an alcohol problem, and his mother became severely depressed. The whole extended family struggled to cope for a few months.

Age 9: Parents separated, barely saw his father who died of an alcohol-related illness. Lived with his mother and older sister. Became close to maternal uncle who lived nearby, loved fishing together. Moved schools several times, loner and bullied. Poor academic performance, didn’t enjoy school and left with no formal qualifications.

Age 15: Uncle took his own life - Bill was deeply affected, started drinking

Age 17: Bills’s Mother died; Bill started drinking heavily and cutting himself. 2 yrs later his sister persuaded him to seek help. (She always looked after Bill, being 5 years older.)

Age 21: Unplanned pregnancy, 1st marriage lasting two years, still good relationship with son.

Age 24: 2nd marriage of 15 years resulting in a son (lives 2hrs away) and a daughter (lives 20mins away).

Current circumstances

• Bill has a couple of close friends, but “ is too busy” to see them.

• Drinking significantly more at home, stopped going to the pub on Friday nights to meet up with the usual early evening darts players, an activity he’d previously always enjoyed.

• Despite serious debt problem, he’s spending more on alcohol since divorce papers arrived: 3-4 cans of strong lager a night except Tuesdays when his 2 local grandchildren visit.

• Regular phone contact with 3 kids and grandkids, including videocalls. Sees son’s kids every 4-6/52

• Bill smoked cannabis a few times a month during his 20s and 30s - he no longer uses drugs.

Pre-morbid personality Lacks confidence, never expressed feelings, rarely confides in others, always been ‘a worrier’. A devoted father and grandfather. He has rarely coped well with difficult life events or stress, saying that he would “ignore things”, “go out on a bender” or “take off fishing for the day” rather than face problems and sort out solutions.

Insight Bill says “I know things aren’t right” and is willing to accept that he is currently unwell and has a depressive illness. Although not keen to take medication (in addition to the painkillers for his back), he is willing to go along with any treatment plan because he knows his daughter is upset and worried about him. Bill is also keen to coproduce a Safety Plan to maximise his ability to stay safe.


Safety Plan for Bill Smith Case Study (Supported Plan)

Supported Safety Plan

Getting Through Right Now

keep a handy reminder of the people and things you love or things which help you get through tough times

Safe Environment

removal/mitigation of access to means and ask patient to identify/avoid triggers such as alcohol or drugs including benzodiazepines for example

Activities to Lift Your Mood


Calming Activities


Distracting Activities

Identify things that distract you when you are distressed or thinking about harming yourself

General Support or Distraction

names and contact details of supportive family, friends, confidants and others

Specific Suicide Prevention Support

list who you can talk to if you are distressed or thinking about self-harm or suicide

Professional Support

Emergency Contacts

Personal commitment to Safety Plan


Nature of the suicidal thoughts

Rare

Mild

Gradually develop

Momentary

No wish to die

Coping well with emotional pain

Easy to ignore/little

Frequent

Intense

Instantly present

Long lasting

Wish to die

Not coping at all with emotional pain

Intrusive/distressing

1. Frequency

2. Intensity

3. Speed of Onset

4. Persistence

5. Wish to Die

6. Ability to cope with emotional pain

7. Intrusiveness and distress

PLEASE NOTE: This should be used only by someone who has had appropriate training in its use and only as part of a full clinical assessment or within an ongoing therapeutic relationship

8. Hope

9. Alternatives toSuicide

10. Method

11. Time

12. Place

13. Means

14. Practical arrangements

15. Chance of discovery

16. Resistibility

Perception of the future

Degree of planning on suicidal act



There is hope

There may be an alternative

No idea how

No idea when

No idea where

Has not obtained the means

No arrangements made

No steps to prevent discovery

Has specifically obtained the means and may have enacted elements

Arrangements made (e.g. funeral, pets)

Care taken to prevent discovery

Knows exactly how

Knows exactly when

Knows exactly where

The future is totally hopeless

There is no alternative

Easy not to act on thoughts

Feels no option but to act on thoughts

The Continuum of Suicidal Thoughts for Bill Smith Case Study






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Exercise 8: Final Reflection and Notes

We suggest using this page to capture your own personal thoughts from the training, and in particular write down:

• What you might stop doing

• What you might continue or do more of

• What you might start doing

Useful 4 Mental Health websites:

• www.4mentalhealth.com

• www.StayingSafe.net

• www.WellbeingAndCoping.net

Suicide Response Part 1 Workbook

Documents