How to Help the Suicidal Person to Choose Life: The Ethic of Care and Empathy as an Indispensable Tool for Intervention

The purpose of this current book was to add to what is already scientifically and experientially known, about the important role that gatekeepers play in suicide prevention. A gatekeeper is defined as a person, who due to the type of work they are involved in, may come into contact with persons who are at risk of suicide. The therapeutic relationship between the gatekeeper and suicidal person was presented as key to helping the suicidal person. Instillation of hope was also promoted because, while persons who are suicidal are in the midst of their despair they cannot see clearly. They may therefore, benefit from a gatekeeper helping them to re-discover their hope. Some hard facts about suicide on a global level were reviewed. It was pointed out that suicide is a complex issue and never occurs in isolation. Therefore, taking into consideration relevant issues that either contribute to, or are associated with suicide were discussed, such as social stressors and cultural issues. Religion was identified as a potential protective factor against suicide. Reasons were given in support of doing more to train gatekeepers. The ethic of care was presented as the theoretical premise for this book and both the ethic of care and empathy were introduced as a tool for suicide prevention. Quantitative and qualitative research were acknowledged as important in enhancing what we know about suicide prevention. This current manuscript draws quite significantly from evidence based data that is quantitative and qualitative. Two modes of qualitative methodologies were utilized to specifically analyze the case studies presented in this book, the narrative case study approach and the psychological autopsy. In this current Chapter, key themes were identified from the narrative case study of a suicidal person who was admitted to the Emergency Room (ER). Placing a suicidal person is a secure room for a lengthy period of time may increase their sense of being alone, and perceived neglect from a gatekeeper may be interpreted by the suicidal person as a lack of care. It was advised that when caregivers do not act in empathetic ways, instead of being self-critical, they must strive to be more selfcompassionate. We were made aware of some of the ethical issues associated with caring for the suicidal person. For example, it was established that there is a risk of clinicians experiencing a violation of their moral agency, or their ability to act on their own moral beliefs.

Chapter two pointed out how stigma negatively impacts people who suffer from mental illness and/or suicidal ideation. Stigma can actually prevent patients from seeking the help that they need. What is alarming is that some of the most distressing stigma that people experience is perpetrated by health professionals. Health professionals who do engage in acts of stigmatization breach the very essence of what the ethic of care stands for. Educational endeavors need to be pursued in order to stop all discrimination. The lived experiences of two patients who presented to the emergency Room (ER) after a serious suicide attempt, was reviewed. Analysis revealed that their suicide attempts were not considered serious by staff and stigma likely played a role. No care plan or follow-up was arranged upon their discharge from the ER. Yet, research has demonstrated that the strongest indicator of a completed suicide is a previous attempt. Subsequently, caregivers were admonished to learn how to differentiate between a deliberate suicide attempt and other forms of self-harm. Dispelling preconceived assumptions about suicide that are not true was presented as another way to help to prevent suicide. It was also pointed out that some suicide risk assessment tools and/or frameworks are limited, and because the causes of suicide are multi-dimensional assessing suicide risk is not always a precise predictor of future outcomes. The warning signs of suicide were highlighted followed by a detailed 11 step process on how to conduct a thorough and focused suicide risk assessment. Key components of a Safety Plan was underscored. A narrative case study was presented as told by a Psychiatrist who was admitted to hospital after being diagnosed with depression, suicidal ideation and plan. Two key themes surfaced. There was a degree of personal shame experienced by the Psychiatrist associated with the notion of becoming depressed and suicidal. A patient’s experience of shame associated with having a mental illness can also be made worse when they feel judged by their caregivers. In short, a few simple strategies to increase gatekeepers’ self-awareness were highlighted as a means to dispel stigma.

Chapter three pointed out that there is a significant connection between suicide and a diagnosis of mental illness and/or addictions. In fact the risk of suicide in people who are suffering from a mental disorder is five to 15 times higher than for people without a co-existing mental disorder. The degree of suicide risk associated with some specific diagnoses was presented first, followed by strategies to address early diagnosis and treatment. We are made aware of the fact that the WHO recommends that every country develop a national strategy for suicide prevention that includes provisions for early diagnosis and treatment of persons suffering from mental illness. Six specific strategies were recommended to address the global shortfall in mental health and addictions services. Psychache, or a mindset of unbearable emotional pain was determined to be a necessary condition for suicide to happen. Constriction of thought often accompanies psychache. The Strain Theory of Suicide was used to explain how psychache is preceded by specific types of psychological stressors. These stressors actually pull a person in conflicting directions that contribute to their hopeless despair. The lived experience of a suicidal person was examined in order to gain a clearer appreciation of the degree of their psychological pain. The following three specific ways were proposed to help the suicidal person to move past a death focused mindset. Attempting to understand their psychological pain fosters connection through empathy. Challenging their constricted thought patterns may help them to choose a coping mechanism other than death, and so will assist them to change the ending of their story from death to life. As an aspect of a psychological autopsy, the contents of a suicide note was examined and two key premises surfaced. The suicide note left clues to the person’s experience of psychache. It also revealed their plea for understanding. In short, fostering resiliency was proposed as another way to help prevent suicide.

In chapter four we became aware that people who are experiencing suicidal thoughts feel especially alone in their experience. If we can help them to know that we genuinely care about them and their situation, we may be able to convince them that their life matters. This is the essence of the ethic of care in action. Empathic responses, in the form of validating another’s experience, can also save lives. Specifically, in the hopeless patient, increased hope is instilled if they feel understood and cared for by their physician or nurse. Explicit aspects of the ethic of care and empathy were identified as a means to help the suicidal person to choose life. These strategies include: establishing connection, fostering a therapeutic alliance, offering unconditional positive regard, heartfelt listening, presencing and compassion. It was pointed out that trust can sometimes be severed in the emergency room (ER) when someone presents with a suicide attempt. For example, suicidal persons are often not even considered as real patients because they are not injured or ill. Key aspects of The Guidelines for Clinicians developed by The Aeschi Working Group of suicidologists were reviewed. These guidelines emphasized the significance of the therapeutic alliance between the clinician and patient. They highlighted the importance of offering empathy and of being non-judgmental and placed the patient’s story as a priority over clinical expertise. We also learned that after a suicide attempt has occurred there is often a window where a patient can be reached. A touching narrative case study was reviewed where we discovered how a total stranger helped a suicidal youth through an act of compassion. A psychological autopsy followed this story and assisted us in gaining a retrospective view of what went wrong in the ER and why. Key themes emerged. The patient experienced the narrow constriction of thought associated with psychache. The ER physician admitted that she did not receive adequate training in suicide risk assessment. The patient reported that he did not feel cared for by the professionals in the ER, and prior to the patient being discharged no care plan was put in place to ensure that they would be safe. We learned that after the initial suicidal crisis has subsided, Cognitive Therapy may help the person to find a sense of purpose and meaning in their life. A dynamic simulation exercise was recommended to help gatekeepers practice being empathetic with a suicidal patient. The role play encouraged the use of both non-verbal and verbal empathic communication skills. At the end of the chapter, caregivers were encouraged to make empathy a habit through the act of journaling to increase self-awareness.

Chapter five begins by pointing out that suicide can be an occupational hazard in the caring professions. For example, physicians are twice as likely to commit suicide when compared to members of the general population. Contributing factors to physician suicide include but are not limited to: heavy work-loads, bullying, unreasonable expectations, stigma and perfectionism. Stigma associated with a diagnosis of mental illness, the dread of being judged, or fear of losing one’s license to practice, all play a role in doctors refusing to get the help that they need. Studies have also demonstrated that there is high prevalence of suicide among nurses, higher than that of the general public. Ready access to means, mental illness, substance abuse, work related stress and even work place bullying were cited as some of the contributing factors to nurse suicide. Stigma toward mental illness was identified as a key factor in nurses not seeking professional help. It was pointed out that due to the fact that caring for the suicidal person can be stressful there is a real risk of gatekeepers developing compassion fatigue. Compassion fatigue was defined followed by an overview of some of the causal factors and symptoms associated with it. If compassion fatigue is to be prevented or effectively treated when it does occur, additional coping strategies need to be adopted and utilized. Therefore, the following approaches were recommended: encouraging gatekeepers to reach out for professional help; fostering self-compassion; and implementing strategies that promote self-care. In conclusion, some take away points from the book were highlighted.