September is Suicide Prevention Month, and for mental health providers assessing for suicidal ideation is one of the more challenging aspects of our work. Unmetabolized trauma, untreated addictions, family histories of suicide, treatment resistant mental illness, victims of cyberbullying, and people experiencing relentless stress and loss in isolation are the most vulnerable to suicide attempts. Although more females attempt suicide, males are four times more likely to die by suicide because their methods are lethal. It is equally important to understand the correlation between an increase in suicide–both attempted and completed–and the deleterious impact of social media and “medical marijuana,” as they both increase anxiety, depression, and suicidal thinking.

In addition to recognizing the potential “red flags” or warning signs that are identified below, mental health professionals, friends and family alike, must be clear that talking about suicide does not increase the likelihood that someone will take their own life. In fact, the opposite is true. It’s essential to understand if the teenageror adult has a concrete plan and the means to act on it. Have they rehearsed it? Is there anything that would prevent them from acting on it? Sometimes, it's their religious beliefs, or not wanting to cause pain to those left behind. Those are important deterrents, and should be explored and strengthened, without debating whether suicide is “right or wrong.” Their answers will guide the necessary and most appropriate interventions.
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"Suicide–escaping pain–may be conflated and confused with the coping strategy of dissociation."
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There are people who say, “I’d be better off if I wasn’t here anymore,” but do not actually intend to take their own lives. They are in pain and suffering, and bereft of hope, and need resourcing and mental health support, often requiring a higher level of care. Once those things are put in place, the suicidal ideation goes away. For clients who experienced chronic trauma or abuse throughout childhood, the idea of suicide–escaping pain–may be conflated and confused with the coping strategy of dissociation-mentally escaping and getting a respite from physical, emotional, or psychological pain. It can be very helpful to distinguish between an actual desire to die, versus wanting the temporary relief that dissociation offered.

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It's also important to recognize that acts of self-injurious behavior are not synonymous with suicidal ideation. Teens and adults who hurt their bodies often do so to mitigate emotional pain, and the release of endorphins that accompany cutting or burning the body, provides that temporary relief. The key distinction relates to intent. If the intent is to “feel better,” that is not about suicide. If the intent is “to die,” then a thorough suicide assessment needs to be verbally and compassionately administered.
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"Borrowing the wisdom of an adult brain is essential."

When dealing with adolescents, it’s also important to remember that their lack of a fully myelinated pre-frontal cortex means they don't have full use of their executive functioning skills until their late twenties. This includes the ability to do abstract reasoning, cause and effect analysis, and have an accurate sense of present and future. Teenagers who are struggling and in pain, and those experiencing bullying, are the most at risk. They lack the ability to recognize that their current situation is temporary. Suicide becomes the permanent solution to a temporary problem. Borrowing the wisdom of an adult brain is essential, and can provide an adolescent with the comfort, support, perspective, and hope that will help them successfully navigate their current painful life circumstances.

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Clinician's Tips:

Here are some important red flags, offered by the National Alliance on Mental Illness, that may be indicative of suicidal ideation:

• Increased alcohol and drug use
• Aggressive behavior
• Withdrawal from friends, family and community
• Dramatic mood swings
• Impulsive or reckless behavior
• Collecting and saving pills or buying a weapon
• Giving away possessions
• Tying up loose ends, like organizing personal papers or paying off debts
• Saying goodbye to friends and family

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Resources:

• Call or text 988; email: chat988lifeling.org
• The Mental Health Hotline: 800-950-6264
• 24/7 National Suicide Prevention Lifeline- 1-800-273-8255
• 24/7 Crisis text Line : Text HOME to 741-741
• National Alliance of Mental Illness: Risk of Suicide, Navigating a Mental Health Crisis‍

• Columbia University Department of Psychiatry: 6 Questions to Screen for Suicide