A different perspective: The assessment of the risk of suicide

By Suzanne Traynor @Traynors
Associate Professor Mental Health (Practice) at Middlesex University & My Care Academy.

Supporting staff to feel confident and competent when working with service users who are suicidal is essential. The Trust’s ‘Keeping the Patient Safe’ learning sessions provide staff with the time and space to refresh their knowledge and skills as well as reflect on how they care for patients experiencing suicidal thoughts. The assessment of suicidal risk is a complex and multifaceted skill and staff need the opportunity to reflect on their current practice as well as focus on specific aspects of their assessment skills.  I have been co-facilitating the Keeping the Patient Safe training day with clinical staff at Camden and Islington NHS Foundation Trust for some time and as part of a recent review I came across this interesting paper: Understanding the process of suicide through accounts of experience – a new focus for suicide prevention.

This article describes a research project working with people who had attempted suicide and those that had lost a close friend or relative through suicide. Using a series of interviews, the authors attempted to explain and describe the experience of those who had attempted suicide as well as gaining a greater understanding of the process of suicide from friends and family’s viewpoint.

What resonated for me in this article were the following concepts:

• Worth
• Trust
• Suicidal exhaustion.

Worth as a concept is complex and may have different meanings for each of us. Worth can be used to describe how we value life and why we do things – what gives meaning to our life and activities. For some, contingent worth is dependent on gaining value from the work we do or the different roles we play. Our sense of worth remains intact for as long as we are able to carry out these roles and activities. However non-contingent worth does not require external influences at all and it resides inside us without the need for an external influence.

The report goes on to discuss that people who are feeling suicidal experience a lack of knowing their non-contingent worth, leading them to question their ability to function or achieve and leads them to think, “Am I good enough?”  Their risk becomes significantly greater if there is an absence of non-contingent worth to fall back on – leading to the belief that nothing (or no one) can help them.

People will go to great lengths to maintain the performance that they are coping in an attempt to maintain their self-worth as well as keeping others away from their true feelings. This performance can convince those around them that all is well when in fact the person is very vulnerable.

Developing trusting relationships is one of the core skills of mental health staff and Values-Based Practice can provide a useful framework. The service user may put up barriers because of a fear or belief that others have lost trust in them or have previous poor experiences of being let down by others. This can be due to previous suicidal attempts and can lead to a cycle of distrust between a service user and staff member.

The hiding of feelings from others is a means of self-protection as well as attempting to protect family and friends.  By putting up a performance in front of staff and others the service user is attempting to manage their greatest fear that no one can help them.

Finally, the article explored suicidal exhaustion as an overwhelming physical and mental exhaustion which the authors attributed to living without trust and non- contingent worth. This exhaustion is compounded by poor night time sleeping as well as the additional energy required to carry out day to day routines.

It is exhausting to maintain this external performance and hide one’s true feelings. This ‘Performance’ is a desperate attempt to provide false assurance to others that all is well.

In summary, this article with a lens on the experience of service users and families highlights some of the real challenges when attempting to assess the risk of suicide. The development of a trusting relationship between staff and service user is essential as well as the need to truly understand their view of the world and their view of themselves. Including friends and family in our conversations with the service users can enrich the assessment process and provide safer care. Reflecting on these points and including the concept of self-worth, trust and suicidal exhaustion in our practice will translate to safe care for service users.