Mednotes

L9 Psych Med Suicide self-harm

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tagspsychmed, lecture, suicide, self-harm
aliasesSuicide and Self-Harm

24 min read

Overview

This lecture covers suicide and self-harm from definitions through to prevention. It begins with the terminology and the language conventions clinicians should use, including the Māori concepts of whakamate and whakamomori, then sets out the epidemiological relationship between attempts and deaths and the continuum of suicidal thinking captured by the C-SSRS. It then works through why people feel suicidal and why people self-harm, and introduces the APEX approach as a non-deficit way of supporting someone who self-harms. Five psychological theories (Baumeister, Shneidman, Joiner, Beck, Linehan) explain the pathway from distress to suicidal behaviour, sociocultural factors situate that risk in colonisation and identity, and the final sections turn to practice: formulating risk with the Pisani model, safety planning, and the community prevention resources available in Aotearoa New Zealand.

Objectives of the lecture

  • Awareness of definitions and language
  • Risk factors associated with self-harm and suicide
  • Psychological theories: Baumeister and the Escape Theory, Edwin Shneidman and Psychache, Joiner’s Interpersonal Theory, Beck and Hopelessness Theory, Linehan and Emotion Dysregulation Theory
  • Formulating risk
  • Suicide prevention and protective factors

Definitions

  • Suicide: when someone has intentionally taken their own life.
  • Suicidal behaviour: behaviours that may occur as a result of suicidal distress, for example suspected self-injury (self-harm), suicidal distress, attempted suicide and suicide.
  • Suicidal ideation: thoughts about taking action to end one’s life, including identifying a method, having a plan, or having an intent to act.
  • Deliberate self-harm: any type of self-injurious behaviour, including suicide attempts and non-suicidal self-injury.

Sources cited: Ministry of Health 2019, Every Life Matters, He Tapu te Oranga o ia tangata: Suicide Prevention Strategy 2019 to 2029 and Suicide Prevention Action Plan 2019 to 2024 for Aotearoa New Zealand; Turecki & Brent, Lancet 2016; 387: 1227 to 39.

Language

Use of “commit” and “committed”:

  • Carries connotations of crime, dishonour and sin, and is hurtful to bereaved families.
  • It is a legacy from the time when suicide was a crime.
  • Suicide is now viewed as a public health issue rather than a criminal or legal issue.
  • Preferred wording: “died by suicide”, “killed themself”, or “took their own life”.
  • The slide also raises “failed suicide attempt” and “successful suicide” as terms to question. [slide does not elaborate]

Māori concepts

Whakamate: “to cause death”, or “to bring about one’s own death”.

Whakamomori:

  • In traditional Māori society, suicide and self-injury were linked to loss, grief, and breaches of tapu.
  • Impact of whakamā: shame and loss of mana (status) contributing to distress and suicidal behaviour.
  • Caution in linking traditional and contemporary suicide: traditional Māori suicidality should not be directly equated with modern Māori suicide.
  • Ongoing impact of colonisation: trauma from land alienation, loss of language and culture, and systemic disadvantage contribute to whakamomori today.
  • Contemporary meaning: whakamomori is now widely used to describe Māori suicide, linked to deep-seated sadness and distress.

Attempts, deaths, and the continuum of suicidality

Ratio of suicide attempts to deaths by suicide, by age group:

  • Youth aged 15 to 25 years: 100 to 200 suicide attempts for every 1 death by suicide.
  • Adults aged 75 years and over: 4 suicide attempts for every 1 death by suicide.

Suicide exists on a continuum. The Columbia Suicide Severity Rating Scale (C-SSRS) grades thoughts from least to most severe:

  1. Thoughts: wish to be dead
  2. Non-specific active suicidal thoughts
  3. Active suicidal ideation with any methods (not plan), without intent to act
  4. Active suicidal ideation with some intent to act, without specific plan
  5. Active suicidal ideation with specific plan and intent

Common causes of suicidal feelings

  • Mental health problems
  • Bullying, prejudice or stigma, such as relating to race, gender, disability or sexual identity
  • Different types of abuse, including domestic, sexual or physical abuse
  • Bereavement, including losing a loved one to suicide
  • The end of a relationship
  • Long-term physical pain or illness
  • Adjusting to a big change, such as retirement or redundancy
  • Money problems
  • Housing problems, including homelessness
  • Isolation or loneliness
  • Being in prison
  • Feeling inadequate or a failure
  • Addiction or substance abuse
  • Pregnancy, childbirth or postnatal depression
  • Doubts about sexual or gender identity
  • Cultural pressure, such as forced marriage
  • Society’s expectations, for example to act a certain way or achieve certain things
  • Other forms of trauma
  • Medication effects

Reasons or motives for self-harm

Acts of self-harm may have a variety of motives or intentions:

  • Escape from a terrible state of mind
  • Finding one’s thoughts unbearable
  • Wanting to get away from an unbearable situation
  • Wanting to die
  • To communicate to others the extent of current distress
  • Trying to get help

These motives are relatively consistent across the life-span.

The APEX approach to self-harm support

APEX (Clare, 2014) has four elements:

  • Attitude: self-harm is a coping strategy to be understood.
  • Purpose of harming is clarified with the person.
  • Emotional First Aid kit of matched needs is developed.
  • X factor is the XYZ self-contract that emerges from this process.

Underlying principles:

  • APEX is based on evolving evidence-based approaches to self-harm.
  • It moves away from a deficit-based model, recognising self-harm as a coping mechanism.
  • It takes the stance that “the person is not the problem; the problem is the problem”.
  • Externalising self-harm enables curiosity and exploration of alternatives.

Identifying the purpose of self-harm

Reasons for self-harm vary. Sutton (2007) identified eight key themes:

  • Coping and crisis intervention
  • Calming and comforting
  • Control
  • Cleansing
  • Confirmation of existence
  • Creating comfortable numbness
  • Chastisement
  • Communication

The ASH group identified a ninth theme, Compliance, which is particularly relevant for youth.

Emotional First Aid, matching needs to alternatives

Alternatives are matched to the need the self-harm is meeting. Examples given:

  • Need to feel pain: use a rubber band, chew on chilli.
  • Feeling angry: engage in intense exercise, use a punching bag, hit a pillow against a wall.
  • Need to see red: use a red pen, tomato sauce.
  • Feeling numb: try chewing ice, taking a shower.

XYZ contract, matching alternatives to purpose

  • Individuals identify the purpose of self-harm.
  • For each purpose they list three alternatives: X, Y and Z.
  • These alternatives must be SMART (Specific, Measurable, Achievable, Realistic, Timely).
  • The goal is to delay self-harm and increase personal agency.

Psychological theories

Baumeister and the Escape Theory of Suicide (1990)

A staged progression:

  1. Falling short of standards
  2. Internalization of self-blame
  3. Aversive sense of self
  4. Negative affect and/or negative consequences
  5. Cognitive constriction
  6. Reckless behaviours, absence of emotion, and irrational thought

Edwin Shneidman and Psychache (1993)

Suicide is not necessarily the wish to die, but rather a means to ending psychological pain. Psychache results when an individual’s vital needs are not met or are frustrated. Shneidman believed the majority of suicides were due to frustrated needs experienced in four ways:

  1. Thwarted love, acceptance or belonging
  2. Excessive helplessness
  3. Damaged self-image
  4. Damaged relationships

Joiner’s Interpersonal Theory of Suicide (2005)

A popular contemporary theory, especially useful in explaining the prevalence of suicide in older adults and in particular older adult males. Covered at length in iE16 Social Connectedness and Suicide Prevention. Three factors need to be present for a suicide:

  1. Thwarted belongingness
  2. Perceived burdensomeness
  3. Acquired capability for suicide

Factors 1 and 2 combined create the desire for suicide; the acquired capability is the additional third requirement.

Beck and Hopelessness Theory (1970)

  • Aaron Beck proposed that hopelessness is the primary driver of suicidal intent, overriding the survival instinct, and is a stronger predictor than depression.
  • Negative models exacerbate feelings of hopelessness at the expense of positive, productive information, through biased interpretation.
  • Beck developed key assessments for mental illness and suicidality: the Beck Depression Inventory (BDI), the Suicide Intent Scale (SIS), and the Beck Hopelessness Scale (BHS).

Linehan and Emotion Dysregulation Theory

  • A bio-social theory emphasising the role of biological and physiological factors in stress responses and emotion regulation.
  • Features heightened emotional sensitivity and intensity, and aversive emotional states.
  • Attempts to manage distress sometimes lead to self-injury or suicide.
  • Led to the development of Dialectical Behaviour Therapy (DBT), comprising problem-solving and skills training, with self-validation and hopefulness as desired outcomes.
  • DBT has been touted as the “strongest single treatment targeting suicidality” (Rudd et al., p.161).

Sociocultural and demographic risk factors

  • Colonisation and suicide risk: recent colonisation is linked to high suicide rates in Indigenous groups, due to loss of power, autonomy and belonging.
  • Cultural identity as protection: strong cultural identity reduces suicide risk, while loss of communal identity increases vulnerability.
  • Impact of discrimination: experiencing discrimination worsens wellbeing, increases depression, and raises suicide risk.
  • Gender and socioeconomic influences: women have higher rates of depression and suicide attempts; suicide risk is lower in medium-income areas, but is not significantly affected by age or deprivation.

Formulating risk (Pisani, Murrie & Silverman, 2016)

The model reframes risk assessment from prediction to prevention: clinical data feed a risk formulation, which feeds forward into planning.

Clinical data fall into two sets:

  • More enduring: strengths and protective factors; long-term risk factors; impulsivity and self-control (including substance abuse); past suicidal behaviour.
  • More dynamic: recent or present suicide ideation and behaviour; stressors and precipitants; symptoms, suffering and recent changes; engagement and alliance.

The risk formulation combines four components:

  • Risk status: risk relative to others in a stated population (fed by the enduring data).
  • Risk state: risk relative to the person’s own baseline or a selected time period (fed by the dynamic data).
  • Available resources: internal and social strengths to support safety and treatment planning.
  • Foreseeable changes: changes that could quickly increase risk state.

Important

The output of the formulation is planning, not a prediction. Risk status and risk state answer different questions (compared with others, versus compared with this person’s own baseline), and both are needed alongside resources and foreseeable changes.

Safety planning

  • Safety planning-type interventions (SPTIs) are a form of brief intervention derived from CBT for suicide prevention.
  • The goal is to reduce imminent risk of suicidal behaviour by constructing a predetermined set of coping strategies and supports in a plan.
  • SPTIs are recommended as best practice by the National Institute for Health and Care Excellence in the UK and the Suicide Prevention Resource Center in the USA.
  • A safety plan is NOT a “no-suicide contract”.
  • Meta-analysis by Nuij et al. (2021) found SPTI for suicide prevention was associated with a 43% reduction in suicidal behaviour.

The six components of a typical safety plan (Stanley & Brown, 2012), as set out in the Safety (Support/Self-Care) Plan worksheet:

  1. Warning signs (thoughts, images, mood, situation, behaviour) that a crisis may be developing
  2. Internal coping strategies: things I can do to take my mind off my problems without contacting another person
  3. People and social settings that provide distraction
  4. People whom I can ask for help
  5. Professionals or agencies I can contact during a crisis
  6. Making the environment safe (reducing access to or use of lethal means)

The blank worksheet prompts three entries for steps 1 and 2, names, phone numbers and places for steps 3 and 4, clinician names with emergency contact numbers plus Emergency Psychiatric Services and the 1737 “Need to Talk” line for step 5, and two entries for step 6.

Warning

The worksheet slide is a low-resolution scan. The Emergency Psychiatric Services number read as “0800 46 76 46” (option 2 for Otago; address Dunedin Public Hospital, 201 Great King Street, Dunedin) and the bracketed qualifier after it are blurred and may be misread.

Manawa, My Own Survival Plan (app)

A smartphone safety-planning app from the Mental Health Foundation of New Zealand, “developed by New Zealanders for New Zealanders”. Features shown:

  • A red “111” call button on every screen.
  • Confidentiality statement: information entered into the plan is confidential, is not shared without permission, and is not stored anywhere other than within the app on the device.
  • A six-step plan, mirroring the safety plan structure: (1) noticing what’s going on, “my warning signs are” (examples: feeling like a burden; angry all the time); (2) my reasons to live, “when I am feeling bad, what are the things I can remember that are worth living for?” (examples: my whānau or friends, my job or volunteer work, my pets, someone I love); (3) to keep safe I can (examples: get someone to stay with me; avoid people who hurt or upset me).
  • Four main tiles: My Plan, Supporters, Resources, Helplines.

Prevention and protective factors

LeVa, Preventing Suicide for Pasifika, Top 5 Tactics

  1. Connect: relationships based on love make us feel valued and develop our self-worth. Connecting with nature, creativity, study or work can also engage positive emotions.
  2. Strong families: family is where life begins and love never ends. Family can give a sense of self, and support during tough times.
  3. Talk: talking helps us process thoughts and feelings and reach out for help when we need it. Good communication is key to nurturing healthy relationships with friends and family, at school or at work.
  4. Cultural identity: culture gives a sense of belonging, pride and identity. For young people, the stronger their cultural identity, the stronger their mental wellbeing.
  5. Spirituality: faith in God, or connecting with something bigger than ourselves, can fuel positive emotions and support a sense of purpose and meaning in life.

Associated programmes and tools:

  • Aunty Dee: a free online problem-solving tool, accessible from any device (www.auntydee.co.nz).
  • The mentalwealth project: equips people to look after their wellbeing (www.mentalwealth.nz).
  • FLO Talanoa: a free suicide prevention education workshop designed for Pasifika communities, aligned with the values of love, respect and reciprocity.
  • LifeKeepers: a free, evidence-based suicide prevention training programme created for New Zealand communities, working to create communities of C.A.R.E.
  • Engaging Pasifika: cultural competency training equipping people to effectively engage with Pasifika people and their families.

Tihei Mauri Ora, supporting whānau through suicidal distress

A Māori resource built around tapu. Whakataukī on the cover: “Nā tō rourou, nā tāku rourou ka ora te iwi”.

  • Tapu is the fundamental principle of life and natural law, guided by boundaries of respect and safety, protected by tikanga Māori and Māori law.
  • From tapu comes tikanga, and from tikanga the idea of kia tika, kia pono, kia mārama: Tika means to be upright, honest and correct; Pono is to believe in the sanctity of life; Mārama is the importance of knowledge, understanding and enlightenment.
  • Applying these principles, integrated into the practice and protection of tapu, allows people to make headway through difficult periods and to uphold the principles of life. Whānau therefore have a responsibility to maintain the boundaries of tapu that protect life.
  • Closing karakia (Dr Te Huirangi Waikerepuru): “Tuia i runga / Tuia i raro / Tuia i waho / Tuia i roto / Tuia te here tangata”, that it be woven above as it is below, woven without as it is within, interwoven within the threads of humanity.

Community prevention messages (poster series, art by Theresa Reihana)

  • TITIRO, WHAKARONGO: pay attention
  • ĀWHINATIA, MANAAKITIA, KŌRERO TAHITIA: talk and listen with compassion
  • MAHI TAHI: work together
  • TIAKI I A KOE ANŌ: take care of yourself
  • KEI A KOE TONU TE RONGOĀ: whānau have solutions
  • KI TE ĀWHINA, KI TE TAUTOKO: assistance and support is available for whānau

Where to get support (as listed in the lecture)

Services:

  • Student Health services: free phone 0800 479 821 (including mobiles); tel 64 3 479 8212, or 8212 if calling within the University, for example halls of residence.
  • Emergency Psychiatric Services: ph 03 474 0999 and ask for EPS; or find your local DHB at https://www.healthpoint.co.nz/mental-health-addictions/
  • Alcohol and Drug Helpline: 0800 787 797
  • Need to Talk 1737: free call or text any time.

Helplines listed on the LeVa resource: Need to Talk 1737; Depression Helpline 0800 111 757; Healthline 0800 611 116; Youthline 0800 376 633; Age Concern NZ 04 801 9338; Samaritans 0800 726 666; What’s Up 0800 942 8787; OUTLine NZ 0800 688 5463 (0800 OUTLINE); Lifeline 0800 543 354.

Student Affairs contacts, ELM: Dr Althea Gamble Blakey (Associate Dean Student Affairs), Associate Professor Tess Patterson (Associate Dean Student Affairs), Jillian Tourelle (Manager, Student Affairs and Medical Education Group). ALM: Dr Ciara Lee (Associate Dean Student Affairs).

Self-test

  1. Define suicide, suicidal behaviour, suicidal ideation and deliberate self-harm as given in the lecture.
  2. Explain why “commit” and “committed” are avoided when talking about suicide, and give the preferred alternatives.
  3. Distinguish whakamate from whakamomori.
  4. Explain how whakamā and colonisation are described as contributing to whakamomori, and state the caution attached to linking traditional and contemporary Māori suicidality.
  5. Contrast the ratio of suicide attempts to deaths by suicide in 15 to 25 year olds with that in adults aged 75 and over.
  6. List the five levels of the C-SSRS continuum in ascending order of severity.
  7. List at least eight common causes of suicidal feelings given in the lecture.
  8. List the six motives for self-harm, and state how they vary across the lifespan.
  9. Describe the four elements of APEX and the stance it takes towards the person who self-harms.
  10. List Sutton’s eight themes for the purpose of self-harm, and the ninth theme added by the ASH group.
  11. Explain what an Emotional First Aid kit is, and give two examples of a need matched to an alternative.
  12. Describe the XYZ contract, including what the alternatives must satisfy and what the goal is.
  13. Describe the six stages of Baumeister’s Escape Theory in order.
  14. Explain Shneidman’s concept of psychache and list the four ways frustrated needs are experienced.
  15. List the three factors of Joiner’s Interpersonal Theory and explain which combination produces the desire for suicide.
  16. Explain Beck’s hopelessness theory, including how hopelessness compares with depression as a predictor, and name the three assessments Beck developed.
  17. Describe Linehan’s emotion dysregulation theory and the therapy derived from it.
  18. Explain how colonisation, cultural identity and discrimination each relate to suicide risk.
  19. Distinguish risk status from risk state in the Pisani formulation, and name the other two components of the formulation.
  20. Sort the clinical data in the Pisani model into the more enduring and more dynamic groups.
  21. Explain what a safety planning-type intervention is, what it is explicitly not, and the effect reported by Nuij et al. (2021).
  22. List the six steps of the Safety (Support/Self-Care) Plan.
  23. Describe the Manawa app and the confidentiality assurance it gives users.
  24. List LeVa’s Top 5 Tactics for preventing suicide for Pasifika, and explain why cultural identity is included.
  25. Explain the relationship between tapu, tikanga, and kia tika, kia pono, kia mārama in Tihei Mauri Ora.
  26. A 78 year old widowed man with long-term physical pain says he is a burden on his family and has nothing left to belong to. Using Joiner’s theory, explain which components are present and what would still be needed for a suicide to occur, and state why this theory is particularly relevant to his age group.
  27. A young person says they cut when they feel numb and unreal. Using APEX, describe how you would work with them from purpose through to contract.
  28. Integrative: Baumeister, Shneidman and Beck each propose a different core driver of suicide. Distinguish the three drivers, and explain what each implies about where an intervention should be aimed.

Answers

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