Risk factors, warning signs, self-injury, protective factors, safety planning, using social media, organisations offering support, social work practice approach, telehealth tips
This page has three sections:
Background Material that provides the context for the topic
A suggested Practice Approach
A list of Supporting Material / References
Different populations have differing suicide needs and practitioners need to be flexible in their approach. Suicide is particularly high among young people, older adults and Aboriginal and Torres Strait Islander people. (Maple et al., 2018)
Particular groups of young people at risk include girls, those from low SES backgrounds and Indigenous children. Many young people don’t seek help and, when they do, are most likely to seek out other young people for support (74%) or parents(49%) before seeking professional help (Terhag, 2020). The period following discharge from hospital is associated with the highest risk for suicide in young people (Robinson et al., 2018).
For older Australians, the period of transition from work to retirement may be an important risk factor in suicide risk, so programs that facilitate continued employment in older age – particularly for men – could be of benefit (Page et al., 2020). Having an active social network – measured through the frequency of social group meetings, phone or personal contacts and number of confidants – was linked to lower rates of both suicide and self-harm in the 45 and Up Study cohort (Erlangsen et al., 2020).
People who die by suicide often have a comorbidity, with mood disorders (including depression) being the most common (Maple et al., 2018). People who have contemplated or attempted suicide need continual support as external pressures and stressors can reappear. It is important to keep individuals in contact with services via brief contact from time to time so follow up intervention can occur (Maple et al., 2018).
People are at greater risk of suicide if they have:
a mental illness,
poor physical health and disabilities,
attempted suicide or have harmed themselves in the past,
had bad things happen recently, particularly with relationships or their health,
been physically or sexually abused as a child,
been recently exposed to suicide by someone else,
alcohol and other substance use disorders,
feelings of hopelessness, and
access to lethal means (Jackson, 2019; Mental Health First Aid Australia, 2014).
Warning Signs (Jackson, 2019)
Warning signs, unlike risk factors, are individual and can signal an immediate risk. Examples of warning signs suggesting an immediate risk for suicide include:
a person talking about killing him or herself, e.g., 'I don't feel like this world is for me; I think people would be better off if I weren't around,'
talking about feeling hopeless or having no reason to live,
looking for a way to kill oneself.
Warning signs that may indicate a serious risk, especially if the behaviour is new, has increased, and/or seems related to a painful event, loss or change include:
talking about feeling trapped or in unbearable pain
talking about being a burden to others,
increased use of alcohol or drugs,
acting anxious or agitated,
withdrawing or feeling isolated,
expressing a significant change in mood,
significantly disrupted sleep—too little or too much,
a sudden change in interests—a shift in what is found pleasurable,
end of a relationship,
death of a loved one,
serious financial problems.
Self-injury Among Adolescents
The following material (Terhaag & Rioseco, 2021) on self-injury is from the Longitudinal Study of Australian Children.
WHAT DO WE KNOW?
People who engage in non-suicidal self-injury deliberately hurt their bodies (e.g. by cutting or burning) as a way to manage intense emotional distress. Non-suicidal self-injury is a concern in young people as it often goes undetected. It is associated with long-term poor physical and mental health outcomes that extend into adulthood, and is also frequently linked to suicidality. Official statistics are likely to under-represent non-suicidal self-injury as they record hospitalised injuries only. Research suggests that population-level prevalence may be twice as high or higher than shown in national statistics.
This snapshot explores the prevalence of non-suicidal self-injury thoughts and behaviours in Australian adolescents between 14 and 17 years, and how engagement in self-injuty may change or persist in that time. It identifies socio-demographic, psychsocial, faily and school factors across childhood that are associated with risk for engaging in self-injury.
Thoughts and acts of self‐injury are common among young people, and both are much higher in girls than boys. Between the ages of 14 and 17, 30% of young people had thought about self-injuring, and 18% reported self-injury.
A small but significant proportion engage in repeated self‐injury (4%), mostly girls. Almost two thirds of those who did had made a suicide attempt by age 17.
Young people who are same‐sex attracted at age 14-15 are at much higher risk of self-injuring.
Having a close relationship with a parent is protective against self-injuring, while poor parent mental health in early childhood is a risk for adolescent self-injury several years later.
Young people who attend non‐government schools are also less likely to self-injure, while young people who have repeated a grade are at elevated risk of self-injuring.
Experiencing bullying, depression, anxiety and poor sleep during secondary school are all associated with a higher risk for engaging in self-injury.
After accounting for multiple variables at different stages of childhood, the main factors associated with a higher risk of self-injury were: being female, same‐sex attracted, and having elevated depressive symptoms at age 14–15.
RELEVANCE FOR PRACTICE
Educate families to recognise signs of mental distress, particularly depression and self-injury, as well as support parents to know how to safely talk about mental health, self-injury and help-seeking.
Build general mental health literacy among young people at school.
Train school teachers to recognise the signs of self-injury.
Increase the students’ sense of belonging or connection with school.
Where young people do report or demonstrate self-injury behaviour, provide adequate treatment and follow-up.
Protective Factors (Jackson, 2019)
In addition to being alert to risk factors and warning signs, it's also necessary to be able to help individuals build and expand protective factors such as
social connectivity to individuals, family, community and social institutions,
life skills including coping and problem-solving skills, ability to adapt to change,
self-esteem and a sense of purpose or meaning in life,
cultural, religious or personal beliefs that discourage suicide.
It is also important to source appropriate clinical care for physical and mental health issues and substance use disorders.
(Lifeline, 2020; Mental Health First Aid Australia, 2014; R U OK?, 2020)
A safety plan is often discussed with a person contemplating suicide. Beyond Blue have an app and a web version on suicide safety planning at https://www.beyondblue.org.au/get-support/beyondnow-suicide-safety-planning. It suggests people complete seven sections with prompts to assist completion:
my warning signs,
my reasons to live,
making my space safe,
things I can do by myself,
people and places I can connect with,
people I can talk or yarn to, and
Using Social Media (‘Chatsafe’ website)
Orygen (2020) has a website called Chatsafe that suggests ways of using social media to safely allow discussion of suicide and help prevent suicide clusters occurring. Orygen suggests social media and online communication can be used to notify stakeholders in the community that a suicide has occurred, or that a suspected suicide cluster may be underway. This can be an opportunity to provide stakeholders with accurate information, thereby helping to reduce the spread of rumours, and provide additional resources that might help them assist others. In addition to offering ‘A Guide For Communities’, Orygen has available a ‘Young Person’s Guide’ that uses a flowchart to provide young people with ideas about posting on social media in five areas:
Posting anything online about suicide
Sharing your own thoughts, feelings or experience with suicidal behaviour online
Communicating about someone you know who is affected by suicidal thoughts, feelings or behaviour
Responding to someone who may be suicidal
Memorial websites, pages and closed groups to honour the deceased.
The following is a brief summary from ‘A Guide For Communities’ outlining how social media can be used.
Community Organisations Providing Support (R U OK?, 2020b)
Besides the list of immediate support listed in the Practice Approach below, R U OK? has lists of other resources to provide support to those
affected by complex trauma
with eating disorders and body image issues
experiencing grief or loss
aged 12-25 experiencing mental health issues
affected by anxiety and depression during pregnancy and parenthood
requiring LGBTI peer support
who want to talk about sexuality, identity, gender, bodies, feelings or relationships?
aged 14-25 who need help with tough times
requiring relationship support
requiring mental illness advice, referral and support
needing postvention and support after suicide
bereaved by suicide
with debt problems
R U OK? also provides a list of useful tools and resources around
Safety planning (an app)
Low-cost health and community services
Multicultural mental health resources
Online assessment, treatment for stress, anxiety and more
Self-help program for people with mild to moderate depression, anxiety and stress
Lifeline Tool Kits (2020)
Beside the tool kit ‘Helping Someone At Risk of Suicide’ that was used as the starting point for the Practice Approach below, Lifeline has a variety of other tool kits including:
‘Suicide Prevention Information for Aboriginal and Torres Strait Islander People’ – covers risk factors, warning signs and a procedure to follow, i.e. act now, have a yarn, share thoughts of suicide, keep safe, stay connected, have a clear plan, and useful resources.
‘I tried to end my life” - outlines strategies that a person who has tried to end their life can put in place, e.g. make a suicide safety plan, identify coping strategies that work, remove items that can be used for suicide, spend time with others, engage in pleasurable activities, avoid alcohol and other drugs, identify the triggers, relieve stress (breathing, use apps that are available. There is a list of support options: Lifeline, smartphone apps, talk to someone, contact a helpline, hospital emergency department, or call 000 if life is in danger. The central message of the document is to “reach out to others”.
The following relies on the above material and the approaches found in Lifeline (2020), R U OK? (2020a), and Jackson (2019).
Sudak and Rajalakshmi (2018) emphasise the importance of the initial contact with a person with suicidal thoughts or behaviour as research in emergency departments shows engagement and retention is a significant challenge. They stress the importance of developing a safety plan by identifying early warning signs, encouraging internal coping strategies, reaching out to family/friends, identifying other individuals who can provide support during suicidal crises, contacting mental health professionals, and lethal means planning. This approach is consistent with the information that follows.
Be aware of the risk factors for suicide (outlined in the background material above) noting suicide is particularly high among young people, older adults and Aboriginal and Torres Strait Islander people.
Build a trustful, supportive relationship:
Don’t give glib reassurance such as “don’t worry”, “cheer up”, “you have everything going for you” or “everything will be alright”.
Use the terms ‘suicide’ or ‘die by suicide’ and avoid stigmatising language, i.e., ‘commit suicide’ or talking about ‘failed suicide’ or ‘unsuccessful suicide’.
Be supportive, understand, show empathy.
Ask “What are you thinking and feeling?” Acknowledge, and allow them to express feelings.
Use open ended questions to find out more about thoughts and feelings; expand into a biopsychosocial-spiritual assessment around social relationships, supports available, employment, finance, family, and substance use.
Summarise and clarify.
Ask direct questions to determine the immediate threat of suicide.
Have you attempted or planned suicide in the past?
Do you have a plan?
How? Do you have the means? Weapon?
Have you been using drugs / alcohol?
Have you told anyone how you are feeling?
Remind the person that suicidal thoughts need not be acted on. Reassure the person that there are solutions to problems or ways of coping other than suicide.
Discuss together what steps you are going to take. “What have you done in the past to manage similar situations?” “How would you like me to support you?" “What’s something you can do for yourself right now? Something that’s enjoyable or relaxing?”
Collaboratively work on a safety plan with the person: how they are going to stay safe, the steps they will take to stay safe, and other people to get involved if things start to get tough. The Beyond Blue app mentioned above may help. Mental Health First Aid Australia (2014) suggests the following when developing a safety plan:
Focus on what the suicidal person should do rather than what they shouldn’t.
Be clear, outlining what will be done, who will be doing it, and when it will be carried out.
Adopt a length of time which will be easy for the suicidal person to cope with, so that they can feel able to fulfil the agreement and have a sense of achievement.
Include contact numbers that the person agrees to call if they are feeling suicidal, e.g., the person’s doctor or mental health care professional, a suicide helpline or 24-hour crisis line, friends and family members who will help in an emergency. R U OK? (2020b) lists the following organisations that provide immediate support
o Lifeline: 131114
o Beyond Blue: 1300 22 4636
o Suicide Call Back Service: 1300 659 467
o Open Arms – a veterans and veterans families counselling service: 1800 011 046
o MensLine Australia: 1300 78 99 78
o Kids Helpline: 1800 55 1800
o 1800RESPECT – for sexual assault, domestic and family violence: 1800 737 732
o Gambling Help Online: 1800 858 858
Ask them how they would like to be supported and if there is anything you can do to help, but do not try to take on their responsibilities.
Remove any means of suicide, including weapons, medications, alcohol and other drugs, even access to a car. Be aware of your own safety.
Encourage the person to get appropriate professional help as soon as possible (e.g., GP). Provide resources to assist the person.
Discuss with the person what issues or situations might trigger further suicidal thoughts. Plan how to reduce this stress and what coping strategies can be used. Building a hope box may help, i.e. a collection of items that remind the person of reasons to stay alive (photographs, inspirational scripture or quotes, poetry, letters, meaningful mementos, and reminders of things that the person wants to do in the future).
Ask the person to promise to tell someone if thoughts of suicide happen again. The person could identify two groups of social contacts: a group with whom she or he may be distracted from the suicidal thoughts, and a group that can help with suicidal thoughts.
Don’t agree to keep suicidal thoughts a secret. Consider enlisting the help of others or suggesting professional help. Keeping the person safe is the first priority.
Stay involved. Try to ensure the person has support:
Put a reminder in the diary to contact in a couple of weeks. If the person is really struggling, follow up sooner. "I've been thinking of you and wanted to know how you've been going since we last chatted."
Ensure the person has 24-hour access to some form of support: you, other family members and friends, or Lifeline.
Accompany the person to appointments if possible.
Advocate for appropriate services.
Continue to be supportive but not overprotective.
Suicide assessment and prevention during pandemics
See Brenna, Links, Tran, Sinyor, Heisel & Hatcher (2021) and Center for Practice Innovations of Columbia Psychiatry (2021) to get more detail about the following points.
Who could be at risk? (Brenna et al., 2021)
High-risk groups vulnerable during pandemics include older adults and older women in particular; individuals who are or who become unemployed or under-employed; individuals with pre-existing mental health and/or substance misuse problems; and frontline health and social service workers.
Risk factors (Brenna et al., 2021)
There are two primary risk factors, contingent on their interaction with each person’s pre-existing vulnerability and specific social contexts:
Anxiety and dread associated with media reports of the pandemic and its impact on community health,
Social isolation and loneliness that resulted from the public health strategies adopted to control the pandemic.
Strategies to use with clients (Brenna et al., 2021)
Limit their own exposure to media reports about the pandemic,
Increase social support for vulnerable individuals, particularly older adults, by promoting interpersonal connections.
Adapting telehealth for suicidal clients (see Center for Practice Innovations of Columbia Psychiatry (2021) to expand on the following)
Prior to contact
Request the person’s location (address, apartment number) at the start of the session in case you need to contact emergency services.
Request or make sure you have emergency contact information.
Prior to contact, develop a plan for how to stay on the phone with the client while arranging emergency rescue, if needed.
Use the C-SSRS tool
Assess the emotional impact of the pandemic on suicide risk.
Identify protective factors.
Inquire about access to lethal means.
Adapt the management plan
Identify ways to increase safety short of sending client to the Emergency Department (ED)
Develop a safety plan that will help clients manage their suicide risk on their own.
Increase contact via brief check-ins till risk de-escalates
Provide crisis hotlines
Seek permission to contact individuals who may help in-person or remotely
If risk is imminent, stay on the phone until other care is present
Adapt safety planning
Emphasise that having a safety plan is particularly important now as a way to stay safe without going to the ED or a medical facility
Arrange a way for the client to get a copy of the plan. Clients can write it down as you go, or the clinician can write it down, take a picture or scan, and e-mail or text to the client
Follow-up and monitoring
Conduct a suicide screen at every contact for those at elevated risk
Review any changes in risk or protective factors
Review and update the safety plan.
Get permission to continue providing follow-up phone contact.
Use of smartphone and internet-based tools (Brenna et al., 2021)
Smartphone and internet-based tools may potentially augment virtual suicide assessment and crisis management. Self-guided internet-based tools, and in particular those which apply cognitive behavioural therapy, have been found to effectively reduce the risk of suicidal thoughts and behaviours when explicitly targeting suicidality. Two review articles:
Büscher R, Torok M, Terhorst Y, Sander L. Internet-based cognitive behavioral therapy to reduce suicidal ideation: a systematic review and meta-analysis. JAMA Netw Open. 2020;3(4):e203933. Saved as Suicide - Internet CBT.
Torok M, Han J, Baker S, Werner-Seidler A, Wong I, Larsen ME, Christensen H. Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials. Lancet Digit Health. 2020;2(1):e25–36. Saved as Suicide – digital interventions.
The Australian National University (ANU) has a tool that rates various depression-related websites (some also cover anxiety). Link to the tool: https://beacon.anu.edu.au/service/website/browse/1/Depression . MoodGYM has been developed by the ANU. Link to MoodGYM: https://beacon.anu.edu.au/service/website/view/25/1
The Black Dog Institute has a number of digital tools and apps for mental health and wellbeing developed and successfully tested through research trials that can be accessed anywhere at no cost. See https://www.blackdoginstitute.org.au/resources-support/digital-tools-apps/
Online Clinic Overall mental wellbeing
Healthy Mind For people with intellectual disability
iBobbly Wellbeing app for Aboriginal Australians aged 15 years and over
myCompass For people with mild to moderate depression, anxiety and stress
HeadGear smartphone app to build resilience
BITE BACK Positive psychology program for the 13 – 16 years old
Supporting Material / References
Brenna, C., Links, P., Tran, M., Sinyor, M., Heisel, M., & Hatcher, S. (2021). Innovations in suicide assessment and prevention during pandemics. Public Health Research and Practice, 31(3):e3132111. https://doi. org/10.17061/phrp3132111
Center for Practice Innovations of Columbia Psychiatry. (2021). Telehealth tips: Managing suicidal clients during the COVID-19 pandemic. Retrieved from https://zerosuicide.edc.org/sites/default/files/Telehealth%20Tips%20with%20Suicidal%20Clients%20-%20FINAL.pdf
Columbia Suicide Severity Rating Scale https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/ Users of this tool ask people a series of simple, plain-language questions. The answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk and gauge the level of support the person needs:
Whether and when they have thought about suicide (ideation)
What actions they have taken — and when — to prepare for suicide
Whether and when they attempted suicide or began a suicide attempt that was either interrupted by another person or stopped of their own volition
Erlangsen, A., Banks, E., Joshy, G. et al. (2020). Measures of mental, physical, and social wellbeing and their association with death by suicide and self-harm in a cohort of 266,324 persons aged 45 years and over. Soc Psychiatry Psychiatr Epidemiol. https://doi.org/10.1007/s00127-020-01929-2. The link to this study is https://link.springer.com/article/10.1007/s00127-020-01929-2#citeas
Jackson, K. (2019). Suicide prevention is every social worker’s business. Social Work Today, 19(1), 10-13. Retrieved from https://www.socialworktoday.com/archive/JF19p10.shtml
Lifeline. (2020). Toolkits and factsheets. Retrieved from https://www.lifeline.org.au/resources/toolkit-downloads/ The tool kit ‘Helping Someone At Risk of Suicide’ was used as the starting point for the Practice Approach above.
Maple M, Wayland S, Pearce T, & Hua P. (2018). Services and programs for suicide prevention: An evidence check rapid review brokered by the Sax Institute for Beyond Blue, 2018. Retrieved from https://www.saxinstitute.org.au/wp-content/uploads/Suicide-prevention-programs-FINAL.pdf
Mental Health First Aid Australia. (2014). Suicidal thoughts and behaviours: MHFA guidelines. Retrieved from http://mhfa.com.au/resources/mental-health-first-aid-guidelines
Orygen. (2020). A guide for communities: Using social media following the suicide of a young person and to help prevent suicide clusters. Melbourne, Australia: Chatsafe. Retrieved from https://www.orygen.org.au/Training/Resources/Self-harm-and-suicide-prevention/Guidelines/Using-social-media-following-the-suicide-of-a-youn/orygen-chatsafe-suicide-clusters-prevention-guide.aspx?ext=
The Young Person’s Guide can be found using this link: https://www.orygen.org.au/Training/Resources/Self-harm-and-suicide-prevention/Guidelines/chatsafe-A-young-person-s-guide-for-communicatin/Guidelines_Orygen_Final_WebLG
Page, A., Sperandei, S., Spittal, M.J. et al. (2020). The impact of transitions from employment to retirement on suicidal behaviour among older aged Australians. Soc Psychiatry Psychiatr Epidemiol. https://doi.org/10.1007/s00127-020-01947-0. Link: https://link.springer.com/article/10.1007/s00127-020-01947-0
Robinson, J., Bailey, E., Witt, K., Stefanac, N., Milner, A., Currier, D., Pirkis, J., Condron, P., & Hetrick, S. (2018). What works in youth suicide prevention? A systematic review and meta-analysis. EClinicalMedicine, 4-5, 52-91. https://doi.org/10.1016/j.eclinm.2018.10.004
R U OK? (2020a). Asking R U OK? Retrieved from https://www.ruok.org.au/how-to-ask
RU OK? (2020b). Find help. Retrieved from https://www.ruok.org.au/findhelp
Safety Plan Template (Stanley and Brown, 2008). Retrieved from https://www.sprc.org/sites/default/files/Brown_StanleySafetyPlanTemplate.pdf
Sudak, D. M., & Rajalakshmi, A. K. (2018). Reducing suicide risk: The role of psychotherapy. Psychiatric Times, 35(12), 12-13. Retrieved from https://cdn.sanity.io/files/0vv8moc6/psychtimes/842fdf56ec50a2381f414559377ddb5244a14c07.pdf
Terhaag, S. (2020). Suicidality and help seeking in Australian young people. Retrieved from https://aifs.gov.au/cfca/2020/10/29/suicidality-and-help-seeking-australian-young-people
Terhaag, S., & Rioseco, P. (2021). Self‐injury among adolescents (Growing Up in Australia Snapshot Series – Issue 4). Melbourne: Australian Institute of Family Studies. Retrieved from https://growingupinaustralia.gov.au/research-findings/snapshots/self-injury-among-adolescents
Zero Suicide Model (2020). Zero suicide tool kit. Retrieved from https://zerosuicide.edc.org/toolkit/zero-suicide-toolkit A model for organisations seeking to become more oriented to noticing and assisting people contemplating suicide
Lead Develop a system-wide culture committed to reducing suicides
Train Provide information on suicide identification, management, treatment,
and safety planning
Identify Use screening and assessment to identify individuals with suicide risk
Engage Develop a suicide care management plan for individuals at risk or
Treat Use evidence-based treatments to treat suicidal thoughts and
behaviours, e.g. Crisis center hotline support and follow-up; Brief
intervention and follow-up; Emergency respite care; Partial
hospitalization, with suicide-specific treatment; and Inpatient psychiatric
hospitalization, with suicide-specific treatment
Transition Support individuals through care with warm hands-off contacts; be
aware of and address suicide risk constantly during this period
Improve Engage in critical reflection after working with each person on suicide