Emotional First Aid Training Manual Nov 2015

Suicide Intervention

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Suicide Intervention

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Suicide Intervention

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Suicide Intervention

Suicide Risk Factors


 
These factors raise the lethality rate of someone who is contemplating suicide, or
who has mentioned that they are suicidal. In your intervention, ask about the risk
factors that have an asterisk *

• Family history of suicide *
• Family history of child maltreatment *
• Previous suicide attempt(s) *
• History of mental illness, particularly clinical depression *
• History of alcohol and substance abuse
• Feelings of hopelessness
• Impulsive or aggressive tendencies
• Local epidemic of suicide
• Isolation, a feeling of being cut off from other people
• Loss (relational, social, work, or financial)
• Physical illness
• Easy access to lethal methods *

Suicide Myths


 
• No one can stop a suicide, it is inevitable.
• If people in a crisis get the help they need, they will probably never be
suicidal again.
• Confronting a person about suicide will only
make them angry and increase the risk of
suicide.
• Asking someone directly about suicidal intent
lowers anxiety, opens up communication and
lowers the risk of an impulsive act.
• Only experts can prevent suicide.
• Suicide prevention is everybody’s business, and
anyone can help prevent the tragedy of suicide
• Suicidal people keep their plans to themselves.
• Most suicidal people communicate their intent
sometime during the week preceding their
attempt.
• Those who talk about suicide don’t do it.
• People who talk about suicide may try, or even complete, an act of self-
destruction.
• Most people think the winter holidays have the highest rates of suicide
• Suicides are lowest in December and peak in the spring.
• Suicides are more common on weekends
• For Adults most suicides fall on Mondays.
• Suicide is an Easy Escape, one that a Coward’s Use
• Suicide is Selfish, a Way to Show Excessive Self-Love

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• People Often Die by Suicide on a Whim
• You can tell who will Die by Suicide from their Appearance
• Most People who Die by Suicide Leave a Note
• It Just a Cry for Help
• Hospitalization is the best treatment for Suicidal Individuals
• Young Children do not Die by Suicide
• It is Easy to Kill Yourself

Signs of Suicide


 

These signs may mean someone is at risk for suicide. Suicide risk is greater if a
behavior is new or has increased and if it seems related to a painful event, loss
or change.

Look for signs in Talk, Behavior, and Mood

 
• Talking about wanting to die or to kill oneself.
• Looking for a way to kill oneself, such as searching online, buying a gun, or

collecting pills
• Talking about feeling hopeless or having no reason to live.
• Talking about feeling trapped or in unbearable pain.
• Talking about being a burden to others.
• Acting anxious or agitated
• Behaving recklessly.
• Withdrawn or feeling isolated.
• Preoccupation with death.
• Suddenly happier, calmer.
• Loss of interest in things one cares about.
• Visiting or calling people to say goodbye.
• Making arrangements; setting one’s affairs in order.
• Giving things away, such as prized possessions.
 

Look for Psychosocial Stressor Events
• Loss
• Unemployment
• Family Shame
• Bullying
• Divorce/Marital Conflict
• Previous Attempts
• Family History
• Financial or Legal Problems

View Suicidal Ideation and Thinking, as a Process rather than a one-time
Event-Rarely are their Spontaneous Suicides

Death by Suicide is not about being selfish, or not thinking of anyone else but the
individual, it is about the unbearable emotional pain, which is known as…

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“Psychache”


 
Psychache is hurt, anguish, or ache that takes hold in the mind. It is intrinsically
psychological-the pain of excessively felt shame, guilt, fear, anxiety, and
loneliness.
Suicide happens when the psychache is deemed unbearable and death is
actively sought to stop the unceasing flow of painful consciousness
Everyone who completes suicide feels driven by the psychache and in all cases
individuals feel that suicide is the only option left!
Psychache Produces the Suicidal State

A Suicidal State of Mind is characterized as a tunnel or
constricted thinking.

Someone who is suicidal has an altered state of mind-
Thinking Changes Dramatically

Suicide is a Solution to a seemly unsolvable Problem
or Crisis, is it merely an option!

In addition, Thomas Joiner in his book referenced on the last past, “Why People
Die by Suicide”, proposes three reasons why people complete suicide:

1. Habituation to Death
2. Thwarted Belongedness
3. Perceived Burdensomeness

The interpersonal-psychological theory of suicidal behavior (Joiner, 2005)
proposes that an individual will not die by suicide unless s/he has both the desire
to die by suicide and the ability to do so. What is the desire for suicide, and what
are its constituent parts? What is the ability to die by suicide and in whom and
how does it develop?

In answer to the first question of who desires suicide, the theory asserts that
when people hold two specific psychological states in their minds simultaneously,
and when they do so for long enough, they develop the desire for death. The two
psychological states are perceived burdensomeness and a sense of low
belongingness or social alienation.

In answer to the second question regarding capability for suicide, self-
preservation is a powerful enough instinct that few can overcome it by force of
will. The few who can have developed a fearlessness of pain, injury, and death,
which, according to the theory, they acquire through a process of repeatedly

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experiencing painful and otherwise provocative events. These experiences often
include previous self-injury, but can also include other experiences, such as
repeated accidental injuries; numerous physical fights; and occupations like
physician and front-line soldier in which exposure to pain and injury, either
directly or vicariously, is common.

Research indicates that three facets – suicidal desire, suicidal capability,
and suicidal intent – cover the domain of the suicide phenomenon

The Anatomy or Process of a Suicide is explained:

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Suicide Intervention

Suicide Intervention Model (SIM) has 3 Phases

Most suicides can be prevented. If there’s a single word that describes the
suicidal disposition, it’s ambivalence. Most suicidal people hang in the balance
between “I really, really want to die” and “I really, really want to live.”

1. Connecting- No overreaction, but emphatic listening, Explore suicidality,
and ask the question

2. Understanding- No judgment, no statements of condemnation “How can
you think of doing that…?”

3. Assisting- Safe plan, brainstorm other solutions, and follow-up


 

Learn to ask the question

The correct way to ask someone if they are thinking about suicide is:

“Are you thinking about suicide/killing yourself?”

Do not ask/say:
• “Are you thinking about harming yourself?”
• “You’re nothing thinking about suicide are you?”
• “You have so much to live for,”
• “Think about how this will hurt your family.”
• “You will go to hell!”
• “You will ruin other people’s lives if you die by suicide!”

What NOT to DO When Faced with an Individual who is Suicidal
• Don’t ever dare a student to attempt suicide.
• Don’t debate with the student about whether suicide

is right or wrong.
• Don’t promise secrecy or confidentiality.
• Don’t panic.
• Don’t rush or lose patience with the student. Realize

that you may need to spend some time with this student in
order to ensure that he or she will remain safe.
• Don’t act shocked. If you do so, the student is likely to feel
that the situation is so bad that no one can help. This will
destroy any chance for rapport and is likely to put distance
between you and the student.
• Don’t be judgmental. Avoid offering opinions of right
vs. wrong or ethical vs. unethical. The main aspect of
communication is just to listen and show concern.
• Don’t preach to the student. Avoid discussing the value
of life and how such a tragic act would affect his family and

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friends. These people may be contributing to the student’s
suicidal crisis and the student may wish to hurt these
people through suicide.
• Never leave the student alone remain with them on the text conversation
• Don’t under-react or minimize. By under-reacting,
you communicate that you don’t really respect the
student’s feeling and don’t believe that the student is
serious. By doing this, you just reinforce the student’s
feeling that no one understands or cares. Assuming that a
student is attention seeking is usually the reason behind
underreacting. Even if a student is seeking attention, you
should act. The benefits could certainly out way the costs.

Ask the person directly-then listen

• If the answer is “No.”
• Don’t respond with relief or a “praise God.” Simply say “okay, that’s good.”

• If the answer is “Yes.”
• You have an Actively Suicidal Individual!
• Do not react with panic, disbelief, or shock that they would even think

about suicide

Instead, seek to understand lethality, how dangerous someone is to
themselves follow the “Yes” with:

• Do you have a plan in mind for how you would kill yourself?
• Do you have access to the _________(gun, knife, rope, pills etc.)?
• When do you plan to kill yourself?
• Have you thought about suicide in the last 2 months?
• Have you ever tried to kill yourself before?
• Do you know anyone who has completed suicide?

Use these tools to access lethality:

Are you having thoughts of suicide? Yes No

If yes, conduct Lethality Assessment. Most of the information below will be
obtained just by listening. You only need to ask enough questions to assess the
level for each one, so if you have already concluded that the capability is high, for
instance, you don’t need to ask about all of the factors in that category.

 

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Instructions:
We make lethality assessments based on information that the caller provides and
our own intuitive sense of the caller. There is no scientifically proven “formula,”
but this tool provides some clear guidance. Capability and intent greatly increase
risk and buffers help reduce risk.

To determine whether each category is low, med. or high, consider how many
factors are involved and which ones they are. For instance, “attempt in progress”
would constitute high intent by itself. Conditions that impair one’s self-control or
judgment, such as intoxication or psychosis, raise the capability significantly.

Note that suicidal intent can only be medium or high if any one of its factors is
checked.

If none of the factors applies in a particular category, check off “low” for the
overall rating.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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  YES NO Overall Rating
SUICIDAL DESIRE NO Low Med High
Suicidal thoughts
Psychological pain NO Low Med High
Hopelessness NO Low Med High
Helplessness Low Med High
Perceived burden on others
Feeling trapped
Feeling intolerably alone
Overall Desire

SUICIDAL CAPABILITY YES
Prior attempts
Impacted by someone else’s suicide
Available means of hurting self/other
History of violence towards others
Currently intoxicated/impaired
Substance abuse history
Recent dramatic mood change
Out of touch with reality
Current sleep deprivation
Current anxiety or agitation
Recent acts or threats of aggression
Overall Capability

SUICIDAL INTENT YES
Attempt in progress

Plan to hurt self/others – method known
Preparatory behaviors

Expressed intent to die
Overall Intent (must be med or high if any
are checked)

PROTECTIVE BUFFERS YES
Immediate support – someone present
Other supports (family, friend, therapist)
Planning for the future
Engagement with telephone worker
Some positive feelings for life
Beliefs that would oppose suicide
Sense of purpose
Overall buffers

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Level of Suicide Risk

SERIOUS: some suicidal thoughts. No suicide plan. Person can state that
suicidal thoughts will not be acted upon.

• Be proactive
• Make a safety plan

MORE SERIOUS: suicidal thoughts. Person has a vague plan, with low
indication of lethality. He/she can state that suicidal thoughts will not be acted
upon.

• Seek to remove all potential means of suicide (pills, weapons, etc.)
• Be proactive
• Make a safety plan

MOST SERIOUS: suicidal thoughts and a specific plan with high level of lethality.
He/she states that suicidal thoughts will be acted upon

• Be proactive
• Walk through the reasons for the psychological pain
• Call police of the town and state where the Person in Emotional Crisis is

located or call 911

IN ALL CASES:
• Encourage positive lifestyle changes
• Continue your support, including follow-up

If the individual can provide you answers to these questions what is the next
step?

• Never leave a suicidal person alone!
• Use guilt and threats to try to prevent suicide
• Agree to keep their plan a secret
• With Teens you have to involve the parents, however, if the source of

suicidal thinking is the home and the parents, also tell another trusted
adult. Let them know for their safety, you have to bring in the parent(s).
• Create a safety plan. This must be done collaboratively and involves three
ideas:

Safety Plan

1. An Agreement- “Can you agree to give the gun to a responsible adult?”
“Can you agree to put the pills away in a hard to reach place?”

2. Be Proactive- Anticipating a future suicidal crisis. “If you feel you might act
on your plan, can you agree to get a hold of me.”

3. Contingency Plan- “If these things don’t work for you can you agree to call
me back and we can work on another safety plan?”

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Discuss Risk Triggers-When the Person in Emotional Crisis begins to move
into the Danger Zone! Ask the Individual, “How will you know when to use
your safety plan?”
4. Provide them with resources- 1-800-273-8255 or your cell number or
someone in your group or the text line 855-449-1212.

Use the outline of the Sample Safety Plan below:


 


 


 


 


 


 


 


 


 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Suicide to Hope (s2H)

Phase 1: Understanding
• Task 1: Explore Experiences and Stuckness- (When did Suicide Come
into Your Life? What made it Stronger? What made it Weaker?)
• Task 2: Describe Issue-(What meaning did Suicide Have? What Purpose
did Suicide Serve?)

Phase 2: Planning
• Task 3: Formulate Goals (Is working on this goal life or death for you?)
• Task 4: Develop a Plan (Have a review process built in)

Phase 3: Implementing
• Task 5: Monitor the Work (How is the work going? Are there any changes
that need to be made?)
• Task 6: Review Process: (Celebrate the wins, what additional work do you
want to do now?

s2H is Trauma-Informed asking not:
• What is Wrong with You?
• What has Happened to You?


 

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Coping Cards

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Survival Kit/Hope Box


 


 

 

 

 

 

 

 

 

 


 


 


 


 


 


 


 


 

It can be an envelope, manila envelope, freezer bag, etc.


 


 


 


 

 

 

 

 

 

 

 

 

 

 

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Suicide-related Terminology

We use a lot of specialized terminology in the suicide-intervention world, and it
can be pretty unclear to those unfamiliar with the field. This white paper is
intended as a quick introduction and glossary to help you understand what is
being talked about in the field of Suicide Prevention, Intervention, and
Postvention.

I’ve broken the terms into three categories: Generally Accepted, New Terms, and
Deprecated/Discouraged. This is because consensus about language happens
slowly; others may disagree about where given words belong. These are my
thoughts.

Generally Accepted Terms
Most people in our field agree on what these mean.

• Attempt (n) (v). To take actions with the intent of dying by suicide.
• Caregiver (n). A person who helps with prevention, intervention, or

postvention. Usually used to describe the people directly interacting with a
person who has thoughts of suicide. It’s also appropriate to use specific
descriptions for a role (counselor, rabbi, police officer, doctor, etc.) if
needed, but we tend to use ‘caregiver’ as the generic catchall term.
• Completed suicide (n). A suicide attempt that ended in the death of the
person attempting suicide. Also “died by suicide”, “suicided”, etc.
• Crisis (n). Hard to define, but we tend to describe it as the condition
where a person’s usual coping methods aren’t getting it done anymore.
Sometimes a crisis is precipitated by a traumatic event, but often it’s a
slow accretion of difficulties until it feels like something has to change
because the old way won’t work anymore. Sometimes a person who is in
crisis will think of suicide as a way to resolve the situation, and we call that
a ‘suicide crisis’.
• Ideation (n). Thoughts about suicide, whether accompanied by intention
to die or not. Suicide ideation is often considered the “thinking about it”
phase of a suicide crisis. Anyone in a crisis where suicide is one of the
options they’re considering could be said to have suicide ideation,
independent of whether they actually want to die right now. There’s no
single word in common use to describe the change from when a person is
considering suicide (ideation) to when they are planning suicide (intent to
die, desire to attempt, etc.), but we usually talk about a shift in intention.
Note that suicide ideation does not always lead to a desire to die, and a
desire to die does not always translate into an attempt. Also called
‘suicidal ideation’.
• Intervention (n). Helping someone who is currently in a suicide crisis. The
crisis may involve thoughts of suicide and may also involve
attempts/actions.
• Person with thoughts of suicide (n). A person who’s thinking about
suicide. We prefer this in favor of more-judgmental terms like “suicidal

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person” because it uses person-first language that doesn’t define the
person solely by the crisis.
• Postvention (n). Working with individual people or groups of people to
support and care for them after a person has died by suicide. Postvention
often aims to promote healing among survivors while also preventing harm
to vulnerable people.
• Prevention (n). Working with individual people or groups of people to
diminish their future risk of suicide. Generally presupposes that the people
are not in a suicide crisis right now.
• Safety contract (n). A verbal or written agreement in which a person with
thoughts of suicide promises not to attempt suicide. There’s a lot of debate
about whether these contracts are effective, and the consensus seems to
be moving away from them.
• Suicide cluster (n). A group of suicide deaths that occurred near the
same place or around the same time. Does not imply that the deaths were
connected or related in other ways. Some people use the term to refer to
attempts as well as completed suicides.
• Suicide contagion (n). A group of suicide deaths where there seems to
be a causal connection between the people who died that led them all
toward suicide. Some people use the term to refer to attempts as well as
completed suicides.
• Suicide crisis (n). A crisis where a person thinks of suicide. Not all
suicide crises lead to attempts; in fact, suicide attempts occur in a
relatively small portion of suicide crises. When someone helps a person in
suicide crisis, we call it ‘intervention’.
• Suicidology (n). The academic study of suicide.
• Survivor (n). Someone affected by the suicide death of another person.
Survivors are often friends, family, or coworkers of the dead person, but
anyone who feels affected by a suicide death is a survivor. Note that we
do not use ‘survivors’ to refer to people who lived through a suicide
attempt; for that, look at ‘suicide-attempt survivors’ under New Terms.

New Terms
These terms are new, growing, or debated. Some people use them; others don’t.

• One bereaved by suicide (n). Proposed as an alternative to ‘survivor’,
i.e., a person who is affected by a suicide death. Not yet in wide use.

• Suicide (v). To die by suicide. Usually used as “he suicided” in place of
more judgmental language like “he committed suicide”. Proponents of this
term feel that it’s a relatively value-neutral word that simply describes a
death by suicide; opponents dislike it because it feels clinical, isn’t a word
in common use as a verb already, and doesn’t add much value over
phrasings like “kill [yourself]“, “die by suicide”, “take your life”, etc. Suicide-
as-verb tends to be used more frequently in academic literature.

• Suicide-attempt survivor (n). Someone who attempted suicide during a
suicide crisis and lived through it. This is different from a ‘survivor’, which

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the field defines as the people left behind when someone dies.
Backwards, I think, but that’s the consensus.
• Suicide-loss survivor (n). Proposed as an alternative to ‘survivor’, i.e., a
person who is affected by a suicide death. Not yet in wide use.

Deprecated/Discouraged Terms
These are terms we, as a field, are asking people to stop using, either because
they pathologize suffering or because they’re not sufficiently precise to be useful.

• Commit suicide (v). Judgmental language. We commit sins, we commit
crimes, and we commit people to mental hospitals. Use “attempt suicide”
to describe an attempt or “die by suicide” to describe a death.

• Gesture (n) (v). People sometimes refer to suicide attempts or thoughts
as “gestures”, often suggesting that the people with thoughts of suicide
are selfish or seeking attention. This is disrespectful (because it trivializes
and devalues what the person is going through). Use “attempt” instead,
and try to avoid judgmental tone.

• Hurt yourself (v). People often use this kind of phrase when they’re
uncomfortable asking directly about suicide. Two issues: it’s not specific
enough (see entry for ‘Self-harm’), and it shows that the speaker is
uncomfortable talking about suicide, which makes it harder for the person
being asked to share openly. Use “attempt suicide” instead.

• Just (adv). You’ll hear this a lot: “just depressed”, “just feeling bad right
now”, “just having a hard time”, “just needed help”, “just not coping very
well”, “just not strong enough”, etc. In each case, the “just” serves to
minimize the problems and casually disparage the thoughts and
experiences of the person with thoughts of suicide. Avoid it.

• Permanent solution to a temporary problem (n). This feels incredibly
disrespectful if you’re the person with thoughts of suicide, because it
shows that the speaker doesn’t take the thoughts or situation seriously.
Consider how you’d sound saying suicide was a “permanent solution to a
temporary problem” if you knew that the person wanted to die because
they’d just been diagnosed with inoperable cancer.

• Self-harm (n). Covers a broad range of self-injurious behaviors from
suicide to substance abuse to cutting to… really anything. Unless you
want to describe the whole range of self-harm, pick a different term.

• Selfish (adj). We ask people not to describe suicide as a selfish action
because (a) it’s not usually true and (b) it makes it harder for people with
thoughts of suicide to seek help if they think they’ll be called selfish.

• Self-mutilation (n). Same as self-harm, but more judgmental. Use “self-
harm” if you want to describe the broad range of behaviors; use the words
for specific behaviors if you want to discuss them individually.

• Successful suicide (n). When someone dies by suicide. We don’t want to
portray suicide death as a ‘success’. Use “died by suicide” instead.

• Suicidal person (n). There’s debate on this one, but most people prefer
“person with thoughts of suicide” because “suicidal person” feels like it

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labels and pathologizes the person more, defining them by their illness.
Compare to “person with lung cancer” vs. “lung-cancer person”.
• Unsuccessful suicide (n). When someone lives through an attempt. We
don’t want to portray suicide death as a ‘success’. Use “attempted suicide”
instead.

 

Additional Information about the Cause of Suicide

 
Empirical research and clinical experience suggest that suicidality is a multi-
faceted phenomenon.

Research to date indicates that three facets – suicidal desire, suicidal
capability, and suicidal intent – cover the domain of the phenomenon (and
importantly, are not redundant with one another). We believe a fourth facet –
buffers against suicidality – also needs to be included to provide a full framework
for suicide assessment in the context of crisis center hotline work. In what
follows, the four facets are described, some research on each is summarized,
and the interaction among facets is discussed.

Suicidal Desire

In studies by Beck, Joiner, Rudd, and colleagues (e.g., Beck et al., 1997; Joiner
et al.,

1997, 2003), suicidal desire has been shown to be made up of the following
components:

• no reasons for living
• wish to die; wish not to carry on
• passive attempt (e.g., not caring if death occurred)
• desire for suicide attempt.

Influenced by several other strands of research (e.g., Rudd et al.,2006; Joiner
2005] on burdensomeness; Williams [2006] on feeling trapped), researchers
have emphasized psychological conditions that, while not the same as suicidal
desire, are strong contributors to it – namely, feeling trapped, like there is no
alternative course of action or escape, feeling hopeless and/or helpless, and
feeling intolerably alone.

Regarding feeling intolerably alone, theorizing and research on the need to
belong is relevant (Baumiester & Leary, 1995). A fully satisfied need to belong
includes interactions with others and a feeling of being cared about. It is this
latter component – not feeling cared about – that seems to produce intolerable
feelings of loneliness.

Additionally, a body of research demonstrates that psychological pain is

a separate but critical factor indicating suicidal desire (Shneidman, 1998).
Psychological pain, also described by Shneidman (1998) as “psychache,” is

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commonly associated with feelings of worthlessness, intense shame, and
loss/bereavement. Of the factors identified by the researchers as indicators of
suicidal desire, two in particular (i.e., perceived burdensomeness and feeling
trapped) may be unfamiliar in risk assessment contexts.

Joiner’s (2005) theory of suicidal behavior asserts that perceived
burdensomeness is a key component of the life-and-death psychological
processes of people seriously contemplating suicide.

Suicidal people perceive themselves to be ineffective or incompetent; moreover,
they perceive that their ineffectiveness affects not only themselves but also spills
over to negatively affect others.

Additionally, they perceive that this ineffectiveness that negatively affects
everyone is stable and permanent, forcing a choice between continued
perceptions of burdening others and escalating feelings of shame, on the one
hand, and death on the other.

According to the current framework, a caller who voices some desire for
death and exhibits psychological pain or expresses feeling trapped can be
said to be experiencing suicidal desire.

Regarding feeling trapped, several prominent models of the development of
suicidal behavior emphasize that suicidal people wish to escape psychological
pain, and that their state of extreme distress diminishes their ability to think of
adaptive ways to do so.

The combination of desperately wishing to escape and being unable to think of
ways to do so leads some people to consider suicide as an escape. A roughly
synonymous concept to feeling trapped is “cognitive constriction” – emotional
crises tend to constrict people’s ability to solve problems, leading in turn to a
sense of desperation, feeling trapped and suicidal behavior as an escape.

A key point about suicidal desire is that, although it is of clinical import, it is not,
by itself, very telling about suicide risk status. This is because suicidal desire is a
very common symptom of mood disorders (Joiner et al., 1997), and indeed a
relatively common experience in the general population (Kessler et al., 2005).

Regarding suicide risk status, suicidal desire is roughly as indicative as are the
other prominent symptoms of depression like anhedonia (inability to experience
pleasure in previously enjoyed activities) and insomnia, for instance. These
symptoms are of concern (and should prompt referrals for treatment), but their
endorsement alone is not enough to raise serious concern about imminent
suicide risk. Rather, it is when suicidal desire occurs in combination with other
facets of suicidality, described below, that concern escalates.

The presence of suicidal desire alerts one to explore and elicit suicidal capability
and suicidal intent.

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Suicidal Capability
The same series of studies that elucidated the nature of suicidal desire also
characterized the components of suicidal capability. They are:

• a sense of fearlessness to make an attempt

• a sense of competence to make an attempt,

• availability of means to and opportunity for an attempt

• specificity of plan for an attempt, and preparations for an attempt.

It is important to note that the “suicidal capability” factor, as defined above,
relates to imminent plans and fearlessness about suicidality. Fearlessness about
suicidality is a key but underrecognized concept. Serious suicidal behavior is by
definition fearsome and is often painful; many clinical case and research studies
show that it is this fearsomeness that prevents many people from acting on
suicidal ideas. Those that do act have come to terms with the prospects of fear,
and often pain. This point does not relate (at least not as directly) to fearlessness
in general, as there are many people who are fearless but who, as a function of
their fearlessness, are not necessarily at risk for death by suicide (e.g., fighter
pilots; NASCAR drivers).

Influenced by past work (e.g., Rudd et al., 2006; Joiner, 2005), researchers
identified the following factors as at least contributing to, and in some cases
defining, suicidal capability:

• History of suicide attempt, particularly multiple attempts (Rudd et al., 1996).
This factor indicates a clear risk for future suicidality due, in part, to the fact
that past behavior is a strong predictor of future behavior. Relatedly, research
indicates that for those who resort to suicidality in the face of distress,
especially repeatedly, suicidality may have become a primary way of coping,
to the exclusion of more adaptive coping methods.

• History of/current violence to others (Conner et al., 2003). This factor’s
relevance resides in the fact that those who are capable of violence or injury
in general are capable of self-injury in particular.

• Exposure to/impacted by someone else’s death by suicide. Some research
has suggested that the impact of suicide on those left behind is associated
with future suicidal behavior and increased frequency of mental health issues
(Agerbo, 2003).

• Availability of means. Seeking access to means of suicide is a clear warning
sign; past research has shown that it is part of a cluster of symptoms
reflecting dangerous parameters like capability and intent (Joiner et al., 1997,
2003).

• Current intoxication (Bartels et al., 2002). Current intoxication diminishes
problem-solving abilities and reduces inhibitions; lowered problem-solving
and lowered inhibitions, in turn; contribute to elevated risk for suicidal
behavior.

• Tendency toward frequent intoxication (Bartels et al., 2002). The tendency
toward frequent intoxication makes intoxication in the near future more likely,

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with attendant risks of decreased problem-solving and lowered inhibitions
noted above.
• Acute symptoms of mental illness (Cavanagh et al., 2002). The experience of
severe and acute symptoms of the vast majority of mental disorders
contributes to many risk factors noted herein; for example, psychological pain,
agitation, insomnia, being out of touch with reality, etc.
• Recent dramatic mood change (Cavanagh et al., 2002). A dramatic mood
change can be indicative of the onset or worsening of a mood disorder or
other disorders –disorders that in turn heighten the risk for suicidal behavior.
• Out of touch with reality (Cavanagh et al., 2002). Problem-solving ability and
inhibitions are both lowered by psychosis; command hallucinations (e.g.,
hearing a voice telling one to injure or kill oneself) are a related concern.
• Extreme rage (Conner et al., 2003). Rage indicates loss of control and
potential for violence, both of which are common precursors to serious
suicidal behavior.
• Increased agitation (Busch et al., 2003). Increased agitation (extreme
physical restlessness combined with emotional turmoil) suggests intense
psychological pain, which, as noted above, constitutes an important risk factor
for serious suicidality.
• Decreased sleep (Sabo et al., 1990). Insomnia can lead to mood changes
and lack of clarity in thinking and is a key symptom of mood disorders.
Research has documented insomnia as a key risk factor for suicidality.

Past research has made it clear that the suicidal desire and suicidal capability
factors are not similarly related to key suicide-related indices. For instance,
Joiner et al. (1997, 2001) showed that, although the presence of either factor is
of clinical concern, the “suicidal capability” factor is, relatively speaking, of more
concern than the “suicidal desire” factor – the “suicidal capability” factor was
more related than the “suicidal desire” to pernicious suicide indicators such as
having recently attempted suicide as well as eventual death by suicide.

Suicidal Intent
Some past research has viewed suicidal intent as part of suicidal desire or
suicidal capability, but the researchers have separated it out for two key reasons.
First, even more than desire and capability, its relation to suicidality is plain –
those who intend a behavior often enact it. In the previously noted SAMHSA
hotline evaluation by Kalafat, Gould & Munfakh (in press), during the weeks
following the suicidal callers’ original calls to crisis lines, callers’ hopelessness
and psychological pain continued to lessen but the intensity of their intent to die
did not continue to diminish.

Moreover, a substantial proportion of the callers (43.2%) continued to express
suicidal ideation a few weeks after the initial call and nearly three percent had
made a suicide attempt after their call. The callers’ intent to die score at the end
of the crisis intervention was the only significant independent predictor of
suicidality following the call, although having made any specific plan to hurt or kill
oneself prior to the call and persistent suicidal thoughts at baseline were also

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significant, albeit not independent, predictors of any suicidality (ideation, plan or
attempt).

Second, neither desire nor capability necessarily imply intent, as evidenced by
those who have desire and capability but do not intend and thus do not attempt
or die by suicide because they are buffered by the factors addressed in the next
section (e.g., ties to family and friends).

According to the current framework, suicidal intent is made up of the following:

• Plan or attempt in progress. This factor is of course the clearest indicator of
intent to attempt, in that the attempt is already in progress.

• Imminent plan to hurt self/other (e.g., method known). Virtually all risk
assessment frameworks emphasize plans for suicide as a key danger sign
(e.g., Joiner et al., 1999), a practice affirmed by research demonstrating that
plans for suicide represent among the most dangerous aspects of suicidality
(Joiner et al., 1997, 2001). Plans to hurt others are relevant too, in light of the
research on violence and aggression noted above.

• Preparatory behaviors. These behaviors (e.g., arranging suicide method,
leaving possessions to others) are noteworthy for the same reasons that
imminent plans are. They can be viewed as behavioral expressions of
imminent plans.

• Expressed intent to die. It is common for suicidal behaviors to be
accompanied by relatively low intent to die or ambivalence about death.
When intent to die is high, the protective aspects of ambivalence about death
are removed. Intent to die is a strong predictor of lethality of attempt (Brown
et al., 2002).

Suicidal intent deserves considerable weight in a suicide risk assessment, but it
should be recognized that some studies have documented a low association
between intent and lethality of method (e.g., Eaton & Reynolds, 1985). We
believe our framework partly explains this – the relationship of intent to lethality is
qualified by factors like buffers (described below) and capability.

Buffers against Suicidality
In even the most suicidal person, there is likely some will to live.

This is demonstrated by numerous instances of extremely suicidal individuals
who have survived highly lethal attempts and have reported back on their states
of mind.

For instance, a New Yorker article in 2003 quoted a man who had jumped off the
Golden Gate Bridge and survived as saying: “I instantly realized that everything
in my life that I’d thought was unfixable was totally fixable – except for having just
jumped.”

A man who jumped into the water leading up to Niagara Falls in 2003 described
changing his mind the instant he hit the water. “At that point,” he said, “I wished I
had not done it. But I guess I knew it was way too late for that.” He survived the
plunge over the falls and now feels a new lease on life. Harry Stack Sullivan

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(1953, pp. 48-49) described people who had ingested bichloride of mercury:
“One is horribly ill.

If one survives the first days of hellish agony, there comes a period of relative
convalescence – during which all of the patients I have seen were most
repentant and strongly desirous of living.” Unfortunately for these patients,
another phase of several days of agony then resumes, usually ending in death.
The will to live is powerful enough that it returns even in people who have
suppressed it enough to imbibe bichloride of mercury, to jump off the Golden
Gate Bridge, or to go over Niagara Falls.

Research has identified the following buffers as key:

• Perceived immediate supports (e.g., person present with the caller). This
factor is of clear pragmatic importance – callers who are with a supportive
other will experience the buffering effects of social support as well as the
practical effects of removal of means, access to emergency care, etc.

• Other social supports. Lack of access to social support is a strong predictor of
suicidal behavior (e.g., Joiner, 2005); its presence, by converse, is protective.

• Planning for the future. Expressed reasons for living, both in the long-term
(e.g., life goals) and the short-term (e.g., plans to complete a project) have
been documented as protective against suicidal behavior (Strosahl et al.,
1992).

• Engagement with helper (telephone worker). This factor is a specific instance
of those more general factors on social support, which are noted above.

• Ambivalence for living (see below).
• Core values/beliefs (see below).
• Sense of purpose. This factor, as well as some reasons for living (i.e., an

ambivalence about death that includes attraction to life) and core
values/beliefs (e.g., duty to family, religious beliefs) all represent the same
process as “planning for the future,” noted above. Specifically, each of these
factors reflects a connection to living.

Presence of these buffers does not automatically offset risk based on the other
three facets of suicidal desire, suicidal capability, and suicidal intent, but as will
be seen in the next section, they may affect risk calculations in significant ways.

The Inter-Relations of the Four Facets and Attendant Implications for Crisis Calls
As previously noted, suicidal desire occurring independent of suicidal capability
and/or suicidal intent typically presents a low-risk-of-suicide scenario. However,
when desire combines with capability and/or intent, then suicidal risk may
dramatically increase and the intervening impact of buffers may also need to
enter into the equation. Below are representations of possible combinations of
factors. It is important to emphasize the non-empirical basis for the risk
formulations (and a need for more research).

.

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Starting with the clearest – and highest risk – scenario, when suicidal desire,
suicidal capability, and suicidal intent are all present, risk is high, and this is
essentially true regardless of the presence of buffers.

When desire is paired with either intent or capability (but not with both), risk is
lower but still considerable, and the determination of whether risk is particularly
high rests with the safety afforded by buffers. If safety is high, risk is more
moderate (though still elevated and in need of regular monitoring); if safety is
low, risk is approximately as high as when desire, capability, and intent are all
present.

Desire by itself is best viewed as a symptom of a mood disorder and does not
entail significant risk by itself. Capability and intent are more pernicious, and here
again, the safety afforded by buffers is partly determinative. If safety is high,
capability and/or intent do not convey the higher risk categories but may convey
moderate risk and require regular monitoring. If safety is low, capability and/or
intent is a more serious concern and requires active intervention, though
probably not to the level of rigor or immediacy occasioned by the combinations of
desire, capability, and intent, as noted in the prior graphics.

It is important to note that formulating an individual’s risk for suicide is best
practiced through a highly collaborative process whereby efforts to engage and
intervene with the caller are often seamlessly interwoven throughout the worker’s
assessment process.

For example, research has shown that an individual’s self-assessment of suicide
risk may outperform clinical judgments (Joiner, Rudd, & Rajab, 1999), suggesting
that workers can further enhance their assessment by asking the caller to rate
his/her own risk of suicide. In addition, the previously cited work by Kalafat,
Gould and Munfakh (in press) showed that “intent to die,” assessed at both the
beginning and end of the call, was the best predictor of the caller’s later
suicidality, indicating that interventions during the call itself can affect the degree
to which the caller is ultimately assessed to be at risk.

Are you thinking of suicide? Have you thought about suicide in the last two
months? Have you ever attempted to kill yourself?

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Mental Health Disorders

Emotional First Aid
Training
Session 3

Mental Health Disorders

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Mental Health Disorders

Mental Health Session
Disorders
3

A lack of understanding when it comes to mental disorders
can leave sufferers feeling isolated and hopeless. Only 25%

of people with mental health issues feel that people are
caring and sympathetic toward their struggles, according to

the Centers for Disease Control and Prevention.

Why should there be a distinction between people who are
sick above the neck and those sick below the neck.

Why is mental illness segregated from physiological

illnesses such as diabetes, cancer, or a heart condition?


 

Mental Health Facts


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mental illnesses are more common than cancer, diabetes or heart disease

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• Mental illnesses are more common than cancer, diabetes or heart
disease

• 10% of children and adolescents suffer from mental illness severe enough
to cause some level of impairment

• Depressive disorders often co-occur with anxiety disorders and substance
abuse

• An estimated 26.2 percent of Americans ages 18 and older — about one
in four adults — experience a diagnosable mental disorder in a given year.

• One in four families have at least one member with a mental disorder.
• Even though mental disorders are widespread in the population, the main

burden of illness is concentrated in a much smaller proportion — about 6
percent, or 1 in 25 people experience a serious mental illness (i.e.
Schizophrenia, Borderline Personality Disorder, Bipolar Disorder, etc.)
• 3.9 million ~ Approximate number of U.S. adults with untreated severe
mental illness in any given year (1.5% of the population)
• By 2020, behavioral health disorders will surpass all physical diseases as
a major cause of disability worldwide.
• There are pervasive delays in getting treatment: the median across
disorders is about 10 years, contributing to greater severity, co-occurrence
of mental illnesses, and lower success rates as people age.


 
The purpose of this lesson is not to teach you to diagnosis, but to make
you aware of the signs and symptoms of a Mental Disorder so you can
provide Mental Health First Aid and Mental Health Crisis Intervention to
someone dealing with a mental health crisis.


 
In the same way that a person provides First Aid to someone who is

physically suffering, mental health first aid, is provided until appropriate
professional help is found.


 
Keep in mind that you are not being trained to be the professional

counselor, therapist, or diagnostician. You are the person understands a
mental health disorder and you are there to walk with an individual until
professional help can be provided. As an Emotional First Aider you are
giving Emotional First Aid.


 

Emotional First Aid is the help offered to a person developing a
mental health problem or experiencing a mental health crisis. The first
aid is given until appropriate treatment and support are received or
until the crisis resolves.

The true focus of this lesson is to help you recognize the symptoms of
mental health problems, how to offer and provide initial help, and how to

guide the individual to professional help, if appropriate.

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Why Do We Need to Learn Emotional First Aid
1. Mental Health problems are common (1 in 5 adults will experience a
mental health crisis in a given year.)
2. Shame and Stigma is associated with mental health problems (for that
reason people do not seek treatment, thus the 10 year span between
when someone first experiences symptoms and when someone seeks
help.)
3. Many people are not well informed about mental health problems
4. Professional help is not always on hand
5. Many people do not know how to respond to someone with a mental
illness

What is a Mental Disorder?

A mental disorder or mental illness is a diagnosable illness that:
• Affects a person’s thinking, emotional state, and behavior
• Disrupts the person’s ability to:
o Work
o Carry out daily activities
o Engage in satisfying relationships

Mental Illness can be:
• Mild
• Moderate
• Severe

The Impact of Mental Illness

Mental illnesses can be more disabling than many chronic physical illnesses. For

example:
• The disability from moderate depression is similar to the impact from
relapsing multiple sclerosis, severe asthma, or chronic hepatitis B.
• The disability from severe depression is comparable to the disability from
quadriplegia.

“Disability” refers to the amount of disruption a health problem causes to a
person’s ability to:

• Work
• Carry out daily activities
• Engage in satisfying relationships

© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 4

Mental Health Disorders

Adopted from the Mental Health First Aid Training 5

© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson

Mental Health Disorders

Identifying Mental Disorder Types

In this section we briefly describe some of the most common Mental Disorder
Types, people who have “features” of a mental illness, but as Emotional First
Aider’s we are able just to know a more “Global Picture” of those who we provide
Emotional First Aid.

Paranoid. People with paranoia are guarded, secretive, and can be
pathologically jealous. They live in logic-tight compartments, and it is difficult if
not impossible to shake their persecutory beliefs. They see themselves as
victims and expect deceit and trickery from everyone. The counseling focus is to
stress their safety needs.

Schizoid. Those with schizophrenia have extremely restricted emotional
expression and experience. They have few social relationships and feel anxious,
shy, and self-conscious in social settings. They are guarded, tactless, and often
alienate others. The counseling focus is to build a good sense of self-esteem
through acceptance, optimism, and support.

Schizotypal. People with schizotypal behavior have feelings of inadequacy and
insecurity. They have strange ideas, behaviors, and appearances. The focus of
counseling is to give them reality checks and to promote self-awareness and
more socially acceptable behavior in a slow-paced, supportive manner.

Narcissistic. Narcissists are grandiose, extremely self-centered, and believe
they have unique problems that others cannot possibly comprehend. They see
themselves as victimized by others and always need to be right. The focus of
counseling is to get them to see how their behavior is seen and felt by others,
while not engaging in a “no-win” debate or argument with them.

Histrionic. People with histrionic personality disorder move from crisis to crisis.
They have shallow depth of character and are extremely ego-involved. They
crave excitement and become quickly bored with routine and mundane tasks and
events. They may behave in self-destructive ways and can be demanding and
manipulative. The focus of counseling is to stress their ability to survive using
resources that have been helpful to them in the past.

Obsessive-Compulsive. Those with obsessive-compulsive disorder are
preoccupied by and fixate on tasks. They expend and waste vast amounts of
time and energy on these endeavors. They often do not hear counselors
because of futile attempts to obtain self-control over their obsessions. The focus
of counseling is to establish the ability to trust others and the use of thought
stopping and behavior modification to diminish obsessive thinking and
compulsive behavior.

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Mental Health Disorders

Bipolar (Manic Depressive). The extreme mood swings of these callers range
from “superman/superwoman” ideation when in a manic phase to “born loser”
ideation in a depressive stage. If they feel thwarted in their grand plans, they may
become very aggressive to those who would stop them. At the other end of the
continuum, their depressive “doom, despair, and agony on me” outlook puts them
at risk for suicidal behavior. Slowing down and pacing these callers in the manic
phase is difficult but needs to be done to put a psychological governor on their
runaway behavior. Confrontation about their grandiose plans only alienates them.
In the depressive stage, suicide intervention is a primary priority.

Dependent. People with dependent personality disorder have trouble making
decisions and seek to have others do so—often inappropriately. Feelings of
worthlessness, insecurity, and fear of abandonment predominate. They are
particularly prone to become involved and stay in self-destructive relationships.
The focus of counseling is to reinforce strengths and act as a support for their
concerns without becoming critical of them or accepting responsibility for their
lives.

Self-Defeating. Those with self-defeating behavior choose people and situations
that lead to disappointment, failure, and mistreatment by others. They reject
attempts to help them and make sure that such attempts will not succeed. The
focus of counseling is stressing talents and the behavioral consequences of
sabotaging themselves.

Avoidant. People with avoidant personality disorder are loners who have little
ability to establish or maintain social relationships. Their fear of rejection
paralyzes their attempts to risk involvement in social relationships. The focus of
counseling is encouragement of successive approximations to meaningful
relationships through social skills and assertion training.

Passive-Aggressive. Those with passive-aggressive behavior cannot risk
rejection by displaying anger in an overt manner. Rather, they engage in covert
attempts to manipulate others and believe that control is more important than
self-improvement. The focus of counseling is to promote more open, assertive
behavior.

Borderline. Borderline personality disorder is so named because such people
are chameleon-like and at any given time may resemble any of the foregoing
mental disorders. Also, they are always on the “borderline” of being functional
and dysfunctional. One of the most problematic of callers, they are dealt with at
length in

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Mental Health Disorders

Depression

Everyone goes through tough times at different points in their lives, and we all
feel sad every now and then. It’s important to understand that feeling sad
temporarily is very different from being depressed-or having depression.

Depression is different from normal sadness in that it engulfs your day-to-day life,
interfering with your ability to work, study, eat, sleep, and have fun. The feelings
of helplessness, hopelessness, and worthlessness are intense and unrelenting,
with little, if any, relief.

Depression interferes with other aspects of your life, like work, school, or
relationships. With the right kind of treatment, many people can overcome it and
lead happy, healthy lives.

Depression is a mental disorder that is more severe and longer lasting than
normal sadness. The diagnostic criteria for mental health professionals to
diagnose someone with depression are to have the symptoms as outlined below
at two weeks or more.

What causes depression?

Sometimes depression has no apparent cause. However, in other cases, it may
be caused by one or a number of factors, which include:

• Genetics: If there’s a history of depression in your family, it could be that
there’s a genetic or biological link that makes the illness more common
among your relatives;

• Biochemical: In certain cases, the chemicals in the brain that control your
moods might be out of balance

• A stressful event: Or chain of events, such as a family divorce or conflict,
physical or sexual abuse, bullying, rape, the death of a loved one, or a
relationship break-up

• Personality: Certain personality types are at a higher risk of depression
than others. This includes people who tend to be anxious, shy,
perfectionist, or those who have low self-esteem.

Depression is not just the result of a chemical imbalance in the brain, and it’s not
simply cured with medication. Experts believe that depression is caused by a
combination of biological, psychological, and social factors. I

In other words, your lifestyle choices, relationships, and coping skills matter just
as much—if not more so—than genetics. However, certain risk factors make you
more vulnerable to depression.

© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 8

Mental Health Disorders

Risk Factors for Depression

These are just a few of the risk factors that make you vulnerable to depression:

• Loneliness
• Lack of social support
• Recent stressful life experiences
• Family history of depression
• Marital or relationship problems
• Financial strain
• Early childhood trauma or abuse
• Alcohol or drug abuse
• Unemployment or underemployment
• Health problems or chronic pain

Signs and Symptoms of depression

People experience depression in different ways depending on the type of
depression and individual differences.

Common symptoms across all types of depression include:
• Sadness that won’t go away
• Feeling irritable or anxious
• Loss of interest in usual hobbies and activities
• Loss of appetite or Eating too much
• Irregular sleeping habits, sleeping too little or too much, having a hard
time falling asleep or early morning wakings
• Unexplained outbursts of yelling or crying
• Reckless or risky behavior like alcohol and drug abuse
• Feelings of Guilt
• Feelings of Helplessness and/or Hopelessness
• Withdrawing from others
• Neglect of Responsibilities
• Fatigue
• Lack of Energy
• Unexplained Aches and Pains
• Frequent Self-Criticism
• Pessimism
• Impaired memory and concentration
• Thoughts of death and suicide

Everyone feels or acts like this from time to time. But for people
experiencing depression, the feelings might be more severe and constant-

they don’t go away over time and they’re not easily explainable.

© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 9

Mental Health Disorders

Types of Depression

According to the American Academy of Child & Adolescent Psychiatry,
Depression affects about 5% of young people in the U.S.

• Dysthymic disorder is a type of depression that may not completely
prevent someone from functioning normally, but keeps someone in a
constant low mood. Dysthymic disorders are chronic and last for two years
or longer.

• Seasonal affective disorder (SAD) is a type of depression that surfaces
during the winter months when there’s less natural sunlight. People with
SAD typically come out of their depression during the spring and summer
months.

• Major depressive disorder is a severe form of depression that interferes
with a person’s ability to eat, sleep, work, study, or take part in daily
activities like he or she normally would. Major depressive episodes usually
last at least two weeks. For most people, a major episode of depression
can occur only once, but for some, it can recur throughout a person’s
lifetime.

• Postpartum depression is a type of depression that occurs in new
mothers within one month after they give birth. Postpartum depression is
likely caused by major shifts in hormone levels after delivery. According to
the U.S. Department of Health and Human Services Office of Women’s
Health, there are several factors that can contribute to postpartum
depression, including a history of depression, young age, and little support
from family and friends.

• Bipolar disorder is a form of manic-depressive illness that can be
characterized by extreme “highs” and “lows” in a person’s mood.

Depression and suicide

For some people, depression may lead to thoughts of suicide. Research shows
that there is a very high correlation between those battling depression and
suicide attempts and completions.

If left untreated, symptoms of depression may worsen and last for months
or sometimes years.

As an Emotional First Aider, you can ask the Person in Emotional Crisis about
the signs and symptoms of depression to get an overview, however, never tell a
Person in crisis that you think they have depression. Rather, tell them they
should get a check-up with their Primary Care Physician and to tell their PC what
they have told you as an Emotional First Aider.


 

© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 10

Mental Health Disorders


 
  Anxiety
 


 
An anxiety disorder differs from normal stress and anxiety. An anxiety disorder is
more severe, lasts longer and interferes with work and relationships

Anxiety is an uncomfortable feeling of fear or imminent disaster, and is a normal
emotional response to danger. What makes one person anxious may not trigger
the same response in someone else. Events like breaking up, exams or a fight
with a friend may cause you to feel anxious, worried or scared.

Everyone feels some anxiety at different times during life. It becomes a problem
if you feel so anxious that it interferes with your normal day-to-day activities.

Anxiety disorders affect about 40 million Americans

The first onset of Anxiety for females is 11 years old

What are the symptoms of anxiety?

Anxiety can affect both the physical health and mental health (behavior and
feelings). The symptoms that are experienced can depend on a number of

factors. These might pass quickly or can stay for a long period of time.

Some common ways that anxiety might affect someone’s mental health include:
• Irritability or constantly being in a bad mood
• Feeling worried, or a constant feeling that something bad is about to
happen
• Often asking many unnecessary questions and requiring constant
reassurance
• Getting upset when your routine changes; for example, a substitute
teacher, unexpected visitors, or a trip to an unfamiliar place
• Being a loner, or hanging out with a small group of group of people (who
are often younger or older)
• Being a perfectionist; for example, taking a long time to complete
homework because you try to make it absolutely correct
• Being argumentative (but not usually aggressive), especially when trying
to avoid a feared situation
• Being pessimistic and easily able to identify what may go wrong in any
given situation

Some common ways that anxiety might affect an individual’s physical health

include:
• Dry mouth or difficulty swallowing
• Nightmares
• Difficulty getting to and staying asleep

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• Difficulty concentrating
• Muscle tension and headaches
• Rapid heart rate and breathing
• Sweating
• Trembling
• Diarrhea

Types of Anxiety disorders and Symptoms

There are many different types of anxiety disorders, each with their own
symptoms and treatments. Here is a list of examples:

• General anxiety is an extreme and uncontrollable worry that is not
specific to any one thing.

• Social anxiety or social phobia involves a fear of social or performance
situations (such as meeting new people) in which an individual may be
embarrassed. People with social anxiety commonly avoid social situations.

• Agoraphobia is anxiety about being in places or situations from which
escape might be difficult or embarrassing if an individual has a panic
attack. It usually leads to avoidance of certain places and situations.

• Claustrophobia is the fear of enclosed or confined spaces. People with
claustrophobia may experience panic attacks, or fear of having a panic
attack, in situations such as being in elevators or trains.

• Panic disorder occurs when you have regular panic attacks. Some
people may develop agoraphobia as a result of the panic attacks.

• Specific phobias involve intense and ongoing fear of particular objects or
situations. Seeing the object you’re afraid of might trigger a panic attack.
Usually the object or situation is avoided.

• Hypochondria refers to an extreme concern or worry about having a
serious illness. People with hypochondria have a constant fixation with
their body, self-examining and self-diagnosing.

• Obsessive Compulsive Disorder (OCD) involves unwanted thoughts,
impulses, or obsessions and repetitive, routine behaviors, also called
compulsions.

• Post Traumatic Stress Disorder (PTSD) is an anxiety disorder sparked
by a major traumatic event, such as rape or accident. It is marked by
upsetting memories, “blunting” of emotions, and difficulties sleeping.

As mentioned earlier, you can ask the Person in crisis questions related to the
signs and symptoms of Anxiety, but do not tell the Person in Emotional Crisis
you suspect they have an Anxiety Disorder. Direct them to the Primary
Care Doctor and instruct them to their doctor what they have told you.

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  Panic
 Attack/Disorder
 

Panic attacks are sudden periods of intense fear or extreme anxiety. They occur
when the “fight or flight” response in the brain is triggered, even though there is
no sign of danger.

The fight or flight response is a survival system that the body uses. It means that
when the brain thinks it is in danger, the body gets ready to fight or run away.

If someone is experiencing a panic attack, their body will react like they are in a
dangerous situation even though you are not.

Panic disorder affects about 6 million American adults and is twice as
common in women as men.

Panic attacks often begin in late adolescence or early adulthood, but not
everyone who experiences panic attacks will develop panic disorder. Many
people have just one attack and never have another.

Panic attacks can happen without any warning but on average only last
about 20 minutes, and peaks at 10 minutes

After the attack, it might take some time to start to feel okay again. It is not
unusual to experience a panic attack. At least 10% of people will experience a
panic attack at least once in a given year.

After experiencing one panic attack, it is not uncommon to worry about having
another. Individuals might even start avoiding situations or activities that they
think might trigger an attack, like busy shopping centers, public transportation,
airplanes, elevators or isolation.

What are the signs and symptoms of a panic attack?

The effects of a panic attack vary from person to person. Some might include:
• Sweating
• Feeling short of breath, or like you can’t get enough air
• A pounding heartbeat
• Chest pains
• Feeling unsteady
• Feeling like you’re choking
• A dry mouth
• Hot or cold flashes
• A tingling feeling
• Feeling faint
• Trembling

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• Nausea or diarrhea
• Feeling like you’re losing control or you can’t escape

What causes panic attacks?

The causes of panic attacks are still being researched. But there is evidence that
stress is associated with panic attacks. Stress alters the chemicals in your body
that influence the fight or flight response.

Keep in mind that many of the symptoms of a Panic Attack mirror that of a
heart attack. Unless the person has mentioned they have been diagnosed
with Panic Attack/Disorder, then you might be dealing with someone who is
having a heart attack.

© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 14

Mental Health Disorders

Non-­‐Suicidal
 Self-­‐Injury
 (NSSI)
 

As an Emotional First Aider working with teens and young adults in crisis, you will
encounter those who are involved in Non-Suicidal Self-Injury, or often called
Cutting.

What is Non-Suicidal Self-Injury (NSSI)?

The Clinical Definition of Non-Suicidal Self-Injury (NSSI) is the deliberate, self-
inflicted destruction of body tissue resulting in immediate damage, without
suicidal intent and for purposes not culturally sanctioned.

Simply put, Self-Injury is a deliberate, non-suicidal behavior that inflicts
physical harm on one's body to relieve emotional distress.

Self-injury has a paradoxical effect in that the pain self-inflicted actually sets off
an endorphin rush, relieving the self-harmer from deep distress.

It's important to note that self-injury does not involve a conscious intent to commit
suicide—and as such, the clinical term for this behavior is called Non-Suicidal
Self Injury (NSSI).

This kind of self-injury can take many forms from cutting, picking, burning,
bruising, puncturing, embedding, scratching or hitting one's self, just to name a
few.

In its simplest form, NSSI is a physical solution to an emotional problem.

Generally, it is a deliberate, private act that is habitual in occurrence, not overtly
attention-seeking behavior, nor meant to be manipulative.

Self-injurers are often secretive about their behaviors, rarely letting others know,
and often cover up their wounds with clothing, bandages, or jewelry.

Symbolically speaking, deliberately injuring one's self can be viewed as a
method to communicate what cannot be spoken.

With self-harm, the skin is the canvas and the cut; burn or bruise is the paint that
illustrates the picture. Most individuals who self-injure have difficulties with
emotional expression.

Many self-harmers are struggling with internal conflicts, may have anxiety,
depression, experienced physical or sexual abuse, or other more serious
psychological concerns.

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Children and Adults Who Self-Injure Are Often Trying To:

• Distract themselves from emotional pain
• End feelings of numbness
• Offset feelings of low self-esteem
• Control helplessness or powerlessness
• Calm overwhelming or unmanageable feelings
• Maintaining control in chaotic situations
• Self-punish, self-shame or self-hate
• Express negative thoughts or feelings that cannot be put into words
• Self-nurture or self-care

Formally, NSSI was not considered a mental illness, but a symptom of a mental
illness. The new DSM-5, now has it classified as a mental disorder. The criteria
for a diagnosis of NSSI is:

In the last year, the individual has, on 5 or more days, engaged in intentional self-
inflicted damage to the surface of his or her body, of a sort likely to induce
bleeding or bruising or pain (e.g., cutting, burning, stabbing, hitting, excessive
rubbing), for purposes not socially sanctioned (e.g., body piercing, tattooing,
etc.), but performed with the expectation that the injury will lead to only minor or
moderate physical harm. The absence of suicidal intent is either reported by the
patient or can be inferred by frequent use of methods that the patient knows, by
experience, not to have lethal potential. The behavior is not of a common and
trivial nature, such as picking at a wound or nail biting.

The intentional injury is associated with at least 2 of the following:
1. Negative feelings or thoughts, such as depression, anxiety, tension,
anger, generalized distress, or self-criticism, occurring in the period
immediately prior to the self-injurious act.
2. Prior to engaging in the act, a period of preoccupation with the intended
behavior that is difficult to resist.
3. The urge to engage in self-injury occurs frequently, although it might not
be acted upon.
4. The activity is engaged in with a purpose; this might be relief from a
negative feeling/cognitive state or interpersonal difficulty or induction of a
positive feeling state. The patient anticipates these will occur either during
or immediately following the self-injury.

The behavior and its consequences cause significant distress or impairment in
interpersonal, academic, or other important areas of functioning. In other words,
it effects a person’s work, relationships, and everyday activities.

Tattoos and body piercing are not typically considered self-injurious
unless undertaken with the intention to harm the body.

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Self-injury can be and is performed on any part of the body, but most often
occurs on the hands, wrists, stomach and thighs.
Why Do People Self-Injure?

Reasons given for self-injuring are diverse. Many individuals who practice it
report overwhelming sadness, anxiety, or emotional numbness as common
emotional triggers.

Self-injury, they report, provides a way to manage intolerable feelings or a way to
experience some sense of feeling. It is also used as means of coping with
anxiety or other negative feelings and to relieve stress or pressure.

Those who self-injure also report doing so to feel in control of their bodies and
minds, to express feelings, to distract themselves from other problems, to
communicate needs, to create visible and noticeable wounds, to purify
themselves, to reenact a trauma in an attempt to resolve it or to protect others
from their emotional pain.

A quick overview of why people self-injure:
• To escape unbearable anguish
• To change the behavior of others
• To escape a situation
• To show desperation to others
• To “get back at” other people
• To gain relief from tension
• To seek help

Some report doing it simply because it feels good or provides an energy rush
(although few report doing it only for these reasons).

Regardless of the specific reason provided, self-injury may best be
understood as a maladaptive coping mechanism, but one that works – at

least for a while.

Studies find that most people with non-suicidal self-injury history report
not considering suicide at all.

Studies of what predicts the likelihood of moving from non-suicidal self-injury
(NSSI) to suicide thoughts and behaviors (including attempt) find that risk
increases as lifetime incidence of NSSI increases, as well as, a sense of
hopelessness increases.

How do we Help Someone who is involved in NSSI?

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First, and this sounds counterintuitive, do not expect the person to stop
self-injury. Do not stop them from NSSI

Self-injury is most common in youth having trouble coping with anxiety,
depression, or other conditions that overwhelm their capacity to regulate their
emotion.

It is thus important to focus on enhancing awareness of the environmental
stressors that trigger self-injury and on helping individuals identify, practice, and
use more productive and positive means of coping with their emotional states.

Focusing on elimination of the self-injury behavior without enhancing
positive means of regulating emotion may simply lead to adoption of other

self-destructive behavior, such as drug abuse.

Some helpful ideas:
• Recognize that self-injury is usually a symptom of serious psychological
distress
• Avoid any negative reactions to the self-injury
• Discuss the situation calmly
• Focus on ways to stop the distress

Do Not:
• Focus on stopping self-injury
• Trivialize the feelings or situations that have led to self-injury
• Punish the person
• Threaten to withdraw care

To help a teen who is doing Self-Injury:
• Re-route self-harm by using less severe forms of sensations. Holding
an ice cube, tearing paper, shredding a sheet, snapping a rubber band
against your skin, sucking a lemon peel, pounding a pillow, write on their
skin using a red marker are just a few of the ways to diminish the need to
self-injure.
• Move your body. Consider the adrenaline rush of running, dancing,
holding a yoga pose, or jumping rope to offset urges to self-harm. The
rush of adrenaline of these positive behaviors have been known to
produce the similar chemical surge that comes from self-injury.

Use some of the coping skills that you will learn in the next lesson. Helping a
teen cope with what they are feeling reduces NSSI and helps them to find other
ways to deal with their pain.

Seek Immediate Medical Attention with Self-Injuries Teens When:

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Seek emergency medical help when someone has:
• Taken an overdose of medication
• Consumed poison
• Has a life-threatening injury
• Has Confusion, disorientation, or unconsciousness
• Rapid or pulsing bleeding

Post Traumatic Stress Disorder

When in danger, it’s natural to feel afraid. This fear triggers many split-second
changes in the body to prepare to defend against the danger or to avoid it.

This “fight-or-flight” response is a healthy reaction meant to protect a person from
harm. But in post-traumatic stress disorder (PTSD), this reaction is changed or
damaged.

People who have PTSD may feel stressed or frightened even when they’re
no longer in danger.

PTSD develops after a terrifying ordeal that involved physical harm or the threat
of physical harm. The person who develops PTSD may have been the one who
was harmed, the harm may have happened to a loved one, or the person may
have witnessed a harmful event that happened to loved ones or strangers.

PTSD was first brought to public attention in relation to war veterans, but it can
result from a variety of traumatic incidents, such as mugging, rape, torture, being
kidnapped or held captive, child abuse, car accidents, train wrecks, plane
crashes, bombings, or natural disasters such as floods or earthquakes.

PTSD is not just about Soldiers Anymore

Signs & Symptoms of PTSD

PTSD can cause many symptoms. These symptoms can be grouped into three
categories:

1. Re-experiencing symptoms
• Flashbacks—reliving the trauma over and over, including physical
symptoms like a racing heart or sweating
• Bad dreams
• Frightening thoughts.

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Re-experiencing symptoms may cause problems in a person’s everyday
routine. They can start from the person’s own thoughts and feelings or

come from words, objects, or situations that are reminders of the event that
results triggering re-experience

2. Avoidance symptoms
• Staying away from places, events, or objects that are reminders of the
experience
• Feeling emotionally numb
• Feeling strong guilt, depression, or worry
• Losing interest in activities that were enjoyable in the past
• Having trouble remembering the dangerous event.
• Things that remind a person of the traumatic event can trigger
avoidance symptoms. These symptoms may cause a person to change
his or her personal routine. For example, after a bad car accident, a
person who usually drives may avoid driving or riding in a car.

3. Hyperarousal symptoms
• Being easily startled
• Feeling tense or “on edge”
• Having difficulty sleeping, and/or having angry outbursts.
• Hyperarousal symptoms are usually constant, instead of being triggered
by things that remind one of the traumatic events. They can make the
person feel stressed and angry. These symptoms may make it hard to do
daily tasks, such as sleeping, eating, or concentrating.

It’s natural to have some of these symptoms after a dangerous event. Sometimes
people have very serious symptoms that go away after a few weeks. This is
called acute stress disorder, or ASD. When the symptoms last more than a few
weeks and become an ongoing problem, they might be PTSD. Some people with
PTSD don’t show any symptoms for weeks or months.

The Impact of Trauma and PTSD

See Diagram on the next page.

© 2015 Emotional First Aid/Teen TXT Crisis Line/Dr. Mike Ferguson 20