Responding to chronic suicidality

An additional challenge for AOD workers is managing and responding to chronic suicidality, which is experienced by some clients, particularly those who have experienced complex trauma [135, 389, 557]. Chronic suicidality may vary in intensity over time, and the difficulty for clinicians is to determine when to intervene. It is important for clinicians to be able to identify and distinguish the differences between acute and chronic suicidality, as chronic suicidality is managed slightly differently [135, 389]. The NHMRC [555] suggests:

• It can be unhelpful, or even escalate behaviour, if chronically suicidal clients are hospitalised or closely observed in attempts to prevent suicide.
• As quality of life improves, intensity of suicidality may lessen. As such, counselling should focus on factors that may improve quality of life.
• People who are at immediate, acute high-risk of suicide are likely to need interventions to ensure their immediate safety (e.g., short-term hospitalisation).

Strategies that might assist workers to determine whether the risk of suicide in a person with chronic suicidality might escalate to becoming acute include [555]:

• Changes in the usual pattern or type of self-harm.
• Significant change in mental state (e.g., sustained and severe depressed mood, worsening of a major depressive episode, severe and prolonged dissociation, appearance of psychotic states).
• Worsening of AOD use disorder.
• Presentation to health services in a highly regressed, uncommunicative, or withdrawn state.
• Recent discharge from psychiatric facility (within last few weeks).
• Recent discharge from psychiatric treatment due to breach of treatment contract.
• Recent adverse life events (e.g., loss or breakdown of significant relationship, legal, employment or financial problems).

Source: NHMRC [555], adapted from Spectrum: http://www.spectrumbpd.com.au/

In terms of responding to the differing levels of risk presented in Figure 14 [555]:

• If a client is at chronic low-risk (the bottom left-hand quadrant of Figure 14), they are at relatively low-risk of suicide and workers should focus on factors associated with improving quality of life.
• If a client at chronic low-risk begins to use more lethal methods of self-harm over a longer term, they become at chronic high-risk of suicide (top left-hand quadrant of Figure 14). Hospitalisation at this point will probably not be appropriate, because the chronic high-risk will likely continue beyond the conclusion of hospital admission. Rather, clinicians should focus on improving quality of life and assisting clients to manage issues that are driving their suicidality.
• If a client who has been chronic low-risk begins to demonstrate new symptoms or behaviours (bottom right-hand quadrant of Figure 14), they should be closely assessed, additional risk factors should be assessed, and clinicians should focus on improving quality of life. Hospitalisation is not appropriate unless new behaviours suggest immediate risk of suicide.
• If a client at high chronic risk of suicide begins to demonstrate new symptoms (behavioural or mental health issues that indicate immediate risk of suicide; top right-hand quadrant of Figure 14), the person’s immediate safety should be ensured. A brief period of inpatient admission may be indicated, followed by counselling on discharge focused on improvement of quality of life and monitoring suicidality.