Suicide is a major public health concern and one of the leading causes of death worldwide. What aggravates the current situation is the COVID-19 pandemic that triggers vulnerable people’s mental conditions and is anxiety-inducing due to social isolation, health dangers, and uncertainty. It is now common knowledge that suicidal ideation and suicide attempts are a serious public issue ignoring which can lead to dire consequences. This paper provides a literature review that covers the epidemiology of suicide, risk and protective factors, and prevention strategies. Moreover, practice implications and therapeutic relationship considerations are discussed with a special focus on the ethical and legal aspects of managing the burden of suicide.
Suicide is a global phenomenon: it transcends race, gender, culture, and ethnicity. It accounts for 1.4% of all deaths across the globe and is the 18th leading cause of them (World Health Organization [WHO], 2017). According to the WHO (2017), suicide takes 800,000 lives worldwide annually; every forty seconds, a person ends their life. For every adult who took their own life, there are 20 people who tried to commit suicide (WHO, 2017). Taking these statistics into account, it should be evident that the fact that people so often kill themselves is highly underestimated.
Seventy-nine percent of all suicides occur in low- and middle-income countries, although the highest individual rates are observed in extremely diverse nations. Europe, Lithuania, Russia, and Belarus are among the countries with the highest numbers of suicide per 100,000 of population. The South American country of Guyana is now seeing 29.2 suicides per 100,000, and the Asian country of South Korea – 26.9 suicides per 100,000 (World Population Review, 2020). World Population Review (2020) states that some high-income countries with superior quality of life and extended social welfare, such as Finland, Sweden, and Belgium, surpass war-torn, less resourceful nations, such as Afghanistan and Syria, in terms of suicide prevalence.
As has already been implied, suicide remains a serious public health concern all over the world. In recent years, Ireland has seen a decrease in suicide rates: if in 2012, there were 578 deaths by suicide, in 2018, the number was down to 362 (National Office for Suicide Prevention, 2019). Despite these encouraging data, it should be noted that certain groups of the population remain fairly vulnerable to mental disease and suicidal ideation. Even though the rates are declining, one trend perseveres, and it is four-fold higher suicide prevalence among men compared to women (282 vs. 70 in 2018, respectively) (National Office for Suicide Prevention, 2019). Moreover, the same source reports that in men, the highest prevalence of suicide is observed in the 25-35-years-old age group, while women aged 45-54 are more likely to commit suicide.
Today, there is no general explanation of suicide and not a single risk factor that absolutely certainly predicts suicide. Connecting for Life (2019) states that suicide attempts may be the result of the cumulative effect of several risk factors at once. These causes do not occur and manifest themselves independently but rather interplay and interact in a variety of ways. Connecting for Life (2019) singles out individual risk factors that include the history of suicide attempts, mental health conditions, substance use, aggressive tendencies, and major physical or chronic illnesses and chronic pain. Arensman et al. (2019) add that impulsivity is a well-established risk factor for suicide. As a result, it is safe to state that emotions play a vital role in enabling such behaviour.
In addition, there are socio-cultural factors that may make a person more prone to suicidal behavior. Connecting for Life (2019) names stigma associated with mental illness and seeking psychiatric health among one of such factors. O’Keeffe et al. (2016) have shown that in Ireland, better mental health awareness is not necessarily associated with increased acceptance; in fact, participants of the study with high mental health literacy had more negative attitudes toward the mental disease.
Sometimes, it is the barriers to timely and quality health care that impede suicide prevention (Connecting for Life, 2019). Ryan (2020) states that it has been 14 years since the introduction of A Vision for Change that exposed significant gaps in the availability of specialist rehabilitation teams and recovery-oriented services. Nevertheless, Ireland is still experiencing a lack of community mental health services, such as crisis houses, high-support hostels, specialist rehabilitation units, and psychiatric intensive care units (Ryan, 2020). The barriers to healthcare are especially pronounced among marginalized communities, such as Irish travelers who are an Indigenous minority group in Ireland. Though accounting for less than 1% of the country’s population, the group constitutes 10% of all suicides nationwide (McKey et al., 2020). Irish travelers experience social exclusion due to discrimination; the community also has higher poverty and unemployment rates than the rest of the Irish residents.
Lastly, there are situational factors that may create a higher risk for suicide. Connection for Life (2019) names job and financial expenditures, relational and social losses, and stressful events. For instance, incarceration may drive a person to the brink of taking one’s own life. Having analyzed prison suicide data worldwide, Fazel et al. (2017) concluded that in European countries, the suicide rates among prisoners are between two- to fivefold higher than in general populations. COVID-19 pandemic is a major stressful event that accounted for a rise in suicide deaths. Niederkrotenthaler et al. (2020) argue that physical distancing, lockdowns, and shelter-at-home measures have exacerbated social isolation that may be deadly for vulnerable people, such as the elderly and the bereaved. Certain professions are experiencing unusual workload that is not only physically but also emotionally draining.
Approaches to suicide prevention need to consider both risk and protective factors. While knowing risks is important for identifying vulnerable populations, it is protective factors that should comprise the basis of any strategy. Connection for Life (2019) single out social cohesion as an important protective factor because people who have fulfilling relationships and are active in local communities are less likely to commit suicide. Niederkrotenthaler et al. (2020) note that during the pandemic, altruistic, prosocial behaviors, such as donating and volunteering, are relieving anxiety and depression. Rubio et al. (2020) add that one’s emotional life also plays an important role. Their research has demonstrated that high positive and low negative affect in young people had an inverse correlation with suicide ideation.
Religious beliefs are an ambiguous factor in the matter of suicide prevention. On the one hand, the world’s most popular religions do not condone suicide. However, as shown by Hameed et al. (2020), while religiousness was a protective factor against suicidal behaviors, it did not relieve suicidal ideation. In other words, religious people are less likely to commit suicide, but they may contemplate doing so regardless. Moreover, in some religions, suicide is seen as a noble act of resolution, which may make belongingness to such confessions a risk factor.
In recent years, the governments of the four nations (England, Scotland, Northern Ireland, and Ireland) have introduced a suicide reduction agenda. In 2015, the UK authorities set a “zero target” for suicides for the NHS; the strategy has now found implementation on a local level as well (Connecting for Life, 2019). It is envisioned that in this culture, suicide prevention and reduction will become a priority, accompanied by improved mental health literacy. The focus of the policy on suicide reduction constitutes an ethical requirement of therapeutic work.
Ireland has multiple initiatives, such as Reach Out, that may provide the basis for the practical requirements of working with suicidal clients. The Health Service Executive (HSE, 2015) states that the program hinges on a number of guiding principles. For instance, action should be front and center of any strategy. The HSE emphasizes the role of shared responsibility in suicide prevention as no single organization, group, or sector is capable of completing the task. All interventions should be evidence-based and employ the latest research findings. Information and communication technology are assigned the role of making mental healthcare services more accessible regardless of individuals’ places of residence.
Part of the reason why suicide management is so flawed lies in the criminal status of cessation of one’s life. Many people believe that by making it legal, governments would cause the death rate to increase. However, Daly et al. (2018) argue that there is no evidence “decriminalization results in an increase in suicidal behavior” (p. 411). In fact, the fear of legal repercussions creates stigma, which prevents vulnerable people from seeking help. Instead, the legal requirement should be the restriction of access to weapons for suicides (Daly et al., 2018). Therefore, decriminalization of suicide is the legislation policy, which can contribute to therapeutic work.
Supervision is essential in guiding the client in managing suicidal behavior. British Association for Counselling and Psychotherapy (BACP, 2017) reasons that “practitioners will often look towards their supervisors for support and encouragement in addition to guidance” (p. 15). This implies that the role of a supervisor is to provide assistance to the therapist via consultations. This task necessitates specialized training in recognizing suicide risk factors and the proper course of action.
BACP’s Ethical Framework for the Counselling Professions may serve as a source of information on practitioners’ key competencies regarding suicide prevention. Healthcare workers need to be able to determine the adequacy of therapy for a person who may or may not be capable of making this step in their life (Connecting for Life, 2019). The Ethical Framework stresses the importance of making contracts that respect clients’ privacy and confidentiality. At the same time, patients at risk of suicide may need to provide emergency contacts, therefore increasing the number of people who are aware of the issue. “Agreeing with clients on how we will work together” is another important competency that promotes the client’s autonomy and self-agency in changing the course of their own life. Overall, therapists should take into account the legal and ethical aspects of the question.
Therapeutic Relationship Considerations
Suicide prevention is a two-fold process, encompassing both clients and therapists. Many requirements are placed on the personnel responsible for the delivery of help to the clients. They have to be knowledgeable enough to recognize suicidal signs. It is a difficult task since human behavior is easy to misinterpret (Fazel et al., 2017). It is multivariate, with feelings of sadness and thoughts of depression being normal. Therefore, therapists have to distinguish between a natural emotional reaction and abnormal behavior. For instance, people with suicidal intentions give external signs of their inclinations (Rubio et al., 2020). Correct interpretation can enable the therapist to acknowledge the problem and work with the client.
Suicide therapy is unique in that its clients actually want to harm themselves. This creates two dilemmas for practitioners, which are not observed in other areas. First, the stigmatization of suicide propels many people to hide their inclinations. As a result, therapists have to decide whether the person is being deceitful about their mental recovery or is indeed free of self-harming thoughts (McKey et al., 2020). Second, some countries have laws prohibiting self-destruction, which puts therapists at a disadvantage. By stimulating their clients to acknowledge their suicidal behavior, they also propel them to announce their intent of committing a crime (Daly et al., 2018). As a result, people may not be willing to seek help, and practitioners have difficulties with persuasion.
The aforementioned challenges constitute the need for certain skills and knowledge. First, therapists need to be able to connect emotionally with the client. In order for a person to receive help, they have to trust the professional (Niederkrotenthaler et al., 2020). Second, practitioners should know how to spot clients’ deception (Daly et al., 2018). The problem with people with suicide intentions is that they are often blind to their own desires. Third, it is essential that therapists handle suicide management properly. This entails taking steps necessary for helping the clients recover from depression and abandon their self-destructive patterns (BACP, 2017). At this point, it should be evident that a substantial psychological and therapeutic background is vital for successful prevention.
As has already been mentioned, suicide prevention is an interactive process between two sides. Therapists’ efforts will prove to be meaningless unless clients themselves are willing to recover and overcome their suicidal inclinations. The first therapeutic need of the client is recognizing the moment when they need professional help (BACP, 2017). It is normal for people to feel depressed and sad, and in most cases, they manage negativity without professional help. However, sometimes, the pressure build-up is too much for a single person to endure. Suicide prevention guidelines should let people recognize when they alone cannot manage their issues. The second need of a client is the feeling of trustworthiness. Sharing suicidal thoughts is an extremely discomforting experience, which requires a person to be vulnerable (McKey et al., 2020). Without trust, they will not be able to receive help and recover. Finally, people need to have the knowledge of how to cope with such issues in the future (Hegerl et al., 2019). All these steps are essential in building a functional therapeutic alliance.
Altogether, though in recent years, suicide rates in Ireland have been decreasing, there is still a lot to accomplish to tackle this issue. Social stigma prevents people from acknowledging their intentions and seeking help. Decriminalization of suicide will help both therapists and clients in taking the necessary steps for recovering. Furthermore, the responsibility for preventing suicide is shared between clients and therapists. Practitioners should be able to recognize the warning signs and act on them. Clients should have the knowledge of how to manage depression on their own and when to seek help. Overall, by combining the efforts of therapists, lawmakers, and the public, it is possible to reduce the suicide rates in Ireland.
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