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By Loren Townsend
Abingdon PressCopyright © 2006 The United Methodist Publishing House
All right reserved.
Chapter OneAssessing Suicide Potential in the Parish
Suicidal thoughts are part of normal human experience. Researchers estimate that nearly 25 percent of the U.S. population has at some point seriously considered ending their own lives. This same literature shows that about one-third of people who seek counseling have contemplated suicide, and about 10 percent of all children and adolescents have at some time considered killing themselves. These figures do not include people who have brief episodes when suicide crosses their mind or angry children who think about punishing parents with their death. Neither do they include temporarily distressed teens who impulsively blurt that they want to die or adults who have fleeting images of stress relieved by death. Images of death-within-life are so universal that Sigmund Freud wrote of a "death principle" that was fundamental to all human motivation. Within the stress of striving for rich life, there is a human factor that also pulls us to the silence of death. Freud believed this innate force explained suicidal thoughts, behavior, and self-destructive acts by individuals and society. Whether or not we accept Freud's analysis of human motivation, religious leaders can assume that many people in their congregations have self-destructive thoughts. Individuals under stress are likely to think about suicide, at least temporarily. Those with psychiatric illnesses, especially mood disorders such as major depression or bipolar disorder, may consider suicide forcefully.
Though suicidal thoughts are nearly universal, Christian history includes a strong suicide taboo. Too often, parishioners interpret this theological tradition of "the unpardonable sin" as condemnation of suicidal ideas over which they may have little control. Self-destructive thought symbolizes spiritual failure. For many committed Christians, this means never giving voice to such out-of-bounds thought in the general discourse of religious life. Suicidal thoughts, impulses, and intentions may lie carefully hidden behind a veil of religious propriety. It is not unusual for a pastor, church members, friends, and family to be completely surprised by a suicide or suicide attempt within the congregation. Strongly religious people may vigorously deny suicidal thoughts and resist disclosing the depth of their despair. It is fair for pastors to assume that at any given time there are people in their care who are considering suicide but are reluctant to disclose their feelings for fear of judgment. Good pastoral care requires that pastors develop nonthreatening ways to ask about depression and suicidal thoughts, assess suicide potential, establish an appropriate pastoral plan for intervention, and implement that plan.
While parish pastors usually are not trained as pastoral counselors, most have both the opportunity and the skills needed to evaluate suicide potential and make an appropriate judgment about intervention. Pastors often ask parishioners a variant of "how is life going?" When pastors are tuned to the fact that many depressed people reside in their congregation, answers to this question become more than a social cliché. Responses are data that give important clues. Good listening requires hearing at two levels—the words people say and the emotional frame, voice tone, facial expressions, and body postures that tell us how to receive another's words. At the first level, pastors need to be alert for a subtle suggestion that a person is in distress—such as "It's been a tough month"; "I could use a prayer"—and direct or humorous reference to ongoing sadness, unmanageable stress, hopelessness, or thoughts about dying. Equally important are nonverbal cues that make a socially appropriate response emotionally unbelievable. "I'm fine, thanks for asking" is incongruent with no eye contact, sad demeanor, soft voice, and a recent history of withdrawal from other social contact. In either case, follow-up conversation can open the door to disclose suicidal thinking.
Pastors who become skilled in assessing suicide potential must become comfortable with asking well-formed, non-threatening questions about depressive symptoms and learn to administer simple depression screening tools. Competence means dismissing the myth that asking about suicidal thoughts suggests suicide to depressed persons. There is no evidence that asking about suicide stimulates suicidal thinking. In fact, direct questions about suicide often free people to voice suicidal fears or talk about a plan to end their life for the first time. Most pastors can complete a three-step suicide assessment through a carefully constructed pastoral conversation. This requires preparation—thinking through and writing out a series of questions that will elicit responses about depression, risk factors, and the content of suicidal thoughts. It also requires a safe place for talking that is conducive to self-disclosure and expression of emotion.
Step One: Identifying Symptoms of Depression
A number of effective depression screening tools are available online without cost to pastors and other professionals. These instruments are relatively simple. Most are designed to help health-care professionals identify and measure depressive symptoms. Some require special training to evaluate physical or mental functioning and may not be appropriate for pastoral contexts. When choosing a screening tool, pastors should determine whether special certification is required to use the instrument and whether they have sufficient training to evaluate the items required to complete the screening process. Publishers usually outline needed qualifications for using instruments. In some cases, consultation or supervision with a pastoral counselor or other mental health professional can provide the training needed to use these instruments appropriately and ethically.
In most pastoral contexts, simple questions about central symptoms of depression will provide enough information to determine if further assessment is necessary. In its initiative to help physicians and other primary care providers identify depressed individuals, the World Health Organization has provided a set of ten focused questions that can be easily adapted to parish contexts. These are drawn from international diagnostic manuals (International Classification of Diseases-10, Diagnostic and Statistical Manual of Mental Disorders-IV). Potentially depressed people are asked: In the past two weeks, to what extent have you experienced: (1) Sadness and low spirits, (2) Loss of interest in daily activities, (3) Lack of energy or strength, (4) Loss of self-confidence, (5) Feelings of guilt or bad conscience, (6) Feelings that life is not worth living, (7) Difficulty concentrating on normal activities—such as reading, watching TV, (8) Restless or subdued feelings, (9) Trouble sleeping at night, (10) Reduced or increased appetite.
Symptoms are rated on a five-point scale. Scores of 1 mean the symptom has not been present, while a score of 5 indicates the symptom is always present. A 3 is scored if a symptom is present about half the time. Clinical diagnosis of depression must be left to certified pastoral counselors or other mental health and medical professionals. However, pastors have good reason to suspect depression and make appropriate referrals if a parishioner reports two or more of these items present more than half the time over a two-week period. Since suicide is directly related to feelings of hopelessness and depression, positive depression scores always warrant an assessment of suicide risk.
Step Two: Evaluating Suicide Risk Factors
About two-thirds of people who take their own life are depressed at the time of their death. At the same time, most depressed people do not harm themselves. While predicting suicide is complex and imprecise, researchers have identified a number of factors that make a suicide attempt more likely. Understanding the following risk factors can help pastors make appropriate decisions about intervention with depressed parishioners.
Men are at higher risk than women. European-American men and women account for more than 90 percent of all suicides in the United States. Large-scale studies by the National Center for Health Statistics show that European-American men account for nearly 75 percent of all suicides. Men complete suicide at a rate four to five times higher than women, and European-American men are twice as likely as men of other racial and ethnic groups to take their own life. This observation is age related. Demographic data shows a linear increase in suicide among European-American men beginning in early middle age. The older a man gets, the more likely he is to take his own life and the less likely he is to confess suicidal thoughts. These men tend to use extremely lethal means to end their life without warning.
High levels of hopelessness are directly related to suicidal action and may be more significant than high levels of depression. Depressive symptoms interact strongly with suicidal behavior, but alone they do not predict self-destructive behavior. Instead, depressive symptoms exacerbate feelings of hopelessness, stimulate social isolation, and impede thinking and judgment.
It is important for pastors to find ways to directly discuss, identify, and attend to feelings of hopelessness. This may be a challenge. As carers, our tendency is to project hope and to reassure a parishioner that all is not lost. It is easy to point to hopeful Scripture and God's ability to overcome all human circumstances. However, hopeless people often hear such encouragement as patronizing, evidence that they have failed in their personal and spiritual lives, or confirmation that not even God understands the depth of their feelings. This can result in emotional withdrawal, intensified resolve to end one's life, or a decision to placate a caring pastor with falsely manufactured pseudo-hope. The psalter is filled with evidence that hope is elusive without first plumbing the depths of despair. Nevertheless, this can be hard for pastors who have little time for sitting with depressed people or whose own sense of well-being is challenged by another's despair. Staring into the abyss with a parishioner can be overwhelming; exploring together what fearsome creatures inhabit the depths can be terrifying. It is much easier to recite that "all things work together for good for those who love God" (Rom. 8:28) and promise prayer from a distance than to share the weight of a blind gaze that sees no future.
When assessing suicide risk, pastors must connect emotionally with a depressed person's experience of hopelessness, speak directly to these feelings as real and understandable, and avoid any hint of easily hopeful solutions. Almost universally, hopelessly depressed people have tried and failed any solution a pastor can offer. Pastors must learn to engage hopelessness without inadvertently complicating the experience.
A history of alcohol or drug abuse is a strong risk factor for potential suicide. Toxicological studies show that more than half of those who complete suicide were legally intoxicated at the time of death. In fact, alcoholism may be the strongest single predictor of completed suicide. One group of researchers found that alcohol-dependent men may be twenty-five times more likely to kill themselves than the general population. The combination of intense stress, interpersonal disruption, loss of support, and alcohol appears to be a deadly combination for men. Men in these circumstances are much more likely to attempt suicide using highly lethal and violent means (firearms, hanging) than the general population or their female counterparts. Studies show that alcohol produces a form of myopia that reduces an individual's perception and range of thinking. Intoxicated people are unable to think beyond preoccupation with immediate experience, are unlikely to consider the effects of their actions, and cannot see exceptions evident to others. This effect makes it easier to carry out suicidal acts.
Recent loss of social support increases suicide risk. Such losses may include moving away from familiar friends and family, death of supportive persons, loss of church relationships, or social isolation resulting from depression. For men, divorce or death of a spouse may shatter social support systems.
Recent loss of employment or socioeconomic status increases suicide potential, particularly for men. Most often, this factor is associated with a sense of hopelessness about regaining what has been lost.
A depressed person with a family history of suicide is at increased risk. Completed suicides within families can model permission to take one's own life and offer death as a viable option to a hopeless situation. Family suicides may also activate long-term, complicated grief processes that erode transmission of hope within and across generations.
An individual diagnosed with a psychiatric illness is more likely to act on suicidal thoughts or impulses. Highest risks are related to affective disorders (such as major depression, bipolar disorder), thought disorders (such as schizophrenia or schizoaffective disorder), and some personality disorders.
Additional risk factors include:
Persons (especially men) who are widowed, divorced, or single;
Persons with chronic physical illnesses;
Persons experiencing intense, immediate emotional upheaval about family or personal matters;
Previous suicide attempts;
Individuals with access to firearms.
Risk factors do not mean that suicide is inevitable or that immediate action is warranted. They can (and should) heighten awareness for pastors who identify both depression and risk factors during an episode of care. Some factors are more important than others in certain situations. For instance, a depressed Euro American male parishioner who expresses hopelessness, has a history of alcohol abuse, and hunts regularly (and so has access to and comfort with firearms) presents a different constellation of risk than a depressed African American woman who is recently divorced, expresses hopelessness, and has good relational support. Understanding risk factors provides essential information for assessing the lethal potential of a depressed parishioner.
Step Three: Assessing Lethality
When depression and risk factors are present, lethality assessment is required. This usually includes evaluation of suicidal intent and potential means. Identifying intent involves exploring suicidal volition—the extent to which a person is invested in ending his or her life. Evaluating means questions the lethality of how an individual expects to die. Suicidal intent can be measured in three stages—thought only, identifiable plan, and timetable. Each stage requires careful investigation.
Stage One: Identifying Suicidal Thoughts. Thoughts about suicide can be observed on a continuum ranging from occasional intrusive images of death to continuous preoccupation with ending life as the only solution to a hopeless problem. At one end of the continuum, occasional thoughts of death may signal emotional distress but may not mark a significant risk for suicide. As thoughts of self-harm become more specific, the potential for self-harm increases.
A series of open-ended questions gives parishioners permission to talk about thoughts of self-harm and helps pastors evaluate the level of suicide intent. Because questions about depression and suicide are highly sensitive, they should be asked only in a context that can guarantee confidentiality and contain expression of intense feelings. This eliminates any public location or any situation in which a conversation could not be extended because of other commitments or priorities. Nonverbal cues such as glancing at a watch, answering a telephone, or looking toward an unfinished sermon on a computer can convey that conversation about depression is an unwanted intrusion. Questions about suicide or depression should always be limited to one-to-one pastoral conversation unless it is absolutely certain that a spouse or close friend is trusted, concerned, supportive, and will promote openness. (Continues...)
Excerpted from Suicide by Loren Townsend Copyright © 2006 by The United Methodist Publishing House. Excerpted by permission of Abingdon Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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