Human-focused care of the suicidal person
Suicide remains a significant public health problem in Canada. More people die by suicide each year in Canada than by homicides and accidents combined. Suicide is the leading cause of death in young men in many provinces. Increased risk of suicide has been linked with a wide range of factors, including misuse of alcohol and other substances. Furthermore, the impact of suicide is felt throughout society, with a conservative estimate of 150 people being affected by each incidence of suicide.
For many years now, suicide has fallen under the purview of health care agencies—most notably, although not exclusively, mental health care agencies—rather than under the legal system. As a result, suicide in Canada has been a legal act since the early 1970s. In the current Canadian health care system, it is well documented and accepted that registered psychiatric nurses (RPNs) often, if not inevitably, have a major role to play in caring for people who are suicidal. It is startling to realize that, despite this long-established role, it is only recently that theory is starting to be generated to guide RPNs in providing care for suicidal people.
The historical emphasis
Historically and traditionally, ‘care’ of the suicidal person has focused on little more than attempting to keep the person physically safe. Accordingly, this has resulted in practices such as ‘observations,’ removing potentially dangerous objects, restricting the movement and freedom of suicidal people, and the use of ‘seclusion rooms.’ These and other ‘custodial’ practices have been likened to ‘policing’ the person and, unfortunately, do very little, if anything, to address the genesis of the person’s suicidal ideation. Policing practices do little to help a suicidal person move from a death-orientated position to a life-orientated position and do nothing to help the person alter their constricted thinking.
In an attempt to better understand the caring processes that RPNs might use when caring for suicidal people, I, together with colleagues from the United Kingdom,1 undertook the largest research study of its kind.2 We wished to have evidence that would subsequently inform current and future RPNs about the micro context of caring for the suicidal person; that is, evidence that would inform RPNs about what they can do to help suicidal people, day by day, hour by hour and minute by minute.
Accessing the service users' perspectives
We used an approach to research that is concerned with understanding the world, and the processes within the world, from the point of view of the participant—in this case, suicidal people and the RPNs who care for them—rather than from the point of view of the researcher. This approach enables access to vital information and evidence that would otherwise be ignored, and is one of the approaches that many eminent suicide scientists (referred to collectively as suicidologists) are advocating for more and more these days.
Our study identified the principal process that RPNs engage in when caring for suicidal people as “reconnecting the person with humanity.” This process contains three linked stages of healing.
In stage one, which we termed “reflecting an image of humanity,” the RPNs were concerned with creating an appropriate inter- and intrapersonal atmosphere that would allow the person to experience a sense of intense, warm, care-based, human-to-human contact. At the same time, the RPNs would implicitly challenge suicidal constructs as a result of encountering contrary experiences.
In stage two, which we termed “guiding the individual back to humanity,” the RPNs were concerned with nurturing greater insight and understanding in the person, and with supporting and strengthening the person’s pre-suicidal beliefs. This was brought about within the context of the person encountering a novel interpersonal, helping relationship.
In the third and final stage, which we termed “learning to live,” RPNs were concerned with helping the person accommodate their existential crisis, and more importantly, helping the person come to terms with going on with their life and helping them make sense of their relationship with suicide.
Where do we go from here?
Since Durkheim’s first formal study of suicide,3 it has been recognized that the suicidal person has become disconnected from humanity, and feels alone and unsupported. Such people need RPNs who can be with them in a therapeutic way, and this is not achieved by increasing the custodial nature of care through more intensive policing.
The suicidal person needs to feel reconnected, and this gradually occurs through the sense of co-presence between the distressed person and the psychiatric care nurse. In effect, the RPN acts as an emissary for humanity, bringing the person back from the brink, reducing risk and inspiring hope. As someone makes personal sense of their suicidal episode in relation to the past, present and future, they gain power over it. Putting the suicide in its place allows more room for reconnecting with life.
People who are making progress in reconnecting still feel vulnerable. This is another important finding from the study. While contemporary models of psychiatric care for the suicidal person are inevitably arranged around ‘management’ of the acute high-risk period and subsequent discharge, our findings indicate that the work needed to come to terms with the suicide has often only just begun during this time. Additional, and often overlooked, support is needed. Perhaps this accounts for why there is such a high risk of suicide in the first year following discharge from psychiatric services.
As a result of our findings, we advocate for a two-pronged shift in the organization of care for the suicidal person: RPN care needs to move radically away from policing to reconnecting the person with humanity (through engagement with the RPN), and facilities/resources need to be made available so that far longer, though less intensive care and support can be offered—formerly suicidal people often remain at high risk for long periods post discharge.
About the authorJohn has recently accepted a senior administration/faculty position at a major US university. He is also an educational consultant for the International School of Nursing and Health Studies, and Director of Cutcliffe Consulting.
Members of the research team included professors Chris Stevenson and Phil Barker of the Republic of Ireland, and Sue Jackson and Paul Smith of the UK.
Cutliffe, J.R., Stevenson, C., Jackson, S., Smith, P. & Barker, P. (2003). Meaningful caring responses to people with suicidal intent: Developing a theory for psychiatric/mental health nursing practice. Unpublished report, University of Northern BC/Teeside University, UK.
Durkheim, E. (1951). Suicide: A study in sociology. Glencoe, IL: Free Press.