1. Suicide
Chapter 6 cont.

2. Risk
Direct verbal warning. A direct statement of intention to commit suicide serves as one of the most useful single predictors. Take any such statement seriously. Resist the temptation to reflexively dismiss such warnings as "a hysterical bid for attention," "a borderline manipulation," "a clear expression of negative transference," "an attempt to provoke the therapist," or "yet another grab for power in the interpersonal struggle with the therapist." It may be any or all of those and yet still foreshadow suicide.
Plan. The presence of a plan increases the risk. The more specific, detailed, lethal, and feasible the plan is, the greater the risk.
Past attempts. Most, and perhaps 80% of, completed suicides follow a prior attempt. The client group with the greatest suicidal rate were those who had entered into treatment with a history of at least one attempt.

3. Risk
Indirect statements and behavioral signs. People planning to end their lives may communicate their intent indirectly through their words and actions—for example, talking about "going away," speculating on what death would be like, giving away their most valued possessions, or acquiring lethal instruments.
Depression. The suicide rate for those with clinical depression is about 20 times greater than for the general population. 15% of the individuals suffering from this disorder killed themselves. Effectively treating depression may lower the risk of suicide
Hopelessness. The sense of hopelessness appears to be more closely associated with suicidal intent than any other aspect of depression

4. Risk
Marital separation (distinct from divorce). For both males and females separation created a risk of suicide at least four times higher than any other marital status. The risk was particularly high for males aged 15 to 24.
Clinical syndromes. People suffering from depression or alcoholism are at much higher risk for suicide. Other clinical syndromes may also be linked to an increased risk. Perhaps as many as 90% of those who take their own lives have a formal diagnosis. Highest suicide rates exist among clients diagnosed as having primary mood disorders and psychoneuroses, with high rates also among those having organic brain syndrome and schizophrenia
Intoxication. Between one-fourth and one-third of all suicides are linked to alcohol as a contributing factor; a much higher percentage may be associated with the presence of alcohol (without clear indication of its contribution to the suicidal process and lethal outcome). As many as half of those who kill themselves are intoxicated at the time.

5. Risk
Sex. The suicide rate for men is more than three times that for women. For youths, the rate is closer to five to one. The rate of suicide attempts for women is about three times that for men.
 race. Generally in the United States, Caucasians tend to have one of the highest suicide rates The suicide rate for Native Americans is greater than that of any other ethnic group in the U.S., especially in the age range of 15–24 years 
Religion. The suicide rates among Protestants tend to be higher than those among Jews and Catholics.
living alone. The risk of suicide tends to be reduced if someone is not living alone, reduced even more if he or she is living with a spouse, and reduced even further if there are children.

6. Risk
Bereavement. Bereavement tends to place survivors at increased risk of taking their own lives
Health status. Illness and somatic complaints are associated with increased suicidal risk, as are disturbances in patterns of sleeping and eating.
Impulsivity. Those with poor impulse control are at increased risk for taking their own live
Rigid thinking. Suicidal individuals often display a rigid, all-or-none way of thinking
Stressful events. Excessive numbers of undesirable events with negative outcomes have been associated with increased suicidal risk

7. Risk
Release from hospitalization. The available figures clearly indicate that the suicidal risk is greatest during weekend leaves from the hospital and shortly after discharge.
Lack of a sense of belonging. Suicidal individuals may experience interactions that do not satisfy their need to belong (e.g., relationships that are unpleasant, unstable, infrequent, or without proximity) or may not feel connected to others and cared about.  

8. Reduce Risk
Screen all patients for suicidal risk during initial contact, and remain alert to this issue throughout the therapy.
Work with the client to arrange an environment that will not offer easy access to whatever the patient might use to commit suicide.
Work with the patient to create an actively supportive environment. To what extent can family, friends, and other resources such as community agencies and group or family therapy help a suicidal person through a crisis.

9. Reduce Risk
While not denying or minimizing the patient's problems and desire to die, also recognize and work with the patient's strengths and desire to live. Patients' awareness of their strengths, resilience, and reasons to live can often help them regain perspective, often lost during despair. 
Communicate caring.
Make every effort to communicate realistic hope. Discuss practical approaches to the patient's problems.
Explore any fantasies the client may have regarding suicide. Reevaluating unrealistic beliefs about what suicide will and will not accomplish can be an important step for clients attempting to remain alive.