By: Kwong Chung Man

Date: 2 November 2004

Suicidal risk could be defined as someone having suicidal ideation because it has the chance of developing into a suicidal attempt. Sokero et al. (2003) found that suicidal ideation is prevalent (95% in the study) and appears to be a precondition for suicide attempts among psychiatric patients with major depressive disorder. On the other hand, in Russ et al (1999) study, 44% patients admitted to a psychiatric hospital because of suicide risk were completely free of suicidal ideation 24 hours after admission. Although, suicidal ideation could be a transient mental state, hospitalization should be considered carefully to prevent suicide. Fadem (2004) suggested the following indications to hospitalize a suicidal patient: 1) Possession of a means for suicide, 2) Presence of a plan for suicide, 3) Acute intoxication, 4) Express feeling of out of control, 5) Psychotic symptoms, 6) Lack of social support, 7) History of repeated suicide attempts, 8) Patient is unreliable. In Hong Kong, under Mental Health Ordinance Chap. 136 (1999), Section 31, involuntary admission to a psychiatric unit could be applied to the Court. The detention period is seven days and an extension of twenty-one days could be applied to the Court by two doctors. Suicidal patient could be genuinely benefited from the safety, respite and support of hospitalization as a result suicidal ideation disappeared after hospitalization (Russ et al, 1999). Leenaars A (2004) also stated that many suicidal patients can be saved only with hospitalization, however, he emphasized that the quality of care – from doctors, nurses and attendants was crucial.

During hospitalization, anti-depressant may be helpful but it has its limitations. It takes at least two weeks or sometime longer to have the therapeutic effect, provided that the patient can tolerate some of the side-effects. World Health Organization (2001) reported that the response rate (remission after 38 months) of anti-depressant (Tricyclics) was only about 50% and the average adherence rate of long-term medication use was just over 50%. Sometime electroconvulsive therapy would be used. It should be careful that a patient’s depressive symptoms reduced after treatment but he could remain suicidal. As a result, quality nursing care is essential to prevent suicide during hospitalization. Suicidal risk is assessed and appropriate supervision is provided to prevent self-harm. The care of suicidal patient is challenging, we not only look after the sick body but also have to promote the healing of painful mind and disorientated spirit. Therefore, a body-mind-spirit approach nursing care plan would be used to care suicidal patient.

Frankl (1963) proposed that mental pain and suffering were coming from the loss of life’s meaning; it is a form of emptiness. He believed that through adaptation of values that provide meaning to life itself, was the way to heal pain and suffering. Mental (psychological) pain was named by Shneidman (1993) as “Psychache”. He stated that suicide was a result of unbearable psychological pain and psychological pain is created and fueled by frustrated psychological needs. He suggested that the remediation of the suicidal state lies in addressing and mollifying the vital frustrated psychological needs. ^aOrbach et al (2003) conceptualized mental pain as a perception of negative changes in the self and its functions that are accompanied by negative feelings. They developed a scale with nine factors: the experience of irreversibility, loss of control, narcissistic wounds, emotional flooding, freezing, estrangement, confusion, social distancing, and emptiness to measure mental pain. The association between suicidality and mental pain was confirmed by using the scale in empirical studies, the experience of irreversibility, loss of control, and emptiness were prominent in suicidal group. (^bOrbach et al, 2003). In order to help a suicidal patient, we have to help him to cope with the experience of irreversibility, loss of control, and emptiness. The Eastern concepts such as accepting life as being unpredictable and tolerating hardship could be useful in coping the experience of irreversibility; letting-go of the self and expectations on other, and self-affirmation and empowerment could be useful in coping the experience of loss of control, finding meaning in suffering could be useful in coping with the experience of emptiness (Chan, 2001).

In order to provide a holistic care, the Body-Mind-Spirit Well-Being Inventory (BMSWBI) from Center on Behaviour Health, University of Hong Kong was used in providing individualized nursing care. The inventory includes measurement of physical distress, daily functioning, affect (positive and negative) and spirituality (tranquility, resilience, and disorientation).

The therapeutic effect of physical exercise not only to body but also to mind because it gives one a sense of purpose and control. Chan et al, (2001) found that even trivial bodily movements, such as hand massage were very useful in helping clients ventilate their emotion and increase a sense of satisfaction. The first step of the nursing care plan was to teach Chinese fitness exercise in the group morning exercise. A comprehensive exercise program was designed in order to bring out the optimal effect. It included hand exercise, acupressure, qi-qong exercise (八段錦), and massage (陳麗雲 等, 2003), (吳兆文, 2003). It last for 25 minutes. Handouts would be given to patients for self practice.

The second step of the nursing care plan was to invite patients to have a body-mind-spirit well-being assessment by using the BMSWBI and a Depression Scale by Department of Psychiatry, Queen Mary Hospital. Nine male patients (7 schizophrenics and 2 affective disorders) completed the inventory and scale. All of them denied any suicidal ideations when they had the assessment but all of them were admitted for suicidal risk. Some of them needed assistance in interpreting the meaning of terms and statements (in Chinese) e.g. grateful, contented, carefree, fortunate, tender and loving, and “I can face life with a moderate state of mind”. The result of the inventory and scale were explained to the patient. At the same time, tailor-made nursing advices and health education were given to them individually. The most common problems in physical distress were insomnia (mean: 4.89, SD: 3.38) and tiredness (mean: 4.22, SD: 2.04). In daily functioning, more patients felt their memory (mean: 4.22, SD: 2.53) and concentration (mean: 4.22, SD: 2.57) were poor. Nursing advice about sleep hygiene, diet, and physical exercise were given. The most prominent negative affect was worried (mean: 5.22, SD: 2.82). As a mental patient, they usually worried being discriminated, worried about their employment, housing, financial difficulty, family, and their future. On the other hand, positive affects such as fortunate (mean: 5.67, SD: 3.02), tender and loving (mean: 5.22, SD: 2.74), carefree (mean: 5.11, SD: 3.14) were felt by them during hospitalization. In spirituality aspect, they expressed strong agreement in “I am grateful to people around me for all the things that they do for me” (mean: 8.22, SD: 1.99) and “To me, facing a predicament is a challenge and a learning opportunity” (mean: 7.33, SD: 2.26). Moreover, they expressed strong disagreement in “I lack the vitality of life” (mean: 2.44, SD: 3.06). It was out of expectation that the mean score of the disorientation subscale was quite low (mean: 17.78, SD: 15.96) but the range was large. However a number of patients strongly agreed with the statement: “I don’t know how to love myself” which indicated further psychosocial intervention was required. In promoting the healing of a disorientated spirit, proverbs therapy (Chan, 2003) was used, patient was asked to read a list of proverbs (statements about accepting life as being unpredictable, tolerating hardship; letting-go of the self and expectations on other, self-affirmation and empowerment, finding meaning in suffering, and how to love oneself). Then he was asked to identify which proverbs were useful to him. Three proverbs were selected by him and wrote on a paper and kept by him. He was asked why he selected the proverbs and what he would do. It was therapeutic as it empowered patient’s self-understanding and the motivation to change. Most of the patients accepted the intervention and some felt very useful for them. This intervention was particularly suitable for Chinese male patient as they usually had difficulty to express themselves and they were more rational.

The third step of the nursing care plan is giving assignments. First, assign patient to write one action for his selected proverbs daily. Second, assign patient to write at least one positive affirmation statement daily regarding self and the future, then positive reinforcement was given to patient for positive, reality-based cognitive messages that enhance patient’s self confidence and increase adaptive action (DeGood et al, 1999).

The result of the depression scale indicated 2 patients were in moderate depression, 2 in mild depression, and 5 in minimal depression. It was compared with the scores of BMSWBI. Although there was inconsistency in one case but the positive relationship between depression scale score and BMSWBI scores was observed. The details could be referred to the attached Excel file. If there were a reference scores for comparison, then the interpretation of the result would be more meaningful. The BMSWBI was not only a research or assessment tool; it could be used as a media in therapeutic communication. It enhanced holistic nursing care for suicidal patient as the meaning of life was addressed and mollified. By finding the values and meaning of life, a suicidal patient would not become suicidal again after leaving psychiatric hospital.

Reference:

Chan, C. (2001). An Eastern Body Mind Spirit Approach: A training Manual with One-second Techniques. Hong Kong: Department of Social Work & Social Administration, University of Hong Kong.

Chan, C.; Ho, P. & Chow, E. (2001). A body-mind-spirit model in health: an Eastern approach. Social Work in Health Care, Vol 34, No. 3/4, 2001, p.261-282.

DeGood, G., et al. (1999). The behavioral medicine treatment planner. New York: Wiley.

Fadem, B. (2004). Behavioral science in medicine. Philadelphia: Lippincott/Williams & Wilkins.

Frankl, V. (1963). Man’s search for meaning: An introduction to logotherapy. New York: Washington Square Press.

Leenaars, A. (2004). Psychotherapy with suicidal people: a person-centred approach. Hoboken, N.J.: John Wiley.

aOrbach, I., Mikulincer, M., Sirota, P., & Gilboa-Schechtman, E. (2003). Mental Pain: A Multidimensional Operationalization and Definition, Suicide and Life-Threatening Behavior, 33, 219-230.

bOrbach, I., Mikulincer, M., Sirota, P., & Gilboa-Schechtman, E. (2003). Mental pain and its relationship to suicidality and life meaning. Suicide and Life-Threatening Behavior, 33(3), 231-241.

Russ, M., Kashdan, T., Pollack, S., Bajmakovic-Kacila, S. (1999). Assessment of suicide risk 24 hours after psychiatric hospital admission. Psychiatric Services, 50(11), 1491-1493.

Shneidman, E. (1993). Suicide as psychache: a clinical approach to self-destructive behavior. Northvale: Jason Aronson.

Sokero, T., Melartin, T., Rytsala, H., Leskela, U., Lestela-Mielonen, P., & Isometsa, E. (2003). Suicidal ideation and attempts among psychiatric patients with major depressive disorder. Journal of Clinical Psychiatry, 64(9),1094-1100.

The Hong Kong Government. (1999). Mental Health Ordinance, Chap. 136.

World Health Organization. (2001). Effectiveness of interventions for depression. The World Health Report 2001, Mental Health: New Understanding, New Hope. Retrieved November 2, 2004, from http://www.who.int/whr2001/2001/main/en/tables/table3.2.htm.

World Health Organization. (2001). Adhering to medical advice. The world Health Report 2001, Mental Health: New Understanding, New Hope. Retrieved November 2, 2004, from http://www.who.int/whr2001/2001/main/en/boxes/box1.3.htm.

陳麗雲， 樊富?， 官銳園 (主編) (2003) 。 身心靈互動健康模式：小組輔導理論與應用。 中國：民族出版社。

吳兆文 (2003)。 天年共享 – 中醫養生與身心靈健康香港：香港大學行為健康教研中心。

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