Karen Kleiman MSW, LCSW
This Isn't What I Expected
The risk is real. Would you know what to do?
Posted Oct 24, 2012
Clinician note: The risk of suicide is significantly increased among depressed women during the perinatal period. While suicide deaths and attempts are lower during the postpartum than in the general population of women, when deaths do occur, suicides account for as many as 20 percent of postpartum deaths (Lindahl, Pearson,& Colpe, 2005).
Recent media attention to suicide attempts and tragic deaths by new mothers has raised public and congressional awareness about the potential devastating consequences of depression during the postpartum period. It is a risk that postpartum women and their families as well as the clinicians who treat them must take very seriously at all times. Passive suicidal ideation is also worrisome. Do not dismiss this.
If you do not ask every single postpartum woman who comes into your office if she is having thoughts of hurting herself, you have no idea whether she is feeling suicidal or not.
Ask every woman.
Below are some guidelines for assessing suicidality with your postpartum client:
- How often are you having thoughts of hurting yourself? (Determine frequency and acute nature of thoughts)
- Are you able to describe them to me? (Assess current level of distress and willingness to disclose)
- Have you ever had thoughts like this before? (History of previous thoughts increases current risk)
- What happened the last time you had these thoughts? (Assess coping potential)
- Does your partner know how bad you are feeling? If not, why not? (Numerous factors contribute to failure to disclose, all pointing toward potential areas of vulnerability)
- Who do you consider your most primary connection for emotional support? (Explore all support options)
- Does this person know how you are feeling? If not, why not? (Explore her resistance in order to determine degree of withdrawal, level of shame, ability to reach out for help)
- Does anyone in your family know how you are feeling? (Engaging family member provides important link when her instinct is to isolate self)
- Have you ever acted on suicidal thoughts before? (Previous suicide attempt increases current risk)
- How do you feel about these thoughts you are having? (Assess affective response and level of distress to confirm ego dystonic nature of thoughts)
- Do you have specific thoughts about what you would do to harm yourself? (Assess intent and plan)
- If you do have a plan, do you know what is keeping you from acting on it? (Assess and increase her awareness of meaningful connections to reduce feelings of isolation and despair)
- Are there weapons in your home? (Never presume to know the answer to this. In addition to the obvious danger, weapons also serve to stimulate the overactive obsessional thought process with temptation too great to ignore. All weapons, whether locked or reported as inaccessible, should be removed from the home without delay)
- Do you have access to medications that could be harmful to you? (All medications she is taking or has access to be monitored by her partner until suicidal thoughts have responded to treatment, reducing risk of temptation)
- Is there anything else you can think of that I can do right now to help you protect yourself from these thoughts? (Gives her permission to reveal any unidentified method or related worry)
- Have you thought about what the implication would be for your baby? (Her connection to her baby may provide a critical lifeline)
- Do you feel able to contact me if you feel you cannot stop yourself from acting on these thoughts? Who else can you contact? What if you are not able to reach them, who then will you contact? (Establish a contract for safety, verbal or written)
IMPORTANT POINTS TO KEEP IN MIND:
- Clinicians should be clear about their ability to help their client.
- Follow up with any and all requests (e.g.,weapons out of the house).
- Determine level of follow up (e.g., having her report in with phone calls to assure safety).
- If a woman indicates that she is having thoughts or feelings about harming herself and/or her baby and she is unable to contract with you or promise that she will not act on them, she should not leave your office.
- Contact family members, if indicated, in her presence.
- Initiate appropriate psychiatric or hospital contact.
- Indications that immediate intervention is required if she:
Demonstrates significantly impaired functioning.Expresses suicidal thoughts with a developed or intended plan.Is ambivalent about her ability to keep herself and her baby safe.Expresses intent to herself or her baby.Reports physical or sexual abuse or any unsafe living situation.Demonstrates signs of psychosis.
- Clinicians should be careful not to avoid questions that make them uncomfortable
A woman who has recently given birth and reports not feeling like herself should be closely monitored. Do not make the mistake of reassuring her that she will be fine until she is adequately assessed. A postpartum woman who is struggling with severe depression believes that her children would be better off without her.
Be informed. Ask the hard questions. Have excellent referral information for her.
In the U.S., call 1-800-273-8255 National Suicide Prevention Lifeline.
Adapted from Therapy and the Postpartum Woman (Routledge, 2009)