This case study discusses themes of self-harm and suicidal ideations.  

Debra is a 63-year-old woman with a mild intellectual disability who is an effective communicator. She lives with three other women of similar functioning ability and attends a day program where she enjoys“retirement” by engaging in various leisure activities, volunteering, and community outings during the day.  

She is an incredibly social woman, active in her church, and seeks out interaction with a variety of people, including staff members, peers, and especially her sister. She has psychiatric diagnoses of depression, anxiety, and schizophrenia, for which she takes several prescription medications.

It is not uncommon for Debra to have short periods (a day or two) of perseveration of issues, such as her family not liking her, that she is not good at her work, that “nobody likes her,” or “she has no friends.”  Historically, these periods are related to negative interpersonal interactions, overcorrection when working, holiday periods, birthdays, or home visits. 

Recently, Debra has begun perseverating on death and dying. 

Debra routinely talks about deceased family members, graveyards, and makes comments such as, “I’m okay with being with God” or “I’m ready to go home (to God).” Twice in the last two months, Debra has visited the emergency department after staff members became concerned for her mental health and possible suicidal thoughts. 

 Context is Everything

Suicidal ideations (and/or actions) are always incredibly serious and concerning behaviors.  Behaviorally, it is important to remember that describing the behaviors and providing current and historical context can be valuable information during crisis management – particularly for first responders and medical professionals. 

Understanding the context in which a person may be engaging in these behaviors is important.  

Is there an identifiable reason the person is saying and engaging in behaviors that can jeopardize their health and safety?  Is the person distraught?  Aggressive?  Calm?  Are they lucid or confused? Are they displaying other psychiatric behaviors, such as delusional thoughts or increased impulsivity?  Observing and describing the person’s behavior beyond the suicidal comments or actions is often necessary.

It is also always imperative to understand the person’s history of suicidal ideations/actions, as this can provide insight into the behavioral patterns. Has the person said or engaged in these behaviors before? If so, what was the reason?  What was the intervention?  What was the outcome?  Past behaviors can provide valuable insight into current presentations. 

Lastly, when describing behaviors to others, it is beneficial to delineate between ideation vs action and general comments vs a feasible plan.  

When possible, it is essential to distinguish between whether the person is expressing thoughts or making comments, as opposed to engaging in a dangerous action.  

For example, if a person has engaged in a non-lethal action (e.g., holding their breath or pinching their nose), the act of “trying” is noteworthy, as it could be indicative of increased impulsivity and willingness to engage in suicidal actions.  

Additionally, if a person is discussing a well-thought-out and feasible plan, it indicates a greater level of concern than making generalized comments about death.   All of this information provides valuable insight for both crisis management and long-term psychobehavioral support.  

*Anytime it is believed that a person’s health and safety is in danger, immediately contact 911.

How Debra Got Support She Needed

Debra has difficulty managing stress, particularly from social situations and environmental events.  Debra’s extended period of hyper-focus on death and dying, which is somewhat atypical, was related to multiple factors occurring at the same time.  

Debra was experiencing stress related to her sister and home visits, in addition to having problems with a housemate.  Additionally, Debra attended several funerals in recent months, as part of being active in her church, which coincided with the period of her hospital visits and comments of, “I’m okay with being with God” or “I’m ready to go home (to God).”

The context of Debra’s comments was important in relation to the known behavior patterns of her perseveration of topics; she had no history of suicidal ideations or actions, and her comments were generalized with no specific plan of action.  

On both occasions, the hospital determined that she posed no threat to herself or others and was discharged that same day.  The interdisciplinary team, including her psychiatrist, met and decided that no medication changes were necessary. Due to the rural location of her residence, Debra did not have access to counseling. However, the behavior, residential, and day program teams developed robust strategies to provide informal counseling and one-on-one social interaction with highly preferred staff members, offering additional support when she perseverated on any topic.

All of Ley’s work is original and no form of AI was used to write this blog. 

This piece originally appeared in HELEN as part of Ley’s co-authored series on “Unlocking Behaviors.”

Never disregard professional medical advice or delay seeking medical treatment because of something you have read in this article.