Biblical Counseling, Suicide and Self-Harm BCC Partner Ministry Resource April/May 2016
About This Resource BCC Staff Note: The materials contained in this document have been posted at the Biblical Counseling Coalition s Grace & Truth blog site. Each one, in various ways, relates to the theme of self-harm or suicide. You will find strength and hope for the counselor as well as for the counselee. We describe the BCC s Grace & Truth blog as Voices from the Biblical Counseling Community. The modern biblical counseling movement spans a diverse spectrum of people and organizations committed to a view of people helping summarized by the Biblical Counseling Coalition s Confessional Statement. It is with this diversity in mind that we have collated these resources into one document exclusively for our BCC Partners. Usage/Quoting/Permission We encourage you to make use of this document. We would ask that whenever quoting from this document, you state: The following materials are used with permission of the Biblical Counseling Coalition and are taken from their collated BCC Partner E-Source Connection Resource, April 2016. If you use the embedded links and then quote directly from the original post, please include the following: The following materials are used with permission of the Biblical Counseling Coalition and are taken from (add the title of the blog post, the author, and the URL). Table of Contents Bringing Self-Harm Habits Into the Light by Mark Shaw Cutting: Bleeding the Pain Away by Amy Baker Why Would She Want to Kill Herself? by BCC Staff Suicide Risk Scale by Garrett Higbee
Bringing Self-Harm Habits Into the Light By Mark Shaw The Rich Relevance of Scripture Princess Diana is one of the most famous persons who struggled with self-injurious behavior. Selfinjurious behavior often occurs when a person is despairing or grieving one of life s circumstances in a fallen, sin-cursed world. This type of behavior is a complex maladaptive way of responding to life s disappointments or uncertainties. It is a means of escape from deep hurts like the death of a loved one. Self-harm is not a new, modern problem, but an ancient one that continues today (Lev. 19:28; Lev. 21:1-6). For this reason, we can find answers in the Scriptures to address the heart behind these destructive behaviors. A Form of Escape To most, self-injury seems odd: why would you want to hurt yourself? That doesn t make sense to most people and often why self-injurers keep this issue hidden for years. Experiencing deep hurt and choosing not to turn to Christ, counselees use self-injurious behavior as a place of refuge and escape. Self-injurers may have other means of escape like alcohol, drugs, comfort-eating, spending money, sexual sin, and the like, but self-harm is often the preferred first option. It is often stated by counselees struggling with self-harm habits that they desire to transfer emotional pain into physical pain that they can understand. Not always, but often, blood appears as a result of cutting and similar self-harm behaviors. That blood is reported to bring relief when the cutter sees it. This statement reminds us of the gospel and the shed blood of Jesus Christ for the remission of sins. No one s blood can really atone for sin and bring true relief in this life or the next other than Jesus Christ s blood shed on the cross. Ultimately, cutters need to put their trust in His shad blood rather than their own. Self-Injury as Addiction When most people think of addiction, they tend to think of the behaviors related to drug and alcohol abuse, but not self-abuse, self-injury, or cutting. However, self-injury and cutting involve a natural, drug-like, euphoric effect that provides an escape experienced after the temporary physical pain. [1]
What many people do not understand is that the patterned, habitual behavior of cutting feels good to the self-injurer. Obviously, there is real pain at first, but it is short-lived when the body s natural mechanisms for pain relief designed by God kick in. The drugs involved in the addiction of this sort are within the self-injurer s own body. The use of addictive substances and the practice of self-injurious behavior produce the same intended goal of escape, and the heart attitudes of both are often the same. Even though the pain relief response of the body is a God-given phenomenon, the cutter is seeking hope, help, and relief from a source other than God Himself which is true of any addiction and idolatrous desire seeking from an outside source that which only God can truly provide: comfort, security, hope, relief, eternal pleasure. God s desire is that we seek first His Kingdom by obeying His commands for His own glory despite our emotional state. We are to lead our emotions and our hearts not follow them (Prov. 4:23).[2] The Only True Hope A key principle in all types of biblical counseling, which becomes especially important when counseling a self-injurer, is encouraging the counselee to bring the issue into the light. John 1:1-5 (ESV) states: In the beginning was the Word, and the Word was with God, and the Word was God. He was in the beginning with God. All things were made through him, and without him was not any thing made that was made. In him was life, and the life was the light of men. The light shines in the darkness, and the darkness has not overcome it. The ESV word overcome in the verse above in Greek is a word that has no exact equivalent in the English language. It can mean both to apprehend and to comprehend, and literally the word means to lay hold of with the mind and to understand, perceive, learn, comprehend. [3] In John 1:5, God is communicating to us that the darkness has no ability to apprehend, overcome, or even comprehend the light; therefore, when a self-injurer has experienced a deep hurt, abuse, or grief, the self-injurer must acknowledge the hurt of being sinned against by bringing it into light. In the light of truth darkness has no power. Fear, shame, and many other experiences motivate self-injurers to keep their behaviors secret, but John 1 offers inestimable encouragement to the believer in Jesus Christ enslaved to this type of addiction. Proverbs 28:13 (ESV) similarly reminds us: Whoever conceals his transgressions will not prosper, but he who confesses and forsakes them will obtain mercy. After the source of the hurt is recognized, the self-injurer must address his own sin. For example, the hurt experienced from abuse is likely not their fault, but their response to that hurt is sinful when it involves self-harm (I Cor. 6:19-20). Only when counselees learn to repent of their self-reliant, idolatrous heart is there real hope. Is the counselee unable to accept the truth of the past, allow Christ to redeem it for His own glory,
and trust in the sovereignty and goodness of God? Is the counselee trying to temporarily fix his pain in his own strength with his own method (self-harm)? Is the counselee looking for his own blood to bring pain relief rather than the blood of Christ? These questions and more must be asked to get to the heart motivations of the addictive self-injurious behaviors. Counseling the Hard Cases Self-injury is an age old problem and not surprising to God. The local church is the body of Christ and has the only answer to offer hope and help to hurting and hardened souls. We cannot ignore selfinjurious behavior in the local church; we must rather encourage those struggling to bring the issue into the light so that Christ may be glorified. As biblical counselors, we cannot be overwhelmed by the difficult-to-understand and often perplexing problem of self-injury. Instead, we must: Trust God. Offer real hope through Christ. Address the heart biblically with probing questions and with God s Word, which will reveal heart issues (Hebrews 4:12). Be gracious to the counselee struggling with the temptation to self-injure. [1] Shaw, Mark, Hope and Help for Self-Injurers and Cutters, Focus Publishing: Bemidji, MN, 2007, p.3. [2] For a more complete explanation of this God-given biological process of pain relief from within the body obtain a copy of my booklet Hope and Help for Self-Injurers and Cutters from Focus Publishing (1-800-91-FOCUS). [3]Strong, J. 1996. The exhaustive concordance of the Bible (electronic ed.) Woodside Bible Fellowship: Ontario.
Cutting: Bleeding the Pain Away By Amy Baker If you re a cutter, you know what it s like to feel the pain welling up inside you. It feels like any second you re going to explode. In the past you may have cried, gotten angry, accused, complied, or blamed yourself, but now you cut. You ve prayed, asking God to change things, to make you want to stop cutting, but you feel as if your prayers stopped at the ceiling. You don t pray anymore. Unlike the emotional pain, you control the physical pain created by cutting. You know it s not normal to get relief by cutting, but it does bring release and nothing else seems to work. You reason, Why would I give it up when nothing else works? In your heart however, you know that this doesn t work either. You are having to cut deeper and deeper, more and more frequently. Cry Out to God When you are hurting badly, sometimes words don t seem meaningful. Therefore I have prayed for God s help for you as you read. Perhaps you could pray also that God will touch your heart and give you hope as you read. The Lord longs to show pity and mercy to those who are struggling. He is close to the brokenhearted, and He binds up their cuts. Please ask the Lord to become your relief, your satisfaction, your comforter, your protector, and your desire. Because God s love compelled him to send his Son to bleed and die for us, His love is strong enough to spill out on every soul who looks to him. Additionally, since His power was great enough to raise Christ from the dead, His power is great enough to provide escape from the snare of cutting. Through Christ s blood, God brings people near who were formerly separate; He brings people near who were formerly excluded; He comes near to people without hope; He comes near to people like you. Please ask God to show Himself to you. Please cry out to God. Precious to Him Psalm 72 says that God will deliver the needy who cry out, the afflicted who have no one to help. He will take pity on the weak and needy. These are comforting truths all by themselves, but the passage continues with something even more comforting. In verse 14 we learn your blood is precious in His sight. For he will deliver the needy who cry out, the afflicted who have no one to help.
He will take pity on the weak and the needy and save the needy from death. He will rescue them from oppression and violence, for precious is their blood in his sight. (Psalm 72:12-14) Please consider the truth that your blood is precious in God s sight. When you ve locked yourself in your room and raised blood in order to feel calm, God has been there and your blood is precious to Him. When you ve reopened wounds, God has been there and your blood is precious to Him. When you ve needed the sight of your blood to prove you re in control, God has been there and your blood is precious to Him. Blood Is Powerful Blood is powerful. You ve been using the sight of your blood as a high powered tool to alleviate your pain, your alienation, your aloneness, your self-loathing, and your guilt. In fact, sometimes you practice cutting to atone for the guilt you feel after you cut. But as you ve come to recognize, your cutting doesn t solve the issues at war within your soul. Cutting only offers temporary relief--a relief that is quickly destroyed by more pain, more anxiety, more sadness, more guilt, and more desperation. Spilling out your own blood in an attempt to find relief falls far short of the image God created you to reflect. God is glorious splendid, magnificent, radiant, holy, and altogether wonderful. And God created you to reflect His glory. We all fall short of this. We all need to be rescued from the pits into which others have shoved us and the pits which we have dug for ourselves. Spilling your own blood is not an effective method to rescue you from the pits. Remember that in Psalm 72 God says that He will take pity on the weak and needy. Even though you ve fallen short of His glory, and even though you ve looked to our own blood to control your pain and provide relief, God is willing to show pity. His pity is shown to you in the brutal death of his Son who suffered and bled so that you could receive a pardon for your sins and begin to reflect the glory you were designed to radiate. The blood you spill can never permanently provide relief or atone for your sins, but the blood Christ spilled for you can. It offers hope beyond relief. We all need to be rescued. Christ s shed blood is so powerful that through faith in his blood we receive forgiveness. Christ suffered and bled not for the relief it would give Him; He suffered and bled to rescue us and provide salvation for us. While you may get short-lived relief from spilling your blood, Christ s blood gives hope for every day and for all eternity. God will deliver the needy who cry out. Cry out to Him for forgiveness and help. Trust in the blood of Christ, not your own blood. Look to Christ to become your relief, satisfaction, savior, comforter, and protector. The alienation, abandonment, sense of being misunderstood, guilt, confusion, and powerlessness you ve experienced has kept you in a dark place. But when God rescues you through Christ, you can
begin to walk in the light, because you re walking with Christ, and He is in the light. In 1 John 1:7 we re told that if we walk in the light, as he is in the light, we have fellowship with one another, and the blood of Jesus, his Son, purifies us from all sin. Notice that walking in the light and Christ s purifying blood also brings us into fellowship relationship with others. The alienation you ve felt from your parents, your peers, your teachers, your bosses, and God has a remedy. The blood of Jesus purifies you and opens the door for good relationships with others. So trust in the blood of Christ, not your own blood. Blood is very powerful when it s Christ s blood!
Why Would She Want to Kill Herself? By BCC Staff Suicide is the 10th leading cause of death in the US, one about every 15 minutes! It is the second leading cause of death between the ages of 15-24 years, with half a million teenagers attempting suicide. More than 5,000 seniors kill themselves annually. Why would a person we love want to end their life? And what is our responsibility to help and how can we? We as family and friends, or as counselors, can make a world of difference by our responses to their struggles and by knowing the warning signs. We may not save everyone from suicide, but if we can save even one, it s worth reading this article and going to our website for additional help. What are some warning signs? When a person talks about suicide or death or makes statements like I wish I had never been born, and starts to give away things he has valued, or plans for the care of pets or dependents, be alert and ask more questions. Another clue is a change in eating, sleeping or grooming habits, or a sudden burst of energy and joy from someone who has been depressed for a long time (It may indicate that a decision has been made and really is a calm before the storm). Also be alert to withdrawing from favorite people or activities or being reckless with dangerous activities. Other high-risk indicators would include a history of drug or alcohol use, physical or sexual abuse, or being in some kind of trouble. When there is a history of depression and antidepressant drugs are given, some have the side effect of suicidal desires and actually make matters worse rather than better! Those who have previously attempted suicide or who have a close friend or relative that has committed suicide are more likely to try. What can I do to help? Encourage the person to talk to you and really listen (Jas 1:19, 20) to determine suicidal intent. The more detailed her plan and the more access she has to her method of choice, the more likely she will follow through. Be compassionate as you hear their pain and suffering (Lam 3:22-24). Remember suicide is not so much about wanting to die as it is not knowing how to live with the problem. Suicidal people must gain a sense of hope, a reason to live, a hope that there is a solution to what to them seems unsolvable (1 Cor 10:13). If you don t know how to help them, take them to someone who can help find that solution. The book of Ecclesiastes shows us that life apart of God is not worth living. Suicidal people must ultimately come to a place of trusting Christ as their personal savior and starting to grow in their trust of God s Word for answers to their life problems. Help them see that suffering is a part of God's will to refine us in Christ, with the goal to change their focus from escape to contentment (realizing
God is in control and loves them) (Php 4:11-13). As they begin to change, they will find their place of service among God s people, helping others to realize that suicide is the ultimate act of self-love to avoid painful consequences (2 Tim 3:1-2) and sharing the hope they have found in Christ. Must I get involved? Talking to someone about his suicidal intent will not encourage him to attempt suicide. Instead, it communicates interest and hope because you cared enough to ask. Jesus commanded us to get involved with our neighbors (Lk 10:25-37, Mt 22:36-40) and to restore a struggling brother to usefulness (Gal 6:1-5). Trust God to use you as His Instrument of hope to someone who needs help! As righteousness leads to life, so he who pursues evil pursues it to his own death. Prov 11:19
ASSESSING THE RISK Counseling the Suicidal When assessing the risk for suicide in a counselee three main factors (SOS) need to be carefully considered: Severity, Ownership, and Support. Please understand the complexity of these factors and consider how they influence the overall risk of a counselee. SEVERITY Level of risk Suicide Risk Level History of Suicidality and Current Condition 0 = Lowest Risk no prior history of or current concern about suicidal behavior 1 = Some Risk 2 = Moderate Risk 3 = High Risk 4 = Imminent Risk prior history of suicidal ideation or behavior and currently struggling with loneliness and worthlessness as well as being depressed and isolated prior history of suicidal ideation or behavior and currently having ruminating or obsessive thoughts about suicide but no plans have been made prior history of suicide attempts and increased desire to attempt suicide with some plan made and some means available prior history of suicide attempts; person in deep despair; plans are made and means are available for example, note may be written, thing are given away, etc. Once the counselor has a good sense of the severity, compliance needs to be established. OWNERSHIP Willingness to comply Compliance and ownership is an important factor to consider as it may raise or lower the overall risk of the counselee. How willing is the counselee to listen to counsel and is he/she willing to be held accountable? If the severity level is moderate or above, a safety contract should be signed (see below). Example: Someone assessed as a moderate risk level may be adjusted to a higher or lower risk level depending on how willing the counselee is to listen, be accountable, and comply with the counsel given. SUPPORT Availability of appropriate care and community Finally, the counselor needs to assess collateral and community support. When assessing the level of support in a person s life we re looking for two pieces: (1) How connected/isolated is the counselee? (2) Who should be contacted as a way to spread liability and extend love and care to the counselee? Once again, the overall suicide risk is affected by this factor depending on the support system s availability and the counselee s willingness to lean on them. Based on this the overall risk level to attempt/commit suicide may be raised/lowered. Regardless of where the counselee is on the risk scale, it s very important to find out who can come alongside the counselee. A family member or good friend should be contact as soon as possible to spread liability and extend love and care to the counselee. In most cases you will ask for a verbal release and/or have the counselee sign a release before calling. In the case of calling the police or an inpatient facility, there may be a time the counselee is not informed to keep them from leaving or attempting self-harm. It is very important to carefully think through these steps and to establish boundaries for safety in order to lay grounds for future care. Of course, informing pastoral staff and possibly an elder, flock leader, or small group leader may be necessary and appropriate. 2011. Biblical Soul Care. All rights reserved. 1
Counseling the Suicidal ASKING THE RIGHT QUESTIONS The section above largely dealt with the information you need to know in order to properly respond to and care for a suicidal counselee. Below are some specific questions you could ask. This suggested order of priority and timing may help to assess where a counselee is in terms of risk and intent? The general categories for asking questions are long-term and recent history and significant current events: 1. Long-term risk factors a. Any history of suicide attempts, mental instability, physical or sexual abuse b. Long-standing tendency toward anger or becoming aggressive with little provocation c. Chronic severe pain or disabling physical illness d. Past suicidal behavior in family member or close associate 2. Recent (within last 3 months) events a. Recent significant loss, acute emotional distress or worsening of depressive symptoms b. Recent drug and/or alcohol use or increase in usage 3. Current (within last week) status a. Current preoccupation with, or plans for, suicide b. Current psychomotor agitation or marked anxiety (i.e. fidgeting, excessive nail biting, etc.) c. Current prominent feelings of hopelessness d. Currently living alone or isolated from community When dealing with a suicidal counselee it is best to ask questions that move from extensive questioning to intensive questioning: Example: - What level of pain or distress would you currently rate yourself (on a scale of 1-10)? - Where would that rating have been 6 months ago? - Have you had any significant loss in your life recently or in the past? - Have you taken any drugs / alcohol that might have contributed to your desperation? - Are you willing to commit to stopping any drug or alcohol abuse before you leave today? - Will you turn these drugs/alcohol over to me (counselor) or a trusted friend? - Have you ever thought seriously about suicide? - Have you ever attempted suicide? - Do you have a gun, access to lethal drugs, and/or a well thought-out plan? - Will you turn these means (gun, drugs, etc.) over to me (counselor) or a trusted friend? - Would you be willing to sign a contract stating that you promise to call me and/or someone else of your choosing before leaving the office today. 2011. Biblical Soul Care. All rights reserved. 2
COUNSELING FOCUS Counseling the Suicidal Once the overall risk of the counselee is assessed, it is important to think about what the focus of the counseling should be. For example, it is inappropriate and possibly harmful to speak to a counselee that is at a level 1 risk as if he was a level 4. Therefore, consider the following chart to guide your focus in counseling the suicidal going forward: Risk Level 0 = Lowest Risk 1 = Some Risk 2 = Moderate Risk 3 = High Risk 4 = Imminent Risk Counseling Focus no prior or current concern about suicidal behavior prior history of suicidal ideation or behavior but preventing suicidal behavior is not a focus of the current counseling preventing suicidal behavior is a part of current counseling but less important than other relational and pressing spiritual issues preventing suicidal behavior is one of the main goals in the current counseling preventing suicidal behavior is the most urgent goal in the current counseling MAKING IT REAL This short section is designed to give you an opportunity to assess how much of the information above you have internalized. Please try to evaluate each vignette below and specify the risk level for each. Vignette 1: Tara arrived early at church to meet with a pastor. She looks tired and angry. You remember her well from the last time she came to see a pastor. Her history is full of loss, loneliness, and rejection. She has attempted suicide before. She tells you of her anxiety, hopelessness, and despair. You understand that she is not at a good place and her indications strongly suggest that she has even thought about taking a bunch of sleeping pills. She is desperate but has come to you wanting help. She says if this doesn t work, who knows what could happen. Vignette 2: William came to you being very down. He feels lonely and has no sense of direction. He started feeling tired a couple of weeks ago and has not spent much time with friends or Family. He sometimes thinks the world is better off without him but mostly feels stuck in his thoughts and feelings. Vignette 3: Elaine has come to you being very tired and depressed. She is nervously playing with a piece of paper and seems absent. She says she has had enough of life and is tired of being disappointed, lonely, and without purpose. When you ask about her situation she deflects and tells you she s not sure why she even came. She makes several attempts to cut you short and even seems to want to leave. While pressing in with questions you find out that she has attempted suicide in the past. She says she is at the end of herself and that she was going to end her life today by overdosing on her anti-depressant. Vignette 4: You are meeting with Nick again after the summer break. Despite your hopefulness for lasting change you find out that he has worsened. As you meet with him, you hear about the bullying by siblings, his tantrums on vacation and for the first time tells you that his thought have been very dark. He tells of sleepless nights and thoughts about running away or even ending his life. Since an incident on the last day of their family vacation he has not been able to rid himself of thoughts of being worthless, unneeded, and having no purpose. Though he has no real plan or intent you feel that things will worsen if he does not receive hope and direction. 2011. Biblical Soul Care. All rights reserved. 3
Safety Contract This contract is to establish boundaries and safety for: First Name: Last Name: I promise that I will contact my husband, wife, parent or trusted friend (circle one) when I first begin to have serious suicidal thoughts or intentions. If this person(s) is not available, I will contact my advocate, counselor, pastor, or an elder no matter what time it is (7 days a week, 24 hours a day). I will call 911 if they are not available and I m tempted to act on my temptation to hurt myself. I commit to stopping the usage of any drugs or alcohol immediately. I have stated and believe that my motive and means to harm myself is now decreased to the point that I am not in imminent danger to harm myself. I understand others who need to know my risk and condition may need to be informed to help care for me. I give the counselor my consent to make these calls at their discretion. I understand and agree to the concept of limited disclosure information will be held highly confidential by all parties involved except when an individual is to be protected from physical harm. I will submit to the counsel of my counselor, pastor, my elders, and any other authorities involved to ensure my safety. 1 st Contact: Phone #: 2 nd Contact: Phone #: 3 rd Contact: Phone #: Signature: Counselee Signature: Counselor Signature: Witness Date: Date: Date: 2011. Biblical Soul Care. All rights reserved. 4
Biblical Counseling Coalition, 2016.