Some tools for talking about suicide

Recent events have had me remembering some of the stuff I learned when I was doing crisis counselling, in particular the stuff we were taught about suicide prevention. I got to use this knowledge rather a lot, unfortunately, since I usually worked a late evening shift which was apparently one of the prime times for suicidal thoughts and actions, as I averaged one or two callers at risk of suicide every shift. (As well as the guy who used to ring up at exactly 8pm on Mondays to tell us how ‘confused’ he was about various sexual issues and fantasies. In detail. But that’s another story.)

Anyway, since a couple of things have made this a bit more relevant than is precisely fun of late, and since it strikes me that a lot of this is useful, or at least non-harmful, information, which may not be quite such common knowledge as I think it is, it seems worth writing some of it here.

Note that I am writing about suicide prevention under the cut.  You don’t have to read it if it’s going to make things worse for you right now.  If you yourself are feeling vulnerable, distressed, or especially suicidal, at the moment, for any reason at all, please talk to someone.  Note, too, that it’s easy at a time like this to feel guilty about being miserable because others have it worse off.  But feelings are feelings, and it’s not a competition.  If you are in Australia, Lifeline is on 13 11 14.  If you are overseas, here is a handy list of suicide helplines all over the world.  Please stay safe.

The first question, I suppose, is how do you identify if a person might be feeling suicidal. And the answer, in its most basic form, is – you ask them. You ask them directly, and use the word suicide when you ask. Or ‘are you thinking about killing yourself?’.  It’s very hard to do this, even with lots of practice, but it’s important for two major reasons, and probably a lot of minor ones. The first reason is one of communication. There is no point asking a question in such vague terms that the answer still leaves you wondering. You are no better off, and perhaps worse off, than you were before you asked. The second reason is the same reason that makes it difficult to ask directly – there is a very strong taboo around discussing suicide. By using the word, by using direct and specific language, you send the message that you are someone who is willing to discuss this taboo subject. If you avoid the word and talk all around the subject, then you signal that you aren’t comfortable with discussing it, and a person who is suicidal might be afraid to talk to you for fear of upsetting or shocking you.

The other part of the first question is when do you ask someone? This is partly a gut instinct thing, but if someone is depressed, particularly if they tell you they are depressed, it is probably worth asking. You will not do irreparable damage by asking someone – you certainly won’t be putting the idea into their heads, because the odds are that if they are depressed, the notion has at least crossed their mind. And probably been dismissed, at which point, phew, you’re off the hook! If someone is using phrases like wanting to end things, not wanting to be here, wishing they didn’t exist, others would be better off without them, etc, that’s a big hint. Actually, it’s more than a hint, it’s often a way for someone who is suicidal to open the conversation about suicide without saying the word – a safe way to test your reaction and find out whether you are someone they can talk to. Use this opening. (Actually, I think it’s a particularly wonderful opening, because the fact that this person is in a sense bringing the subject of suicide up suggests that they are not just suicidal, but worried about being suicidal – perhaps they are afraid of acting on suicidal feelings, but do not entirely wish to die. This is a good thing, and probably increases your chances of helping them, at least through the immediate crisis.)

Another clue can be if someone is engaging in the famous ‘risk taking behaviours’. Drinking or using drugs to excess; doing stupid things while driving; looking for fights; self-harming (cutting themselves, deliberately overdosing but not with intent to suicide, though the line here is very blurred); attempting to cross Sydney Rd… this behaviour can take many forms. I used to wander around the streets of Brunswick in the middle of the night in the hope of being randomly hit by a car or murdered. There are many ways to be stupid. But these are all signs that someone does not, perhaps, value their life, and may be looking for ways to passively commit suicide.

It seems important here to bring up the whole idea of suicide or the threat of it as a cry for help, as a way to get attention – in essence, as something someone won’t follow through on.

In a purely practical sense, it doesn’t matter whether this is the case or not – you have to treat any threat of suicide as genuine, because a person who is willing to self-harm may not know how much harm they can safely inflict on themselves. Bluntly, it is possible for someone to commit suicide by accident – by overestimating their ability to get help before the drugs work, or they bleed out, or whatever. In an emotional sense, perhaps suicide can be a cry for help or a way to get attention – but it’s a remarkably dangerous and painful way to do so; if someone feels the need to do something that extreme to get attention, they are clearly in a pretty bad place. In other words, they probably do need the attention. And why take the risk?

So. You’ve established that someone may be at risk. You’ve asked the hard question, and they have said that yes, they have been thinking about killing themselves. You have had quiet internal hysterics, and they may well have had more obvious ones. Your next step is to try to find out their level of risk.

Actually, a quick break here to point out that I am focusing here primarily on practical responses. This is because your aim is to keep the person alive long enough to sort out whatever is the underlying reason for the suicidality. So while you are (hopefully) being empathic, engaging in active listening, and being understanding, your real goal here is to keep this person safe right now. While you will want to talk a bit about why they feel this way and where they are coming from, much of this can wait until the crisis is over. And for most people (not all, alas, but the vast majority) the danger period in which both the desire to commit suicide and the energy to do so are both present lasts around half an hour. So while you are sitting there going ‘Oh my god, this person is going to kill themselves unless I do something’, remind yourself that if you can get them through these next few minutes, this next hour, you will have succeeded. For now.

First risk factor is – does this person have a plan? Are they saying ‘I’m going to kill myself’ or ‘I’m going to take all the drugs in my medicine cabinet’? Ask them. I always find this the hardest question to ask. ‘You’ve said you want to kill yourself. How were you planning to do this?’ sounds to me like encouragement. But it’s also the only way to find out how advanced the plan is. Things you want to know are: do they have a method in mind? Do they have the means required to carry out this method? Do they have a particular plan in terms of time and location? When and where do they have in mind, and how hard is it for them to get there? Obviously, the more detailed a person’s plan, particularly with regards to means, the higher the risk. ‘I’ve just taken a whole lot of pills’ is worse than ‘I’m going to take an overdose and the bottle is right in front of me’ is worse than ‘I’m going to take an overdose and the bottle is in the medicine cabinet’ is worse then ‘I’m going to take an overdose.’

Incidentally, if someone has already cut themselves, or taken something, or whatever, stop right there. This is no longer about suicide prevention, it’s about first aid. You don’t need a checklist, you need to get them to a hospital. This means you need to find out where they are, find out what they have taken or what they have done, and call an ambulance. Better still, get them to call an ambulance (preferably from another line, or get them to call you straight back). It’s always better to give someone as much agency as possible, because that means that next time, if there is a next time, they have the knowledge that they were able to rescue themselves.  And anything you’ve done once is something you can do again. This is precisely as difficult as it sounds.

If you can’t get them to give you this information, then if at all possible keep them on the line while you call the police (Notr that in some cases, police involvement will make things worse, particularly, unfortunately, for people of colour or other visible minorities.  Please bear this in mind. Australia is, I think, relatively good these days – we had a number of terrible incidents in the 1990s, and they changed how police were trained to deal with mental illness. But… the maths might still be different for a person of colour.). The police can trace calls, but this is easier if you have been on the phone longer and easier still if you know what time the call started. Even if they hang up, you should not. If you have to hang up to call the police, record the time the call ended. Having traced a call, the police can go to the house and check if everything is OK, but you need to give them a very good reason to do so, which is why you want to know what they have taken and how much of it (It has also been pointed out to me that you really want to be certain of where the person is before you do this.  Coming home to a house where the door has been broken down is… not particularly helpful for anyone’s mental health).

And no, I don’t want to call the police for someone I know, and I’d rather go there myself if at all possible, but if I don’t know where they are, and they might be dying, frankly, I’ll take the fact that they called me as an indication that they are at least somewhat ambivalent about dying, and will intervene any way I can. Alive and angry is preferable to dead. And if it isn’t, sadly, they will probably try again, and not call anyone. And if someone does that, there really isn’t much you can do (and there are also people who really don’t give any warning signs because they are quite determined and have no intention of letting anything stop them. This is also not your fault. You can’t help someone who is that determined not to be helped).

By this point, you’ve got a pretty good idea how immediate the risk is. Two other things will help you clarify this further: Have they attempted suicide before, or do they know anyone who has attempted or completed suicide? People who have previously attempted suicide, or who know someone who has, are more likely to attempt again. I don’t know the theory behind this, but I suspect it relates to the fact that it has become a real option, which real people attempt – not just something from books or TV. This is mostly to help you work out just how worried you should be right now.

Your third set of questions are the cheerful ones – what resources does this person have. Are they alone in the house (it’s great if the answer is no – people rarely kill themselves when others are around)? Do they have friends or family they can call on? Neighbours? Colleagues? A doctor or psychologist or social worker who they see regularly? Make a list.

Now you know where you stand, it’s time to do something. Go back to the question of means. Your aim is now to remove the means from the person at risk. Can the medicine they were thinking of overdosing on, or the gun they were thinking of using, be locked up or given to someone else to look after? If it is in front of them, can they at least put it back in its usual place? Every extra step someone has to take in order to kill themselves is a step that makes it harder. Look again at the person’s resources. Is there someone who lives with them who will be home soon? Can you go and visit them? Is there anyone else who can keep them company?

Ask if they have ever felt like this before. What happened? Did they attempt suicide? What stopped them from succeeding? What stopped them from attempting? What do they enjoy doing? Can they do that now?

What you are aiming at now is to come up with a plan that will keep the person going for the next few hours or days. Ask them to identify people they can contact if they are feeling suicidal. Make them promise that if they start feeling suicidal again they will call one of the people on the list. Give them the number for Lifeline (131 114) or the equivalent in your own country, and make them promise that if none of those people answer, they will call it.  Give them a number for the suicide helpline if there is one. Try to find them other resources that might help. Ask them to tell you, themselves, in their own words, what they are going to do if they feel this way again.  Again, getting someone to speak about their plan themselves makes it more real to them, and shows a degree of commitment that passively agreeing does not, always. Encourage them to contact their psychologist, social worker or doctor if they have one. If they don’t, help them find one.  Did you know that in Australia, you can get a referral from your GP, and get your first ten visits on Medicare?  Well, you know now.  Offer to go with them if that would help.

I think I’ve just run out of steam. But basically, you want to ensure that someone is not alone when they are feeling suicidal; that the means to commit suicide are out of their reach as far as is possible; that they have people to contact or strategies to cope with this crisis; and that they have longer term plans in place to get help. And you want to make sure they know that you care enough to be worried about them, that you are really concerned that they are at risk of killing themselves, that you will help to the best of your ability. That, again, they are not alone with this. That you will still be their friend after the crisis passes.

Tomorrow, perhaps you can be the friend who just listens and hugs them and lets them cry. But right now, you are aiming to get them through the night in one piece, or as many as they originally started in. And if you can do that, you’ve done something wonderful.

(And if you can’t – it’s awful and it’s horrible, but in the end if someone is completely determined to die, they will succeed, and it is Not Your Fault. You can only do your best with the resources you have. And hope.)

Edited to add: I do want to reiterate that what I’ve been describing above is really a form of first aid. You’re trying to help keep someone alive, and this is a vital short term goal, but don’t lose sight of the long-term goal, which is for that person to want to stay alive.  The underlying issues, be they psychological, physical, political or interpersonal (or a combination of these and more), will need to be addressed.  This is not all going to be your job – it can’t be – but you can help by being there and being a friend and not giving up.  If you have the time and mental energy yourself, you can help them find the resources they need, and that’s important too.

I also want to acknowledge that all of this is work, of a sort.  It can be tiring, and emotionally draining, and you can find yourself taking on someone else’s trauma.  So make time to look after yourself, too.  You deserve that, and so does your friend.

Below are some handy phone numbers (for Australia, again). Note that Lifeline, and particularly the Suicide Helpline, are also there for you, the friend and the carer. The Suicide Helpline even has parent or friend information packs that contain lots of useful information and resources. You can ask for one of these. I can also thoroughly recommend the ASIST Applied Suicide Intervention Skills Training Course by LivingWorks.

Also, if you know more about this than me and you think I have things wrong, please comment. I am not by any means an expert, and would much rather get this entry right.

Suicide Helpline – 1300 651 251
Lifeline – 131 114
Crisis Line – 136 169
Police, Fire and Ambulance – 000

Edited to add: This is a post where reading the comments is actually useful!  Azurelunatic has shared some useful information below on locating online friends who you think may be at risk and need help.