Suicidality—both the feeling state itself, and the cultural consciousness that allows people to discuss the phenomenon—is on the rise. More people than ever have to contend with the terrible experience of either hearing a disclosure of suicidal ideation, or knowing that a loved one has made a suicide attempt. This article will attempt to give laypeople a road map of how to deal with this worst-case-scenario addressing risk assessment, finding resources, and how to be available to the suicidal person in a genuine and helpful way, without fostering dependence, causing additional strife, or burning out themselves. (I will not attempt here to address the difficult terrain of the aftermath of a suicide that results in the end of a life, and instead recommend this article for guidance).
I’ll be answering these questions:
—How do we define suicidality?
—How do professionals assess for suicide risk?
—How should one handle conversations with a suicidal person?
—How and where do you find appropriate care resources?
—What should you communicate about your ongoing availability?
What is Suicidality?
Suicidal feelings can mean having abstract thoughts about ending your life or feeling that people would be better off without you. Or it can mean thinking about methods of suicide or making clear plans to take your own life. Because there is such a wide range of degree of risk, assessing and differentiating thoughts and feelings from risk of death is an essential component of assessing the level of suicidality.
Some degree of questioning the meaning of life, or whether one has the capacity to carry on can be a normal part of an emotionally varied life, and even lead to breakthroughs that are ultimately life-affirming. It is important that people with this low-risk level of suicidality find environments in which they can freely express these feelings, so suicidal ‘ideation’--ideas without plans—should not be treated with hospitalization. Instead therapy and social support, with perhaps more contact or monitoring, is appropriate.
If someone has a higher degree of risk, they should be in an environment where they have no access to ‘means’ to kill themselves (weapons, medications, hanging implements, heights) and be under observation until the acute feelings pass. Generally hospitalization for suicidality is not a pleasant or mental health-affirming environment, but it is a necessary step if there is acute risk. An unpleasant experience, even one that leaves the suicidal person mad at the person who facillitated their hospitalization, is decidedly preferable to a death.
How Do Professionals Assess for Suicide Risk?
Here is a more comprehensive guide for assessing the risk of suicidality, if you’d like to see the sort of template that mental health professionals are often trained with. I’ll summarize here:
Professionals will be keeping an eye out for risk factors that may trigger unmanageable feelings that would prompt a desire to abruptly end one’s life. This can include, but is not limited to: a traumatic event, like a rape, violent crime, the death of a loved one, the loss of an identity-affirming job, the loss of a significant relationship or the loss of financial stability or social standing, such as in the case of an episode of public humiliation.
Professionals will also look at past behavior and family history: a person who has made a previous suicide attempt is at a decidedly increased risk of dying by suicide. It is a dangerous myth that a failed suicide myth is a ‘cry for help’ or evidence that the person did not genuinely intend to die—with each suicide attempt the risk of ultimately dying from suicide increases. A family history of suicide similarly increases the chances that an individual will die by suicide, and alarmingly, suicide appears to be socially contagious. If, for example, you’re the parent of a child whose friend has recently committed suicide, or an artist they admire has died by suicide, it is important to recognize that as a risk factor.
This brings me to perhaps my most important point, which is that in order to do any risk assessment at all it is important to ask if a person intends to harm themselves.
How Should One Handle Conversations With a Suicidal Person?
The general line of questioning in a therapy office looks a little something like this:
Therapist: “I understand that circumstances have been exceptionally difficult lately. Do you ever have thoughts about suicide?”
Client: “Well sure, but not in a major way, just like, you know, when you would rather not wake up in the morning. That doesn’t mean I’m going to do anything about it.”
Therapist: “I understand, and I’m glad you’re willing to be honest with me about that. I’m here to support you. Just to be clear, have you ever envisioned a way that you would kill yourself, if you chose to kill yourself?”
People tend to shy away from being so overt about suicide for a variety of reasons: it feels invasive or morbid, it’s uncomfortable for the person asking to enter into the discussion, we may worry that to get so specific about a suicidal plan might plan ideas in the mind of the depressive person. The evidence does not support this—being asked if you are suicidal does not increase the risk of committing suicide, it decreases it. It is likely that the depressive person takes such questioning as a form of genuine care. You are demonstrating that you have a vested interest in them remaining alive, and it is a good idea to state that, overtly.
Client: “Why are you asking me these things? Are you trying to put me in a hospital? I don’t want to be locked up.”
Therapist: “I care very much that you remain alive and well. It is both my duty as your clinician, and my position as a human being: I am glad you are alive and I would be devastated if you chose to end your life. It matters to me that you are on this earth.”
While a therapist is morally obligated to report certain levels of suicidality, a person simply expressing thoughts of death, or difficulty with the life that they are living, does not rise to the level that would indicate the need for involuntary hospitalization. The risk factors you want to look out for that would indicate an immediate and urgent need would be:
-A specific plan for death, including a means by which to die and a time they plan to do it
-An increase in well-being from baseline, because there will be some degree of relief at anticipating the cessation of suffering. Do not be fooled by an uptick in mood, that is not always a good sign.
-lack of a support network
-lack of positive responsibilities (a job, a pet, school—these are protective factors if the work load is not so high as to negatively impact mood)
-Isolation
Another important question to ask yourself is whether you are the correct person to be having these conversations with the suicidal person. If they have come to you directly, you are in a good position to be helpful, because they have already demonstrated a degree of trust, and are either overtly or covertly letting you know that they want your help. Still, you should ask yourself whether you personally have the capacity to provide the care they need, or if you need to find someone else who can talk to them directly
It is important to listen more than you talk. A good rule of thumb is to let them speak for at least two thirds of the time, and to only speak to ask clarifying questions or ask whether they’d like specific help. Consent-based care is important here, and jumping to something like hospitalization would demonstrate a degree of fear and mistrust that is an escalation of the circumstance rather than a helpful thing to do.
It is entirely appropriate to turn such nuanced conversations over to a professional who is good at dealing with suicidality. Unfortunately, in a pragmatic sense, it can be hard to get such a professional on the phone with urgency, and not all therapists are good at handling this matter with nuance and will turn instead towards self-protective measures like early reporting.
My favorite method to work with suicidality involves a rather unusual stance, but one that’s been largely effective with my client base—separating out life circumstances from the literal end of life, and using a technique that might be called ‘ego death’ rather than literal death. The premise is thus: suicide is always available to human beings. We may not like that this is true, but it is. But it should be seen as a method of absolutely last resort, because of the degree of finality of the act. A person should do almost anything before they kill themselves. Leave a major job, move cities, end committed relationships, anything that will reduce the circumstances of their lives that make reality unlivable, rather than literally ending their life. Another component of this technique is to use procrastination to your advantage. Some mental health professionals will have their clients sign safety contracts, literal agreements to stay alive for a specific and prolonged length of time, in order to allow treatment to have a chance to work. I once had a client who, in our initial intake call, told me that he was being discharged from a hospital that didn’t have enough beds, even though he was actively suicidal, because he had a specific suicide date in mind and it wasn’t for another month. I asked him to agree to see me twice a week in the four weeks until that date, and by session three he no longer had an intention to die. Instead he accepted the logic of the ‘ego death’ argument—if reality feels unlivable, any choice, even seemingly impossible choices, in service of saving your own life, are allowable. He left a job he hated, ended his romantic relationship, and ceased communicating with his family. All of these things seemed impossible to him, but in recognition of the finality of death, even an ‘impossible’ choice, like not talking to family you feel obligated to support, is something worth trying.
I’ll sometimes hear from college-aged people that leaving school would be impossible or too socially shameful to face, especially if they come from families that have a large investment in the appearance of normalcy, but facing social shame is a temporary state whereas death is permanent, and there are lots of people who take time off of school and go on to be successful adults. Similarly, if there are resources, genuine time off is often called for. A family may not want to support or ‘enable’ what they’d consider a vice, like laziness, but nurturance is a pretty essential ingredient to any recovery process, and if it can be done at home there will be a huge degree of savings and probably a better mental health prognosis than facility care.
The best thing that you can do is foster an environment of unconditional support and care. Most people respond to that kind of help with an intrinsic desire to better themselves and be mutually contributive, they do not languish.
On a more personal note, there have been times in my own life when I have questioned the terms of existence, and contemplated ending my own life. In those moments mental health resources were largely cold and insufficient—when I talked to other people in the field no one could think of an intensive outpatient program or inpatient care facility that was genuinely beneficial to the bulk of clients, and each individual I talked to was so burnt out they weren’t providing great client services. (Frankly I was still seeing clients at the time, overwhelmed as I was.) The thing that genuinely helped me was that I had one friend who let me know that—no questions asked—if I ever didn’t feel safe alone with myself I was welcome to stay with her. I took her up on that offer exactly once, but knowing that it existed, that someone cared enough about me to have an open-door policy, was enough of a balm that my psyche began to rebuild itself around the strength of the kind of social support.
How and Where Do You Find Appropriate Care Resources?
Certainly, there are crisis hotlines, and many of them are staffed 24/7 with people willing to assist both the directly suicidal and their family members.
‘988’ is a national hotline that will connect callers with a local crisis center. It is toll free and available 24/7.
If someone you love is in immediate danger and should be hospitalized, and you have the wherewithal to drive them to the hospital, and they are willing to go to the hospital, drive them to your nearest emergency room and let the check in desk know that they need emergency psychiatric services, are a danger to themselves, and are willing to voluntarily check in.
If they are not willing to go with you to the hospital, but need to be assessed, it is better to call the ‘PET Team’ (Psychiatric Emergency Team) than 911. Like 911 this is a public service and not something associated with a cost. This number varies by region. In LA County it is (800) 854-7771, and a web search can easily locate your local PET team. However, it generally takes them many hours to respond because of the demand on their services. If you call the PET team prepare to cancel the rest of your day to keep the suicidal person company, and try to keep them calm and at a consistent location until the PET team can arrive to evaluate them.
If circumstances are more urgent, call 911 and let them know that the suicidal person is unarmed, not a risk to anyone but themselves, and what you need is a “wellness check.” This will let the police know, explicitly, that there is no reason for them to use force, and they are walking into a situation where they should be employing care. That said, It is the mandated procedure of police personnel to handcuff those they are taking in for psych services. This can be disconcerting. If the suicidal person is not a flight risk, you should let them know that they should emotionally prepare themselves to be handcuffed, and it is for their own safety.
For lower-risk situations and ongoing care, websites like Psychology Today or psychcentral.com can provide a roster of local providers. There is also likely ‘community mental health’ in your region that can offer sliding-scale services, though these tend to have long wait lists. Perhaps try local universities or search for ‘community mental health’ plus your city online. Some therapists take insurance, but finding a directory of people within network can be complex. Most insurance organizations will offer you a case manager upon request, or search for specific appointments with covered providers upon request. If they are unable to find you covered resources, you can ask for a ‘single case agreement’ with the therapist of your choice, even someone out of network. This takes some persistence, but because insurance is legally bound to treat mental health with the same degree of coverage as any health services, they will eventually have to pay if you know and insist upon your rights.
When choosing a therapist ask in your (likely free) consultation call whether this therapist is experienced with suicide. Key things to ask about are whether they provide “comprehensive care” (availability outside of session times) or work with other professionals to provide “wraparound services” like psychiatry. Make it explicitly known that you are looking for a hands-on and collaborative approach, and that the designated patient is on-board with this degree of collaboration, willing to sign releases to allow professionals to speak to one another. Generally “comprehensive care” and “wraparound services’ will have higher price-points, because there is a higher degree of time-investment from the mental health professional. It is an unfortunate reality, but the bulk of professionals I attempt to collaborate with will not return phone calls or emails, so this is a service that must be explicitly available. Generally comprehensive care will be anywhere from a $50 surcharge to double the clinician’s hourly rate. Some “concierge” mental health professionals instead have a flat monthly rate that includes house calls and unlimited phone calls, but this is a prestige service generally available only to the uber-wealthy, and starts at about $10k a month.
What Should You Communicate About Your Ongoing Availability?
First, assess what you are available to do. It is better not to promise anything at all than it is to promise to follow up or be available, and not be able to genuinely do so.
If you genuinely want to ‘be there’ for the suicidal person, you may have to cut down on other responsibilities, or communicate to the people in your life that a circumstance has arisen that may mean you have to be on-call for a period of time.
It is normal for our physiological systems to respond with focus and additional energy to something that is an immediate emergency. It will be natural to check in a few times while this event is top of mind, and then the tendency is for our attention to dissipate. Try, if you can, to override this bias. Perhaps set an alarm on your cell phone, letting you know to check in on the suicidal person at regular intervals, maybe every 72 hours, and then on a weekly basis, until they explicitly tell you that the crisis has passed.
Finally, do not be discouraged by all of the above. 9/10 people who make suicide attempts go on to live normal, healthy lives without dying by suicide. The odds are in favor of this not resulting in death. But do take this seriously, and be sure not to let the suicidal person know that there is a negative impact upon you because of the disruption of taking care of them. Find your own mental health resources, and support of loved ones, to garner support in this difficult time. Follow the Circle of Grief Ring Theory and “complain out” while “supporting in”--recognizing that the person at the center of the crisis is having a harder time of it than anyone else.
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This article is written by Hannah Rose Bernstein AMFT #123532