One of the things that took the most getting used to when I started seeing clients early on in my education was asking if someone is suicidal. I remember the first time that I had to ask a complete stranger if they had had been considering possibly the most extreme thing that you could do to yourself, and the intense apprehension that followed during the pause between when the question left my mouth and their answer that followed: “No”. Even when the answer was the one that I had secretly hoped to hear the fear that it could instead be quite the opposite still lingered somewhere in the back of my mind. It wasn’t until I started learning more about suicide and suicide prevention that I came to understand just how momentous both asking and answering that question could be and the immense importance of having these open conversations is in truly being able to help somebody who is in crisis.
The Center for Disease Control (CDC) reports that, in 2018, there were approximately 48,344 deaths caused by suicide making it the tenth leading cause of death across all age groups in the United States. From that same report, suicide was the second leading cause of death in individuals aged 10 – 34. The National Institute of Mental Health reported that suicide rates over the last two decades have been on the rise with a 35% increase in suicides between 1999 and 2018 (10.5 per 100,000 in 1999 to 14.2 per 100,000 in 2018). In a 2018 National Survey on Drug Use and Health (NSDUH) conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) an average of 4.3% of adults aged 18+ had serious thoughts about suicide, with the highest outlier being adults aged 18-25 with a 11% incidence rate. These data show that suicide is incredibly prevalent in the United States, with a heightened risk for younger adults.
While these numbers may be distressingly high, there is some hope in that suicide is also one of the most preventable deaths out there. In fact, all that it takes to prevent a possible suicide is a simple intervention on the part of someone who cares enough to have that difficult conversation and get someone help. I have been training individuals and organizations in suicide prevention for the last two years and one key component to all trainings, no matter the specialization or methodology, is that communication and connection are at the core of preventing suicide. For this blog, I will outline what I view as the simplest procedure for suicide prevention, which is question, persuade, and refer from the QPR Institute for Suicide Prevention.
(Note: This is not a full training on QPR, just an overview of the steps presented during trainings. If you would like to have a complete training for your organization please contact Crossroads Behavioral Health Services to schedule one.)
The first step, question, is a deceptively simple, but possibly most important one. While it may sound easy to simply ask someone about suicidal ideation, it is often quite difficult to put in to practice, especially if you have never done it before. There are two ways that you can ask someone if you suspect they are thinking about suicide: direct and indirect. Direct questioning is straight and to the point: “Are you thinking about killing yourself?” “Have you had thoughts about wanting to die recently?” “You have been seeming pretty miserable today, are you contemplating suicide?”. The direct approach has the benefit of getting you right to an answer; however, those who have not used it before may feel uncomfortable or might perceive this as too blunt of an approach to such a sensitive topic. If this is the case, one could take the indirect approach to questioning: “Do you ever wish you could go to sleep and never wake up?” “Have you been unhappy lately? So unhappy that you might be thinking about killing yourself?”. This indirect approach offers a way to lead up to the question or provides an alternative way of getting to the answer that might not feel as abrupt. Pay attention to the answers that you get from these questions. Remember: anything less than a direct “no” can be a “yes”.
A point to remember is that it is less important how you ask the question than that you ask the question to begin with. That being said, there are a few ways you should avoid asking the question: “you’re not thinking about killing yourself, are you?” “Suicide is a dumb idea. You wouldn’t be thinking of doing something like that right?” “You aren’t thinking of doing something drastic or crazy to yourself, right?”. These questions all have one thing in common: they pass judgement on the individual who is thinking about suicide and frame them as a bad person for having those thoughts. It may be tempting to try to convince someone that suicide is morally wrong and that they should either look inward or toward a higher power instead, however, this frames the person as the problem instead of the suicide. You are instead encouraged to put your personal beliefs about suicide away for the time being and focus instead on the individual you are speaking to and attempting to make a positive connection with them. It is important to remember that, when working with individuals who are suicidal, a little empathy goes a long way.
The second step is to persuade the individual that you are on their side and are there to help them. Oftentimes individuals who are considering suicide feel hopeless and believe that nothing will get better and that nobody cares about them. By listening empathetically, genuinely and openly one can show that they are here and supportive of the person in crisis and that they are not alone. After showing your support and hope for the person the next part of persuade step is to attempt to persuade the individual to get help either through direct action or through you as a spokesperson for them. Try asking someone if they are willing to get help on their own or if they would be all right with you getting help for them. In either case, it is important that you follow up with the individual about getting help, be that going with them to get help or ensuring that they in fact did reach out for help.
The final step is to refer the individual to someone who can help. This can include talking to a family member, close friend, and/or medical professional. The best way to refer the individual to someone is to go with him or her directly to get help such as going with him or her to the hospital or an initial appointment if available. If you are unable to go with the individual or if they refuse to go with you it is encouraged to try to get a commitment from the individual that they will seek help independently. The important part of this step is to attempt to connect an individual in crisis with services that can help them with more long-term solutions.
As stated before, suicide is one of the most preventable deaths in the United States. Often times all it can take is assuring someone that someone else cares and is willing to take the time to help them in a time of need. Suicide prevention is everyone’s concern and if everyone works together there could eventually be a world in which suicide is treated with the same level of concern as all other causes of death. By working on getting past old taboos and increasing our level of comfort with difficult topics we can all work together to achieve this goal. Getting started saving a life is sometimes as easy as asking the hard questions.