Thursday, June 30, 2011

Talkin' bout suicide

I used to work at a hospital program for people at risk of psychiatric hospitalization. I worked with a lot of people who were at risk of suicide or who had made an actual attempt. Part of this work involved talking with clients' family members and educating them about talking about suicide with the client.

Hopefully you never have to have this kind of conversation with someone you love, but with an estimated 750,000 suicide attempts in the US each year, this kind of talk is more common than you might think. Because it is a taboo subject, people often struggle talking about suicide. I pass on what I know here in the attempt to help with these conversations.

If you take one thing away from this post it is this: if you are concerned that someone you care about may be suicidal, urge them to seek care from a therapist or psychiatrist. It is beyond your role to be assessing someone's suicidality.

I am offering these guidelines because I know that in reality people who are thinking about suicide do talk to family members and friends. But as a friend or family member, your goal should be to urge the person you are worried about to get professional help.  

  1. The best way to know if someone is suicidal is to ask. You can say something like, "I know you have been depressed for a while, and this may be a weird question, but have you been thinking of hurting yourself?" 
  2. Sometimes friends or family are afraid to bring up the subject because they don't want to give someone an idea they have not already had. Don't worry about this; if someone is not thinking about suicide, your asking them will not make them suddenly think that killing themselves is a good idea. Bottom line: you do not increase someone's chance of suicide by asking them if they are thinking about suicide. 
  3. Plans, means, and intent help determine risk. 
    1. Plan: Has the person thought about how they would kill himself? A person with a plan is likely at greater risk than someone with no plan.
    2. Means: Does the person have the means to carry out their plan? Someone who has the means to do so (i.e., "I would hang myself, and yes there is a rope in the garage") is likely at greater risk than someone who does not have the means, or has no plan to get the means. Note: If someone who is thinking about suicide has access to a gun, this greatly increases the chances that they will kill themselves.
    3. Intent: Is the person actually planning on going through with it? When? Someone may have a plan and means but no intent: "If I killed myself, I would jump off the Golden Gate Bridge, but really I would never do this." Or they may be planning suicide but only if something they fear comes to pass "I will not kill myself unless my husband leaves." Obviously, someone who says they plan to kill himself in the near future is at extreme risk.
  4. Certain risk factors can increase the chance someone will attempt suicide. Consider:
    1. past attempt at suicide
    2. people close to this person killed themselves or attempted suicide
    3. drinking or drug problem
    4. history of impulsive acts
    5. hopelessness
    6. history of abuse or trauma
    7. isolation
  5. Certain protective factors can decrease the chance someone will attempt suicide. Consider:
    1. stated desire not to hurt friends and family by killing oneself
    2. stated obligation to care for others (i.e., "I would like to kill myself, but I need to care for my children.") 
    3. Religious beliefs against suicide
    4. Person talks about future events they are looking forward to
    5. Presence of family, friends, or mental health professionals who the person feels they can talk to and lean on
  6. The phone number for the National Suicide Prevention Hotline is 800-273-8255. The hotline is open 24/7 Give this number to the person thinking about suicide. Call it yourself for support or advice if need be.
  7. The emergency room or 911 is the right choice if someone is in immediate danger. If you are worried that someone is going to commit suicide in the near future take this person to the emergency room, or if they won't go, call 911. Having the police show up or going to the ER is a lot of drama, but far less than if someone kills herself. Err on the side of caution here. 
  8. People who are suicidal are sometimes ambivalent about killing themselves. This can result in a person jumping from saying they are going to kill themselves to saying the reverse. The rule here is if the person you are talking to cannot convince you that they will be safe in the near future at least, take them to the ER or call 911.
  9. People at risk of suicide need professional help. I am repeating myself here, but if someone is in a bad enough place to be thinking about suicide, they need to talk to a therapist or psychiatrist. Unless you are a mental health professional, you lack the training to be keeping this person safe. Urge them to get help. 


  1. They say when people suicide, there is often the wish (unconscious?) by family members that they do so. Though that's probably not the case with suicides of young people. But with longterm depressed adults it seems more likely. So, the sense of that kind of vibe in the family may be another indicator of suicidality

  2. Anonymous, you raise a difficult subject. I have heard this too anecdotally, but I have never seen it in the literature.

    I think when a family member is severely depressed for a very long time, it takes a toll on other family members. It would not surprise me if, after a number of years, a family member could lose hope, and a part of them could want the depressed person to just get it over with.
    One way to think about this is as the hopelessness of depression overwhelming not just the depressed person but also the family member who has this kind of thought.

    While I want to express understanding for this feeling in family members of depressed people, I don't want a depressed person who reads this to assume that their family members want them dead.

    I believe that family members who have this (maybe unconscious) wish really want their loved one to get better, but after a long time, give up hope and a part of them, wanting resolution, sees the person's death as the only way for the individual's and family's suffering to end.

  3. This was a very helpful entry. The comment that resonated with me the most was that asking someone whom you think might hurt themselves if they will, does not put that idea into their heads: either that idea is already there, or else they are not planning to do something.

  4. Thank you anonymous. Yes, fear of putting the idea into someone's head can keep family and friend's from asking about suicide.

    One point about the wording of your comment: people can have suicidal thoughts and not be planning to act on them.

  5. This is helpful. I've heard of families doing suicide watches 24/7 with family members rather than putting them in a mental hospital (since these might be a noxious experience for the depressed person).

  6. How long have the families you have heard about done this? I agree that hospitals can be noxious, but a 24/7 suicide watch sounds extremely draining on the family.

  7. What do you think about assisted suicide? I saw the HBO show on Kevorkian and thought he did a lot of good. But I was raised Catholic and there just seems to be something spiritually wrong with offing yourself. I don't know...

  8. Thank you for the comment anonymous.

    Before I answer your question, I want to make the distinction - though it might be obvious - between doctor assisted suicide and the more general topic of suicide I am talking about in this blogpost.

    In this post, I am talking about suicide related to emotional problems, particularly depression. Doctor assisted suicide involves people who are terminally ill and suffering, but not mentally ill.

    There are approximately 30,0000 suicides in the US each year according to the Suicide Awareness Voices of Education website. By comparison, 65 people in Oregon used doctor assisted suicide in 2010. Even considering other states where das is legal (Montana, Washington) and where it goes on under the radar in other states, we are still talking relatively small numbers.

    In states where DAS is legal, there are safeguards to ensure that the patient is terminally ill with less than 6 months to live (in Orgeon), that they are of sound mind, and that they are not being coerced into their decision. In other words, the idea is to end the suffering of someone who is in pain and is nearing death.

    Personally, I am in favor of laws that allow people this choice. From what I know, the laws have worked well in states that have enacted them. I don't know how I would feel if I was dying a painful death, whether I would want to end my suffering this way or not. I don't know how my spiritual beliefs would come into play in the face of painful and prolonged death. But in general, I am in favor of allowing people to make choices about their own lives and health.

  9. I have dealt with this subject many times throughout my nearly 50 years of life. Severe childhood abuse and trauma and other painful issues have brought this subject up numerous times. I've made several attempts, some half-assed,knowing I wasn't doing enough to actually succeed, some just being reckless with my prescription med's and alcohol(the most dangerous)And then sometimes driving my car going 95 mph down the freeway not giving a shit if I crashed or not. Then there were the times I just wanted the pain and suffering to end, but I didn't want to really die. Sometimes, because I was raised by a religous freak, I was scared I'd go to hell if I killed myself. I guess looking back on all this, I'm glad I'm still here, I think it's worth it that I survived. I have alot of gifts and abilites, Freinds, and family who love me, and a great therapist too!

  10. I'm glad you're still here too, anonymous. Someone told me once that they were seriously suicidal and a child smiled at them so lovingly and purely that their suicidal mood evaporated. Amazing how we all can affect each other.

  11. I am glad you are still here too anonymous, and thank you for sharing your story. I wanted to point out that even "half-assed" suicide attempts can be harmful or even lethal. Overdoses on meds that don't kill you can have very harmful effects on the body's organs, and I probably don't need to tell you about the possible effects of reckless driving at 95 mph. (Hope that didn't sound scoldy.)

    Other anonymous: I have heard a similar story about someone not killing himself because a person, this time an adult smiled at them on the street. Amazing how we can affect each other, yes, but also amazing how we often don't see the effect we have on each other. I think if we could actually see these effects, the world would be a kinder place.

  12. Thank you to both anonymous and Noah for the kind reply, and useful information about my story. I find it very touching, that a person who doesn't know me would say I'm glad you're still here too. God bless you both, and no, you didn't sound scoldy at all Noah, that's not your style.