Health & Safety, Training

Hands On Suicide Prevention (How to Ask)

You can create a safe space to move to
the next steps

By asking them directly if they are thinking about suicide, you give them permission to open up, share their struggles. (pexel)

By Dena Ali

Over the last several years, there has been an upswing in attention brought to firefighter suicide. Lately such words as “epidemic” and “crisis” are being used. While there is no valid or reliable data to indicate an epidemic, just one suicide is one too many.

This is because suicide is not only a leading cause of death in the United States, but it is also profound human tragedy caused by a complex interplay of underlying factors. There is rarely just one cause. After his department experienced seven suicides in an 18-month period, Chicago Fire Battalion Chief Daniel DeGryse (ret) dug into the literature to find out what was happening. He found that “suicide was just one outcome of serious internal struggles for an individual that could manifest for some time before they made the decision to die by suicide (DeGryse, 2012).” With this statement, he hit on the progressive nature of suicide by recognizing that through its manifestation, mitigation is possible by altering a person’s course along a trajectory. But he also discovered what so many others have as well, suicide is a difficult phenomenon to understand, and despite the recent upswing in research, our understanding is still limited.

Researchers have found several factors leading to suicide and they agree that there is no effective algorithm to predict its outcome. In fact, the QPR institute says that our ability to predict suicide today is not much better than chance or a coin toss. This is because most people who have the documented risk factors will never attempt suicide. For example, 60% of people who died by suicide were suffering from depression, yet most people with depression never attempt suicide. This also holds true for each of the other risk factors including major loss, early life adversity, addiction, divorce, and mental health disorders. For example, the most robust risk factor for suicide is a previous suicide attempt, yet, 90% of previous attempters do not later die by suicide. In fact, a suicide attempt can reverse a person’s desire to die. Research conducted on survivors who jumped from the Golden Gate Bridge found that a near death experience was sufficient to shock the will to live back into a person, and 95% percent of the survivors from that jump never attempted again (Joiner, 2011).

For example, the gold standard historically has been forced hospitalization, yet, risk for suicide is quite high in the first three months after discharge. This is because forced hospitalization is associated with increased feelings for thwarted belongingness and perceived burdensomeness. Both of these are posited to lead to the very hopelessness that creates a desire for death. Although prediction is just a little better than chance, this does not mean suicide is inevitable or prevention is impossible.

Leading researchers have found that small interventions go a long way in terms of preventing suicide. Of all interventions, belongingness is the greatest protector against suicide. One theory from the 1960’s found that by simply receiving caring letters, risk of suicide was reduced by 50% (Cohen, 2020). This study was later replicated with similar findings in Australia.

Consistently, we are learning that little acts of kindness go so far in terms of creating belonging and connectedness.

Belonging is a simple word for a complex notion. More than simply being in the presence of others, it is the feeling of meaningful connection at a level where a person can be their authentic self without fear of judgment. Meaningful connection is an innate human need for all people. There is no substitution.

Asking directly about suicide is one intervention that has been found to be effective for suicide prevention. If you are worried about a friend, coworker, or family member, you should ask them directly if they are thinking about suicide. Don’t worry, the question is not offensive to somebody considering suicide, and evidence has found that it will not implant the idea in a vulnerable mind.

Those who are considering suicide report relief when directly asked in an empathic and sincere fashion. By asking them directly if they are thinking about suicide, you give them permission to open up, share their struggles, and take the first step to healing — finding alternatives to suicide. You become their ally to finding solutions for their pain.

Timing is also important because suicide intensity ebbs and flows, and, sadly, when it’s most intense, the individual is generally alone. Most suicides occur between 12:00 am and 4:00 am. Conversations ahead of time, before the person is alone, can be lifesaving. Any barriers that are present between a suicidal person and their means has a preventive value.

In a recent lecture, Sally Spencer-Thomas PhD provided guidance on how to ask directly about suicide. Here is some of the information that she provided. If you have any questions, comments, or concerns about the following, please reach out to me or go to workplacesuicideprevention.com.

Workplace Suicide Prevention

Before engaging in a conversation about suicide, you should understand that there are no magic words that can take someone’s pain way. The most valuable thing you can do for them is to show up and truly listen to what they have to say. Dr. Spencer-Thomas shares the idea that we should think of the conversation like a partnership on a road trip where they are the one’s driving, and you are just a passenger. While you may have the GPS or even have taken the road before, they are the ones at the wheel. You can’t take the wheel, but your presence in the passenger seat can help determine which turns they choose to take.

Ensure you truly show up by employing active listening skills. This means tune into your body language: get on their level, face them, and lean in! Make eye contact, mirror their responses, and focus on what they are saying. Forget about problem solving or crafting the perfect response. Your goal here is to help them feel connected and safe by conveying calmness and

trustworthiness. In doing this, you provide them with an opportunity to open up and share their thoughts and feelings. Then and only then can they feel safe sharing their struggles.

You can start the conversation with a simple, “I’ve noticed you don’t seem like yourself lately…” Then list the specific things you’ve noticed about their behavior, moods, and/or life circumstances. There is no script for this; you have to follow your gut. Make sure you explain your concerns, let them know that you are bringing the issue up because you care about them, and you want to be someone in their life they can talk to about hard times. Don’t hesitate to be honest and let them know that you too know how important it is to have somebody to talk to when things become overwhelming. If you have a similar experience, share briefly that you’ve walked a similar road. But, be sure not to flood them with your experiences. They should be doing a majority of the talking in this conversation. A gauge of your progress is their willingness to open up. Your goal is for them to do 90% of the talking.

Employ effective listening through creating a space that lets them know that they are being heard and their story matters. The best way to do this is to talk less and listen more. To keep them comfortably talking, use minimal encouragers such as “umm hmm,” “what else,” and the best prompt, “tell me more.” This lets them know that you are aware something is missing, and you not only care, but you are not burdened by this conversation.

If you get silence, know it is ok. Silence in an opportunity for them to develop the courage to keep talking. Effective pauses in conversation are just that, effective. Savor the silence and try not to be the first to break it.

Throughout the conversation, imagine you are holding up a mirror to the person, reflecting back what they say to show that you understand. This sort of reflective communication helps to validate their concerns and thoughts. The best way to do this is by summarizing what you hear and summarizing it by tying it to emotions through and active listening skill known as emotional labeling.

For example, after they explain a loss and you detect that they are sad, you can say: “Let me see if I got it right, you are sad because you have lost…”

Conveying your willingness to be present while another is in a dark and difficult place is more important than any advice you may have to offer. You don’t have to know the answers. Showing you are willing to provide unconditional support is what’s most important.

Make sure you offer gratitude for their willingness to open up to you. Feel free to let them know that the relationship is reciprocal by saying something like, “thank you for sharing this with me. I know you will do the same for me when it’s my turn. This is how we look out for each other (Spencer-Thomas, 2019).”

Don’t forget that finding the courage to open up and share your struggles is scary, and when people finally do it, it’s because they feel miserably trapped with no other option. More than anything, they are looking for connection and relief from their pain. Sally says, “People experiencing suicidal thoughts often feel backed into a corner, like they have been stripped of all of the control they have in their life. Building choice and empowerment into the conversation can benefit the individual by instilling confidence and purpose (2019).”

You build choice by asking permission to talk, and by allowing the individual to determine where the conversation takes place. Whatever decisions are made, ensure them that they have control over their recovery. They determine what turns to make. You can empower them by phrasing questions to them such as: “What would you like to see happen” or “What do you think would happen if____”, or “What steps are you willing to take to____”.

Suicide ideation is a common way people experiencing overwhelming thoughts, hopelessness, self-hate, and disconnection cope with those feelings. When talking to somebody going through a difficult time or major loss, it’s important to always assume that suicide is on the menu. Sally explains, “by assuming the suicidal thoughts are already there, you don’t need to wait to be given a big, red warning flag. Instead, you make what we call a pivot statement (2019).” A pivot statement occurs when you summarize the risk factors and warning signs you hear, and then connect them to the possibility of suicide. An important part of the pivot is checking with the person to make sure you are hearing them correctly.

Example:

Supporter may say, “let me see if I’ve got this right. So, what I’m hearing is that you are going through a divorce, you are having a hard time concentrating at work, and you fear a personal financial collapse, yes? You know, sometimes when people are going through a divorce, having a hard time concentrating and experiencing financial stress, they also think about suicide. I’m wondering, how many times suicide may have crossed your mind, even if it was just fleeting in nature. (Sally Spencer-Thomas, 2019)”

Through letting the person in crisis know that you understand why people think about suicide, though a gentle assumption, you help the person feel validated and less isolated. With compassion and a willingness to walk with them, you can make a huge difference in their outcome.

Through asking, “are you thinking about suicide,” you offer the best opportunity for that individual to open up and express themselves.

Understand, a person who is thinking about suicide may respond with a “no,” especially if they are a fellow firefighter who may fear judgment, loss of job, discrimination, or forced hospitalization. If somebody answers no, but you note discrepancies between what you see and what you hear, just reflect it back by telling them that, “you are telling me that you’re fine, but I am seeing and hearing somebody who is distressed, would you tell me more about what you are going through?” Follow you gut, stay calm, and don’t force conversation. And, don’t forget, there is no script for this, you truly have to enter into their experience and work to help them open up.

Sometimes when asking about suicide, you might get a “yes.”

How do you respond to “yes?”

First, make sure you stay calm.

Here are a few responses that will make a huge difference:

Express gratitude: The first words out of your mouth should be, “thank you.”

“Thank you for trusting me.”

“Thank you for your courage to be vulnerable with me.”

“Thank you for valuing our relationship.”

When people admit thoughts of suicide for the first time, they fear judgment and anticipate a negative reaction. However, when they receive a genuine expression of gratitude, this helps to put them at ease. By responding calmly and with gratitude, you create a safe space to move to the next steps.

Make sure you reassure your partnership with them. You are along for the ride and not planning on going anywhere! Make sure you express that you are here for them, and ensure they know that you have their back. One significant fear for someone living with suicidal thoughts or a mental health disorder is rejection though judgement. Reassurance that you are not afraid and not planning to toss them like a “hot potato” can be very grounding for them.

Your partnership ensures they know that they are not alone, and they have an advocate. Connection may provide a flicker of hope that keeps them alive.

Make sure you provide hope through offering choice and empowering them to take the next steps. Hope is the antidote to suicide, and the best way to offer hope is through action. You provide action through resource sharing and tackling issues in a step by step method. We must remember that we can’t fix everything today, but we can start with the most pressing issue or the one thing we can tackle today. Small attainable goals are the key to change and success.

Championing change with broad statements like, “you have so much to live for,” is not an effective means for building hope. Hope forms through an individual plan for healing. While you don’t want to inject your own ideas for their reasons for living, you may listen to, and reflect back the reasons for living you hear them say. For example, you can say something like, “On one hand, I hear you say you feel so overwhelmed, you don’t know if you can go on. On the other hand, I am hopeful when I hear you say things like you want to be a good role model for your kids. The way you say that, it sounds like a part of you is fighting against this despair. Tell me more about this internal battle of wanting to live and feeling like it’s hard to go on (Spencer-Thomas, 2019).”

What you want to communicate to them is that they matter to you, to their family, and to their organization. They are not a burden and they are worthy.

With compassion and collaboration, you can help them consider their options. Understanding the true meaning of compassion may help you understand your role. According to Pema Chodron, “Compassion is not a relationship between the healer and the wounded. It’s a relationship between equals. Only when we know our own darkness well can we be present with the darkness of others. Compassion becomes real when we recognize our shared humanity.”

Remember, you are not the solution; you are the bridge to the resources. Your role is to remain in the passenger seat and share the best routes in hopes of eventually handing them off to professional resources.

If they are in need of immediate help, you can choose together to call the National Suicide Prevention Lifeline (1-800-273-8255) or to text the Crisis TextLine (text HELLO of 741741). Or you may reach out to a known mental health provider, peer support team, or first responder crisis line.

Even in the warm hand off to professional care, you can be with them. Just ask permission or offer to join them for their first appointment. From this author’s experience, that first appointment is daunting, and having support can make a huge difference.

Finally, before ending the conversation, make a plan to follow up. Ask for permission to check in next week or even offer a lunch/coffee meeting. Let them know that you want to make sure the plan is working, and if it’s not, you will help them adjust. Ensure they know that you would love to hear about their successes and challenges. It’s ok to let them know that they may face challenges as they are common, but persistence will help them fade. By offering to follow up, you let them know that you are willing to walk in the darkness with them.

When someone shares with you that they are having thoughts of suicide, they trust you and you must treat this with gratitude. Sally says, “This is a gift, they have invited you into a vulnerable part of their world, and you are a guest in this space.” There is no script for this conversation, and at any point if you find the individual is an immediate threat to themselves or others, you must reach out to emergency resources.

But, when they are not an immediate threat, your willingness to courageously walk through the darkness with them may be what leads them to healing. We are fortunate in North Carolina because we have a statewide resource of 300 peers and we work closely with our law enforcement support team, NCLEAP. We have the resources to ensure a member in need will have support.

If you would like more education on asking about suicide, go to the QPR institute, Living Works, or the IAFF Peer Support program. Lastly, thank you to Dr. Spencer-Thomas for her help on this work. Please visit her website, https://workplacesuicideprevention.com/, and take the pledge to commit now to prevent suicide.

References

Cohen, D. (2020, January 19). Reaching out: How caring letters help in suicide prevention. Retrieved from https://www.cbsnews.com/news/reaching-out-how-caring-letters-help-in-suicide-prevention/

DeGryse, D. (2012, August 14). Chicago Union EAP Embarks on Firefighter Suicide Study. Retrieved October 11, 2015, from http://firechief.com/suicide/chicago-union-eap-embarks-firefighter-suicide-study

Joiner, T. E. (2011). Myths about suicide. Cambridge, MA: Harvard University Press.

Motto, J. A., & Bostrom, A. G. (2001). A randomized controlled trial of post crisis suicide prevention. Psychiatric Services, 52(6), 828-833

Spencer-Thomas, S. (2019, October). Rosecrance Florian Symposium. Rosecrance Florian Symposium. Austin.

Dena Ali is a captain with the Raleigh (NC) Fire Department where she has worked her way up the ranks. She previously served as a police officer for five years. Ali has a degree from North Carolina State University and an MPA from the University of North Carolina—Pembroke, where her research focused on firefighter suicide. As a graduate student, she was awarded the 2018 MPA student of the year. She has also received several awards throughout her career. One that she is most proud of is the NC Office of State Fire Marshal Honor, Courage, and Valor award that she earned in 2018 for her steadfast effort to bring awareness to firefighter mental health through her vulnerability. Dena is an advocate of awareness, education, and understanding of mental health disorders and suicidality. She speaks locally and nationally on these topics and is a QPR Suicide Prevention Gatekeeper Instructor. She has written several articles on topics such as suicide prevention, peer support, wellness, and post-traumatic stress. Dena is the founder and director of North Carolina Peer Support where she helped to develop their statewide curriculum. She is also a founding member of the Carolina Brotherhood, a group of cyclists/firefighters in North Carolina who honor the fallen and their families annually.