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Let’s suppose that you have just made contact with someone who is either openly suicidal or could be entertaining thoughts of suicide. You immediately know two things: (1) the situation may be serious, or it may not, and (2) either way, you need to do something. The first rule of suicide intervention is do something!
Don’t stop to worry about doing something wrong. It’s doing nothing that gets people killed. Bear in mind that the suicidal, or possibly suicidal, person with whom you’re dealing is still with us, so at least part of him or her wants to live. Trust me on this: The part that wants to live is more forgiving of our missteps as interventionists and therapists than you might imagine. So go ahead. Take the first steps.
Six Lifesaving Steps
In an initial interview with a person who may be suicidal, you will need to accomplish a number of basic goals, which are outlined below. But before you embark on a full-scale crisis intervention, you’ll first have to decide whether the person in your office is suicidal.
1. The S Question
If the question “Is this person possibly suicidal?” has already entered your mind, it is reasonably likely that thoughts of suicide are already in the mind of the person you’re worried about. But you can’t be certain – so just ask.
“You look pretty upset. Are you having any thoughts of death or suicide?”
“Have you been thinking about ending your life?”
“Have you ever wanted to stop living?”
“Do you ever wish you could go to sleep and never wake up?”
If the person has hinted at suicide – saying something like, “I’d just like to get life over with,” for instance – go ahead and confront him or her with an explicit question: “Do you mean you’re thinking of killing yourself?” Or, “Have you been thinking of suicide?”
There are any number of ways to ask about suicidal thoughts and feelings, and, in the face of a real situation, you may come up with ones that suit you better than any of these. But here is how not to ask the question: “You’re not thinking of suicide, are you?” Framing the question in this way encourages a negative reply – it suggests you want a “no” answer, not a “yes” one – and so it closes the door on the suicidal person. It says, in effect: “Please don’t burden me with your troubles.” Other than that, any question that goes right to the heart of the matter will work.
However, not unlike asking about another S subject – sex – asking about suicide can be difficult. I have trained thousands of clinicians over the years, and one of the most common complaints I have heard about raising the question of suicide is that “the words seem to stick in my throat.” But the words should stick in your throat: You’re asking someone whether he or she wants to die. It’s hard to imagine a more emotionally charged question.
You may also find yourself thinking, “What if I find out that this person really is suicidal? What do I do then?” Or you may wonder, “Am I going to put the idea in this person’s head by asking? What if I make things worse?” It is okay to worry about what will happen next, but try to limit your worry to less than thirty seconds. In particular, do not worry that asking the S question will foster suicidal thoughts. Research has shown that talking about suicide doe not increase suicidal thinking or behaviour (Gould et al. 2005). On the contrary, asking about suicide can, and does, save lives.
Stop worrying, then, and just ask the question. If you don’t ask, the person you’re trying to help may conclude that you can’t even bring yourself to talk about what they’re thinking of doing to themselves. And if you, a professional, can’t talk about suicide, then who can? If you’re not sure you’ll be able to ask the S question when the time comes, practice it with a colleague.
Asking whether someone has recurrent thoughts of death or suicide should become a routine and comfortable habit. It should, in fact, be part of your standard workup. If such inquiries are not a matter of routine, many suicidal people will escape detection on their initial interview. For thirty years, I was the director of a large clinical service at Spokane Mental Health, where asking incoming patients about suicide was mandatory for all clinical staff. At intake, close to half – 46 percent – of those admitted to outpatient programs evidenced suicidal thoughts or feelings and/or proved to have a recent history of attempted suicide.
The fact remains, thought, that routine questioning about suicidal thoughts and feelings is not the current standard of care for many in the helping professions, apart from psychiatrists. Among other things, lack of specific training in suicide risk detection and assessment discourages such questioning. As a physician once put it to me: “What am I supposed to do if they say “yes”?” Another objected: “If they say “yes,” there goes my schedule for the day! Now I’ve got to stop and listen. I’ve got a waiting room full of people, you know.” In other words, those who are seriously depressed cannot count on their doctor – or even a mental health professional – to inquire about recurrent thoughts of death or suicide.
Understandably, we are all at least somewhat reluctant to talk about a subject as upsetting as suicide. And yet suicidal thoughts and feelings are often the most important indication that someone is suffering from a serious, but treatable, clinical depression or a substance abuse disorder (or, as is often the case, both) that has so far escaped notice. Until the S question becomes the standard of care in all health-care settings, we will continue to miss opportunities to prevent suicide.
When you first conduct an interview with someone you suspect may be suicidal, you should try to ask the S question no later than twenty minutes into the session. That way, if you get a “yes,” you will have enough time to conduct a more in-depth assessment and develop collaborative crisis and risk management plans. After all, if the answer to the question is “yes,” you must take that answer seriously. It is extremely unwise to disregard suicidal thoughts or feelings, nor should their importance ever be minimised. I once saw a young man in my office who had gone to an emergency room only a week before complaining about insomnia, overwhelming depression, and constant thoughts of self-destruction. He had recently suffered terrible losses and, with a history of clinical depression dating back to childhood, coupled with substance abuse, he was now in a suicidal crisis. At the hospital, he had been seen by a psychiatrist who had explained to him that he was “not all that suicidal” and had prescribed a thirty-day supply of an antidepressant. Three days later the young man locked the door of his apartment, took all the remaining medication, and tied a plastic bag over his head. Fortunately, he didn’t die.
If you ask the S question and get a “yes,” then, as a professional, you are obligated to take reasonable and responsible action to prevent a suicide attempt. And this means you must also be prepared to share the sufferer’s pain. We humans are social creatures. We depend on each other and are stronger for it. If you ask me whether I am thinking about killing myself, then it must be that you have noticed my pain and care enough about me to ask. And if you care about me that much, then surely I must care about you enough to talk about my pain. If I admit to you that I am thinking about suicide (because you asked), I am no longer as alone as I thought I was. You have broken through my isolation, and, in a positive sense, I owe you. Asking the S question – being willing to begin a conversation about life and death – means that we are in this together.
Provided it is not worded so as to encourage a negative reply the S question works a certain magic. In its best outcome, asking the question produces an immediate sense of relief in the suicidal person. The result can be the beginning of a lifesaving intervention.
Some years ago I conducted a small study of patients presenting to our mental health center with thoughts of suicide. Each underwent a structured clinical interview regarding their suicidal thoughts and feelings, their plans for suicide, and their past history of thoughts or attempts. Patients who saw their clinician as comfortable and competent when it came to asking questions about suicidal thoughts and actions reported higher levels of hope about the future than did patients who did not share this perception (Quinnett 1998).
Finally, don’t be afraid to ask the S question because you think it is somehow intrusive. It’s the unasked questions that lead to tragedy. Threats of suicide are often coded in some way, appearing as hints that can sometimes be difficult to interpret. Under such circumstances, it is better to be bold and blunt than shy and sorry. And, after all, if you ask the question and discover that your patient is not suicidal, that’s good news.
2. Assessing Immediate Risk
Once you know that the person you’re talking to is indeed feeling suicidal, the question becomes, How suicidal? I will have more to say about assessment later in the chapter. But at this point in the intervention it is important to get answers to a couple of basic, and closely related, questions. First, is this person determined to die right away, or can his or her suicide attempt be put on hold? And, second, is the person willing to talk?
If the answer to the second question is yes, we can talk, then there’s no need to push the panic button. In fact, people who have just been asked whether they’re feeling suicidal are usually quite willing to talk. Most of them have wanted to talk to someone for weeks, or months, or years. This is why, if you’ve just learned that someone is suicidal, it’s a good idea to make at least an hour available to begin the listening process.
As a first step in assessment, you will need to determine whether the person in your office has ingested any medications or other chemicals that could prove fatal. If you have reason to believe the person you’re dealing with has taken an overdose or is in any other way in physical danger, call 911 or 211 and request a paramedic or emergency medical service unit. Folks who overdose often haven’t a clue about how much of what kind of medication or poison or combination thereof they have taken. Unless you are properly trained to assess possible medical emergencies, let the folks who are take over.
Remember, though, that the great majority of suicidal people we encounter re not in the throes of an actual suicidal attempt, nor are they planning to kill themselves within the next ten minutes. Maybe tomorrow, or next Friday, or by the end of the month, but not right now. Acutely suicidal people – those who are in a high state of arousal and agitation as they approach some final act of self-violence – are rarely seen outside of emergency rooms or psychiatric hospitals, or at the physical location they have selected to make a suicide attempt, or occasionally in hostage situations. Moreover, imminent-risk-for-suicide episodes typically last only a short while, at most a few hours. Emergency department staff see such patients, as do police, firefighters, paramedics, and acute-care mental health professionals.
In the case of suicidal people who are not in imminent danger, the desire to die may be relatively strong or weak, and it is unlikely that you will know at the outset just how at risk someone is. If you are in doubt about the answer, ask more questions. In multiple studies (Beck, Brown, and Steer 1997; Joiner, Rudd, and Rajab 1997, Joiner et al. 2003), suicidal desire has been demonstrated to consist of the following basic elements: the absence of reasons for living, the wish to die, the wish not to carry on, passive suicide attempts (example, not eating, or not taking needed medications), and the wish to make a suicide attempt. Other researchers have suggested that feeling trapped, feeling hopeless and/or helpless, and feeling intolerably alone also contribute to suicidal desire (Rudd et al. 2006; Williams et al. 2006; Baumeister and Leary 1995). So do severe psychological pain (Shneidman 1998) and the belief that one is a burden on others (Joiner 2005).
The open expression of suicidal desire might thus include statements that the person is thinking about suicide or sees no reason to go on living or feels trapped and hopeless, and so on. Asking questions about these states of mind will help you to determine the intensity of the person’s desire for death. For example, you can ask, “On a ten-point scale, how hopeless do you feel about the future?” Or, “Do you feel you are a burden on someone else?” Or, Can you tell me how you’re going to find your way out of this mess?” Only by drawing the person out will you be able to establish the level of comfort you need with a patient in order to continue to be helpful. One way or another, though, your immediate goal is to determine how urgently the person in front of you wishes to die.
It may be that your job description doesn’t include working out an answer to this challenging question. If you are in the detection and referral business, for instance, your task is simply to identify the fact that some degree of suicide risk is present and then to arrange for someone with the necessary training and experience to conduct a risk assessment interview and determine the best course of action and the plan for treatment. Otherwise, and especially if you are a professional with medical and/or legal responsibility for the services you render, you may wish to consider formal training in suicide risk assessment.
3. Building Rapport
Even though you may ultimately be going to refer the suicidal person to someone else for longer-term care, if the work of intervention is to be productive, you must establish some degree of rapport with the person in your office. Among other things, you need to find out what the suicidal person believes that suicide would accomplish. You can begin simply by asking the suicidal person to describe the situation he or she is facing. When the person falls silent, ask more questions:
“It sounds like you may lose the house. Where would this leave your family?”
“From what you’re saying, it doesn’t seem like there’s much hope she’ll come back. What do you think?”
“If you fail this course, doe it mean your parents won’t let you go on to college?”
Remember that the world’s oldest safe assumption is “Assume nothing!” The more questions you ask, the more answers you’ll have, and the more you’ll understand. And the more the suicidal person believes that you really do understand, the better things will go.
Here are several suggestions that will help you win the trust of someone who is suicidal:
What most encourages suicidal people to share their innermost thoughts and their emotional pain is a compassionate human response to their description of suffering. Expressing a solid faith in a positive outcome also helps. But this optimism cannot be Pollyannaish or simple minded. If the sufferer’s problems were easily solved, chances are they would have already been solved.
The main message you need to convey to a suicidal person during your first meeting is this: “Yes, the situation is desperate, but it is not hopeless. Something can be done, and something will be done!” You can cement this good-faith offer with the assurance that “No matter how rough things get, we’re going to get through this together.” If this produces even a weak smile or a small sigh of relief – to say nothing of an agreement to put off what seemed inevitable only minutes or hours before – then you can consider your mission well on the way to being accomplished.
4. Creating a Safe Environment
Once the suicidal person has agreed to wait and talk, we also need to work on ensuring the person’s immediate safety. You have already taken a step in this direction by establishing that no medical emergency exists. But creating a safe environment also means removing any means to self-harm the person may be carrying or have at home. To do so, you will need to ask whether the person has any knives, razors, guns, or pills in his or her immediate possession. Then, if the person is holding onto such materials, you will need to persuade him or her to relinquish them.
If you are talking to a man standing on the ledge of a ten-story building who says he intends to jump, getting him inside to talk is the first step toward a safe environment. So is convincing someone to hand over a stash of pills or put a gun down on your desk so that it can be put away somewhere. (Suicidal people are typically not homicidal toward those trying to help them. But accidents can happen – so if you’re not familiar with firearms, it is best not to pick a gun up yourself.) If the means to suicide are at home, it is essential that the suicidal person agree to their disposal. If the client is a child or an adolescent, a responsible adult must be enlisted to make the home safe.
The timing of this step is up to you, but it is generally wise not to embark on it at the very start of the interview. Convincing someone who is overwhelmed with despair to relinquish the means to suicide can be difficult. After all, you are asking that person to give up what may very well seem like the one remaining avenue to escape. And so don’t be surprised if a suicidal person is reluctant to hand over the means to suicide right off the bat. It may be that a safe environment cannot be achieved until you have established a degree of rapport with the suicidal person and have the beginnings of a relationship of trust.
If you are simply not able to obtain a commitment to safety from someone who is suicidal, then you will need to consider inpatient hospitalisation. This is a topic I will discuss in the following chapter. But securing someone’s consent to be safe is worth whatever effort it entails. Keep in mind that if you show yourself prepared to leave an agitated, anxious, hopeless person in possession of the means to suicide, the suicidal person could interpret this as a lack of concern (“If my therapist really cared, she wouldn’t have let me keep my pills”).
Telephone counselling is especially challenging. If your best efforts to convince someone to make a commitment to safety and future treatment fil to produce that promise, you must up the ante. When the person on the phone cannot or will not agree to be safe, and you feel the risk is high, start a trace and initiate rescue procedures. Send in the police, paramedics, or a mental health crisis team. You obviously can’t reach down a phone line and take away a gun, nor can you determine (with any reliability) how many pills someone may have taken or how recently. If you are in any doubt, reach out.
Yes, there will be those who subsequently complain that you violated their privacy by sending in a third party to assess them against their will. Rest assured, though, that those who threaten to sue almost certainly won’t. After all, they called you; you didn’t call them. Then, too, they would have to prove to a judge and jury that you harmed them in some way by violating their civil rights, and this will be a hard case to make when you are clearly a good-hearted, well-intentioned human being who was trying to save a life.
In the course of my long career at Spokane Mental Health – which offered outpatient programs, in patient liaison, emergency services, medication management, and a 24-hour crisis line – we were occasionally threatened with lawsuits on the grounds that we had violated someone’s civil rights. All these threatened lawsuits – including those stemming from an intervention that resulted in an involuntary psychiatric hospitalisation – evaporated into thin air after the person got treatment and began to feel better. Besides, in the end, I would rather have a patient angry with me for a few days than dead forever. So don’t let a fear of lawsuits stop you from summoning help when you feel it is needed.
5. Extending The Safety Net
Now relax. You’re doing fine. You’re not even an hour into this, and already you can see glimmers of hope. The suicidal person has agreed to stick around long enough to see what can be done. You’ve laid the foundations of a life-saving relationship. Now, in the breathing space you’ve established, you need to start widening the safety net. You can approach this task from two angles.
You can start by gathering additional information from the person who is at risk. This means continuing to ask questions. It means delving into the person’s life to learn all you can about what is driving the present crisis. Is there a family history of suicide and/or of mood disorders, substance abuse, domestic violence, or other known contributors to suicide risk? Is there a role model for suicide? What has pushed the suicidal person to the very verge of a suicide attempt? Was there a trigger of some sort? Other than putting an end to emotional pain, is there anything else the person thinks that suicide would accomplish? Again, there is safety in knowledge. The more complete and nuanced your understanding of the person and the situation, the better able you will be to offer effective help.
In addition, you can get others involved. Others may be your colleagues or your supervisor, or they may be psychologists or psychiatrists able to offer second opinions and useful advice. If the suicidal person has family in the area, give careful consideration to letting them know that one of their loved ones is contemplating self-destruction. In particular, parents of young people need to know when their child is in trouble. In some states, the law requires the disclosure of such matter by, for example, school personnel when a child is under a certain age.
The decision to notify other people will also depend on the laws governing confidentiality and on your employer’s own rules about disclosure. In addition, the suicidal person’s wishes should be taken into account. Sometimes a person wants to die in order to hurt someone else. If this appears to be the case, make certain that contacting this “someone else” won’t make the problem worse. However, under no circumstances should you promise to keep a suicidal person’s status a secret. To be drawn into such an agreement puts you both at risk.
To get others involved, ask the suicidal person whom he or she would like to have informed about the crisis. Simply say: “Who else needs to know you are in this much pain?” Then ask permission to get in touch with the person or persons. Although this is not likely to take place during the initial interview, once the network of communication has been expanded and the needed permissions obtained, you will be able to learn more about the suicidal person’s situation from friends, loved ones, or family members.
I cannot overemphasise the importance of information known to the family but not to you. For whatever reason, the suicidal person may well minimise his or her suicidal status to you, but family members may be more forthcoming – and their observations often prove critical in assessing risk. At your first opportunity, then, you should make every effort to learn all you can, not only from family members but from anyone else who knows the person well, including the person’s doctor.
6. Crisis Management
As a final step in saving a life, unless the person in your care is being admitted to the hospital, you will also need to set up a crisis management plan. It is best to keep such a plan simple. An effective crisis management plan consists of three basic elements: safety, phone access, and clear instructions about what to do if the going gets rough.
Safety. The best way to manage a crisis is to try to prevent it from ever developing. And so, as we have seen, you need to ensure that the suicidal person will be safe once he or she returns home. This means arranging for someone who genuinely cares about the person to be immediately available, preferably under the same roof. It also means that someone responsible has removed all the means to suicide, such as guns or pills, from the place of residence. Remember that, especially among the young, suicide is sometimes an impulsive act. By removing temptation, a safety plan frustrates suicidal behaviour. It also sends a very important message. We don’t want you to kill yourself!
Phone access. Everyone knows 911 or 211, but many people are reluctant to use these numbers – so don’t assume they will. Instead, give both the suicidal person and the person who is going to be part of the survival plan at least three telephone numbers: (1) 1-800-SUICIDE or 1-800-273-TALK and/or the number of a local crisis line; (2) the number of a hospital emergency department where immediate medical care is available; and (3) your office number, as well as any backup number that may be appropriate. It’s up to you whether to give out your home number or cell phone number. The more personal the connection, the better, however. You’ve already built a lifesaving bridge to the suicidal person. Now the person needs to know that the bridge will still be there once he or she leaves your office, and that it is open and easy to cross.
Crisis instructions. Give clear instructions to the suicidal person and to his or her friend, parent, or caregiver about what to do should a crisis appear to be developing. In particular, make sure that someone knows for certain how to get from crisis to solution – how to get to the nearest hospital or mental health crisis team in an emergency, for instance. Murphy’s Law – if things can go wrong, they will – seems to operate overtime with suicidal people. So, again, assume nothing.
Once a plan for immediate crisis management is in place, you will still need to persuade the suicidal person to commit to continuing treatment. This future care may come from you, or it may be that you will refer the person to someone else. If so, you will naturally want to make the best possible referral you can under the circumstances – but what counts most is that the suicidal person not walk out your door without a follow-up appointment. Make sure you’ve done at least the following:
As a safety net, this human connection is everything. If you feel the person you’ve been working with is resistant to following through with the referral, you can plan to take the person to the appointment yourself or arrange for some significant other to do so. But before making such arrangements, you would do well to reevaluate the situation. It could be that you’ve underestimated how bad things really are and that hospitalisation would be the more sensible course of action.
Risk Management
Whether you are going to treat or counsel a suicidal patient yourself or refer the person to someone else, the relative success of your efforts to secure and honest, good-faith commitment to future care is an important test of how willing the person is to give life another try. People are unpredictable. They can be desperately suicidal, and yet, given a chance to commit to treatment that will help them stay alive, they’ll take it. Other people, whose suicidal feelings appear to be of roughly equivalent strength, will not make such a commitment.
That said, the outcome of an intervention – whether the interview ends with the patient recommitted to life or still resolved to die – very often depends on the relationship between the sufferer and healer. There can be little doubt that the quality of the rapport that has been established influences the quality of the data collected and, therefore, the quality of the assessment and the intervention. My experience both with suicidal people and with those who evaluate and treat them strongly suggests that interviewers who are perceived as aloof and uncaring, or perhaps even subtly hostile, can actually enhance the risk of suicide. Interviewers who are seen as friendly, open, warm, and sincere are the ones who contribute most to reducing that risk. Of course, we can never be certain how we are coming across to another person – but we can do our best to convey our honest concern and our desire to help and to create a genuine sense of connection.
It is generally best to hold off on asking someone to make a safety arrangement and participate in a risk management plan until you are convinced that the person trusts you. Unless the sufferer believes that you are genuinely on his or her side, your efforts to secure a commitment to safety may meet with little success. Then again, after an hour or so of working with someone, you may feel so confident about how things are going that asking the person for a specific agreement to stay alive seems unnecessary. My advice, however, is to ask for a recommitment to life anyway – if only to be sure you haven’t misread the person. That way, if the worst happens, at least you’ll have the comfort of knowing you left no stone unturned.
A full-fledged risk management plan involves much more than the promise to stay alive, however. It involves informing the suicidal person of the benefits and the potential drawbacks of a proposed approach to treatment (possibly including a referral) and then collaborating in an action plan designed to reduce risk factors and increase protective factors. As part of this action plan the suicidal person also commits to remaining safe and following medical advice so that the work of healing – counseling, a program of medication, family therapy – can begin.
As research has shown, a large proportion of people who kill themselves are under the influence of alcohol at the time they die (Murphy and Wetzel 1990; Foster 2001; Bertolote et al. 2004). To take one example: A study conducted in 2004 that examined the toxicological profiles of suicide victims in thirteen different states revealed that alcohol was a contributing factor in 33.3 percent of the deaths. Drugs were also implicated: 16.4 percent of the victims tested positive for opiates, 9.4 percent for cocaine, 7.7 percent for marijuana, and 3.9 percent for amphetamines (Karch, Crosby, and Simon 2006). Because alcohol and other mood-altering substances play such a major role in suicide, it is critical that the suicidal person agree not to drink or use drugs until treatment is under way. Although the immediate psychological effects of alcohol in the bloodstream are to some extent unpredictable, alcohol distorts our judgement. It also clouds our ability to imagine the consequences of our acts, including suicidal ones. If we’re depressed and/or angry, alcohol may provide short-term relief, but the effects of intoxication on our mood can seriously impair our ability to think clearly and to make sound decisions. This impaired judgment, coupled with the increased impulsivity that alcohol can produce means that highly lethal situations may develop very quickly.
If you suspect that a suicidal person has been drinking or is under the influence of drugs, ask. Moreover, never assume that someone who’s had something to drink is sober just because he or she says so – and be aware that no one under the influence of alcohol or drugs can make a good-faith commitment to anything, let alone a recommitment to life. If the person is unable or unwilling to make a commitment to safety by agreeing to abstain from alcohol and drugs until treatment is in progress, a more rigorous intervention may be necessary, including a formal assessment for substance abuse. My clinical experience has convinced me that recovery programs for alcoholism and addiction, including Alcoholics Anonymous, are among our most powerful tools in the suicide prevention movement.
A safety agreement can be a simple verbal understanding. Your conversation with the suicidal person may culminate with something like, “Will you give me your word not to kill yourself until we’ve had a chance to sort these problems out?” Or, “If we’re going to work together, I need you to agree to stay alive. Will you do that?” Suicidal people who are highly distraught and/or intoxicated, or who appear to be suffering from acute mental illness, are in no condition to make promises. Otherwise, for the vast majority of suicidal people, their word is their bond – and if you can get the verbal promise sealed with a handshake, so much the better.
Alternatively, a safety agreement can involve a signature. A written agreement is not unlike the informed consent that patients sign when they agree to a surgical procedure. The patient is presumed to be legally competent and to have the capacity to understand and appreciate both the benefits and the risks of the treatment proposed. I will have more to say about no-suicide contracts in the following section. For now, let me just say that I’ve never been one who thought much of written agreements between us and the people who need us. A formal contract tends to suggest that we don’t trust each other and ought to have lawyers involved. So I’ll take a handshake and smile every time.
The patient’s medical record will record a great deal more information than is covered in the suicidal person’s agreement with you, however, especially concerning the elements of the proposed plan for safety and future treatment. Your employer (hospital, clinic, counseling center, etc.) may have a written statement outlining what patients can, in general, expect by way of a standard of care, such as certified staff and the provision of a safe environment. Typically, though, such statements do not specifically mention measures designed to prevent suicide. In fact, the matter of patient safety as regards suicidal behaviour has only recently been formally targeted as a goal by the Joint Commission on Accreditation of Healthcare Organisations (Joint Commission 2007).
No matter what else you say – or don’t say – to the suicidal patient, you will always be expected to deliver the standard of care for your community. After all, at the very least the patient has a right to competent and ethical service. Beyond that, however, many things are possible – and only you can determine what you are personally willing and unwilling to put on the line for a given suicidal patient. Some therapists won’t take calls after business hours; others will. Some agree to make house calls; others refuse. You must decide for yourself what you are prepared to include in your offer of treatment – your half of the bargain, whether explicit or implied. Whatever your do, thought, don’t bet the patient’s life on a promise you can’t keep.
Any intervention that ends with a person who was actively suicidal only a short while before agreeing to remain safe and to pursue treatment has achieved its purpose. Hope, however tenuous, has been revived. Thanks to you, the suicidal person may be ready to step forward into the future.
When More Is Needed
In most cases, suicidal people will agree to hold off on their plans for suicide without putting up much of an argument. They’ll shake your hand and promise to wait and talk. Having found a sympathetic listener, they already feel some measure of relief. In some cases, though, suicidal individuals may be suffering from a serious psychiatric disorder or may be so emotionally distraught and/or intoxicated that asking them to make a commitment to safety is simply not reasonable. Some will outright refuse to consent to a safety agreement, while others will be evasive or will promise to stay alive only for the next twenty-four hours, or for three days, or for a week.
If a suicidal person is willing to postpone suicide for, say, a month, you have some cause for hope. But if you can’t persuade someone to agree to a few hours, a day, or a week, or if you’re unable to elicit any sort of good-faith promise from the person to remain alive long enough to see a referral plan through and begin treatment, then you have a problem. In all likelihood, you are dealing with someone who is so deeply mired in despair that what he or she is really saying is, “Thanks for listening, but I’m still going to kill myself.”
If so, then you will need to consider a more aggressive course of action.