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The last chapter focused on suicidal people who were probably only just beginning the journey toward self-destruction. They may have been entertaining the notion that death might be preferable to life, or they may have been temporarily convinced that it would be, but they were not yet overwhelmingly invested in dying. No matter what the risk factors stacked against them – age, sex, race, alcohol abuse, clinical depression – they were, at least for the time being, willing to consider the idea of sticking around to see how the rest of life might turn out. To pursue our traveller’s analogy, they could agree to keep on living long enough to discover whether the stretch of bumpy road they’d been travelling was perhaps only a short section under construction on the way to a smooth highway not too far ahead.
To put it another way, these people didn’t so much want to die as to end their suffering, and so persuading them to commit to safety and treatment was relatively easy. Where hope is readily restored by a single intervention – by a healing act of kindness and compassion – the risk of suicide diminishes rapidly. So rapidly, in fact, that beyond checking from time to time to make sure a subsequent problem hasn’t triggered fresh suicidal thoughts, you can generally lay those worries aside. Once treatment is under way and the person has begun to feel better, life’s problems start to seem more manageable. As a result, the idea of suicide can quickly lose its appeal.
Sometimes, though, interventions don’t go so well. The person you’re talking with is headed into what he or she sees as the last mile of life and isn’t willing to give up suicide as a solution. The person may be facing so many different problems – acute, lifelong, or both – that it appears there is no way out. You have worked as hard as you can for an hour or more, but the sufferer remains unconvinced that there is any reason for hope to be revived.
And why should the person trust you? For someone who is overwhelmed with despair, making a leap of faith is difficult. And, after all, you may have only just met. For all the person knows, you’re merely some do-gooder who has never known and cannot possibly understand real psychological pain. And yet here you are, asking for the sacrifice of the only solution that promises real relief.
When Someone Is Unwilling to Accept Help
As we have seen, a suicidal person who is intoxicated or so severely agitated as to be out of control is in no condition to ensure his or her own safety. But, although it may seem strange to say, under most circumstances the only person who can ultimately reduce the risk of suicide is the suicidal person. To put it another way, people who are truly determined to kill themselves will probably find a way to do so, sometimes even in the security of a psychiatric unit while they are under a close suicide watch. In attempting to safeguard someone’s life, we therefore need help from that person in the form of his or her cooperation. This is one reason why the quality of the relationship we have with the suicidal person is so important. When the person is unable or unwilling to cooperate, however, our best bet is to rely on the power of treatment in the safest environments we can create.
As a rule, people who have invested a good deal of time, effort, and sometimes money in a plan for killing themselves will not let it go without a struggle. They may not have figured out how to live, but they may very well have determined how best to die. In fact, coming up with a plan for suicide may have given them the only real sense of personal control and accomplishment they’ve recently known. They may thus feel that, in seeking to keep them alive, you are trying to take way their power – that you want to rob them of this one promise of relief. And so they resist your help, which may also seem to them too little too late. When asked for a commitment to safety and treatment, some take evasive maneuvers. For example:
When you start hearing this sort of thing, and you begin to feel uneasy, you should. You can figure the suicidal person is thinking something like this:
If a suicidal person refuses to give you a clear, good-faith commitment to safety and to the future, you have more work to do – and you’re facing a tough situation. What you do next is probably going to make the situation seem worse. I say “worse” because what you do next will probably run counter to the wishes of the suicidal person and leave him or her even more upset, as well as angry. However, you’ve come this far, and there’s no other way out. After all, you now know that something is terribly wrong, and you are morally bound to try to do something that will help make whatever is wrong right. You are in a life-and-death crisis with the suicidal person.
It is at this point that the healer usually realises that he or she cannot safeguard the suicidal person’s life all alone. Additional support is needed. There may be o choice but to consider the safety of a psychiatric hospital, a hospital emergency department, or some other secure place. Under such circumstances, you simply must move ahead. But forcing the issue will surely test any small alliance with the patient that you’ve managed to establish.
Known Risk Factors
No matter how obvious a suicide may seem after the fact, predicting suicide is impossible. The laws of probability tell us how likely or unlikely it is that a particular type of event will occur, be it a plane crash, and earthquake, or the suicide of an individual. But they cannot give us specifics. We know there will be plane crashes, but which plane and when? Similarly, those of us who work with suicidal people, and are familiar with the profiles of high-risk individuals, know that many older, white, alcoholic males in the throes of depression will kill themselves. But we cannot say precisely which ones, under what circumstances, and on which days.
In the United States, the base rate for suicide is approximately 12 deaths by suicide per 100,000 persons per year (American Association of Suicidology 2007). In other words, the number of suicides is very small – so small that our chances of making an accurate predictions are almost nil. If you were asked to wager whether a given person will die by suicide, your best bet would be to say no. And in most cases you would win your bet. Typically, then, “predicting” suicide is a matter of 20-20 hindsight – “I knew he was going to do it; all the signs were there.” But even warning signs don’t enable us to make accurate predictions. Thousands of suicidal people send warning signs, but only a few complete a suicidal act.
The Surgeon General’s Call to Action to Prevent Suicide, 1999 (U.S. Public Health Service 1999) lists the following as major factors in the risk for suicide:
The list of risk factors could go on and on. But the risk of suicide cannot be adequately assessed simply by adding up risk factors. Likewise data from psychological tests or personality inventories leave too many questions about the current level of risk unanswered.
Risk factors can include stable variables – age, psychiatric illness, past attempts at suicide, a history of divorce – as well as unstable ones, such as agitation, lack of sleep, or intoxication. But suicide generally occurs in a swirl of the above, and most often in a psychosocial context over which we have very little control – a circumstance that considerably complicates risk management. A statistically vulnerable person may be at a relatively low risk for suicide one week but at a relatively high risk just a few weeks later. Similarly, we may judge a teenaged girl who is terribly upset because she has just been jilted by her boyfriend to be at a statistically lower risk of taking her life than a seriously depressed, narcissistic, alcoholic sixty-year-old man who is equipped with a gun, bullets, and a specific plan to end his suffering. But that does not mean the girl will live and the man will die. Just the opposite could happen. Despite our best efforts at prediction, clinical experience has proven, again and again, just how wrong we can be.
But if we can’t predict suicide, we can take all reasonable precautions to prevent suicide, especially once we know a person is thinking about taking his or her own life. We can familiarise ourselves with the known risk factors and make efforts to reduce them. We can also educate suicidal people and their families about the factors that increase the risk of suicide, thereby providing them with information that could help them manage that risk. We do this for people at high risk for cardiac illness, diabetes, and cancer. So why not do it for people who are at risk of suicide?
In addition, we can gather information about protective factors and do what we can to enhance them. Although the notion of protective factors – buffers against suicide – is perhaps less familiar than that of risk factors, enhancing protective factors plays a crucial role in reducing the risk of suicide. It is well known that even acutely suicidal people are ultimately ambivalent about dying. The will to live has not altogether vanished. Preserving that part of them that wants to stay alive are the sustaining beliefs and core values the person holds most dear, as well as a fundamental sense that there must be some purpose to life. Good health, close friends, religious convictions, a sense of responsibility to others, especially children – factors such as these give a suicidal person reasons for living. In particular, the existence of a network of social supports helps to shield suicidal people from actual suicide attempts (Joiner 2005); so does the existence of plans for the future (Strosahl, Chiles, and Linehan 1992). Yet another buffer is engagement with someone who is trying to provide the suicidal person with alternatives to death – someone who represents life-affirming ideas and options. Once someone is in treatment, the person’s relationship to his or her therapist may therefore provide an additional protective factor, as can the person’s willingness to adhere to a medication regimen, to eat a good diet, and to get plenty of rest.
When it comes to assessing how at risk someone is, gaining insight into protective factors is at least as important as evaluating risk factors. A person thinking of suicide who can quickly list ten reasons why he or she should go on living is probably not on the very verge of an act of self-destruction. More often than not, though, when suicidal people are asked to name reasons why they might want to continue living, they are unable to come up with more than a very few. A thorough clinical interview – one that elicits both risk factors and protective factors – offers the most effective means to deter a planned suicide, especially when the protective factors, however initially slim, can be marshaled to support life.
Above all, in conducting an assessment, we need to forget about trying to be omniscient. We must remain humble and proceed on the basis of what we actually know, rather than cling to preconceptions. We must be able to answer the question, “How do I know what I know?” Even though we may do so unwittingly it is dangerous to rely on myths, on antiquated ideas, or on possible prejudice. Especially when it comes to directing a suicidal person into a more restricted environment, such as a psychiatric hospital, we need to have asked enough questions to make an informed judgement – however imperfect that judgement may prove to be. No matter what methods you use, how skillful you are, or how many times you have seen similar suicidal people and been led to the same conclusion, your judgement will be always just that, a judgement. The more you have learned about someone, however, the more reliable your judgement is likely to be.
Making the Decision to Hospitalise
Hospitalising someone who is at risk of suicide is not always the best thing to do. But under some circumstances it is. Making this call is one of the most delicate, and most important, tasks that mental health practitioners are paid to do. However well or poorly they do it, their actions are always based on facts and judgements derived from the risk assessment interview.
If we think about a suicidal person’s journey toward self-destruction as a process with a beginning, a middle, and an end, then by the time such a person can no longer be persuaded to make a commitment to safety and treatment, he or she is well down the road to an actual suicide attempt, and possibly death. A suicidal individual who cannot or will not accept help is automatically at high risk. In the language of the law, he or she now presents a “danger to self.” If a person appears to be out of control and/or if you judge that person to be unable to make a firm and considered promise to remain safe and pursue treatment, then hospitalisation is generally the best choice. In fact, if you cannot secure a good-faith commitment to safety, you have little choice but to recommend hospitalisation, or at least to get other people involved who can help you make this decision. Failing the suicidal person’s willingness or ability to consent to a safety agreement, to dispose of the means of suicide, and otherwise to cooperate in this or her own future well-being, few choices remain.
Almost always one or more symptoms of severe depression, serious or global insomnia, raging anxiety, alcohol or drug intoxication, a psychotic disorder, or other signs of acute psychiatric illness will accompany the acute suicidal state. Therefore, although arriving at the decision to recommend hospitalisation can be difficult, justifying that decision generally is not, although you will need to be prepared with convincing information regarding the suicidal person’s status. Whether or not the hospital will be able to admit the person is another matter, but if the interview data and reports by third parties clearly indicate that someone is a danger to self “by reason of a mental illness,” hospitalisation is understood to be the safest course of action.
If you are not yourself a mental health professional, it is not your job to decide whether admission to a hospital is indicated. There are, unfortunately, continuing problems with suicide risk assessment – what it should be and how best to standardise it. These problems include questions concerning the proper standard of care (Simon and Shuman 2006). If in doubt, and especially if no psychiatrist or psychologists is immediately available to give you a second opinion on your assessment, step outside the intervention relationship momentarily and make some calls. In such circumstances, you need support from others. You certainly don’t want to steer someone away from a hospital if that’s where the person belongs.
Confronted with the prospect of going to the hospital, whether voluntarily or involuntarily, many suicidal people will suddenly try to convince you that they aren’t really all that suicidal or begin explaining why hospitalisation just isn’t feasible. They’ll say things like:
“But I’ll be all right. Honest I will!”
“I was only kidding. I’m not going to kill myself.”
“Oh, come on! Why are you taking all this so seriously?”
“Mental hospital? Do I look crazy to you? I’m not going to any mental hospital.”
“Hospital? I can’t go to a hospital! Who will look after my cat?”
“I’m already broke. I can’t afford to go to a hospital.”
Having decided to recommend hospitalisation, you should expect some anger from the suicidal person. After all, you’re restricting – or threatening to restrict – this person’s freedom. Some may get downright nasty and start swearing at you, while still others may threaten to sue.
These reactions are unfortunate but unavoidable. But once you have made up your mind that the suicidal person you’re working with is not safe and needs a supervised and secure environment, you can’t afford to give into the person’s anger. If, down deep, you believe that this person is at serious risk and is struggling to break free from the safety net you are constructing, you cannot back away from your decision. In fact, if you back off from your decision at this juncture, a suicidal person could interpret your reversal as evidence that you’ve changed your mind about whether the future holds any promise. The suicidal person might conclude, “Ha! I was right! There is no hope.”
Emotional Involvement
At this point in any difficult suicide risk assessment interview, strong feelings are bound to come up on both sides. The suicidal person came in upset and is probably even more upset by the suggestion that he or she cannot be trusted to manage his or her own life.
The person’s autonomy is in jeopardy. He or she may claim that his or her constitutional rights are being infringed and argue that this is a free country and you can’t force people into confinement. The person’s hostility can be very genuine, and you too will be feeling some strong emotions.
The good feelings of empathy and understanding you had toward the suicidal person only moments before may be replaced with boredom, impatience, anger, fear, or frustration. In my experience, such negative reactions to a suicidal person are an important source of information. They tell you that the sufferer is attempting to drive away or alienate the very person who could be of help. It is as if the person is saying, “Get away from me! Can’t you see I’m already dead?”
So, when you are working with suicidal people, it is a good idea to monitor your emotional reactions to them.
Boredom, impatience. Feeling suddenly bored with a suicidal person’s problems may signal that you have sensed, probably unconsciously, impending defeat and so are withdrawing emotionally from the relationship. You’ve devoted all this time and energy to someone, and now the person doesn’t want to cooperate and follow your guidance. You’re tired, it’s late and, after all, there are better things to do than to keep spinning your wheels with someone who can’t seem to understand that what you’re proposing is for the best.
Anger, fear. It is very possible that you will feel angry. If someone places his or her life in your hands and then tries to tie your hands behind your back, becoming angry is an understandable reaction. Anger is usually caused by fear. When you’re trying to save a life, the fear comes from the feeling that you’re failing. Here you’ve been trying so hard to help, and now you’re being told to get lost – that your efforts haven’t been effective. You may also have the sense that you’re being backed into a corner. Given that the person currently in your care won’t agree to hospitalisation and yet is at serious risk, you have only two alternatives: Give in to the person’s objections, which might result in a suicide, or resort to an involuntary admission, which means calling in the law. The thought of having to choose between two not-very-appealing options may make you angry, but it can also produce fear.
Frustration. Even if you do suicide assessments for a living, expect to feel frustrated. Someone’s life is at stake. The person is now less than cooperative and is testing all your skills. Without necessarily meaning to, the person may be pushing you to the limits of your kindness, and your patience. This is okay. Consider that a lot of people may have let this person down lately. As he or she sees it, you just happen to be the next one in line.
Knowing that these emotions are to be expected may help you identify them as they occur. Being aware of such emotions is good, not bad. It means that you’re on top of things, that you know what’s going on inside you. Depending on the circumstances, it might be a good thing to share your reactions with the suicidal person. For instance, you might say, “You know, I’m getting a little frightened here. We’ve been talking together for a while, and we’d gotten started on sorting out some of your problems. But now you’re acting like you don’t want me to help you anymore. Have you had this reaction with other people you’ve talked to?”
The answer you get to this question could prove quite valuable. Very often a suicidal person will have had other, similar conversations in the past, conversations that were ultimately unhelpful. Your question could cut right to the heart of the matter and so help put your relationship with the suicidal person back on track. In addition, acknowledging that you share the suicidal person’s sense of fear and impotence can have an equalising effect, making you seem more like a human being and less like a figure of authority who is trying to force the suicidal person to agree to confinement.
Another potentially useful approach is to say something like: “I realise you may not be able to make a commitment to safety and treatment right now. That may be okay for you, but it isn’t okay for me. I’m here to do the best job I can to keep you alive, and I intend to do it.” When you make it clear that you’re determined to make a stand, a suicidal person will often calm down and go along with the program. As he or she will understand, what you’re essentially saying is, “Look – I’m the one with the objectivity and good judgement here, and I’ve decided to pry your fingers from the wheel and take over the driving.” You’re the designated driver, the clear-thinking and sober one, and you’re doing the right thing. More often than not, the suicidal person will return later on and thank you for having had the courage to act in his or her best interests.
Voluntary Hospitalisation
In addition to psychiatric units and psychiatric hospitals, any residential treatment centre, nursing home, structured group home, or other facility where patients remain overnight can be considered an inpatient setting, at least in terms of the increased responsibility borne by staff once they know that a patient presents some clear and present danger to himself or herself. If a suicidal person will agree, however reluctantly, to enter a hospital voluntarily, this is best. Involuntary hospitalisation can get complicated, and it is always tougher on the patient’s sense of pride and self-worth.
Voluntary hospitalisation should be relatively easy to arrange, provided you have the essential risk information needed to convince the admitting staff of the seriousness of the crisis. But I must warn you that because of the limited number of inpatient beds, admission of a suicidal patient is not guaranteed. In fact, you may have to argue your case at some length to get the person admitted – which is why you need to do a comprehensive interview and have indisputable data at hand.
Meanwhile, your main message to the suicidal person should be that you want him or her to be safe. You want the person to get a good night’s rest, to get started on medications, to talk with some doctors and nurses – to put things on hold and stay for a while in a safe place. Suicidal people have been struggling, usually for a long time, to solve their problems and will very often welcome the chance for a little relief – even after a show of initial resistance. They can always save face later on by explaining to their friends, “I didn’t want to, but they insisted.”
You can ease the transition to a safe environment by knowing a little about modern psychiatric hospitals and sharing what you know with the suicidal person and his or her family. Addressing fears, whether these are imagined or real, is the quickest and most effective way to persuade someone who is seriously suicidal to agree to a voluntary admission to the hospital. Here is some information to help you in you efforts.
Once you have convinced the suicidal person to enter a hospital, your remaining work with the person should be reasonably straightforward. The customary steps to a psychiatric hospitalisation are:
1. If you haven’t already done so, call a psychiatrist or an emergency room physician who can agree to hospitalise your suicidal person. He or she will need the following information:
– The person’s sex and age; the nature of crisis; whether the person has been drinking or has taken drugs; and what (if any) prescribed medications the person is on.
– Your diagnostic impressions. Everything you’ve learned about the person’s suicidal thoughts and feelings, about his or her degree of impulse control, and about any past history of suicide attempts is important.
– The phone number of a family member or significant other.
Some admitting physicians will want more information, but unless you are yourself a highly trained professional, it is unlikely they will expect very much. They will need to know enough to justify an admission, but solid evidence of the imminent potential for suicide is usually sufficient.
Not all hospitals have psychiatrists on call, and so you may be told to contact a mental health centre. Staff will take responsibility for screening the person for hospitalisation.
2. Anticipate the patient’s worries and agree to manage arrangements for child care and pets, or to talk to employers or apartment managers, or to do whatever else might stand between the person and his or her safety.
3. If a responsible adult is not available to take the suicidal person to the hospital, arrange transportation. Most suicidal people could, in fact, get themselves to the hospital, but why take chances? Just about any adult person can drive someone to the hospital. Cabbies do fine. If the person is acutely suicidal, however, and wants to die right now, do not ask any nonprofessional to assume the burden of saving a life. Instead, call 211 or 911 and let the emergency response operator arrange for an ambulance or a police transport.
4. In the case of young people, have a parent or responsible person available at the time of admission to offer support and reassurance and to provide relevant history.
5. For your own peace of mind, have the hospital call you when your referral is safely tucked in bed.
Involuntary Hospitalisation
Involuntary hospitalisation is a last resort. It is what we are obliged to undertake when someone we have identified as at imminent risk of suicide refuses to cooperate in his or her own welfare. If a seriously suicidal person will not agree to voluntary hospitalisation, or at least make a good-faith commitment to an outpatient program or the care of a crisis respite service, then we have no choice but to turn to the law. Although the eventual decision will not be ours to make, we must at least try to ensure the person’s safety.
Involuntary commitment laws vary in their specifics, but in one form or another they all address the following question: By reasons of a mental illness, does this person represent a threat to his or her own safety? If the answer to this question is yes – according to the clinical findings and professional opinions set forth in the petition to the court – then a court has the power to violate someone’s civil rights and commit that person to the care and safety of a facility. These facilities are usually state-run mental hospitals or state-approved psychiatric hospitals or units within general medical hospitals. In the United States, an initial commitment is usually limited to no more than two weeks, unless continuing evidence exists that the person poses a danger to self.
Unless you function in an official capacity and have the right (as well as the appropriate legal protection) to order an involuntary psychiatric admission, you don’t need to understand, or even necessarily be familiar with, all the particulars of the involuntary treatment laws operative in your state. But you do need to know how to access the people responsible for taking legal action and when to call them.
The systems that govern involuntary detention and treatment vary from state to state, and sometimes even from country to country. For your own sake – and for the sake of any suicidal person with whom you may come into contact – learn how your system works. Then write down the names and numbers of the appropriate contacts and keep the information somewhere handy. When you can answer the following questions, consider yourself properly schooled for your community:
If you can answer these questions, you should be in good shape if and when you are obliged to call on the power of the law to stop a suicide. If you can’t answer these questions, contact your local mental health department and get the answers.
As an alternative to involuntary hospitalisation, a few crisis treatment systems will provide on-site evaluation and intervention, referral services, respite services, and a complete community safety net. The good news is that these same people will assume responsibility for the survival plan and its implementation. The bad news is that such a sophisticated mental health delivery system may not be available in your community.
Above all, what you need to remember about involuntary hospitalisation is that, in the end, the suicidal person’s safety is out of our hands. It is not up to us – mental health professionals, school counselors, therapists, nurses, or any human service worker caught up in a suicide assessment situation – to make the final decision about the appropriate course of action. Only a court can decide to infringe someone’s constitutional rights for the sake of that person’s safety.
The Burden of Decision Making
When we work with suicidal people, we have to ask ourselves: Where else could we find a greater challenge with a greater potential for reward?
Answer? Nowhere.
The moment you become involved in decisions about a suicidal person’s future safety, you have accepted one of life’s greatest burdens: to prevent someone from dying.
Personally, I cannot think of a heavier burden. As I once remarked to a staff person after a tough suicide consultation, “If this work wasn’t noble, I wouldn’t do it.” Doctors performing extremely delicate brain surgery have a room full of people to assist them, people who will offer consolation if the operation fails – people who will, if need be, stand up for them in court later on and swear, “Yes, Dr. Smith did everything humanly possible.”
It is helpful to remember that, to do our work well, we don’t have to be gods. We don’t need to possess great wisdom, infallible insight, or perfect judgement. All we have to do is make the best call we can based on what we know at the time. This is why getting the facts is so important. Better information leads to better decision making – and yet far too often we do not have all the facts. Suicidal people hold things back. Families keep secrets. Third parties fail to provide us with critical information in a timely fashion. The methods available to us for suicide risk assessment are far from foolproof. Too frequently, they do not give us what any safety engineer would demand to know before making a decision in which lives could be at stake.
But if our work can seem lonely and difficult, it is also enormously fulfilling. Surgeons save people with lasers and scalpels; we save them with words. Abraham Lincoln suffered from serious depression and considered killing himself many times. He was fortunate in his strong will to live, which helped him through periods of despair. In addition, though, he was shielded from suicide by the love of his family and by the support of his friends and colleges – and by caring words. In the end, all we can do in this work, as in any other, is care enough to do our best. The comfort is that our best is usually good enough.