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How to Talk About Suicide: Questions to Ask

It’s intimidating to talk to someone about suicide. This guide walks you through some of the steps to ask someone if they’re thinking about suicide.

Ask A Question, Save a Life: Asking the Suicide Questions

Estimated watch time: 37 mins 

Available credits: none

Presentation Materials:

Welcome to the Community Education Series hosted by The Recovery Village and Advanced Recovery Systems.

My name is Michael Crisanto. I’m a community outreach specialist here at ARS. I’m going to turn my video off just for the remainder of this because of certain light issues. Today, if you do have any questions, I do want this to be as interactive as possible. I have the chat open as well, so you can type it in the chat and I would love to see people’s reactions and things of that nature.

A little bit about what my experiences moving in: as Brian mentioned, I did work as a community liason, as a regional suicide prevention specialist with different federally-funded suicide prevention grants. In that work, I had the opportunity to present different evidence-based trainings. So I would train different clinicians, teachers, case managers, and counselors but my favorite training to do was with the community.

I would often use evidence-based training called QPR. QPR stands for question, persuade, refer. The reason it was my favorite thing to do with the community is because it, my work with the suicide prevention grants, my job was to try to reduce the suicide rates in the state of Florida. I found that reaching the community and reaching out to them, first of all is kind of the best way to do that.

There’s a stigma around suicide that makes it really difficult for us to talk about suicide. So whenever we’d have these community trainings, we’d have people coming in because they had someone at home that they were worried about, or they worked with a high-risk population.

QPR stands for question, persuade, refer. We call it a gatekeeper training. It’s three easy steps that anybody could take to potentially save someone’s life, so when I got the opportunity to come here and speak to you guys today, I thought it’d be a really important thing to talk about considering everything that’s going on in the world today, with all the added stressors that we have. You know how difficult things have been for everybody learning something that we can all do to potentially save someone’s life.

Today we’re going to touch on that Q portion of QPR, which is going to be the suicide question. That suicide question is going to be, “are you thinking about killing yourself or are you thinking about suicide now?”

I know that for many of you right now, that may seem like a really direct way of asking that question. Some of you may even be thinking, “I’m not sure if I can actually ask that question.” We’re going to touch on why it’s important that we ask it in that way. We’re going to talk about why it’s important to ask the question and also how we can go about asking that question.

Before we dive into all of that, I wanted to talk about what suicide looks like in the country today. Suicide has been a growing problem over the last couple of decades. In fact, the suicide rate has slowly increased over the past 20 years or so.

When we look at 2018, these are the most recent statistics that we have. It takes about two years to gather this data. So in 2018, we saw that there were over 48,000 completed suicides. To put that into perspective, it’s about one person, every 10.8 minutes or 134 people a day. That would be like if there was a commercial airliner going down every single day with no survivors.

If that were to happen, we’d hear about it. Right? We’d hear about it in the news. We’d hear about it every single day. We don’t really hear about suicide as often we hear about it if it’s a high profile celebrity or if it happens in a school or something along those lines, but we’re not really talking about how common it really is.

In fact, suicide is this common that it’s the 10th ranking cause of death in the US, and homicide is 16th. When I first started working in suicide prevention, I remember I was really surprised by that. I think that like many of us, I have the misconception that homicide happens more often. I think we see it so much more in the news and in media and movies. We kind of assume that it just happens more often. Suicide is actually accounting for more deaths than homicide. In fact, suicide is the second leading cause of death amongst youth ages 15 to 24.

The only thing that accounts for more deaths in that age demographic is accidents. It’s important to highlight accidents because although we saw over 48,000 suicides in 2018, some of the research is starting to show us that that number is probably closer to about 70,000 or 80,000. Accidents are a big reason for that. Sometimes accidents get reported as accidents, but may in fact, be suicide attempts. A single driver motor vehicle accident, for example, or someone falling onto train tracks during an overdose.

Sometimes those are reported as accidents and they may very well have been suicide attempts. It’s important that we understand that suicide is common enough to the point that we may be actually seeing about 80,000 suicides every single year.

When we talk about suicide attempts, we see that females attempt at a higher rate. There’s about three female attempts for each male attempt. On the other hand, we see that males are dying at a higher rate from suicide. There’s about 3 ½ male deaths for each female death.

I wanted to ask you guys, I mentioned that I want this to be as interactive as possible. If you wouldn’t mind putting in the chat, what do you think some of those reasons are? Why, although females that are attempting at a higher rate we see males dying at a higher rate by suicide? I’ll give you guys a couple of seconds. If I don’t see any answers, I’ll just give you guys the answer. It’s no problem. Curious to see what you guys think.

We have means of attempt, less lethal means. Absolutely. Someone said use of guns and that’s actually the main reason. Men are more likely to use firearms, which has a higher lethality. Whereas females are more likely to use different forms of suicide, such as asphyxiation or overdoses that have a higher survival rate. Although females are attempting at a higher rate, the use of firearms accounts for more male deaths.

We look at Florida. I worked in Florida. I live in Florida. I like to use Florida as a comparison to how the U S is doing. The suicide death rate in the U S is 14.2. So that’s per capita 14.2 per 100,000 people. In Florida, our suicide death rate is about 14.8, so we’re not too far off. It ranks us 29th, meaning there are 28 states that have higher suicide rates than us.

Some of those states are going to be Montana, Alaska, Colorado. Some of those mentioned there, Oklahoma West, Virginia, Tennessee, I’d like you guys to think about what are some of the things that these states have in common that you think account for higher suicide rates? What are some of the commonalities that you see among states like Montana and Oklahoma and Tennessee that you think are accounting for higher suicide rates.

So I’m seeing isolation, poverty, less populated and then rural. So, yeah, absolutely. Some of the things that I often hear sometimes are weather. You know, these tend to be colder states. They have longer winters that can account for seasonal affective disorder because winters are so long and dark and cold. Sometimes people get depressive symptoms associated with the weather and, you know, we know that depression is highly correlated with suicide, so that’s one of them, but you guys are absolutely right.

Poverty could be one of them. A lot of these states tend to be lower on socioeconomic status. There’s higher drug use, but being rural is really the biggest issue there. When we have rural communities, we see that there are less resources and there’s more isolation and less opportunity for social connectedness. Those are really the biggest reasons.

I’ve worked here in Florida, and when we look at the different counties here in Florida, we see the same trend, the more rural communities tend to have higher suicide rates because they have less resources. They have more isolation and less opportunity for that social connectedness.

Some of the counties that I’ve worked in, we’ve seen things such as less access to resources. There’s not enough mental health providers. There’s not enough mental health providers who take certain insurances. There’s no public transportation, things of that nature. All of those things play a big role in that.

I wanted to start off by looking at some of these numbers, because I wanted to show you guys how common suicide really is, but as common as suicide is, oftentimes we find it really difficult to talk about suicide, right? We may have seen someone who may be struggling with something. We may even get that gut feeling like they may be thinking about suicide, but we have a really hard time talking about suicide.

When it comes down to a friend or a loved one or a coworker that we’re concerned about, sometimes we hesitate to intervene or we fail to intervene. I want to ask you guys, why do you think that people hesitate to intervene when they think that someone may be struggling with something, when someone may be thinking about suicide or going through something really difficult?

Let’s hear what you guys think in the chat. So we have, “I don’t want to imply the other person is depressed.” Fear of overstepping, afraid of saying the wrong thing. They may not be comfortable discussing it or understanding the issue. You guys are pretty spot on.

I’ll show you what some of the most common things that we see are. So, not sure about how severe the risk is. What if they’re wrong? I mentioned that there’s a stigma around suicide, a stigma around mental health in general. If someone isn’t thinking about suicide and we asked them, we’re worried that maybe we offend that person, right? Because there is such a stigma around that.

Worried about doing or the right thing. We had someone say that as well, feeling like maybe you’re not prepared or that there’s a very specific thing you’re supposed to say in those situations, and you’re not quite sure what that is. If you don’t say that, then maybe you say the wrong thing.

Feelings of inadequacy, feeling like you’re not necessarily qualified to intervene in that situation.

One of the biggest ones that I often hear is afraid to put the idea in someone’s head. This is probably the biggest myth and misconception that’s out there around suicide is being afraid that if we ask someone about suicide, who’s not thinking about suicide, are we going to give them the idea to think about suicide? Or are they going to think that maybe I should be thinking about suicide, and that’s just absolutely not true. When someone’s thinking about suicide, they’re either thinking about suicide or they’re not thinking about suicide. A question isn’t going to be able to persuade someone not to.

As human beings, we kind of have this biological instinctual need to survive. It’s kind of ingrained in us. There’s this threshold that needs to be crossed in order for us to be able to actually attempt suicide, and we’ll touch on those in a little, in a couple of slides, but simply asking a question isn’t going to override that instinctual need to survive. Someone who is thinking about suicide is already thinking about suicide. A simple question isn’t going to get them to change their mind about things.

Feel like it’s not their issue, and then the bystander effect is a big one. So for those who aren’t familiar with the bystander effect, it was this phenomenon that came back and around the late 1960s.

There was a young lady named Kitty Genovese. She was brutally stabbed to death in front of her apartment building. What made it really interesting was the fact that there were tons of onlookers. There were people who were watching through windows who were walking by and no one did anything about it. No one called the police, no one tried to stop. No one tried to intervene and people were really confused by this. Why didn’t anyone do anything to try to help this young lady?

Researchers looked into it and they came up with what was called the bystander effect. It breaks down into two parts. The first part is called perceived diffusion of responsibility, which is just a really fancy way of saying that the more people that are around the less we feel like that responsibility falls on us, right? In the case of kitty Genovese, people probably saw that there were a lot of people there. They felt like, “well, I don’t need to be the person to call the police. I don’t need to be the person to intervene because surely someone is going to step-up.”

What ends up happening is everyone has that same mindset. No one does anything about it. When we talk about suicide we have the similar thing happen. It can be someone that we see that’s really struggling, maybe having a tough time. We get that gut feeling like something may not be right, but we don’t intervene because we assume, “well, someone is seeing what I’m seeing, I’m sure, right?”

Whether it’s a family member, a friend, a coworker, maybe it’s a teacher or classmates or someone at church or a teammate, someone involved in their life is clearly seeing what I’m seeing and they’re intervening and the situation is being taken care of. Someone’s talking to them about it. What ends up happening is very similar to Kitty Genovese. No one does anything about it. This person ends up struggling alone and no one lends a helping hand. No one has a conversation with them to see what’s actually going on.

The other part of the bystander effect is called normative social influence. Again, another fancy researcher way of saying that whenever we’re not really sure what we’re supposed to do in a situation, we look at other people to learn how we’re supposed to act.

An example of this is a really common experiment in sociology. It takes place in an elevator. What researchers do is they have people inside of the elevator waiting for people to come on, but they face the back of the elevator. When people come in, they hit the floor that they’re going to. Instead of normally facing the front of the doors, like we normally do, they see that everyone’s facing the back, and they turn around and face the back even though it’s something they’ve probably never done. Maybe it doesn’t even feel comfortable to do. The reason for that is when we’re unsure, and we see other people doing something we feel like that’s what we’re supposed to do.

When it comes to suicide, it’s really similar. We might grow up because of certain cultural norms, not wanting to get involved in people’s business, or, it’s not something that we’ve learned to be able to intervene in those situations.

I’ll give you an example. I’m Hispanic. My parents are from Peru and in our culture, it’s common to be really private about our lives and the other hand, respect other families’ privacy. If someone is going through something with mental health issues or struggling, it’s not really our business. That’s something that I grew up learning and it took me going and working in the mental health field to really understand that we’re really doing a disservice.

I bring up the bystander effect so that one, we understand what happens and then, so that we can try to override it. Intervening is going to be a potential way of saving somebody’s life because maybe no one else is.

On the other end of that when someone is potentially thinking about suicide or they’re really struggling for something, what are some of the reasons that you think people hesitate to ask for help? So I’d love to hear what you guys think in the chat as to why people who may be thinking about suicide hesitate to ask for it.

Shame is one of the things I’ve heard. Fear of being judged by stigma. You guys are right on this. Probably the biggest one is stigma. Feel that other people might not be able to help them. That’s a good one. Embarrassed. All right.

One of the more common things that we see or hear, and I think you guys touched on some of these, so unwilling to admit, needing help. That could be part of that embarrassment. I’m afraid to upset or anger others, right? Maybe it’s a parent or a spouse family member. We don’t want to get them involved because they have enough going on. We don’t want to scare them. We don’t want to upset them or anger them.

Unable to describe their feelings or needs. This may be the first time they’re ever dealing with some of these thoughts and some of these feelings. They might not be able to articulate what’s going on, or be unsure of available help or resources.

Maybe not even having access to some of those resources. We talked about rural communities sometimes not having a lot of resources. Maybe there just aren’t resources available.

Struggling with symptoms of depression. One of the common symptoms of depression is decreased energy, right? If we’re having a hard time getting out of bed in the morning, chances are we’re going to have a hard time reaching out for help as well.

Don’t know what to expect, right? How is this going to affect my relationships with, you know, my significant other or my friends? How’s this gonna affect my employment? What if I get Baker Acted? What is that going to mean? How is that going to affect my future? A lot of things to worry about, and then shame, fear. Stigma is the biggest one. I think all, a lot of you guys touched on that, you know, stigmas have a big part not just with suicide, but with mental health in general. People are afraid of being judged.

When we talk about stigma, you know, people oftentimes could be shunned because of it, or is there a stereotype? There may be people who don’t trust them anymore because of that. Society sometimes looks at suicide and people who attempt suicide as being a coward or being selfish. Right? There’s all of this negativity and all of this taboo around suicide that we’d rather just not even come out and talk about it because we’re afraid of what people are going to think.

We’re afraid of being judged, and we’re afraid about that stigma. The way we talk about suicide kind of feeds into that stigma as well. Right? When we hear suicide being talked about, we often hear it with the word commit, right? We hear someone say “this person committed suicide,” or “this person’s going to commit suicide.”

When we think about that word commit for a second and think about other things that people commit, we think about crimes and sin and adultery and murder, all taboo, negative things. When we use that word commit, when we talk about suicide, we’re kind of placing that negative connotation on suicide as well.

There’s this really big move in the mental health community to try to shift the verbiage that we use. Instead of seeing someone committed suicide, we say that someone died by suicide. We try to look at it as a form of death, the same way someone dies of a heart attack, the same, same way that someone dies of cancer, someone dies by suicide, right? Something that happens.

We know that there’s a lot of different factors that play a role when someone thinks about suicide, right? Maybe a lot of things that aren’t in their control,so we want to be sensitive to those things. When we have family members who lost someone to suicide, and we hear the word commit being used, there’s a lot of that shame attached to it as well.

We try to be a little more sensitive as far as how we use that word and how we describe it. If someone died of lung cancer, because they smoked for 40 years of their life, we wouldn’t say that that person committed lung cancer, right? So we look at suicide in that same way.

When we’re talking about what are some of the things that lead up to it, we mentioned that there are a lot of factors that play a role in why someone thinks about suicide, and also what differentiates them between just thinking about suicide and actually being able to attempt suicide.

To get a closer look at that, we’ll look at Thomas Joiner’s theory of suicide. Thomas Joiner is a world renowned suicidologist at Florida State University. Brian mentioned at the beginning that I went to The University of Florida. I’m not going to hold that against him. We’re big rivals, but Thomas Joiner has studied his entire life and dedicated his entire career to studying suicide. His father actually died of suicide, and it was kind of his main motivating factor to try to understand more about it.

What are some of the things that go on? So, Thomas Joiner came up with this theory and he says essentially that whenever you have thwarted belongingness, which just means that you are alone at a chronic level, that could be, you know, literally alone, right?

For elderly people, for example, their families leave, their friends pass on, maybe their spouse as well, or other people who feel alone in their feelings. Maybe they have mental health issues that they feel no one understands or post traumatic stress that people wouldn’t understand. They feel alone in that.

That loneliness that’s twarted belongingness paired with perceived burdensomeness, which again, just a fancy way of saying that they feel like they’re a burden on their loved ones on their friends or family, maybe even society, when you have those two things together is when we get a desire for suicide. That’s when someone may be starting to think about suicide as an option.

I mentioned before that attempting suicide is hard to do. We kind of have this ingrained biological need to survive. There’s a threshold that needs to be crossed in order for someone to actually attempt suicide. It’s not until we introduce a capability for suicide that we actually see a suicide or near-lethal suicide attempt.

What does capability for suicide entail essentially are things that influence someone to not be as afraid to die anymore, or lowers that fear of death. There’s a couple of things that play a role in that.

Thomas Joiner says that the more that we’re exposed to trauma, whether that’s directly or indirectly, for example, first responders, physicians, they see some of the most traumatic things on a daily basis. Whenever we experience trauma, it increases our capability for suicide because we become less and less afraid to die. We become desensitized to that trauma.

The other part of that is a desensitization to pain. Thomas Joiner did a lot of experiments where he found that there was a strong correlation between people’s threshold for pain, their ability to tolerate pain, and their capability for suicide. Part of that touches on self-harm behavior.

Whenever we have someone or we see someone who’s self-harming, it’s important that we understand that it’s a) it’s a coping mechanism. It’s their way of dealing with something that’s been really difficult for them, and it’s something that works for them. The problem with self-harm behavior very much like substance use is that the more we go on with whatever problem it is that we’re trying to cope with, the higher the intensity needs to be, whatever it is that we’re doing to cope.

So for example, with substances, they need a higher intensity, a higher dosage of whatever they’re using to feel the same effect. With self-harm behavior, it’s really similar as well. Something that may be a small cut may not do it for them anymore. It needs to be multiple cuts or deeper cuts or cuts on more sensitive parts of the body.

What ends up happening is they run the risk of getting to the point where it no longer serves as a coping mechanism and suicide becomes an option, but then that increased tolerance for pain is there. Now the more that they can tolerate pain, the more that they can inflict pain on themselves, the more that capability for suicide increases. So just to kind of summarize what Thomas Joiner says: whenever we have thwarted belongingness and feeling like a burden, that’s when we get a desire for suicide.

When we entered this we introduced this third component, which is the capability for suicide, that’s when we actually see a suicide or suicide attempt. What are some of the clues that tell us that someone may be thinking about suicide?

The clues that we use are going to be in the form of risk factors and warning signs. There’s a clear difference between a risk factor and a warning sign. Just to quickly go over that risk factors and warning signs. We can look at risk factors of heart disease and warning signs of a heart heart attack as a good example of trying to understand the difference between them. A lot of us tend to be familiar with those. If we talk about risk factors of heart disease, for example, things like family history, increased cholesterol, high cholesterol, high blood pressure, poor diet, lack of exercise, these are all things that increase someone’s risk for heart disease.

It doesn’t necessarily mean they’re ever going to develop heart disease, right? It just kind of places them in this pool where the risk is elevated. When we talk about a warning sign of a heart attack, for example, those are more things that tell us that risk is imminent, right? There are things that we can see– someone holding their chest, someone who has chest pain, maybe numbness in an arm, sweating shortness of breath, someone saying, I think I’m having a heart attack.

These are all things that tell us we need to intervene right away. When we look at risk factors and warning signs of suicide, it’s really similar. Risk factors of suicide are going to be things that increase risk in general, but does not necessarily mean that risk is imminent. With risk factors of suicide it tends to be situational, and loss is a common theme.

We’ll look at some of the common risk factors of suicide. Warning signs on the other hand are going to be very specific changes, very specific to that person that we can see. They tend to be changes in behavior and they tell us the risk is imminent. We need to intervene right away.

Let’s take a look at some common risk factors of suicide. As I mentioned, these tend to be situational and loss is a common theme. We see loss of any major relationship, loss of a friend, loss of employment, right? Loss of freedom. These are all things that are situational. These happen to a lot of people, but it’s our ability to cope with resiliency that we’ve built that differentiates how we’re able to manage these certain things that happen to us.

For some people, this may be just something that you know, is difficult for a little while, and they’re able to get through it. They’re able to cope through it, but for many people, this could be that trigger event. It could be that one thing that really makes them feel hopeless enough to look at suicide as a potential option.

When we look at warning signs, things that tell us that risk is imminent, their behavior changes. There are things that are pretty specific that someone is doing that tell us that something has happened and we need to have a conversation with them. We need to intervene right away. So feeling trapped with no way out, statements of hopelessness and acquiring a gun or stockpiling pills, the statements of hopelessness, and despair are some of the biggest things, right?

When someone’s thinking about suicide, oftentimes it’s not necessarily that they want to die. It’s just that they haven’t found the solution to whatever problem they’re going through. And so they just have this feeling of hopelessness that feels like there’s no way out. Whenever we see some of these things, we can tell that something’s happened and we need to intervene.

Sometimes these warning signs are going to be verbal cues. Sometimes they’re really direct and obvious– someone saying, “I wish I were dead.” “I’m going to end it all.” Most of the time what we’re seeing are indirect verbal warning signs, things like I’m tired of life. It just can’t go on.

Gives us that feeling like something’s wrong, but the person hasn’t really directly said that they’re thinking about suicide. Maybe that’s not what they mean. Maybe they’re just frustrated with everything that’s going on. When we hear some of these things such as, “you know, I just want out, my family would be better off without me,” it’s important that we have a conversation and we ask more about what’s going on. These are kind of our invitations and our opportunities to start that conversation, to intervene.

It’s with the conversation that we can learn more about what’s going on and then get to the point where we asked that suicide question. We can’t ask the suicide question unless we start with a conversation and we can start a conversation with something as simple as “how are you doing.” Really simple question. I know I get asked this question almost every day. I’m sure you guys get asked this question almost every single day, but most of the time it’s just in passing. It’s a formality. “How are you doing?” “I’m doing well.” “How are you? Good.” Then you go on with your day, but the question itself can be really powerful. If we give someone the opportunity to really talk about what’s going on, especially if they’re struggling, it could be a really powerful question.

I’ll give you an example of how there’s a man named Don Richie who’s since passed, but he used to live in Sydney, Australia next to this place called the Gap. For those who aren’t familiar, the Gap is really similar to our Golden Gate Bridge. It was kind of notorious for suicide. Don Ritchie happened to live right next to this place.

So, what Don Richie would do is he’d often see people walking up to the gap, knowing exactly what they were thinking and what was going to go on. He would go up to them and he’d ask that simple question, “how are you doing?” “Why don’t you tell me what’s going on?” “Is there something that I can do for you?”

Don Richie would often invite them back to his house for a cup of tea and he’d do the most powerful thing you can do, which is just listen. He would invite them over and have them tell their story. He’d listen to what’s going on and through that simple act of kindness, Don Ritchie was able to save 160 people’s lives.

Many people believe that that figure is probably actually closer to 400. By simply asking that question and inviting people over, he was doing two things. One, he was getting them away from that dangerous situation, right? He was getting them away from the cliff, getting them away from that thing that could be potentially dangerous to them. The second part is he was instilling hope. He was showing people who felt hopeless that there is someone who cares and that there’s someone who’s willing to listen to them. A lot of times just having a conversation and for someone to be able to talk about everything that’s going on could be an immense relief of stress and can make someone feel much better and see things with much more clarity.

For us, that’s something that any of us could do, right? Getting in touch with some people that maybe we haven’t been close with or touching base with people that, you know, we’re a little concerned about. Starting that conversation, asking people how they’re doing so we could start that conversation. Then when we start to see some of those clues, those warning signs, those risk factors, we can move on to asking the suicide question.

When we ask the suicide question, there’s a couple of things that I like to tell people that they can do and to remember that I like to use the acronym “ALIVE.” It stands for acknowledge, listen, invest, validate, and engage. When we acknowledge we’re acknowledging two things.

One, we’re acknowledging the person themselves. So we can do that by actively listening, right? Eye contact, posture, gesturing, verbal nods. These are all things that show someone that we’re listening to what they’re saying.

The second thing that we’re acknowledging is the problem and the concern. We’re making sure that we recognize whatever is going on is a real problem to that person, right? We’re trying not to minimize whatever’s going on and acknowledge that it’s a very real thing.

The next thing is to listen, right? The L stands for listening. When we listen, we want to make sure that we offer empathy rather than try to fix the problem. A lot of times when someone is coming to you with a problem, it may be a natural reaction to want to solve it immediately. Right?

I know that sometimes I’ve gone to someone with an issue and really all I wanted was to be able to talk about it, but I immediately got two or three solutions to try to fix the problem right away. Really, what is going to be helpful is to be able to talk about it and to unload some of that weight that may be on your shoulders. When we listen, we’re there just to be there with that person. We’re fully present. We allow the person to talk freely and we empathize with them rather than trying to fix whatever is going on.

The next thing is to invest. We want to be invested in their lives. We want to be in the moment and take the time to listen to what’s going on. Process feelings, emotions, behaviors, and actions with them. Make sure that we’re not going to be interrupted during this time. This is something that’s really difficult. Maybe they’ve never talked about what’s going on. So you want to be invested in them and what’s going on.

The next is to validate. We want to make sure that we don’t minimize their pain, right? It may be something that doesn’t seem like a big deal to a lot of people, but may be the worst possible thing that’s ever happened to them in their life. We want to accept that. We want to make them feel like it’s okay to feel how they’re feeling because it is.

Then, lastly is to engage. That’s where we’re going to ask the suicide question that I mentioned earlier. When we engage, we’re going to ask clearly and directly, “are you thinking about suicide or are you thinking about killing yourself?” I know that sounds really direct, but the reason we want to ask it in that way is we want to make sure that we don’t lose anything in it. We want to make sure that doesn’t get misinterpreted. We don’t want to lose anything in translation. Right?

It may seem easier to ask someone if they’re thinking about hurting themselves. It sounds a little softer. It sounds like you’re leading into it a little more, but we don’t really know what they’re answering. If they answer yes or no. They may be answering yes to self harm behavior.

Do we know if they’re talking about self-harm behavior? Are they talking about suicide? Maybe they found a way to attempt suicide that isn’t painful, right? Maybe they found that suicide is their way to end the pain. So, no, I’m not thinking about hurting myself. This is how I’m going to end the hurt. When we ask it directly, we’re showing we know exactly what it is that they’re answering to. We know exactly the information that we’re getting. It’s the only way that we’re really going to know what’s going on.

We also don’t want to just come right out and surprise someone by asking if they’re thinking about suicide. So I always give people three tips to asking the suicide question and they’re fairly easy.

The first one is just to show that you care and show that you’re concerned, right? Show that this is coming from a good place. The second is to justify why you’re asking the question, right? We can recite back some of the warning signs that we’ve seen, some of the risk factors that we’re seeing, maybe some of those verbal warning signs that we talked about, repeating some of those things back and explaining that those are the things that are causing you concern. We’re justifying why we’re asking that suicide question. Then, the last part of that is asking the suicide question directly and confidently. Now this could be really hard, right?

Not all of us are going to be comfortable asking the suicide question, and that’s okay. If you feel like you can’t ask someone directly if they’re thinking about suicide, you don’t have to be the one to ask it. You can get someone else involved and let them know why you’re concerned.

Maybe they’re the front that can ask them the suicide question, but we want to try to ask it as confidently as possible. If someone feels like you’re scared when you’re asking or you’re scared of what the answer might be, they may try to protect you. Even if it’s just trying to seem like you’re confident or seem like you’re not scared, we want to make sure that we try to do it in that way. Again, it’s okay if you don’t feel comfortable asking the question, just to make sure that you get someone who is. It could be a friend or family member or someone else that the person trusts.

So moving on, it’s really not as important how we ask the question. It’s just important that we ask the question in general, we want to make sure that we have that conversation and we let them know that we are a support system for them. There’s really only one way to not ask the suicide question and it’s one of these “you’re not suicidal, are you?” “You wouldn’t do something stupid, would you?” “Suicide is a dumb idea, you’re not thinking about killing yourself, are you?”

What’s the answer to all of those questions? It’s no, right? We’re leading with that question, and so we want to make sure that we don’t ask it in that way, because we want to give someone the opportunity to really answer the question. So I mentioned that this is the Q portion of QPR. QPR is evidence-based training question, persuade, refer.

I highly advise you guys that if you want to learn little more about what to do afterwards, that you take QPR. So, this is just going to kind of briefly go over that, and once we have that conversation, we always want to make sure we try to get the person to safety. If we feel like a threat is imminent, and we’re really scared that someone is going to do something about it, make sure that you always call 9-1-1.

You can request the IT officers, which are crisis intervention, intervention-rained officers. They tend to be a little more experienced when it comes to a mental health issues and suicide and things of that nature. You know, you always want to err on the side of safety, if you’re not really sure, or you’re not really, you know, a hundred percent convinced you still want to get 911 involved and get the police involved to be able to, you know, mediate that situation.

If someone says they’re not thinking about suicide, or maybe you’re not worried about them, we still want to make sure they get help. There are different resources that you can reach out to.

The National Suicide Prevention Lifeline is one that’s available 24/7. It’s something that I always advocate for. The phone number for that is 1-800-273-TALK. That’s 8-2-5-5. That’s something that is always available. They have people on the other line that are trained highly on how to deal with crisis intervention. They can help whether it’s the person at risk or someone who’s just asking questions and not sure what they’re supposed to do. They can talk you through all of that. Some additional resources are going to be primary care providers, psychiatric hospitals, walk-in clinics, the emergency department, right?

These are all people who have been trained to be able to recognize some of these signs and some of these risk factors and then know who they can refer to. We want to get a mental health provider involved as well. Then at the Suicide Prevention lifeline, there’s a special prompt when you call that asks for veterans. If you are a veteran they have veterans on the other line who are there and ready to talk to someone, so it’s one when you call.

Then there’s also a text line for people who feel more comfortable texting. That’s something that came about in the last couple of years and that’s 7-4-1-7-4-1. The crisischat.org is another good resource. Again, if you’re not sure, 9-1-1 for any emergency. The main thing is that we link this person to additional resources and we get them to the help that they need.

So, kind of just to wrap up today, I mentioned that part of the reason why I wanted to talk about this today was just with everything that’s going on in the world and all of these added stressors, you know, we have a unique opportunity to make small changes in the world and spread kindness and do little things that might really change someone’s life.

It can be as simple as checking in with someone, sending a text to see how someone’s doing, starting a conversation with someone who, you know, maybe they haven’t had the opportunity to talk to people, giving genuine compliments, someone who did good work. The important thing is that we try to reach out to people nowadays that we’re in a situation where we may not feel as connected as we did before trying to increase that social interaction with other people.

Then again, if we are ever concerned about someone who may be struggling with something, starting that conversation, not being afraid to listen to what’s going on and now, you know, not being afraid to ask that suicide question.

So if anyone has any questions, I’ll stick around afterwards, you can throw them in the group chat. If someone wants to contact me and discuss something on a more personal level, I have my email and my cell phone number. This is my personal cell phone. So you can feel free to call me or text me.

I’m always happy to talk to anyone about anything that maybe they don’t feel comfortable talking about in the chat, but I will stick around and answer any questions that might be in this, in this group chat right now. I want to thank you guys all for being a part of today and thank you guys for being here and for the opportunity to come talk to you guys today. So thank you so much. Thank you for watching this video. We hope you enjoyed the presentation.

Objectives and Summary:

The presentation will take a look at the growing problem of suicide and discuss why people hesitate to intervene and hesitate to ask for help. Michael Crisanto, community outreach specialist at Advanced Recovery Systems, introduces the basics of QPR (question, persuade, refer) and explains the importance of suicide awareness and how to address the issue with a loved one or friend.

After watching this presentation, the viewer will be able to:
  1. Recognize the impact suicide has on people across America and risk factors
  2. Understand the stigma surrounding suicide and talking about mental health
  3. Know how to recognize warning signs, broach the subject of suicide and get their friend or loved one help

Presentation Materials:

Welcome to the Community Education Series hosted by The Recovery Village and Advanced Recovery Systems.

My name is Michael Crisanto. I’m a community outreach specialist here at ARS. I’m going to turn my video off just for the remainder of this because of certain light issues. Today, if you do have any questions, I do want this to be as interactive as possible. I have the chat open as well, so you can type it in the chat and I would love to see people’s reactions and things of that nature.

A little bit about what my experiences moving in: as Brian mentioned, I did work as a community liason, as a regional suicide prevention specialist with different federally-funded suicide prevention grants. In that work, I had the opportunity to present different evidence-based trainings. So I would train different clinicians, teachers, case managers, and counselors but my favorite training to do was with the community.

I would often use evidence-based training called QPR. QPR stands for question, persuade, refer. The reason it was my favorite thing to do with the community is because it, my work with the suicide prevention grants, my job was to try to reduce the suicide rates in the state of Florida. I found that reaching the community and reaching out to them, first of all is kind of the best way to do that.

There’s a stigma around suicide that makes it really difficult for us to talk about suicide. So whenever we’d have these community trainings, we’d have people coming in because they had someone at home that they were worried about, or they worked with a high-risk population.

QPR stands for question, persuade, refer. We call it a gatekeeper training. It’s three easy steps that anybody could take to potentially save someone’s life, so when I got the opportunity to come here and speak to you guys today, I thought it’d be a really important thing to talk about considering everything that’s going on in the world today, with all the added stressors that we have. You know how difficult things have been for everybody learning something that we can all do to potentially save someone’s life.

Today we’re going to touch on that Q portion of QPR, which is going to be the suicide question. That suicide question is going to be, “are you thinking about killing yourself or are you thinking about suicide now?”

I know that for many of you right now, that may seem like a really direct way of asking that question. Some of you may even be thinking, “I’m not sure if I can actually ask that question.” We’re going to touch on why it’s important that we ask it in that way. We’re going to talk about why it’s important to ask the question and also how we can go about asking that question.

Before we dive into all of that, I wanted to talk about what suicide looks like in the country today. Suicide has been a growing problem over the last couple of decades. In fact, the suicide rate has slowly increased over the past 20 years or so.

When we look at 2018, these are the most recent statistics that we have. It takes about two years to gather this data. So in 2018, we saw that there were over 48,000 completed suicides. To put that into perspective, it’s about one person, every 10.8 minutes or 134 people a day. That would be like if there was a commercial airliner going down every single day with no survivors.

If that were to happen, we’d hear about it. Right? We’d hear about it in the news. We’d hear about it every single day. We don’t really hear about suicide as often we hear about it if it’s a high profile celebrity or if it happens in a school or something along those lines, but we’re not really talking about how common it really is.

In fact, suicide is this common that it’s the 10th ranking cause of death in the US, and homicide is 16th. When I first started working in suicide prevention, I remember I was really surprised by that. I think that like many of us, I have the misconception that homicide happens more often. I think we see it so much more in the news and in media and movies. We kind of assume that it just happens more often. Suicide is actually accounting for more deaths than homicide. In fact, suicide is the second leading cause of death amongst youth ages 15 to 24.

The only thing that accounts for more deaths in that age demographic is accidents. It’s important to highlight accidents because although we saw over 48,000 suicides in 2018, some of the research is starting to show us that that number is probably closer to about 70,000 or 80,000. Accidents are a big reason for that. Sometimes accidents get reported as accidents, but may in fact, be suicide attempts. A single driver motor vehicle accident, for example, or someone falling onto train tracks during an overdose.

Sometimes those are reported as accidents and they may very well have been suicide attempts. It’s important that we understand that suicide is common enough to the point that we may be actually seeing about 80,000 suicides every single year.

When we talk about suicide attempts, we see that females attempt at a higher rate. There’s about three female attempts for each male attempt. On the other hand, we see that males are dying at a higher rate from suicide. There’s about 3 ½ male deaths for each female death.

I wanted to ask you guys, I mentioned that I want this to be as interactive as possible. If you wouldn’t mind putting in the chat, what do you think some of those reasons are? Why, although females that are attempting at a higher rate we see males dying at a higher rate by suicide? I’ll give you guys a couple of seconds. If I don’t see any answers, I’ll just give you guys the answer. It’s no problem. Curious to see what you guys think.

We have means of attempt, less lethal means. Absolutely. Someone said use of guns and that’s actually the main reason. Men are more likely to use firearms, which has a higher lethality. Whereas females are more likely to use different forms of suicide, such as asphyxiation or overdoses that have a higher survival rate. Although females are attempting at a higher rate, the use of firearms accounts for more male deaths.

We look at Florida. I worked in Florida. I live in Florida. I like to use Florida as a comparison to how the U S is doing. The suicide death rate in the U S is 14.2. So that’s per capita 14.2 per 100,000 people. In Florida, our suicide death rate is about 14.8, so we’re not too far off. It ranks us 29th, meaning there are 28 states that have higher suicide rates than us.

Some of those states are going to be Montana, Alaska, Colorado. Some of those mentioned there, Oklahoma West, Virginia, Tennessee, I’d like you guys to think about what are some of the things that these states have in common that you think account for higher suicide rates? What are some of the commonalities that you see among states like Montana and Oklahoma and Tennessee that you think are accounting for higher suicide rates.

So I’m seeing isolation, poverty, less populated and then rural. So, yeah, absolutely. Some of the things that I often hear sometimes are weather. You know, these tend to be colder states. They have longer winters that can account for seasonal affective disorder because winters are so long and dark and cold. Sometimes people get depressive symptoms associated with the weather and, you know, we know that depression is highly correlated with suicide, so that’s one of them, but you guys are absolutely right.

Poverty could be one of them. A lot of these states tend to be lower on socioeconomic status. There’s higher drug use, but being rural is really the biggest issue there. When we have rural communities, we see that there are less resources and there’s more isolation and less opportunity for social connectedness. Those are really the biggest reasons.

I’ve worked here in Florida, and when we look at the different counties here in Florida, we see the same trend, the more rural communities tend to have higher suicide rates because they have less resources. They have more isolation and less opportunity for that social connectedness.

Some of the counties that I’ve worked in, we’ve seen things such as less access to resources. There’s not enough mental health providers. There’s not enough mental health providers who take certain insurances. There’s no public transportation, things of that nature. All of those things play a big role in that.

I wanted to start off by looking at some of these numbers, because I wanted to show you guys how common suicide really is, but as common as suicide is, oftentimes we find it really difficult to talk about suicide, right? We may have seen someone who may be struggling with something. We may even get that gut feeling like they may be thinking about suicide, but we have a really hard time talking about suicide.

When it comes down to a friend or a loved one or a coworker that we’re concerned about, sometimes we hesitate to intervene or we fail to intervene. I want to ask you guys, why do you think that people hesitate to intervene when they think that someone may be struggling with something, when someone may be thinking about suicide or going through something really difficult?

Let’s hear what you guys think in the chat. So we have, “I don’t want to imply the other person is depressed.” Fear of overstepping, afraid of saying the wrong thing. They may not be comfortable discussing it or understanding the issue. You guys are pretty spot on.

I’ll show you what some of the most common things that we see are. So, not sure about how severe the risk is. What if they’re wrong? I mentioned that there’s a stigma around suicide, a stigma around mental health in general. If someone isn’t thinking about suicide and we asked them, we’re worried that maybe we offend that person, right? Because there is such a stigma around that.

Worried about doing or the right thing. We had someone say that as well, feeling like maybe you’re not prepared or that there’s a very specific thing you’re supposed to say in those situations, and you’re not quite sure what that is. If you don’t say that, then maybe you say the wrong thing.

Feelings of inadequacy, feeling like you’re not necessarily qualified to intervene in that situation.

One of the biggest ones that I often hear is afraid to put the idea in someone’s head. This is probably the biggest myth and misconception that’s out there around suicide is being afraid that if we ask someone about suicide, who’s not thinking about suicide, are we going to give them the idea to think about suicide? Or are they going to think that maybe I should be thinking about suicide, and that’s just absolutely not true. When someone’s thinking about suicide, they’re either thinking about suicide or they’re not thinking about suicide. A question isn’t going to be able to persuade someone not to.

As human beings, we kind of have this biological instinctual need to survive. It’s kind of ingrained in us. There’s this threshold that needs to be crossed in order for us to be able to actually attempt suicide, and we’ll touch on those in a little, in a couple of slides, but simply asking a question isn’t going to override that instinctual need to survive. Someone who is thinking about suicide is already thinking about suicide. A simple question isn’t going to get them to change their mind about things.

Feel like it’s not their issue, and then the bystander effect is a big one. So for those who aren’t familiar with the bystander effect, it was this phenomenon that came back and around the late 1960s.

There was a young lady named Kitty Genovese. She was brutally stabbed to death in front of her apartment building. What made it really interesting was the fact that there were tons of onlookers. There were people who were watching through windows who were walking by and no one did anything about it. No one called the police, no one tried to stop. No one tried to intervene and people were really confused by this. Why didn’t anyone do anything to try to help this young lady?

Researchers looked into it and they came up with what was called the bystander effect. It breaks down into two parts. The first part is called perceived diffusion of responsibility, which is just a really fancy way of saying that the more people that are around the less we feel like that responsibility falls on us, right? In the case of kitty Genovese, people probably saw that there were a lot of people there. They felt like, “well, I don’t need to be the person to call the police. I don’t need to be the person to intervene because surely someone is going to step-up.”

What ends up happening is everyone has that same mindset. No one does anything about it. When we talk about suicide we have the similar thing happen. It can be someone that we see that’s really struggling, maybe having a tough time. We get that gut feeling like something may not be right, but we don’t intervene because we assume, “well, someone is seeing what I’m seeing, I’m sure, right?”

Whether it’s a family member, a friend, a coworker, maybe it’s a teacher or classmates or someone at church or a teammate, someone involved in their life is clearly seeing what I’m seeing and they’re intervening and the situation is being taken care of. Someone’s talking to them about it. What ends up happening is very similar to Kitty Genovese. No one does anything about it. This person ends up struggling alone and no one lends a helping hand. No one has a conversation with them to see what’s actually going on.

The other part of the bystander effect is called normative social influence. Again, another fancy researcher way of saying that whenever we’re not really sure what we’re supposed to do in a situation, we look at other people to learn how we’re supposed to act.

An example of this is a really common experiment in sociology. It takes place in an elevator. What researchers do is they have people inside of the elevator waiting for people to come on, but they face the back of the elevator. When people come in, they hit the floor that they’re going to. Instead of normally facing the front of the doors, like we normally do, they see that everyone’s facing the back, and they turn around and face the back even though it’s something they’ve probably never done. Maybe it doesn’t even feel comfortable to do. The reason for that is when we’re unsure, and we see other people doing something we feel like that’s what we’re supposed to do.

When it comes to suicide, it’s really similar. We might grow up because of certain cultural norms, not wanting to get involved in people’s business, or, it’s not something that we’ve learned to be able to intervene in those situations.

I’ll give you an example. I’m Hispanic. My parents are from Peru and in our culture, it’s common to be really private about our lives and the other hand, respect other families’ privacy. If someone is going through something with mental health issues or struggling, it’s not really our business. That’s something that I grew up learning and it took me going and working in the mental health field to really understand that we’re really doing a disservice.

I bring up the bystander effect so that one, we understand what happens and then, so that we can try to override it. Intervening is going to be a potential way of saving somebody’s life because maybe no one else is.

On the other end of that when someone is potentially thinking about suicide or they’re really struggling for something, what are some of the reasons that you think people hesitate to ask for help? So I’d love to hear what you guys think in the chat as to why people who may be thinking about suicide hesitate to ask for it.

Shame is one of the things I’ve heard. Fear of being judged by stigma. You guys are right on this. Probably the biggest one is stigma. Feel that other people might not be able to help them. That’s a good one. Embarrassed. All right.

One of the more common things that we see or hear, and I think you guys touched on some of these, so unwilling to admit, needing help. That could be part of that embarrassment. I’m afraid to upset or anger others, right? Maybe it’s a parent or a spouse family member. We don’t want to get them involved because they have enough going on. We don’t want to scare them. We don’t want to upset them or anger them.

Unable to describe their feelings or needs. This may be the first time they’re ever dealing with some of these thoughts and some of these feelings. They might not be able to articulate what’s going on, or be unsure of available help or resources.

Maybe not even having access to some of those resources. We talked about rural communities sometimes not having a lot of resources. Maybe there just aren’t resources available.

Struggling with symptoms of depression. One of the common symptoms of depression is decreased energy, right? If we’re having a hard time getting out of bed in the morning, chances are we’re going to have a hard time reaching out for help as well.

Don’t know what to expect, right? How is this going to affect my relationships with, you know, my significant other or my friends? How’s this gonna affect my employment? What if I get Baker Acted? What is that going to mean? How is that going to affect my future? A lot of things to worry about, and then shame, fear. Stigma is the biggest one. I think all, a lot of you guys touched on that, you know, stigmas have a big part not just with suicide, but with mental health in general. People are afraid of being judged.

When we talk about stigma, you know, people oftentimes could be shunned because of it, or is there a stereotype? There may be people who don’t trust them anymore because of that. Society sometimes looks at suicide and people who attempt suicide as being a coward or being selfish. Right? There’s all of this negativity and all of this taboo around suicide that we’d rather just not even come out and talk about it because we’re afraid of what people are going to think.

We’re afraid of being judged, and we’re afraid about that stigma. The way we talk about suicide kind of feeds into that stigma as well. Right? When we hear suicide being talked about, we often hear it with the word commit, right? We hear someone say “this person committed suicide,” or “this person’s going to commit suicide.”

When we think about that word commit for a second and think about other things that people commit, we think about crimes and sin and adultery and murder, all taboo, negative things. When we use that word commit, when we talk about suicide, we’re kind of placing that negative connotation on suicide as well.

There’s this really big move in the mental health community to try to shift the verbiage that we use. Instead of seeing someone committed suicide, we say that someone died by suicide. We try to look at it as a form of death, the same way someone dies of a heart attack, the same, same way that someone dies of cancer, someone dies by suicide, right? Something that happens.

We know that there’s a lot of different factors that play a role when someone thinks about suicide, right? Maybe a lot of things that aren’t in their control,so we want to be sensitive to those things. When we have family members who lost someone to suicide, and we hear the word commit being used, there’s a lot of that shame attached to it as well.

We try to be a little more sensitive as far as how we use that word and how we describe it. If someone died of lung cancer, because they smoked for 40 years of their life, we wouldn’t say that that person committed lung cancer, right? So we look at suicide in that same way.

When we’re talking about what are some of the things that lead up to it, we mentioned that there are a lot of factors that play a role in why someone thinks about suicide, and also what differentiates them between just thinking about suicide and actually being able to attempt suicide.

To get a closer look at that, we’ll look at Thomas Joiner’s theory of suicide. Thomas Joiner is a world renowned suicidologist at Florida State University. Brian mentioned at the beginning that I went to The University of Florida. I’m not going to hold that against him. We’re big rivals, but Thomas Joiner has studied his entire life and dedicated his entire career to studying suicide. His father actually died of suicide, and it was kind of his main motivating factor to try to understand more about it.

What are some of the things that go on? So, Thomas Joiner came up with this theory and he says essentially that whenever you have thwarted belongingness, which just means that you are alone at a chronic level, that could be, you know, literally alone, right?

For elderly people, for example, their families leave, their friends pass on, maybe their spouse as well, or other people who feel alone in their feelings. Maybe they have mental health issues that they feel no one understands or post traumatic stress that people wouldn’t understand. They feel alone in that.

That loneliness that’s twarted belongingness paired with perceived burdensomeness, which again, just a fancy way of saying that they feel like they’re a burden on their loved ones on their friends or family, maybe even society, when you have those two things together is when we get a desire for suicide. That’s when someone may be starting to think about suicide as an option.

I mentioned before that attempting suicide is hard to do. We kind of have this ingrained biological need to survive. There’s a threshold that needs to be crossed in order for someone to actually attempt suicide. It’s not until we introduce a capability for suicide that we actually see a suicide or near-lethal suicide attempt.

What does capability for suicide entail essentially are things that influence someone to not be as afraid to die anymore, or lowers that fear of death. There’s a couple of things that play a role in that.

Thomas Joiner says that the more that we’re exposed to trauma, whether that’s directly or indirectly, for example, first responders, physicians, they see some of the most traumatic things on a daily basis. Whenever we experience trauma, it increases our capability for suicide because we become less and less afraid to die. We become desensitized to that trauma.

The other part of that is a desensitization to pain. Thomas Joiner did a lot of experiments where he found that there was a strong correlation between people’s threshold for pain, their ability to tolerate pain, and their capability for suicide. Part of that touches on self-harm behavior.

Whenever we have someone or we see someone who’s self-harming, it’s important that we understand that it’s a) it’s a coping mechanism. It’s their way of dealing with something that’s been really difficult for them, and it’s something that works for them. The problem with self-harm behavior very much like substance use is that the more we go on with whatever problem it is that we’re trying to cope with, the higher the intensity needs to be, whatever it is that we’re doing to cope.

So for example, with substances, they need a higher intensity, a higher dosage of whatever they’re using to feel the same effect. With self-harm behavior, it’s really similar as well. Something that may be a small cut may not do it for them anymore. It needs to be multiple cuts or deeper cuts or cuts on more sensitive parts of the body.

What ends up happening is they run the risk of getting to the point where it no longer serves as a coping mechanism and suicide becomes an option, but then that increased tolerance for pain is there. Now the more that they can tolerate pain, the more that they can inflict pain on themselves, the more that capability for suicide increases. So just to kind of summarize what Thomas Joiner says: whenever we have thwarted belongingness and feeling like a burden, that’s when we get a desire for suicide.

When we entered this we introduced this third component, which is the capability for suicide, that’s when we actually see a suicide or suicide attempt. What are some of the clues that tell us that someone may be thinking about suicide?

The clues that we use are going to be in the form of risk factors and warning signs. There’s a clear difference between a risk factor and a warning sign. Just to quickly go over that risk factors and warning signs. We can look at risk factors of heart disease and warning signs of a heart heart attack as a good example of trying to understand the difference between them. A lot of us tend to be familiar with those. If we talk about risk factors of heart disease, for example, things like family history, increased cholesterol, high cholesterol, high blood pressure, poor diet, lack of exercise, these are all things that increase someone’s risk for heart disease.

It doesn’t necessarily mean they’re ever going to develop heart disease, right? It just kind of places them in this pool where the risk is elevated. When we talk about a warning sign of a heart attack, for example, those are more things that tell us that risk is imminent, right? There are things that we can see– someone holding their chest, someone who has chest pain, maybe numbness in an arm, sweating shortness of breath, someone saying, I think I’m having a heart attack.

These are all things that tell us we need to intervene right away. When we look at risk factors and warning signs of suicide, it’s really similar. Risk factors of suicide are going to be things that increase risk in general, but does not necessarily mean that risk is imminent. With risk factors of suicide it tends to be situational, and loss is a common theme.

We’ll look at some of the common risk factors of suicide. Warning signs on the other hand are going to be very specific changes, very specific to that person that we can see. They tend to be changes in behavior and they tell us the risk is imminent. We need to intervene right away.

Let’s take a look at some common risk factors of suicide. As I mentioned, these tend to be situational and loss is a common theme. We see loss of any major relationship, loss of a friend, loss of employment, right? Loss of freedom. These are all things that are situational. These happen to a lot of people, but it’s our ability to cope with resiliency that we’ve built that differentiates how we’re able to manage these certain things that happen to us.

For some people, this may be just something that you know, is difficult for a little while, and they’re able to get through it. They’re able to cope through it, but for many people, this could be that trigger event. It could be that one thing that really makes them feel hopeless enough to look at suicide as a potential option.

When we look at warning signs, things that tell us that risk is imminent, their behavior changes. There are things that are pretty specific that someone is doing that tell us that something has happened and we need to have a conversation with them. We need to intervene right away. So feeling trapped with no way out, statements of hopelessness and acquiring a gun or stockpiling pills, the statements of hopelessness, and despair are some of the biggest things, right?

When someone’s thinking about suicide, oftentimes it’s not necessarily that they want to die. It’s just that they haven’t found the solution to whatever problem they’re going through. And so they just have this feeling of hopelessness that feels like there’s no way out. Whenever we see some of these things, we can tell that something’s happened and we need to intervene.

Sometimes these warning signs are going to be verbal cues. Sometimes they’re really direct and obvious– someone saying, “I wish I were dead.” “I’m going to end it all.” Most of the time what we’re seeing are indirect verbal warning signs, things like I’m tired of life. It just can’t go on.

Gives us that feeling like something’s wrong, but the person hasn’t really directly said that they’re thinking about suicide. Maybe that’s not what they mean. Maybe they’re just frustrated with everything that’s going on. When we hear some of these things such as, “you know, I just want out, my family would be better off without me,” it’s important that we have a conversation and we ask more about what’s going on. These are kind of our invitations and our opportunities to start that conversation, to intervene.

It’s with the conversation that we can learn more about what’s going on and then get to the point where we asked that suicide question. We can’t ask the suicide question unless we start with a conversation and we can start a conversation with something as simple as “how are you doing.” Really simple question. I know I get asked this question almost every day. I’m sure you guys get asked this question almost every single day, but most of the time it’s just in passing. It’s a formality. “How are you doing?” “I’m doing well.” “How are you? Good.” Then you go on with your day, but the question itself can be really powerful. If we give someone the opportunity to really talk about what’s going on, especially if they’re struggling, it could be a really powerful question.

I’ll give you an example of how there’s a man named Don Richie who’s since passed, but he used to live in Sydney, Australia next to this place called the Gap. For those who aren’t familiar, the Gap is really similar to our Golden Gate Bridge. It was kind of notorious for suicide. Don Ritchie happened to live right next to this place.

So, what Don Richie would do is he’d often see people walking up to the gap, knowing exactly what they were thinking and what was going to go on. He would go up to them and he’d ask that simple question, “how are you doing?” “Why don’t you tell me what’s going on?” “Is there something that I can do for you?”

Don Richie would often invite them back to his house for a cup of tea and he’d do the most powerful thing you can do, which is just listen. He would invite them over and have them tell their story. He’d listen to what’s going on and through that simple act of kindness, Don Ritchie was able to save 160 people’s lives.

Many people believe that that figure is probably actually closer to 400. By simply asking that question and inviting people over, he was doing two things. One, he was getting them away from that dangerous situation, right? He was getting them away from the cliff, getting them away from that thing that could be potentially dangerous to them. The second part is he was instilling hope. He was showing people who felt hopeless that there is someone who cares and that there’s someone who’s willing to listen to them. A lot of times just having a conversation and for someone to be able to talk about everything that’s going on could be an immense relief of stress and can make someone feel much better and see things with much more clarity.

For us, that’s something that any of us could do, right? Getting in touch with some people that maybe we haven’t been close with or touching base with people that, you know, we’re a little concerned about. Starting that conversation, asking people how they’re doing so we could start that conversation. Then when we start to see some of those clues, those warning signs, those risk factors, we can move on to asking the suicide question.

When we ask the suicide question, there’s a couple of things that I like to tell people that they can do and to remember that I like to use the acronym “ALIVE.” It stands for acknowledge, listen, invest, validate, and engage. When we acknowledge we’re acknowledging two things.

One, we’re acknowledging the person themselves. So we can do that by actively listening, right? Eye contact, posture, gesturing, verbal nods. These are all things that show someone that we’re listening to what they’re saying.

The second thing that we’re acknowledging is the problem and the concern. We’re making sure that we recognize whatever is going on is a real problem to that person, right? We’re trying not to minimize whatever’s going on and acknowledge that it’s a very real thing.

The next thing is to listen, right? The L stands for listening. When we listen, we want to make sure that we offer empathy rather than try to fix the problem. A lot of times when someone is coming to you with a problem, it may be a natural reaction to want to solve it immediately. Right?

I know that sometimes I’ve gone to someone with an issue and really all I wanted was to be able to talk about it, but I immediately got two or three solutions to try to fix the problem right away. Really, what is going to be helpful is to be able to talk about it and to unload some of that weight that may be on your shoulders. When we listen, we’re there just to be there with that person. We’re fully present. We allow the person to talk freely and we empathize with them rather than trying to fix whatever is going on.

The next thing is to invest. We want to be invested in their lives. We want to be in the moment and take the time to listen to what’s going on. Process feelings, emotions, behaviors, and actions with them. Make sure that we’re not going to be interrupted during this time. This is something that’s really difficult. Maybe they’ve never talked about what’s going on. So you want to be invested in them and what’s going on.

The next is to validate. We want to make sure that we don’t minimize their pain, right? It may be something that doesn’t seem like a big deal to a lot of people, but may be the worst possible thing that’s ever happened to them in their life. We want to accept that. We want to make them feel like it’s okay to feel how they’re feeling because it is.

Then, lastly is to engage. That’s where we’re going to ask the suicide question that I mentioned earlier. When we engage, we’re going to ask clearly and directly, “are you thinking about suicide or are you thinking about killing yourself?” I know that sounds really direct, but the reason we want to ask it in that way is we want to make sure that we don’t lose anything in it. We want to make sure that doesn’t get misinterpreted. We don’t want to lose anything in translation. Right?

It may seem easier to ask someone if they’re thinking about hurting themselves. It sounds a little softer. It sounds like you’re leading into it a little more, but we don’t really know what they’re answering. If they answer yes or no. They may be answering yes to self harm behavior.

Do we know if they’re talking about self-harm behavior? Are they talking about suicide? Maybe they found a way to attempt suicide that isn’t painful, right? Maybe they found that suicide is their way to end the pain. So, no, I’m not thinking about hurting myself. This is how I’m going to end the hurt. When we ask it directly, we’re showing we know exactly what it is that they’re answering to. We know exactly the information that we’re getting. It’s the only way that we’re really going to know what’s going on.

We also don’t want to just come right out and surprise someone by asking if they’re thinking about suicide. So I always give people three tips to asking the suicide question and they’re fairly easy.

The first one is just to show that you care and show that you’re concerned, right? Show that this is coming from a good place. The second is to justify why you’re asking the question, right? We can recite back some of the warning signs that we’ve seen, some of the risk factors that we’re seeing, maybe some of those verbal warning signs that we talked about, repeating some of those things back and explaining that those are the things that are causing you concern. We’re justifying why we’re asking that suicide question. Then, the last part of that is asking the suicide question directly and confidently. Now this could be really hard, right?

Not all of us are going to be comfortable asking the suicide question, and that’s okay. If you feel like you can’t ask someone directly if they’re thinking about suicide, you don’t have to be the one to ask it. You can get someone else involved and let them know why you’re concerned.

Maybe they’re the front that can ask them the suicide question, but we want to try to ask it as confidently as possible. If someone feels like you’re scared when you’re asking or you’re scared of what the answer might be, they may try to protect you. Even if it’s just trying to seem like you’re confident or seem like you’re not scared, we want to make sure that we try to do it in that way. Again, it’s okay if you don’t feel comfortable asking the question, just to make sure that you get someone who is. It could be a friend or family member or someone else that the person trusts.

So moving on, it’s really not as important how we ask the question. It’s just important that we ask the question in general, we want to make sure that we have that conversation and we let them know that we are a support system for them. There’s really only one way to not ask the suicide question and it’s one of these “you’re not suicidal, are you?” “You wouldn’t do something stupid, would you?” “Suicide is a dumb idea, you’re not thinking about killing yourself, are you?”

What’s the answer to all of those questions? It’s no, right? We’re leading with that question, and so we want to make sure that we don’t ask it in that way, because we want to give someone the opportunity to really answer the question. So I mentioned that this is the Q portion of QPR. QPR is evidence-based training question, persuade, refer.

I highly advise you guys that if you want to learn little more about what to do afterwards, that you take QPR. So, this is just going to kind of briefly go over that, and once we have that conversation, we always want to make sure we try to get the person to safety. If we feel like a threat is imminent, and we’re really scared that someone is going to do something about it, make sure that you always call 9-1-1.

You can request the IT officers, which are crisis intervention, intervention-rained officers. They tend to be a little more experienced when it comes to a mental health issues and suicide and things of that nature. You know, you always want to err on the side of safety, if you’re not really sure, or you’re not really, you know, a hundred percent convinced you still want to get 911 involved and get the police involved to be able to, you know, mediate that situation.

If someone says they’re not thinking about suicide, or maybe you’re not worried about them, we still want to make sure they get help. There are different resources that you can reach out to.

The National Suicide Prevention Lifeline is one that’s available 24/7. It’s something that I always advocate for. The phone number for that is 1-800-273-TALK. That’s 8-2-5-5. That’s something that is always available. They have people on the other line that are trained highly on how to deal with crisis intervention. They can help whether it’s the person at risk or someone who’s just asking questions and not sure what they’re supposed to do. They can talk you through all of that. Some additional resources are going to be primary care providers, psychiatric hospitals, walk-in clinics, the emergency department, right?

These are all people who have been trained to be able to recognize some of these signs and some of these risk factors and then know who they can refer to. We want to get a mental health provider involved as well. Then at the Suicide Prevention lifeline, there’s a special prompt when you call that asks for veterans. If you are a veteran they have veterans on the other line who are there and ready to talk to someone, so it’s one when you call.

Then there’s also a text line for people who feel more comfortable texting. That’s something that came about in the last couple of years and that’s 7-4-1-7-4-1. The crisischat.org is another good resource. Again, if you’re not sure, 9-1-1 for any emergency. The main thing is that we link this person to additional resources and we get them to the help that they need.

So, kind of just to wrap up today, I mentioned that part of the reason why I wanted to talk about this today was just with everything that’s going on in the world and all of these added stressors, you know, we have a unique opportunity to make small changes in the world and spread kindness and do little things that might really change someone’s life.

It can be as simple as checking in with someone, sending a text to see how someone’s doing, starting a conversation with someone who, you know, maybe they haven’t had the opportunity to talk to people, giving genuine compliments, someone who did good work. The important thing is that we try to reach out to people nowadays that we’re in a situation where we may not feel as connected as we did before trying to increase that social interaction with other people.

Then again, if we are ever concerned about someone who may be struggling with something, starting that conversation, not being afraid to listen to what’s going on and now, you know, not being afraid to ask that suicide question.

So if anyone has any questions, I’ll stick around afterwards, you can throw them in the group chat. If someone wants to contact me and discuss something on a more personal level, I have my email and my cell phone number. This is my personal cell phone. So you can feel free to call me or text me.

I’m always happy to talk to anyone about anything that maybe they don’t feel comfortable talking about in the chat, but I will stick around and answer any questions that might be in this, in this group chat right now. I want to thank you guys all for being a part of today and thank you guys for being here and for the opportunity to come talk to you guys today. So thank you so much. Thank you for watching this video. We hope you enjoyed the presentation.

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