Need to know
‘Do you remember that scene in Avengers: Endgame? When Captain America is fighting himself?’
‘I do,’ I assured Bethany.
‘That’s how I feel every night,’ she confessed, tucking her long, blonde hair back behind her ears. ‘It feels like I am fighting myself to stay alive.’
I had been meeting with 17-year-old Bethany twice a week for the past six months to help her understand and move through her depression. Bethany was smart, pretty, a talented musician, and had a streak of sarcasm that made her funny as hell.
And Bethany couldn’t stop thinking about killing herself.
She fought herself to stay alive every day, a dichotomy so beautifully explained in her Captain America reference. (Fortunately, I was a Marvel fan myself, so this gave us an excellent platform to relate back to during the course of treatment.)
There were points during the two years I treated Bethany that it seemed as if the only things that allowed her to stay alive and put one foot in front of the other were small, time-limited goals. Little things that she could look forward to, such as the release of a new movie, or a musical performance she had spent months preparing for.
Bethany ended up in hospital once during the course of treatment. Her psychiatrist was frustrated that her medication wasn’t working, and sent her for a psychiatric consult. She was at the hospital emergency room for six hours, worrying that she was going to fail her French test the next day because she wasn’t getting a chance to study.
This should have been a sign that Bethany was not in immediate danger. But, of course, no medical or mental health professional wants to be wrong in such a situation. No one wants to end up reading about a dead teenager the following morning because they weren’t cautious enough.
How do you ask a friend or loved one if she’s thinking about killing herself? How should high-school teachers and college professors approach someone they’re concerned about?
When a patient comes to me with symptoms of depression and anxiety, by the end of the first session, I always ask about suicidality – in detail rather than merely as a formality. I allow the words they might have been frightened to hear spoken aloud to leave my mouth.
Because I am not frightened of words.
When I was growing up, my mother’s depression and suicidal ideation were never to be spoken about with outsiders. Her suicide attempts and hospitalisations were hidden for longer than should have been possible. By the time I was old enough to realise that my silence had been purchased through years of subtle, silent oppression, her anger and hostility and unpredictable nature had isolated all of us from the friends and family who should have been there to support her – and us.
This realisation, as an adult, freed my mouth to speak openly and honestly as a clinician.
‘It sounds like you’ve been feeling really awful. Have you ever had thoughts of hurting yourself, or of taking your own life?’
If the answer is even the teensiest bit of a yes, I explore it further.
‘I know we just met, and it must have been really difficult for you to tell me that. There is a huge difference between thoughts and actions. How often do you think about killing yourself? Have you ever thought of how you might do it? Have you ever made a real plan and considered following it through?’
Those last questions, a method to take one’s life – and the realistic possibility that this method might result in death – the formation of a concrete plan and the intention to act on it, are the most important pieces of information.
There is a huge difference between a person who thinks about killing himself with a gun, has easy access to a gun, and who would ‘probably do it on a Friday so that Mom didn’t have to be the one to find me’ versus someone who ‘sometimes thinks it would be easier for everyone if I was dead. I don’t know how I would do it, maybe I would just jump in front of a car, or drive into incoming traffic.’
Both are painful to hear. But one is more likely to end in suicide than the other.
Indeed, you don’t have to be a therapist to intervene and help to save a life. What most patients with suicidal thoughts actually want is to have their fears and feelings heard without judgment. Some might want to voice their secret, scary, suicidal fantasies to see if they’re shunned. To see if they are, in fact, as hopeless as they feel.
The purpose of this Guide is to help lay people listen to and support friends and loved ones throughout their depression and suicidal thoughts before professional assistance comes onboard – and during that period as well. Reach out to the people you suspect need help. At worst, your kindness is rejected. At best, your words make someone feel less alone. Your words might be the difference someone needs in order to stay alive another day.
What to do
End the cycle of guilt and shame
The most important part of preventing suicide is encouraging open discussion. Time and again I have heard well-meaning, loving parents advise their depressive, suicidal teenager to remain silent.
‘Don’t tell grandma,’ Mom says, rubbing her daughter’s back encouragingly.
‘I’m not sure you need to tell your friends,’ Dad says. ‘After all, you wouldn’t want them to get the wrong idea.’
‘We have decided not to tell the school,’ a mother informs me – a stance that often precedes the termination of therapy. ‘We don’t want this to affect her ability to get into college.’
The problem is that these well-meaning parents have just implied that this depression, these thoughts of suicide, are something to be ashamed of.
And when that secret is broken – as it will inevitably be, since teenagers depend on their friendships as a part of their burgeoning self-identity – then guilt follows.
Well-meaning parents can make well-meant mistakes. But the need for secrecy adds shame and guilt to the already overwhelming burden of a depressed teenager who is waging a daily war with herself as to whether she can stay alive for one more day. Many people also have the mistaken belief that talking about suicide can encourage it. This is not the case.
When we speak only in whispers about mental health, we’re implying that there’s something ‘less than’ about those who seek treatment to effect change.
Cultivate emotional intelligence
Mental health isn’t an extensive part of our core curriculum, and it’s only recently that having a therapist has become an acceptable norm. We need to find ways to improve our emotional intelligence to prevent suicide.
Put simply, emotional intelligence is:
- Awareness, understanding and the ability to manage your own emotions.
- Awareness, understanding and the ability to manage and/or navigate the emotions of others.
Our expectations of ourselves, and the expectations that we perceive others have for us, take a tremendous toll on our mental health. ‘I’m not thin enough.’ ‘I’m not smart enough.’ ‘I have to get into a good college.’ ‘My wife doesn’t appreciate me.’ ‘My husband left me.’ ‘I don’t make enough money.’ ‘No one will ever love me.’ ‘I hate myself.’ ‘I’m going to be depressed forever.’ ‘Things will never get better.’ We focus on what we feel we lack, rather than focusing on our emotional responses and how we handle these emotions.
How can you improve your emotional intelligence? Think before you act. Consider the consequences of your actions from the other person’s point of view. Take an honest, non-judgmental look in the mirror. How can you be a better person, and are you willing to do the work to get yourself there? Take responsibility for your actions. Apologise if you make a mistake, and make attempts to remedy the situation.
A fine-tuned emotional intelligence will empower you to help your depressed or suicidal friend by asking, directly, whether or not she has thought of taking her life. You should be able to do this without judging that person or making her feel ashamed.
Remember, a person who attempts suicide has given up hope that things will get better. The quantity of happiness she experiences has long been eclipsed by sadness, despair and loneliness – no matter how many people surround them, no matter how much reassurance anyone gives them. They might not mention suicide to their close friends or even to their therapists, even if they have it in mind. I can count on one hand the number of patients who have reported wanting to end their own life as their primary reason for seeking help, because mentioning suicide to your therapist or even a friend is scary. If you don’t ask about this issue, your distressed friend might not bring it up at all.
In an emergency, call for help
If a friend or loved one tells you that she is thinking about killing herself, you should encourage her to seek help but, in order to know what kind of help is needed in the moment, you need to know how immediate the danger is. Is this something your friend is thinking about doing today? Tonight? Immediately?
If the threat is immediate, call emergency services (eg, 911 in the US; 999 in the UK; 000 in Australia); in the US, you can ask them to do a ‘safety check’ because you’re concerned about a loved one’s wellbeing. A police officer and/or other emergency rescue unit will be dispatched to your loved one’s current location. It is important you have their address available before you call.
If the threat is not immediate, encourage your loved one to make an appointment with a mental health professional or primary care physician as soon as possible instead of going to the hospital, where admission to an emergency room or psychiatric ward might just end in referral to an out-patient treating psychiatrist anyway – sometimes delaying the help a suicidal person needs. If you have a small window of time, offer to help with the details of arranging an appointment, which can be overwhelming in and of itself.
The struggle of the social media era is that the people we’re close to are often not physically close, and you might have friends halfway around the world with whom you’ve never been in the same room. In this case especially, the burden of your loved one’s secret might seem like too much for one individual to bear, and so it’s also important to reach out to other people who can help support this person. Encourage your loved one to tell a parent, roommate, relative or neighbour what’s going on – especially if you live far away.
You aren’t faced with the Hobson’s choice of either ‘just listening and not intervening’ or ‘calling an ambulance and taking someone to hospital’. You are a brother, a sister, a parent, a friend. In that role, you can always be there for your loved one while encouraging professional help.
Stay alert to triggering language
Be aware of an ongoing debate over word choice when speaking to suicidal individuals or those grieving a loss. Some branches of the American Foundation for Suicide Prevention, for instance, have taken a firm stance against the word ‘stigma’ to discuss suicide, and the accompanying need to ‘destigmatise’ mental health. The argument is that simply bringing up the word ‘stigma’ at all evokes an additional burden of negativity. The other side of that argument is that, just because we refuse to speak a word, doesn’t mean that this issue ceases to exist.
Another issue involves the phrase ‘committing suicide’. I have spoken to mothers whose children have taken their lives and who are hurt and angry because the phrase makes the death of their child sound criminal. Mental health organisations also advise against using the phrase. And yet, to me, the word ‘commit’ means dedication too, and the 17-year-old me wants to account for that as well. In the 24 years since my mother first attempted suicide, not a day has passed that I haven’t wondered if today would be the day when she’d finally complete this quest for death, which she seemed to want so desperately but was so terrible at achieving.
If there’s a correct answer to either of these two issues, I don’t know it. But if you choose to be an advocate for those who are suffering – and I hope that you do – be aware of the word triggers and missteps that might harm those who have already been harmed more than we can imagine.
Key points – How to talk to a suicidal friend
- You don’t have to be a therapist to intervene when a friend or loved one seems so depressed that he or she could be suicidal. Most people with suicidal thoughts actually want their fears and feelings heard without judgment. Simply allowing them to express their feelings is the first step toward them getting help.
- Don’t cause your suffering friend or family member to feel guilt or shame over a mental illness by asking them to keep their emotions in the shadows.
- To help a suicidal friend, you must cultivate emotional intelligence: the awareness, understanding and ability to navigate your own emotions and the emotions of others.
- If your friend or loved one appears at imminent risk of suicide, call emergency services even if the emergency room seems like it will be an unpleasant experience. It’s better to be safe, and you can always find a specialised therapist in the days and weeks that follow.
- Ask your depressed friend or loved one, directly, whether they’re contemplating suicide.
- When speaking to a suicidal friend or someone grieving a loss from suicide, try to stay away from triggering language such as ‘commit suicide’ or ‘stigma’ that can instil hurt or upset.
- Remember that men and minorities are less likely to seek help, and therefore have an increased risk for suicide. Men are more likely to take their own lives following a divorce or financial crisis. They are also more likely to have access to firearms, which increases the danger; the stricter the gun laws, the lower the rates of male suicide per country.
Most suicidal patients don’t want to keep their thoughts and feelings a secret, but often they do. That’s why one of the most important means at your disposal for protecting a loved one is simply understanding the signs that a suicide attempt might be on the cards. These signs include:
- History of mental health issues: a 2018 study by the US Centers for Disease Control and Prevention found that, of all the people with a known mental health condition when they died by suicide, 31 per cent were female and 69 per cent were male. Mental health issues can be one of many factors that contribute to the risk for suicide.
- History of chronic pain: over prolonged periods of time, pain can increase the risk for suicide due to hopelessness, a desire to escape the pain via death, and a reduced fear of death.
- Self-harm behaviour and suicidal ideation: research from 2016 shows that people who presented with deliberate self-harm behaviour in emergency departments were 56.8 times more likely to die by suicide within a year. People who reported suicidal ideation were 31.4 times more likely to die by suicide within a year.
- Previous attempts: a European study from 2007 found that the two countries with the highest suicide rates (Belgium and France) were also the countries with the largest frequency of suicidal attempts. The countries with the lowest suicide rates (Italy and Spain) also had the lowest frequency of suicidal attempts.
- Past or present stressful life event: a history of interpersonal trauma, childhood trauma and sexual trauma significantly increased the risk of suicidality in both men and women. In the aftermath of a divorce, men are 2.4 times more likely to kill themselves and, during the 2008 financial crisis, one study found that unemployment and financial difficulties contributed substantially to 14 per cent of suicide deaths.
- Talk about feeling helpless and hopeless: in psychology, we speak about ‘learned helplessness’, feeling a total lack of power, control and ability to make positive changes. This is usually the result of a traumatic event, continued failure to succeed in life, or sometimes a part of a prolonged struggle with depression.
- Isolation: suicidal individuals often feel hopeless, misunderstood and isolated from their loved ones. As one patient described it to me: ‘It’s exhausting to have to pretend to feel normal all the time. It’s easier just to stay home.’
- Giving away prized possessions: if you knew you were going to die, wouldn’t you attempt to get your affairs in order? For some people, there is a certain poignancy – is it power? Is it gratitude? – in deciding what part of yourself, of your memory, you want to leave to the people who mattered.
As you go about helping a person in your circle, remember that suicide can be contagious, particularly among teenagers and 20-somethings. Last year, in a six-month period of time, there were three teenagers who killed themselves by the same method within a 10-mile radius of my small hometown.
The risk for suicide is twice as high when a family member has taken their own life. In fact, a family history of suicide can predict suicide even in the absence of a severe mental health issue.
Which brings us back to my story. To her. To she whom I somehow cannot bring myself to name because, even now, a part of me is still struggling to get out from under that pressing thumb of the secret society of suicide: a club for family and friends. Almost exactly a year ago, I put some distance in place. I still answer when my family calls, but I also need to engage in my own self-care and self-protection. I need a warm heart to care for my children. I need a soft heart to forgive myself for not being able to help her. And I need an open heart to listen to my patients, to provide them with the hope, reason and strength they need to stay alive.
As a therapist, I have the opportunity to ask my patients, my friends, my loved ones the difficult questions about depression and suicide. I ask them exactly how likely they are to act on their desperation. I ask them the questions that other people try to avoid, and yet it is these questions that have the potential to save a life. I suggest you do the same. Ask questions. Be curious. Be supportive. And let them know that they are loved.
Links & books
For support and information, try these sites first:
- Beyond Blue: an Australian non-profit working to address issues of depression, suicide, anxiety and mental illness.
- American Foundation for Suicide Prevention: covers the basics and provides suggestions and contacts for local help.
- Samaritans: offers advice for those struggling with suicidal thoughts, and for those close to them, with special sections on the pandemic and for key workers.
For deeper immersion and greater insight, these books can help:
- The Gendered Landscape of Suicide: Masculinities, Emotions, and Culture (2019) by the Irish sociologist Anne Cleary. Men are at heightened risk; here’s what you need to know to help them.
- How I Stayed Alive When My Brain Was Trying To Kill Me (rev ed, 2019) by the American author Susan Rose Blauner. After multiple suicide attempts, this motivational speaker and writer explains how she saved her own life.
- It’s OK That You’re Not OK: Meeting Grief and Loss in a Culture That Doesn’t Understand (2017) by the American grief advocate Megan Devine dives deep into the author’s own life to explore how love and healing come together after a loss.
- Aftermath: Picking Up the Pieces After a Suicide (2019) by the American grief counsellor Gary Roe. For grieving survivors, this book by a former missionary and pastor offers a way to get through the upheaval and pain.
- Calypso (2018) by the American humourist David Sedaris reflects on family and life, including the painful suicide of his younger sister, Tiffany.
- For Colored Girls Who Have Considered Suicide/When the Rainbow is Enuf (1976) by Ntozake Shange. The award-winning ‘choreopoem’ from the late African American playwright and poet shows how seven women of colour overcome life’s troubles with help from their friends, in poetry and in song.
In the US, the National Suicide Prevention Lifeline is 1-800-273-8255
In the UK and Ireland, Samaritans can be contacted on 116 123 or email
firstname.lastname@example.org or email@example.com
In Australia, the crisis support service Lifeline is 13 11 14
Other international helplines can be found at www.befrienders.org