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Suicide Prevention & Intervention CE Notes
Louise Dunn, M.A., June 2004

Suicide Quiz

Complete the attached quiz and send this in for CE credit.

Demystifying Suicide Intervention

For most New Hope counselors, the concept of having to handle a suicide call or chat is very anxiety provoking. We somehow feel that the process is alien and completely different from what we normally do. In fact, the basic process is the same, with certain additions. We still utilize the techniques of active listening, including reflecting and summarizing. We add in the assessment questions, and we work to establish a contract for living in place of the usual close. We also add in the intervention process when indicated. Yet the essential core of New Hope counseling, showing care and concern, active listening, brainstorming and forming a plan, remain the same.

Establishing Rapport/Red Flags

As with all New Hope chats or calls, we open by establishing rapport. This is accomplished with feeling reflections in response to the chatter's opening remarks. Reflections such as "It seems you are in a great deal of pain, " or statements such as "tell me about today" help to open up the dialogue. Chatters/callers do not always indicate that they are suicidal in their remarks, but often other clues are provided. Statements such as "I am just wasting your time, " or I can't take it any more," may be indications of depression or suicidal thinking. (See the attached handout "Red Flag Expressions of Suicidal Callers/Chatters.") These red flags should prompt us to assess for possible suicidal thinking or planning. If the caller is not suicidal, they will quickly correct you by saying no, and you can continue the normal ABC process with them.

The Assessment Process

When assessing the caller or chatter for suicidal thinking, we take a direct approach. "Are you having suicidal thoughts?" "Do you want to kill yourself?" "Do you have a plan to kill yourself?" If the chatter/caller indicates thoughts of suicide, but says no to having a plan or intending to do it today, this tends to indicate that they are not at imminent risk. We still take the chat or call very seriously, however, as suicidal thinking can lead to a future suicide attempt.

If the chatter /caller indicates that they have a suicide plan, but does not plan to do it today, the risk is measured against the lethality and availability of the plan. For instance, if a loaded gun is present in the house, the lethality is still high, even if the chatter/caller says they do not plan to do it today. A plan that involves steps, such as going to the store to buy something which will facilitate the plan, is actually less lethal, even if the chatter says they may do it today. In either case, if the chatter/caller will not make a contract for living, it may still be appropriate to do an intervention (dispatch the police) if that is possible.

Suicide Intervention

The decision to dispatch the police is a serious one. Certainly if the chatter/caller seems to be making progress towards choosing life, an intervention could be needlessly disruptive. However, our main goal is to ensure the safety of the caller/chatter, and if there is any real indication that they are at risk of completing suicide, we would rather error on the side of caution.

Telephone counselors have an advantage at this point, as they usually get to work in teams of two. It is then the assistant counselor who is going to contact the police or the phone company if a trace needs to be initiated. Online counselors can check the AOL Instant Messenger, however and often another counselor may be available to assist as well. The police can be contacted with all the available information. The first questions they will ask are the assessment questions. Are we sure the person is suicidal, what is the plan, are they planning on doing it now. If a caller plans to take pills, they will also ask if they have taken any yet, what kind of pills they have and the quantity. For this reason, the counselor needs to have done a complete assessment before asking for any assistance.

Reflecting Feelings

Throughout the conversation with the chatter/caller, we continue to reflect their feelings. It is important to validate the feelings, without concurring with the decision to choose suicide. Most people will minimize the feelings of someone who is suicidal, saying things like "Oh you don't mean that." Or "Come on, look at all you have to live for." It is extremely important to validate the fact that the chatter/caller is feeling like there are no other choices, no light in their life. This gives them a feeling of relief at finally being heard. Once the feelings have been fully reflected, you can move forward into diffusing with empathy. (See the attached list of feeling words to use when reflecting the suicidal chatter/caller's feelings.)

Advantages of Suicide

As the chat/call continues, the counselor continues to try to establish rapport and trust. This is done in part, by diffusing the caller/chatter's emotions with empathy. Unlike most people, we do not attempt to pull the chatter/caller out of their world of pain and confusion. Instead we step into the situation, to walk through the darkness with them. Asking about the advantages of suicide allows us to explore their feelings and to be able to reflect these back to them accurately. The decision to kill themselves is often about the desire to stop the pain which is being experienced. This dialogue will also reveal to us where the chatter/caller's thinking is off base. For instance the belief that the family will be better off if they die, or that no one will care, is common and not true. We also ask about the disadvantages of living, which shows that we understand that life does not seem to be an appealing option to them at this point.

Reasons to Live/ Reinforcing Positives

As we continue to move the chatter/caller towards a contract for living, we can begin to focus on reasons to live, by reinforcing the positives in their life. We need to be sensitive to their situation, realizing that what may at one time be a positive can also have become a negative. For instance having a family is generally a positive. However, if the chatter is suicidal because his spouse left him or her and took the kids, this would then be a negative and not an area we wish to dwell on. There are always two positives we can draw on. One, the fact the person reached out for help and second, the relationship we have established. Sometimes, when all else fails, our care and concern about the caller/chatter is enough to make a difference. We also ask the chatter/caller to begin to explore possible advantages of living. We can ask them about things they have enjoyed in the past that they could again enjoy in the future. To think about the good parts of life, to see some hope.

Once we have discussed positive reasons for living, we can also begin to discuss the disadvantages of suicide. Often the chatter/caller has not thought out all the implications of suicide. Suicide is painful. The attempt may not succeed and could leave them disabled or in a coma. Who will find the body? Perhaps a small child, a parent or a beloved pet. Who will really be affected by the death? The chatter usually has no concept of the devastation death by suicide leaves on the survivors.

Setting a Contract for Living

The best possible outcome of a suicidal chat/call, is when you can get an agreement to set a contract for living. We ask specifically if they will contract not to attempt suicide. We explore whom they can talk to for support, by drawing upon all the possible options the chatter/caller can think of, including such things as calling a family member or friend, seeing a therapist or talking to their pastor. We then ask the chatter/caller for a commitment to make that contact. If there is no one the chatter/caller will commit to contacting, we can ask them to follow-up with New Hope the next day to indicate that they are not going to attempt suicide and for continuing support.

Debriefing

Following a suicide chat or call, it is important for the counselor to debrief. For telephone counselors they may have the option of talking to staff, during the day or to their shift mates or a Night Supervisor at night. For the online counselor, contact with the Online Manager or another counselor via AOL Instant Messenger may be available. It is important to take time to process the chat/call and for you to have your own feelings reflected. Taking a short break to regroup, to relax and to pray for the caller is important. You can also pray that you be released from the emotions and the investment you may feel in the contact, turning over the chatter/caller's situation to God to handle. If there is no one available to talk with during your shift, be sure to contact a New Hope staff member the next day, to discuss the contact and to make sure the feelings the contact raised, have all been resolved. Providing support to one another is just as important as the support we give the suicidal person.

Using God's Light to Dispel the Darkness

The subject of suicide intervention and prevention is a serious one. It can feel like an awesome responsibility when we are handling one of these contacts. It is important to remember that God is in control and He has selected you to be His conduit in that moment. The suicidal person is in a place of great darkness and pain, but God uses us to bring His light to dispel the darkness. Our caring, compassion and willingness to listen, can have a serious impact on the chatter/caller who may not have experienced this level of caretaking for a long time. There is hope in every situation, because the person did reach out, giving us the opportunity to bring God's healing touch to them in that moment. We must also trust that God will continue to watch over them, bringing others to shed His light after our chat or call is over.

Red Flag Expressions

of Suicidal Callers/Chatters

The following expressions should alert the counselor to the need to assess for possible suicidal thinking or planning.

I am probably just wasting your time
I don't know why I called; it's all-pointless
There is no reason to go on
I just can't take it anymore
I don't understand why I am still here
It's hopeless
I feel so empty
I can't see any light
No one can help me with this
I have no one in my life who cares what happens
Every day is just so hard to get through
My life has no meaning
I have no energy for anything

I can't undo all the wrong I have done
I just called to say goodbye to someone
I feel so lost and alone
I no longer care about anything or anyone
I don't see why I should keep struggling
The pain is too overwhelming; I just want it to stop
I can't bear living like this anymore
Today is the one year anniversary of my loved one's death by suicide

I have committed the unforgivable sin
Do people who die by suicide go to Hell?
I don't know how to keep going anymore
I am so tired; I just want the craziness to stop
I am a burden to all my loved ones
I hope God can forgive me for what I am about to do
I have stopped taking all my medications, including my heart pills
I feel so disconnected from everything and everyone
I have lost everything
No one cares if I live or die

Feeling Reflection Words to Use with Suicidal Callers/Chatters

Abandoned
Abused
Angry
Anxious
Ashamed
Bored
Confused
Depressed
Discouraged
Grief/loss
Guilt
Hollow
Hopeless
Humiliated
Hurt
Isolated
Lonely
Lost
Numb
Obsessed
Overwhelmed
Pain
Rejected
Resentful
Sad
Scared
Stressed
Struck
Tired
Worn out