New Hope CE Notes
Suicide Workshop March, 2006
Louise S. Dunn, M.Ed.

INTRODUCTION

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.

LATEST STATISTICS

Suicide Deaths and Attempts
Current estimates of suicide completion are 87 per day in USA.
1 death every 17 minutes
25 Attempts for each completion
11th Leading cause of Death in US

Groups at Highest Risk
50% Higher Risk in Elderly
3rd highest cause of death among 15-24 year olds
Males complete at a rate 4 X woman: However
Woman attempt at a rate 3 X more than men.
Socially isolated people are at a much higher risk
Alcoholics complete suicide at a rate 50-70% higher than general population.
People diagnosed with depression complete 50% more than general public
90% of people who completed suicide have a presence of a psychiatric disorder such as depression, drug or alcohol addiction, behavior or conduct disorders, schizophrenia.

Most Common Means Used
Firearms are the most common about 54% of Fatalities
Hanging is gaining in its use
Pills and wrist cutting high among attempts for women

Signs to watch for:
Thoughts of suicide, death, dying
Expression of feelings of boredom, sadness
Lack of interest in previous activities
Significant weight loss or gain
Insomnia
Fatigue or loss of energy
Inability to concentrate or indecisiveness
Impulsive and aggressive behavior Expressions of rage
Increased use of drugs/alcohol
Acting recklessly
Withdrawing from friends and family
Giving Away prized possessions
Not interested in personal appearance Dramatic mood swings
Anxiety
Talking or writing about death
Sudden mood elevation
Making out a Will

Recent severe stressors
Loss of job
Unplanned pregnancy
Extreme financial difficulties, (Foreclosure/repossessions)
Sexual orientation issues
Have lost someone to death
Have lost someone to suicide
Have attempted before
Have limited social support
Have a debilitating disease


SURVIVORS OF SUICIDE

What is a Survivor?
Survivors are any loved ones left behind when someone completes suicide. This includes family, friends, co-workers and others who knew the individual personally. Statistics indicate that at least 6 people are seriously impacted by every suicide, but I believe the number to be far higher due to the ripple effect. Virtually everyone we encounter is profoundly affected by our life and our death.

Survivors have a high risk of suicide immediately following the loss of a loved one to suicide. Somehow being close to someone who makes that choice makes it seem more viable. Survivors often feel tremendous guilt, feeling they should have been able to so something to stop the suicide, or that they should have known that the person was in such anguish.

How Does a Survivor Survive?
Survivors have a special need to talk with other survivors. Support groups are helpful, as the normal grieving process is complicated by anger, confusion and guilt issues which go beyond usual grieving, and it hard for anyone who has not experienced this to understand. Survivors of suicide also may have to deal with more stigma issues than survivors of other losses. People may tell them the loved one is going to Hell, and may avoid them all together. They may also feel disconnected, as memories of the loved one may be more painful because of the choice they made.

How Do We Walk With Survivors?
Friends and relatives usually cannot offer enough of the support needed. Survivors will go through the same stages of grief as others, but it may take as much as twice the length of time. One reason is that may get stuck on asking "why?" a question that often has no real answer. In order for true healing to begin, the survivor has to reach a point where they realize it was not their fault. They also need to forgive the loved one for what they chose to do. They need not to place blame on anyone, as they may often do in the beginning, just to deal with the pain. Listening and reflective listening are our best tools to help. Giving our non-judgmental caring is also very valuable. Referrals to support groups or counseling may also be needed.

How Does a Survivor Learn to Thrive?
Being allowed to fully express their grief is an important step for survivors to move forward with life. For many survivors, doing things to honor the loved one helps them to feel reconnected. This can be walking in suicide prevention marches, volunteering at a suicide hotline or hospital, or perhaps donating to charities that deal with families of people who died by suicide. Other ways of honoring loved ones can be the same as anyone who has suffered a loss. Planting a tree in the person's name, donations in their name or anything that keeps the memory of the loved one alive may help.


A SURVIVOR'S STORY (Louise Dunn)

For 15 years I had a friend named Diane. Diane was a special person, born to a poor family. There often was no food, no presents for birthdays and Christmas, no Christmas tree. But she rose above it all, completing her Master's degree in counseling and becoming a vocational rehabilitation counselor. What I loved most about Diane, was her great love of God. She studied the Bible all the time and seemed to have an amazing, positive faith which had guided her through a hard life.

Diane started an antique business which flourished for a few years, but with the recession of the nineties the antique boom slowed to a crawl. Eventually, I joined her business as a kind of "silent partner." She remained the main person running the business, and I helped out at shows on weekends, which was kind of fun. The business eked out a meager living for Diane, and as I was renting a large house, I asked her to become my roommate, as it would help us both financially. Then, one day, just before the fourth of July, a neighbor kid's bottle rocket hit our shake roof, and lit it on fire. Diane was home at the time, and heard the neighbors shouting for her to get out of the house. The fire department came and put out the fire, and the damage was minimal. But a huge hole, about 10 by 10 was left in the roof of our family room.

It would take weeks to replace the roof, and since we were only renting, we decided to move. Diane went to stay with her cousins and I stayed with friends, while we both searched for a permanent residence. I ended up buying a mobile home, and Diane stayed with her cousins, but all the business inventory went into storage units, which cost a great deal to maintain. Diane became depressed and obsessively worried about finances. I persuaded her to move in with me, but unlike my previous house, there was no room to store the inventory or to work on pricing. Diane continued to be depressed.

On Sunday night, December 13, 1998, Diane's truck engine woke me in the middle of the night. I looked out the door to see her pull out of the carport, and she waved to me. I was torn between jumping in my car to follow, or letting her go. Once before she had taken off for a couple days, just to collect her thoughts. It was late; I was in my pajamas and had to be up for work in a few hours. I went back to bed. The next day I was worried, and called some of her friends, but no one had heard from her. I alerted her family members that she was missing. When she still did not call or come home, I called the police and filed a missing persons report. No word came for ten days.

On Christmas Eve, I checked the mail and found a letter addressed to "The family of Diane Johnson." I felt a chill, but took the letter in the house and sat down before opening it. It was an impound notice for her truck. It had been towed two days after she left. I called the number on the letter. A police detective told me that Diane's body had been found a couple of blocks from her truck. They were positive it was her and that she had died by suicide. I don't remember hearing much more because of the roaring in my ears. My heart beat fast and I felt cold all over.

I hung up, knowing I had to call her brother, and it was Christmas Eve. I called two of her brothers, and the second one said I'll take it from here. I was relieved, but now I did not know what to do. My friends were all out of town for the holidays. I realized I was utterly alone. I cried a long time, then tried to watch TV, but could not. I was desperate to talk to someone, but no one was available. I felt so guilty. "I should have stopped her" "I should have helped her; I should have told her family she was so depressed".

The next several months my guilt feelings continued. I had so many people I had to tell. I had to work the antique business alone or lose all my investment. People at shows would come asking, "Where's your buddy?" I stopped telling the truth. I told them she had died suddenly of a rare cancer. It was easier on them, it was easier on me. I told people who did know how she died that I was sleeping and didn't get up in time to stop her, I couldn't face the truth. People would tell me, "Don't feel bad, you couldn't know how depressed she was." I DID KNOW!!! I didn't tell them. I kept working, I stayed busy to stifle the feelings. I got angry: Angry that Diane left me and stuck me with running a business I had no skills to maintain. Angry that she abandoned me. Angry that I didn't save her.

In March I saw a billboard advertising "The Glory of Easter." I bought a ticket and went. I had never been to the Crystal Cathedral, but I found it beautiful. I came back for Easter. Over the next two years I would come to services from time to time, I was drawn here. I had not been a regular church goer for a long time. I started to think about volunteering at New Hope, but my CE classes always conflicted with the training. After two years, I finally could take the classes.

I had healed a lot, and wanted to put what I had learned personally about suicide to some use. I couldn't save Diane, but maybe I could save someone else. New Hope did give me that opportunity and so much more. I started to heal at a deeper level, and drew closer to God again. I joined the Church and began to come every week. I began to understand I was not responsible for Diane's death. I could only help those who gave me the chance. Eventually I came onto staff. And God has continued to use my experience of suicide to not only save lives, but to teach others how to save lives. Diane fell into the darkness of hopelessness. But every day New Hope counselors shine God's Light into the lives of depressed people, and give them hope. NEW HOPE. New Hope really does save lives.


NEW HOPE SUICIDE INTERVENTION PROCESS

Establishing Rapport
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 following "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.


Red Flag Expressions of Suicidal Callers/Chatters
These expressions alert the counselor to assess for possible suicidal thinking or planning:
I am probably just wasting your time
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
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
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 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 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, I feel so disconnected from everything


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 the phone number is needed. 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


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 Supervisor 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.


HOPE: THE RAY OF LIGHT

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 caring 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.