Module 3: Talking about suicide Risk: How you ask makes a difference

Following up on “Yes”

What do you do if the person says “yes, I have thought about suicide?”

If they answer affirmatively to questions about thinking about suicide, having a plan, or having warning signs, you should determine how far along they are in their plan to attempt suicide. It is crucial not to underestimate the danger by not asking for details.

If the answer is “Yes, I do think of suicide,” you must take it seriously. However, you should not become overly alarmed or fearful that there is an impending situation, like a heart attack in progress, but continue to assess if there is a problem. People who study suicide have found that most individuals suffering from moderate or severe depression experience suicidal thoughts; however, relatively few of them actually end their lives in suicide. While there certainly is no formula, try to assess the potential protective factors. These include such things as whether they have someone who can monitor them constantly vs. being alone, the recent course of events, and other important considerations. However, if you have any sense that they could attempt suicide in the near future, take them to the emergency room of a hospital or to a local mental health clinic for a formal evaluation to better determine their risk.

As you start to learn how to discuss suicide risk with faith members, there are some key questions that can guide you through the general flow of the discussion. The National Alliance on Mental Illness (NAMI) recommends asking the following questions (http://bit.ly/g0IkIb) to better understand a person’s suicide risk. These provide a sort of ‘conversational template’ for engaging in dialogue with faith members about whom you are concerned.

For each of these, you should think about where each would live in a conversation; how  each connects into the risk factors, warning signs, triggering events, and protective factors; and how you would respond to your faith member’s responses—that is, what would you do next?

“Do you have any actual plans to kill yourself?”
 
If the answer is “yes,” ask him to describe his specific plans. Make note of the method used in the plan (E.g., Hanging, Jumping, Pills, gun)? Ask if he has done anything to start implementing the plan (e.g., having bought a rope or a gun, collected pills, sat holding the gun, tied the rope, held pills in the hand, searched for methods online) The risk becomes greater as the plans are clearer and more specific, when they have made actual preparations, and when the method they have chosen is more lethal.

“When do you plan to kill yourself?”
 
If the suicide attempt is a long way off (say, in five years) danger is clearly not imminent. If they plan to kill themselves soon, the danger is grave.

“What would you be accomplishing if you killed yourself?”
 
What are the person’s reasons for dying by suicide? If the person says that people would be better off without them, and if they have no deterrents, a suicide attempt is much more likely.

Reasons why
“Reasons why” are important to know about because they suggest possible places for preventive interventions, but knowing whether there is intent (Q4. desire/wish to die) or plans to die or rehearsals underway (Q5) are the key to understanding level of risk.

“Is there anything that would hold you back, such as your family or your religious convictions?”
 
A person who can describe compelling reasons for living (not attempting suicide) is of relatively lower risk than someone who cannot answer the question.

“Have you ever made a suicide attempt in the past?”
 
Previous suicide attempts indicate that future attempts are more likely. Even if a previous attempt did not seem serious, the next attempt may be fatal. All suicide attempts should be taken seriously. Suicidal “gestures” can be more dangerous than they seem, since many people do kill themselves on subsequent attempts.

“Would you be willing to talk to someone or seek help if you felt desperate? With whom would you talk?”
 
If the person who feels suicidal is cooperative and has a clear plan to reach out for help, the danger is less than if they are stubborn, secretive, hostile, and unwilling to ask for help. The development of a plan to protect the person, a safety plan, will be covered in a later module.

In Order?
Although throughout this module we have stressed that there isn’t a cookie cutter ordering of questions, we include these questions and the suggestion of doing them “in order” to give you a place to start. In the long run, however, your experience will guide you in selecting and ordering questions during a particular discussion.

Let’s look at some examples of how faith leaders respond to yes’s and no’s.

Following up on “Yes and No:” Case Videos

Reverend Molock and Carter

Reverend Molock and Carter. Throughout this interaction, Reverend Molock follows up on yes and no responses in ways that leave the door open and continue the conversation. Because she feels there is no clear risk present, she disengages by opening that door wide for future communication. How does she help put Carter at ease? Which strategies does she use that you are already doing or which you might adopt yourself? Are there any aspects of the conversation you might do differently?

Bishop Young and Kaden

Bishop Young and Kaden. In this situation, Bishop Young identifies some important risk factors and follows up on those directly. How does he effectively continue the conversation? Are there opportunities that may have been missed?

Reverend Sherry and Allie

Reverend Sherry and Allie. In this situation, Reverend Sherry follows up on both no’s and yes’s and identifies significant risk. So much so she opts to do a handoff to additional care. What strategies does she use to help Allie open up and to keep her at ease in the conversation? Are there places where the conversation surprised you? Does it suggest any approaches you might use yourself?

How are these situations similar and different? Do you think the faith leader handled the the followup well? Did they use strategies you could use? Is there something you would do differently?

Plan + Means = Crisis Situation

If the person has made a suicide plan and has acquired the means to kill herself and they have any indication that they could attempt suicide in the near future, you should treat this as a crisis or emergency situation that requires  immediate mental health care.

Reassure them that no matter what, you will be there for them. This is especially important if you determine the person to be at high enough risk to warrant a trip together to the hospital or another mental healthcare provider. Again, because the stigma of suicide is so powerful, the faith member might be frightened or worried about what will happen in the hospital. Knowing that you will be there, as a trusted ally, will ease the transition from the location of the conversation to the emergency care location.

Really responding to Yes
Though this module discusses how to followup on yes answers in order to better understand risk, and some suggestions are provided for next steps, Module 4 covers handling risk, that is, responding to situations where you have established some level of risk, in far greater detail.

Beyond Yes and No: Returning to the Related Factors

In the end, both Yes and No responses to questions about suicidal thoughts and behaviors should lead you right back to the risk factors, triggering events, and warning signs with which you started the conversation. If the person says no, then you can circle back to these factors in order to continue the conversation and continue to assess risk. You may find there is little risk, or you may find another way into the question of suicide to which the person may respond differently.

If the answer was Yes, then you return to the risk factors, triggering events, and warning signs in order to better understand the level of risk, and to better understand how you might help the person. To the mix of risk factors, you would also explore protective factors. Moving toward responding in helpful ways to the answers of “yes” is the core topic of the next module; however, for now, keep in mind: when in doubt, err on the side of caution and elicit help from mental health providers and others in your community in order to ensure the person’s safety.