A publication of Vietnam Veterans of America, Inc. ®
An organization chartered by the U.S. Congress
October 2000/November 2000
How You Can Prevent A Suicide
By Father Phillip Salois
The subject of suicide is extremely difficult to talk about and is a topic that most of us would prefer to avoid. As veterans of the Vietnam War and those who care for them, many of us have known someone who has committed suicide and others who have either attempted it or seriously thought about it. As uncomfortable as this subject may be, I encourage you to read on. You may find information useful in helping a friend or relative contemplating suicide.
Accurate statistics on deaths by suicide are not available because many suicides are not reported. However, we can offer some general statistics. Each year, some 22,000 completed suicides are officially reported in the United States--an average of 60 a day. However, the number of actual suicidal deaths is believed to be around 50,000--130 a day. Since 1962, there has been a 300 percent increase in adolescent suicides. The highest potential suicidal risk is among adolescents of college age. White males aged 19-25 pose the highest risk. Suicide is the third-ranking cause of death in the 15-19 age group and the second-ranking cause of death among college-aged people.
The types of people who attempt and commit suicide, from the highest to the lowest are: 1) divorced persons; 2) persons who have lost a spouse; 3) single persons not previously married; and 4) married persons. A misconception is that most suicides occur around the Christmas holidays. Actually, most suicides occur in March, April, and May--with the highest month being April. Suicide usually has been underreported as a cause of death in the United States because it holds a societal stigma. Firearms and explosives are most frequently used for suicide. Hanging and strangulation rank second.
I would like to emphasize one important fact. If you do not remember anything else, remember this: The only thing that will save a human life is a human relationship.
Suicidal people use a particular logic that brings them to the conclusion that death is the only solution to their problems. We can observe the thought process of a suicidal person.
Once we learn to recognize the elements of this process, we are better equipped to affect an intervention. The thought process begins with a precipitating event that leads to crisis, depression, and suicide.
What Defines A Crisis
Everyone at one time or other experiences psychological trauma. Neither stress nor emergency conditions of the trauma constitute a crisis. However, when a traumatic event is perceived as a threat to needs, safety, or meaningful existence, some people enter a crisis phase. A crisis is a temporary state of upset and disorganization, characterized by an individual’s inability to cope with a particular situation using customary methods of problem-solving and by the potential for a radically positive or negative outcome.
A crisis has an identifiable beginning, a precipitating event that the person views as particularly threatening, painful, or challenging. Oftentimes, the event is interpreted as being the last straw or a seemingly minor happening at the end of a long list of stressful events.
A crisis tends to be temporary and self-limiting. One need not probe deeply into a suicidal person’s psyche or background to determine the root cause. The crisis moving the person in this direction is generally in the forefront of his thoughts. A therapist, clergyman, or friend need only ask the person about it. Individuals in crisis are generally receptive to those who reach out to listen and to help. Many crises follow stages that are readily identifiable. Effective help in resolving the crisis does not have to come from trained mental-health professionals. A friend or relative with a listening and compassionate ear is extremely effective and often preferred.
The Process Of The Crisis
The crisis follows a process. The first element is the precipitating event causing the person to lose hope to the extent of wanting to take his or her life. This crisis causes an initial rise in tension, which in turn initiates habitual problem-solving responses. When these initial problem-solving responses do not produce the desired results, the tension continues to increase and the person experiences greater upset and becomes ineffective in finding a solution to the precipitating event. As the tensions increase, other problem-solving resources are mobilized.
The crisis could be averted by reducing the external threat; coming up with new coping strategies; redefining the problem, or giving up tightly held goals that are unattainable. If none of these works, the tension mounts to a breaking point that can result in severe emotional disorganization.
Suicidal Decision-making
When people are in a state of emotional disorganization and at risk of suicide, they begin to appraise experiences in a negative way. They begin to overinterpret their experiences in terms of defeat and deprivation. They regard themselves as deficient, inadequate, and unworthy. They foresee a lifetime of unremitting hardship, frustration, and deprivation. Since they are filled with self-hatred and self-blame, they begin a process of dysfunctional problem-solving.
What follows is an outline of the ten steps in suicidal decision-making.
STEP ONE: Unendurable Psychological Pain. The enemy to life is pain. Pain, therefore, is the one thing the suicidal person seeks desperately to escape from.
STEP TWO: Frustrated Psychological Needs. The individual has basic needs that are essential for good psychological health, such as security, achievement, trust, and friendship. When these needs are not met, tension rises and the person feels a sense of loss. This affects self-worth.
STEP THREE: The Search for a Solution. Suicide is never done without a purpose. It is a way of getting out of a problem, a crisis, or an unbearable situation. It is often an answer to the question: "How do I get out of this mess?"
STEP FOUR: Helplessness and Hopelessness. The person contemplating suicide is experiencing despair--a strong sense of powerlessness. Nothing or no one can take this pain away or solve the problem. Hopelessness is the core of the depression experienced by the suicidal person. This is one of the most crucial steps in contemplating suicide.
STEP FIVE: Constriction of Options. In the face of crisis, depressed and suicidal persons are frequently unable to see choices or alternatives that might ease the situation. A kind of tunnel vision prevents them from pursuing a course that would lead them out of their desperate state. All other options have been driven out by desperation and pain. The only option they can see is death.
STEP SIX: Ambivalence. For the suicidal person, ambivalence is a matter of life and death. In the typical suicidal state, a person cuts his throat and cries for help at the same time. Both acts are genuine. The ambivalence of the suicidal person allows the helping person to shift the inner debate that is going on inside the suicidal person between life and death to the side of life.
STEP SEVEN: Communication of Intent. About eight out of every ten suicidal people give clues about their intention to kill themselves. They give indications of helplessness, make pleas for response, and create opportunities for rescue. These are attempts to get others to see their pain and to stop them from killing themselves. These clues may be verbal, behavioral, or situational.
STEP EIGHT: An Attempt To Regain Power. Suicide is an effort to do something effective, dynamic, memorable, noteworthy, and special. At the moment of committing suicide, the individual may have a sense that he is in control of his world. He believes he has control of his own destiny and can influence the destiny of others as well.
STEP NINE: An Attempt To End Consciousness. Suicide is a movement away from pain and a movement to end consciousness. The aim of suicide is to stop awareness of a painful existence.
STEP TEN: Departure. Suicide is the ultimate escape--a plan for a radical and permanent change of scene. None of these steps is lethal by itself, but together they form a deadly process. Suicide is the desperate act of a constricted mind that is in seemingly unbearable and irresolvable pain. That pain is driven by blocked or unfulfilled psychological needs that the suicidal person feels are critical for psychological survival. In this state, people view annihilation, cessation, or escape to a better universe or loss of life as a more attractive option than the torment of life with these needs unmet.
Therapeutic Intervention
The immediate goal for intervening with someone contemplating suicide is to buy time. The short-term goal is to be present to help the person by listening and by helping the individual strengthen his or her ability to cope with adversities and losses in the future. There are eight steps to this process:
STEP ONE: Establish Rapport and Build Trust. Because a human life is at stake, time is of the essence. A good working relationship needs to be established quickly so that the potential destructive process the individual has embarked upon can be brought under control. Establishing trust is the key element in this step so that the individual will be able to let his guard down enough to let you find out what the problem is. Listen attentively to the person’s words, pauses, intonation, and the meaning he gives to what is happening to him. Maintain eye contact. Try to understand what is happening to the individual from his point of view. Be predictable, honest, and dependable. Of paramount importance is to not be judgmental or critical.
STEP TWO: Expand the Common Frame of Reference. The person intervening needs to find common ground that can become a reference point in the intervention. He must know the meaning the suicidal person assigns to words, phrases, and feelings (e.g., "I feel depressed") that the intervener may interpret differently. The more he can expand this shared frame of reference by listening for feelings and by establishing shared words, the clearer communication will become. The suicidal person should analyze what his behavior accomplishes, why he uses it, and what it communicates.
STEP THREE: Clarify the Immediate Problem and Facilitate Catharsis. The suicidal person is often very confused. Conversation is often disjointed and rambling. She may have difficulty thinking clearly about the problems that led her to see suicide as a reasonable alternative. The objective of the intervener is to rank the person’s needs in two basic categories: issues that need to be addressed immediately and issues that can be postponed until later.
The suicidal person who is in a disorganized state may attempt to deal with all issues all at once and may not be able to distinguish what must be dealt with immediately. The intervener can help clarify this.
There are three basic types of problems that will cause a person to become suicidal. Internal problems are the ones within the person. These problems are caused by anxiety and depression. Interpersonal problems are problems dealing with other persons. Physical problems are basically medical problems.
STEP FOUR: Assess the Level of Danger. This is not an easy thing to do or to predict. There are no reliable methods of determining who will take his own life and who will not. It is important for the intervener to guard against dividing people into those who carry out a "serious act" and those who make "gestures" or are "merely manipulating you." Every suicide attempt is serious. The gesture and serious attempt should be seen as points on the continuum of suicidal behavior.
There are ten critical questions that the intervener should ask the suicidal person in a calm and matter-of-fact approach:
Question 1: Have you been thinking of killing yourself?
Question 2: What has happened that makes your life not worth living?
Question 3: How will you do it?
Question 4: How often do you have these thoughts?
Question 5: How long do the thoughts stay with you?
Question 6: Have you ever attempted suicide?
Question 7: Have you been drinking heavily lately or taking drugs?
Question 8: Has anyone in your family committed or attempted suicide?
Question 9: Is there anyone or anything to stop you?
Question 10: On a scale of 1 to 10, what is the probability that you will kill yourself?
STEP FIVE: Give Message of Caring and Hope. The intervener needs to send a message to the suicidal person that he understands and cares and is willing to offer hope for the end of the pain and offer alternatives that are life-giving. The concepts of Permission-Protection-Potency must be employed. The intervener assists the person to accept that it is all right, appropriate, and necessary to change. The intervener needs to reassure the suicidal person that he is not alone in this crisis, that there is someone who cares whether he lives or dies. The intervener needs to help the person become empowered once again to make good, sound decisions towards life and living.
STEP SIX: Generate Alternatives. The intervener needs to help the suicidal person generate realistic alternatives and to bring the person on more solid ground. The intervener may suggest alternative perceptions to the problem at hand. He may propose alternative solutions. He may even explore some alternatives that have worked well in the past for the suicidal person.
STEP SEVEN: Make a No-Suicide Contract. Making a contract between the intervener and the suicidal person is an effective method of stalling or preventing an individual from attempting suicide. Contracting creates an agreement not to take the final step of suicide while the person is interacting with the intervener. It is important that the person get in control over suicidal urges. The No-Suicide Contract offers the control the individual needs.
STEP EIGHT: Take Action. After the intervener makes a No-Suicide Contract with the person, a mental health professional should be notified for a referral. The intervener should brief the mental health professional about the facts surrounding the case. Finally, the intervener should escorts or have the suicidal person escorted to the mental health professional.
I hope this article will be a resource for those who may face a situation in which a loved one or a friend is contemplating suicide. Much of what has been written here is common sense and can be employed by anyone. I have attempted to put some order in a process that will make sense and be a tool for future reference.
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