How to help someone suffering from suicidal ideation?

By Tiago Zortea.

[Warning message: this article contains discussion of sensitive topics that some may find upsetting. If you need someone to talk to, Samaritans are available round-the-clock (and free to contact) on 116 123 (UK & ROI)].

The quote “let’s talk about suicide” has spread online, contributing to the engagement of the general public on the topic of suicide and helping to break the taboo and reduce the stigma which has been associated with suicide for far too long. However, there are practical implications of talking about suicide: what should or shouldn’t we say? How should I approach the topic when someone is suffering from suicidal thoughts?

In the present blog, we will introduce some of the fundamental principles of how to initiate and conduct what could be a daunting or difficult conversation about suicidal thoughts. But before we can do that, we need to know some vital information that will help us to identify potential warning signs

Suicidal thoughts: signs to look out for

Often suicidal thoughts are associated with depressive symptoms. Indeed, research shows a strong association between them. However, it is still uncertain how much depressive symptoms explains the emergence of suicidal thoughts since depression is also an effect of other prior factors. Additionally, there are cases in which suicidal thoughts and behaviours do not seem to be associated with depression [1]. Nevertheless, it is possible to notice a change in the person’s mood and this shift is generally related to the circumstances of their life. Several studies suggest that the formation of suicidal thoughts is related to a combination of contextual events and the person’s difficulty to get out of a ‘trapping situation’ where they feel unable to find solutions and escape from the problems and the unbearable pain. These circumstances may produce thoughts and feelings of defeat (e.g., the person fought as much as they could, but was unable to achieve what they wished); hopelessness (e.g., they feel unable to imagine/visualise positive future outcomes despite the difficult circumstances – a result of defeat); and entrapment (e.g., the person thinks that there is no way out or solution to the problems and suffering they are experiencing) [2].

Some people may talk explicitly about ending their life or of dying, saying sentences such as “I am feeling suicidal”, “I want to end my own pain”. However, sometimes these communications may be indirect. For example, thoughts and feelings may be identified through sentences (or variations of these sentences) such as:

• “I can’t see any meaning in my life.”
• “I can’t see an exit. There is no way out for me.”
• “I just want to disappear from this world.”
• “If I could, I would sleep and never wake up again.”
• “I don’t see the point in being alive, to be honest.”
• “I should not have been even born.”

How to initiate a conversation?

Before starting a conversation, it is crucial to show respect, empathy and compassion for the person suffering. Think about how you can form a connection with them and show that you are there for them. These qualities should form the basis of any conversation, and without them we run the risk of potentially contributing to a person’s suffering rather than helping them.

If someone asks to talk, the interaction may start in an easier way. However, if you are worried about someone’s mental health, you may have to approach this person and start a conversation. Questions that may help to initiate the chat could involve:

• “Hi, how have you been? … How are you feeling?”
• “How are things with you?”
• “What have you been up to?”
• “I’ve been noticing that you may not have been feeling well recently, and I would like to know if you would like to talk about it?”

If the person says they don’t want to talk, that everything is fine, or if they change the direction of the conversation, it is important to say that it is okay and, leave the ‘door open’ for future chats. In case the person responds positively to the approach, the conversation may then progress to more sensitive topics. In this case, here are some pointers to consider:

• Try to find a quiet and safe place to talk.
• Being either a friend, relative, or acquaintance, your function is listening actively.
• Avoid speaking about you. It is better to leave your own issues for a future conversation.
• Do not try to solve the other person’s problems. If you do it so, there is a chance that you will contribute to intensify their feelings of entrapment, as the conversation may lead them to confirm the belief that, indeed, there is no solution.

How to ask questions and proceed with the conversation?

Often, listening is the main and most important thing to do. However, if the person is finding it difficult to speak or if you need to guide and encourage to a conversation, here are some important details to look at.

Ask open questions. Avoid yes/no questions. It is important that your words help to encourage, in a respectful and non-invasive way, the person to speak about how they are feeling and what they are going through. Some examples may include: “When did you realise that this was happening?”, “And what happened after?”, “Where did that happen?”, “How did that make you feel?”, “What sort of things came to your mind in that moment?” [3].

Be careful about asking “why”. Sometimes, asking why can sound judgmental – the person may feel judged by you. They may also feel that you do not understand them and react in a defensive way bringing the conversation to an end, since the person might not feel comfortable to talk about what is happening with them.

What should be avoided:

• Reactions of surprise, shock, or fright. Some verbal expressions that exemplify such reactions include: “What?”, “Oh my God!”, “You’re having a laugh!”, “I can’t believe you’re telling me this”, “Shut up!”, “You’re joking/kidding me!”.
• Reactions that may elicit feelings of rejection: “Stop talking shite!”, “Don’t say these things”, “Why are you saying this?”.
• Expressions of incomprehension through sentences that may appear to be positive: “I can’t understand this. You always had all reasons to be happy”, “You should look at the bright side of things”, “You should focus on the positive things you have in your life”, “Think positive”, “Don’t worry, be happy!”, or glib: “Things will get better”. It is important to note that “positive thinking” is not necessarily a protective factor against suicidal ideation.
• Expression of religious aspect: “You need God in your life”, “This is a Devil’s work”, “God knows everything, and he will help you”, “This is lack of faith. You need to have more faith in God”, “You are paying your sins”, “Don’t worry, God has a plan for you”.
• Other expression to be avoided include: “Don’t cry!”, “This doesn’t make sense”, “I understand perfectly how you feel”, “Could we speed up our conversation a little bit?”, “Be strong and take courage”, “Pull yourself together”, “Keep your chin up!”, “Man up!”, “Don’t do something silly!”.

Avoid providing any interpretation of what is going on in the person’s life. If you are providing support, your function is not to provide interpretations nor formulate explanations about the person’s life circumstances. If you want to help, even if you have the best of the intentions, just listen and encourage the person to talk, by creating a safe and non-judgemental space.

How to listen actively?

There are five steps to listen actively [3]:

1. Ask open questions (as previously mentioned).
2. If convenient, summarising part of the conversation demonstrate that the person has your complete attention and that you are understanding what has been said. An example could be: “I hear what you’re saying. You have been cheated by your wife, but you still love her.”
3. Repeating a word or a sentence may encourage the person to continue to open themselves. For example, if the person says “Things are extremely difficult for me recently”, you can continue the conversation reflecting upon this phrase saying “I do feel that you are going through a very tough time”.
4. If the person you are talking to goes over an important topic, you may say something such as “Sorry, would you mind to tell me more about…” or “This seems to be a difficult topic for you to talk about”. This may help to clarify some points not only for you but also to the person themselves.
5. Avoid listening like a robot. Express empathy, respect, and demonstrate that you are listening carefully what the person is saying.

How to approach the topic of suicide?

• If you suspect that the person is experiencing suicidal thoughts and feelings, simply ask: “Are you feeling suicidal?”.
• If the answer is yes, try to stay calm and keep listening. You may continue the conversation asking for more information about these feelings. For instance:
  • “When did you think about taking your life for the first time?”
  • “What do you think is making you feel this way?”
  • “Have you talked to someone else about these feelings?”
  • “Do you know where and how to seek for professional help?”
• After all these questions, it is important to help the person to seek professional help and keep them in a safe space. Try to encourage the person to make an appointment with their GP, psychiatrist, or psychologist. Offer yourself to go with them.
• If the person has a suicide plan (they have planned how to end their own life) and they say that they are sure they will do it, do not let the person on their own. Seek professional help immediately, taking them to a mental health service, or to an emergency department, or calling the Samaritans and ask for advice. Make sure the person is in a safe space and under professional care.

If the answer to the question whether they are feeling suicidal is no, you can say that you just noticed they haven’t been themselves lately and that you wanted to check out that they are okay as you care for them. Let them know that you are there to listen. This might open the door if they are feeling distressed at a later date.

Helping someone under a distressing situation may be stressful itself. If you are helping someone who is feeling suicidal, remember that you have to take care of your own self. If you feel that you need to talk to someone about how you feel, call the Samaritans of talk to a mental health professional [4].

References:

[1] Joo, J., Hwang, S., & Gallo, J. J. (2016). Death ideation and suicidal ideation in a community sample who do not meet criteria for major depression. Crisis, 37(2), 161–165.

[2] O’Connor, R. C., & Nock, M. K. (2014). The psychology of suicidal behaviour. The Lancet Psychiatry, 1(1), 73–85.

[3] NHS Scotland (2015). The art of conversation. Choose Life.

[4] Samaritans. (2016). What should I do if I know someone who is feeling suicidal?

Tiago Zortea (@zortea_tiago) is a Clinical Psychologist and a Postdoctoral researcher in the Suicidal Behaviour Research Laboratory, University of Glasgow (Tiago.Zortea@glasgow.ac.uk).