How to ask if someone might be thinking about suicide

Connecting with someone by asking how they are is more crucial than ever

A man seems depressed as he sits near a window and looks out in this illustration for a story about suicide

Ask. Then listen.

Those are key actions someone can take if they fear a family member or friend might be thinking about suicide.

To have a conversation may seem difficult, but it’s better than doing nothing.

“Friends and family typically are willing to take the more difficult route if they think it will result in a good outcome,” said Dr. Jerrod Spring, a Sanford Health psychiatrist. “I think now is one of those times … that people should lower that threshold for just asking how people are doing.”

Make the question “How are you doing?” more than a greeting. Encourage an honest answer. Listen and make a connection with the person. Connecting is even more crucial during the coronavirus pandemic.

Dr. Spring and Ashlea McMartin, a licensed professional clinical counselor and clinical manager for Sanford Health who specializes in trauma and crisis response, offer insights about suicide. They also have guidance for what to say — and what to avoid — when you’re having that conversation with someone.

Struggling during the pandemic

In a study published in August by the Centers for Disease Control and Prevention, 40.9% of more than 5,000 adults surveyed across the U.S. said they had had at least one adverse mental or behavioral health condition during April to June 2020, in the midst of the coronavirus pandemic. The survey also found that 10% of respondents had seriously considered suicide in the prior 30 days.

Both statistics were far higher for the youngest age group of 18- to 24-year-olds (74.9% and 25.5%, respectively).

Survey results pointed to a significant increase compared to statistics from the most recent years available. Suicide ideation in the overall population, for example, had more than doubled from a 2018 survey that had asked about the previous 12 months. Anxiety disorder had tripled from the second quarter in 2019, and depressive disorder had quadrupled from that same quarter.

COVID-19 has changed many elements of our lives. Dr. Spring and McMartin expect it to alter even our epigenetics, which are heritable changes in how our genes are expressed that can be influenced by environmental factors such as stress.

“The people that went through the Great Depression, you see what mental health looks like after so many years,” McMartin said. “So I’ll be interested in seeing how that develops” from the pandemic.

Now, we know far more about how to develop resiliency, she added. “I’m hopeful that as these groups start coming back together, like schools and employment, that there’ll be ongoing conversations around, ‘How do we develop resilient people?’”

Effects on adolescents

With the pandemic stretching on as long as it has, Dr. Spring expects that we’ll be able to see epigenetic changes in the population of kids in America.

And as McMartin points out, the pandemic has lasted for a larger portion of kids’ lifetimes than adults’. Uncertainty about the future and social changes can be more difficult to cope with when kids haven’t learned all of the skills adults have, and while kids’ brains are still developing at a rapid pace.

Parents have adversities in their past to help give perspective to the pandemic, Dr. Spring said. A teenager, meanwhile, can lack the ability to see beyond it.

“For a 17-year-old that doesn’t see six months ahead, this is very much kind of a catastrophic scenario. … No more friends, no more school, no more senior year,” Dr. Spring said. Stressors at home can add to the difficulty.

With school back in session this fall, McMartin thinks there will be an increase in calls to the crisis line. That’s not unusual — school has higher expectations and responsibilities for students than summertime does, and kids may get less sleep on their school schedule. Plus, more adults may be around the child to notice signs that the child may need services.

But after this isolated summer caused by COVID-19, McMartin thinks adults will be especially sensitive to issues kids are having.

Signs to watch for

During a pandemic, when many people isolate themselves intentionally for health reasons, the term “social distancing” may seem to give people permission to not connect at all with others, McMartin said. Her crisis response team prefers the term “physical distancing.”

When a person isolates from others and stays out of touch, that can be a worrisome sign, she said. An increase in substance use is another sign — and high substance use can affect a person’s ability to make rational decisions.

Watch for other changes in behavior, too, such as their day-to-day routine, McMartin said. Listen to their language. Do they talk about the future as if they won’t be around — as if things will be taken care of and they’re no longer needed? Consider the comments as an indicator to have a conversation.

Suggestions for what to say

  • Express concern. The best approach, Dr. Spring said, is to come from a nonjudgmental place of love: “I’m concerned about you. I’m concerned about what I’ve seen today. We tried to get you to come out, but you didn’t want to come out. I notice you don’t talk to your friends anymore. Is anything going on? Anything I can do that will be helpful?”
  • Don’t be afraid to bring up the topic. McMartin said parents or friends or family members express fear that if they ask too directly, it may put the idea of suicide into someone’s head. But research refutes that notion, she said. “If someone has been feeling suicidal and you ask it directly … there’s actually relief from the person suffering,” she said — relief that they can acknowledge it openly with someone who truly wants to know.
  • Rehearse what you’ll say. If the question “Are you thinking about suicide?” seems difficult to ask, McMartin recommends practicing with someone else. If you’re trying to ask your teenager, for example, then first role-play with your significant other. On the other hand, if your teenager is worried about a friend, have your teen practice with you to get more comfortable with the language.
  • Relate through a similar experience. If you can relate to the emotions a loved one might be going through, connecting on that level will help them feel less alone, McMartin suggested: “A couple of years ago when I had this really hard thing happen in my life, I started to think about what it would be like if I weren’t here. And my gut is worried about you. And I’m wondering if you’re having that same experience.”
  • Plan to share a resource. Dr. Spring urges people to already have a resource in mind to share with their loved one, such as a suicide or crisis hotline or team.
  • Ask a resource for help. Resources such as suicide or crisis hotlines also can be consulted if a person needs help figuring out what to say or do to help their loved one.

What to avoid saying

Although they may be well-intentioned, some statements are best avoided, McMartin and Dr. Spring said.

  • Don’t tell the person, “It could be worse,” Dr. Spring said. While technically it may be true, “it’s never helpful,” he said.
  • Avoid using the words “always” and “never,” which are rarely true, he added.
  • Dr. Spring also advises against saying, “It’s going to get better.” He said, “That can feel like too much — too overwhelming and unrealistic.”
  • McMartin says to avoid invalidating statements such as, “Well, at least you have a job,” or, “Well, at least you have your family.” Those types of statements don’t reflect “the current emotional state that people are in,” she said.

Risk factors for suicide

A variety of factors can put some people more at risk of suicidal ideation or suicide attempts than others. A history of previous suicide attempts certainly is one.

A history of significant trauma also can contribute to suicidal ideation, McMartin said.

Women are more likely to attempt suicide, but men are more likely to complete a suicide because of the use of more lethal means, she added.

Dr. Spring said suicide deaths are also more likely to involve people who are white and older and using substances.

He points to behavioral health factors as well, such as impulsive personality disorder and depression. Ultimately, he added, suicide may be considered a form of avoidance for someone who faces something they feel is too intolerable.

Ways to increase safety

McMartin cites helpful information from the Suicide Prevention Resource Center intended for professionals who work with people at risk for suicide.

Called CALM, the training course stands for Counseling on Access to Lethal Means. A handout for people at risk of suicide and their families gives tips for helping prevent suicide during a crisis window, which McMartin said tends to be a short period of time, say 15 or 20 minutes.

“Once they’ve exceeded that window … their rational brain kicks in then to come up with reasons why they wouldn’t want to kill themselves.

“But while people are in that window, their ability to problem-solve is really, really minimal,” McMartin said. So if they decide on a method but encounter a problem with it, they can’t think of how to get around it, and the delay can result in a loss of desire to go through with suicide.

CALM advocates for storing firearms and medications safely to make it much harder to access them in a short period of time. Temporary off-site storage is preferred for firearms, but other tips include locking them up without access to the keys or combination; disassembling them and storing a key component separately; or storing ammunition elsewhere. Medications, too, can be locked up, or limited to nonlethal quantities.

Getting professional help

Experiencing suicidal thoughts, Dr. Spring said, should be considered a medical emergency. Just as a person with a heart attack is recognized as having an emergency, taken to the hospital and treated accordingly for that condition, so should a person considering suicide be recognized and treated appropriately.

Many resources can help a person in crisis. One is cognitive behavioral therapy for suicide prevention, which is an effective therapy focusing on what people tell themselves about suicide and about the future, Dr. Spring said.

Medications can help treat some mental health disorders. Crisis response teams can provide skilled and experienced crisis care.

In primary care clinics, screenings and integrated behavioral health therapists can help recognize potential problems when people have appointments. “We know that typically, a large majority of people that died by suicide had contact with their primary care within the last six months,” McMartin said.

Peer support has emerged as an effective role as well, McMartin said. Similar to AA sponsors, these peer supporters have had a similar life experience as the people in crisis they’re working with and are strong advocates for healthy outcomes.

Dr. Spring wants people who are suffering to know that help and support are there. They should make a call if they’re having a crisis.

“If plan one is call Mom, plan two is call a best friend,” he said. “But if it’s 3 in the morning and nobody answers, call 911. We consider this a medical emergency. Use the resources available.”

Where to call

  • National Suicide Prevention Lifeline: (800) 273-8255
  • National hotline for community resources: 211

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Posted In Behavioral Health, Children's, Coronavirus, Wellness

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