Suicide Awareness and Suicide Awareness and Intervention:Intervention:

The Role of the GatekeepersThe Role of the Gatekeepers

Florence-Carlton Florence-Carlton Elementary and Middle SchoolElementary and Middle School

Guidance and Counseling DepartmentGuidance and Counseling DepartmentChrissy Hulla & Joy JonesChrissy Hulla & Joy Jones

The most common The most common response to a response to a statement of statement of suicidal intent is suicidal intent is silence. silence.

“Oh God. What do “Oh God. What do I do.”I do.”

The Purpose of SuicideThe Purpose of Suicide

““The common purpose of suicide is to seek The common purpose of suicide is to seek a solution. Suicide is not a random act. a solution. Suicide is not a random act. It is never done pointlessly or It is never done pointlessly or purposelessly. It is a way out of a purposelessly. It is a way out of a problem, a dilemma, a bind, a crisis, an problem, a dilemma, a bind, a crisis, an unbearable situation. It has an unbearable situation. It has an inexorable logic and impetus of its own… inexorable logic and impetus of its own… Every suicide makes this statement: ‘This Every suicide makes this statement: ‘This far, and no further.’”far, and no further.’”

Edwin Scheidman, Ph.D.Edwin Scheidman, Ph.D.

10 10 Commonalities of Commonalities of

SuicideSuicideEdwin Scheidman, Edwin Scheidman,

Ph.D.Ph.D.

Common PurposeCommon Purpose

To seek a solution to one or more problemsTo seek a solution to one or more problems Seemingly insolvable problemsSeemingly insolvable problems

Bad gradesBad grades Failed relationshipFailed relationship Not getting accepted to collegeNot getting accepted to college A personally humiliating exposureA personally humiliating exposure

No suicide is a random act; all have No suicide is a random act; all have purpose and meaningpurpose and meaning

Solve the problem and suicide loses it Solve the problem and suicide loses it appealappeal

Common StimulusCommon Stimulus

Unendurable Psychic pain.Unendurable Psychic pain. When mental/emotional pain becomes When mental/emotional pain becomes

unendurable; you can’t stand to be unendurable; you can’t stand to be there.there.

““psychache”psychache” There is no suicide without pain. There is no suicide without pain.

Common StressorCommon Stressor

Frustrated psychological needsFrustrated psychological needs Loss of loveLoss of love Loss of identityLoss of identity Loss of belief systemLoss of belief system

Physical pain adds to risk, but it is Physical pain adds to risk, but it is our psychological, social and our psychological, social and emotional needs that are frustrated emotional needs that are frustrated in a suicide crisis.in a suicide crisis.

Common EmotionsCommon Emotions HelplessnessHelplessness

““I can’t do anything to fix what is wrong.”I can’t do anything to fix what is wrong.” HopelessnessHopelessness

The utter belief that nothing will ever be right The utter belief that nothing will ever be right or well or bright again forever and ever.or well or bright again forever and ever.

““Hope deferred maketh the heart sick.”Hope deferred maketh the heart sick.” A lack of hope has been shown to contribute A lack of hope has been shown to contribute

to:to: Higher rates of disease, suicide, productivity, etc.Higher rates of disease, suicide, productivity, etc.

2 cc’s of hope a administered 3x/day.2 cc’s of hope a administered 3x/day.

Many more men commit suicide Many more men commit suicide than women. than women. ““Men don’t get depressed. Men don’t get depressed.

They get angry, homicidal, They get angry, homicidal, suicidal, but not depressed.”suicidal, but not depressed.”

Common Internal Common Internal AttitudeAttitude

AmbivalenceAmbivalence ““To be or not to be.” ShakespeareTo be or not to be.” Shakespeare The only interesting question is whether The only interesting question is whether

or not to kill yourselfor not to kill yourself There are lots of pro-suicide groups on the There are lots of pro-suicide groups on the

internet—people with web cams committing internet—people with web cams committing suicide togethersuicide together

Questioning each other, “You don’t look sleepy Questioning each other, “You don’t look sleepy enough. Did you take enough pills?”enough. Did you take enough pills?”

These sites are largely unrestricted.These sites are largely unrestricted.

Common Cognitive StateCommon Cognitive State Depression is a cognitive diseaseDepression is a cognitive disease

Depressed individuals:Depressed individuals: Do poorly on decision making testsDo poorly on decision making tests Have trouble thinking creativelyHave trouble thinking creatively Constriction of thoughtConstriction of thought Depressed people practice revisionism—Depressed people practice revisionism—

they turn every positive situation into a they turn every positive situation into a negative.negative.

Common Cognitive State---Common Cognitive State---ContinuedContinued

Slowed thinkingSlowed thinking Tunnel vision (cognitive restriction)Tunnel vision (cognitive restriction) Russian revisionism (recall only negative stuff)Russian revisionism (recall only negative stuff) Capacity to draw hasty, negative conclusionsCapacity to draw hasty, negative conclusions Impaired problem solvingImpaired problem solving Poor logic, thus suicide makes “sense” Poor logic, thus suicide makes “sense” Inability to name reasons for living Inability to name reasons for living Stuck in the now of sufferingStuck in the now of suffering

Suicide is a hasty, negative conclusion to what are usually Suicide is a hasty, negative conclusion to what are usually the ordinary problems of livingthe ordinary problems of living

Common ActionCommon Action

EscapeEscape Suicide provides a way out when Suicide provides a way out when

none is otherwise perceived.none is otherwise perceived. For humans, there is always a well For humans, there is always a well

lighted exit sign over the door to lighted exit sign over the door to death.death.

Common Interpersonal Common Interpersonal ActAct

Communicate the wish to die to othersCommunicate the wish to die to others When we are in pain, we want to tell When we are in pain, we want to tell

someone.someone. If you are going to get a root canal, you If you are going to get a root canal, you

tell someonetell someone Often suicidal individuals will tell Often suicidal individuals will tell

someone what they are thinkingsomeone what they are thinking Not typically a health providerNot typically a health provider

This is our window to save lives.This is our window to save lives.

Common PatternsCommon Patterns

A lifelong pattern of failing to copeA lifelong pattern of failing to cope Relationship endingRelationship ending Poor gradesPoor grades Job lossJob loss

Common GoalCommon Goal

The cessation of consciousnessThe cessation of consciousness Being aware is the great burdenBeing aware is the great burden Death removes awareness and Death removes awareness and

obliterates all consciousnessobliterates all consciousness

How do we know what we How do we know what we know?know?

Assessment is based on:Assessment is based on: How much we learn from the personHow much we learn from the person The context in which suicide is being The context in which suicide is being

consideredconsidered Recognition of warning signsRecognition of warning signs Presence of risk factorsPresence of risk factors Presence of protective factorsPresence of protective factors What the suicidal person is willing to What the suicidal person is willing to

do to help us save his or her lifedo to help us save his or her life

GatekeepersGatekeepers

People who People who regularly come regularly come

into contact with into contact with people in distresspeople in distress

Who Are Gatekeepers?Who Are Gatekeepers?

TeachersTeachers CounselorsCounselors Bus DriversBus Drivers CustodiansCustodians Cafeteria WorkersCafeteria Workers ParaprofessionalsParaprofessionals

ParentsParents PeersPeers AdministratorsAdministrators SecretariesSecretaries CoachesCoaches NursesNurses

Community Shared Community Shared ResponsibilityResponsibility

Low-LowLow-Low

We don’t care to We don’t care to help, and we don’t help, and we don’t know how to help.know how to help.

Low-HighLow-High

We don’t care to We don’t care to help, but we know help, but we know what we could do to what we could do to help.help.

High-LowHigh-Low

We care a lot, but we We care a lot, but we don’t know what to don’t know what to do.do.

High-HighHigh-High

We care a lot and we We care a lot and we know what to do to know what to do to helphelp

Relationship is Relationship is Everything!Everything!

How much we learn depends on how How much we learn depends on how much they like us, and how much we like much they like us, and how much we like them.them.

We didn’t call them, so they want help.We didn’t call them, so they want help. Don’t let them make you mad to prove Don’t let them make you mad to prove

they can’t be helped.they can’t be helped. Find something to like.Find something to like. Buy time.Buy time. Keep ‘em talking.Keep ‘em talking.

Listen, Listen, ListenListen, Listen, Listen

Listening is the greatest gift one human Listening is the greatest gift one human being can give to another.being can give to another.

Listening to someone suicidal can save a life.Listening to someone suicidal can save a life. Listening means taming your own fear so Listening means taming your own fear so

you don’t rush to judgments.you don’t rush to judgments. Listening means sharing the burden of Listening means sharing the burden of

another’s pain.another’s pain. Listen means paying perfect attention while Listen means paying perfect attention while

the other person finds his or her own the other person finds his or her own solution to life’s problems.solution to life’s problems.

Listen!Listen!

““Tell me more” inspires hope.Tell me more” inspires hope. Your ears receive, your heart understands.Your ears receive, your heart understands. Listen not to just Listen not to just what what the person is the person is

saying, but what he or she is saying, but what he or she is tryingtrying to say. to say. Confirm you hunches about what’s wrong Confirm you hunches about what’s wrong

with questions; getting with questions; getting yesesyeses saves lives. saves lives.

Remember: It is very hard to kill yourself Remember: It is very hard to kill yourself when another human being truly when another human being truly understands you.understands you.

Do’s and Don'tsDo’s and Don'ts

Do listen for the problem or problems Do listen for the problem or problems suicide would solve; help them with suicide would solve; help them with this and they will choose to live.this and they will choose to live.

Do keep your voice low, calm and Do keep your voice low, calm and well-modulated; nothing so upsets the well-modulated; nothing so upsets the person in crisis as believing everyone person in crisis as believing everyone is as out of control as they feel.is as out of control as they feel.

Don’t say you understand when you Don’t say you understand when you don’t.don’t.

Do believe the person will live!Do believe the person will live!

Trust your fear!Trust your fear!

Felt fear is valuableFelt fear is valuable Goose bumps and standing hair Goose bumps and standing hair

matter!matter! The fearless died youngThe fearless died young It’s okay to say you’re afraid for It’s okay to say you’re afraid for

someonesomeone They’re scared, tooThey’re scared, too

Dealing with ResistanceDealing with Resistance

Don’t take the bait or step in the trapDon’t take the bait or step in the trap Stay CalmStay Calm Don’t condemn/suicide as interesting Don’t condemn/suicide as interesting

optionoption Normalize feelingsNormalize feelings Avoid platitudesAvoid platitudes Say you don’t understand when you Say you don’t understand when you

don’tdon’t Lt. Colombo has the movesLt. Colombo has the moves

S QuestionsS QuestionsNot sure? Ask!Not sure? Ask!

SAMPLESSAMPLES Have you had thoughts of killing Have you had thoughts of killing

yourself?yourself? Are you considering suicide?Are you considering suicide? Are you contemplating ending Are you contemplating ending

your life?your life? Have you had any personal Have you had any personal

thoughts of death or suicide?thoughts of death or suicide?

QPRQPR

Q for Question the person about Q for Question the person about suicidesuicide

P for Persuade the person to P for Persuade the person to get helpget help

R for Referring the person to R for Referring the person to someone who can helpsomeone who can help

Three things you’ve already done Three things you’ve already done aa million timesmillion times

Q Q QUESTION TO ASSESS QUESTION TO ASSESS RISKRISK

What is wrong?What is wrong?Elicits the person’s narrative explanation or Elicits the person’s narrative explanation or

“story.”“story.”

person’s perspectiveperson’s perspective Value in story telling/emotional releaseValue in story telling/emotional release Don’t but in, except to clarify or Don’t but in, except to clarify or

understandunderstand Your opinion doesn’t count, or matterYour opinion doesn’t count, or matter Definition of rapport: Shut up and ListenDefinition of rapport: Shut up and Listen

Sample QuestionsSample Questions

Okay John, why don’t you tell me a little Okay John, why don’t you tell me a little bit about what’s happening in your life bit about what’s happening in your life right now?right now?

Audrey, what made you decide to call this Audrey, what made you decide to call this evening? I’d very much like to hear your evening? I’d very much like to hear your version of what’s wrong right now.’version of what’s wrong right now.’

““You know, when people are as upset as You know, when people are as upset as you seem to be, they often think about you seem to be, they often think about suicide. I wonder if you’re thinking about suicide. I wonder if you’re thinking about suicide now?”suicide now?”

HOW HOW NOT NOT TO ASK THE S TO ASK THE S QUESTIONQUESTION

“You’re not thinking about killing yourself are you?”

Other examples?

WHY NOW?WHY NOW?

Elicits the precipitating event or Elicits the precipitating event or eventsevents

Current crisis?Current crisis? Hopeless a long timeHopeless a long time Magnitude of change event doesn’t Magnitude of change event doesn’t

mattermatter No reserves leftNo reserves left Hair trigger conditionHair trigger condition Final straw Final straw

““I just can’t take it anymore.”I just can’t take it anymore.”

Why Now QuestionsWhy Now Questions

Things have been bad for a long Things have been bad for a long time, what’s happened recently?time, what’s happened recently?

What’s changed so much that What’s changed so much that you’re now thinking about you’re now thinking about suicide?suicide?

Why now? Why are you thinking Why now? Why are you thinking about killing yourself today?about killing yourself today?

WITH WHAT?WITH WHAT?

Elicits methods of suicide under Elicits methods of suicide under consideration consideration

Only so many ways to dieOnly so many ways to die How? (name them)How? (name them) Access to means?Access to means? More than one method?More than one method? Degree of lethal planning? Degree of lethal planning? Backup plan? Backup plan?

With What Sample With What Sample QuestionsQuestions

Have you thought about how you Have you thought about how you would kill yourself?would kill yourself?

Can you tell me the way in which Can you tell me the way in which you’ve considered ending your you’ve considered ending your life?life?

How would you kill yourself?How would you kill yourself? How else might you kill yourself?How else might you kill yourself? What method of suicide are you What method of suicide are you

thinking about?thinking about?

Where and WhenWhere and When??Elicits possible location and Elicits possible location and timing of a suicide attempttiming of a suicide attempt

Lethal planning (less is good)Lethal planning (less is good) Soon? Next week? Next year?Soon? Next week? Next year? Anniversary date? (“Why that day?)Anniversary date? (“Why that day?) Uncontrolled contingency, e.g., “If Uncontrolled contingency, e.g., “If

she leaves.” ”she leaves.” ” Home? Work? MVA?Home? Work? MVA? Chance of rescue?Chance of rescue?

When and With What in the When and With What in the Past?Past?

Elicits important suicide Elicits important suicide historyhistory Past attempts?Past attempts?

Past suicidal ideation?Past suicidal ideation? Rescue sought or avoided?Rescue sought or avoided? Timing of attempt?Timing of attempt? Social response to attempt?Social response to attempt? What saved them?What saved them? New method vs. old method?New method vs. old method?

Sample QuestionsSample Questions

““Pat, you’ve been struggling with a lot of Pat, you’ve been struggling with a lot of different feelings lately and tell me you’ve different feelings lately and tell me you’ve been considering suicide. Have you ever been considering suicide. Have you ever had thoughts of suicide in the past?”had thoughts of suicide in the past?”

If ‘yes’ then, “When was that?”If ‘yes’ then, “When was that?” ““How did you attempt to kill yourself?”How did you attempt to kill yourself?” ““What method did you try?”What method did you try?” ““What helped you get through that What helped you get through that

crisis?”crisis?”

Who’s Involved Sample Who’s Involved Sample QuestionsQuestions

““Who’s important to you?”Who’s important to you?” ““Who else knows you’re in this much Who else knows you’re in this much

pain?”pain?” ““Who is your main support?”Who is your main support?” ““Who could help right now?”Who could help right now?” ““Who needs to know about your Who needs to know about your

troubles?”troubles?” ““Who have you told about your suicidal Who have you told about your suicidal

thinking?”thinking?”

Why Not Now?Why Not Now?Elicits protective factorsElicits protective factors

Reasons for living?Reasons for living? Spiritual or religious prohibitions?Spiritual or religious prohibitions? Duties to others/pets?Duties to others/pets? Tidying up or ‘to list’ before dying?Tidying up or ‘to list’ before dying? Fear of death?Fear of death? More reasons is good, none is badMore reasons is good, none is bad Low risk does not equal no riskLow risk does not equal no risk

Sample Why Not Now Sample Why Not Now QuestionsQuestions

““Give me some reasons why Give me some reasons why you may want to live?”you may want to live?”

““You given me reasons why You given me reasons why you want to die, can you tell you want to die, can you tell me why you still want to me why you still want to live?”live?”

““Give me three reasons to Give me three reasons to keep on going?”keep on going?”

Additional Useful Additional Useful QuestionsQuestions

““Who else knows?”Who else knows?” ““Why in the past?”Why in the past?” ““Why not in the past?”Why not in the past?” ““Who else in the past?”Who else in the past?” ““What will happen after you’re What will happen after you’re

dead?”dead?” ““How will people react?”How will people react?” ““Who will find your body?”Who will find your body?”

PP Persuading Someone to Persuading Someone to Get HelpGet Help

Your active listening and questions Your active listening and questions may have already won the battlemay have already won the battle

Find life-affirming solutionsFind life-affirming solutions Refusal to seek help = greater riskRefusal to seek help = greater risk Angry hang up = greater riskAngry hang up = greater risk Unwillingness to give up means = Unwillingness to give up means =

greater riskgreater risk Help refused? Reassess riskHelp refused? Reassess risk Send in the Marines?Send in the Marines?

RR Referral Referral

Referral is an art and a sales job.Referral is an art and a sales job. You’re going to feel better, trust me.You’re going to feel better, trust me. Resources ready?Resources ready? ‘‘How to’ instructions matter!How to’ instructions matter! Can you personalize the endorsement?Can you personalize the endorsement? Culture/ethnic/profession/color Culture/ethnic/profession/color

sensitive?sensitive? Got a clinical buddy? Find one.Got a clinical buddy? Find one.

Safety PlanningSafety Planning

Suicide risk is determined, in Suicide risk is determined, in large part, by the person’s large part, by the person’s willingness to assume personal willingness to assume personal responsibility for his or her own responsibility for his or her own safety.safety.

Suicide risk is Suicide risk is low to low to moderatemoderate when the when the person agrees to:person agrees to:

- Remain clean and soberRemain clean and sober- Seek help/accept referralSeek help/accept referral- Remove the means of suicideRemove the means of suicide- Not harm or kill selfNot harm or kill self- Seek help in case situation worsens Seek help in case situation worsens

(involve others)(involve others)- Makes verbal agreement to safety Makes verbal agreement to safety

planplan

Suicide risk is Suicide risk is high high when when the person:the person:

Has not been cooperative. Not making sense? Has not been cooperative. Not making sense? Psychotic? Agitated? Unable to care for self?Psychotic? Agitated? Unable to care for self?

Cannot regain emotional control, e.g., can’t stop Cannot regain emotional control, e.g., can’t stop crying.crying.

Is distant, evasive, aloof or paranoidIs distant, evasive, aloof or paranoid Is in the act of overdosing, has pistol in hand, is Is in the act of overdosing, has pistol in hand, is

bleeding or calling from a 19bleeding or calling from a 19thth floor window floor window Refuses to accept responsibility for self or Refuses to accept responsibility for self or

safety plan, e.g., give up the means to suicidesafety plan, e.g., give up the means to suicide

Suicide risk is Suicide risk is highhigh when:when:

Past treatment has failedPast treatment has failed There is a risk of personal humiliation, There is a risk of personal humiliation,

e.g., fear of pending arreste.g., fear of pending arrest There has been recent heavy drinkingThere has been recent heavy drinking There are repeated statements of There are repeated statements of

hopelessnesshopelessness There is no perceived exitThere is no perceived exit You’re ticked offYou’re ticked off

Motto, Clark & FaucettMotto, Clark & Faucett

Who are the Marines?Who are the Marines? As a teacher, counselor, staff member, As a teacher, counselor, staff member,

etc. What do you do if it is an etc. What do you do if it is an emergency, life or death, situation:emergency, life or death, situation: If possible, call the parents, inform them of If possible, call the parents, inform them of

what is going on, and take the student to what is going on, and take the student to the Emergency Room. The ER will do a the Emergency Room. The ER will do a complete evaluation:complete evaluation:

Physician evaluationPhysician evaluation Mental Health Evaluation (Emergency #:532-Mental Health Evaluation (Emergency #:532-

9710)9710) Admit to the hospital or refer to services in the Admit to the hospital or refer to services in the

CommunityCommunity

SEMANTICS ARE SEMANTICS ARE IMPORTANTIMPORTANT

Don’t settle for ambiguity.Don’t settle for ambiguity. ““I guess I’ll be okay,”I guess I’ll be okay,” is vague. is vague. ““I’ll call somebody if things get I’ll call somebody if things get

bad”bad” lacks specificity. What is lacks specificity. What is “bad?” Who is “somebody?”“bad?” Who is “somebody?”

If you don’t understand, say If you don’t understand, say so!so!

Assume nothing!Assume nothing!

Best Outcome: Best Outcome:

A recommitment to life and A recommitment to life and independent confirmation independent confirmation that the person got into a that the person got into a treatment programtreatment program