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Key points
- Mental disorders increase the risk for suicide. A patient's loved ones should be part of the team to manage this risk.
- The best way to determine if a loved one is at risk for suicide is to ask their clinician directly.
- It's important for loved ones to know how to talk to a patient about suicide and what proper care in a crisis looks like.
Each year, over half a million people show up at emergency rooms because they are contemplating suicide or have already hurt themselves. In the year that follows this visit, these people are at very high risk for completing suicide.
This is a nightmare scenario for anyone who cares about these individuals. Family and friends will carry the burden of wondering what their role is (or should have been) in preventing tragedy in these peoples’ lives.
It is important to have guideposts for when your concerns rise to the level of fears for someone’s life. Of course, an ER visit may often be appropriate. However, very few people are hospitalized for feeling suicidal. This still leaves loved ones wondering what to do next. So, we’ll review how to approach things before, or preferably without, an ER visit.
The first such guidepost is to understand what your role is as someone close to a person at risk for suicide. This is relevant at the very beginning of the development of a mental disorder, as merely having one puts you at greater risk of suicide. But not all risk needs active attention. So how do you know whether or not your family member/friend is seriously at risk? You ask the primary mental health clinician.
Anyone can look up risk factors, but your concern is one person. Become educated about the person you care about. The primary clinician may have specific signs or symptoms for you to look out for based on the patient’s history. There may also be particular precautions she would like you to take. For example, sometimes it is better if a person other than the patient holds medication. Or perhaps substance use brings on suicidal thinking and has its own signs. If the patient is a gun owner, there must be a family discussion about who will take control of the guns outside of the home.
Being involved
Let’s assume, then, that the treatment team feels there will be an ongoing risk of suicide. Is it your role to figure out when someone is in trouble because they are suicidal? No. That is the task of the treating clinician. Your job is threefold:
- Observe for signs of suicidality as told to you by the primary clinician.
- Be able to talk with the patient about their suicidal thoughts and/or plans.
- Know what appropriate care looks like when the patient is at risk and the clinician takes over.
Let’s look at each of these points.
It is very difficult to predict when someone is truly about to attempt to take their life. That task should be left to the clinician. Your job is to watch for direct and indirect signs. Direct signs are when a person says they feel like hurting or killing themselves.
Indirect signs are early warning signs that someone is generally worsening. They say very negative things such as "Life is not worth it anymore,” “I am useless,” or they try to gather means of suicide like saving up pills or acquiring a gun.
Beyond this, do not try to figure out what the risk is. At this point, you go right to the patient and discuss it. This should be done before contacting the clinician or other help if things are safe for the moment. You will have much more to tell these people if you take this step and you may change the outcome of these later conversations.
How to talk about suicide
When discussing suicide, remember these things:
- You will not make anyone suicidal by saying the word “suicide” or asking about how someone might hurt themselves. In fact, effective interventions are ones in which suicide is mentioned and talked about directly.
- Showing that you are comfortable with the words and the discussion takes some of the power and shock out of thoughts of suicidality. Such thoughts may be normal for the person. If so, it will be reassuring that they can discuss it without upsetting you. If the thoughts are new, it may be scary for the patient. Again, your calm and concerned tone will be very helpful.
- Ask about a plan. How will they do it? When? Ask for specifics. Otherwise, just listen. Let them know that you’d like them to speak with their clinician. If they will not, obviously you must. Do not get into a struggle. If things feel out of control, call 911 and then the clinician for help.
Clearly, there are times when the situation may get much more complicated. What if, for example, I cannot be sure if my family member/friend is being open and truthful with me? This and other complexities certainly happen. You should not be the one to have to figure out how to handle the specifics of your own situation. Get guidance from the clinician.
What proper treatment looks like in a crisis
A voicemail instructing you to go to ER or call 911 for any problems after office hours is not acceptable from clinicians but remains all too common today. A visit to the ER is necessary for significant emergencies but more often than not accomplishes little.
Unless urgent action is needed, it is better to work things out with clinicians as they know the patient; their problems, weaknesses, and strengths. If the clinician feels a visit to the ER is necessary for safety, then she should make that decision and call the ER you will be going to in order to give appropriate history and be in touch with the staff there to discuss follow-up.
Principles of management for clinicians: I think of these three principles whenever I have a patient thinking of suicide. It doesn’t matter how risky the situation is. These principles always apply.
- External control. This is providing protection when a person cannot protect themselves. It always means taking away harmful means (pills, guns). From here on, it can mean many things such as not being alone for a day, staying home from work, coming in for an emergency appointment, a medication adjustment, or a hospital visit. This is all up to the clinician. The goal is to decide how much control someone needs to be safe, and no more. This can be just a conversation or may mean the complete control of the hospital.
- Make sure the patient feels connected. This connection could be to you, a therapist, another person, anyone. People who are suicidal usually feel disconnected from others. This allows them to not see the ramifications of suicide. Who will your family member/friend feel connected to going through this crisis?
- Symptom reduction. Anxiety is an enemy of safety. Meds for anxiety and insomnia decrease suicidality. They do not disinhibit and increase it. The same holds for other symptoms: depression, psychosis, etc. The clinician will likely need to treat the main problem, commonly depression (but bipolar disorder, anxiety disorders, and psychosis also have very high suicide rates). The patient may also need therapy around a recent crisis like a medical diagnosis, break-up, job loss, other interpersonal problems. These are also a form of “symptom reduction,” in that they attempt to decrease the pain from these life events.
To summarize: If a person has had significant suicidal ideation, made a suicide attempt, been psychiatrically hospitalized, or has a major mental disorder, then the possibility of a future suicide attempt should always be considered and discussed with the primary clinician.
Your role as a family member is not to know for sure when someone needs intervention. But you do have an important role in observing changes in someone’s state of mind, allowing them to tell you potentially frightening things without being shocked yourself, and knowing the general form of appropriate action when someone is at risk.
If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 contact the National Suicide Prevention Lifeline, 1-800-273-TALK, or the Crisis Text Line by texting TALK to 741741. To find a therapist near you, see the Psychology Today Therapy Directory.
