A post shared by Elephant Journal (@elephantjournal) on Apr 6, 2019 at 11:00am PDT

In 2004, my 16-year-old son took his own life.

Despite having trouble with his grades and some minor disciplinary issues, there were no visible warning signs. He hadn’t started giving his things away, talking about death, withdrawing from others, or any of the other “classics.”

His death left my family in a turbulent black ocean of grief. We have spent 15 years trying to figure out what happened and how we could have prevented it.

In the interim (and in part because of this tragedy), I became a psychotherapist. To date, I have spent countless hours with clients from all walks of life who were, and are, in various suicidal states of mind. What I have noticed is that suicidal thoughts, like all mental health issues, occur on a spectrum, and that being able to discern where someone is on that spectrum could mean the difference between life and death.

I believe most normal human beings have at least one moment when they consider what it would be like not to be alive. This is generally not because things are going so well. It’s not a neutral moment of reflection, like, Oh, I wonder what it’s like to not exist the same way I wonder why the sky is blue, (though that can happen as well). It’s more like, This day/relationship/job/experience is so crappy that I just want to opt out. There are no follow-up thoughts, and the idea comes and goes with little impact. Let’s call that a “1” on a scale of 1 to 100 of suicidal ideation. There is a great deal of room on that scale before we get to 100, which I will categorize as “having become determined to die.” Learning to talk to someone about their mindset can go a long way toward successfully helping them.

I’ll use my client Lea (not her real name) as an example. Lea is a 17-year-old, accomplished volleyball player with decent grades, nice friends, a father who suffers from Bipolar I Disorder, and a mom (in part from dealing with her father) who battles depression and anxiety. Lea’s little sister was diagnosed with anorexia and hospitalized several times, and mental illness runs on both sides of her extended family.

In part due to the family legacy of being labeled as mentally ill, Lea was resistant to considering her own mental health issues, which were intense enough to make her drop out of school for a semester, have self-harm behaviors, and stop bathing for days at a time. When she finally landed in my office, she looked haunted and would barely speak above a whisper. Obviously, I was concerned for her safety.

Though that was true, I did not begin with the “Do you have thoughts of harming yourself?” line of questioning. In my experience, going there too quickly only serves to alienate people who might open up if they felt safe first. Not every professional has the luxury of waiting; those who work in ERs or are doing standard intake information in any number of settings are mandated to establish whether someone is suicidal right away. But for people who can adopt a more subtle approach, I recommend it, and this applies to non-professionals as well.

Bring up the subject of suicide with those you might suspect are suicidal only if you feel that they can trust you.

If the trust between you and the potentially suicidal person has been compromised for any reason, it is best to consider a third party who might be more successful in communicating. This could be a friend, family member, or professional. It is not surprising that when someone feels safe, we get a much more accurate read of where they may be on the suicidal spectrum. In the case of Lea, who like many 17-year-olds had a natural suspicion and dislike of counselors, I waited until about the fifth session to broach the subject and did so only after she made the statements that “life seemed pointless” and “she didn’t see herself living past 30.” We won’t always have such convenient openers, but we can ask more subtle questions than “Are you suicidal?” and see where they lead.

Some practical ideas for such questions include:

I notice you seem extra exhausted/bummed out/quiet lately. Am I imagining that, or does it seem that way to you too?

You have so much stress in your life, I’m not sure how you’re handling it all. Do you ever feel completely overwhelmed?

I feel like I remember you being a lot more lighthearted at one point. I’m not sure what’s changed, can you help me understand?

You’ve had a lot of major challenges to deal with in the last few weeks/months. Has that been weighing you down? 

After you ask, plan on listening. Really force yourself to wait patiently and don’t fill the silence to soothe your own discomfort. Talking to someone about scary things is scary, and we need to be brave. If you’ve waited a minute or so and there is no answer forthcoming, you can gently offer something along the lines of, “I’m not here to judge you, I’d just really like to hear what you’re going through.” If you still get nothing, try, “If it’s okay, I’d like to bring this up later. Would you be alright with that?”

Generally speaking, you’ll probably receive a nod, a shrug, a grunt, or no reaction at all, but you’ve still established contact. You can rest assured that the person to whom you are speaking is thinking very long and hard about what you’ve said, and you just raised the likelihood of their talking about it in the future. Worst-case scenario, they don’t, but they weren’t talking in the first place, so you haven’t done any harm and you can have some measure of peace knowing that you tried to help.

In this case, I do not recommend dropping the issue, but instead (if the person is an adult) finding an appropriate counselor on their behalf that is in their area and takes their insurance and leaving that information somewhere they will definitely see it— preferably with a caring note attached. Or (if the person is a minor) doing the same thing and (if you are their guardian) accompanying them to treatment or (if you are not) sharing that info with their guardian. Either way, check back in after they’ve either been to a professional or after enough time has passed that they’ve seen the note and say, “I don’t want you to think I’ve brushed this under the rug. I am still here to talk or just be with you any time for any reason.” Again, you may receive a brusque response—but that still keeps the door open for further communication.

In the case of Lea, after several gentle tries, I was able to determine that, while she often fantasized about not being alive, she did not have an active plan to kill herself. So, while her situation was critical, she was not yet at what I call the point of no return, or 100 on the spectrum of suicidality. The point of no return is essentially when someone has a fixed and indelible idea in their mind that they have to die. In such cases, they may be beyond reason and could require temporary hospitalization. If they haven’t gotten to that point, hospitalization could work against them by further traumatizing and isolating them and making them feel as if they can’t trust anyone. This, in turn, makes them much less likely to reach out for or accept help in the future.

I won’t pretend that there are any black-and-white answers here. This is a tricky business. But I do know that, in part because we are afraid of talking about suicide, many people suffer, and sometimes die, needlessly. Many of us are under the misapprehension that talking about suicide increases the chances of it happening. Studies show that, while an actual incident of suicide does raise the risk of suicide in people associated with the deceased, simply talking about it doesn’t. Do not stay silent.

If I’d known 15 years ago everything I know now, would my son still be alive? I try not to ask myself that question. Instead, I advocate for suicide prevention in any way that I can.

I urge everyone to reject the stigma of mental illness and learn better ways of connecting with those who are suffering.

Suicide is not a dirty word. Those who think about suicide or complete suicide are not selfish or bad.

Together, we can take this issue out of the dark and shine a loving and courageous light upon it, and we can save lives.

~

For more information about suicide prevention go to the National Institute of Mental Health.