An added bit – Sept 11th 2019
After sharing this on twitter yesterday I got a lot of feedback. It was mostly very positive but there were some really valid critiques too. Perhaps the biggest message is that validation and empathy is your most effective tool. I totally agree with this and spending time with someone in a thoughtful and empathic manner often changes the narrative of a conversation about death.
Some people were aghast at some of the ways I was suggesting we might talk to people. What I will emphasise is that the suggestions I’ve used here are not your starting point – they’re what you use when you think someone is genuinely going to die. There was some feedback that using some of these could cause people to kill themselves but I can’t quite get my head around that concept. If you’re convinced someone is going to die I don’t think there’s anything you can say to make that worse. What I will say is that I’m not right about about most things so pay attention to people with lived experience who say this is not the way to go.
Finally there were a couple of other additions. I can’t get behind being more supportive of people taking their own lives but it was a suggestion. Another was to talk about suicide as an illness that is trying to kill you. I’m really uncomfortable with that but….if I knew someone thought of their difficulties in that way then I’d use it. Whatever works in that moment.
I’m hoping someone will write a piece refuting everything below and giving clinicians some really clear ideas around how to be helpful. Remember to start gently first though. In the ER staff will generally begin with a conversation but in an emergency they’ll crack your chest open. Let’s not start with that, but don’t be afraid to use what you can to keep the people you care for alive. You’re more likely to regret the things you didn’t say.
This job is not easy. Working with people who’s job this is is not easy. Lets all do our best
So its suicide prevention week (or month or day, depending what hashtag is being used at the time) and there is much talk of how to help people who feel suicidal. There are lots of people speaking about never having had any training in this area, and lots of service users saying that the response they have had has been awful. As someone who has been responsible for some awful responses in my career I thought I’d share some ideas around working with suicide. Now I’m not suggesting that this is THE way to work with people who are suicidal, I’m not even saying that it works. What I do find is that having these tools and ways of thinking in my head makes me more confident and capable of working with someone who is telling you they want to die. Do excuse the arrogance and I’m sure there are better ideas out there which I’m eager to hear.
Learning The Hard Way
My big introduction to working with suicidal people came when I started doing duty in the CMHT. We had someone who phoned around once a week to say they had lined up their tablets on the table and were going to take them all. I then took on all the responsibility for keeping then alive and got panicky when they couldn’t assure me they would be alright. Very often the conversation ended with them hanging up because they were so frustrated with me, me calling an ambulance to go to their house and sometimes both. It was in the CMHT that I started to pick up the idea that suicide was someone else’s business. One whiff of suicide and I could free myself from any anxiety around being responsible for them by packing them off to A&E or calling in the crisis team to take them off me. While this solution worked wonders for me, it did little for the service user who would tend to be passed around a range of services and sometimes be sent off to a placement miles from home. This was partly to address their suicidal tendencies and partly to do us the great service of not having to worry about them anymore.
I started thinking differently as a result of working in a day therapeutic community for people with personality disorder who were frequently suicidal. This got me used to staying with people who wanted to die but trusting the group to help, not feeling that I needed to fix it. I went on to do DBT and spent a few years working with highly suicidal people and people who manage their distress in ways that are potentially lethal. I think back to the naive practitioner sitting on duty and hoping the phone wouldn’t ring. In a way, this is a gift that might have helped him be more useful. Again, I’m not saying you have to do this, I’m not saying that it will work, I am saying that the more tools you have in your box the more comfortable you will be. Regardless of the effectiveness, feeling more confident might be enough to keep you going.
“I’m having suicidal thoughts…”
Find out what they are. Asking won’t make it worse.
If they’re being vague, let’s get some clarity – “When you say ‘It won’t matter or I won’t be here’ it makes me think you’re going to kill yourself. Are you?”
What are you going to do?
When are you going to do it?
Often I find that being able to talk about the horror that’s in their mind is enough to reduce their distress.
Once we have the What and When of what’s in someone’s mind we can start working on the Why. If we think about suicide being the solution to a problem, try to understand what the problem is.
Sometimes I will use the words above but something like “Can you help me understand why being dead is appealing?” “What would being dead be better than?” “What is so unbearable at the moment that means being dead would be useful?” can be used. You can probably put it better…
Start building hope – “It sounds like it’s this issue and the thought that nothing will change is what’s behind your decision to die. If that issue could be changed would you feel the same way?”
Give examples of similar situations which have changed (or ask them for some).
Don’t solve the problem for them but try to generate alternative solutions to deal with the issue.
Ask if they have felt this way before and gradually felt differently – “It is worth making a literally life changing decision when you’re feeling a way you don’t always feel?” or “You felt this way x months ago, then had y time where things were bearable. Might you feel differently in a few days like you did last time?”
A desperate one – “You have felt like this for x years. We have been trying to change your life for y time. Can we really undo x amout of problems in y amount of time? Can you give it a bit longer before you make a final decision?”
All the above can make a difference. I suspect it’s less about what you say and more about helping someone feel listened to. If your input finishes there you’ll tend to feel pretty good. If nothing has changed you might want to try some things that make you feel a bit meaner.
Attack their rationale for dying.
“I want to be at peace” – What if the afterlife is worse? Some people believe in hell, what if that’s true? What if those ghosts people report screaming and wailing is what death is all about? “We don’t know what it’s like when we die. There’s no evidence. Taking your own life is a gamble. It’s worth gambling if you’re a lucky person…..Are you a lucky person?” (People often cry at this point)
“They’ll be better off without me” – They will not. Almost everyone I work with has had massive trauma in their lives. I will end up working with them if you kill yourself. You know how you blame yourself for everything? They will do that. Their risk of attempting suicide will more than double if you kill yourself. This hell you’re in now, you will be putting them in that.
It can be helpful to describe the horror of a dead body if there’s a chance people will find them. “Do you want their last memory of you to be your purple body covered in blood and sick? Don’t think you will be falling into a peaceful sleep…”
Alternatively – “Are you going to let them win? After all the suffering they put you through it seems unfair that you’ll be dead with people missing you while they carry on with their lives”
Those bits might make you feel awful but might get you some commitment to stay alive a bit longer.
Once we have some commitment we can start exploring ways to stay alive that keep the service user in charge as much as possible.
Get rid of the means to kill yourself – “There’s a million ways to kill yourself out there and if you’re determined you will do it. Can we get rid of that rope/stash/weapon so that you don’t do something fatal on impulse?” Best for them to do it, good for them do to it with someone, ok for them to give it to you. Try to avoid just taking things.
Make it harder to go – I’ve written you a suicide note – “I wont read it. I’ve deleted it. I won’t let you say goodbye to me.” Get them to delete/dispose of it. They can always write another one.
If you have a good relationship – “I will miss you.” “I come to work to help people and it will destroy me if you kill yourself” OR “I will go to court and someone will criticise every aspect of our work together to make it my fault that you’ve died. In my notes somewhere I’ll have written something wrong or written it too late and I’ll get struck off. I might never be able to do my job again if you do this.” This can sound totally self centred by at some point you might just want to say anything you can to keep someone alive. If they’re set on dying, it’s not as if anything you say can make it worse.
And I’ve never done this but if pushed – “You can die. We are part of Europe and there are places you can go that will help you. I’m asking you not to die today. You can fill out an advance directive refusing treatment. It takes a bit of time but it means you can do it. I’ll be honest and I hope you change your mind during that time but it can be done.”
A few more things I might say are –
“The obvious thing to do is get you into hospital and have people force you to stay safe. My experience is that once someone else is responsible for keeping someone alive, everything they were doing to keep themselves safe up until now goes out of the window. If we can consider the idea that admission could be more dangerous for you, can we think other things that might keep you safe?”
“Admission sounds like a good idea but you often cope by cutting. In hospital they will take away the ways that you normally cope so you’ll be feeling like you do now, but without being able to do what you normally do to cope. Can we think of other ways….”
When offering solutions try to make them fit with their normal life – support from friends, family, call lines, more time with people they trust. A change of environment. Even time in a 24 hour Mcdonalds is time spent around people when it’s harder to act on that urge.
“Feel free to talk to me again” lets people know you’re not dismissing them. I always include a warning that I will be no help at all if they phone five minutes before the office closes.
With all the above I’d add the importance of validating someone’s reasoning. “That makes sense.” “If I felt like that I would want rest.” “I would want that pain to stop.” We don’t agree with their solution but we agree with their problem and can see how they thought dying would help.
Rather than tell people to distract themselves, ask what they’ve tried so far. It can sound really invalidating if we suggest things they’ve already tried. Also try to avoid telling people they’re wrong about how they feel. When someone feels like dying, “But you’re doing so well…” isn’t going to fly. If you really disagree, validate their thinking first before offering a different view.
With all these interactions it’s important to try to be curious. If you feel someone is saying one thing but communicating something else don’t be afraid to say that. I sometimes use the preface “This might sound like I’m trying to trick you or catch you out, but honestly I’m just trying to understand…” which can then lead on to “There’s people who jump under a train and there’s people who have no thoughts about dying at all. I’m thinking that you’re sitting here telling me this and I wonder what that means about how determined you are to die. I’m not saying you don’t want to. I can see how much you’re struggling. Can we think about what it might mean together? Does that sound like I’m not listening?” This can often change a conversation from ‘I’m going to’ to ‘I want to’ and urges are easier to work with than firm plans.
What I often hear service users saying is that they were dismissed, not listened to and abandoned. In my experience you can agree solutions that are massively different from what the service user wanted when they walked through the door if they feel you are interested and care. Not admitting someone on the back of a sound rationale which relates to their past/current services can be much more acceptable than “Your notes say admission isn’t helpful”.
Sometimes someone’s desire to die is so acute they might need to be protected from themselves. This is always my least favourite option but short term and with people you don’t know it might be your only one. My gut instinct is for the admission to be short term and that time used to assess and formulate rather than just warehouse. The decisions we make when we understand might be significantly different to those we have to make when caught by surprise.
And I think (to inappropriately use a military expression) those might be all the weapons in my arsenal. Remember that these are tools to use when the service user is on the phone or right in front of you and you’re caught by surprise. There is no substitute for assessing/formulating risk beforehand so that you can act as if this is the 10th time they have been in this situation rather than make all your decisions as if it’s the first time it has ever happened. You will feel more comfortable if you have a plan that the service user has co-produced beforehand. If there’s lots of positive risk (and in hindsight anything other than infantilising, detaining and restricting will be labelled reckless) get senior clinicians and the service user to give the plan their blessing.
I hope this is useful. I think it might have been useful to me when I qualified. Any extra tips and tricks be sure to comment at the bottom. I know I can always learn new things and you never know, it might just save a life. Again, excuse the arrogance of writing something that might be a bit (a lot) patronising but honestly, it’s a genuine response to people saying they felt stuck. Looking forward to hearing your thoughts. @keirwales
Keir is an Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk