STEPHEN FRY

In response to a question asked of me I realised we have no formal information about what to do if someone is in a suicide crisis - even applied to yourself if necessary though that is harder. By crisis I mean imminent risk, not someone saying they are thinking about it at some later date. Here is what to do in a suicide crisis followed by some risk factors (just some, the most common, there are more) that show someone may be in one.

~KSx

In a SUICIDE CRISIS, WHAT YOU SHOULD DO NOW (be this a friend or you acting on your own behalf):

1. Do not leave the suicidal person alone, or be alone if you are suicidal.

2. Trust your instincts, follow these procedures listed below, as it is better to get help and be safe than to leave it and regret it for years.

3. Talk to them about your concerns and listen. Do not be afraid to ask questions. This will not “put ideas into their head,” or make the person become suicidal if they are not already.

4. Do not be judgemental. For example, do not say, “How could you want to kill yourself and upset me so much?” The suicidal person will probably feel guilty about this already, and will certainly feel too bad to cope with judgemental comments. They will be highly emotive, but not rational, and may overreact. You will be emotional; that is natural; but you have to be the strong one, and think before you speak.

5. Do not promise confidence about what they tell you because if you need to seek outside help, breaking this promise will spoil your relationship, and might mean that on a future suicide crisis, the person is not honest with you.

6. Determine if the person has a specific plan to carry out the Suicide. The more detailed the plan, the greater the risk. For example, do they plan to use a gun; have they already purchased a gun; is it loaded and ready; is it near by? Does the person plan to overdose; have they bought alcohol to help them; have they decided what to use; have they purchased or saved up pills they want to use? Are the pills all ready popped out of the container ready to swallow?

7. If you can do it without leaving the person alone, remove any means of attempting suicide that you can think of such as guns, knives, drugs or medications. Certainly remove any dangerous items the person has with them.

8. It is better that the suicidal person does not drive, especially not alone.

9. Do not try to counsel the person yourself: if you recognise these signs, you must get professional help.

10. Take them to their general practitioner for an emergency appointment, or a psychiatric hospital to be assessed, or even an emergency department of a hospital if you are suitably alarmed. It is better to assume the worst and act accordingly, than have a dead friend or relative.

11. Be proactive. The person you care about might be deliberately unhelpful to the professionals trying to help. Explain your concerns to the doctors, and offer evidence, especially of a suicide plan if you have it.

12. If the suicidal person resists all help, get it anyway. If you cannot make them go with you to get themselves help, speak to the professionals yourself, and if necessary the person can be assessed at home or brought by force to be assessed. Then they might be sectioned (hospitalised involuntarily) for their own safety.

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Risk Factors for a Suicide Crisis.

Eighty percent of people who plan to commit Suicide give signs of their intended action. These signs (not all have to be present; indeed one is quite enough) you can recognise in yourself or a loved one, indicative of a Suicide crisis necessitating professional help for yourself or a loved one, are:

Precipitating Event.

Almost any recent life event that is upsetting to you/the person involved. (If you are protecting someone else, keep in mind that something you don’t consider important or ‘bad’ might feel catastrophic to them). Common examples include bereavement, possibly even a friend’s Suicide, events such as the break up of a marriage or relationship, being diagnosed with a terminal illness, or loss of a career, bullying, doing badly at school or university exams, being raped or attacked, or not getting into the university of choice. Or it might be suddenly realising that you/they are ruthlessly trapped in an illness, such as Anorexia that has been ongoing without your full awareness, or suddenly deciding that you/they will never recover from something like Depression.

Intense moods in addition to Depression.

Usually people who commit Suicide do it with desperation. This might include desperation to resolve a situation such as ongoing illness where death represents closure. Also common are one or more of the following: torment, guilt (e.g. for hurting people left behind), anxiety, anger, a sense of abandonment and above all, hopelessness that anything positive can happen ever again.

Changes in emotional behaviour.

Intense moods may be present, but do they change? A colleague, friend, loved one, or you yourself, may begin acting in ways that seem unusual. Someone usually content suddenly being sad and withdrawn. The classic example to be wary of is a person who has been Depressed, maybe for a long while, suddenly cheering up and being happy. They won’t tell you that this is because they have made the decision to end their life and hence suffering, giving them some sense of peace. (You may also be able to notice these happening to you if you are suicidal).

Any spoken or written communication suggesting the person might soon commit Suicide.

Many people give clues about what they are thinking of doing, perhaps with the last remains of hope that someone might help, or in order to say goodbye to people, even asking for unconscious permission. They might say something like “I might not be around.” Some people say things quite obvious but sometimes it is more discreet, such as saying that other people would be relieved if they were to die, but not actually saying that they will die or are planning to die. Some people write a Suicide note, or similar and leave it where is might be found. These might even be on the computer.

Definitive Actions.

Writing a will, giving away special, treasured items, buying a gun, buying drugs, and/or buying lots of alcohol. Effectively putting one’s affairs in order, purchasing items with which to commit Suicide and/or things to help them manage to kill themselves such as alcohol or drugs.

Self-destructive behaviour and decline.

A decline in personal behaviour and in level of functioning. This can be at home, socially or at work. You/the person might get angry, upset, drink more, use recreational drugs, overuse prescription drugs and/or behave strangely. Note that such self-destructive behaviour might actually cause a precipitating event such as loss of a driving license for driving whilst drunk, or losing a job due to reduced capability, thus adding to the suicide crisis.

Recovering from Depression.

When people are very depressed they often do not have the energy to put together and carry out a realistic, lethal suicide plan. When you/they have begun to feel a little better, you/they feel slightly more energetic but still depressed. This extra energy can cause you/them to put their suicide plan in to action. I assume this is applicable to psychiatric disorders other than depression, but concurrent depression is highly likely in these.

Release from psychiatric hospital.

Many suicides take place shortly after a person has left the relative safety of a psychiatric ward. This is because the person may be pretending to feel better to get out and commit suicide. Or they may have more energy due to partial recovery (see reason above), or actually they cannot cope with their life when released, particularly if hospitalised for a long time. At this time family or friends are vital and should be aware of this risk and do anything appropriate to prevent it. Checking, or even watching whilst medication is being taken (particularly if it is dangerous in overdose) is a good example. That tip saved my life.
Inpatient Suicides account for up to 16% of deaths, which may seem like a large number of people, until you consider that many of the most at-risk people will be found in a psychiatric hospital population. Psychiatric wards are often busy, understaffed, and some people “slip through the net” in this way, when checks that should be made are not, or people manage to escape. Escape from many psychiatric wards is not difficult if one is determined.
Many suicides occur when patients are allowed leave from the ward, be that for an hour or much longer. The time people are most at risk, and when most suicides take place, is when they have just recently been discharged from psychiatric in-patient care; 24% of deaths are found in people who had been discharged in the previous three months. In most cases, as you might expect, medical staff believed the person to be at low risk. In some instances (like for myself), patients are released despite being high risk; this is because they are not benefiting from, or being kept safe by, hospitalisation.

Reckless behaviour, “Russian roulette type behaviour.”

Driving dangerously, wasting or giving away money, not caring about things that were once important to you/the person. Even up to playing Russian roulette or behaviour you could liken to playing Russian roulette such as reckless abandonment, cycling like a mad woman in and out of cars and buses in Oxford. This behaviour can include a lack of concern for the future, such as taking up smoking despite understanding the associated risks, because you/that person feels that they have no future to worry about.

Self-Harm.

Additional self-harm, (cutting, burning, overdoses, etc.) which might be of escalating frequency and/or severity with respect to how dangerous and life threatening it becomes.

Return of psychiatric symptoms after a period of recovery.

Veterans of psychiatric illness will recognise the return of an illness that they consider too awful and painful to experience again.

Physical illness, particularly if painful and or terminal.