Because most people who die by suicide give warning signals of their intentions, the best way to help prevent suicide is to learn how to recognise – and then respond to – those signs. It may be helpful to think of a continuum, at one end of which is a healthy desire to live life to the fullest, and at the other end of which is a completed suicide. Somewhere on that continuum – possibly in the half closer to the healthy desire to live – we peg the first marker of three on the road to suicide. It is about the risk factors or conditions which are correlated with suicide.

Risk factors (conditions associated with increased risk of suicide)

All of the more difficult life challenges can be included in this category:

• Terminal illness or chronic pain
• Death of a relative or friend
• Divorce or separation
• A broken relationship
• Social isolation or loneliness
• Impulsive or aggressive tendencies
• Stressful life events or stress on the family
• Loss of health, whether real or imagined
• Loss of job, home, money, personal security, status, or self-esteem
• Alcohol or drug abuse
• Anxiety, depression or other mental illness (note: depression can appear as “normal effects of ageing” in the elderly. It isn’t! Similarly, teens may mask their depression by acting out. Someone in the early stages of recovery from a depressive episode is at particularly high risk, as is someone during the first two months on antidepressants)
• Previous suicide attempts
• Family history of suicide
• History of trauma or abuse (Florida Office of Drug Control, 2009)

Risk factors associated with adolescent suicide

In addition to the general risk factors above, both teenagers and older adults are at higher risk. Teens are going through emotionally turbulent years, trying to fit in and succeed. They struggle with issues of self-esteem, self-doubt, and feelings of alienation. Of the above conditions, depression, childhood abuse, impulsive and aggressive tendencies, and experience of a recent traumatic event are particularly serious risk factors. Other risk factors particularly potent for this age group include:

• Lack of a support network
• Availability of a gun
• Hostile social or school environment
• Exposure to other teen suicides
• Identification as gay, lesbian, or transgender (and the ensuing isolation) (Florida Office of Drug Control, 2009).

Risk factors associated with suicide in older adults

Owing in large part to the frequently undiagnosed and untreated incidence of depression, people over 65 years of age have the highest suicide rates for any age group. In addition to depression, the general risk factors prominent for this age group are: recent death of a loved one; disability, illness, or chronic pain; and isolation and loneliness. Not on the above list of general factors, but also risk factors for the elderly are:

• Major life changes, such as retirement
• Loss of meaning and sense of purpose
• Loss of independence (Ainsworth, 2011; Smith et al, 2012)

Emotional and behavioural changes which may be associated with suicide

Obviously, not everyone who suffers from one of the above conditions will become suicidal, but there is elevated risk. People who experience some of the above conditions will go on to experience changes in personality and behaviour; these changes comprise the second peg marking the journey towards suicide:

• Overwhelming, ongoing pain. Pain may sometimes have been at the same level for a long time, and even if the person managed to cope before, suicidal feelings may be exacerbated by having the sense that their pain-coping resources have come to be depleted. Also, precipitating events can worsen pain, causing suicidal feelings.
• Hopelessness-helplessness. More than most of the other negative intense emotions, the sense that the pain (whether physical or emotional) will continue or get worse is a strong predictor for suicidal behaviours. When feeling hopeless or helpless, the person convinces him or herself that there is no hope for the future, and no one can help: “There’s no way out.”
• Changes in personality. The person becomes sad, anxious, irritable, tired, withdrawn, or easily angered.
• Feelings of guilt, shame, self-loathing; the sense that no one cares, or that one is worthless; fears of losing control and/or harming others. People with these emotions may feel like a burden, and proclaim, “Everyone would be better off without me.”
• Decreasing interest in previously enjoyed activities, including meeting with friends and having sex.
• Social withdrawal or falling in with a group with very different standards to those of one’s family.
• Declining performance in school or work.
• Feeling rage or uncontrollable anger, or seeking revenge.
• Violent, rebellious behaviour or running away (in teens).
• Powerlessness: the feeling that one’s resources for reducing pain or sorting out problems are exhausted.
• Deepening neglect of physical appearance and/or physical deterioration.
• Changes in sleeping or eating habits (in either direction: suddenly sleeping or eating too much, or sleeping or eating poorly). Elderly people may deliberately forgo food or medications, or disobey doctor’s instructions (Ainsworth, 2011; Smith et al, 2012; Florida Office of Drug Control, 2009).

Suicidal behaviours

Not all people who experience emotional and behavioural changes will become suicidal, but again, the risk for it is higher. Some who do have such changes will go on to exhibit suicidal behaviours, the third and final peg marking the journey to suicide. Suicidal behaviours include the following:

• Direct statements of suicidal ideation or feelings. Some may say things such as, “If I see you again . . .”, “I’d be better off dead”, or “I wish I hadn’t been born.”
• Preoccupation with death. Suicidal people may make requests for information on euthanasia, do inappropriate joking, or read or create stories, essays, poems, or artwork with morbid themes. Teens may find music with themes of death.
• Development of a suicide plan, acquiring the means to commit suicide (such as purchasing a gun or stockpiling medications), rehearsal behaviour, and setting a time for the attempt.
• Self-destructive behaviour or self-inflicted injuries, such as cuts, burns, or head-banging. Teens may act or drive recklessly, as if they have a death wish. Others may increase alcohol or drug use, or practice unsafe sex. There may be unexplained “accidents” among young people and the elderly.
• Making out a will, giving away prized possessions, making arrangements for family members, or otherwise putting affairs in order.
• Inappropriate goodbyes, or unexpected visits to friends and family members, especially combined with saying goodbye as if they won’t be seen again.
• Verbal behaviour that is indirect or unclear, such as, “You won’t have to worry about me anymore”, “I want to go to sleep and never wake up”, “I’m so depressed; I just can’t go on”, “Does God punish suicides?”, or “Voices are telling me to do bad things.”
• Withdrawing from friends and family, increasing social isolation, having the desire to be left alone.
• Exhibiting a sudden sense of calm, where earlier the person was either depressed or agitated (Smith et al, 2012; Ainsworth, 2011).

A warning about the warnings!

It would be easy to be complacent about spotting potential suicides, thinking that a person is not close to suicide unless they have many of the above features. Yet many completed suicides never had multiple of the characteristic conditions, emotional or behavioural changes, or suicidal behaviours we describe here. If the person exhibits even a few of the above features in any of the categories, they need to be taken seriously.

Protective factors: the things that keep suicide from happening

We’ve been naming all the factors that put people at risk for suicide. Protective factors, conversely, reduce the likelihood of suicide. They enhance resilience and may serve to counterbalance risk factors. What are these conditions that might help to keep the person in the flesh when they are going through tough times?

• Effective clinical care for mental, physical, and substance use disorders
• Easy access to a variety of clinical interventions and support for help-seeking
• Restricted access to highly lethal means of suicide (for example, no guns available at home)
• Strong connections to family and community support
• Support through ongoing medical and mental health care relationships
• Skills in problem solving, conflict resolution, and nonviolent handling of disputes
• Cultural and religious beliefs that discourage suicide and support self-preservation (Florida Office of Drug Control, 2009).

In addition to the general protective factors above, there are several that are youth-specific. These are:

• Sense of connection or participation in school
• Positive self-esteem and coping skills
• Access to and care for mental/physical/substance disorders
• Contact with a caring adult (Florida Office of Drug Control)

Prevention Tips: Keeping your supported person in life

Despite the intensity of the urge to suicide, there are things that you can do as a support person to bring someone back from the brink. In the immediate term, they revolve around showing care and respect for the person – and for the gravity of the situation – and seeking immediate professional help. In the longer term, support will hinge on your ongoing presence in their life, encouraging them towards actions which keep them in life. Here are some tips to help.

#1: Take the situation – and the person – seriously

The indirect or ambiguous comments, the preoccupation with and joking about death, or any of the above personality changes and behaviours are all roaring calls for help, and they must be tended to very quickly; you do not know what window of time you have before the person might act on any suicidal thoughts. Don’t delay. Get face-to-face with the person right away, and give them every opportunity to download. Your job is neither to give advice nor to argue. You are not there to criticise or to lecture on the value of life. Your job at this stage is to listen compassionately (Rose, 2008). Depending on what they say, you may need to respond very quickly.

#2: Be pro-active: start “The Conversation” about suicide

If you believe that you have spotted warning signs that the person is suicidal, but they have not said anything direct about it yet, it might be up to you to start the conversation. You can use your door-opener micro-skills, with statements like the following:

“I have been feeling concerned about you lately.”
“I wanted to check how you’re doing, because you haven’t seemed yourself lately.”
“I have noticed changes in you recently and wondered how you are going.”

Important starting questions

If they acknowledge feeling suicidal or having suicidal ideation, you can ask:

“When did you start to feel this way?”
“What happened to make you begin feeling like this?”
“How can I best support you right now?” or “What kind of support do you need from me?”
“Have you thought about getting help?”

There are no magic words except those that form micro-skills responses, such as the open questions and feelings-reflecting interventions you have already learned. Through your supportive, caring presence, you are giving the person relief from being alone with their pain. Your sympathy, patience, and acceptance allow the person to unburden themselves of their troubles, ventilating their feelings. You cannot deeply do this listening if you do not respect them.

Helpful statements

Some statements that others have found helpful are:

“You may not believe this now, but the way you’re feeling will change.”
“You are not alone; I’m here for you.”
“I may not get exactly how you’re feeling, but I care about you and want to help.”

#3: Assess their risk level

Once the person has confided that they are thinking about suicide, you need to evaluate how immediate a danger they are in. The further along their plans are, the higher the risk they are at. Those at the highest risk for dying by suicide in the near future have a plan, the means to carry it out, a time set to carry it out, and a clear intention to follow through.

The following questions can help you assess their immediate risk level.

The questions to ask

“Do you have a suicide plan?” (Plan)
“Do you have what you need to carry out your plan?” (Such as pills, a gun, a rope, etc: the means)
“Do you know when you would do it?” (Time set)
“Do you intend to commit suicide?” (Intention)

Level of suicide risk

• Low: The person is having some suicidal thoughts, but has no plan, and says that they will not commit suicide.
• Moderate: The person has suicidal thoughts and a vague plan which may not be very lethal (for instance, they plan to take just a few too many prescribed medications, but not a huge number of them). The person says they will not commit suicide.
• High: The person has suicidal thoughts and a specific plan that is highly lethal. The person says that they will not commit suicide.
• Severe: The person has suicidal thoughts, a specific and lethal plan, and says that they will commit suicide.

As stated above, do not worry that, by talking about suicide, you are bringing it into reality. If they are thinking of killing themselves, it already exists as a potential reality for them. In inviting them to open up about it, you are reducing the immediate threat by offering them caring, which may lead to them having hope that there is a way out besides suicide. If they are actively suicidal, you have some more immediate work.

#4: Be prepared to act quickly in a crisis

Get crisis help. If suicide seems imminent, call a local crisis centre, dial 000 for emergency services (in Australia), or take the person to an emergency department. The emergency mental health team may need to come. Especially if the person is actively suicidal, it is important for you to remain calm; it sets the emotional tone for the whole conversation and makes it easier for the person to tell you what they need. If you seem panicked or overwhelmed by the person’s intentions, the person will feel that they cannot confide in you, and you will not be able to help as much (Rose, M.P., 2008).

• Remove all means of suicide. Take any guns, medications, knives, and other potentially lethal weapons away from the vicinity. If you are at their house, you don’t have the option of putting the person into a padded cell, but you can reduce the ease with which they could die by suicide.
• Stay with them. Under no circumstances should you leave an actively suicidal person alone! You must stay with them until the urge passes or more professional help arrives. There are no exceptions to this rule; your presence might be the only factor preventing them acting on their plans (Rose, 2008).

#5: No secrets

Do not agree to keep suicidal plans a secret! This person needs your help. Keeping secrets will only ensure that the person does not receive the help that they need. All professional medical, psychological, and emergency services organisations have strong policies in place to protect the privacy of their clients/patients (Rose, 2008).

#6: Urge professional help

The person may not believe that a doctor, counsellor, psychologist, or other health professional can help them. You may need to use patience, persistence, and all your skills of persuasion to get them to treatment, but it is worth the effort. You should not and cannot tend to this by yourself (unless, of course, you are qualified to do so). You can get advice and referrals from crisis lines. You can be pro-active about locating a treatment facility, and you can drive the person to the doctor’s appointment, when you have secured one.

#7: Make a safety plan

Once the person is out of immediate danger, work with them to develop a safety plan: a set of steps that they commit to following if they have another suicidal crisis. Jointly list triggers that are more likely to bring on a crisis for the person; these could include anniversaries of losses, stress from relationships, employment issues, and abuse of alcohol or drugs. Make sure to list contact numbers of all relevant health professionals: doctors, psychiatrists, counsellors, etc. Put down the names of family members and friends who have agreed to help out in an emergency.

#8: Plan to follow up on their treatment

If medications are prescribed, you can have a role in helping to ensure that they are taken as directed. And, much more easily than the doctor or psychiatrist, you can observe your supported person for side effects from the drugs. If they appear to be getting worse, you are better placed than most to make a call to the treating professional to let them know. There are many medications, and it often takes patience, persistence and time to find the right treatment for a particular person.

#9: Assure the person of your support over the long haul; offer it proactively

Supporting someone through a suicide attempt and the subsequent period of recovery is about offering compassion and a solid listening ear, and about letting the person know that they are not alone; you care. Note that it is not about doing the person’s healing for them; only they can commit to getting better and making the decision to stay in life. Similarly, you cannot take responsibility for them, and it will not be your fault if they do self-harm further down the track.

That said, your most potent role is, again, a pro-active one. It is one thing to say, “Call me if you need anything.” Many depressed or suicidal people will not reach out on the strength of that. Your more effective role is to regularly call or drop in to see how they are going, or to invite them out. You are thus powerfully backing up your “lip service” of caring with actions that show it, and your supported person has a much greater chance of staying on the recovery track (Smith et al, 2012).

#10: Encourage a healthy lifestyle

We all know that exercise, good diet, and a proper sleep regimen, plus forgoing alcohol and drugs, are hugely important components of recovery from most health threats. Those aspects, plus soaking up the healing effects of sunlight and fresh air every day, are no less crucial aids on the road to recovery from a suicide attempt. And therein lies the challenge. If someone is so down that they are considering making their body stop working altogether, how easy will it be to convince them to go 180 degrees in the opposite direction: not just towards life, but towards a healthy life? Your role as support person may be critical in swinging by with your track pants and trainers on, to bring them with you on the walk. Or you may suggest that you get together for a shared meal, and you help them learn (or remember) how to make simple, nutritious, delicious dishes that induce a sense of wellbeing. Your support is key; your own healthy lifestyle adds a heartening force of example to the persuasion.

There is another reason for you to encourage someone’s recovery by modelling a healthy lifestyle. It takes courage and tremendous emotional reserves to deal with and fully support someone who is severely depressed and/or suicidal. There is much evidence to show that carers looking after someone who is mentally ill (including depression and anxiety disorders as examples of mental illness) puts those carers at highly elevated risk of depression themselves. A recent study showed that 56 per cent of carers in such situations develop either “moderate” or “severe” depression. A further 9 per cent fit the clinical description of “mildly depressed” (Cummins, R.A., Hughes, J., Tomyn, A., Gibson, A., Woerner, J., & Lai, L., 2007).

Thus, your own example-setting of adhering to healthy lifestyle practices will help you as well. And you also need to know very clearly where your emotional support is coming from, as you care for your suicidal supported person. To whom do you turn when you feel overwhelmed or discouraged? Get those people lined up now. If you do not, you may find that by the time you need those relationships in place, it is too late.

References

• Ainsworth, M. (2011). What can I do to help someone who may be suicidal? Metanoia.org. Retrieved on 26 March, 2012 from: hyperlink.
• Cummins, R.A., Hughes, J., Tomyn, A., Gibson, A., Woerner, J., & Lai, L. (2007). The Wellbeing of Australians – Carer Health and Wellbeing. Australian Unity Wellbeing Index Survey 17.1, Report 17.1, October, 2007. Retrieved on 24 February, 2012 from: hyperlink.
• Florida Office of Drug Control. (2009). Understanding & Preventing Suicide: A Customizable PowerPoint Training. Florida Office of Drug Control. Statewide Office of Suicide Prevention and Suicide Prevention Coordinating Council. Retrieved on 27 March, 2012 from: hyperlink.
• Smith, M., Segal, J., & Robinson, L. (2012). Suicide prevention: Spotting the signs and helping a suicidal person. Helpguide.org. Retrieved on 26 March, 2012 from: hyperlink.
• Rose, M.P. (2008). Suicide prevention: Crisis intervention and suicide prevention: A guide for the campus community. Retrieved on 26 March, 2012 from: hyperlink.