If you’re reading this, than you may have a friend who has said that they’re feeling suicidal, or who you think might be feeling this way. This can be a very scary place to find yourself. When we think our friends are in danger, it can bring up a lot of very strong feelings, including:
And others. It’s very noble that you care enough about your friend to visit a website like this one, looking for information. At the same time you should also remember that no one person is responsible for another. No matter what happens, you have no control over what they do.
The first thing to recognize is whether your friend is actually suicidal. When people say things like “I don’t think I can go on”, “I wish I could fall asleep and never wake up” and “There’s no way out”, this is a clue that they are feeling overwhelmed and are considering suicide.
Asking someone if they’re feeling suicidal does not put the thought in their head. What asking someone about suicide does is allow them the opportunity to talk openly about what they’re experiencing.
A sample conversation between Amy and Sarah.
Amy: Since Jeff broke up with him I don’t know what to do. I just wish I could make it all go away, you know?
Sarah: “Sounds like it’s really weighing on you, Amy. Sometimes when people say they want to make it all go away, they mean they’re thinking about suicide. Is suicide something you’ve been thinking about?”
In this exchange, you can see the key aspects of talking to someone who is feeling suicidal:
Empathy – By saying “Sounds like it’s really weighing on you”, Sarah has identified Amy is not feeling well and has begun to open the dialogue.
Validation – By saying “Sometimes when people say they want to make it all go away, they mean they’re talking about suicide.” This tells Amy that her problems aren’t unique to herself, and it uses the language she used which helps her feel heard.
Asking directly about suicide – When Sarah says “Is suicide something you’ve been thinking about?” she directly uses the word suicide. This acknowledges that suicide isn’t anything to be afraid of.
At this point, you’ve opened up the dialogue and you’ve established that your friend knows you’re there for them. Telling someone you’re feeling like killing yourself is one of the hardest things a person can tell another, and suicidal individuals often fear that they’ll be judged, dismissed or not taken seriously.
Remember: talking about suicide is never a “cry for attention.” All suicidal threats should be taken seriously. Asking your friend for details on their suicide plan (if they have one), how long they’ve been feeling this way, if they have ever attempted suicide before (or if they’ve ever lost anyone in their life to suicide), and who in their life they feel like they can talk to are all important questions.
Once you have this information, it’s important to connect your friend with resources to help them. This can include counsellors/therapists, friends and family who they can talk to for emotional support, crisis lines and other supports.
You may even find it helpful to create a “crisis plan” with your friend; a crisis plan is simply a list of things that they’ll do if they are experiencing suicidal thoughts. Items on the crisis plan can include “self-care”, things we do to feel better (like talking a bath, listening to music or baking cookies) and actions we can take to directly protect ourselves (pouring alcohol down the drain if your friend drinks when they’re feeling bad or calling you or a crisis line if they don’t think they can keep themselves safe in the moment.
Sometimes you can feel overwhelmed yourself, and it’s important to keep your own self-care in mind. Even professional crisis workers who talk to suicidal people all the time can experience negative emotions like guilt, anger and powerlessness when they’re talking to someone who wants to take their own life.
Calling a distress or crisis line yourself may prove helpful, because it allows you the opportunity to vent in a safe, confidential space. Additionally, they may be able to share with you advice on working with your suicidal friend. If the helpline you’re working with is American Association of Suicidology (AAS) accredited, they may also be able to do what’s called a “third-party suicide intervention”, where you give them your friend’s information and they call them up. This can take some of the pressure off of you, but at the same time it means your friend will know that you’ve told someone they’re feeling suicidal.
Should I “tell” on my friend?
As we said earlier, knowing your friend is feeling suicidal can bring up a lot of strong emotions in you, not to mention the strong emotions brewing in your friend. Sometimes they may ask you not to tell anyone what they’re feeling, that you would be breaching your trust if you tell. You may be wondering whether you should contact someone.
The answer to this is very simple: if you’re not comfortable or you’re worried, you have to tell someone. Your friend deserves to get the help that you need, and although they may believe that you keep their suicidal thoughts secret is the best option, in reality it will only put them in more danger. Most often, when a friend finds out you’ve told someone else of their thoughts, they’ll be relieved that they’ll be getting the help they need.
Besides, would you rather have your friend alive, having told their secret – or dead, having kept it?
As helpline workers, one of the most important duties we have outside of our actual work on the lines is to continue regular training. Training can help reinforce existing skills in areas such as emotional support, suicide risk assessment and crisis intervention, but also teach you skills in areas you may not have experience in such as working with youth, mental illness, self-injury and others.
Depending on your helpline’s resources, you may or may not have access to a large body of training beyond your organization’s initial training for new workers. At my centre, for instance, volunteers have access to the following:
In-Service Trainings at Team Meetings four times a year
While my Centre has a lot of training on offer, other organizations may offer no training at all. Whether you are a helpline worker looking to develop your skills on an individual basis or an organization looking to boost your worker’s competencies, I hope you find the following resources helpful.
Identify Available Resources
There are a number of choices for training. Depending on your location, many community organizations provide education as part of their service offerings. These are sessions of 1-8 hours, provided at low or no cost and can often make for effective in-service training materials.
There are also a number of professional/paid trainings which can help give your workers confidence in the areas of suicide assessment and mental health. They include:
LivingWorks Applied Suicide Intervention Skills Training (ASIST)
ASIST is a first course in suicide intervention. ASIST is light on suicide risk assessment, instead focusing the majority of time on the intervention piece after you’ve asked an individual if they are suicidal and you have gotten a “yes” answer – although a bit of time is dedicated to building rapport and comfort to encouraging the potentially suicidal person to open up to the helper.
ASIST is two days long and costs between $100 and $250 depending on the agency you get it at, and the T4T (Training for Trainers) course costs about $5,000 after hotel and other expenses are taken into account.
The suicideCare course is an advanced course in suicide case management. In contrast to ASIST which is designed for the general public, suicideCare is designed for helping professionals including social workers/social service workers, Psychologists, and other mental health workers.
It is described by LivingWorks as “[helping] to develop suicide-specific clinical competencies beyond suicide first aid, including performing a comprehensive risk assessment and negotiating an appropriate help strategy.”
suicideCare teaches workers how to use the Suicide Intervention Response Inventory (SIRI) to judge their initial suicide helping skills, before continuing on to suicide risk assessment and case management. suicideCare differentiates between external events causing suicidality that may require case management, and internal events that may require counselling or therapy.
suicideCare costs $150 – $250 and may be difficult to find; I had to go to a hospital several hours of the way in order to find an organization delivering it.
QPR Institute – Online Counseling and Suicide Intervention Specialist (OCSIS)
The OCSIS certification is better covered in my full article on that training, but in short it is a training on how to provide online crisis chat and suicide assessment and intervention through a text-based environment. It is priced at $200 and an excellent value for the money, although perhaps not as useful as it could be for more experienced helpers.
QPR Institute – QPR Gatekeeper Training
The QPR Gatekeeper Training is an inexpensive, limited time (~1 hour) online course that can be used to teach basic suicide awareness. This course is similar to the ASIST safeTalk training which is 3 hours long and often costs similar (between $30 and $75 dollars.)
Finally, there are a number of online certificate courses that you can take advantage of. The ones listed below are free.
Helpline Direct Service
Counseling on Access to Lethal Means (CALM) – The CALM course discusses statistics on suicide methods, as well as how to bring this conversation up to clients in a counselling situation. It is especially valuable for working with adolescents and teenagers, who are more prone to impulsive suicidal actions.
Domestic Violence Risk Assessment and Management – Learn the skills to identify and assess intimate partner violence and how to intervene to keep someone safe. A 3-hour self-study online course, free from Western University in London, Canada.
Living Hope Bereavement Support – This course is offered free by the Salvation Army of Australia, and in their words “all aspects of suicide bereavement in order to equip caregivers to support individuals and families through the devastating experience of losing a loved one by suicide“
7 Cups of Tea Online Training – 7 Cups of Tea is an online platform connecting trained active listeners and individuals in need of emotional support chat. New active listeners can get started in about an hour, and there are nearly 30 additional certificates covering topics like Anxiety, Depression, and Self-Injury that volunteers (called “Listeners”) can take part in.
Columbia Suicide Severity Rating Scale (C-SRSS) – The Columbia Suicide Severity Rating Scale is an evidence-based tool for assessing and documenting a risk assessment. You receive a certificate of completion when you are done the 1-hour training.
A number of courses are provided by the Suicide Prevention Resource Centre (SPRC). They are well researched and very user friendly. These links will take you directly to the descriptions provided by the SPRC.
There are many prevailing myths about suicide, suicide risk assessment, and suicide intervention. Learning that someone is suicidal can be very frightening both for the person experiencing the thoughts and helpers. It’s important that as a well-informed helper you do your best to stop the spread of these myths by educating yourself in the basic theory of suicide risk.
These myths below are common in individuals with no training in suicide risk, but even if you have no formal training, dispelling these myths can help you to reduce the stigma. How many did you get right?
#1 – Asking someone about suicide will put it in their head
False! Humans have a strong self-preservation instinct, and asking someone if they’re feeling suicidal will in no way put it in their heads. (Dazzi, et. al., 2014) Instead, asking someone if they’re feeling suicidal will often result in relief if they are feeling suicidal, because it shows that you’re willing and able to talk about it openly.
#2 – Someone who talks about suicide is unlikely to attempt it
False! Many times people who are feeling suicidal will drop hints (lethality statements) like “Sometimes I wish I could just fall asleep and not wake up.” People not trained in suicide assessment may not pick up on these subtle hints, or they may fear asking whether they are feeling suicidal because they don’t know what to do if the person says yes.
As suicide statistics reveal, most women to die by suicide have attempted before, and most men use such lethal methods that they don’t get a second chance. Therefore you should always treat a suicidal threat or statement as real.
#3 – Revealing suicidal thoughts will lead to being hospitalized against one’s will
False! While people who are in immediate danger can (and are encouraged) to go to their local hospital emergency room for urgent help, most people who are experiencing suicidal thoughts can get help on an outpatient basis, connecting with their loved ones and getting referrals to counsellors, therapists, or other mental health care.
#4 – You have to be crazy or mentally ill to experience suicidal thoughts
False! Although upwards of 90% of people who die by suicide have a mental illness (Mann, 2002), having suicidal thoughts by no means you are mentally ill. In fact, most people report having suicidal thoughts at one point or another during their life. They are a normal experience and as long as steps are taken to help, most people with suicidal thoughts can overcome them.
#5 – Once a person has been to the hospital for a suicide attempt, their risk is eliminated
False! Certainly, going to the hospital and seeking emergency physical and mental health care is important. Someone who has overdoses needs physicians to make sure they’re healthy, and to get an assessment of their mental state. But this reduction in risk is only temporary.
Once a person has been discharged, if nothing else changes in their environment they are likely to find themselves in the same suicidal thoughts as before. In fact, sometimes suicide risk can even speak after a discharge. (Large, et. al., 2011)
This is why it’s so important to ask what happened during a person’s last suicide attempt, if they have one, as part of a risk assessment. You want to know what has changed.
#6 – Suicide only affects poor people
False! Suicide is blind. Young and old, poor and rich, in every country of the globe people die by suicide, an estimated 800,000 people a year. (World Health Organization, n.d.)
Sometimes people feel like they’re not entitled to feel suicidal because they’ve lived a life of privilege but this is not the case, and bottling those feelings up and not talking to people can make things worse.
#7 – Feeling suicidal is a sign of weakness
False! Suicide is a response to an overwhelming set of circumstances. Humans have evolved to problem-solve, and sometimes we run out of solutions. In that situation, suicide can look like an attractive solution. This is not a sign of weakness, it’s simply a sign that you don’t have enough resources to deal with what you’re going through.
By widening your support network it’s like adding floor joists to your sub-floor. You’re still carrying the same amount of weight but it’s spread out over a larger area, reducing the amount of load on any one spot.
#8 – Suicides are more common during the cold winter months
False! Depending on country, suicides peak at different months (Fruehwald, et. al., 2004), and in Canada and the US tend to peak in April and May (Bridges, et. al., 2005), and are often quite high during the summer. There are a number of explanations for this, one of which is that during the cold winter months, everyone is inside (and so are you.) When the winter is over, people begin to go outside, and it gets warmer; the suicidal person sees that everyone is enjoying themselves but they are not, and the incongruence can elevate suicide risk.
Additionally, the winter months are often associated with the holidays. Thanksgiving (in the US) and Christmas are a time of celebration and being together with family, who in many cases are a strong protective factor. During the spring and summer there are not as many holidays and people don’t see their families as often (if at all.)
#9 – Teenagers and young adults are at greatest risk for suicide
False! Although teenagers experience an increase in suicide risk compared to earlier adolescents, people in their 20s actually have one of the lowest rates of suicide. After a person’s 20s and 30s, suicide risk tends to climb with age, and individuals 65 and over experience the highest rates of suicide, followed by middle-aged individuals, aged 45-54. (Statistics Canada, 2014)
Explanations for this include empty-nester syndrome in women, where they feel like their purpose has been served and they are only a burden on others, and a “mid-life crisis” in men where they begin to evaluate where they are and where they’ve been and decide that they haven’t lived up to their potential.
#10 – If someone has lost someone close to them to suicide, their grief will prevent them from doing the same
False! In fact, losing someone to suicide (becoming a suicide survivor) actually increases risk. (Jordan, 2008) This is because losing that person has provided a behaviour role model, which serves to give the suicidal person permission.
Additionally, they may experience a lack of support because the person they relied on is now gone. Factoring in grief from the loss and a desire to want to be reunited and it becomes easy to see why suicide bereavement is such a powerful predictor of suicide. (McEnamy, 2008)
These are just a few of the myths that are frequently spoken or thought when the topic of suicide comes up. With your help, you can change people’s attitudes towards suicide and create a more open atmosphere for everyone. Can you think of any other suicide myths?
Dazzi, T., Gribble, R., Wessely, S., & Fear, N. T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence?. Psychological Medicine, 44(16), 3361-3363. doi:10.1017/S0033291714001299
Mann, J.J. (2002). A current perspective of suicide and attempted suicide. Annals of Internal Medicine. Vol 136
Large, M., Sharma, S., Cannon, E., Ryan, C., & Nielssen, O. (2011). Risk factors for suicide within a year of discharge from psychiatric hospital: a systematic meta-analysis. Australian & New Zealand Journal Of Psychiatry, 45(8), 619-628. doi:10.3109/00048674.2011.590465
World Health Organization. “WHO | suicide Data” (n.d.) Retrieved electronically from http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/ on January 29, 2015
Statistics Canada. (2014) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on January 29, 2015.
Fruehwald, S., Frottier, P., Matschnig, T., Koenig, F., Lehr, S., & Eher, R. (2004). Do monthly or seasonal variations exist in suicides in a high-risk setting?. Psychiatry Research, 121(3), 263-269. doi:10.1016/S0165-1781(03)00253-1
Bridges, F. S., Yip, P. S. F., Yang, K. C. T. (2005). Seasonal changes in suicide in the United States, 1971 to 2000. Perceptual and Motor Skills, 100, 920–924
McMenamy, J. M., Jordan, J. R., & Mitchell, A. M. (2008). What do Suicide Survivors Tell Us They Need? Results of a Pilot Study. Suicide & Life-Threatening Behavior, 38(4), 375-389.
Jordan, J. (2008) Bereavement After Suicide. Psychiatric Annals. 38(10)
One role of helpline managers is to manage their workers so that they can answer the most calls possible within the available resources. Even helplines that run 24-hours and have 100% coverage can’t answer 100% of the calls that come in if they have more callers calling in than workers available.
Using a system like Chronicall can give you real-time information on the calls that you answer and don’t and prepare more detailed results (for instance, noting where calls are not answered because the worker is already on a call.)
Given a series of values that are related to each other, regression allows us to predict values where we either don’t have the data or where we want to know the “average” of a piece of data.
For this task, we assume all you have is the data about how many hours your helpline is covered (either in hours or percentages) and the percentage of calls that you answer.
Hours Covered (out of 24)
Call Answer Percentage
While we can use the regression formulas by-hand, Excel provides simple techniques for deducing the formula. The first step (for the purpose of this article) was to do the calculations by hand to demonstrate. You can see the regression article for full details on how to do this.
Regression By Hand
Hours Covered (out of 24) [X]
Call Answer Percentage [Y]
b = (12*20574 – 263*937) / 12*5817 – 263^2
b = 0.71969
a = 937 / 12 – 0.71969 * (263/12)
a = 62.3101
So our final equation is:
Y’ = a + bX
Y’ = 62.3101 + (0.71969)X
We can use Excel to simplify this calculation. Starting with an Excel spreadsheet containing our X and Y values:
Next, we use Excel’s LINEST function. This requires you to select TWO cells at once. The first required value (called an “argument” in Excel) is the known Y values. In this case, it is C2 through C13. The next value is the known X values (B2 through B13.)
The third argument is whether to set b to zero, or to calculate it normally. Since we’re using the equation Y’ = a + bX and not the equation Y = mx + b, we’ll set it to TRUE. The final argument asks whether we want additional statistical information included, so we set this to FALSE.
So our final equation is:
After we’re done typing this, instead of hitting enter like normal, we hit Ctrl-Shift-Enter. This is very important! If we neglect to do this, Excel will only give us part of the information we need. If we’ve done this correctly, Excel will put brackets around the formula, like this:
And you’ll notice that both cells you selected are filled in. The first cell holds the b value and the second cell holds the a value. Putting them into the formula, we have:
Y’ = 62.31024 + (0.719685)X
So, if we want to calculate what our answer percentage will be if we have 21 hours of coverage:
Y = 62.31024 + (0.719685)21 = 77.42
This falls right in line with our expected values, and this technique can be used with any other data where you need to predict values in a linear fashion.
The Recognizing Suicide Lethality (RSL) scale, also called the “Thirteen Questions on Successful Suicide” is used to identify whether a person who may be exposed to suicidal individuals (such as a physician, social worker, minister, or educator) can recognize the signs of suicide.
The questions in the RSL are based off the factors identified in the Suicide Potential Rating Scale (Holmes and Howard, 1980), and both that study and the RSL were created by Cooper Holmes and Michael Howard.
The RSL contains 13 items, each with four possible answers. Each correct answer nets one point. A suggested answer key is below:
Holmes, C.B., Howard, M.E., 1980. Recognition of suicide lethality factors by physicians, mental health professionals, ministers, and college students. Journal of Consulting and Clinical Psychology, 48(3), pp. 383-387.
Royal, C. (2003) “Knowledge of Suicide Intervention Skills: Do Crisis Line Volunteers and Clergy Differ?” MA Thesis. Trinity Western University. Accessed at http://www2.twu.ca/cpsy/theses/royalchristine.pdf on January 26, 2015.