Suicide assessment first step for depressed friend

Question: I have a friend who is suffering from depression and has recently joked about suicide. He is a people person and able to maneuver to just about any conversation with anyone. He lives a comfortable life with a lavish house, car and new tech toys. He acts happy and worry-free when he is around people, but once he is alone he starts feeling depressed and would call me or send me messages about his uneasiness and hopelessness. In the last five years he has suffered some health problems along with insomnia.

I (tried introducing) him to my friends, and he would start talking about his depression. My other friends would then chastise me for bringing him. I also tried introducing him to my other single friends. They would hit it off in the beginning, then he would start to get clingy, which leads them to get uncomfortable and end up deserting him.

He has a long-distance relationship with another person who also happens to be married. I am afraid he is setting himself up for heartache. He is the sole breadwinner of the family. To add insult to injury, a member of his family was recently diagnosed with cancer. I am worried that if he gets involved with the wrong person or crowd due to his vulnerability he can end up in a more uncompromising situation. He mentioned to me that he tried seeking professional help before but it did not help. I am running out of resources and will on where and what I can do as a friend. Please help.

— P.J., Spokane, Wash.


You don’t have to be a professional therapist to execute a skillful suicide assessment and intervention. Indeed, a skillful suicide assessment is the beginning of a competent intervention.

The larger number of people in an acute, suicidal crisis do not make overt threats. They make covert threats. They "joke" about suicide. They make inferences. They talk in crypticisms: "People would be better off without me" … "I wish I could go to sleep and never wake up" … etc. They withdraw suddenly from relationships or pleasurable activities. They give valuables and sentimental belongings away.

The most important step is the first one: making the covert overt! You ask. Straight up. You can ask graciously, "one-downing" yourself: "This is kind of embarrassing, and I’m sorry if this question sounds crazy, but … are you having thoughts about killing yourself?" Often this is all it takes to make a person say: "What?! No! Why would you ask me such a thing?" And then you can reference the "joke" about suicide, shrug and say, "Just checking." Even if people are lying baldfaced, making the issue overt is sometimes all it takes to wake them up and get them back to a firmer, more stable grip on their own lives.

And sometimes you’re not gracious. In some cases, when the evidence and threats are more acute and obvious, we ask uncensored: "Are you going to kill yourself?"

If they say anything close to "It has crossed my mind," then, as a friend, we let them know firmly and compassionately that their suicide is not OK with us. At once, we accept that we don’t have the power to keep anyone alive, yet we also bind them — in words — to the ties and accountability of our relationship.

Once the issue is overt, the assessment continues …

History: Does this person have a history of suicidal ideation or attempts? Plan: Does this person’s current ideation focus on a plan (gun, medication, etc.)? Means: Does this person have access to a gun, medication, etc.? (Amazing that some folks’ spoken plan for suicide has no likely means to execute the plan.) Intent: The assessment ends where it began. "Are you going to kill yourself today?"

With each "yes," the person is assessed as a more acute suicidal risk.

If they are a moderate to high risk, you insist they seek treatment. And if they make an overt threat and insist they are going to die and refuse to seek help … you do your moral duty. It’s called "danger to self." You call the police and ask for a "welfare check." You report the threat as you heard it. Not because you have the power to keep suicidal people alive but because, should the person insist on dying, you want to be able to tell yourself you didn’t participate in the suicide because you knew and did nothing.

Originally published in View News, Aug. 10, 2010.

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