Last week, we examined many of the facts and fictions associated with suicide, as well as some of the warning signs to watch out for when you come into contact with citizens who might have suicidal tendencies. If the warning signs have been missed, the first chance to intervene with a depressed, suicidal subject may come when the crisis is already peaking. The intervener’s task now is to keep the subject alive long enough to get appropriate follow-up care, and this can be accomplished by applying some fundamental principles of crisis intervention.
Define the Problem
While some personal crises relate to a specific incident, many evolve cumulatively as the result of a number of overlapping stressors, until a “breaking point” is reached. In such cases, the subject himself may be unclear as to what exactly led to the present suicidal state. By helping the subject clarify what’s plaguing him, nonlethal options and coping resources may be explored. It also shows that the intervener is listening and trying to understand.
SUBJECT: My life is out of control. I don’t see any way out.
INTERVENER: What’s out of control?
SUBJECT: Everything, man, everything. The job, my wife — it’s all crap.
INTERVENER: Can you give me an example? What about the job?
SUBJECT: I work like a slave all year, put in for extra overtime, volunteer for the boss’s pet programs, and then they tell me the city says there’s no more raises, overtime, or bonuses this year — that’s after we already put the down payment on the new house.
INTERVENER: Is that related to the wife thing?
SUBJECT: Yeah, so she’s all over me now because she’s scared we’ll lose the house. So it’s nonstop fighting. And on top of that, Human Resources is after me because of some bogus customer complaints.
INTERVENER: So you got caught by surprise with the no-raise thing, plus the HR complaint, and now all the family plans are backed up. And everybody’s freaked.
SUBJECT: Yeah, that’s about it.
Without seeming tricky or manipulative, the intervener should encourage the subject to put even a few short steps between the idea of self-destruction and the act itself.
INTERVENER: Is there anything in there with you that could hurt you?
SUBJECT: I got a Glock with a full mag. Yeah, that could hurt someone.
INTERVENER: Any chance of you putting the gun away while we talk?
SUBJECT: So what, so you can all bust in here and drag me away to the nut house?
INTERVENER: Actually, I just want to make sure you’re safe. If you’re gonna do something, then you’re gonna do it; but for right now, how about popping out the mag and the cap in the chamber, and putting everything on the table in front of you. That way, if you really want the gun, it’s right there, but at least you’ll give yourself a second to think about it.
Remember that the purpose of crisis intervention is not to solve all of the subject’s problems in this one encounter, but to instill just enough motivation for him or her to emerge from the danger zone. The intervener should keep the conversation focused on resolving the present crisis, perhaps gently suggesting that the larger issues can be dealt with later — which subtly implies that there will indeed be a “later.” In the meantime, just “being there” with the subject helps reduce his/her sense of isolation.
INTERVENER: When a lot of crap happens at once, it can seem like that’s all there ever was, even if there was some good stuff tucked away in there.
SUBJECT: Good stuff, what good stuff?
INTERVENER: Sometimes looking at things in a different way, trying things out you didn’t do before, sometimes just staying away from certain people or situations, things like that. At least it may be worth a shot. But right now, all I’m saying is I hear where you’re coming from, I hear a world of hurt, and I’m hoping you can get things together for yourself.
SUBJECT: I dunno, man, but hey, thanks anyway.
Often, subjects in crisis are so fixated on their pain and hopelessness that their cognitive tunnel vision prevents them from seeing any way out. The intervener should gently expand the range of nonlethal options for resolving the crisis situation. Typically, this takes one of two formSubject: accessing practical supports and utilizing coping mechanisms.
Are there any persons or groups that are immediately available to help the subject through the crisis until he or she can obtain follow-up care? The intervener must always be mindful of the risks and liabilities of relying on these support people instead of professional responders, and should be prepared to make the call to commit the subject involuntarily if he truly represents a danger to himself.
SUBJECT: I already told you, I’m not going to some damn hospital to be locked up and pumped full of drugs.
INTERVENER: Okay, let’s leave the hospital out of it. I know you told me about your problems with the job and your wife, but is there anyone you know out there who you trust, who could stand up for you and help you out?
SUBJECT: I dunno, maybe my friend Dave. We worked at the shop together, and we got to be buddies. He’s a good guy, down to earth.
INTERVENER: If Dave agreed to look after you for the rest of the weekend, till things cool off, would that be okay with you?
SUBJECT: I guess so.
These can consist of cognitive strategies, religious faith, distracting activities, accessing positive images and memories of family, or successful handling of crises in the past, that show the subject that hope is at least possible.
INTERVENER: You said something earlier about how you’ve had crap happen to you before. Can you give me an example?
SUBJECT: Well, about six years ago, I got fired from a job for stealing, but it was really some other guy who pinned it on me. Their investigation was sloppy, so I filed a union grievance, and we ended up working out a deal where I’d resign and the charges wouldn’t go on my record. Even though I wasn’t guilty, I took the deal. Now I couldn’t qualify for the security job I wanted, so that’s how I got this job, which ended up paying more and being a pretty good job — till this shit all started happening.
INTERVENER: So you went from almost being fired and busted to getting a better job. It was f’d-up to be falsely accused, but you handled it, and you made it come out the best way possible. When you put your mind to something, it seems, you’re able to work it out.
Make a Plan and Obtain Commitment
Again, this involves a combination of both practical supports and coping mechanisms, as well as both short-term and longer-term plans.
INTERVENER: Okay, I want to make sure I have everything straight. You’re gonna chill with Dave for the weekend, and first thing Monday morning, you’re gonna contact your EAP or go over to County Clinic so you can get some help in dealing with this, all right?
SUBJECT: Now I gotta see a shrink for the rest of my life?
INTERVENER: Probably not. But you may need a few sessions just to straighten things out. Let’s do this right, so that in a couple of months, it’ll all be just a bad memory, okay?
SUBJECT: It’s gonna be a long weekend, man.
INTERVENER: Hey, I respect what you’re doing; it’s not easy. But you’ll make it.
Post-Crisis Mental Health Intervention
When the acute crisis has passed, referral to a mental health clinician is crucial for two reasons. First, if this is a work-related issue, a psychologist may have to perform a fitness-for-duty evaluation to determine if the employee is able to return to work. Second, specialized psychotherapeutic techniques may be applied, that involve a combination of emotional exploration, realistic confidence-building, and practical problem-solving approaches.
As in any area of crisis psychology, there is no cookbook formula for dealing with suicidal subjects, either in the acute crisis stage, or at follow-up, but applying the fundamental lessons of effective crisis intervention may not only save the subject’s life in the short term, but even nudge his or her life in a more productive and satisfying direction.