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    What is intervention?

    Intervention is the act of having a conversation with someone who is considering suicide – meeting them in their moment of crisis and supporting them to stay safe for now.

    A person at the point of suicidal crisis has typically lost all hope and sees no alternative to their deep, psychological pain than death. They describe feeling overwhelmed, stuck, and not being able to see a way out. They’re experiencing internal conflict (or ambivalence): they want to live but they want the unbearable pain to end.

    When someone reaches out to the person thinking about suicide, they see that people do care about them, and that their life does matter. They’re not alone and help is available.

    Intervention can be a lasting solution to suicidal crisis for certain individuals. Studies have found that 90% of people who were in the process of acting on their plan to die by suicide but were stopped before attempting – either by a passerby, security staff, or police – did not go on to attempt suicide ever again (Seiden, 1978).

    Another reason intervention is so powerful: people who think about suicide are desperate for human connection, and intervention gives them that connection they’re seeking. One man who died by suicide on the Golden Gate Bridge in San Francisco wrote in his suicide note: “If one person smiles at me, I will not jump” (Friend, 2003, p.6).

    *This section will explain how to talk to someone in crisis, but will not teach formal intervention skills. Applied Suicide Intervention Skills Training is a 2-day in-person workshop that teaches these skills.

    Myths

    Talking about suicide will cause someone to think about suicide.

    This is a myth. Asking someone directly, ‘Are you considering suicide?’ actually reduces the risk that they will attempt suicide. Asking the question allows the person in crisis a chance to release and talk through their feelings and thoughts, giving them the opportunity to broaden their view and see that there are reasons for living.

    People who talk about suicide should not be taken seriously.

    This is also a myth. Everyone who talks about suicide should be taken seriously and should be connected to the necessary supports so they can find help. If you suspect someone is telling you that they’re thinking of suicide so that you’ll give them attention – they are. You need to give them your attention and connect them to help, or connect them to someone else who can do that.

    Warning signs and acute warning signs

    People who think about suicide typically exhibit warning signs.

    Any significant change in behaviour can be a warning sign for suicide. We can be more alert to this when we are sensitive to people around us, appreciating that anyone can have thoughts of suicide. Active listening can help us tune in to comments that may indicate someone’s struggling.

    Some warning signs include:

    • Statements that indicate hopelessness or being a burden
    • Threatening suicide or talking about wanting to die*
    • Looking for ways to die*
    • Suicide attempt
    • Increased substance use
    • No sense of purpose in life or evident reason for living
    • Withdrawal from friends and family
    • Rage, anger, irritability
    • Recklessness
    • Dramatic mood changes

    *These warning signs indicate immediate suicide risk. Stay with the person who is exhibiting these signs and connect them to help. In Canada, call the crisis line at 1-833-456-4566.

    (American Association of Suicidology, n.d.)

    How to talk to someone considering suicide

    Individually, we can create a safe space through open, non-judgmental conversation and gentle questioning for people to share and express emotions. We can also check-in regularly with them to have a conversation and build strong social connections.

    If someone you know is exhibiting warning signs, have an open, non-judgmental conversation with them. You can start the conversation by mentioning your concerns, “I haven’t heard from you much these days. Is everything okay?”

    Keep the conversation going by asking questions and listen to what they’re saying. You don’t have to offer solutions.

    If you’re still worried about them, ask directly: “Are you thinking about suicide?” If they say yes, don’t panic. Let them know you’re there for them and help them access mental health supports, including by calling the crisis line at 1-833-456-4566.

    Being able to recognize the warning signs of suicide requires a deep shift in how we’ve been taught to interact with people. Rarely do we learn to have the ability to be present enough with those around us, those that we see every day, to recognize a change in behaviour. We don’t often learn how to talk about our emotions, let alone the emotions of others, so starting a conversation with someone we’re worried about can be very difficult. Finally, connecting that person to help and supporting them through their journey, if you chose to do so, can be exhausting and scary. But this can be lifesaving and life-changing.

    Ambivalence

    People who are considering suicide want to die to end their pain, but the fact is that they are still alive: there is another part of them that wants desperately to live – this duality is ‘ambivalence’ (Bergmans et al., 2017).

    When intervening with someone, focus on the part of them that wants to live: What do they have to live for? How are they coping? How have they weathered the storm up until now? Discussing these questions with the person in crisis helps them move past their state of crisis, at which point, they can be connected to further supports and a safety plan can be created.

    Safety planning is best done after a point of crisis, once everyone is calm again. Safety planning helps support and guide someone to help avoid a state of intense suicidal crisis reoccurring.

    Best practices

    Specialized supports

    Specialized supports are activities that directly assist a person considering suicide. They can be provided by a variety of caregivers including professionals, skilled volunteers, and trained peers and in a variety of settings such as emergency departments, inpatient and outpatient care, and community agencies. Support groups, and self-help practices also play roles. Coordinated systems and access to services is key. Here are some examples of specialized supports:

    Suicide crisis lines provide free, 24/7 access to speak with a trained responder. Responders provide a listening ear in a moment of crisis. This alone can be lifesaving: a person in suicidal crisis cannot stay in that heightened state forever. Offering them the space to talk about what they’re experiencing is often enough to keep them safe in the moment. Responders can also begin the safety planning process with them and can connect them with other community supports (Centre for Suicide Prevention, 2018). Further, responders assess immediate suicide risk and send emergency services when needed.

    Canada Suicide Prevention Service 1-833-456-4566crisisservicescanada.ca
    Hope for Wellness 1-855-242-3310 hopeforwellness.ca
    Kids Help Phone 1-800-668-6868 kidshelpphone.ca

    In many communities, hospitals play a pivotal role in medical care. Emergency departments (ED) offer brief, rapid interventions in times of crisis. Presenting at the ED does not necessarily lead to being admitted to in-patient care, and in-patient care is not always the appropriate setting for someone considering suicide. Therefore, it is important for hospitals to be connected to community care to provide smooth transitions for people in crisis (Centre for Suicide Prevention, 2017).

    Training and networks

    Varying levels of suicide prevention training are relevant for people playing different roles in a community. It is not exclusively for professional caregivers. Training helps break down stigma. It gives people language and license to talk about suicide. It can create a caring safety net among caregivers.

    Typically, social workers, first responders, healthcare workers, teachers, and other ‘caring professions’ receive some level of suicide prevention training. However, anyone can learn how to identify and support someone considering suicide.

    Skills training is effective suicide prevention because it equips community members to recognize and reach out to someone considering suicide. There are various levels of training available, from one-hour online learning modules that teach people how to recognize warning signs and have a conversation, to two-day workshops that train people to step in and intervene with a person who is actively thinking about suicide, and possibly even attempting suicide.

    Training is a key component of a larger suicide prevention strategy including other best practices – when training is the only best practice implemented, its effectiveness is limited.

    People considering suicide display warning signs, or, put out invitations, for help. Typically, these signs are communicated to people they trust – ordinary people in their lives. People are more likely to go to friends and colleagues when they’re struggling than to a professional. If we see a friend struggling, do we know what to do?

    Gatekeeper training provides people with the skills and knowledge to recognize someone considering suicide, and connect them to help. A gatekeeper can be anyone with the will and capacity to help.

    Community gatekeepers are people like first responders, social workers, healthcare workers, and teachers, who see lots of people, especially those who may be considering suicide, on a regular basis.

    Gatekeeper training has been shown, in studies, to be an effective form of suicide prevention (Shannonhouse et al., 2017; Coleman & Del Quest, 2015; Gould et al., 2003).

    A large majority of people who die by suicide see a doctor within a year of their death, and over half of those within the month before (Gould et al., 2003). Training for primary care physicians is key. This type of training focuses on identifying suicidality in a patient, regardless of the health concern prompted which the appointment. It also involves breaking down stigma in health care settings, and instilling confidence in physicians to have conversations with their patients about suicide. Finally, it equips physicians to direct the patient to follow-up support and care (Centre for Suicide Prevention, 2017; Centre for Suicide Prevention, 2016).

    Suicide screening is used in clinical settings to identify people who may be considering suicide. Screening methods include questionnaires about thoughts of suicide, suicidal behaviours, and risk factors. Based on the screening results, participants are connected to further supports.

    A safety plan is a document that supports and guides someone when they are experiencing thoughts of suicide, to help them avoid a state of intense suicidal crisis. Anyone in a trusting relationship with the person in crisis can help draft the plan; they do not need to be a professional.

    When developing the plan, the person experiencing thoughts of suicide identifies:
    • their personal warning signs
    • coping strategies that have worked for them in the past, and/or strategies they think may work in the future
    • people who are sources of support in their lives (friends, family, professionals, crisis supports)
    • how means of suicide can be removed from their environment
    • their personal reasons for living, or what has helped them stay alive

    A safety plan is written when a person is not experiencing intense suicidal thoughts. It may be written after a suicidal crisis, but not during.

    A person’s unique strengths, abilities, and support people are identified in the plan so that they can draw on them when they experience intense thoughts of suicide.

    Resource
    Safety plans to prevent suicide
    Centre for Suicide Prevention

    References

    American Association of Suicidology. (n.d.). Warning signs. https://suicidology.org/resources/warning-signs/

    Bergmans, Y., Gordon, E. & Eynan, R. (2017). Surviving moment to moment: The experience of living in a state of ambivalence for those with recurrent suicide attempts. Psychology and Psychotherapy: Theory, Research and Practice, 90(4), 633-648.

    Centre for Suicide Prevention. (2018). A caring conversation: What suicide prevention can look like. https://www.suicideinfo.ca/resource/caring-conversation-suicide-prevention/

    Centre for Suicide Prevention. (2017). Aiming for perfection: The zero suicide movement. https://www.suicideinfo.ca/resource/ie23-aiming-perfection-zero-suicide-movement/

    Centre for Suicide Prevention. (2016). What does successful recovery look like?  https://www.suicideinfo.ca/resource/recovery-suicide/

    Coleman, D. and Del Quest, A. (2015). Science from Evaluation: Testing Hypotheses about Differential Effects of Three Youth-Focused Suicide Prevention Trainings. Social Work in Public Health, 30(2), 117-128.

    Friend, T. (2003). Jumpers: The fatal grandeur of the Golden Gate Bridge. New Yorker. Retrieved from https://www.newyorker.com/magazine/2003/10/13/jumpers

    Gould, M. S., Greenberg, T. E. D., Velting, D. M., & Shaffer, D. (2003). Youth suicide risk and preventive interventions: a review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry42(4), 386-405

    Seiden, R. (1978). Where are they now? A follow-up study of suicide attempters from the Golden Gate Bridge. Suicide and Life-Threatening Behavior, 8(4), 203-216.

    Shannonhouse, L., Yung-Wei, D., Shaw, K., Wanna, R. & Porter, M. (2017). Suicide intervention training for college staff: Program evaluation and intervention skill measurement. Journal of American College Health.