[Editor’s Note: Here on our blog, MCN’s Director of Witness to Witness, Kaethe Weingarten, PhD, shares stories, resources, and helpful tips to support health care workers through the many stressors of their daily lives. Dr. Weingarten also offers a newsletter (called the W2W Update), filled with resources, recent articles, and her news and views.]

September is Suicide Awareness Month and many organizations and lifelines have come together to emphasize that awareness is a first and important step in suicide prevention. There are many places one can read alarming statistics about rates of suicide for youth and adults in the United States. This blog will not be one of them. Instead, I am going to drill down into the meaning of awareness and consider what this means for any of us.

First, and most obviously, people who are contemplating suicide or who think about it on impulse are hurting. No one is faking the unhappiness that leads to suicidal thoughts. While it is a truism that suffering is intrinsic to the human condition, not everyone responds to the pain of suffering with thoughts of killing themselves. Most clinicians and researchers who study suicide believe that people who consider or attempt suicide feel disconnected from others or themselves, profoundly alienated from internal and external sources of support. That is why suicide awareness is so important. Reaching out to individuals who are suffering and isolating themselves can make a difference.

However, awareness that someone we know is suffering emotionally and finding life intolerable or too heavy to bear is not a simple matter. Sometimes awareness is thrust into our consciousness by an act of self-harm that is completed and a person we know dies. That is one kind of shocking awareness that most of us will never forget. But there are also experiences of awareness that are less clear because they signal less obvious expressions that someone is in pain. These kinds of experiences of awareness are often described as “slippery,” as causing uncertainty and confusion. We ask ourselves, “Is this person at risk?” “Should I do something?” “If I ask if they are thinking of hurting themselves, am I going to make things worse?” “What if I ask and I plant an idea they never had?” This kind of awareness and its accompanying uncertainty is common. Fortunately, many organizations have produced materials to help people navigate through the uncomfortable terrain that awareness of someone’s suffering with suicidal thoughts and feelings can bring. 

Here are five concrete steps, followed by a list of recommended resources, to turn awareness into action.

1. Consult 988 Lifeline's five steps: On the website of the new 988 Lifeline, established one year ago, there is an easy-to-follow set of five steps that scaffold anyone who wants to help someone they think may be suicidal. These steps help someone move from awareness into effective action. At the Witness to Witness Program, we also focus on helping people move from helpless awareness to effective action so the 988 Lifeline approach is compatible with our conceptual framework. On the site, they list the steps and for each step there is a set of resources to help someone accomplish the step. The steps are: Ask, keep them safe, be there, help them connect, follow up.
   
   The 988 services include phone and text that are tied to the 988 number, a service for Veterans, a service for LGBTQI+ youth and young adults, a Spanish-language text and chat and, most recently, American Sign Language services for the deaf and hard of hearing that became available for callers via video phone and the 988 website.
    
2. Use the QPR method: Cardiopulmonary resuscitation, the emergency medical intervention commonly known as CPR, helps stabilize people medically until the person can reach medical care. Modeled after CPR, QPR -- Question, Persuade, and Refer -- is an emergency mental health intervention for suicidal persons created in 1995 by Paul Quinnett. The purpose of QPR is to interrupt a person who is suicidal from moving into action to end their life and instead direct them to resources that are equipped to help suicidal individuals. There are resources to help people enact each of the three QPR steps, like this QPR Suicide Prevention Training. Specialists in suicide prevention understand how hard it is for most people to know how best to help someone they believe is suicidal and the resources are geared for people who want to help but lack confidence they know the best way to do so.
    
3. Ask questions to determine the stage: In a blog post that I wrote in August 2022, I noted that recent research on those who contemplate and then attempt or complete suicide has led to a stage theory of how suicide occurs. The Narrative Crisis Model of Suicide proposes that a late stage in suicide is when the person feels trapped with no options and no way out of their life circumstances. Quoting from the blog: “They are in unbearable emotional pain and they ruminate on the circumstances they believe have led them to feel this way, blaming themselves and others. They may feel a great deal of panic at this stage that is so overwhelming that they dissociate from it. Paradoxically, although they may later go on to attempt suicide, at this stage, it is hypothesized, they actually fear death. It is only after this stage that the person takes action toward suicide. Their thought of doing so may have only occurred briefly, just before they make their attempt. In other words, asking someone if they are suicidal may not be as useful a question as asking someone if they feel trapped.”
   
   In the blog, I suggest that at this stage, there are a few gentle questions a person could start with to see if the person might open up:
   
   “I can tell something is bothering you. Do you want to talk about it with me or someone else?”
   
   “You don’t seem to be yourself these days. I’d really like to hear how you are feeling.”
   
   
   To determine if someone is feeling trapped, you can then ask: 
   
   “You seem to feel there is no solution to your current problems. Is that how you are feeling now?”
   
   “Are you feeling that you cannot escape your problems?”
   
   “Have you been feeling emotional pain that is so intense it’s unbearable?”
   
   “Do you want to do anything to stop the unbearable pain you feel?”
   
   Considering this new conceptual framework opens avenues of exploration that many of us might not have considered before learning about the Narrative Crisis Model of Suicide.
   
    
4. Help a person identify and act on external factors: New research on adolescents and young adults in Northern California indicates that youth who live in economically disadvantaged neighborhoods were at higher risk of depressive symptoms and suicidality. In fact, researchers found a “clear gradient relationship,” such that as neighborhood disadvantage increased, so too did adolescent depressive symptoms and suicidality. Pointing out to youth from poor neighborhoods – and if they did the studies, research might show this to be true of anyone living under disadvantaged conditions – that the environmental conditions of their lives impact their emotions can lead to recommendations to participate in community groups advocating for neighborhood improvements. This also has the benefit of helping youth see that their individual unhappiness may be shared by others in the same group as they, or in this case, in the same types of neighborhoods. This often opens up new perspectives for youth (see blog from September 2022). For many people, identifying reasons for their despair in external factors, and acting in solidarity with others who are working to change those conditions, shift people from helplessness and isolation to hopefulness and community. 
    
5. Encourage safe gun storage or removing firearms altogether: About 40% of Americans say they live in a household where someone owns a firearm and about 32% of people claim to own guns themselves. More men (40%) than women (25%) own firearms and more people in rural (47%) than urban communities (20%) do. There are more guns in circulation in the US than there are people. According to Everytown Research and Policy, access to a firearm triples the risk of death by suicide.
    

These are some statistics from 2021, from the American Foundation for Suicide Prevention:

• In 2021, 55% of all suicide deaths in the US were by firearms.
• In 2021, of all firearms-related deaths in the US, 54% are suicide deaths.
• 85 – 90% of suicide attempts with a firearm are fatal.
  
  Although there are major cultural divides about how people feel about guns and the rights of people to own them, there is some common ground when it comes to how people feel about safely storing guns. A new campaign from Ad Council and gun control advocacy group Brady is using film to raise awareness about the link between gun access and suicide. “In the documentary-style film, seven people from across the country recount the times they almost lost their lives to self-inflicted gunshots (the leading cause of firearm deaths in America) and how they were saved thanks to guns that were stored properly, which Ad Council describes as locked, unloaded, and away from ammunition.” This film is part of a larger campaign that has as its slogan, “End Family Fire.” The term “End Family Fire” was developed to describe shootings caused by someone having access to a gun in a home when they shouldn’t have it. This includes children and those who might harm themselves or others. The Ad Council conducted a study to see how effective the message of this campaign was in changing attitudes about safe gun storage and found that 18% more people who are aware of the “End Family Fire” campaign agree that storing their guns locked and unloaded reduces the risk of someone dying by suicide in their home, 74% of respondents as compared to 56%.
  
  While any of us is unlikely to persuade a gun owner to part with their guns, it may be possible to convince them to store their guns safely. A successful conversation may well be an effective action to prevent a suicide.
   

All five of these steps are actions that individuals and clinicians can consider to move from awareness to action to help prevent suicide. Each year, research provides more options that people can take to help those who are suffering so profoundly that they can only think of suicide as a means to end their misery. Most of us know that when people conclude that suicide is their only option, it represents distorted logic. Suicide is never a person’s only option. Now there are many concrete ways to persuade people otherwise.
 

General Resources:

The Witness to Witness Program at Migrant Clinicians Network has many resources that can be useful when people are in distress.

Adult suicide risk screening pathway, available in English and Spanish.

Youth suicide risk screening pathway.

OxRisk’s OxSATS Suicide after self-harm calculator.

Suicide Is Different provides education and coaching for people supporting a person thinking about suicide.

Crisis Hotlines and Text Services:

988 Lifeline: The 988 website and Lifeline are available in Spanish. Press 1 for Veterans.

Crisis Text Line: Text HOME to 741741.

RAINN Sexual Assault Hotline: Call 800-656-4673 24/7.

IOA Friendship Line: 800-971-0016 nationwide; 888-670-1360 in California. To reduce loneliness.

Apps and Online Services:

Calmharm: A free app for self-harm that can also be used as a distraction tactic when a person is struggling with thoughts of suicide. It provides the person with distraction strategies and it checks in with the person occasionally to see if they are still having thoughts.

988 Chat: Individuals can text to 988, or they can use the website to start chatting. Chat is available in Spanish as well.

LGBTQIA+ crisis services:

The Trevor Project: The Trevor Project has a LGBTQIA+ crisis hotline at 1-866-488-7386. They also have messaging and chat services on their website.

Teen crisis services:

Teenline: You can call Teenline at 800-852-8336 to talk to a peer from 6-10pm PST. You can also text TEEN to 839863 or go on their website.

Other Resources:

The American Foundation for Suicide Prevention

American Association of Suicidology

International Association of Suicide Prevention

InsightLA Deep Suffering H.O.P.E. Affinity & Practice Group