When Someone is Suicidal or Expressing Suicidal Thoughts

So I’m going to start out today with a story. It was about, I think 10 years ago, give or take. I was meeting with this guy and he was probably in his mid-40s, Caucasian guy. This was after the economy collapsed, and he was really struggling. He had lost his job. Financial trouble and marital struggles. In part of the conversation, he said, “I just want to go to the beach and I wish I would drown.” And I hear the statement and I hear a lot of things like this in similar fashion, where people are talking about and saying not wanting to be here. The question is, how much emphasis do you put on what is being said? How uncomfortable could it be for people? Are they really telling me something, or are they just expressing an emotion?

So today what we’re talking about is suicide. What I’m going to do is I’m going to go through a number of things. First I’m going to give you some statistics on it, pretty interesting, and then we’re going to look at three things. One, how do I assess if someone is actually suicidal? Two, how do I intervene? The third thing is going to be how do I provide support when someone is suicidal? These become very difficult topics for people to talk about. The reason why I’m sharing it with you is because you’d be surprised how common it can be.

We’ve had this discussion over and over again, that with mental health issues, people want to dismiss it or it’s an uncomfortable topic, so they don’t want to talk about it. But when you don’t talk about it, that’s when things get worse. So I’m going to put this qualifier in. Remember when I share these videos with you, this is not a substitute for treatment. This is not to say, hey, if you follow these steps then you’ll have no issues. Or that you’ll be able to help someone through their stuff. Really what I’m trying to do is provide information so you’re much more aware. When things are said or are done, you can kind of have a better understanding of what’s going on, and then how you might make choices going forward.

Suicide is a very difficult one. So let me just start with a couple of statistics. We hear about homicides in the news all the time. Oh this person was shot or this person was killed. There are twice as many suicides in the United States every year compared to homicides. So it’s two for one. So for every homicide you hear about, there were two suicides. The question is why does the news not report this stuff? Now could it be again what we’re talking about, that when it comes to mental health issues, nobody wants to actually acknowledge that there is a serious issue here?

So twice as many suicides as homicides in the US. Suicide is the 10th leading cause of death in the United States. What’s more remarkable is for those that are aged 10 to 34, suicide is the second leading cause of death. So think about it. Ages 10 to 34, suicide’s second leading cause of death. Women are shown to have more, or at least acknowledge more, suicidal thoughts than men, and have more attempts than men. But men are much more successful in completing suicides. And when I’m saying completing suicides, I mean that they die from their attempt.

The next one’s going to tie back into the story that I was telling you. The highest rate of suicide is in middle aged Caucasian males. Okay? And that’s completed suicides. People that actually die from their attempt. And just an interesting statistic, and we’ll talk about it too, is that for young women, a hundred attempts will pretty much equals out to one completed suicide. So, with young women, multiple attempts. And when you factor them all together, a hundred attempts would equal one completed suicide.

So then the question becomes… Oh, let me start. For those of you that don’t know me, I’m Dr Jerry Grosso. I’m the clinical director at Nsight Psychology and Addiction in Newport Beach, California. Again, my intent with these videos is to help you guys better understand psychological issues, emotional issues and so forth. Mental health stuff that people are afraid to talk about. Or maybe they’re willing to talk about, but are kind of guarded about it. So I’m trying to provide more information for you guys.

So, a lot of people will say, hey Jerry, why is it suicide is not really mentioned much? How can I tell if someone’s suicidal or not? And I will tell you, I have active involvement in every client that looks to come into Nsight or is here at Nsight. And there’s a lot of times we will take clients that other treatment facilities won’t take. They may have been in a psychiatric hospital on involuntary hold because they were a danger to themselves. And I’m going to talk a little bit about that. But when they come out, because you can’t hold someone in a hospital forever, there’s some treatment facilities that don’t want to treat them because they think, well they’re too high risk. Or they’re going to kill themselves. I think a lot of times people’s reluctance to see a client that struggles, which really makes it difficult for the person. But I think the reluctance is they don’t understand what’s in front of them.

So I’m going to explain a little bit of this stuff. I’m going to put this qualifier on it. No matter how well you follow some of the steps that I talk about, please understand you cannot predict suicide. Okay? That would be like a heart doctor saying to somebody, I know exactly when you’re going to have a heart attack. They can’t do it. Because if that was the case, they would say, hey, you better go to the hospital at this day and time because you’re going to have a heart attack. Suicide is no different. You can’t predict it. But you can see warning signs. And you can, as we talk about this, and we’ll go over it a number of times, but just because someone thinks about suicide, doesn’t mean they need to be in a hospital. And you got to look at it like this. You can’t have someone spend their entire life in a hospital because they think about suicide. Okay?

So let’s talk real quick about what could be causes or not. You’ll see it a lot of times it runs in families. So is there a biological component? Hasn’t been shown yet, at least from the research I’ve done. You can’t tell as far as that. But we do know it does run in families. Cultural differences. I will share with you that in the United States, the native American, American Indian population and native Alaskans, they have the highest rate of suicide of any culture. So there could be cultural factors and so forth.

So I’ll comment on a couple of diagnoses that we see a lot of suicide in. One would be major depression. So people that suffer from very severe depression can be at high risk for suicide. But that doesn’t mean, just because you have depression, that suicide is going to be part of it. They can be totally separate.

We’ll look at suicide and ask, what do some of these people have in common? One is severe depression. Two, people that struggle with bipolar disorder. And three, schizophrenia. Now if you notice with all three of these diagnoses, depression is part of it. But I’m going to share with you big components. There could be individuals that maybe have chronic pain and commit suicide, or attempt suicide. And it may not have anything to do with depression.

So then we’ll ask, okay, well what is it? Think about it like this. Hopelessness and helplessness. Two huge factors, okay? So if I feel helpless, like no matter what I do, I can’t overcome whatever challenge it is that I’m dealing with, that puts me at risk okay? Or if I’m hopeless. Okay? Hopeless that no matter what happens, my condition is never going to get better. So one, I’m helpless to do anything. And two, I’m hopeless that it’ll ever get better. Those two are major, major factors when it comes to suicide. So I got to just put that out there. So when you’re looking at an individual, let’s say you have a loved one, friend, family member, and you’re concerned about suicide. And you can look at, well they don’t seem depressed, but they’re reporting that they want to kill themselves. Are they hopeless and helpless? Are they in a situation that’s very difficult?

So let’s look at a couple of other things. When it comes to assessing, how do you determine? So there’s four things that you should always look for. One could be suicidal thoughts, and that’s the number one thing that this starts with. So I’m going to comment too. Think about suicidal thoughts. Just because someone has one, that’s not abnormal. And you can say, Jerry, that’s really weird. What part of normal would include thinking about suicide? We’ll think about it like this. If I’m in a lot of pain, whether it’s physical or emotional, I could be really stressed out. It can be really bad anxiety and so forth. My brain starts to go through coping skills. So there’s healthy coping skills, and not healthy coping skills. Well, one of the things, and I don’t know why brains go here, but if I wasn’t here, meaning I’m no longer alive, I wouldn’t be in this pain.

So if you look at this on a continuum of coping skills, at the very end, suicide could pop up as an option. That doesn’t mean I’m suicidal, doesn’t mean I’m going to kill myself. It just means that popped up as one of my coping skills. Wow, if I wasn’t alive, I wouldn’t have to deal with this pain. Or I wouldn’t have to deal with whatever the distress is that I’m dealing with, okay? So one suicidal thoughts.

The next thing that’s important. So if I’m with somebody, and I’m trying to determine what’s going on with them, I don’t want to avoid the conversation. People are very reluctant to talk about it because they think if I tell you I have suicidal thoughts, you’re going to put me in a hospital. Or you’re going to call the police. Or you’re going to call an assessment team and so forth. Personally, I want to listen, okay? So tell me what’s going on. Have you ever thought about suicide? You think about not wanting to be here and so forth. They may say, yeah, I think about not wanting to be here, but that doesn’t mean I want to kill myself. But if someone acknowledges, yeah, no, I do think about killing myself. My next question would be, have you ever thought about how you would do it? Meaning do they have a plan?

So a lot of people never go that far. Nah, never thought about how I would do it, right? Or they might say, well, I might jump off the Golden Gate Bridge. One of the things that I have to look at. If I’m in Nebraska and the Golden Gate Bridge is in San Francisco, what’s the feasibility of that plan? Now is that just some random thought, like, oh yeah, I guess if I did it I would jump off this bridge. I’m trying to look at, is this a good feasible plan? Or is it again an expression of distress? Like I’ve thought about how I would do it. I would be much more concerned if they said, hey, I’m going to overdose on some pills I have in the medicine cabinet. Do you actually have those pills in there? Yeah. Okay. To me, that’s much more significant, than a plan that’s not feasible at this time. Because there would be a lot of effort, let’s say to get from Nebraska to California, that we can intervene in. Okay?

Third thing is, so we have thoughts, we have a plan I might do something. So the third thing is means, and that’s kind of what I was talking about. Am I near something? Do I have something? Do they have the actual means to do something? So I could share with you, oh I’m suicidal. I have thoughts about it. I think I’m going to I want to shoot myself. Well, do you have a gun? No. Will they have access to a gun? No. I think I might buy one. Do you have the funds to buy one? No. Do you know how to do that? No.

So what I’m doing is, as you explore, that’s a lot different than if you ask someone: Yes, I’m suicidal. I think about shooting myself. Do you have a weapon? Yeah, it happens to be in my car. And I’ve actually had people say this. So there’s a huge difference between the two. I’m trying to assess where is their level of distress? Are they talking about this just in thought as a coping skill, as a means to get out of certain pain, or kind of think about how I would not be in pain? Or is this pretty well thought out, and I’m looking for ways in which to accomplish this?

The next thing is intent. Okay. That is the most important. So when people get put on, let’s say in involuntary holds, I don’t want to go to a psych hospital but I am suicidal. They can be evaluated by a mental health professional. And if they have thoughts, they have a plan and they have means. The next thing is intent. Yes, I intend to do this. Which is when I need to intervene at this point. And intervening would be making sure that they are in a safe place, which would be an inpatient psychiatric facility that can handle clients that struggle with this.

And I’m going to tell you that most people that are in this amount of distress and think about killing themselves, ultimately as much pain as they are in, and that they want to be out of it, that they’re not going to just go and do something. They wouldn’t be telling you all of this stuff if they had already made up their mind, okay? So in all of this conversation, I want to be very validating. I want to be very supportive. I want to be understanding. And I want to pick what is the best area for me to intervene. And I’m going to tell you right now. If you’re ever confused about, always go with the most safety first. Take them to an emergency room. Have them evaluated or called the police department. Or call 911. That is the biggest thing.

You don’t want to ever take risks thinking somehow, hey, I can predict this and I can understand what’s going on. By default, if there’s major concern, I need to intervene in this way. But what we’re talking about is the different steps that people go through. So thoughts, plan, means and intent. I’ve worked with people where they say, hey Jerry, I have thoughts. I have a plan. I have means. So my plan would be I’m going to overdose on these pills. They’re in my medicine cabinet and that’s how I would do it. But I’m going to tell you right now, I’m not going to do it, because I don’t want to. I’m just telling you. My brain has gone that far as thinking through it. But that’s not what I want to do.

So this is really where mental health professional needs to make a very strong clinical decision. How do I continue to work with this individual? Are they safe? They’re contracting for safety, saying, hey yeah, I’m expressing the amount of emotional distress I’m in, but I’m not going to do anything. And remember, as a mental health professional, or even a layman, I cannot predict. No different than a cardiologist can predict a heart attack. I’m going to have to default to safety if I have any concerns that go beyond the trust and working relationship I have with an individual. So this is how I assess, okay?

So really, and I’m going to tell you this is the majority of the time. When I see someone, I would also have to look at multiple attempts. What were the previous attempts? Where they serious? Were they significant? Were they by lethal means? We may have a client says, oh yeah, I overdosed one time on… I took three aspirin, and it said to only take one. So did you need medical attention there? There’s certain questions we would ask to see the lethality of the previous attempt. I’m going to share with you, the more lethal the attempt was, then the more likelihood another lethal attempt can occur. So there’s a lot of factors that I’m trying to take into consideration as I’m doing this.

So then again, how do I intervene? One, it may be validation and support. Someone just tells me… And really the suicidal thoughts are just an indication that I’m in a lot of emotional distress, and I just want to be able to talk to someone and work through it.

So number one would be get them to outpatient therapy. Get them to see a psychiatrist. Medication could be beneficial to help increase their mood, increase their feelings of hopefulness that they’ll get out of this distress. Psychotherapy can help them work through the issues that are causing conflict, improve their coping skills and so forth. And then I might look at, so for example, when individual therapy doesn’t work, and people need more intensive treatment where they’re actually staying away at a treatment center, more long term like several weeks as opposed to several days that you might do inpatient. They would come to a place like Nsight, let’s say, where they would be receiving a lot of services. So group therapy, individual therapy, medication management and so forth. All of this stuff to help them transition back to their life, to get over the crisis that’s making things difficult.

So the last thing I want to share with you guys is support. Like I need to be supportive. I don’t want to avoid the conversation because avoiding it is just going to make things worse. Meaning like the person’s not going to improve. They’re going to feel dismissed. They’re going to feel like their emotional needs aren’t being met, which makes me more helpless. It makes me more hopeless. I just think nobody wants to help me. There is no hope for me, and it’s over. So these are some of the things that I want to do, is I want to be very supportive of them. And let them know that, hey I do care about what it is that you’re saying, and I want you to get better, and be able to work through this. Okay?

So when it comes to suicide, this is what I’m going to do. I’m going to come back to the first case. So think about it. I was telling you about a guy, significant emotional distress, right? Financial, marital and career-related. So unemployed, no money, conflict with wife, possible divorce and so forth. The guy was a middle aged, Caucasian male, high risk population. Now, no history of previous attempts. Then he tells me, okay, did he actually indicate suicidal thoughts? Well, I would have to take them on what I kind of believe to be true. If he’s saying like, hey, my thought is I’m going to go down to the beach and I hope by drowned, I have to look at it. This guy was a very good athlete.

And if his plan was a little bit more specific, meaning I’m going to swim out into the ocean. Not just swim out and hope to waves drown me, but I’m going to just keep swimming until I can’t swim anymore. That would be a pretty significant plan. And one that would warrant possible hospitalization, because it’s one thing to just make a comment. It’s another thing to say, you know what I’m going to do? Is I’m going to just keep swimming and swimming as far as I can, knowing that I’ll get so exhausted when I’m far enough out, I’ll never make my way back in.

And again, it’s troubling stuff to talk about. I know that this is not an easy conversation, but I’m bringing this up for a specific reason. The reason is, it’s more common than people think. There’s also a tendency to dismiss individuals that say I feel suicidal. Oh you’re just attention seeking and so forth. Nobody wants to, and I’m not negating that. People may use this as a way of expressing emotional distress, but nobody picks that as their first line. Hey, I want attention from you. Really I’m looking for emotional validation and so forth. It’s very extreme to go, hey, I’m going to kill myself, just to get you to pay attention to me.

And people will do that, but it’s a pattern of unmet emotional needs over and over again. So now I’m going to the extreme. While the risk may be lower. So for example, we were talking about, hey, it may take a hundred attempts for one completion. When you put together the population, I don’t want to have the one I’m working with it to be that one completion. So I always take this stuff seriously. I’m supportive. I try to thoroughly assess. I tried to intervene in the best way possible. So not to hurt the person more, but to let them know that they’re cared for and loved and so forth.

So I hope that makes sense to you guys. Again, with all of these videos, if you like them, thumbs up, share. If you don’t like it, give it a thumbs down, but also write in comment. Write what you didn’t like about it. If you don’t agree with what I’m saying, or you want to add additional thing. So think about it. For mental health professionals, if you guys comment on these videos, you may have different viewpoints, different perspectives, more stuff to share. The more everybody is involved talking about difficult subjects around mental illness, we de-stigmatize that. No different than physical illness. These are things we struggle with in life. The overall goal is physical health here. Here the overall goal is emotional health.

So again, I’m Dr Jerry Grosso from Nsight Psychology and Addiction in Newport Beach, California. And until I see you guys next time, have a terrific day. Thanks.

Dr. Jerry Grosso

Dr. Gerald “Jerry” Grosso is a Licensed Marriage and Family Therapist with over 20 years of experience assisting individuals and families struggling with addiction, depression and trauma. He obtained his Bachelors of Arts degree in Psychology from San Diego State University before enrolling in Chapman University where he acquired a Master of Arts degree in Psychology.  Dr. Grosso continued his education and received a Doctorate degree in Clinical Psychology with a Specialty in treating Chemical Dependency. He holds a professional membership with the California Association of Marriage and Family Therapists (CAMFT).

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