The Nature of Suicidal Communications

Suicidal communications can be broken down into four general categories: direct verbal communications, indirect verbal communications, behavioral communications, and suicidal situations. The fourth category (suicidal situations) are really not communications per se, but crisis contexts in which, were we caught up in a similair web of seemingly impossible circumstances, suicide might seem like the "only" solution.

For example, in the Navy's psychological autopsy research noted above, otherwise non-psychotic but acutely stressed completed suicides were often facing a personally humiliating event; an arrest, a pending courts martial, the launch of invesitigation into alleged improprities or dishonorable conduct, etc. The percieved "impossibility" of surviving the crisis psychologically was not apparent until after the death. As with beauty, the severity of a personal crisis is in eye of the person at the center of the storm, not in the eye of those of us standing by.

In general, however, persons facing an abrupt end to their life's dreams and careers are, all too often, suffering from co-existing untreated depression as well. Whether the depression began before the final crisis, in anticipation of it, and/or was triggered by a series of final and unacceptable losses, real and imagined, only more research will tell. But we do know that, worldwide, it is estimated that 60% of all suicides are completed by people suffering from this largely underdiagnosed and undertreated disorder. As a result, the "final straw" that triggers the attempt may seem minor in retrospect.

Warning signs: verbal suicidal communications.

Direct verbal communications are relatively easy to undertand and do not require any special listening skills or intrepetive powers. "I'm going to kill myself," "I can't get through another shift, I'm going to have to shoot myself," are not difficult communications to understand. What is difficult to accept these communictions for what they are; attempts to seek help, understanding and even to be rescued. The key is to not ignore or deny what you've just heard, and to respond in a positive and forthright fashion.

Because direct communication about suicidal intent is often rejected out of hand by potential rescuers, suicidal persons often revert to coded clues or "hints" at what they are considering. For example, men will often make what is called a "dire prediction." The statement, "You will find a dead man in a car outside the house next Tuesday," was made by a man to his wife after she filed for divorce. "I want you have my gun collection when I'm gone, I know you'll take good care of it," was made by an otherwise physically healthy but suicidal banker to his son. A nurse said to her supervisor, "You won't have to worry about me after the weekend."

Perhaps because of the strong taboo about suicide in our culture, suicidal people may not wish to offend others with their unacceptable thoughts, feelings and plans. Or perhaps they are afraid no one cares if they live or die. Whatever the motivation, the rule for understanding an indirect verbal suicidal communcation is this: If the word suicide crosses your mind after you hear such a statement, it's probably crossed the mind of the speaker...., so go ahead and confirm what you think you heard. The worst you can do is be wrong; the best you can do is save a life.

Behavioral clues may be even more challenging to interpret. Not everyone in a suicidal crisis wishes to state verbally what he or she is about to do, in either coded language or uncoded language. Rather, they let their actions speak for them. Any behaivor which suggests death is planned for should raise your suspicion index and trigger a QPR response (see side bar for examples).

A possible solution, QPR, CPR for Suicide Prevention

QPR is a three step suicide intervention that trains people to Question, Persuade and Refer those at risk for suicide. The success of the intervention hinges on the now replicated fact that the vast majority of those considering suicide tell someone what they are planning to do to before they do it. This documented need to tell someone you are about to kill yourself is, in some ways, our only window of opportunity to act bodly to prevent a tragedy. People willing to take such action are called gatekeepers.

The Centers for Disease Control has recommended gatekeeper training as a top priority in its national mission to reduce the American suicide rate. QPR is a gatekeeper training program designed and targeted specifically to train such gatekeepers. Gatekeepers, or first finders, are those people in every community or institution who, because of their contact with those at risk for suicide, are often in the best position to detect, identify and refer people thinking about suicide.

Like CPR, QPR trains people in a given community, work setting, or insitution to know what steps to take when a suicidal communication is intercepted. The more people trained in QPR, the greater the odds a suicidal person has to survive his or her crisis. By analogy, if you must have a heart attack outside a hospital, have it in Seattle. Why? Because Seattle, Washington has more CPR certified citizens per capita than any other city in the Unitied States.

QPR is based on this same, public health philosophy. The more QPR trained people in any defined community, the greater the odds a suicidal person will recieve emergency intervention, which leads to treatement, which leads to survival. Since mental health professionals typically wait in their offices for people needing help to call them for appointments, it is this author's view that unless a non-traditional, community based, wide spread behavioral health education training program that proactively detects, identifies, and refers those contemplating suicide, the suicide rates among law enforcement personnel will not decline in the near term. Denial of the problem, coupled with a passive response system, loses lives.

The nature of the suicide journey

Attempted or completed suicide can be seen as the end of a psychological journey, a journey that begins with the idea that suicide solves problems, and that sometimes ends with an act of self-destruction, either fatal or non-fatal. Once the idea of suicide is under consideration as a final solution to life's suffering and problems, the journey to find a time, place and means may be long or short. Sometimes the journey to suicide is a matter of hours; more typically it is a matter of days, weeks or even years. Typically, the acute phase of a suicide crisis begins and ends within approximately three weeks from the onset of the crisis. The final crisis is often triggered by some last straw, precipitating event that tips the person in the final, acute hours of unrelenting psychological pain.

If an intervention is made in the beginning of this journey, preferably at the early, "ideational" phase, Questioning, Persuading and Referring someone can quickly abort the journey to a suicidal act. Alternative solutions can be offered, hope instilled, and treatment, in whatever form it takes, can begin to bring about better health status, both physically and psychologically. Most people, if they do not die in their first suicide crisis, not only begin to feel better almost immediately, but go on to live long and productive lives, as did Abraham Lincoln.

QPR is specifically designed to detect persons in the thinking or ideational, or early planning phase of a suicide plan. QPR may also detect people who are much further along in their journey to suicide and, in some cases, the person may have already made one or more non-lethal attempts.

The QPR intervention is initiated by a trained gatekeeper upon his or her interpreting suicidal communications, whether spoken, written, coded or uncoded, behavioral or suggested by a set of what may reasonbly be seen to be a personal crisis from which the individual may be unable to percieve a graceful, face-saving exit.

Designed to be taught in a single hour, QPR teaches audiences how to recognize the clues and warning signs sent by someone on a suicide journey, and how to make a successful intervention by asking the Question, Persuading the person to get help, and Referring them to a known and familiar resource. Resource and referal training, as well as the role of drug and alochol intoxication in suicide cirses are also taught.

It is important to note that research has found many otherwise caring people encouraged the use of, or suppiled alcohol to friends or loved ones during a suicidal crisis. Several post mortem toxicology studies have found alcohol blood levels exceeding the legal limit in the majority of completed suicides -- even in those cases where alcoholism was never diagnosed. There is, in a word, no safety for suicidal people without sobriety.

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