By Brian J. Boon, Ph.D., and Al Whitehurst, CARF International

Although suicide is rare, it is a serious public health threat and a tragedy to those whose lives it touches. Suicide remains the 11th leading cause of death among all ages in the United States.

Yet there is encouraging news: Suicide is preventable, and prevention begins with an open conversation on the subject. We invited four behavioral health experts to share their insights on ways to prevent and survive suicide loss.

Chronic and acute factors can lead to suicidal thoughts

Many factors -- not a single cause -- contribute to a person thinking about suicide or acting on thoughts about suicide.

Lanny Berman, Ph.D., ABPP, executive director of the American Association of Suicidology and president of the International Association for Suicide Prevention, says suicidal thoughts are often preceded by what he terms "a precipitating event, such as the end of a significant relationship or fear of exposure of something that the person is ashamed of."

Berman hastens to add that a precipitating event alone does not trigger thoughts about suicide. "Disappointments and setbacks in life happen to each one of us," he says. "That does not mean we become suicidal if we lose a job, experience a failed relationship, or have a financial crisis." Berman says that a significant behavioral health condition, such as depression, another mental illness, or substance abuse, combined with a predisposition to being suicidal can make it possible for a precipitating event to stress a person beyond their limit of tolerability.

"A number of chronic risk factors can make a person predisposed to be suicidal," Berman explains. "Some factors are readily identifiable -- for example, having a suicide in one's family history. Other chronic risk factors, such as having any of a large number of psychiatric disorders that are associated with increased risk for suicide, require professional assessment."

In addition to chronic risk factors, Berman cites acute risk factors -- or warning signs, such as a sense of hopelessness or symptoms of insomnia or agitation -- which contribute to suicidal thoughts and behaviors. "The presence of any warning sign should prompt us to ask whether the person is an emotional state, such as despair or anguish, that they might be considering taking their life," he says.

Be alert to the warning signs

The National Suicide Prevention Lifeline urges seeking help as soon as possible by contacting a mental health professional or calling the lifeline at (800) 273-TALK (8255) if you or someone you know exhibits any of the following signs:

• Threatening or talking about wanting to hurt or kill oneself
• Looking for ways to kill oneself by seeking access to firearms, available pills, or other means
• Talking or writing about death, dying, or suicide when these actions are out of the ordinary for the person
• Feeling hopeless
• Feeling rage or uncontrolled anger or seeking revenge
• Acting reckless or engaging in risky activities -- seemingly without thinking
• Feeling trapped -- like there's no way out
• Increasing alcohol or drug use
• Withdrawing from friends, family, and society
• Feeling anxious, agitated, or unable to sleep or sleeping all the time
• Experiencing dramatic mood changes
• Seeing no reason for living or having no sense of purpose in life

How to respond

Detecting a warning sign of suicide should prompt a speedy response. Unfortunately, many people feel paralyzed when they suspect another person is considering suicide. John Draper, Ph.D., project director of the National Suicide Prevention Lifeline, says that people might ignore the warning signs because of a fear of not knowing what to do if someone voices suicidal thoughts.

Draper offers straightforward advice: Ask the person in crisis to tell you what is causing such emotional pain and ask directly about suicidal thoughts. He suggests saying, "People who are in such pain will sometimes think about suicide. Are you thinking about killing yourself?"

People can be afraid that raising the question of suicide might plant the idea of suicide in a distressed person's mind. The opposite is true, Draper insists. "Research shows that such questions do not cause harm in people who are not suicidal, and, for people who are having suicidal thoughts, such questions open the way to talk openly about a forbidden subject."

Draper adds, "You don't need to have the solutions to the problems to be helpful, but you must be willing to listen carefully to a person's reasons for wanting to die." He also recommends you:

• Remind the distressed person that thinking about suicide does not mean that it must be acted on; other solutions can address the emotional pain.
• Ask the person if behaviors, activities, or supportive people have helped them cope with similar feelings in the past, and discuss how these approaches might be helpful now.
• Talk with the person about their plan for suicide, if any. Ask about any weapons, pills, or other lethal means they might have acquired; and talk about how the person can avoid using these means.

Most important, Draper says that delivering a message of the urgency of seeking professional help is not enough. Tell the person in crisis that you care and want to help.

"It is important to communicate to persons in crisis that they do not need to go through this alone, and that you and others will get them help to ensure they remain safe," Draper advises.

Behavioral health professionals can intervene and stabilize a crisis

"If you believe a person may be considering suicide, tell the person that treatment and support services are available and effective," says Elizabeth Winkelman, J.D., Ph.D. "Thoughts of suicide are serious red flags that professional help is needed. Help the person to access appropriate services by calling a crisis line, making an appointment with a psychologist or other mental health professional, or accompanying the person to a hospital emergency room for an evaluation."

As director of regulatory development for the American Psychological Association, Winkelman says that many kinds of treatments, such as psychotherapy, medication, or a brief hospital stay, are effective. Even if a particular therapy or medication was not helpful in the past, a different one might be effective today. She adds, "If a person is depressed, they may feel hopeless and be unable to think clearly about the positive things in their lives or about how to make changes for the future. Personal and professional support can help them to see their problems as more manageable."

Winkelman urges people to not minimize or discount a person's feelings of distress or suicidal thoughts. "Many persons who take their own lives have made previous suicide attempts or they tell others about their plans in advance, but they do not get the intensive treatment services that could have helped them," she laments.

Dealing with the irrational aspect of suicide

Daniel J. Reidenberg, Psy.D., FAPA, warns against attaching a stigma when talking about suicide. "Instead of being afraid of the topic, we need to talk about suicide like any other medical illness," he says. Reidenberg is executive director of the Suicide Awareness Voices of Education and managing director of the National Council for Suicide Prevention.

Reidenberg believes that conversations about suicide should include accurate and helpful information that convey a message of hope. He affirms, "Things can get better, and life is worth living."

Although Reidenberg recommends talking about suicide honestly, he says people need to resist sensationalizing or glorifying the act. "Persons who die of suicide should be remembered for their full life, not their final act, and the good things they brought their family, friends, and community. Their legacy is not their suicide." He cautions that romanticizing suicide increases the risk of copycat suicides, particularly among youths.

Reidenberg insists that we have a responsibility to avoid normalizing the idea of suicide. "We cannot think that suicide is normal behavior or that lots of people are doing it," he states.

Surviving suicide loss

Most people experience shock and feelings of sadness or anger after losing someone to suicide. Guilt is one of the most common and difficult feelings to face. What did I do? What could I have done? Why didn't I do more?

Reidenberg counsels, "Coping with guilt means trying to understand something that doesn't make sense. Suicide comes from a place of complete irrationality and unthinkable places in the mind. The person who died wanted out of pain and wasn't able to think about others at the moment of death."

Reidenberg reports he often hears people say, "I should have been a better parent." or "He would still be here if I hadn't broken up with him." Reidenberg responds, "If suicides were about bad parenting or relationships that didn't work out, none of us would be here. The reality is that suicide isn't about these things. Suicide is rooted in illnesses that take hold of the brain."

Medical and mental health professionals, suicide experts, and other concerned persons can help survivors of a suicide loss by sharing what they know about suicide, its underlying causes, and challenges to preventing it. Survivors often find relief from guilt by talking with others who have lost a loved one to suicide.

To help in the healing for persons who have lost someone by suicide, the National Survivors of Suicide Day is observed every November on the Saturday before the Thanksgiving holiday in the United States. On this day, 250 simultaneous conferences for survivors of suicide loss take place throughout the country and around the world.

Reidenberg reflects, "We need to make sure people understand if they talk about suicide, others will respond seriously. In this way, we all have a part in caring for each other."

Resources for suicide prevention

• The American Association of Suicidology leads the advancement of scientific and programmatic efforts in suicide prevention through research, education and training, the development of standards and resources, and survivor support services, including links to crisis centers and support groups.
• The American Foundation for Suicide Prevention is dedicated to understanding and preventing suicide through research, education, and advocacy. The foundation coordinates annual activities on National Survivors of Suicide Day.
• The American Psychological Association is a scientific and professional organization that represents psychology in the United States. Its website includes information on suicide, struggling with thoughts of suicide, and preventing teen suicide.
• CARF International's provider search tool can find accredited behavioral health professionals in your area. In the advanced search tool, select Assessment and Referral, Crisis and Information Call Centers, Crisis Intervention, Outpatient Treatment, or Crisis Stabilization programs. The search results are sortable by provider name, city, state/province, or country.
• The It Gets Better Project offers messages of hope and support for lesbian, gay, bisexual, and transgender (LGBT) youths, a group identified at higher risk for suicide.
• The National Action Alliance for Suicide Prevention is a public-private partnership that provides an operating structure to catalyze planning, implementation, and accountability for updating and advancing the National Strategy for Suicide Prevention (PDF). The Suicide Prevention Resource Center (SPRC) formed the alliance with funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) and input from many individuals.
• The National Council for Suicide Prevention furthers effective suicide prevention through collaborative activities and information sharing in order to save lives.
• The National Suicide Prevention Lifeline at (800) 273-TALK (8255) is a free and confidential 24-hour hotline available to anyone in suicidal crisis or emotional distress. The lifeline, in conjunction with the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA), also hosts a Veterans Suicide Prevention Hotline at (800) 273-TALK (8255), then press 1.
• The Suicide Awareness Voices of Education (SAVE) aims to prevent suicide through public awareness and education and features information, news, and resources.

About the authors

Brian J. Boon, Ph.D., is president/CEO of CARF International, an independent accreditor of health and human services, and serves as a founding member of the executive committee of the National Action Alliance for Suicide Prevention. Al Whitehurst coordinates CARF International's corporate communications.

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