The webinar covered in this article was presented to clinicians and medical personnel. The duties and responsibilities discussed here do not apply equally to nonmedical people. Before becoming a support for a suicidal person, establish boundaries around how you will support them and secure support for yourself, especially if you are alone in supporting them. If someone threatens suicide or self harm to get you to comply with their instructions or desires, seek help immediately.
In a recent HRSA webinar, Joe Hyde, LMHC, CAS, spoke about understanding, managing, and treating suicidality in men. Although suicide has gradually lost some tabboo as a topic, cultural biases about men and emotions stunted conversation about men’s mental health to the point of creating a lethal lag in in the improvement of men’s mental health. Clinicians are often the first line of defense in catching and treating mental health crises in men. “A patient’s ambivalent thoughts about dying are an opportunity for you to save a life,” Hyde said.
The facts around suicide and men paint a stark picture. Men are less likely to seek help for mental health, regardless of age, nationality, or race, and just half as likely to seek help for depression or anxiety. At the same time, men account for 75% of suicide deaths in the U.S. Although this data can make it seem as though men account for just a third of mental health crises and a disproportionate 75% of suicide deaths, the disparity largely lies in the number of men with poor mental health and the number of men seeking mental health care.
Just as in how men are much less likely to seek preventative care, masculine gender norms demanding that men be pillars of unwavering strength impede men’s ability to accept and seek help for mental health problems. Consequently, mental health issues in men are underdiagnosed and often overlooked by both patient and provider. Instead, men are more likely to seek help for external symptoms of internal illness, such as anger management or alcoholism, rather than the root of their health crises.
What is suicide?
The CDC defines suicide as “death caused by injuring oneself with the intent to die,” but Hyde reiterated the importance of the human factor. “I feel like it strips the humanity away from someone who is profoundly suffering, and kind of sanitizes what’s going on,” said Hyde. Actively distancing or sanitizing heavy emotions in an effort to protect masculinity is a common theme in discussions around men’s mental health, and perpetuating that habit does nothing to disrupt the norms that led to the crisis of men’s mental health. Centering the human emotions inherent to mental health, especially for men, helps to shift the paradigm.
Hyde explained that suicide is not about wanting to die, but about not wanting to live. It is often seen as an escape to unbearable suffering, a means to end a hopeless situation. The most common emotion inherent to suicidality is hopelessness, but no single explanation can account for all suicidal behavior — not even depression. Only about 50% of suicidal men also experience major depression.
Suicidal ideation has two types: passive and active. In passive suicidal ideation, the person wishes they were dead, but have no plans to commit suicide. In active ideation, the person has a plan in mind. “In both of these circumstances,” Hyde said, “these men are suffering.” To people experiencing suicidal ideation, their suffering is so great that the thought of suicide is comforting.
“What I think is really useful about the contemporary thinking around suicide, and redefining our understanding around suicide that moves away from that single-cause over-medicalization,” said Hyde, “is we need to understand and address suicide as an issue unto itself. It is way more than a manifestation of some underlying condition.”
Screening for depression, suicidality, and other behavioral health issues needs to be a standard of care — “because if you don’t ask, you just don’t know,” said Hyde. Especially for men, who are more reluctant to address mental health issues, it should not be assumed that a patient will bring up mental health problems without being asked directly. Hyde advised that triage screening with the PHQ2 should include Q9 about self harm, since not all suicidal patients are depressed. By screening patients, clinicians can connect them to evidence-based behavioral health interventions.
Many misconceptions surround suicide, such as the idea that suicidal behavior is a symptom of one underlying issue. A broad spectrum of factors can contribute to suicidality, from personal and family crises to sudden changes in health to chronic social determinants of health and much more.
Other common misconceptions include:
- ‘Asking someone about suicide will increase the risk of suicide.’ In reality, it’s been shown that asking about suicide lowers anxiety, opens communication, and lowers risk.
- ‘Only experts can stop a suicide.’ Anyone can stop a suicide by listening and offering hope. “I know somebody who freely says ‘My schoolteacher kept me alive when I was a senior in high school because she cared.’ People from anywhere can have an important impact,” said Hyde.
- ‘Suicidal people don’t talk about it, and those who talk about suicide don’t do it.’ Most suicidal people give some sort of clue or communicate an intent prior to attempting, and talking about it is an important red flag.
- ‘Once a person decides to attempt, nobody can change their mind. No one can stop suicide.’ Suicide is preventable. Almost any positive action may save a life. If people get the help they need, they are far less likely to attempt suicide.
Clinics should use standardized screeners, such as the Columbia Suicide Severity rating scale, to assess a patient’s risk level. When a patient comes into the office with a mental health crisis, knowing how to engage them is paramount to handling a critical situation successfully. Hyde gave a list of protocols for providers to follow when handling these interactions.
- Ask the patient about what they are feeling.
- Use motivational interviewing skills to engage with kindness and compassion.
- Voice your concern.
- Reinforce connection, which offers a sense of belonging.
- Offer hope things can get better.
- If they are high-risk, do not leave them alone.
- Screen for severity of risk.
- Make a treatment plan.
- Document as much as possible.
- Always follow up.
- Engage in philosophical discussions about suicide.
- Describe it as attention-seeking behavior.
- Promise to keep someone’s suicidal feelings a secret.
- Try to talk patients out of thinking the way they’re thinking.
- Be patronizing or judgmental.
Making a treatment plan with the patient is the next step. “Our first goal is to keep the patient alive,” said Hyde. Defusing hopelessness, understanding the context of the patient’s suicidal intent, and implementing a plan are the keys to successful treatment.
Ensure that the patient knows the warning signs that precede their mental health crises, such as common triggers, feelings, thoughts, or behaviors, and use motivational interviewing skills to help the patient self-define coping mechanisms that can get them through those rough times.
Help the patient identify resources like professionals, family, and friends who can help them. The crisis hotline, 988, is one example. Ask the patient if they have the contact information for the family and friends they plan to rely on, and ask about contacting those people now with the patient to see if they feel comfortable and capable of supporting the patient. Offer those people information about how to support the patient where possible. Most importantly, ensure that the patient’s environment is safe — for example, that any firearms are kept out of the home. Some areas have law enforcement agencies that provide gun locks or remote storage. Longer-term treatment plans have a variety of evidence-based approaches, including dialectical behavioral therapy, cognitive behavioral therapy, and medications.
Document the treatment and safety plans made with the patient in writing and provide everyone a copy, including the clinic. Write detailed progress notes and incident reports, and review events with supervisors. If something happens, thorough documentation will be necessary, Hyde advised.
“Managing suicidality has two parts to it,” said Hyde. “One is keeping your patient alive — that’s our first job here. The other part of it is protecting your practice — that you are doing a decent standard of care, that if something does go wrong and this person takes his life, then you have done the best you can do.”
To view the webinar, click here: https://vimeo.com/731074862