Susan Dingle
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December 1, 2020
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If You're Worried About a Friend at Risk…

Say Something & Do Something: Suicide Prevention, For Friends Helping Friends

By

Susan G. Dingle M.A, LCSW

ABSTRACT: This article will train readers to recognize danger signs and intervene effectively when a friend or roommate is in danger of self-harm. Readers will learn three strategies to help a friend at risk: 1) practice reflective listening and compassionate neutrality; 2) form a safety plan; 3) carry out the plan by communicating effectively with family members and institutional helpers. With this training, readers will learn how to advocate for peers, and create a safety net for suicide prevention that will benefit their entire community.  

Suicide is the second leading cause of death among adolescents.  Each year a thousand students kill themselves, leaving families, friends and roommates with endless unanswerable questions: What could we have done, what should we have done? Family members and friends pour over all the signs they didn’t know were signs, that change in personality over a short period of time, that increased isolation, that friend who said, “I think something’s wrong with my mind…”

80-90% of college students who complete suicide were not seen by university mental health services.  That statistic suggests several interpretations—are mental health services difficult to access? Are the mental health services overwhelmed by the number of students requiring help, turning people away?

Or is it that the people most at risk are the least likely to seek services?

Those who need most help often want it least. This paradox demonstrates the power of stigma, the toxic shame that still surrounds the topic of mental illness. If guilt is the feeling that “I’ve done something wrong,” shame is the feeling that “I am something wrong.”  Shame can be overpowering, leading to self-loathing.  A person engulfed by shame does not want to be seen or noticed.  A person engulfed by shame just wants to hide, and doesn’t anyone to know anything is wrong.  Shame prevents people from seeking help. As a teenager, I was afraid I had a problem. So I went to see a therapist. But I was afraid the therapist would judge me if I admitted anything was wrong. So I talked around the problem, never even saying what it was. I quit therapy the minute the therapist started asking uncomfortable questions.

As a therapist, I remember that dark place, and want to help others who wind up there.  People in dark places often turn first to friends for help. Friends listen and care without judging.  But sometimes friends may need help, to help their friends. Sometimes friends are the only lifeline a person has.

Maybe you have a friend who is in a dark place.  You’ve noticed some changes in behavior. Maybe among your friends, smoking a little weed is a normal way to chill out. But we’re talking about that friend who’s taking it a little too far.  Weed, and alcohol, can mask anxiety, for awhile. Seems like a solution to the problem. But that solution has a downside. Substance use can lead to abuse, and dependency. It’s an addictive behavior that doesn’t seem like a problem, for those of any age. But for adolescents, smoking weed and drinking can kick off underlying mental disorders like bi-polar disorder (manic depression) and schizophrenia. A colleague in long-time recovery from substance abuse asserts that her bi-polar disorder first emerged while she was in college, after she smoked weed cut with hashish.  She wound up in a hospital with delusions and mania. That first episode led to three years in and out of hospitals before the disorder could be managed with medication and treatment.  Many young people are not so fortunate.

Recently, a member of my family was one of those casualties, dying by suicide at the age of 19, devastating family and friends. Months later we are still trying to understand what it was we missed.  In long and agonizing conversations, family and friends piece together the signs they didn’t know were signs.  I am writing this for them, and for all those high-achieving students who would rather die than talk to a therapist. Instead they fly under the radar,  imagining that with all their intelligence they “should” be able to figure out their problems themselves. Certainly with enough weed, and a little help from their friends, they should be able to figure it out…but instead it just gets darker, the more they hide.

It’s not that they don’t trust people, it’s that they believe that they “should” be able to handle it  themselves. Figure it out. Their parents expect them to be self-sufficient, if not perfect.  In family systems theory, that high-achieving child, often the eldest, plays the role of the “hero,” that “perfect” child whose accomplishments and achievements make the family look good.  The hero believes they have to earn or deserve love.

The child in the role of “hero” can’t admit to vulnerability or “weakness,” because in their family, they not supposed to need help.  “Needing help” is for other people, usually younger siblings, people who aren’t smart enough to figure it out. Heroes would rather die than admit they need help. So obviously a kid like that isn’t going to the student health service. Instead they smoke more weed, and maybe experiment with hallucinogens, in an effort to gain control over their thoughts and feelings.

Even as I write, parents and friends of this gifted young woman—and the parents and friends of so many other victims of suicide—pour over journal entries and poems, recall conversations, compare what they knew and when they knew it, looking for an explanation for the inexplicable.  

After the funeral in our family, a group of us were taking a walk on the beach. It was an overcast afternoon. As we walked along, the sky cleared, and we saw a rainbow. It reminded us of her, that bright spirit that lit up our lives for a time, and will never die.  

A rainbow is such a powerful sign. It is the sign God sent Noah, as a promise and covenant, that the world would never again be destroyed by floods.  

Seeing that rainbow gave me a sense of hope, that maybe there is something we can do to help others.  As a therapist as well as a family member, I wanted to empower other friends and roommates so that we can be prepared to act powerfully when suicide prevention is called for.

We need to recognize the signs, protect the person who is at risk, and help them to safety. Imagine we are lifeguards, seeing someone in danger. We know the signs, we know what to do to rescue that swimmer who is suddenly in trouble.  A friend who is showing the signs of mental illness is like that swimmer in distress. There is something we can do.

Most important, let’s keep it simple. Let’s do the next right thing, rather than wish we could have done something. Friends can make a difference, by using a 3-part suicide prevention strategy.

Right now, for those who have experienced the recent trauma of a loss like this, learning what to do in the future can help start the healing from this devastating grief. Although we may still be in trauma, we can begin the process of Post-traumatic growth by looking for what we can learn. We develop resilience as we heal ourselves and others. We discover resources we didn’t know we had. We will become stronger, more compassionate and wiser, as we experience the healing power of love. As we support each other, over time we will see how love overcomes death. That’s the power of grace, as manifest in Post-Traumatic Growth.  

May this article shine the light of love into the darkness of unimaginable loss.

To friends and roommates in the aftermath of this tragedy, may you find peace, knowing that you did the best you could with what you knew at the time. You did many things right, as you stood by your friend day after day.  It’s not your fault you didn’t know what you didn’t know. Instead, learn to help others, so that next time a friend is in trouble, you will know what to do, and will be able to empower others.

Just remember 3 Steps for Suicide Prevention: 1) Recognize when your friend is at risk; 2) Make a safety plan with your friend; 3) Take your friend to the ER.  Simple, right? Here’s how it works.

1) Recognize when your friend is at risk.

Have you noticed any recent changes in your friend’s behavior?

Warning signs can show up as changes in behavior or attitude.

The change may be gradual or precipitous. Is your friend using drugs more often than usual, or more than other peers? Is your friend using substances alone, rather than as a social thing?  Has your friend become quieter, more moody?  Have they  lost interest in activities they used to be involved in?  One example would be if they are dropping out of courses or activities they once enjoyed. Have they begun talking about things they didn’t used to talk about?  Pay special attention to conspiracy theories, topics such as “the end of the world,” the apocalypse, and preoccupation with things that seem “dark,” as in related to death and dying.  Does your friend express concerns that seem irrational or bizarre to you? Pay attention. Encourage your friend to tell you more about these things. This is what clinicians call the “Assessment” phase. It is what we do before deciding on a course of treatment.

A key to assessment is, “when someone tells you who they are, believe them.” For suicide prevention, we might revise that slightly: When someone tells you something is wrong, believe them.  Ask them to tell you more about it.  Ask them what they mean if they say anything you don’t understand. Assume an attitude of “compassionate neutrality.” That’s the attitude of mindfulness, the openness and non-judgmental attitude we practice as therapists, so that clients feel safe and not judged. We create a space of acceptance where what can’t be said, can be said.

We use “reflective listening”.   First repeat back to the person what you heard them say. Literally say, “I heard you say…”  Then follow with an effort to interpret or understand the statement:  “It sounds like….” Then your friend can agree or disagree, enabling you to understand the situation in greater depth. When your friend is able to convey a thought or feeling that troubles them, consider it an honor, that they are trusting you. Imagine what it means for someone carrying a painful burden, to finally tell someone. This is when you understand that you are called to respond as one who has been trained.  Maybe in real life you aren’t a therapist , but right here, right now in this moment with your friend, you are the closest thing to a therapist your friend has.

So here’s how to listen like a therapist. Compassionate neutrality--no judgement, and no “quick fixes.” You don’t have the answers, that’s not your job.  Your job is to listen, to hold the space. If it was hard for your friend to admit “something’s wrong,” it may be equally hard for a friend to resist trying to fix a friend, or deny anything is wrong.  “Oh you’re fine,” a friend or parent might be tempted to say, or “there’s nothing wrong with you!”

This is how denial reinforces shame, and how unconscious stigma prevents change. The stigma around mental illness engulfs us all. But mental illness is not someone’s fault.  And it’s not a quick fix. We need to change the conversation about mental illness, by listening without judging.

Consider the situation from the perspective of a helper .  A helper overcomes the stigma and stereotypes around mental illness, by not denying or trying to fix anything. Maybe you’re not trained, but you know more than you think you do   about what it takes to provide a safe space.  Just listen and don’t judge. Encourage your friend to speak more.  It will help your friend to come out of isolation and shame.

Your encouragement and acceptance will counteract the shame your friend might be feeling about what they have admitted to you. Right now, you are listening for “symptoms” contained in those expressions of thought or feeling. “Symptoms” are not judgments, but observations used as criteria to evaluate a medical condition.  

In suicide prevention, we need to know whether the person can distinguish between fantasy and reality. Listen especially for any thoughts or feelings that suggest the person may present a “danger to themselves or others.”  Thoughts such as “my family/the world would be better off without me,” “it’s too late for me,” are evidence of cognitive disorder, and may be accompanied by paranoia and other delusions.  Once present, delusions can take over the mind.  Conspiracy theories show how delusions knit together into an air-tight case.  The rational mind yields to darkness, as fantasy takes over reality.  Obviously this takeover of the mind by delusion is exacerbated by drug use. You don’t have to be a weatherman to know which way the wind is blowing.

Just keep it simple, and ask, “what makes you think that?”  Then listen.  Listen long enough, and a delusion may emerge, something that just “doesn’t sound right” to you. Follow up with “What do you mean by that.”  Say, “I’m not sure I understand. You mean that…?”  Trust your instinct. You will know when delusions are present. People who smoke weed often enough do lose touch with what it’s like not to be stoned. They inhabit that fine line between detachment and paranoia.  

Paranoia is a major warning sign, the delusionary train of thought, that persons, institutions or unnamed forces may be out to harm the person. A person with paranoia feels the threat is real, though it is imaginary—a state of fear is so deep and pervasive the person cannot feel safe. They fear that something bad going to happen. They see “signs” that convey an ominous meaning that others may not notice.  Ask them to tell you about such signs. Listen for any suggestion the person feels endangered, or that may do something to hurt themselves in response to such signs or “messages”.

The person does not feel safe: they sense that their mind is becoming unreliable, an unnerving feeling that contributes to the sense of un-ease.  Once you know what your friend is thinking, find out how your friend FEELS about these thoughts.  The medical term for feelings is “affect” or “mood.” Affect is how the person presents themselves—subdued, numbed, excited.  Mood is how the person is feeling—happy, sad, fearful. The two don’t always match.

Your job is just to notice.  Trust your observations, your instinct. You know your friend. You know if your friend seems “different” and in what ways.  Your observations are important, and will help later.

Keep in mind that suicide is an impulsive act, a “permanent solution to a temporary problem.”   A person who is at risk for acting out on a suicidal impulse should not be left alone. If you have that instinctive feeling about your friend, pay attention to it.  

2) Make a safety plan with your friend.

You instinctively want to protect your friend from harm, even if you don’t know what kind of harm there may be.  Trust that feeling.  Maybe you feel like you shouldn’t leave your friend alone.  You also don’t want to scare your friend or lose their trust.  So be transparent, clear and up front. Before you do anything, let your friend know what you are doing.  Obviously if you are concerned about your friend’s safety, you will want to reach out to other friends, maybe one or two, so you can share the responsibility for keeping your friend safe.

Does your friend need a safety plan? The only way to find out is ask:  

Do you have any thoughts or feelings about hurting yourself?

If your friend says yes, then ask:  Do you have any idea of what you might do or how you might do it?

If the answer is vague or “no”, your friend has suicidal ideation but no plan. You might ask your friend if they would be willing to talk to someone in the student counseling office. Encourage them to make that call.  

But if your friend says “yes”, ask the person to describe what they might do and how they might do it.  If someone has a plan, then immediate hospitalization is called for, because the person presents a danger to themselves or others. This is the specific language used in the Emergency Room to identify those who require hospitalization.  

The worse off your friend is, the less likely they are to reach out for professional help. So here you are, alone on the front line. What do you do now?  

Get back-up.  Ask your friend if anyone else knows about this. Identify another friend they would trust.  Reach out to that other friend or friends as your support team, to make sure your friend is safe in the short term and in the long term.

Trust your instinct. If you feel uneasy about your friend going out alone, make sure one of you is with your friend at all times.  For sure, you need more than one friend to insure your friend has a safe landing. When you communicate with your friends, let your language reflect that you are an empowered helper, not “just” a friend. If there are three friends, one person can interface with the parents, one with the person at risk, and one with the institutional helpers.  

The vocabulary you use should be clinically correct, laser-focused, to convey your concern clearly.  You won’t need a lot of words to get your point across. Maintain an attitude of compassionate neutrality and urgency. Contain your emotional reactions, as a therapist would, so that you can be a helpful helper. Freaking out about your friend is not going to help.  

Your job now is to orient your friends to the task at hand: to make sure your friend is safe. Tell them the specific symptoms that lead you to fear your friend may be a danger to self or others. This narrative will empower you with the parents and the institutional helpers. It’s the case you will present.

Say: I’m concerned that X presents a danger to themselves or others.  The following symptoms (delusionary thoughts, affect, mood, behavior) lead me to this conclusion. Then be specific about what the person has said or done. For example, “Over the past several weeks, X has been smoking weed all day, staying in their room, and not talking to anyone. X told me that (examples of delusions).  The most concerning thing is that they said ________.”

A friend who either freaks out, or denies the danger will not be helpful as an advocate.  Your friend at risk needs advocates who will not be intimidated, overreact or back down if parents minimize or ER personnel try to dismiss your concerns.  Your friend needs empowered, committed helpers.  Like lifeguards, literally. Because your friend may be caught in something like a riptide, of thoughts and feelings that are overwhelming and uncontrollable.

Now you have your support team, your lifeguards, you’re ready to reach out to appropriate adults and agencies. If you are afraid to let your friend go out of the house alone, that’s an indication that it’s time to get your friend to the ER as soon as possible.

Depending on the situation, you may or may not want to let the parents know what is happening.  Before you make that call, ask your friend if it’s okay for you to call their parents.  You might say something like, “I hear what you are saying, and it sounds very scary. I would like your permission to call your parent, so we can let them know your concerns.”  If your friend does not want you to call their parents and your friend is over 18, then don’t call the parents. But if you think your friend is a danger to themselves or others, you are on the front line. You are that lifeguard. So how do you handle it, without losing the trust of your friend?

Say something like, “I know you don’t want us to call your parents, and under ordinary circumstances I wouldn’t.  I promise that we are going to stay with you. We are going to be here. We just need to let your parents know what is going on.” If you sense that informing the parents will jeopardize the trust of your friend, then follow your instinct.  The ER or the hospital can deal with informing the parents, it’s part of their job.

Respect your friend’s feelings, using reflective listening and compassionate neutrality. Assure your friend that you and your friends will stay close.

I am not suggesting you “ask” the parents what to do.  The parents are quite likely clueless,  and may be part of the problem, for all you know.  In any event, you are communicating to them not a child, but as an empowered helper of their child. Use that clinical vocabulary and language.  Say: Mr. and Mrs. X, we are your child’s best friends and we are very concerned about the changes in behavior and danger signs we have noticed.  (3 strongest warnings.) We think X is in danger of doing harm to herself or others. We are afraid to let X leave the apartment by themselves, and we are calling you to let you know it is time for X to be hospitalized in a safe situation away from any risk.”

The most important thing for the parents to hear from you, is that you do not feel comfortable about letting their child be alone right now because of some things that your friend has said or you have noticed. This is the most important message to convey:  We want our friend to be safe, so we do not let them go out alone.

Request that the parents come to where you are, rather than send your friend home. The reason is if your friend is decompensating,  they may become increasingly unstable and more likely to panic. If you don’t feel safe about letting your friend go to the grocery store, it certainly won’t be safe to send them home alone.

3) Take your friend to the ER.

You sense the danger your friend is in. You feel the urgency. Trust yourself. You need to get your friend admitted into the hospital.  Suicide prevention involves skilled intervention. You will be your friend’s advocate. You will convey the sense of urgency to the ER staff. Remember that the main criteria for admission to a behavioral health unit is whether the person presents a danger to self or others. Use your observations and what your friend has told you to inform admitting staff, who will inform the psychiatrist, who makes the decision about whether to admit. Keep telling the same story, and keep it simple. You are the close friend, the empowered helper. You know what is going on. If you present a case based on facts, you will convey the urgency.  Your commitment to your friend’s safety will speak volumes, when you don’t take “no” for an answer. Your objective is to have your friend evaluated and admitted. Don’t let them turn you away. Your friend’s safety is at stake.

But what if your friend doesn’t want to go to the ER?  Again, be transparent, direct and upfront. Remind your friend of your concern for their safety, using the same language they have used when they told you what was going on. You are coming alongside your friend, being their advocate, by voicing their concern in the language they have used. Agree with them that something should be done to address this situation.  Suggest that someone at the ER might recommend how to handle situation. Make sure that your friend knows you are on the same side, looking for the helpers, wanting only what is best for your friend. You propose going to the ER for a consultation on the best way to stay safe. But if your friend refuses to go to the ER, say that you are committed to doing whatever is necessary to protect their well-being. If they are not willing to go with you to the ER, then you will have to call 911.  

Of course, you don’t want to call 911. They will send the police, and it could get out of hand, especially is your friend is a male or person of color. Unfortunately many police are not well-trained in responding to psychological emergencies. So just keep talking to your friend, with the intention of “talking them down from the ledge,” as it were—making them feel soothed and comforted, that what you want to do is find them someone to talk to who will understand what is going on and be able to help them.

In fact, that’s true. Let your friend know that a) you hear them; b) you empathize; c) you are with them…no matter what.  When you know your friend perceives themselves to be in danger, their safety is your primary goal.  You need them to trust you. In the lifeguard comparison, the lifeguard needs to quiet the drowning person, in order to get them to safety.  Be that calming presence for your friend. Remind them as often as needed, that you hear them, you feel for them and you are there for them.  Reassurance, acceptance and love can be life-saving.

This is your truth. An intervention like this is a community effort, where one person brings another person onboard, thus strengthening the safely net around the person at risk.  You will be carrying the message, so do it powerfully.  

When you arrive at the ER, two of you stay with your friend. One person speaks with the hospital staff:  We are concerned about our friend. They have been acting differently and expressing that “something is wrong.” (List any ‘red flag” statements or behaviors that signal paranoia, delusion or the intent to self-harm.)  We are so concerned that we do not let our friend go out alone, because we do not think our friend is safe. We believe our friend may be a danger to themselves, and we want our friend to be safe. Can you help us help our friend?.

Your goal is to keep your friend safe. In a hospital, your friend can be supervised, monitored, medicated and counselled.  As an ally and advocate, you have recruited a support team of friends, and now will include hospital staff.  Hospital staff have to be convinced to admit your friend. You will need to be that empowered advocate. You are that lifeguard, trying to save your friend’s life. That is the level of commitment you need, to powerfully convey your concern to hospital staff.  Here is where your persuasive skills pay off. Once the staff sees the need your friend exhibits, they will communicate with the parents. Let the hospital do its job.  The hospital can communicate a message the parents may not accept from the peers of their child.

This suicide prevention strategy is the result of years of clinical experience distilled into a simple approach. To summarize the protocol: First, listen, and ascertain the degree of risk.  Second, recruit a team of friends to support and advocate. Third, take action to make sure your friend is safe by admitting them into a hospital for treatment through the ER.

That’s the 3-Step Suicide Prevention plan for Friends Helping Friends. It will not mitigate our grief for having lost our loved one, but it may provide a rainbow of hope for the future, when we can help the next person help a friend to safety.  It’s a lot of responsibility for roommates and friends. But you are the frontline of protection and love, and your actions can make a difference. You can save your friend’s life, by following your heart, and doing the next right thing.  It doesn’t matter how old you are or whether you think you can do it.  If you have even a mustard seed of faith in the power of friendship and love, that’s enough. You got this. May the spirit of love give you the courage to listen to your heart when you listen to your friend, and the wisdom to do the next right thing.  That sounds a little like a certain prayer well known in the recovery community:

God grant me the serenity to accept the things I cannot change,

Courage to change the things I can;

And the wisdom to know the difference.

So as a therapist who started out as an adolescent at risk, let me leave you with a story.  When I was 20 and still trying to solve my problems with alcohol and weed, one night I decided to go down to the bay and end it all by drowning myself.  I was in over my head, when I heard laughter on the beach. It was a bunch of kids, sitting around a campfire on the beach.  I thought “I can’t do this to them.”  I imagined them having to rescue me, or how awful it would be for them to see someone drown.  I couldn’t do it to them. So I turned around, walked out of the water and went back home.  Those kids saved my life, and didn’t even know it.  Kids no older than you.  You have more power than you know to make a difference for your friend. Those kids didn’t even know me.  But you do know your friend. And you can make a difference, just by doing the next right thing.

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