Winning the Hidden War

Like other populations, First Responders are at risk for depression, substance use disorders, and suicide. Here are some expert tips on the warning signs along with prevention tactics.

By Dena Ali

Since 1999, suicide rates in the United States have climbed by over 30%. Researchers have discovered several factors leading to this rise and recognize that few populations are immune from its outcome. Troubling for researchers and those involved with prevention alike is the fact that there is no effective algorithm to predict a suicide. The Question Persuade Refer (QPR) Institute says that our ability to predict suicide today is not much better than chance or a coin toss. This is because most people who have the documented risk factors will never attempt suicide, and many people who die by suicide displayed few of the documented risk factors.

While understanding risk factors are important in terms of prevention, it is now recognized that prevention by design can be more effective. This is achieved by creating communities where it’s more difficult to die by suicide due to greater barriers between those at risk and their means to die. 

Moreover, protective factors can serve as a wall of resistance between risk and outcome. Effective protective factors include strong support networks, access to mental health resources, coping skills, sleep, and practice of mindfulness. 

Connectedness is one of the greatest protectors against suicide. Meaningful connection is an innate human need for all people, and there is no substitution.

A method any layperson can learn to help prevent suicide is asking directly about suicide. If you are worried about a friend, coworker, or family member, you should ask them directly if they are thinking about suicide. Don’t worry, the question is not offensive to somebody considering suicide, and evidence has found that it will not implant the idea in a vulnerable mind.

Those who have considered suicide reported relief when directly asked in an empathic and sincere fashion. By asking them directly if they are thinking about suicide, you give them permission to open up, share their struggles, and take the first step to heal — finding alternatives to suicide. You become their ally in finding solutions for their pain.

Timing is also important because suicide intensity ebbs and flows, and, when suicide intensity peaks, a person is most at risk.  Fortunately, we know this intensity is often short-lived. Any barriers that are present between a suicidal person and their means have a preventive value, and the conversation should lead to enhanced barriers. 

In a recent lecture, Sally Spencer-Thomas Ph.D. provided guidance on how to ask directly about suicide. Here is some of the information that she provided. If you have any questions, comments, or concerns about the following, please reach out to me or go to workplacesuicideprevention.com.

Workplace Suicide Prevention

Before engaging in a conversation about suicide, you should understand that there are no magic words that can take someone’s pain away. The most valuable thing you can do for them is to show up and truly listen to what they have to say.

Ensure you truly show up by employing active listening skills. This means to tune into your body language: get on their level, face them, and lean in! Make eye contact, mirror their responses, and focus on what they are saying. Forget about problem-solving or crafting the perfect response. Your goal here is to help them feel connected and safe by conveying calmness and trustworthiness. In doing this, you provide them with an opportunity to open up and share their thoughts and feelings. Then and only then can they feel safe sharing their struggles.

You can start the conversation with a simple, “I’ve noticed you don’t seem like yourself lately…” Then list the specific things you’ve noticed about their behavior, moods, and/or life circumstances. There is no script for this; you have to follow your gut. Make sure you explain your concerns, let them know that you are bringing the issue up because you care about them, and you want to be someone in their life they can talk to about hard times. Don’t hesitate to be honest and let them know that you, too, know how important it is to have somebody to talk to when things become overwhelming. If you have a similar experience, share briefly that you’ve walked a similar road. Be sure not to flood them with your experiences. They should be doing a majority of the talking in this conversation. 

Employ effective listening by creating a space that lets them know that they are being heard and their story matters. To keep them comfortably talking, use minimal encouragers such as “umm hmm,” “what else,” and the best prompt, “tell me more.” This lets them know that you are aware something is missing, and you not only care but are not burdened by this conversation. 

A great acronym I use is “Awe.” “And what else”.  Awe reminds me to keep the conversation going by letting them know that I am invested, and I want to hear more. 

If you get silent, know it is ok. Silence is an opportunity for them to develop the courage to keep talking. Effective pauses in conversation are just that, effective. Savor the silence and try not to be the first to break it.

Throughout the conversation, imagine you are holding up a mirror to the person, reflecting what they say to show that you understand. This sort of reflective communication helps to validate their concerns and thoughts. The best way to do this is by summarizing what you hear and adding emotional labels to their story. 

For example, after they explain a loss and you detect that they are sad, you could say: “Let me see if I got it right, you sound sad because you have lost…”

Conveying your willingness to be present while another is in a dark and difficult place is more important than any advice you may have to offer. You don’t have to know the answers. Showing you are willing to provide unconditional support is what’s most important.

Don’t forget that finding the courage to open up and share your struggles is scary, and when people finally do it, it’s because they feel miserably trapped with no other option. More than anything, they are looking for connection and relief from their pain. 

Thoughts of suicide are common for people experiencing overwhelming hopelessness, self-hate, and disconnection. When talking to somebody going through a difficult time or major loss, it’s important to always assume that suicide is on the menu. Sally explains, “by assuming the suicidal thoughts are already there, you don’t need to wait to be given a big, red warning flag. Instead, you make what we call a pivot statement (2019).” A pivot statement occurs when you summarize the risk factors and warning signs you hear and then connect them to the possibility of suicide. An important part of the pivot is checking with the person to make sure you are hearing them correctly.

Example:

“Let me see if I’ve got this right. So, what I’m hearing is that you are going through a divorce, you are having a hard time concentrating at work, and you fear a personal financial collapse, yes? You know, sometimes when people are going through a divorce, having a hard time concentrating, and experiencing financial stress, they also think about suicide. I’m wondering, how many times suicide may have crossed your mind, even if it was just fleeting in nature. (Sally Spencer-Thomas, 2019)”

By letting the person in crisis know that you understand why people think about suicide, you help the person feel validated and less isolated. With compassion and a willingness to walk with them, you can make a huge difference in their outcome.

Asking, “are you thinking about suicide,” offers the best opportunity for an individual to open up and express themselves.

Understand, a person who is thinking about suicide may respond with a “no,” especially if they are a fellow firefighter who may fear judgment, loss of job, discrimination, or forced hospitalization. If somebody answers no, but you note discrepancies between what you see and what you hear, just reflect it by telling them that, “you are telling me that you’re fine, but I am seeing and hearing somebody who is distressed, would you tell me more about what you are going through?” Follow your gut, stay calm, and don’t force conversation. Don’t forget, there is no script for this conversation.

Sometimes when asking about suicide, you might get a “yes.”

How do you respond to “yes?”

First, make sure you stay calm.

Here are a few responses that will make a huge difference:

Express gratitude: The first words out of your mouth should be, “thank you.”

“Thank you for trusting me.”

“Thank you for your courage to be vulnerable with me.”

“Thank you for valuing our relationship.”

When people admit thoughts of suicide for the first time, they fear judgment and anticipate a negative reaction. However, when they receive a genuine expression of gratitude, this helps to put them at ease. By responding calmly and with gratitude, you create a safe space to move to the next steps.

Reassure your partnership with them. You are by their side and not planning on going anywhere! A significant fear for someone living with suicidal thoughts is rejection through judgment. Reassurance that you are not afraid and not planning to toss them like a “hot potato” can be very grounding for them.

Your partnership ensures they know that they are not alone, and they have an advocate. A connection may provide a flicker of hope that keeps them alive.

Provide hope through offering choice and empowering them to take the next steps. Hope is the antidote to suicide, and the best way to offer hope is through action. You provide action through resource sharing and tackling issues in a step-by-step method. We must remember that we can’t fix everything today, but we can start with the most pressing issue or the one thing we can tackle today. Small attainable goals are the key to change and success.

Championing change with broad statements like, “you have so much to live for,” is not an effective means for building hope. Hope forms through an individual plan for healing. What you want to communicate to them is that they matter to you, to their family, and their organization. They are not a burden, and they are worthy.

Remember, you are not the solution; you are the bridge to the resources. Your role is to remain in the passenger seat and share the best routes in hopes of eventually handing them off to professional resources.

Even in the warm hand-off to professional care, you can be with them. Just ask permission or offer to join them for their first appointment. From this author’s experience, that first appointment is daunting, and having support can make a huge difference.

Finally, before ending the conversation, make a plan to follow up. Ask for permission to check in next week or even offer a lunch/coffee meeting. It’s ok to let them know that they may face challenges as they are common, but persistence will help them fade. By offering to follow up, you let them know that you are willing to walk in the darkness with them.

When someone shares with you that they are having thoughts of suicide, they trust you and you must treat this with gratitude. Sally says, “This is a gift, they have invited you into a vulnerable part of their world, and you are a guest in this space.” There is no script for this conversation, and at any point, if you find the individual is an immediate threat to themselves or others, you must reach out to emergency resources.

But, when they are not an immediate threat, your willingness to courageously walk through the darkness with them may be what leads them to heal. 

If you would like more education on asking about suicide, go to the QPR Institute, Living Works, American Foundation for Suicide Prevention (AFSP), or the International Association of Fire Fighters (IAFF) Peer Support program. Lastly, thank you to Dr. Spencer-Thomas for her help on this work. Please visit her website, https://workplacesuicideprevention.com/

Dena Ali is a captain with the Raleigh, NC Fire Department where she has worked her way up the ranks. Ali has a degree from North Carolina State University and an MPA from the University of North Carolina—Pembroke, where her research focused on firefighter suicide. She received the NC Office of State Fire Marshal Honor, Courage, and Valor award in 2018 for her steadfast effort to bring awareness to firefighter mental health through her vulnerability. She is an advocate of awareness, education, and understanding of mental health disorders and suicidality. She speaks locally and nationally on these topics and is a QPR Suicide Prevention Gatekeeper Instructor and is the founder and director of North Carolina Peer Support where she helped to develop their statewide curriculum. She is also a founding member of the Carolina Brotherhood, a group of cyclists/firefighters in North Carolina who honor the fallen and their families annually.

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