8 reaching out responding to suicidal people by joel fay

Reaching out: Responding to suicidal people AUTHOR Joel Fay Joel Fay is a Psychologist practicing in Marin County, USA, and a retired police officer with over 30 years of experience working as an emergency responder. He is a founding member of the First Responder Support Network (www.FRSN.org), a lead clinician with the West Coast Post-trauma Retreat (www.wcpr2001.org), and is actively engaged with the first responder community. He can be contacted by email: joel.fay@gmail.com This article provides an overview of a line of enquiry that is used by crisis intervention officers throughout California when responding to people who are suicidal.

Keywords: suicide, emergency responders, negotiation

THE INTERNATIONAL JOURNAL OF NARRATIVE THERAPY AND COMMUNITY WORK 2014 No.2 www.dulwichcentre.com.au

Page 49

INTRODUCTION

ambivalence into the conversation. To develop the questions I relied on my work as a therapist which has been greatly influenced by the work of David Epston and Michael White.

At about 7:30am, a bicyclist commuting into San Francisco reported to the Golden Gate Bridge patrol that a woman had climbed over the railing and was standing on the cord of wires that runs alongside the bridge. She was obviously distressed and was one step away from a 300 foot fall into the Pacific Ocean.

The officers who responded worked for the California Highway Patrol and were part of a select group of officers who respond to suicidal people on a regular basis.

In Edwin S. Shneidman’s book, The suicidal mind (1996), he discussed the ten commonalities of suicide. He felt that these factors were often present in a suicidal person. The commonalities are helpful in thinking about suicide, and I utilised these factors in creating a practical and straightforward negotiation guideline that I hoped would be easy to learn and apply in the field. I utilised the commonalities as a starting place to develop the questions.

The Golden Gate Bridge is the most popular suicide location in North America and the second most popular suicide site in the world, with many successful suicides each year and many more prevented suicides. According to the California Highway Patrol (personal communication, October 2013), at the time of this article there have been approximately 40 successful suicides and over 100 prevented suicides in 2013.

Over the years, some questions have been modified or eliminated and more useful questions added. Obviously, as with any intervention, there is no substitution for good clinical (or officer) judgement. It is important to be careful when asking questions and to pace the questions with the effect the person is able to tolerate.

In 2001, shortly after the events of 9/11, the California Highway Patrol was assigned the task of protecting the Golden Gate Bridge from terrorist attacks. To accomplish this task they patrolled the bridge on car, bike and foot. While they fortunately have never encountered any terrorists, they did encounter many suicidal people. The officers realised they were being asked to perform a community service in negotiating with suicidal subjects but did not have appropriate training.

I was asked to provide training to the California Highway Patrol regarding metal illness and negotiations with suicidal subjects. My background as a police officer, psychologist and a trained crisis negotiator helped me develop a protocol that has been found to be useful. My work as a coordinator for the County’s Crisis Intervention Program provided me with the opportunity to speak with hundreds of suicidal subjects. I am also the Clinical Director for the First Responder Support Network, a residential program that treats first responders for Post-Traumatic Stress Disorder.

The ideas contained in this article come from these experiences and the conversations I have had with many crisis intervention officers.

Please note that this article is not intended to be an exhaustive review of suicide literature but rather a brief explanation of a way of talking with people who are experiencing suicidal ideation with the hope of creating ambivalence towards the suicidal act.

The analogy I use when I teach suicide negotiations is that of a door, slightly ajar. If the person is still alive, the door is still open and there is a chance to help. Our job as negotiators was not to fix the person’s problems but rather to convince the person that committing suicide today might not make the most sense.

Our task was to open the door further and to make room for ambivalence to enter the conversation. Since suicidal people are often not thinking rationally and are frequently convinced that suicide is the only way out of their predicament, our job as negotiators is to introduce ambivalence and help the person think more rationally about the decision to commit suicide.

The questions are asked with the intention of contradicting the person’s inescapable conclusion that suicide is the only possible course of action open to the person.

The ideas are simple and the questions are designed to introduce

I decided to arrange the questions under some of the suicide commonality categories. Where appropriate, I added a brief explanation of a category. The primary purpose of listing them under a category was to provide a sense of structure for the officer engaged in the intervention. Obviously many of the questions could fit under multiple categories.

The categories and questions are:

1. Seeking a solution a) ‘Why are you here?’ b) ‘What were you hoping to resolve as a result of your suicide?’ c) ‘Can you think of any way that committing suicide would not be helpful?’ d) ‘What aspect of your life is causing you the most difficulty now?’ e) ‘What else have you tried to overcome the problems?’ f) ‘What do you think kept those solution attempts from being successful?’ g) ‘So let me see if I understand this, you are planning to kill yourself because you can’t find a job (your husband is leaving you, etc.)?’

2. Cessation of consciousness.

The cessation of consciousness is closely related to ending the unbearable psychological pain they are experiencing (see #3). A suicidal person may think, ‘If I could just find a way to not have to think any more’. a) ‘I know you are hoping that once you are dead you won’t have to think about all the pain, but what do you think the people left behind will be thinking?’

3. Unbearable psychological pain Most people I have interviewed after they attempted suicide have said something similar to, ‘Not committing suicide wasn’t an option’. They tried to manage the problem, their coping strategies have failed and they were out of ideas. Sometimes this can occur catastrophically and happen within just a few hours. a) ‘You’re obviously in a lot of emotional pain. Could you help me understand what you are experiencing?’

THE INTERNATIONAL JOURNAL OF NARRATIVE THERAPY AND COMMUNITY WORK 2014 No.2 www.dulwichcentre.com.au

Page 50

b) ‘Could you tell me what is happening?’ c) ‘Do you want the bad feelings to go away or do you want to die?’

4. Frustrated psychological needs/hopes The suicidal person may want to be in a relationship or want to physically feel better, or perhaps they reached a place in their life where they feel there is no meaning to their existence. These questions are designed to draw out that information. a) ‘If something could be added (or taken away) from your life that would stop you from committing suicide, what might that be?’ b) ‘Have you ever had … (love, meaning, etc.) in your life?’

If yes, ‘When? Tell me more about that. What were you doing to achieve that?’ c) ‘How might that happen (it being added or subtracted)?’ d) ‘Aside from your death, what are you hoping your suicide would accomplish?’

5. Ambivalence.

There is a saying on the Golden Gate Bridge, ‘Jumpers don’t talk and talkers don’t jump’. While this isn’t necessarily true, it does separate the people who drive to the bridge, walk onto the span and jump without hesitation, from the people who climb over the railing and hang on in terror, seeing no way back and no reason not to jump. There are many stories of negotiations that went on for hours with the suicidal person turning to the officer and saying something like, ‘You have been very kind, but I need to go now’, and then jumping. But in general, if you can engage someone in a conversation, you have an excellent chance of convincing that person to try living at least one more time. a) ‘What would you need to know or feel that would convince you to live?’ b) ‘Tell me about the part of you that isn’t sure about committing suicide.’ c) (If they say, ‘There is no part’ respond): ‘There is always a part, even if it is only 1%. If I could talk to that “1%”, what would it be telling me about you or the problem?’

6. Hopelessness a) ‘I imagine that you must be feeling very hopeless right now, but do you know that most people who attempt suicide and survive, never attempt suicide again. Why do you think that happens?’ b) ‘What might you say to your brother, sister, friend, who was in the same position you are in today?’

7. Constriction It has been my experience that when people are suicidal they have difficulty thinking about options. The belief develops that suicide is the only solution to the problems they face.

These questions are designed to understand the nature of the individual’s constricted thought process and to look for ways to open their thinking to other possibilities. a) ‘Why do you think …?’ (Or, How did you come to think) • ‘There is nothing else to do.’

• ‘The only way out is death.’

• ‘The only thing I can do is kill myself.’ b) ‘Where do those beliefs come from?’ c) ‘How were these ideas introduced into your life?’ d) ‘How have you been able to resist those ideas until now?’

suicide?’ b) ‘What do you think you would lose?’ c) ‘What do you think the people who know you would lose?’

9. Lifelong coping styles We all have coping patterns that we develop over our lifetimes.

One of my coping strategies is to exercise. But I also know that when I am stressed and feeling overwhelmed, exercise tends to be the first thing I give up. By understanding how people cope with stress we can help connect them to their usual coping strategies. a) ‘What else have you tried to ease the pain?’ b) ‘Have you felt this way before? What stopped you then?’ c) How have you coped with other setbacks? d) ‘It appears that these problems have been going on for some time, what skills/traits/beliefs have you relied on to cope this far?’

10. Protective Factors Research tells us that people who have certain characteristics are less likely to attempt suicide. Some of these traits include hopefulness, self-efficacy, coping skills and social support (Kaslow et al., 2002). In this category I was looking for questions that would get the person to focus on these protective factors not mentioned in other categories. a) ‘How do you think your suicide would affect your family?’ b) ‘How do you think your suicide will affect other people?’ c) ‘Who do you think would miss you the most?’ d) ‘Who do you think will be most affected by your death?’ e) ‘Did you know that if you commit suicide you greatly increase the risk of your children committing suicide?’ f) ‘What if tomorrow ...?’

11. ‘Closing’ question For a brief period I worked in sales and was told that it was important to ask for the sale a number of times during your contact with the potential customer. Some ‘sales trained’ people might think of this question as a closing question. The type of question that will make the suicidal person say, ‘Okay, not today’.

The officers working on the bridge have found the following type of statement useful.

• ‘The bridge will be here tomorrow, why not allow us to help you today, you could always come back.’

The following vignette demonstrates how this line of enquiry can be used. Negotiators always work as a team. Speaking to a suicidal person is intense work. You are very focused on what the person is saying and at the same time thinking about your reply. A life literally hangs on your every word. Being so focused, it is easy to miss some of what is being said or expressed non-verbally. The back-up can be there to point these issues out to the primary negotiator.

When the officers first contacted Mary she wouldn’t talk to them.

Officer: ‘Hi, my name is Bob and I am an officer with the Highway Patrol, I can see how upset you are and I am here to help you.’

Mary did not respond.

8. Escape a) ‘What do you think you would accomplish by committing

Officer: ‘Can you tell me your name. I really want to help.’

THE INTERNATIONAL JOURNAL OF NARRATIVE THERAPY AND COMMUNITY WORK 2014 No.2 www.dulwichcentre.com.au

Page 51

Mary:

‘I didn’t ask for your help.’

Officer: ‘I know but now I am here so we might as well talk.’

Mary:

‘You don’t care if I die. You are only here because it is your job.’

Officer: ‘That is true that this is my job but I am a senior officer and I have a lot of options for work assignments. I work the bridge because I care about people and I am at a point in my career that I’d rather help someone than arrest them.’

Mary:

‘You can’t help me. Can you get me a job?’

Officer: ‘No, I can’t get you a job but I can talk with you about what is happening in your life that brings you here and maybe together we can come up with a plan.’

Mary:

‘I don’t think that would work.’

Officer: ‘It may not but maybe we could start with you telling me your name.’

Mary:

‘My name is Mary.’

The officers were able to find out that Mary had been a successful business woman whose business had failed and who was experiencing a difficult time finding a job in a down economy.

In response to the officers’ enquiries she told them that she was married and had a ten-year-old adopted daughter.

The officers asked Mary what she hoped her suicide might accomplish. She told them that ever since her bankruptcy she considered herself to be a burden on her family and her inability to find a job demonstrated her lack of self-worth. The family was in danger of losing their home. She told them that she had life insurance and that she had checked and it would be paid out even if she died by suicide.

They asked her how she came to believe that being unemployed meant she was worthless, and they shared some personal stories of times in their lives when they had been unemployed. One of the officers described graduating from college with a degree in criminal justice and looking for a job. ‘I spent almost two years trying to find a job and was turned down by several agencies.

Some weren’t hiring, or hired someone they thought was more qualified. My dream was to be an officer and the best I could do was find a job working security.’

Mary listened very attentively as the officer described the two years of self-doubt, disappointment and discouragement. While she wasn’t ready to climb back over the bridge railing, she was paying attention. The officer explained that every time he was turned down he felt so dejected and found it harder and harder to get ‘up’ for the next interview. The officers knew they were making progress when Mary began asking them questions.

‘Why didn’t you give up?’ she asked. ‘Did you ever believe that you would never achieve your goals?’

The officer answered these types of questions with a similar theme. He said, ‘I had the belief that if I didn’t give up on myself, something would shift and it did.’

Mary still wasn’t ready to climb back over the rail, but she was talking and listening. When asked, ‘Who do you think would be the most affected by your suicide?’ Without a moment’s pause she replied with an air of certainty and conviction, ‘I don’t think anyone would be very affected’.

To contradict her conviction, the officer asked her if she truly believed her daughter would not be affected by her suicide. She replied that her daughter loved her husband and would therefore be okay. They asked Mary if she thought her daughter valued money more than she valued her mother.

Officer: ‘How can you be so sure that your ten-year-old daughter who was chosen by you to be a part of your family would take your suicide as not having anything to do with her?’

He added, ‘I have unfortunately been required to make many death notifications during my career and I have never known a child who did not blame themselves after a parent’s suicide. They usually say or think, ‘It must have been because I wasn’t good enough today, or because I lied about brushing my teeth. That is why mom killed herself.’

He continued, ‘I’m a dad and I think that children naturally think that the world revolves around them. I don’t believe a ten-yearold is capable of believing that her mother committed suicide because she couldn’t find a job and it had nothing to do with her.’

Mary insisted that her daughter loved her husband as much as her and for that reason would not be left on her own or take on the blame and therefore would be okay.

In what appeared to be crucial in bringing ambivalence into the conversation and seeding some contradiction to Mary’s convictions, the officer asked Mary, ‘Do you think your daughter values money more than she values having a mother? Do you think your daughter would be willing to never see you again as long as she received a cash payment upon your death?’

The officer turned to his back-up officer and said, ‘I don’t know about you but I wouldn’t sell my mother for all money in the world.’ The other officer nodded in agreement.

While tearful at this point, Mary still wasn’t ready to climb back over the railing. The officers were able to introduce further contradictions to Mary’s convictions by asking a number of questions including, Officer: ‘Did you know that if you commit suicide you greatly increase the risk of your children committing suicide?’

Mary:

‘That is bullshit. You are just saying that.’

Officer: ‘No it is true. This happens because by taking your own life you have demonstrated that suicide is an option when coping with difficult feelings. It also breaks the taboo on suicide in your family. I am not making this up. We learned about this in training classes (Wilcox et al, 2010) and it makes sense to me. I know that if you smoke when your kids are growing up, they are more likely to smoke. That’s why I stopped. Why wouldn’t I assume that committing suicide would have a similar affect?’

THE INTERNATIONAL JOURNAL OF NARRATIVE THERAPY AND COMMUNITY WORK 2014 No.2 www.dulwichcentre.com.au

Page 52

A quizzical and perplexed expression came over Mary’s face as she scrutinised the faces of the officers who remained steadfast in their conviction based on research evidence which directly countered her belief that everyone would be better off if she were dead.

‘Who do you think would miss you the most?’ the officer asked.

Mary now willingly acknowledged that her ten-year-old adopted daughter would likely be the most affected. And now that she knew about the increased risk of her daughter committing suicide, she was certainly having second thoughts about pursuing this attempt much further.

They followed up by asking her, ‘What if you got a job tomorrow, would you still want to die?’

Mary said she would probably want to live. The officers kindly joked with her and said that if things were still bad a month from now she could always come back. ‘The bridge isn’t going anywhere!’ Mary agreed to climb back over the railing.

The officers helped her over and almost immediately she began crying and thanked them for being there. She continued shaking her head and repeating to them, ‘I was really going to do it. I wasn’t faking it, you know. I wasn’t seeking attention just for the hell of it.’

The officers reassured her that they had no doubt that, if they hadn’t met and together talked the matter through carefully and thoughtfully, she may very well have ended her life. The entire interaction took about an hour from first contact. The officers said that as they asked the questions they could see by how she looked at them that she was growing more ambivalent about her decision to kill herself.

While this line of enquiry was developed for law enforcement suicide negotiations, I have used the same questions in my practice when speaking with suicidal clients. I found that although I have spoken with hundreds of suicidal people as an officer and negotiator, it is very different when sitting in front of someone in your office who expresses suicidal ideation and intent. Like other therapists, I have struggled with the idea of calling the police and having the client placed on a hold. I worried that doing so could damage the clinical relationship and worried that not calling the police could allow the client to suicide. I have experienced a number of sleepless nights hoping I made the correct decision.

One word of caution, if you are going to negotiate with suicidal people, it is important to remember that not everyone will be saved and I tell negotiators, ‘You get to save some of the people some of the time and it never gets better than that’. I know from personal experience that even well trained and experienced negotiators ‘lose’ one every once in a while. It is hubris to believe that as a trained negotiator or clinician you can tell when someone will really kill themselves. I have found that the people who lie the best are sometimes the people who have truly made up their mind to die.

The purpose of this article was to provide an overview for a line of enquiry that has been shown to be helpful. It is my hope that you find these ideas useful and easy to adopt. The model is widely used by crisis intervention officers throughout California. I am sure that most readers of this article would be able to come up with many new and useful questions. I welcome your ideas as the guide is continually changing.

References

Kaslow, N., Thompson, M., Okun, A., Price, A., Young, S., Bender, M., Wyckoff, S., Twomey, H., Goldin, J., & Parker, R. (2002). Risk and Protective Factors for Suicidal Behavior in Abused African American Women. Journal of Consulting and Clinical Psychology, 70(2), 311–319.

Shneidman, E. S (1996). The suicidal mind. New York, NY: Oxford University Press.

Stanford, E. J., Goetz, R. R., & Bloom, J. D. (1994). The No Harm Contract in the Emergency Assessment of Suicidal Risk. Journal of Clinical Psychiatry, 55:344–348.

Wilcox, H., Kuramoto, S., Lichtenstein, P., Langstrom, N., Brent, D., & Runeson, B., (2010). Psychiatric Morbidity, Violent Crime, and Suicide Among Children and Adolescents Exposed to Parental Death. Journal of the American Academy of Child & Adolescent Psychiatry, (49), 5: 514–523.

Like all clinicians I have to rely on my instincts and clinical judgement. I find it isn’t always an easy decision. One strategy I use is the use of a ‘no suicide, no self-harm’ contract. In utilising this intervention a clinician may ask a client, ‘Can you promise me that you will do nothing to harm yourself unless you and I get to talk first. Just sending me a text message does not count as talking with me.’ I am sure most readers are very familiar with this strategy and are aware that the literature is mixed on the practice (Stanford et al., 1994) but I have found it useful in my practice. First I have found that clients do take it seriously, and at times I will write down a formal contract that we both sign. I have had clients tell me that they did think of hurting themselves but didn’t want to violate the contract. But I also use the contract to look for the people who are unwilling to comply. As an example, a client might say, ‘Joel, I can’t promise that to you’. Those are the clients for whom I get emergency help.

THE INTERNATIONAL JOURNAL OF NARRATIVE THERAPY AND COMMUNITY WORK 2014 No.2 www.dulwichcentre.com.au

Page 53

DEAR READER This paper was originally published by Dulwich Centre Publications, a small independent publishing house based in Adelaide Australia.

You can do us a big favour by respecting the copyright of this article and any article or publication of ours.

The article you have read is copyright Š Dulwich Centre Publications Except as permitted under the Australian Copyright Act 1968, no part of this article may be reproduced, stored in a retrieval system, communicated, or transmitted in any form or by any means without prior permission.

All enquiries should be made to the copyright owner at: Dulwich Centre Publications, Hutt St PO Box 7192, Adelaide, SA, Australia, 5000 Email: dcp@dulwichcentre.com.au Thank you! We really appreciate it.

You can find out more about us at:

You can find a range of on-line resources at:

You can find more of our publications at:

www.dulwichcentre.com.au

www.narrativetherapyonline.com

www.narrativetherapylibrary.com

THE INTERNATIONAL JOURNAL OF NARRATIVE THERAPY AND COMMUNITY WORK 2014 No.2 www.dulwichcentre.com.au

Page 54