Tell, ask, listen, keep safe
Reprinted from "Young People: Self-Injury" issue of Visions Journal, 2017, 13 (2), p. 35
The Canadian Mental Health Association (CMHA) BC Division recently received a grant from the BC Ministry of Health to bring suicide prevention training to communities throughout the province. In collaboration with the BC Crisis Line Network, the First Nations Health Authority and other community organizations, the CMHA’s Community Gatekeeper Training Project intends to train 20,000 British Columbians in basic suicide prevention. That includes knowing what to look for to determine if a person is thinking about suicide, learning how to ask the person directly about this and knowing what to do if the person is indeed at risk of taking his or her own life.
But wait a minute, you say: What does suicide and suicide prevention have to do with self-injury?
It’s a good question. Self-injury is usually not about suicide at all. Instead, it is a way to deal with painful or challenging feelings. But it is not always possible to know the purpose of someone’s behaviour without first talking with the individual about this, taking time to listen and understand the reasons and intention behind the person’s actions.
Most of the time, self-injury functions as a coping mechanism—albeit a maladaptive one. But we know that sometimes the psychological struggle or emotional pain that led to an individual’s use of self-injury may also lead him or her to see suicide as an option, especially if for some reason self-injury no longer works to alleviate the individual’s distress, or if the distress increases in severity.1,2
The practice of self-injury may over time serve to habituate the individual to acting in ways that are self-destructive, enabling him or her to more easily engage in increasingly dangerous behaviour. In some cases (certainly in the case of cutting, one of the most common forms of self-injury), self-injury itself can cause severe or even lethal damage, even if that was not the intended outcome.
There may also be a good deal of shame, secrecy and self-isolation associated with self-injury. Not only can this add to the emotional pain a person carries but it also makes it more difficult for the individual to reach out for help if problems multiply. Feeling alone, ashamed, hopeless and helpless are states often associated with suicidality.
In fact, young people with a history of nonsuicidal self-injury (NSSI) are nine times more likely to report suicide attempts of their own and six times more likely to report a suicide plan for themselves.3 From this, we can assume that someone who self-injures might be thinking about suicide in one way or another. The only way to find out for sure is to ask. This is where suicide prevention training comes in. It helps us become more comfortable with knowing what to look for that might indicate someone is at risk, how to ask directly and specifically about suicide and what to do if we discover that the individual is indeed thinking of suicide as a possibility.
The half-day safeTALK workshop developed by LivingWorks Education is currently being delivered throughout BC as part of the Community Gatekeeper Training Project. It teaches participants to use four simple steps to talk with someone about suicide: tell, ask, listen and keep safe.
Briefly, if we are thinking about suicide as a way out of our own pain or turmoil, we need to tell someone. If we are concerned that someone else may be thinking about suicide, we need to ask the individual about it, clearly and directly, so that he or she can tell us. We then need to listen carefully, long enough to learn more about what the person is going through. Then, if the person is indeed thinking about suicide and based on what we’ve learned, we need to help the individual find supports and resources to keep safe for now.
What if an individual is engaged in self-injury but not thinking about suicide? Will discussing suicide lead the person to think about suicide or cause the individual to be offended?
Experts agree that discussing suicide with an individual does not suddenly open up the individual’s mind to the previously unconsidered possibility of suicide as an option.4 Instead, discussing the matter shows the individual that you care enough to notice their distress and ask about it. Beginning this dialogue can lead to the possibility of help.
On the off-chance the individual is offended by your questions, you can respond by assuring the person that your questions come from a place of care and concern. You might even take the opportunity to talk about what the individual could do if things ever got so bad that suicide seemed like a possibility. It will still be important to provide a compassionate listening ear and to provide resources (particularly if we know the individual is engaging in NSSI), and to let the individual know that if he or she starts thinking about suicide, help is available. A good first step can be the province-wide 24/7 helpline 1-800-SUICIDE (1-800-784-2433), a family physician, a walk-in clinic or a local mental health resource.
In addition to safeTALK, the Community Gatekeeper Training Project also offers Applied Suicide Intervention Skills Training (ASIST). ASIST is a two-day interactive workshop in suicide first aid. It provides a more in-depth look at suicide prevention, including how to develop a collaborative plan to help someone keep safe and how to use brief intervention as a way to ensure an individual’s immediate safety until longer-term options for well-being can be established. Brief intervention might include collaboration to reduce or limit the individual’s access to lethal means, encouraging the individual to agree to limit or not use alcohol and other de-inhibitors in the short term, and ensuring that the individual is not alone until the immediate crisis passes or alternative supports and resources are put in place.
In 2015, 614 British Columbians died by suicide.5 Each death devastated the lives of many more—spouses and lovers, family members, friends, colleagues, teachers, coaches, helpers. These deaths are particularly tragic because suicide is for the most part preventable.
Suicide prevention is everybody’s business. Anyone can learn how to help another individual, whether it is someone close or a stranger who may be at risk. If you want to participate in a workshop or help bring a workshop to your community or workplace, contact one of our five regional coordinators for the Community Gatekeeper Training Project. Regional coordinators can help plan and organize a workshop for your community, workplace or organization, and can advise you of public trainings you could attend in your area.
Vancouver Island: Judy North at email@example.com
Lower Mainland: Steve Baik at firstname.lastname@example.org
Interior: Shannon Hecker at email@example.com
North: Devon Flynn at firstname.lastname@example.org
Kootenays: Lyle Stuart at email@example.com
For more information on self-injury and recovery, see the Cornell Research Program on Self-Injury and Recovery at www.selfinjury.bctr.cornell.edu.
As the provincial manager for the Community Gatekeeper Training Project, I am always very pleased to answer questions and talk with people about how they can help build suicide-safer communities throughout our province. You can reach me at firstname.lastname@example.org or 604-688-3234 (or toll-free at 1-800-555-8222), local 2714.
To learn more, see www.cmha.bc.ca/communitygatekeeper.
About the author
Dammy manages CMHA’s Community Gatekeeper Training Project. She is a therapist, former manager of SAFER (Suicide Attempt Follow-up Education & Research), past President of the Canadian Association for Suicide Prevention, and co-author of Strengthening the Safety Net: Report on the Suicide Prevention, Intervention, Postvention Initiative for BC
Hawton, K., Zahl, D. & Weatherall, R. (2003). Suicide following deliberate self-harm: Long-term follow-up of patients who presented to a general hospital. British Journal of Psychiatry, 182(6), 537-542. doi: 10.1192/bjp.182.6.537.
Klonsky, E.D., May, A.M. & Glenn, C.R. (2013). The relationship between nonsuicidal self-injury and attempted suicide: Converging evidence from four samples. Journal of Abnormal Psychology, 122(1), 231-237.
Tracy, Natasha. (n.d.). Self-harm and suicide: Can self-injury lead to suicide? www.healthyplace.com/abuse/self-injury/self-harm-and-suicide-can-self-injury-lead-to-suicide/.
Dazzi, T., Gribble, R., Wessely, S. & Fear, N.T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361-3363. doi:10.1017/S003329171400129.