A gentleman went in for treatment of an illness that doctors said would result in losing his eyesight. He was not working, he had money problems from a divorce, and he was questioning what was left for him.
The social worker involved in the case had training, said Virna Little, and very specifically said to him: "Many people who are experiencing what you are experiencing die by suicide. Are you thinking of suicide?" The man responded: "Yeah. I think about suicide a lot. I was planning to die this weekend."
He did not go through with his plan, said Little, LCSW, PsyD, director for clinical innovation at the Center for Innovation in Mental Health at the City University of New York Graduate School of Public Health and Public Policy.
She added that stories like these are becoming more common as outreach positively affects more people. And most important for providers is: "You don't know anything unless you ask."
Suicide rates are rising in nearly every state in America. Many of these deaths are preventable if everyone from family to friends to health-care providers asks the right questions, uses the right language, and helps them get the right care.
A Leading Cause of Death
Nearly 45,000 Americans age 10 and older died by suicide in 2016, making it one of the leading causes of death in America. And the suicide rate is rising, the Centers for Disease Control and Prevention states in its Vital Signs report in June, which compares the data with statistics from 1999.
Suicide rates per 100,000 residents increased in nearly all states, the report says. State increases ranged from just less than 6 percent in Delaware to more than 57 percent in North Dakota, and 25 states had suicide rate increases of more than 30 percent compared with 1999.
Suicide is rarely caused by any single factor, and more than half 54 percent of those who died by suicide did not have a known mental health condition, Vital Signs states.
In a 2015 report, the CDC's National Violent Death Reporting System states that 44,000 people died by suicide, while "homicide claimed over 17,000 people."
When talking about suicide, word choice is important, said Kimberly H. McManama O'Brien, LCSW, PhD, a psychiatry instructor at Harvard Medical School, a research scientist in psychiatry at Boston Children's Hospital, and an Education Development Center research scientist.
The word suicide can be used, but avoid the word commit, she said.
"The word commit is more punitive," O'Brien said. "It's important not to use it. Use 'kill yourself' or 'die by suicide.'"
Little said the word commit also has legal implications or can indicate guilt. And do not use the words successful or unsuccessful with suicide attempts, she added. "That is a really inappropriate way to talk about it."
Why do people kill themselves? "That's different for every person," O'Brien said.
It is not always related to stress, but when it is, it's typically not just one stressor. It can be multiple sources of stress with a lot of interpersonal factors on top, she said.
"They can have a hard time tolerating stress, and they can feel hopeless, trapped in a situation they can't get out of," O'Brien said. "It's different for all people, and you always have to see it with a developmental lens, because stressors are different with teens and older adults, and the way they cope is different as well."
For developmental reasons, teens lack the ability for abstract thought, she said. "They can't see a future that's better, because they can't see any other way things could be."
Bullying is sometimes a factor for adolescents, said Little, and with men particularly those from 47 to 62 years old a medical diagnosis might be what causes them to consider, attempt or complete suicide.
Employment, or the lack of it, money, and substance abuse also can be reasons, said Little, who holds a research faculty position in the CUNY School of Public Health and received the NASW Foundation's Knee/Wittman Outstanding Achievement Award this year.
Jerry Reed, MSW, PhD, senior vice president for practice leadership at the Education Development Center in Washington, D.C., where he directs its suicide, violence and injury-prevention portfolio, said suicides are rarely attributable to a single event and usually are the culmination of events over a lifetime.
"It can be one event that's one event too many," he said.
Picture a glass of water sitting in a sink with single drops dripping in at a time, Reed said. One day, one drop hits the glass and it spills over.
"Usually, people don't want to die by suicide, they just want to end their pain," he said. "We want to catch people and alleviate that pain so they don't turn to lethal means and make the decision to end their life."
Suicide in youth is generally more impulsive, Reed said.
"Sometimes a bad event is overplayed in their mind," he said. "It's seen as more consequential than it is, because youths are still learning about life. Older adults, those 65 and over, are far more intentional."
For every four suicide attempts in older adults, there is one completion. For younger people, there is one completion for every 200 attempts. But you have to take every warning of suicide seriously, Reed said.
Professionals do not know the reasons for the rising numbers of suicides, O'Brien said.
"It's a puzzle to everybody," she said. "Ultimately, we don't know why. Researchers all have different theories, but there's no actual answer we know definitely."
Is the current state of the country and the world a factor in more suicides?
"I get asked that a lot," Reed said, noting the early 2000 recession that reduced economic stability and jobs; the drying up of jobs in industries like mills, mines and factories; the fact that our nation has been at war for decades; and more people seem isolated now.
"I think it's a lot of things coming together," he said. "We have to respect the fact that we are all human beings on the same planet."
O'Brien believes how people perceive and react to what's going on in the world could be a factor in the rise in suicide rates.
"We're in a culture of fear, and there are tons of stressors," she said. "In the digital world, information is coming at us all the time. It's so quickly sent to us, and it's so good and so bad. Life is just harder now for people, some would argue. It's a strain if we have all these different stressors coming at us all the time."
Little noted two high-profile celebrity deaths in June: Chef Anthony Bourdain and fashion designer Kate Spade. "We always see an increase after celebrity suicides," she said.
Reed said there can be an effect from media coverage when celebrities kill themselves, and the deaths should not be romanticized in any way nor should the means be mentioned.
Many people will articulate thoughts of suicide, Little said. "They'll say they've been thinking of dying or they'd be better off dead. Sometimes you see they've written letters or posted something on social media about dying or suicide particularly adolescents."
One man recently made arrangements for a person to take his tools, she said, adding that if someone mentions they've been thinking about suicide, talk to them.
"Do not minimize it," Little said. "Don't think it's not serious or try to dismiss it. Take it seriously and say ÔI'm very concerned about you.' Connect them with a lifeline get them help."
Even if they haven't said anything but you suspect something, ask, she said.
"I always tell people ask what you want to know," Little said. "Asking questions like how are you doing are not really getting to that person, and it's not getting them help if they really need it."
O'Brien agrees the person should be asked openly and directly, and she said it's important to say "I'm concerned about you" so they know you care. "You need to be ready to accept the answer without saying 'you don't want to do that.'"
Warning signs can include changes in functionality, changes in energy levels or moods, visible stress, substance use and nonsuicidal injuries like cutting themselves.
"The key is, if it's someone you know well and they seem not quite themselves and that concerns you, ask," O'Brien said. "Insist on finding out."
And always ask if they have access to firearms, she added.
Reed said isolation is almost a universal risk factor, and research shows that asking directly about suicide can help because it conveys a message of caring and assistance.
"It is a very, very helpful intervention for someone struggling with pain, and it can help alleviate that pain," he said.
Assessments and Screenings
Little is actively working in health care settings, where one thrust is to develop what is done in primary care when someone comes in to see a doctor and is given the PHQ-9, the ninth version of the Patient Health Questionnaire. An indicator of risk, the questionnaire asks if the person is feeling sad or hopeless. Anyone can take the questionnaire, which is available online.
For minors, the DSM-5 is a depression diagnostic considered as the Bible for mental health providers, she said.
Little developed a screening protocol implemented at the Institute in 2015 she calls "a catch/notification for professionals, an alert that interventions might be necessary."
"We took some existing tools and built a comprehensive suicide pathway to be incorporated in health care records," she said. "One thing that's important to understand is, even if a patient is not getting services for mental health, they're still getting medical services for things like diabetes."
Once risk has been reported, when a patient's record is opened and that risk is on record, the whole top of the record turns red.
"Then providers can assess for risk every time those patients can come in," Little said. "With the combination of other tools, it helps us care for people at risk and identify them. They should still be asked about certain prescriptions they have to find out if they have access to those legal means."
Other tools include Zero Suicide principles, she said.
O'Brien was co-presenter at a 2013 NASW Specialty Practice Section presentation, Prevention and Intervention with Suicidal Youth: Schools, Hospitals, and Outpatient Settings; the presentation includes numerous resource links.
For those with known risk, safety planning is essential.
"The critical thing we need to do for all is something that's done a lot clinically and not yet empirically based: safety planning," O'Brien said.
The steps include sitting down with the individual and working together collaboratively; figuring out a person's warning signs for suicidal thought; identifying people who can help and ways the individuals can help themselves; listing therapeutic and emergency resources they can contact; discussing actions they can take to make their environment safer so if suicidal thoughts arise, they can't act on them; and making a list of reasons to live.A National Public Radio story on July 26 used CDC data from 2006 to 2016 to report that roughly 218,000 Americans ended their lives in that period by using a firearm.
"Right now, perhaps the most important prevention we're doing has to do with means safety," O'Brien said. "If somebody owns firearms and is having suicidal thoughts, ideally they should remove the weapon from their home. If they're not willing, they can lock it in a lock box."
Little said if pictures of family members and loved ones are attached to the lock box, that can help someone avoid an impulsive act. And if suicidal thoughts arise, they should "do something quickly," like calling someone or going to Walmart where it is always open and there are people around.
"One of the most important things is hope giving someone hope," she said. "If someone says 'I have hope for you,' it is one of the most effective things you can do."
Reed is an advocate for the importance of both a public health and mental health approach to injury, violence and suicide prevention.
"We generally view through the lens of mental health when we look at suicide prevention," he said. "We see it as a health condition, which it certainly is. There's also a very strong piece to be played in public health. If you look at means, many die by lethal means, and if you can stop those, you can save lives."
Lethal doses of medicine should be removed from medicine cabinets, poisons should be removed from under the sink, and guns and ammo should be stored separately, he said.
More funding is needed for research and for prevention in communities, Reed said.
"Most people decide to kill themselves and within one hour take action," he said. "We have an hour to intervene. I believe we have time to change a life."
Training in communities is important so people know how to identify potential problems in those they know and care about and know what to do, Little said.
If you know a person who is not going to a mental health provider or a youth who doesn't have access to health care, it's important to ask, and it's important to make sure young people have a number on their phone they can call, she said. There are dozens of apps, some that are more credible, and the help those can provide is "huge."
Social Work Role
Social workers can set the stage with young children in schools to provide them with social and emotional skills, O'Brien said.
"I think skills and resilience and learning how to talk with each other compassionately about somebody is very important," she said. "We need to incorporate it."
Those studying social work and those in the field have an ethical responsibility to be trained in this area, O'Brien said.
"It's imperative for them to do it, because it's something every social worker will encounter at least once in their lives," she said. "If they don't know how to deal with it and pass off a person to someone else, that makes matters worse."
Training in this area is not always required, so students should be told to seek it out, O'Brien said.
Those working in clinics can make sure new people are trained or get needed training and everyone is aware of new research and information, Reed said.
"There is always turnover, and there's always new science," he said. "We need to make sure new science and new practitioners are introduced to it so we're state of the art. That's what we do in other areas of care. Health is health, whether it's above the neck or below the neck."
Right for the Job
Social workers are especially qualified for this area because they are attentive to a client's mind, body and spirit, Reed said.
"I'm a very proud social worker, and my training taught me to see the individual and their environment and how we help an individual in that environment," he said. "We have a micro and macro perspective and the ability for policy advocacy. I think social workers are uniquely prepared to be active champions in this."
O'Brien was part of a study of children inpatients that involved interviewing teens after they tried to kill themselves. They asked them why.
"One of the things that came out of that was how important it was for them to feel listened to by professionals," she said. "I think we can't as social workers discount the importance of active listening. These teens know if people are listening to them."
If social workers can sit with them and empathically connect with them, they're doing the best work, O'Brien said.
"For them, it was very healing to be able to tell their story and be listened to," she said. "These kids need someone to ask them what makes you want to live. We need to flip the switch on suicide prevention. It's more about life promotion and life enhancement."