Sometimes we are our greatest "people problem" and we experience a deep suffering comprised of complex beliefs and feelings that make use turn on ourself. Suicidal Ideation occurs when the mind overrides the animal instinct to survive, unable to recognize the impermanence of the suffering, and begins considering death as a reasonable solution to end that suffering. Suffering comes in many forms of dysregulated emotion, including depression (sadness), anxiety (fear), and hostility (anger/disgust); and it is usually a combination of many. When considering an individual's level of danger, remember that any level of suicidal ideation should be treated seriously and with compassion and support. A person in crisis with an assessment of "low" risk can quickly escalate to "medium" or "high" risk when treated discompassionately. Irregardless, every person you meet deserves to be treated with dignity, compassion, and basic decency.

WHAT IS RISK? Risk is the level of danger assessed to determine how likely a person is to harm themself. The term is used clinically to determine what type of treatment a person needs. Anyone experiencing suicidal ideation is "at risk of harm". To maintain safety, some people will require regular counseling or therapy (low risk) or intensive treatment multiple times per week (low to medium), while others might require inpatient treatment (high risk) or crisis intervention with on call access or daily check-ins (medium risk).

WHAT DOES BEING IN CRISIS MEAN? Crisis is the state of emotional dysregulation and/or dysfunction a person is experiencing and generally indicates "high" risk; but can also be during "low" or "medium" risk as well. A person is in crisis when they feel out of control with their thoughts, feelings, or behavior, and/or they intend to to harm themself or someone else, and/or they are unable to maintain their own basic needs (food, shelter, health, and safety). 

If you or someone you know is experiencing intrusive thoughts or impulsive feelings to harm themself or someone else, please utilize local crisis teams and national crisis lines for support and/or instruction. If you or someone you know has begun planning or preparing to harm themself or someone else, please go to the nearest emergency department for evaluation or call emergency services for an ambulance to go to the hospital. If the person is unwilling to cooperate, you can request that a designated crisis responder (DCR) complete a risk assessment (in WA State) and/or request law enforcement intervention (and they will contact the DCR) for an involuntary detention. Any involvement from law enforcement is for the security of the person being detained and any force used should only be used to prevent harm and may be court ordered by a DCR.

WHAT CONSTITUTES AN EMERGENCY? An emergent situation requires the IMMEDIATE intervention of a trained professional to prevent an active threat to safety. If you believe someone is going to harm themselves in the next 30 mins, CALL 911. This generally requires a response from law enforcement because they are both the fastest option and the most qualified for "hands on" intervention. It is NOT because anyone has done anything wrong. Again, any involvement from law enforcement is for the security of the person being detained and any force used should only be used to prevent harm and may be court ordered by a DCR.

Suicidal Thoughts

Suicidal ideation will often start as a fleeting thought that is sometimes unnoticed by the person experiencing it, and certainly goes unnoticed by the people around that person. Fleeting thoughts do not necessarily involve emotional anguish. It’s simply a thought, and generally it is dismissed as quickly as it presents. People can go their entire lives having fleeting thoughts and never harm themselves, but that doesn't mean suicidal thoughts are "normal" or "nothing to worry about". Opposition to our human instinct to survive against all odds is an indication of injury to the psyche and should be treated as any other injury that is sustained. And while fleeting thoughts are common and can be "low" risk, they should never be ignored. Fleeting thoughts will progress into intrusive thoughts or passive feelings which will progress into intrusive feelings. 

Any suicidal thoughts you have should be shared with someone you trust. Like a family member, a peer counselor, or a close friend. Talking about it can help uncover the root of the problem and reduce anxiety that these thoughts provoke. Mental Health Therapy is always an appropriate option even before fleeting thoughts are noticed.

Suicidal Feelings

Ignoring suicidal thoughts can lead to emotional anguish, but sometimes suicidal symptoms begin with emotional anguish before they become fully formed thoughts. The emotional urge to end your life, even without a thought is a suicidal feeling and it is a clear indication of a progressing problem. Generally thoughts grow into passive feelings, which will escalate and become intrusive thoughts and intrusive feelings which are often disturbing or startling and seem to torture the individual. Intrusive thoughts and feelings leading to impulsive ideas which are suicidal thoughts that occur during a random experience: seeing a knife and considering its use as a tool to harm oneself; driving across a bridge and considering how easy it would be to turn the steering wheel an go over the edge. Impulsive ideas can also lead to suicidal fixation or an impulsive act of suicide, which is the mind exploring ways to end one’s life with or without having to take action: praying for your life to end; hoping you will be killed; considering reckless options with death in mind. 

Any suicidal feelings should be addressed with a professional. Your doctor, a licensed counselor, or the local crisis team should be informed so the symptoms can be monitored for risk.

Development of a Plan

Untreated suicidal thoughts and feelings will likely lead to planning, preparation, and action. Thinking about suicidal behaviors with yourself in mind is called developing a plan. The development of a plan is an unequivocal indication that someone is in danger. Whether that comes from one’s imagination (ruminating thoughts) which can lead to impulsive action, or whether one seeks information (research) which leads to planned action. It’s important to know that these two escalations, impulsive vs. planned action, are not mutually exclusive. They can both occur in the same person. Planned action is the more lethal of the two, but both are very high risk. 

Developing a plan, either ruminating/intrusive thoughts or conducting research, should result in contacting your local crisis team for support and resources. It may also require intensive outpatient treatment, psychiatric treatment, and should involve Mental Health Therapy.

Intent to Act

Planned action increases in risk as the process progresses and the emotional anguish dissipates into a calm resolve. It begins with an intent to act, which leads to preparation, which can include research, purchasing, making arrangements for items, pets, and close relationships, and setting the scene.  It can be easy to believe that someone is ok when emotional anguish seems to go away, but it is a dangerous mental state to exist in. Identifying the signs of planned action is imperative and should prompt contact with the local crisis team. Purchasing or otherwise obtaining items allows someone access to means, which just means the materials are readily available for use to harm. But a purchase is not always necessary and sometimes the means are impossible to remove from someone's evironment, like a bridge, electrical cords, or medication. Intent to act WITH access to means together presents the highest level of risk. 

Intent to act requires stabilization on medication in a controlled environment to ensure safety of the individual during stabilization. Sometimes friends and family can provide the controlled environment with the support of local crisis authorities, but often times it requires inpatient psychiatric care.

 Intent to act WITH access to means will result in a completed suicide if ignored.

Impulsive Action

Impulsive action is an abrupt act of suicide that is less likely to be completed but will likely lead to damaging injuries that require medical intervention. Impulsive action usually occurs in the midst of severe emotional anguish and will often result in immediate regret, subsequent shame, and ongoing social embarrassment due to the stigma of suicidal behavior. Even though impulsive action is less lethal than planned action, it is still lethal and should be treated as an EMERGENCY. Emergency services should be called immediately. Even if no injury is sustained. When someone engages in impulsive action, both intent to act AND access to means present instantly without planning, preparation, or other prior warning signs. Even if the intention is a fleeting impulse, accidental death and permanent physical damage are substantial risks. 

Any impulsive action should be treated at an inpatient psychiatric facility for stabilization on medication in a controlled environment with trained professionals. Friends and family should not attempt to provide the controlled environment when impulsive action occurs.

The Greatest Risk

The greatest risk of suicidal ideation is inaction. If a person does not get help for suicidal ideation, it will progress. If you or someone you know is experiencing suicidal ideation, support them in accessing care. If they are resistant to or evading care, contact your local crisis team for additional resources. An act of suicide should not be the first time someone receives professional treatment for anxiety, depression, trauma, grief, or psychosis. No one with suicidal ideation should be made to feel weak, selfish, broken, or needy. Suicidal ideation is a symptom of another problem that can be addressed with the right treatment. 

ANY act of suicide should result in a trip to an emergency department for psychiatric evaluation. Even if it is days later, an incomplete act is a reliable indication that another act of suicide will occur. The emergency department will complete an evidenced-based risk assessment, provide appropriate resources, and assist in the process of accessing inpatient psychiatric treatment if necessary. If the nearest emergency department does not have a social worker on staff or a psychiatric provider on call, you may be able to find these resources at a different emergency department nearby. NEVER ignore ANY suicidal behavior.

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