This is a chapter from my book, Hardcore Self Help: F**K Depression called “A Chapter About Suicide”. There has been a great deal of mention about suicide recently in the media and on social media. There have also been many questions and misunderstandings about the topic. This chapter is definitely not the end-all-be-all regarding suicide, but it’s supposed to be a tool to help you better understand yourself or a loved one. Many have expressed that they don’t know what to do when a friend is suicidal or how to help people aside from sharing the hotline number. This post is one way you can help. Share this post directly or for everyone on your social media feeds. You never know who is watching. Full written chapter below the video.

A Chapter About Suicide

Time to be straight up. I want to talk about suicide. That’s right, I said it. Suicide. Some people seem to think that suicide is like Voldemort and we should never utter the name out loud, or that it’s like Beetlejuice and if we say it three times, suddenly someone will decide to kill themselves. That’s not how it works. In fact, I think that a lot of people kill themselves because it isn’t talked about. In this chapter I’m going to talk about it. I would say “trigger warning,” but I wouldn’t mean it. It’s something that we need to talk about and something that we need to stand up to.

Suicidality is a spectrum. Most of us have had the passing thought about what things would be like if we were gone or what it would feel like to die. Probably fewer of us have made a game plan and identified the method and circumstances that we would use to kill ourselves if we felt the need to. I think that we all lie somewhere on this continuum. Yes, being on the extreme end of it is dangerous, but just because you may fall farther to one side of this spectrum than the other does not mean that you are crazy or that you are hopeless.

We have to get into a few terms here because I think that they get thrown around pretty casually, and I want to make sure that you understand them. The first one that I want to clarify is “suicidal ideation.” The term sounds scary and intimidating, but it’s not too bad. Suicidal ideation just means that you are thinking of suicide. On the lower end of this spectrum, it crosses your mind every once in a while and on the high end of spectrum, you are virtually obsessed with the idea of killing yourself. A word with a very different tone is “suicidal intent.” The word intent is a little scarier because it refers to the degree to which you plan to kill yourself at some point. Finally, it is important to understand the term means. This references the method that you might use to kill yourself (gun, bridge, knife etc.). Let me use a hypothetical example here to illustrate how these terms are used in a practical way.

So, let’s say that we are trying to understand Sally, who is a 23 year old recent college graduate who just suffered the loss of her mother and has been unemployed for the past 6 months like many others in her cohort. She certainly has a lot going on, but where does she fit on the suicidality spectrum? Sally has had fleeting thoughts about death during the rough patches throughout her life, but she currently can’t seem to get the thought of it out of her head. No matter how hard she tries to shake them off, thoughts of death seem to creep into every empty space in her brain. Her little internal voice tells her that this is all just too much to deal with. She envisions herself taking every medication in her bathroom cabinet and falling asleep in a hot bath. This scares the shit out of her. She really does not want to die. In fact, she feels like she has to live for the rest of her family … it’s just so damn scary having these thoughts. For now, she feels very confident that she will not try to kill herself and she wants it to stay that way.

Okay, sorry if that was a little intense. I just wanted to give you a realistic scenario to wrap your head around. In this case, Sally definitely has suicidal ideation that is at least moderate if not severe. She is really preoccupied with the thought of dying. However, her fear of death and desire to find a way to live indicates that her intent is actually pretty low. Even though her intent is low at the moment, her level of ideation is definitely worthy of concern. For that reason, we want to be careful about her means of killing herself. She identified one for us, which was taking the pills in her cabinet. In this scenario, it might be a good idea to enlist some help to make sure that she is able to maintain her safety as well as she wants to.

I’m going to ask you to do something pretty damn brave for me here. You can do it. I want you to compare yourself to Sally. Right now, in this moment, where do you lie in the dimensions of suicidal ideation, intent, and means? There is no wrong answer here, but it is important for you to know. If your intent is high and you have a means that comes to mind immediately, I want you to seriously consider putting this book down right now and getting help. If you are in the United States, you can call 1-800-273-8255. This is the national suicide prevention hotline where people are trained to help you stay safe. If you live in another country, you can google “suicide hotline” and find some options near you. Depending on the country, you might need to adjust the words slightly. For instance, in some countries the translation for “suicide” is closer to “self-murder”, so play around with the terminology until you find what you are looking for. If you don’t want to deal with a hotline and would rather just get the hell out of dodge, you can call 911 or your country’s equivalent emergency services number. If you tell them that you are worried about killing yourself, they will come out and do an assessment with you and, if necessary, take you to a hospital where you will be kept safe. I know this doesn’t sound fun (and it probably isn’t), but this is not the time to think about convenience. We are talking about the permanent destruction of your life here. As far as I’m concerned, that’s the most pure example of a medical emergency there is.

I want you to live. Suicidality that comes from depression is often a symptom that stems from the hopelessness that we talked about earlier. Your asshole of a brain in tricking you into thinking that there is no way out of your situation and no point in hoping for anything different in the future. The old saying still definitely rings true: suicide is a permanent solution to a temporary situation. Don’t make that mistake, my friend. Things can change, even if your douchebrain won’t let you believe that right now.

If you aren’t quite on the crisis/emergency side of the suicidality spectrum, there are some other things that you can do to help yourself cope. My first advice would be not keeping it a secret. I know that talking about suicide is scary as hell, and it should be. It’s a frightening prospect. However, keeping it a secret only gives it more power. Take the power back, my friend. Drawing suicidality out into the open can be one of the most protective things that you can do. I don’t mean getting on Facebook and shouting it from the rooftops (unless that is really your style). I mean that you should tell your family, your significant other, your closest friends, or your doctor.

One of the terrifying things about bringing up the topic of suicide is the prospect of people overreacting. I think some people imagine that as soon as they utter the word suicide, a Special Forces group will breach their wall or rappel down from helicopters and violently extract them straight to a mental hospital. That’s not going to happen. Your family might react strongly for sure, but that’s because you are important to them. It may also be a big shock to them to hear this from you, because you are better at hiding these thoughts than you realize. Of course this is personally loaded. We don’t all have good families, but I hope you see the point that I’m trying to make. If the people that you tell about your suicidal thoughts overreact, educate them about where you lie on those spectrums we talked about, and help them understand what your level of intent is at the moment. If you aren’t looking to kill yourself in the immediate future, let them know, and also tell them that it is something that you are struggling with. Tell them that you need them to be on your team while you find your way out of these scary and confusing feelings. I know that it can be very difficult to find the right words to say in situations like this. Just try your best. The words don’t need to come out right. They just need to come out.

So, you tell people that you have been thinking about killing yourself. Groovy. What now? Well, there are a few things that they can do to help. All of this comes down to the level of severity that you are experiencing with your suicidality. (It is a little bit difficult to write in generalities, so please pardon anything that doesn’t directly apply to you here.) One thing that most families or friends would be happy to do is limit your access to the likely means of killing yourself. The scenario that I described with Sally earlier is actually quite common. Pills are an easily accessible, non-violent means of ending a life. If you are on a prescription medication or have access to drugs that have overdose potential, such as Xanax or strong pain killers, consider buying a tiny safe for the storage of those pills and giving the key to someone that you trust. You can keep a small amount for treatment or emergency, but not enough on hand that you could possibly hurt yourself. If you need to access the whole bottle for any reason, you must go through that trusted person. The point of this strategy isn’t just to take away your autonomy. In fact, if you live alone and have no access to trusted people to help out, I would still encourage you to try out the safe method. The trick here is giving yourself intermediate steps. When you are in crisis, your brain tries to trick you into jumping from point A to point Z. Crisis states are temporary. If you include things designed to put more time between the impulse to kill yourself and your means of doing it, you will give yourself more opportunities to make a different, non-fatal choice.

You know how fire extinguishers usually have that bold text on their storage cases that says IN CASE OF EMERGENCY BREAK GLASS? In this method, you make your own “in case of emergency” box. With my patients, I have often made this literal by using a display case with glass on the front. (If your means of suicide includes cutting yourself, please use your noggin and don’t include the actual breaking of glass in your method. Just make a box with a latch or something.) Anyways, the box itself is something that you fill up when you are feeling your best, most hopeful self. When you have some clarity about your desire to live. Fill it with pictures of people you care about, movie releases that you are looking forward to, clippings of grass, a Rubik’s Cube, a list of 20 reasons to stay alive… whatever makes sense to you as a person. Think of this as the emotional version of the shot of adrenaline that action heroes stab themselves with in the movies when things are most dire, and they need to somehow get their broken body to push through another hour of over-the-top destruction. It is a quick shot of hope, reality, and reasonable thinking designed to postpone you taking action during the peak of your crisis, allowing you to reach out for emergency help if needed.

Talking to your friends or family about your suicidal thoughts is one thing, but telling a professional like your doctor or therapist is much more risky, right? Well, I wouldn’t call it risky. It is certainly a different experience, because most medical professionals as well as people in helping roles like psychologists, therapists, and social workers are mandated by law to report you if they are concerned that you might be a danger to yourself. However, this isn’t just an off-the-cuff judgment. The professional needs to evaluate you to see what your level of risk is. If you are just having thoughts, but have no intent and no immediate means, you probably wouldn’t expect any immediate action. However, after careful evaluation, if your doctor suspects that you are in serious risk of harming yourself, you can be held for your own safety. I know this sounds harsh, but I want to stress to you that this DOES NOT happen every time you talk about these topics.

Let me put it into perspective for you. Over the past year, I was working in a major healthcare setting, seeing probably around 15 new patients every week. I talked about suicide with probably 100 of them, and there was only one case that I ended up collaborating with to work out a voluntary hospitalization.

Just like I suggested with your loved ones, be honest and clear with any professionals that you tell about these issues. Help them understand that you need support and how confident you may or may not feel about your personal safety in the moment. It is SO important to keep your providers aware of your situation in terms of suicidality. In some cases, it could even be related to a medication side effect. In others, they will simply want to be checking in with you over time to make sure that things haven’t taken a downward turn.

When your doctor or helping professional evaluates you, there are a few things that they will be looking for. In addition to assessing you ideation, intent, and means, they will want to know if you have had any previous suicide attempts. Previous attempts are actually the largest predictor of future attempts, so that is something that would definitely to communicate to them. They also want to see what you are living for. I always ask, “On a scale of 0 to 10, where 10 is completely confident in your safety and 0 is the opposite, how do you feel today?” When the patient answers, I follow up with, “Why not lower?” Even if they are at a pretty low 3 out of 10 on this scale, their answer will tell me some valuable information about what is still keeping them alive at this moment. Clinicians will also want to look at things like your level of guilt, any substances that you might be taking, and what type of social supports that you have. Trust me, any doctor would be much happier to enlist the help of you family and send you home into their loving arms to keep you safe than send you to a hospital, if that is a reasonable option.

Let’s say that your doctor does determine that you are at serious risk of harming yourself and would like to put you on a hold to ensure your safety. What does that look like? This is another area that is hard to write about in generalities. I’ll tell you about what it looks like in good ol’ California, USA, where I practice. In my state, if a doctor, peace officer, or other qualified clinician determines, after their careful assessment, that you are at immediate risk of harming yourself, they may place you under an “involuntary hold” for a few days. This is a way to keep you safe in the short term and hopefully connect you to resources that will allow you to move forward with your life with support while lowering the risk of harming yourself. Let me be the first to say that I 100% understand that this possibility sounds terrifying. I know it does. However, it’s really super-important to know that being hospitalized for suicidality does not mean you are going to live out One Flew Over the Cuckoo’s Nest or wind up in Arkham Asylum. Let me paint a more realistic picture.

When you hear the term “hospitalization”, it makes you think of sanitariums and other scary clinical settings. While there is definitely some variability in quality between the different psych hospitals out there, in general they are designed to be as comfortable as possible. They will look much like any other clinic or hospital you’ve visited. When you arrive to the hospital, you will undergo an intake process in which your belongings will be collected and documented. You are usually allowed to have some personal items with you. However, they may temporarily confiscate any items that could be used in a suicide attempt. For example, you probably won’t be keeping glass items or clothes with drawstrings because an actively suicidal person could use those to harm themselves. You will most likely also undergo a short psychiatric evaluation. In many cases, they already have some information from the person or agency that referred you, but they will want to make sure that they get a good picture of your current state, medically and psychologically. After going through your intake, you will be given a room. This is where you will be sleeping while you are staying at the hospital, and frequently you will be cohabitating with a roommate. It’s no Holiday Inn, but it’s not a jail cell either.

At the hospital, you will meet a large range of people. There will be those who probably would not have actually killed themselves, but are just not completely confident in their own safety. There will also be those who are talking to themselves, yelling in the night, and convinced that the staff is trying to poison them. This can be jarring, but it can also give you some much needed perspective on your own situation. You will have a few different evaluations with therapists and doctors during your stay. Their goal is to help stabilize you, develop a plan for moving forward, and to get you back out into the world. You will also be expected to attend groups intended to help you build coping skills and learn ways to regulate your emotions. It can be a bit overwhelming and scary for sure. Luckily, you are usually able to speak on the phone at certain times of the day and may have loved ones come to visit you. Sleeping is usually a bit restless in the hospital because it’s unfamiliar, and you are checked on throughout the night to ensure that you are still safe. It’s annoying, but it’s necessary. You will be discharged from the hospital when your hold has expired and when the doctors feel confident in your personal safety. You won’t just be dumped out on the curb with no plan. The whole idea is to help ride out your crisis, give you some skills to take with you out the door, and to develop a follow up plan with mental health providers in the community to keep you going in a positive direction once you are back out in the world.

I won’t lie to you. Being hospitalized is tough. It isn’t a fun experience. However, sometimes it is absolutely the right choice. Looking back on her hospitalization, someone that I know in my personal life made a metaphor that has always stuck with me. She said that she hated going to the hospital. She felt guilty that she had to go, and she just wanted to come home once she got there. However, she said that she would never take back the experience, because it was a necessary step in her recovery. She described it like a broken bone. Sometimes when you break a bone, the doctors will have to re-break it in order to set the bone in the proper position for healing. Being hospitalized for your safety serves the purpose of resetting you and putting you on the path toward healing. I hope it is something that you do not need to deal with. However, I hope you now have a better picture of what the process looks like if it does come to that. It’s nothing to be ashamed of. Sometimes it is just one important step on the path to overcoming depression.

The final topic I want to address in this chapter is self-harm without suicidal intent. In the field we call it non-suicidal self-injury (NSSI). NSSI is an interesting topic because it can serve several purposes. I think the most common reaction to NSSI (by people who have never been through it) is to interpret it, especially the cutting variety, as a “cry for help.” While that can certainly be the case, there is often much more to it. If you cut, scratch, slam, burn, rip, or engage in any other variety of self-harm, you know what I’m talking about. Many times it is used as a tool. Self-harm is often a coping skill. It’s not a good one, and it’s not safe, but it is a coping skill. Sometimes it occurs when things are too overwhelming and you want to feel like you at least have control over your own body. Other times, it happens when you are so numb and anhedonic that it seems like the only way you can actually feel something. I want you to think of NSSI as a symptom. That tells you that you need a coping skill that you haven’t been able to locate yet, and this is what you are using in the meantime. If you are in the NSSI camp, I do not want you to be ashamed, but I do want you to try to stop. A solid portion of completed suicides are accidental, and I do not want you to die. As you may have noticed, there is also often a diminishing return effect that happens with self-injury. It’s almost like an addiction where you need more and more physical feedback to have any emotional effect. That is a slippery slope.

If you engage in NSSI, the best course would be to get professional help. It is something that you can transition out of as you find more healthy ways of coping. Many people are scared about the prospect of bringing their self-injury up to their parents or to their doctors. I know it’s scary, but I will echo my sentiment at the beginning of this chapter by saying: your permanent health needs to outweigh your temporary discomfort or embarrassment at this time. Another worry is how your doctors will react when you tell them. I want to stress to you that they should not simply sweep you away to a hospital if you tell them that you cut yourself. If you want to be very sure that they understand, you will need to tell them why you cut. Tell them the purpose that it has served, that you don’t want to die, and why you need help stopping.

In the meantime, I would like to give you one tip that could possibly help you scale back on your self-injurious behavior until you can get in to see a professional. I absolutely need to mention that this particular approach has not been researched for NSSI in particular, but I think that it could potentially apply. There has been some research indicating that puzzle games such as Bejeweled, Tetris, or Candy Crush can help to reduce the strength of cravings. The reason this research may be relevant here is that NSSI is sometimes very much like an addiction. From what I have learned from people who self-harm, they are often fighting a losing battle with the growing thought of it. Even if they don’t want to do it, they can visualize themselves cutting, burning, or whatever method, and the more they try to push the thought away, the bigger and more vivid it gets. With these puzzle games, they basically override the portion of your brain responsible for temporarily storing visual information. It doesn’t mean that you won’t be able to visualize yourself going through with the self-injury, but now it will be competing for mental real estate with the puzzle you are working on. I’ll stress again that this is an extrapolation on the existing research and this particular method has not been supported yet, but it is essentially a zero risk strategy to try out for yourself. So, next time you find yourself starting to picture the process or the release of your self-injurious method, instead reach for your phone and play 10 minutes of a puzzle game. See if that brings down your urge enough to make a more healthy decision. I’m sure I don’t need to say it, but this is not a substitute for professional help. You still need to do that. This is just an in the moment coping strategy that you can try out.

Phew! We made it, guys. I know that was a tough chapter. It can be hard to hear these things. I’m proud of you for making it through. If this chapter really struck a nerve with you and you feel like there are some immediate steps that you need to take in order to invest in your own safety, please go do those right now. I will be here when you get back.

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