Like my other psych-based articles this is not medical advice.
This is the viewpoint of someone that suffers constant ideation and has real intent now and again. It is also based on conversations with other people in similar situations. The intent of this essay is to give you some of the inner thoughts that will hopefully help you gain insight on something that can be unfathomable to those that have never had these thoughts and might need to help someone else get help. If you are suffering from this hopefully this will give you some measure of peace as it is something that can be learned to live with if you can not manage to rid yourself of it.
It is always consoling to think of suicide: in that way one gets through many a bad night.
Friedrich Nietzsche
Is there any meaningful difference between suicidal ideation and intent?
There is, but that raises a few questions such as, “How can I tell?” and “How do I react?”. Those are not easy to answer, so the default advice you will find is to treat all suicidal comments and hints as serious. I am not sure that is useful or productive advice and sometimes can be damaging. I cannot come up with a better alternative.
It is like my last year of taking classes in grad school. Someone decided it would be fun to call in and post bomb threats on campus many times over several months. Obviously, they were pranks designed to get classes canceled on certain days. Maybe the goal was to just be as annoying as possible. Classes were only canceled once university-wide, but a building would get randomly closed. The alternative would have been to simply ignore it and not close down any buildings. All a tragedy takes is one real threat in a sea of fake threats. Who wants to make that call?
So what do you do, and what happens after that? The answer to that might be equal parts confusing and horrifying.
Suicidal ideation is simply thoughts of killing oneself. That is straightforward, but the meaning is not.
Suicidal intent is having plans and the means to carry it out.
Is suicidal ideation part of that? Yes and no. Of course, to have the intent, you need the thought. From what I have read, a literal spur-of-the-moment suicide with no ideation preceding it is extremely rare.
If someone has the intent, get them help. Full stop.
They may or may not be incoherent and in obvious distress. Some people will decide to kill themselves and take their time to get things in order. Others will appear to be almost a spur-of-the-moment thing. Think of it as the difference between a hurricane and a tornado. One is slow-building and can be tracked over time. The other comes on very quickly and can also vanish quickly - but warning signs of a possible tornado are present for some time before it happens.
Both are very dangerous, and the difference in signs between a slow build-up and a quick onset can be subtle. Both typically have long-term ideation. If it is quick there may not be many obvious signs. Like the analogy suggests, the time to react is different. A slow build-up is less critical but still needs immediate attention. It is just not a real emergency if that makes sense.
For myself, a quick onset is that I get very quiet and feel very empty and numb, and at the same time, my mind is chaotic. How that sort of thing is expressed outwardly can vary wildly. In my case, I think the only typical outward sign is that my voice becomes very soft and almost empty sounding.
I tend to want to take a long walk and want to be alone way more than usual. I will be uncharacteristically aggressive in seeking solitude. The morning of my birthday last year, I was exactly this. Unfortunately, I think that aggressive insistence scared my sister.
Well, I was going to step in front of a rather large truck but sadly got dizzy and kind of fell into the ditch. It is sad how stupid little things can stop me.
Some signs of suicide
- Withdrawal from friends and activities
- Giving away prized possessions
- Uncharacteristically poor hygiene
- Uncharacteristically poor behavior or a change in personality
- Unusual sleep patterns that can be too much or too little sleep
- Change in personality that can be overly nice or unusually angry
- Unusual drug or alcohol usage
- Expressions of hopelessness, worthlessness, or lack of a future
- An overt conversation about death or morbid topics that is unusual for that person
Of course, this list is hardly exhaustive, but it boils down to a negative change in behavior and outlook on life.
In these trying times, depression is more common. Especially in extroverts. Even introverts are not immune to this. This is coming from people with no previous history of mental distress. I think that is more dangerous since such feelings are new, and it is harder for people to deal with it that aren’t used to it. People you might not have had to worry about may now find themselves in distress.
Ideation is much more complicated. Many, if not most of the seriously mentally ill patients have ideation. Often all of the time. Surprisingly, this is typically not dangerous and can be helpful. It is a pressure relief valve.
When I saw a shrink, they always asked: “Do you have thoughts or a plan to hurt yourself or others?” A “no” answer usually ends it unless they see that you are lying. I am not a fan of the profession. I hesitate to call them doctors, but they are usually pretty good at detecting deception, even if the patient is a good liar.
A yes response will draw out further questions. “Yourself or others?” and if you say “myself”, then they ask if you have a plan. A no response pretty much ends it, and you can go your not-so-merry way. I am not sure what happens if you say “others,” it is probably something very similar. A yes response to whether you have a suicide plan will trigger more questions and possibly get you involuntary committed.
If it gets to that point, they will try very hard to get you to go voluntarily. Depending on where you live, if they believe you are a danger to yourself or others, they can hold you for 48-72 hours. This is generally the case in the US. After that, the doctors need to see a judge or magistrate before they can force you to stay longer, and the bar for that is extremely high. That puts your shrink in an adversarial position against you. That is counterproductive, so they try to avoid it.
There are benefits and few risks to going voluntarily. The two most important benefits are that you said yes, so your attitude towards it will likely be better. As I witnessed, a good attitude will help you while you are there. Involuntary patients were not happy campers. They looked at it as a prison and were antagonistic to everyone. The other benefit is that you walked into the hospital voluntarily, so you can leave when you want to. Of course, you are giving them the ability to see you 24/7, which might give them more information to change it to an involuntary commitment, if you try to leave.
I ended up in the psych ward in the middle of a school term and was there for about 8 days. I do not remember why my therapist pushed for me to go in. I do not remember what I said or did. Severe depression causes memory loss.
Luckily, I went in on a Friday, and by the following weekend, I was out. The actual process to get committed was horrible, and I was alone when I did it. They drew blood, did a very invasive physical exam, had me sign countless papers, and asked me over and over if I really am agreeing to it. It was easier to get through the paperwork and physical to join the military!
I did not want to miss out on school anymore. It was a fight to get out, with my sister helping out. They threatened to let me go without meds, which is a cruel threat because withdrawal effects are extremely painful. Luckily for me, I had a lot of my meds at home. With psych meds, it is a comfort to have a buffer so if a refill takes longer, you won’t run out. Withdrawal effects truly and utterly suck. That is a terrible threat to put over a persons’ head, it is coercive, and if it works, it is no better than kidnapping and should be prosecuted as such.
The head of the inpatient ward told me that there is no way that I could succeed in school right now. I finished that term on the Dean’s list, just like every other term.
I can’t say much about my stay because I have little memory of it. I just kept to myself, and whenever a doctor or nurse asked me a question, I answered in as little detail as possible.
I am not sure staying there helped, but it didn’t hurt either. If it helped, it was because I unplugged from my day-to-day life and was not anything specific that they did. I also don’t know if I would be alive or dead had I not gone. Probably not, so I suppose that is good.
So, what if you observe suicidal ideation or intent? What should you expect? If the person is doing poorly, they will either passively give up or fight against getting help. Which one depends on circumstances. There are times that I would be very passive about it, like when I did go in, but I also fought it several times - it has not come up in 15 years. I am either good at hiding it or can just deal with it better.
Remember that you are not a mind reader, and it is hard to tell from the outside what is going on with someone. It is also true that they may get so angry at you that they may not talk to you for a while or forever. This isn’t to dissuade you but to let you know what to expect. You might also be surprised about the reaction from medical professionals, which is why I added personal anecdotes.
The big question is whom to get help from. It makes a difference, but in an emergency, people tend to grab onto the nearest solution. That is not necessarily a bad thing, but it could bring up issues and cause problems.
The best way is to get them to their therapist or psychiatrist. They know the patient and are in the best position to help them. There is hopefully some level of trust there. I can not overstate how that makes a difference. If it is during office hours, try to call and explain the situation. They are accustomed to this happening, so they will have a protocol in place. They can be of great help over the phone. After hours, they might have an emergency phone number where someone is on call each night.
The next best is an emergency room, they will have people trained in this, and if this is after hours, it is the best available option.
Another option is to call a suicide hotline - there are some links to the right - and tell them you are calling for someone else. They will be able to offer guidance on defusing the situation and pointing you to options. If there is a hotline in your city, that may be the best way to go since they will know what is available in your area.
Depending on where you live, the worst is calling 911. There exist some forward-thinking police departments that have officers trained well to handle a mental crisis. Most are not. Frankly, they should not be required to do this. Endless budget cuts on mental health services cause this. This is one of the points that the current defund the police movement is addressing. An ill-trained person who is armed is not a good solution. If they are not well trained, it can end and sometimes does end very badly. You need to understand this. This is truly a last resort. A mental health crisis is not the time to learn if your local police department bothered to make sure its officers are trained in this area.
I have had the police called on me several times in my life over mental issues. Luckily I am never violent and lived in places that sent trained officers and social workers.
In the late 90s, my therapist would randomly call the police to do a wellness check. She probably did this out of spite. Those visits were easy. They are simply making sure that I am breathing and not acting in obvious distress. A short talk at my door, and they were off.
During this same time, a neighbor lady whose daughter was friends with my oldest called the police because I showed up at her door around 6 AM with my arms sliced up and dripping blood. At the time, I was so angry at her, but she is a take-no-nonsense woman and said she did not care. I understand now why she did it.
An officer showed up at my door with two social workers. The social workers were in charge of the interaction with the officer there only to make sure I didn’t get out of hand. They were not remotely interested in how bad my wounds were. It took over 10 years before the scars faded away enough to be mostly hidden, and now only one or two scars are visible at all. I remember laughing at this proposed contract that they wanted me to sign that said I promised I would not hurt myself. If I did not sign, the officer would drive me to the VA hospital for evaluation. I thought it was the most ridiculous thing and said so and all he did was reach for his handcuffs, so I signed it. I still think it is ridiculous, and it is very coercive.
The last time was the day after my birthday last fall when my oldest daughter did it. Which was odd. I was on the other side of the state with two sisters. I am not sure what prompted her to do it. It was not done out of malice, so why would I be angry? Two sheriff deputies showed up, and they were obviously very well-trained in it, so it went well. Two armed men - something I am accustomed to being around - asking me questions when my mind was not right was not a stress-free experience. I said very little and sat as quietly as I could so they would not try to take me in to be evaluated.
They also told me if I needed help, I was in one of the best counties in the country for emergency mental services - which I have no doubt - and it might be good if I make use of it. I believe that they were concerned about me. They might have been right about the availability of the services there. Getting back into the mental health system is the last thing I need. I learned to control my illness, even when it is working overtime trying to control me, and I prefer to do things like this alone. I have had to learn to do everything by myself.
Despite my interactions going well, the police should be summoned only as a last resort. If you don’t believe me, there are many news reports about when things go wrong simply because an officer was called on the scene.
It may not be their fault that they are not trained well enough - I am not claiming malice on their part - but it doesn’t change the fact that they often are not. Woefully untrained officers often create serious and deadly problems when the issue was only a relatively mild one.
If things are really serious and you are out of options, go ahead. Make sure you tell the 911 operator if there are weapons present or not to help defuse the situation if the person in distress. This is important regardless if there are weapons present or not. If you are not expecting it, getting a weapon shoved in your face does add more than a little bit of stress, as I have found out once or twice. Let them know everything they need to so they are prepared.
That advice goes for every time you need to call 911 to summon the police, not just with someone with mental distress. Help them to help you.
So, now what?
If you ask if you can take them in or call a hotline for them, and they refuse, back off a little and try a different path to get them to agree. The idea presented properly can make the person agreeable, and the proper presentation can seem random.
Sometimes, talking to you might be enough to defuse the situation and end the crisis. That is a difficult thing to ascertain. When that happens to me, I become more relaxed and more reasonable and amenable to trying to sleep. Everyone and every situation are different. Even if you can calm them enough that the intent goes away, get them to see their therapist or psychiatrist as soon as possible. They may seem stable right now, but it might not take much to pull them back into the darkness, and that can happen very quickly.
If they have decided to get help by seeing their shrink or going into an ER or mental ward. Or the police took them in for observation. What happens next?
Someone will talk to them and try to understand the current pressing problem and assess the seriousness. They will discuss plans, thoughts, and anything else that comes up. In an ER or mental ward where they do not know the patient, the visit could take some time. It can be very difficult to open up to a stranger, especially when in a crisis. If they only have ideation and no plan, the odds are that they will be released within a few hours. This is the part that can be surprising and stressful for those close to the patient.
An ER’s goals are to treat them and street them. It is not a place to get treatment beyond stabilization. At that point, they will be admitted or sent home. If it is their shrink or therapist, they will either make arrangements at a psych facility or send them home with similar instructions as the ER.
Meds might be prescribed, so they must know what the patient is currently taking. Drug interactions can get nasty. If you do not already know what meds - not just psych meds - try to find out before going. Psych meds can take weeks to start working, so it might be quicker acting meds like benzodiazepines and something else possibly in shot form.
Often, a good conversation with the psychiatrist or social worker will be enough to relieve whatever pressure caused the crisis. If the person is a danger to themselves or others, they will hopefully get admitted. That is not a given. In the US, and probably most of the world, psychiatric services are not great, and availability is often terrible. Especially for those with limited insurance.
If they are sent home, make sure you understand the discharge instructions. You might be needed for quite a while. A circle of friends or family can be invaluable. If they are safe to be released, they hopefully do not need to be watched 24 hours a day. That is stressful for all parties involved and can end up counterproductive.
They may be upset and try to send you away, and sometimes being alone is a good thing and sometimes not. It is a difficult thing to do that but try to not be suffocating.
Try to understand their viewpoint, which can be difficult in these situations. Always be gentle and nonconfrontational. If they do not want to talk about a subject, find something else to talk about.
Sometimes, not talking about the incident is the most helpful. Trust me on this. It is very embarrassing to be in this position. It is difficult to even write about it here, even though I am fairly anonymous.
Trying to guilt or place blame. That can send the person into an even worse state. I have a few sisters that can attest to how far from my normally reasonable state I can get. This is a very challenging thing to do for everyone in the conversation.
What does your loved one want and need?
I would not try to speak for all mentally ill people, but I can tell you what I want when I am like this and actually all of the time. My list of wants and needs doesn’t change.
I need to be taken seriously and especially not have my issues minimized, dismissed, or ridiculed. That would be super nice.
I also want to have someone to talk to without fear of losing that person or their respect. These thoughts and feelings do not define me, nor do they control who I am. I need to know that those that love and care for me will not vanish on me. They certainly do not need to be in constant contact with me, but knowing beforehand that they won’t be around for the next day or week or two goes a long way to keep me calm. Perhaps I don’t deserve basic consideration, but it is still on my list of wants.
Most of all, I just want to be a normal person. No one can help me be that. I will go to the ends of the earth and beyond for my loved ones without conditions. I do not ask for anything close to that in return. I don’t really ask for anything in return and will accept various kinds of rejection and poor treatment and still go to the ends of the earth for them.
I try to present a very consistent behavior. This is to hide my issues and not scare them away. I will act the same and be polite no matter if I feel good or am sick or have severe headaches or if my mind is noisy or chaotic.
The fear of losing friends and family is pervasive across many psychiatric disorders. It is odd. Losing people is one of the few constants in my life, yet I fear it. I do not lash out at others because I am upset. They will not usually know that I am upset. Even if I am doing very badly, I will deny it, which admittedly might escalate things.
The reason I do that is that I need to be perfect all the time. That is what it takes to be treated like a below-average person and feel like they will not abandon me. Showing emotions that are not positive makes me appear less than perfect, so I go from below-average to simply nothing in their eyes. It is stressful and exhausting.
It goes something like this:
When I do not get consistent behavior back - I never do because real people are not so consistent at all times - it confuses me. It makes it hard to know what I can and can not say. The issue is not knowing where I stand with that person, which brings severe insecurity and uncertainty. In turn, it brings along feelings of rejection - even if I had not been explicitly rejected.
The feeling of loneliness is stronger in a room full of people than when I just spent the last two weeks completely alone. I am hyperaware of small things like facial expressions and body language, especially when in distress. I take those facial expressions and body language along with statements out of context often. I might be highly attuned to social cues. I have a pathetically difficult time interpreting them correctly, and that is a serious problem for me.
A person can spend lots of time with me, and this fear causes me to feel utterly alone. That sort of thing makes trust difficult, even though it is completely in my head. Reality can be very fluid in my mind. I have slammed the door on people INFJ style when that person did nothing overtly and possibly nothing at all.
I have never completely opened up to anyone about my issues, and I am not sure I ever can. When I try to push towards that, I get a negative reaction or worse, an indifferent one. It is expected that I will get rejected or abandoned because of it.
Even if it hurts me physically, I will do something that someone else wants to do just so they do not find a reason to disappear because I couldn’t keep up with them.
The point of all this rambling is that personality quirks and insecurities are amplified during times of distress. Effectively helping others involves recognizing that so you can help to diffuse the person.
I have talked to some people with a variety of mental issues, and it seems that they have at least a somewhat similar thought process and approach to opening up. They may not have a similar outlook on themselves that I have of myself. The fear and dread of being judged and possibly losing family and friends are similar.
Never underestimate the fear of rejection and the resulting insecurity.
Hopefully, that helps give you a way to approach this problem. It is a personalized approach that is needed.
What not to do or say to a suicidal person
Everyone is different and reactions to these situations, so it is hard to give a things to-do list. Such a list is personalized.
It is much easier to give a “don’t ever do or say this” list.
- “It’s not that bad”
- “Snap out of it”
- “Stop whining”
- “It is a sin”
- “You are being selfish”
- “Do you know how much you would hurt me and others”
- “Don’t be a coward”
- “Others have it worse than you and they aren’t trying to kill themselves”
- “It is a permanent solution to a temporary problem”
- “Stop seeking attention”
- “You are crazy”
- “Don’t do something stupid”
- “Just keep busy”
I know it is difficult to not say these things. You will be shocked and hurt but remember that placing judgments, minimizing the pain they are feeling, and laying a guilt trip on them will make them worse.
It is not about you even though you are hurting because of their desire to end their life. Would you be so judgmental if a family member had cancer? This is no different.
Go the other direction: show love, concern, and understanding and gently nudge them towards getting help. Listen, but do not judge them or point out how ridiculous and illogical they are being.
“Just keep busy” is the wrong thing to say. This is because these thoughts are always present no matter what the person is doing. While it is not judgmental or placing blame on them, it shows a deep lack of understanding of what it is like to have these thoughts. They are all-consuming and almost constant, and they can not be ignored by staying busy. Nothing removes those thoughts.
Feeling that they are understood is vitally important.
It is easy to say the wrong thing. If you do say something that is upsetting, apologize and tell them that you panicked. Let them know that you are here for them. Unless they are completely out of control, they will likely understand and appreciate it. If you need to, take a few minutes to collect yourself.
Do not double down on saying the wrong things even if you are angry and scared. Panic kills.
The goal is to show them unconditional love and get them the help they need.
In the US, most mental health services suck. That is without getting into the fact that psychiatry is mostly a pseudoscience. When someone needs help, it can and often does save lives.
Recognizing the signs and a simple question like ‘what is going on?’ is the start of what can be a long and hard journey.
I didn’t want to wake up. I was having a much better time asleep. And that’s really sad. It was almost like a reverse nightmare, like when you wake up from a nightmare you’re so relieved. I woke up into a nightmare.
Ned Vizzini
