Suicide Intervention Flowchart
Step 1: Listen for- and reflect statements or hints of suicidal feelings
Hints:
- "I just can't take it anymore."
- "I want to escape."
- I want to go to sleep forever."
Step 2: Ask directly about suicide
"Are you thinking about killing yourself?"
Yes - Go on to step 3
No - If you really believe the person is not suicidal, go to step 12.
No - (but you really believe they are suicidal)
Ask, "Have you thought about suicide in the last few months?"
And/or, "Have you ever attempted to kill yourself?"
If this reassures you that they are not currently suicidal, go to step 12.
If you still believe they are suicidal, go to step 12 and come back to step 2 after you have established more rapport.
Won't answer - handle like "No" choices.
Step 3: Reflect ambivalence and ask if the person has already done something trying to kill themself.
Yes - go to step 4
No - go to step 9
Won't answer - go to step 9 and come back to step 3 after you have established more rapport.
Step 4: Find out HOW the person has attempted suicide shortly before (or during) the call.
If the person has attempted through injuring their body by cutting, burning, etc. - go to step 5
If the person has attempted by ingesting medications/chemicals/etc. - go to step 6
Step 5: Reflect ambivalence and ask the person to place non-medication method(s) out of sight so they won't continue focusing on (or use) this while talking with you.
- Do not make demands or argue with the person.
- However, if the person refuses, return to this request after more rapport has been established.
- If a firearm is near them, ask the person to move it out of sight with as little handling as possible.
- Do not ask them to unload it while they are still so close to acting on suicidal thoughts.
Step 6: Reflect ambivalence and gather information for consultation with a medical professional to determine whether the person needs medical attention.
Refer to workbook for specific information needed.
Step 7: Reflect ambivalence and ask the person to get ALL method(s) out of sight, so they won't continue focusing on (or use) this while talking with you.
- Address all methods involved with this attempt.
- Do not make demands or argue with the person. However, if they refuse, return to this request later.
- Ask if, in addition to what they have already used, do they have other suicide plans?
- Ask them to get all methods out of sight
- If a firearm is near, ask the person to move it out of sight with as little handling as possible. not ask them to unload it while they are still so close to acting on suicidal thoughts.
- Do not ask them to unload it while they are still so close to acting on suicidal thoughts.
Step 8: While waiting for medical recommendation, re-start counseling with a summary.
- Interrupt counseling to share medical recommendation
- If medical attention was recommended - go to step 11
- If no medical attention is needed - go to step 12
Step 9: Find out if ther person has a suicide plan - or plans - so that you identify all methods available or considered.
- Yes -
- Ask: 1) When would they do this? 2) What methods are involved? 3) Do they have that/those available? 4) Is that/ are any of those near them currently?
- Make sure to ask about all methods the person is considering. (The person may have a plan that includes multiple methods, or may have multiple plans.)
- Go to step 10.
- No - go to step 12.
- Won't answer - go on to step 12, and come back to step 9 when you have established more rapport.
Step 10: Reflect ambivalence and ask the person to get ALL method(s) out of sight, so they won't continue focusing on (or use) this while talking with you.
- Address all methods involved with this attempt.
- Do not make demands or argue with the person. However, if they refuse, return to this request later.
- If the method is a firearm, ask the person to move it out of sight with as little handling as possible. Do not ask them to unload it while they are still so close to acting on suicidal thoughts
Step 11: Reflect ambivalence and encourage the person to get medical attention when it has been recommended.
If they are willing -
- Help them plan how to get there: friend, family, taxi, case manager or other outreach worker from their community mental health center, or ambulance (only if appropriate)
- Offer to call to arrange that transportation and stay on the phone with them until transportation arrives.
- When ambulance is needed, talk with one of the responders who arrives to treat the person.
- When ambulance is not needed, offer to call the hospital so they will be ready to treat the person when they arrive
If they resist -
- Reflect ambivalence, express your concern, explore their resistance to getting help. and encourage getting needed help.
- If caller appears to be at imminent risk of death from action already taken, and resists getting help. reflect ambivalence, state your concern for them.
- Consult with Director or Director of Counseling Services, our licensed social work staff
- If there is truly imminent risk, the recommendation will be to reflect ambivalence, express your concern, and state that you need to arrange for an ambulance. Ask the person for location and phone information. When we have the person's location or when the phone number is available from caller or Caller ID, contact emergency dispatch for the person's area. Stay on the phone with the person until emergency response arrives.
- Call them back if necessary, with the goal of staying on the phone until emergency response has arrived.
- If possible, get the person's agreement to a follow up call. If person is not able to stay on the phone to arrange this, schedule follow-up at a time after the person has received treatment and is likely to be able to answer
Step 12: Use great counseling skills.
- Invite the person to talk about what lead up to the suicide/self harm thoughts/actions today. Try to gain understanding of what they are trying to fix, and help them come up with safe ways of managing that.
- Find out more about their history of self-harm or suicide. If the person has attempted suicide/used self-harm in the past, what happened then?
- Reflect ambivalence - accept and acknowledge the part that wants to die as well as the part has some hope that help is available. (Reflect ambivalence you actually hear.)
- Listen attentively and take them seriously.
- Reflect feelings and values.
- Empathize, share your concern about their safety, and offer support.
- Find out about their use or alcohol or other substances
- Find out how they are doing with basic self-care - sleeping, eating healthy, drinking enough water, getting some exercise - as all these affect mood
- Explore what is in this person's life, what gives them a sense of purpose Explore reasons for living and plans for the future
- Find out about personal supports - therapists, friends, family, faith community.
- Remind the person of the strengths and/or supports they mention including the crisis line.
Step 13: Help the person plan what to do after the contact. What will the person do for the next few hours, the night, the next day,...?
- It would be safer to be with someone for a while.
- Is there someone they would be comfortable being with - friend, family? Can we help them make arrangements to be with that person?
- If this person is a child or teen-ager living with parent/guardian, offer to talk with the adult they live with. If the child/teen needs protection, offer to call law enforcement or DCF.
- If the person has a therapist or case manager, urge them to contact this person and inform them about this crisis, so they can help.
- Would they like help contacting this person?
- If the person is a client of the Bert Nash or another community mental health center, that center offers extensive crisis support resources. Encourage use of these resources.
- Is hospitalization needed for safety? If so, offer to help make arrangements for this? (We can call the local hospital or community mental health center, as appropriate.)
- If the person has access to firearms, encourage them to have all firearms and ammunition stored elsewhere for a while - with a friend or family member. Offer to help contact such a person.
- Help them develop a Safety Plan for when they are in crisis. For many people, having this in writing and keeping it nearby is very reassuring. The plan should be a written list based on our Safety Plan example, with basicaily three components:
- Things the person can do while alone
- Involving personal support people
- Involving mental health supports
- Offer follow-up whenever there is a high risk of this person acting on their suicidal thoughts in the near future
- If the person will not allow follow-up, urge them to call HQCC/NSPL again: after a few hours, in the morning, if they are having thoughts of suicide again.
- Tell them how much you appreciate that they were able to contact HQCC/NSPL this time, and that they can call when needed to prevent things from getting this bad again.