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BY DAVID M. WOOLDRIDGE

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Can We Talk?Suicide is one of those things that no

one likes to talk, or even think, about. Itis an awkward and uncomfortable sub-ject. We don’t like to acknowledge that,for some people, life seems not to beworth living. We don’t like to admit thatwe might be subject to suicidal thoughts.Such thoughts may seem to be a greatweakness or even a serious moral short-coming. The act of suicide is gruesomeand unpleasant to consider.

Perhaps we have had thoughts of suicideat some time in our lives, and the shame of

those thoughts keeps us from discussingsuicide with others. Perhaps shame comesfrom a different source–suicide or anattempt at suicide by friends or relatives,for which we (irrationally) feel shame byassociation. Perhaps, we are afraid that bytalking about suicide with someone weincrease the likelihood of its happening.

Similar to many problems in our society,we make the problem worse by our reluc-tance to talk about it, learn about it and doanything about it. But to reduce suicide, wemust talk about suicide. We must learn alittle about suicide. And we must be pre-pared to do something about suicide.

Is This Really aProblem?

Suicide is the eighth leading cause ofdeath in the United States.1 Typically, morethan 30,000 people take their lives hereeach year. Another 250,000 people eachyear are reported as having attempted sui-cide and then received some formal med-ical attention.2 Firearms are used in 55 per-cent of completed suicides. Contrary topopular wisdom, more suicides occur inthe spring than any other season.

Some groups are more likely to commitsuicide than others, but it touches all soci-ological groups. Men are four times morelikely to die from suicide than women, butwomen report attempting suicide at a ratethree times more often than men.Lawyers, as a group, are twice as likely tocommit suicide as the general public. Fartoo many lawyers in Alabama have takentheir lives in the last several years.

Can We DoAnything About It?

There are many areas in which professionals in the field would prefer laymen not to meddle. Suicide preventionis NOT one of these areas. Health careprofessionals have developed various pro-grams, such as “QPR” and “ASIST,” toteach laymen when to intervene with apotential suicide and what to do about it.3

It is not complicated. The layman’s rolecan be only a limited role–limited, butimportant. Like CPR and the Heimlichmaneuver, intervention can be the essen-tial first step to prevent a suicidal act.

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The first premise of intervention is thefinding by researchers that most individ-uals who attempted suicide gave identifi-able signs to one or more persons in theweeks before the act. The signs were notmade solely in the presence of family andclose friends, but often were given to co-workers or acquaintances in contact withthe individual during this critical period.

The second premise is that even amodest contact with another person–if ofthe right kind–can dissuade the personfrom acting, for at least a short criticalperiod. With followup attention byhealth care professionals, the suicide canusually be avoided altogether.

Spotting theProblem

There is nothing we can do, if we can-not identify a person who may be at riskof suicide. Identifying such people is dif-ficult, and it can never be certain. Youshould be willing to act on a reasonablesuspicion; certainty is not necessary.There can be little harm done, and muchgood, by merely expressing your concernfor another person’s health and feelings.

However, this is a great barrier to iden-tifying people at risk–few of us want tobelieve that the person facing us is capa-ble of suicide. On some level of con-sciousness, many of us really do not wantto see any symptoms. Moreover, many ofus don’t like to get involved in the per-sonal lives and emotional problems ofothers. Ignorance is not bliss, if you laterrealize you might have saved a person’slife merely by showing a little concern.

We must get past this reluctance. We canquickly learn to recognize the symptoms.And our modest involvement in interven-tion can and will saves lives among ourcolleagues, friends and family members.

There are a number of signs that mayindicate that a person is at risk. Not allpeople at risk will exhibit all, or even any,of these signs. Furthermore, many peoplewho are not at risk may exhibit many ofthese signs. Remember that certainty isnot required; suspicion is sufficient foraction. You action is not offensive; it ismerely a caring inquiry. Reluctance to act,for fear of being wrong, is usually unjusti-fied, and in some cases will be fatal.

The following are lists of most commonsigns of depression4 and potential suicidalthoughts. The signs fall into categories:

■ The individual may provide obviousdirect verbal clues like these:

• “I’ve decided to kill myself”

• “I wish I were dead”

• “I’m going to end it all”

• “I’m going to commit suicide”

• “If such and such doesn’t happen,I’ll kill myself”

■ More often the individual gives onlyindirect or coded verbal cues likethese:

• “I’m tired of life”

• “What’s the point of going on”

• “My family would be better offwithout me”

• “Who cares if I’m dead”

• “I can’t go on anymore”

• “I just want out”

• “You would be better off without me”

• “Nobody needs me anymore”

• “I don’t fit in anymore”

• Other statements reflect hopelessnessor preoccupation with death.

■ Many clues are behavioral, such as these:

• Abrupt changes in personality

• Pervasive, exaggerated or inappro-priate displays of sadness or anger

• Inability to tolerate frustration or tocope with stress

• Withdrawal or unwillingness tocommunicate

• Eating disturbances or significantweight changes

• Sleeping disturbances

• Abruptly putting business affairs inorder or changing a will

• Sudden happiness in a depressedperson may be signal of suicide5

• Unusual reckless or self-destructivebehavior, such as sexual promiscuityor excessive use of drugs and/oralcohol

• Depression or unusual sadness, dis-couragement or loneliness

• Extreme or extended boredom

• Inability to concentrate

• Unusually long reactions to grief

• Neglect of work

• Neglect of personal appearance

• Giving away prized possessions ordonating body to medical school

• Ceasing activities that they once loved

• Buying a gun for the first time

• Stockpiling pills

■ Some situations should increase yourconcern from other clues:

• Ending a marriage, divorce or separation

• Ending a romance or long-termrelationship

• Death of someone close (especiallyif by suicide)

• Serious illness or trauma to self orloved one

• Previous suicide attempt

• Sudden rejection or unexpectedseparation

• Diagnosis of terminal illness

• Anticipated loss of financial securityor personal freedom

• Loss of status, prestige or identity

What Can We Do?–The “QPR” Model

It is a myth that suicide can’t be pre-vented. It can. QPR is one technique thatworks. QPR stands for “Question” (themabout suicide), “Persuade” (them to gethelp) and “Refer” (them for help).Research shows that the great majority ofthose who attempt suicide give some sig-nal first. Yet, those in a position to dosomething about it are often reluctant toget involved.

When deciding whether to intervene, toask about thoughts or plans for suicide, tobreak a confidence about a friend’sthoughts or plans of suicide–the best ruleis safety first. Conflicts, discomforts andembarrassments are resolved much morereadily than the pain of losing someone topremature death. Sometimes, because the

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thought of death is frightening, we denythe person may be suicidal. Overcomingthe denial is an important step.

QUESTIONThe first step in the QPR Model is to

question. Get the person alone or in aprivate setting and, ultimately, ask themif they are contemplating suicide. Youmight start by asking questions thatexpress your concern and acknowledgethe individual’s distress, questions like:“Have you been unhappy lately?” “I’venoticed recently that . . ..” “I’ve been con-cerned about you. How are you feeling?”

Ultimately, you must ask the “suicidequestion” directly: “Do you want to stopliving,” or “Has it been so bad that you’vethought about suicide?” It is importantthat you directly ask about suicide. Do notbe afraid to use the word. Asking the “sui-cide question” does not increase the risk.Asking actually reduces the risk of suicidalaction: first, because it opens the door tohelp, and, second, because asking conveysan implicit message to suffering individu-als that someone cares deeply and thatthey do not have to be alone in their pain.

After asking the questions, you mustactively listen to the responses and con-cerns. You must be sincere, supportive andunderstanding. Avoid the lawyer’s profes-sional pitfall–giving advice. Advice tendsto be easy, quick, cheap and wrong.Listening takes time, patience andcourage, but it is always right. Give yourfull attention and don’t interrupt the indi-vidual. Do not judge or condemn him.Listen particularly for the problems thathe believes death by suicide would solve.

You may conclude that the individualis not suicidal and no further action isneeded. The individual will probablyappreciate your concern, although admit-tedly there may be an awkward moment.Or you may get evasion and denial, per-haps even some anger. You must evaluatethese responses for yourself, and mayconclude that no action is needed.

An affirmative answer opens the doorto further action and often is a release forthe individual. It can make them feel bet-ter, not worse, for getting it in the open.The suicide question is now on the tablefor discussion. But that also means thatyou have more work to do.

PERSUADEThe second step is to persuade the indi-

vidual to get help, to get the person tosay, yes, they will get help. For example,ask: “Will you go with me to see a coun-selor (doctor, priest, rabbi, minister,nurse, etc.)?” “Will you let me help youmake an appointment with . . ..” or “Willyou promise me to talk to . . ..” Accept thereality of the person’s pain.

Sometimes, a person will agree to gethelp. Others may resist the idea. If thereis resistance, you might make a “no-sui-cide” contract with the individual–apromise not to hurt himself until help issought. Because making a promiseappeals to one’s honor, and becauseagreeing to stay safe offers some relief,the answer is usually yes. Thereafter, con-tinue to express your concern and revisitthe idea of getting help.

If the individual refuses, decide if hemay be a danger to himself or others. Youmust decide if unilateral action is appro-priate. Err on the side of safety.Commitment might ultimately be neces-sary, but more immediate emergencymedical help may be most appropriate.Take the person to an emergency room.Call 911. Do not worry about being dis-loyal. You are trying to save a life. Do notworry about breaking a trust or not hav-ing enough information to call for help.

There are other things to consider.Remove firearms, car keys, medications,knives, and other instruments which maybe used to commit suicide. By restrictingaccess to the means of suicide you buytime for another solution to be found.Removing the means to suicide is, initself, an act of hope.

If someone is contemplating suicide,keep him sober. People who take theirlives have to overcome a psychologicalbarrier before they act. This final wall ofresistance is what keeps many seriouslysuicidal people alive. Alcohol dissolvesthis wall and is found in the blood ofmost completed suicides.

All of us can challenge an individual’sbelief that he is a burden or will never fitin. We can reinforce the individual’s rea-sons for living. Remember that small actsof acknowledgement, appreciation andkindness can have tremendous impact onsomeone in crisis.

REFERThe final step is QPR is to make a

“referral.” Get the person to someone whocan help. Call a crisis line for referrals, orseek the other resources listed in this issue.Go with the individual, and do not leaveher alone. The best referrals are when youpersonally take the person you are worriedabout to the appropriate professional.

No one in the great emotional painthat such a person feels should be alonewith that pain. Also, you should not bealone in the effort to support a desperateperson. Sources of immediate helpinclude crisis lines, hospitals, physicians,therapists, and the referral and treatmentresources available through lawyer assis-tance programs. After the crisis, 12-stepprograms such as Alcoholics Anonymousand mentoring by volunteer lawyers haveproved invaluable to attorneys recoveringfrom the mental illness and substanceabuse problems often associated with sui-cidal thinking and behavior. ■

Endnotes1. The data is from the Web sites of the Centers for

Disease Control. Suicide is the third most common

cause of death for young people ages 15-24. The

rate of suicide among this group is roughly 4,000 out

of the 30,000 total suicide deaths each year.

2. However, the number of unreported attempts is

believed to be considerably greater.

3. The “QPR” Program, discussed below, is just one of

several such programs. Discussion of QPR should not

be considered an endorsement of QPR over the other

programs.

4. Most of these signs are also those of clinical depres-

sion. It is no surprise that depression generally

accompanies suicidal thoughts.

5. Since depression saps energy and purpose, some-

times a depressed person is “too tired” to carry out a

suicide plan. However, as the depression begins to

lift, the person may suddenly feel “well enough”

to act.

David M. WooldridgeDavid Wooldridge practices

with Sirote & Permutt in

Birmingham. He is a past chair

of the Lawyers Helping Lawyers

Committee of the Alabama

State Bar.

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