Suicide. It is one of those words that makes people stop and listen. Just hearing the word “suicide” uttered can make it feel as if time stands still and people often instinctively ask “What? What happened?” As if there is a single simple explanation that could make it make sense. The one thing that is straight forward about suicide and suicide attempts is the immense suffering it represent.

When it is a beautiful, well-known, successful person like Stephen “tWitch” Boss who has died from suicide it catches the attention of the world and social media feeds are consumed..at least for a few days or weeks. When we look at Stephen “tWitch” Boss, on the outside we see a 40 year-old-black man who appears healthy, handsome, vibrant, successful, and by all accounts connected to many people who loved him and whom he loves. In the mental health field, we would say he has many protective factors (individual, relationship, community, and society level factors that protect against suicide risk - more about this later) that should have protected him against suicide. But this week, at 40 years of age, he died by suicide. He should still be here. He and so many others should still be here but they are not. And the reality is that this could be any of us. 

I have spent more than 20+ years providing psychiatric services - first as a nurse, then as a psychiatric-mental health nurse practitioner, and now also as a researcher. I have learned more about suicide that I would ever have imagined.I have worked with countless people struggling with thoughts of suicide or who were recovering from a suicide attempt. I have had many conversations with family members reeling from the grief of the near-loss by suicide attempt or sudden loss of their loved one by suicide. But experience does not make this topic easier. Yes, my training makes me feel confident that by providing evidence-based care I can partner with people to help them recover. And I have seen many people fully recover and that keeps me hopeful. But the conversations are always difficult and I have grieved alongside each of the individuals and families. And this experience has helped me know that none of us are immune to mental illness and periods of hopelessness. 

This week, as we learned about Stephen “tWitch” Bosses death, and as I read people’s responses, and heard questions people were asking, I was reminded that many people simply do not understand suicidal ideation or suicide. I knew I needed to delve into this topic so decided to hit pause on my other blog posts. This is too important and complex of a topic to skip or to cover in one blog post so for today we will focus on: 

What is it? 

How common is it?

Who is at risk?

What can I do?  

What is it? Suicide is a death caused by injuring oneself with the intent to die. Suicide attempt is when someone harms themselves with the intention to end their life, but they do not die as a result of this self-harm behavior. The tricky part is sometimes we don’t know about people's “intention”. Particularly in the case of suicide - sometimes a suicide note gives insight into the thoughts the person was having close to their death and can provide insight into whether they were intending to end their life. Other times “accidental deaths” like car wrecks, falls, or farming accidents, etc. are suicide but this suicide method makes the intention less clear.    

How common is it? The short answer - suicide is much more common than you would imagine and it affects all ages. Suicide is the leading cause of deaths in the United States. In 2020, 45,979 people died by suicide. This means someone dies by suicide every 11 minutes in the US. Recent data from North Carolina demonstrates that, in 2021, 10% of high school students attempted suicide. Meanwhile 22% seriously considered attempting suicide in the 12 months prior. Yes, read that again. We can not be silent and we can not ignore how serious this is. 

Who is at risk? The short answer - everyone. But there are some groups of people who have higher suicide rates. For example, people who are: 

- non-Hispanic White (caucasian)

- non-Hispanic American Indian/Alaska Native

- a military veteran

- live in a rural area

- workers in certain occupations (mining, construction)

- young and who identify as lesbian, gay, or bisexual

What can I do? These 4 steps will go a long way 

1) Approaching this topic/conversation of suicidal thoughts nonjudgmentally 

Remembering none of us are immune can help us keep a non judgemental stance. Thinking about how we would want someone to respond if/when we have these thoughts is also a good guide. You can trust your empathy but I’ll give you some more tips below. Also remember we do not have to have experienced such thoughts to show the care and understanding a person needs. However, if you have had similar thoughts, consider sharing this (what we call “therapeutic use of self”) as could make a huge difference for that person as they may see you as a trusted expert who has survived and can remind them of the hope.   

2) Listening to what the person is saying with their words and demonstrating through their actions

Are they acting “different” or “off”? Are they telling you or showing you they are not enjoying the things they typically do? What about the future - are they making comments or acting in ways that make you think they are not planning for the future as you would expect? Or are they giving loved items away? Are they having worsening symptoms of anxiety, depression, trauma or other mental health symptoms? Does it feel like they are making statements that make you think they are losing hope that things will get better? Are they saying things like “I just can’t live like this” or “I don’t want to live now that…” Listen to what they are saying and also listen to what they are demonstrating. And if you are noticing it, let them know you notice, this could be just the open door they need to see you have noticed and being reminded that you care. For example, “Michelle, you used to love going out to dinner with me and our friends but, recently when we invited you know you have said you don’t want to go. We really miss you. I’m getting worried that things are hard and are getting harder for you right now. Can we talk about this?”

3) Being prepared to ask if they are having suicidal thoughts 

Asking people if they are having thoughts of wanting to die or are are considering ending their life will NOT make them become suicidal (there is evidence to support this so you can be confident asking is safe and life-saving); but, staying silent or ignoring their struggle just might. We can not stay silent and we can not let shame or stigma have control in our homes, our schools, our communities, our nation, or our world. 

Silence, shame, and stigma about mental health concerns like depression, anxiety, and trauma are poison and suicide is a byproduct. It is critical that people know you are a safe person to speak with.  

These are some of the questions that I routinely ask and I would encourage you to consider using. Ask straightforward questions and give them time to respond. When people are really struggling their thinking can be slower and/or they are preoccupied by many other thoughts. Just give them time and if they don’t answer the first time, calmly ask again demonstrating you will wait and this is an important questions. Tip-toeing  around the subject will just make them feel more isolated, ashamed, alone. So again be open and hornets.  

Passive suicidal ideation is when a person is feeling like they don’t want to live anymore. Active suicidal ideation is when the person wants to die and they have a specific plan on how they would harm themselves.

These are my go-to questions that tend to help me assess from all the important angles. I typically go in this order as well but tailor to what the person is saying. It is always important that it does NOT feel like an interrogation. Again, a non-judgmental, empathetic attitude is key. 

• I know things have been hard for you recently. And I know it can be really common for people to start feeling hopeless or begin thinking like they may not be able to tolerate life like this. Have you been having any thoughts or feelings like this? (normalizing and destigmatizing)

• Are you having any thoughts of feeling hopeless? (hopelessness about the future)

• Have you been having any thoughts that you can not live like this any more? (active and/or passive suicidal ideation) 

  • If yes: Can you tell me more about those thoughts?

  • If no: Have you experienced these thoughts in the past? (history of passive and/or active suicidal ideation)

• Are you having any thoughts of wanting to die? (passive and/or active suicidal ideation?

  • If yes: Can you tell me more about that?

  • If no: Have you experienced these thoughts in the past? (history of suicidal ideation)

• Have you been having any thoughts like - if you didn’t wake up in the morning that would be okay? (passive suicidal ideation)

• Have you been having thoughts that things are so hard right now that you may do something to end your life? (active suicidal ideation) 

• If yes (to active suicidal ideation), have you thought about how you would do this? (suicidal plan)

These types of conversations are hard but also always worth it. Sometimes the person shows obvious relief as they are no longer alone with these thoughts. Sometimes it may not be immediately obvious, it is a hard conversation to have but it can break down barriers and they may come to you first next time. 

Lastly, I always thank the person when they share their thoughts they are having about suicidal ideation/suicide because I know it takes a lot of courage to do so. I remind them that if anything changes I hope they will let me know or someone else they have identified as a safe person to have this conversation with and whom they can trust will help them get the help they need. 

4) Knowing how to respond including helping them get professional help

Recovery is possible and it is incredibly beautiful to see. It is what has continued to sustain me in this work and what helps me keep hope alive when the person themselves feels like hope is still foreign. I will sometimes even say, “I know you are having a hard time having hope that this is going to get better. But, I want to make sure you know that until you can hold the hope again I’ll be holding it for you. I look forward to celebrating with you and reflecting back on this journey with you.” This battle for mental health is always worth fighting, but it is also a battle people can not fight well alone. We have to help people know that they are seen, cared for, and this suffering can be helped with the right tools. 

It is important to remind them of the tools in the tool box - therapy, medications, exercise, being a part of a faith community, mindfulness practice, and other interventions that need to be used to fight effectively. One resource that is free to anyone anytime is texting or calling 988 which is the Suicide and Crisis Lifeline that is available 24 hours a day. Seeking medical and psychiatric evaluation with a health care provider they trust is also critical. However, if someone is at acute risk of harming themselves or someone else urgent evaluation at an emergency department is needed.

What I have shared with you has been some of the keys I have picked up and represents some of the most rewarding work I have done. It has also been some of the most exhausting. The conversations I have had and the people I have had them with in my professional roles and personal roles, will always echo in my mind. Those conversations I had late at night as a nurse on the psychiatric unit, the outpatient therapy sessions I provided as a NP, the partial and inpatient hospitalization stays helping people with eating disorders refeed their bodies and experience hope return as their brain is nourished. It has been an honor to fight alongside each of them helping them become well enough to return back home and re enter their daily lives and see them thrive. I can see their faces. I still remember their stories. I hold it all as sacred and as I have witnessed that much suffering – for me I have not gotten discouraged about the weakness of humanity actually it is the complete opposite. I have seen in news ways the complexity of the human brain. The impact our experiences and environment have on us and the ways all of this interacts with our genetics, and problems in our brain regions and neuronal circuits etc.  

In closing, one of the main challenges with mental illness is that we are relying on the person’s organ that is struggling - their brain – to make the decision to clearly articulate the problem, to seek help, and to continue with health seeking behaviors until they recover. This is not the case with other physical conditions. The person with diabetes is able to make the decision for treatment with their mind independent of their pancreas. Similarly, the person with most types of cancer also has clear cognition and is able to understand the risks and benefits of seeking treatment or not. This is part of what makes it hard for people whose minds are struggling; but, this should help guide us on how to effectively partner with them for care. I cannot overstate how much hope there is and if you take one thing from what I have shared, let it be this: 

The news of Stephen “tWitch” Boss’ passing has made my heart so heavy. And it has reminded me that so many are unprepared to understand what they or those they love may be experiencing. So I will be sharing more over time. We have to take time to grieve but then we honor him and others who have suffered by pushing for greater services and support for people who are currently suffering or will suffer. We must fight for access to quality mental health services in the communities where people deserve to be able to continue living, working, and playing. We have a long way to go but I’m hopeful about that too and promise you I will not quit until I see this realized.