The suicide death rate in most states has risen sharply since in the late 1990s, according to data released in June by the Centers for Disease Control and Prevention, with 25 states recording increases of more than 30% during that time. In 2017, the national suicide rate rose 3.7%, the sharpest annual increase in nearly a decade.
Melanie Harned, a psychologist who specializes in suicide prevention, discussed what to do when you think someone is suicidal and explained Dialectical Behavior Therapy, an approach that research shows can be effective at reducing suicidal thoughts and attempts. Dr. Harned is the coordinator of the DBT program at the VA Puget Sound Health Care System and a senior research scientist in the department of psychology at the University of Washington. She has been researching DBT and how to prevent suicide in high-risk populations—including adolescents and people with PTSD, borderline personality and opioid dependence—for 14 years. Here are edited excerpts from the interview.
Can suicide be prevented?
Absolutely. There are indirect warning signs to look for, things like increased hopelessness, viewing oneself as a burden, more substance use, a change in sleep patterns, withdrawing from activities, aggression. The American Foundation for Suicide Prevention has a list on their website. There are also more direct indicators: Is the person thinking of killing themself? Are they communicating intent to anyone?
The biggest risk factor is that the person has attempted suicide before. Access to lethal means, such as a firearm or medication, is another consideration. Suicide is very often an impulsive decision. Most people who attempted suicide and survived said they thought about killing themselves for less than an hour before they acted. So you want to restrict their access to the means to hurt themselves, to prevent the impulsive attempt.
One of the biggest interventions is to simply ask someone if they are thinking about suicide and if they have a plan. They may not give an honest answer because of shame or the fear that someone will throw them into a hospital. But if you ask in a caring, compassionate way, a person will be more likely to disclose their intent than if they were just left on their own.
How do you ask?
You don’t want to sound judgmental. Don’t say: “What is wrong with you?” or “How could you imagine doing that to yourself?”
Ask: “Are you thinking of killing yourself?” And express compassion and care. Communicate to the depressed person that their thoughts and behaviors make sense, that many people think of killing themselves.
A common fear is that if you ask someone if they are thinking of suicide this will give them the idea and they will go do it. Research shows this is not true. It gives them an opportunity to talk about it. Most people who are thinking of killing themselves don’t want to be dead. What they want is relief from some sort of pain that is intolerable.
What should you do if you suspect someone is suicidal?
Try to connect the person to professional care. The National Suicide Prevention Lifeline can provide resources and give advice on what to do. Its hotline is 800-273-8255. You should try to restrict the person’s access to lethal means, such as medications and guns. And if a person is showing an intention to act you should not leave them alone until they get connected with care. If it’s a really high-risk situation, take them to the emergency room.
What is Dialectical Behavior Therapy?
It’s a treatment that balances cognitive behavioral therapy with acceptance strategies taken from Zen philosophy and Eastern practice. CBT is very change-focused. You have a problem and we are going to help you solve it. It teaches patients a lot of skills—how to better manage and regulate their emotions, how to have stronger relationships and communicate effectively. DBT layers in acceptance strategies, helping people accept reality as it is in this moment and their pain. It doesn’t mean they can’t change it. But in order to change pain you need to accept you are in it. The overall goal of this treatment is to help patients build a life that they experience as worth living.
How does DBT work?
There are four components: individual therapy; a group-therapy component that is less like traditional group therapy and more of a skills-training class; phone coaching between sessions—the therapist is available 24/7 to take calls; and a therapist-consultation team.
What does DBT teach patients?
Four sets of skills. The core set is mindfulness skills. Mindfulness is about learning to live in the present moment with awareness and without judgment. It’s in this treatment because if you can’t pay attention to the present moment and just the facts and reality of it, then it is really hard to make wise and effective decisions on how to act.
The next set of skills is distress tolerance. Some of these are crisis-survival skills. They teach you how to get through a high-stress situation without doing anything to make it worse. If you are having urges to kill yourself, these skills will get you through the crisis period without acting on those urges. There are also reality-acceptance skills. Acceptance does not mean giving up or not trying to change. It means accepting that in this particular moment this is reality. Denying or suppressing pain actually makes it worse.
The third set of skills is emotion regulation. One way to change your emotions is to reduce your vulnerability to having intense emotions in the first place. You can do this by making sure you are regularly doing pleasurable things, getting enough sleep, eating well and exercising. And once an emotion has gotten started, there are strategies you can use to reduce the intensity of it. The fourth skill set focuses on interpersonal effectiveness. We teach people how to build and maintain relationships, how to get what they want and say no to things they don’t, how to maintain their own self-respect.
How does DBT treat suicidal
First, we target it. The standard approach is to treat suicide as a symptom of another problem, such as depression. You treat the depression and see if this makes the suicidal behavior stop. DBT is different because it makes targeting the life-threatening behavior the number-one priority.
One really important piece of DBT is we do everything we can to keep people out of psychiatric hospitals. Ultimately people don’t live in hospitals, so we need them to be able to manage suicidal urges in their everyday life.
It also uses a very structured assessment and problem-solving technique called chain analysis. We try to look moment-to-moment at the chain of events that led up to and followed whatever the behavior is—either a suicide attempt or self-harm urges becoming high—so we can see what to change.
Validation also plays a big part. We communicate to patients that they are understandable and acceptable exactly as they are.
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