The Suicidal Caller

By Craig S. Judd, MA and Kathlene B. LaCour, MA

Dec 05/Jan 06

It is your shift and that call comes to you.  The voice on the phone is low, nearly inaudible, saying, "I need some help."  You respond saying, "Okay, how can I help you?"  It is then you hear, "I'm feeling like killing myself."  Your breath becomes short, your pulse starts racing, and your mouth gets dry.  Your thoughts turn to "What do I do now? Should I get the doc?" "Is this a prank?"  You are at a profound loss as to what to do.  You freeze, not wanting to say the wrong thing or worse yet, they hang up leaving you worried that you may have been the last person they reached out to before ending it all. 

Your profession promotes the value of helping people, especially people who are sick and in need of medical attention.  Your training and experience has prepared you to assess the signs and symptoms of most medical disorders, not mental disorders.  You wish you would have listened closer in those psychology classes while in nursing school, but at the time you figured, "I don't plan to become a psych nurse," so you didn't pay much attention to these types of patients.  All of a sudden, you find yourself more concerned with your own feelings of inadequacy and anxiety and less on how you can help this person.

It does not need to be this way: Telephone triage is now in vogue.  It is the trend in several professions including medical and mental health organizations.  It was one thing to have dealt with a suicidal patient as a face-to-face contact; you often had other available resources at your disposal.  Now with telephone triage, contact with this type of caller may be the very first contact between them and a helping professional.

In an effort to respond to the needs and skill sets of nurses and other medical personnel, we have provided some basic information and useful techniques for screening the suicidal caller on the telephone.  We intend for this information to provide medical professionals with some very fundamental screening techniques.  Let us start with some facts and myths surrounding suicide: 

Facts:

• Seventy percent of those who commit suicide display some warning sign(s) prior to an attempt.

• Sixty-six percent of those who commit suicide visit a physician less than one month prior to their death.  This means that two-thirds of all successful suicides had an opportunity for early detection and intervention by a medical professional. 

Myths: 

• "Talking about suicide gives people the idea of attempting suicide."  This is false; openly discussing suicidal thoughts does not create these thoughts nor does it trigger any decision to act on them.  Talking about their thoughts actually provides them an opportunity to share their feelings with someone who can help.

• "If they're going to kill themselves, no one can stop them."  This is also false; verbalized statements are warning signs — pleas for help.  It's the lack of attention to these signs that may contribute to a person's decision to end their life.  If a person is calling, they are ambivalent about suicide and possibly you are the one to intervene.

What can you do?

• Increase personal comfort and professional confidence in handling the mental health needs of these patients through learning new skills sets.

• Make a therapeutic connection.

• Complete an appropriate assessment of risk.

• Provide an accurate intervention so to provide for the patient's safety and well-being.

Personal comfort/therapeutic connection - The first and most critical telephone intervention you will perform consists of creating an immediate, undistracted, unhurried, unbiased, and calm connection with the caller.  The first 30-45 seconds of the conversation are critical, as you set the tone of empathy and concern for the caller.  Empathy is the ability of one person to convey the feeling of sensitivity and understanding, while maintaining a healthy emotional boundary.  It is the balance between being too objective, which often communicates a sterile, overly clinical, distant impression and being too subjective.  This can contribute to clinical ineffectiveness and personal feelings of helplessness.  There are specific listening skills and techniques that can assist you in developing this critical empathic environment for the caller.

Complete an appropriate assessment of risk - Once you have established rapport with the caller, you can begin to focus more on gathering critical risk information.  Some key risk indicators are:

• Actual suicidal statements

• Developed suicide plan

• Intention

• Drug/alcohol intoxication 

• History of suicide attempts or gestures 

• History of psychiatric illness/treatment 

• Natural supports

• Current psychosocial stressors

Obtaining this information is imperative and best gathered creatively through learned interviewing techniques, preferably not in a checklist-style interaction.  Risk of suicide is influenced by the absence, presence, and the combinations of these indicators and others. 

Accurate intervention - After collecting the vital risk information, your focus shifts to where and when the caller's needs are best addressed.  The determined level of risk will dictate the level of intervention. 

• Low risk may allow for routine follow up with mental health services. 

• Moderate Risk may require immediate face-to-face assessment at the ER.

• High Risk will necessitate calling 911 and coordinating a police well-being check while remaining on the phone with the caller.

With regard to all telephonic suicide screening where it is uncertain whether the risk is between moderate and high, always recommend the high risk intervention. 

This article is intended to provide a brief overview of conducting effective telephone suicide screening.  We are confident that when that call comes to you, you will be more prepared to perform.   Keep in mind, focus on developing quick rapport with your patient, make note of information related to the key risk indicators, and make a confident intervention decision.  It is likely your pulse will still increase, your palms may get sweaty, and you may still worry about the outcome, but you will be more confident, provide the caller with more hope and feel more helpful.

Kathlene LaCour and Craig Judd provide training and consultation services to medical and mental health call centers. They may be reached at 269-929-1292 or interface_consultation@comcast.net;.