Talking Through a Crisis


Tailored Techniques

There is no such thing as a set formula for a crisis conversation. Every person is unique in every way. This means their circumstances are different, their personalities will vary, their intent and plans will change from person to person, and they will respond best to different approaches. Every conversation should start with a simple invitation for the person to tell you what's going on. Where you go with it from there is up to your judgment of what will work best.

It is next to impossible to say something so wrong that you can't recover from it. Finding someone's style and figuring out what will work best with them can take some trial and error. As long as you don't suggest anything actively harmful, you'll be okay. If the person in crisis reacts badly to something you say, a simple apology followed by asking why they reacted as they did should move things forward. What matters is that you're present in the conversation and showing you care.

Rogerian Intervention Style

This style is very patient-centered. It involves active listening - encouraging the person in crisis to talk much more than you do, offering sympathetic and encouraging comments along the way. Voicing acceptance of the issues they face and any triggers they've experienced, acknowledging them as hardships, and showing approval of good coping skills where appropriate. Give helper responses to encourage them to finish incomplete thoughts.

It's worth noting that this approach has been proven most effective at reducing suicidal urgency only in non-chronic crisis cases. Elements of it may be helpful in dealing with chronic suicidal people as well, but overall it may not be as effective.

Directive Intervention Style

This approach is a "no nonsense" style. With it, you'll take control of the conversation, asking direct investigative questions to identify the person's condition, current risk, and contributing factors to the crisis. This method is heavy on suggestions and advice, offering things the person in crisis can do to improve their situation. Offering limited personal information about yourself can be helpful here, if it will serve to establish you as the voice of experience in a particular area or, at the very least, demonstrate they're not alone.

Elements of a Successful Intervention

More often than not, you'll use a combination of elements from both of the above techniques. Additional elements to include are:

  • Supportive approach. Be honest with people about the difficulties they face, but help them see they are able to overcome them.
  • Collaborative problem-solving. Work together with people on finding solutions. The more invested they are in figuring out their next steps, the more empowered they'll feel to take those next steps.
  • Show empathy and respect. Treat everyone in a manner that shows you assume they're capable of handling whatever life throws at them.
  • Ask clarifying questions to make sure you fully understand the situation or the problem that brought them into crisis.
  • Always offer resources. Google is your friend, and you should make sure you're familiar with all the pages on the TransPulse site.
  • If possible, outline a concrete plan of action to address the situation.
Some crisis centers put a lot of faith in no-harm contracts - a more formal sort of agreement between counselor and person in crisis dictating that the person in crisis won't take any harmful actions until the situation can be reevaluated after some condition or other is met. Do not do this. There is considerable evidence that forcing people into these agreements doesn't help their suicidal urges in the least. What it does is makes them feel guilty for continuing to be suicidal. This leads to shame and the sense that they've failed yet again, and can easily be the trigger for an attempt.

When Suicidal Intent is Declared

When someone says anything that indicates an attempt is coming - even if you're not completely certain that's what they mean - this needs to become your immediate focus. Start by asking if they've made a plan. If so, have they chosen the means? Have they settled on a specific time for their attempt?

If they've chosen a method, ask if they have that method with them at the moment. If they do, ask them to put it away while you talk. From there, you can work on convincing them to safely store or dispose of the means. Some people will hesitate to put it away during your conversation. In those cases, keep the chat going, but ask again periodically for them to remove the means from the room.

Never suggest alternative methods. If the person in crisis doesn't tell you they've considered it, don't bring it up.

One very helpful tactic we've used over the years has been warning people in crisis of the potential disastrous effects of their chosen means. Someone who intends to slice their wrists may well survive the attempt and end up with permanent muscle or tendon damage. Someone planning to overdose might survive and have to deal with severely damaged organs for the rest of their life. Suggesting these possibilities isn't just grasping at straws - these things have actually happened.

Remember that mental disorders are not direct causes of suicide. While it is often helpful to point out that diagnosed disorders are the reasons for negative or intrusive thoughts a person may be having, the disorder itself is not the cause of the suicidal feelings. This gives us an opening to work with people on counteracting negative, illness-induced thoughts with more positive truths, which is a very effective way of reducing suicidal urgency.

Something to keep in mind is that some disorders may develop as protective factors before they become harmful disorders. OCD, for example, could manifest initially as a compulsion to repeat an activity that will save a life, only to spiral out of control. Substance abuse is another common "protective" disorder, as drugs and alcohol allow people to escape their present pain, even if only for a short time. Conversely, it's not uncommon for people to view substance abuse as a "slow," indirect method of suicide.

As you suggest ways to build protective factors, remember that things like social integration, romantic relationships, and building solid social support are harder to obtain and maintain for people with mental disorders. Unemployment is also more prevalent among the mentally ill. Be ready to listen to the person in crisis as they tell you how they personally struggle with these things so you can offer practical, individual tips on overcoming those difficulties.

The stigma, marginalization, and dependency that result from mental disorders are all significant risk factors that can complicate a person's situation. Think of the number of minors we see on a regular basis who suffer from depression or anxiety, but who can't seek treatment because their parents don't believe in mental illness or psychiatry. For many, suggesting and then reinforcing healthy coping mechanisms is the best support we can offer.

Note that medication compliance is a tricky area for suicidal people. Of course non-compliance with treatment is a risk factor, as there is no beneficial effect to be gained from medication one isn't taking as prescribed. It's worth reminding people that psychiatric medications can take several weeks to become effective. It's also possible that a person will have to try several medications before finding one that works; working closely with the prescribing doctor is an absolute must.

What most people don't consider, though, is that the first stages of effective medication can be just as dangerous. As the medication begins to take hold, people find new organizational ability and motivation to act, while the effects of their disorder aren't yet fully mitigated. This can result in someone being very much suicidal and having ability to act on that feeling they didn't have before they started taking their medication. Be watchful for this, and always counsel patience and close contact with the prescribing doctor.

Most crisis situations we deal with in chat don't involve working with people who are on the edge of attempting suicide. Either because of their gender or a mental disorder, people may have fragile or nonexistent social supports and difficulty coping. Situations you might find regular and manageable are perceived by people with mental disorders as impossible to navigate as a result of poor coping skills, impaired cognitive abilities, and/or lower resilience. Offering good coping tools and a more positive, realistic view of the situation is often all that's needed to resolve the immediate issue.

When the immediate problem is severe dysphoria, the most successful remedy you can suggest is distraction. Brainstorm with the person to find out if there's something they can work on or a hobby they can engage in to take their mind off of the dysphoria while it settles down. Don't suggest it immediately as it may escalate the dysphoria, but if the person indicates they have a gender-confirming activity available, such as dressing a certain way or experimenting with cosmetics, encourage them to do that.

Above all, remember the individuality of each person you speak with. You will find, as everyone who has done crisis work has, that some people respond well to things that seem utterly counterintuitive. Use your knowledge of the people involved where you can, and don't be afraid to alter your approach with people you don't know to see what works best for them personally.

A Note About Self-Harm

If someone discloses to you that they've been engaged in harmful or injurious behavior, immediately find out what they've done and what effects remain. If they've been cutting, find out whether there are wounds still open and bleeding. Stop the conversation until they've applied bandages, elevated the injured appendage, or run cold water over it to stop the flow of blood. If they overdosed on something, get them to tell you exactly what and how much. Google it to find out what the lethal dose is and if there is any question in your mind insist they visit the hospital.

Before you engage in any conversation about what prompted the self-harm, make sure any appropriate medical attention has been given. If the person indicates they are actively harming themselves while talking to you, refuse to discuss the matter further unless they agree to stop for the duration of your conversation.