As a vegan, one of my favorite jokes goes like this:
Q: How do you know someone you just met is vegan?
A: They’ll tell you.
While the joke asserts that vegans are quick to self-disclose, the opposite tends to be true of people who are in serious pain. That’s why we need to ask people how they are–directly and frequently. By responding to early signs of distress, we can keep it from escalating to the point of crisis; in other words, we should aim to prevent suidicality, rather than suicide.
Many suicide prevention efforts focus on preventing suicide attempts. This can take the form of training community members to identify signs of suicidality (also known as “gatekeeper training”) or providing crisis counseling services (including phone or text helplines) where youth can receive emergency support. Other approaches focus on reducing access to means (such as building physical barriers on the walkways of bridges, or implementing stricter regulations on buying and storing firearms).
Both of these are valuable approaches, but they only address the crisis of suicide itself.
Let’s consider an analogy to a heart attack (another life-threatening condition with an extreme risk of dying). In the event of a heart attack, it’s essential that emergency services are available, from crisis lines (911) to skilled workers and dedicated centers (doctors and hospitals) that are trained and resourced to keep the person who is experiencing the heart attack alive.
But emergency interventions are costly and risky. Anyone who has ever seen a hospital bill can attest to this. Additionally, emergency interventions are often just the first step in a long process of returning to health. Think of people who experience a heart attack and arrive in the ER, undergo emergency surgery, recover in the hospital, get discharged to a rehabilitation facility, then go home with a list of prescription medications, only to continue working with a physical therapist and occupational therapist. All this is the best-case scenario, assuming that the person got to the hospital on time, assuming that the emergency surgery was successful, assuming that recovery was relatively uncomplicated.
The same is true for emergency interventions for individuals who have made, or might make, a suicide attempt. The risk is not over at the end of a conversation with a crisis counselor or after being discharged from the hospital; the path to recovery is only just beginning.
Early interventions offer drastically better outcomes, at lower costs. Imagine someone undergoing a routine physical exam that detects elevated cholesterol levels and high blood pressure, leading to suggestions about specific lifestyle and/or medication changes that might help prevent a risk of a heart attack. This person might make some dietary changes, some exercise changes, and take a daily pill. In this case, the person in question may not have been aware of the risk factors in place. But, by implementing lifestyle changes, this person never has to experience the acute distress of a heart attack. How might all this apply to people who are on the road to suicidality?
Preventing suicide is good, but preventing suicidality is better. Learning about signs of suicidality is akin to learning about signs of a heart attack. It’s important, but I believe it’s also important to identify risk of suicidality: precursors that, if addressed properly, can take someone off of the path that could lead to suicidality and death by suicide.
The Three-Step Theory of Suicide posits that suicide is the result of:
- intense pain and hopelessness that
- overpowers a sense of connectedness, coupled with
- capability to attempt suicide (including access to fatal means).
This theory suggests that identifying people experiencing lingering distress, and especially those who experience a low degree of connectedness, can serve as a starting point for preventing suicidality. But it also presents a conundrum–especially when it comes to young people, who are increasingly at risk.
Youth experiencing psychological pain often avoid seeking support. Many tend to withdraw, and they may interact in ways that alienate others. There are many reasons for this, including fear of acknowledging their own challenges, fear of being judged, uncertainty about the benefit of asking for help, and lack of awareness regarding the presence or importance of the distress they are experiencing.
Even when youth do seek support, they may do so in ways that are muted, subtle, or otherwise unclear, often due to their own ambivalence. But if youth avoid seeking support, how would we know that they need it? Simple: We can ask them how they are.
Effective check-ins do not need to be formal. However, they should be: proactive, frequent, individual, confidential, and specific. A frequency of once a week seems to work for most people; but even a monthly check-in is better than no check-in at all. Questions about specific aspects of life (such as “How’s your sleep?” or “How are things going with friends?”) tend to elicit more thoughtful and sincere responses than general questions like “How are you?”
Check-ins that are individual and confidential allow youth to respond honestly, without fear of judgment from peers and authority figures. Because young people don’t always seek support when they need it, it’s important to check in with them proactively (rather than wait for signs of distress); this has the added benefit of creating opportunities to celebrate times when things are good.
When we are in pain, we usually want someone else to know; but we also have a hard time remembering that others really do want to know. When we proactively check in with others, they don’t need to worry about whether or not we care.
People will express how they are doing, when asked. Internal data from Early Alert, which offers weekly proactive wellness check-ins for students in schools and universities around the country, shows that about 65% of students showing a potential for severe distress (according to their responses) are not currently on anyone’s radar. They look good from the outside, and they are not seeking support. When Early Alert suggests to administrators that it would be a good idea to reach out to such students and see what support can be offered, those administrators report that over 60% of the outreach results in the prevention or shortening of crises. It’s worth adding that students are typically grateful for this offer of support. Just as they were beginning to feel overwhelmed, a friendly person reaches out and offers help.
Checking in at scale is challenging–and doable. Checking in with your loved ones at regular intervals does require some intentionality, both in terms of remembering to check in and in terms of asking the right questions. But if you are responsible for a large number of people (say, students at a university) it actually becomes challenging to check in with each and every one of them on a frequent basis. Solutions include scheduling regular meetings with advisors or counselors, implementing buddy systems (perhaps with some guidance on principles of checking in and supportive listening), or implementing automated check-in systems that facilitate referrals to professionals.
Checking in is key to identifying risk of suicidality. Individual check-ins are a powerful tool for identifying those who are at risk or already experiencing distress. Surprisingly few suicide prevention efforts focus on the seemingly mundane act of checking in with people to see how they are feeling and learn about the cause of their distress. Implementing a system for checking in with your loved ones is fairly straightforward: Establish the tradition of checking in during dinner, make a habit of going on a walk-and-talk on weekends, schedule a weekly phone call. At an institutional level, ensuring everyone gets a regular check-in requires more rigorous planning, but is well within reach.
This week, schedule a time for yourself to come up with a plan to check in regularly with the ones you care about most. Why wait for a crisis?
Eran Magen, PhD, is the founder of Early Alert, which works with K-12 schools and universities to prevent student suicide by implementing proactive wellness check-ins, coupled with instant referrals. He is also the founder of Parenting for Humans, a relationship-first, trauma-informed approach to parenting that empowers parents to build stronger, more joyful relationships with their children and with themselves. Dr. Magen earned his M.A. in Education and PhD in Psychology from Stanford University, completed post-doctoral training in population health as a Robert Wood Johnson Health & Society Scholar, and served as the research director for the University of Pennsylvania’s Department of Counseling and Psychological Services. Dr. Magen is a member of the JED Advisory Board.