Important disclaimer: this manual is NOT a substitute for mental health care. If someone is experiencing suicidal thoughts/behaviors, call emergency services immediately.

This manual provides evidence-based guidance for recognizing and responding to suicidal ideation. It is designed for the community, more specifically, those who may encounter someone experiencing suicidal ideation. Over 30 papers were reviewed by the YSSA research team, and the analysis conducted by the team was heavily scrutinized with a third-party software (NVivo) for the accuracy of the analysis.

The manual was created in memory of a high school student who fell victim to suicide, and the Fort Lee Community.

Understanding Suicidality

What Drives Suicidal Thoughts?

Research previously showed that suicidal behavior is often goal-oriented or directed rather than impulsive. Many factors serve in conjunction for its purpose, including escaping unbearable emotional pain, ending the feeling of burdening, cutting life circumstances, and even communicating distress when other methods have failed.

Risk Factors and Protective Factors

Suicidality stems from negative thinking patterns that are often maladaptive; some of these examples may include mental health conditions such as depression, anxiety, bipolar disorder, and substance abuse. However, many interpersonal factors may contribute to suicidality, including the loss of a relationship, job loss, or even disconnection from family, friends, or community. There may also be visual or genetic factors, having easy access to lethal methods, or a previous history of suicide attempts. The protective factors negate the risk in terms of cycling (the loop of feeling good/bad, participating/not participating in pleasant hobbies, and intrapersonal thoughts). For a more beneficial cycle, factors tend to include strong social connections, access to mental health care, or even a sense of purpose.

Recognizing Warning Signs

Immediate Warning Signs

Immediate Warning Signs may include direct statements, specific plans, acquiring means, giving away possessions, or even sudden calmness. However, there are many nuances in behavioral warning signs in terms of withdrawal from social norms, sleep changes, appetite, risk-taking, and a decline in performance (school, work, or daily functioning).

Risk levels can categorize suicidality: Low Risk: Thoughts without specific plans or means for self-harm. Moderate Risk: Thoughts with vague plans but no immediate risks or means. High Risk: Specific plans with risk and a timeline. Imminent Risk: Plans and intention to act immediately

Support and Evidence-Based Approaches

Communication and Intervention

A basic safety plan can be formulated with the removal of lethal methods, the identification of support, whether being friends, family, or professionals, regular check-ins, distractions (distraction kits), and professional contacts.

Mindfulness and Grounding Techniques can manage intense emotions; the 5-4-3-2-1 Grounding Technique can serve as a distraction from maladaptive thoughts and negative ideations. With the target of your five senses, the grounding technique can intertwine with distraction kits. The technique includes 5 things you can see, 4 things you can touch, 3 things you can hear, 2 things you can smell, and 1 thing you can taste. With YSSA Distraction Kits, these mindfulness techniques provide a solid framework for the avoidance of negative ideations. Additionally, Behavioral Activation, an evidence-based intervention founded by Carl Lejuez, offers a professional-suitable economic treatment for those experiencing anxiety or depression. With the alteration of daily activities and routine in terms of significance and enjoyment, the method can profoundly reduce maladaptive behaviors in terms of angles or nest steps.

In conversations with someone who is experiencing suicidal ideations, show support and presence with affirmations, hope, partnership, and understanding. A form of these values can be amorphous, but examples may include dialogue such as “I'm here for you”, “You matter to me”, “This feeling can change”, and “What's been happening that's brought you to this point?”

However, dialogue may consist of efforts that may undermine feelings rather than help. Many conversations may minimize pain, add shame and judgment, dismiss experience, and invalidate pain. Avoid phrases such as “Just think positive”, “You have so much to live for”, “Suicide is selfish”, “I know exactly how you feel”, and “Things could be worse”.

Active listening techniques include the reflection of feelings, summarization, open-ended questions, emotional validation, and the avoidance of rushed solutions.

When Someone Refuses Help

Understanding resistance stems from the stigma of being labeled or judged and factors that may include previous negative experiences, cultural factors, fear of consequences, and autonomy concerns. Bad experiences with mental health care, family or cultural beliefs about mental health, the fear of hospitalization and job loss, and the belief that nothing can help are all nuances that contribute to the stigma and the maladaptivity of seeking help. When professional help is refused, respect their autonomy and acknowledge their right to make decisions. Avoid pushing or creating power struggles and express your concerns clearly but respectfully. Start small in peer support groups or online resources and subject them to nest steps where constant activity may alter beliefs. Address specific concerts like the cost, time, and stigma, and maintain a supportive presence. Be available for crisis moments, celebrate the small improvements, and continue regular check-ins. However, know your limits and set boundaries; be clear about what you can and cannot provide, seek support for yourself, and most importantly, do not take responsibility for their choices. In conjunction, create alternate support networks such as family meetings, friends, and community connections, such as religious organizations, clubs, or volunteer opportunities.

Self-Care for Supporters

Supporting someone experiencing suicidal thoughts can be emotionally exhausting and stressful. Common reactions can include anxiety about their safety, feeling overwhelmed, guilt, fear of saying the wrong thing, and emotional exhaustion from constant worry. Self-care strategies include setting realistic boundaries, seeking support, and practicing self-care activities. Share concerns and know your limits and responsibilities. Acknowledge what you can and cannot control and practice self-care activities. Stay informed, but don't overdo it. Learn about the stigma and avoid obsessive research, focus on reliable sources, and remember you are not the therapist. Warning signs you need more support include the loss of sleep, neglecting your responsibilities, feeling constant anxiety or depression, and isolating yourself from your support system.

Professional Resources and Referrals

Seek professional help immediately when active suicidal ideation with plans and means, recent suicide attempt, severe depression or mental health symptoms, substance abuse, familial history, lack of support, and the level of personal comfort is exceeded. Types of professional help include the crisis hotline (988 suicide and crisis lifeline), mobile crisis teams (community-based), and emergency departments. Other ongoing mental health care can include primary care physicians, psychiatrists, therapists, and community mental health centers. Offer to help with the logistics, be patient, follow up, and attend appointments if welcomed. Making appointments, transportation, or insurance questions can significantly reduce the stigma surrounding the need for help. Additionally, explain the benefits and normalize help-seeking. Address concerns and offer a choice to provide a more homogenous and inclusive construct in time and effort.

Remember, you don't always have to be perfect, and recovery is always possible.

988 Suicide & Crisis Lifeline

• Phone: 988

• Text: Text "HELLO" to 741741

• Chat: suicidepreventionlifeline.org

• Available 24/7, free, confidential

Crisis Text Line

• Text: "HOME" to 741741

• Available 24/7, free, confidential support via text

The Trevor Project (LGBTQ+ Youth)

• Phone: 1-866-488-7386

• Text: "START" to 678-678

• Chat: thetrevorproject.org

Trans Lifeline

• Phone: 877-565-8860

• Run by and for transgender people

National Sexual Assault Hotline

• Phone: 1-800-656-4673

• 24/7 support for sexual assault survivors

National Suicide Prevention Lifeline

• Website: suicidepreventionlifeline.org

• Comprehensive resources and information

American Foundation for Suicide Prevention

• Website: afsp.org

• Educational materials and support resources

Crisis Text Line

• Website: crisistextline.org

• Information about text-based crisis support

National Alliance on Mental Illness (NAMI)

• Website: nami.org

• Mental health education and support resources

Local Emergency Services:

• 911: For immediate life-threatening emergencies

• Local crisis hotlines: Search "[your area] crisis hotline"

• Hospital emergency departments: Available 24/7 for psychiatric emergencies

• Mobile crisis services: Community-based crisis response teams

National Suicide Prevention Lifeline

• Website: suicidepreventionlifeline.org

• Comprehensive resources and information

American Foundation for Suicide Prevention

• Website: afsp.org

• Educational materials and support resources

Crisis Text Line

• Website: crisistextline.org

• Information about text-based crisis support

National Alliance on Mental Illness (NAMI)

• Website: nami.org

• Mental health education and support resources

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