>>How to Help a Friend In a Mental Health Crisis

Midway through the morning session of Mental Health First Aid, a course at the Mental Health Center of Denver, my instructor asks me to turn to one of my tablemates, look them in the eye, and ask a simple question: “Are you thinking about killing yourself?” Not “hurting yourself,” because the semantics will work against you. “Killing yourself.” Simple, direct, straight-faced.

I fail. I ask the question with an uncomfortable laugh and a half smile. It turns out that question is really, really hard to ask, even when you’re interrogating a nonsuicidal stranger in a training exercise who knows it’s coming.

And that’s the point. The instructors at these increasingly popular learn-to-help classes want us to ask the question aloud so that when we need to use it in real life, we won’t hesitate or otherwise botch it.

That’s because one in five Americans has a mental health disorder, and whether we like it or not, there’s a good chance that we—the friend, the parent, the confidant—will be the emotional first responder to someone’s panic attack, depression, or suicidal musing. During the pandemic, more adults reported depression and suicidal thoughts. And, like me, most of us have no clue what to do.

What Mental Health First Aid is

Mental Health First Aid has been around since 2000, when it was created in Australia by a nurse and a professor of mental health literacy to educate the public about mental disorders. At libraries and other public facilities, it teaches the signs and symptoms of various conditions, and then—and this is crucial—how to talk about them with the person in distress. In the U. S., 12,000 MHFA instructors have trained more than a million people. After the Sandy Hook school shooting in Newtown, Connecticut, President Obama allocated $15 million to the Substance Abuse and Mental Health Services Administration to implement the program through state and local education agencies.

In my adult MHFA class, an eight-hour course that cost me $20 (prices range from free to $75), our ranks are filled mostly with non–mental health professionals, including a nursing student, a USDA representative who works with rural farmers, and a homeless-shelter volunteer—all of whom are often faced with crisis intervention. As a journalist who works from home, I am not.

But at the tail end of 2018, I became worried about a close friend. His family and business were falling apart. He was drinking and repeatedly mentioned being in a “dark place.” I let him know that I was concerned, asked questions, and offered support and dinners at my home. I brought up therapy and counseling, but I never once asked him the most important question: “Are you thinking about killing yourself?” I thought I could dance around the word suicide because we both understood that the “dark place” was a waiting room where he was making up his mind. But avoiding the word, I am now learning, let him dance around it with me.

In class, we watch low-budget videos featuring people suffering from a slew of mental disorders and we look for the signs, like the way depression shows its hand in someone’s flat affect or the way a person pulls away from friends and misses work. We watch depression suck the life out of them as it did my friend. We draw what we think anxiety looks like; most of us draw dark spirals like the kid in The Ring did. Then we repeat the exercise with schizophrenia and bipolar disorder. We cram a Psych 101 semester into four hours and retain as little as you’d expect.

Over the course of the day, we learn and recite with numbing repetition the program’s action plan, ALGEE: Assess for risk of suicide or harm, listen nonjudgmentally, give reassurance and information, encourage appropriate professional help, and encourage self-help and other support strategies. After the third time it’s drilled into us, I exchange exasperated glances with a few other students; it’s clear how much everyone resents this part of the class. We’re spending an eight-hour workday under fluorescent lights in a beige room with the shades drawn. I don’t want an action plan; I want more time with a script; I want to know what to say and how to say it. We role-play a conversation once; we go over ALGEE at least five times through assorted games.

Some mental health professionals have criticized MHFA for being overly reductive. Others say the one-day class stigmatizes mental disorders by encouraging students to diagnose and label based on a boilerplate list of symptoms and that its push to refer people to mental health experts just isn’t realistic for parts of the country where those services aren’t readily available. An exercise in which we all line up as various disorders, from least to most disabling, would make more than a few professionals squirm.

Asking the key question

I’ve made a career out of knowing how to talk to people, and I’ve worked extensively with survivors of trauma. But my interview subjects know ahead of time that we’re going to have a tough conversation. Approaching someone you love feels different. It’s scary to have a talk you don’t feel qualified to have. What if you escalate things? What if you do it wrong?

It’s itchy business intervening in someone’s personal life, even if you’re genuinely concerned. According to the National Council for Behavioral Health, most people will avoid somebody experiencing a mental health crisis. That fear, a police consultant in the class points out, also leads too many of us to mind our own business when we should be checking in. “Friends and family are always taken by surprise when someone they knew becomes an active shooter,” he says. “But the signs were all there—the signs always are. They just missed them.”

Fear also leads us to get squirrelly about being direct with the “Are you thinking about killing yourself?” question. “If it’s clear that you dread the question, your friend might not think you can handle the answer,” says the instructor. We learn that the key to having these discussions is calm confidence, feigned or real. That means no fidgeting. Keep an open body position. Listen attentively. Sit side by side, not across from each other, because you need to not feel on the spot to have a hard conversation. And contrary to what you may think, asking someone about suicide won’t intensify their feelings; it usually defuses them. As the day unfolds, our time is filled with useful segments and mind-numbing ones.

The limits of information

Among the big issues that some psychologists and recovery-center directors are raising about the effectiveness of MHFA is that there’s no research showing that people have benefited from attendees’ intervention. A recent study at the University of Colorado School of Medicine found there was an almost 30 percent increase in mental health awareness and confidence in intervening among MHFA attendees. But no one knows how often graduates have intervened or whether what they did was effective.

We need a starting place, however, and education is one. Because most people don’t know that the average age for the onset of an anxiety disorder is 11. Or that panic attacks can last as long as 20 minutes. Or that a worrying sign of suicide risk is inexplicable happiness in someone who hasn’t been happy. Or that you should pay extra attention to people during the first three months after they’ve sought help for suicidal thoughts or survived a suicide attempt, because that’s when they’re at the highest risk of killing themselves.

If anything, a class like this offers a game plan—perfect or not—and, more important, a reminder that oftentimes we’re the stopgap and need to step up. Thankfully, my friend found AA on his own. We’ve since had honest conversations about his suicidal thinking, and I feel better knowing that if his dark place comes up again, I know what to ask.

Do I feel like a trained professional? No. Did I forget things and need to revisit my notes to write this story? Yes. Does it make me more likely to intervene? With friends and family, absolutely; with strangers, I’d still be hesitant.

But if someone in the grocery store were to have a panic attack and people were standing around just looking at one another, I like to think I’d take the reins until help could arrive. What you can do:

Make a tough talk less tough

One of the most valuable pieces of MHFA is the playbook it teaches for bringing up big issues with someone in crisis. If your friend raises concerns for you, use these strategies.

• Let your friend know you’re concerned because of what you’ve observed. Start most of your sentences with “I,” such as “I can tell you’re having a hard time” or “I noticed you’ve been coming in late to work.” It’s less accusatory.
• Don’t make promises you can’t keep or agree to keep the suicidal thoughts a secret.
• If your friend answers yes to “Are you thinking about killing yourself?” follow up with: “Do you have a plan?” “Have you decided when you’re going to do it?” “Have you collected the things you need to carry it out?”
• Ask open-ended questions, and don’t be patronizing by saying, “You have a lot to live for.” Let your friend set the pace. Always empathize with what they’re feeling, not with the story they’re telling themselves.
• If your friend has a plan, offer to call a hotline like the National Suicide Prevention Lifeline, and stay with them. You can also offer to find other help, such as a peer-support group or a mental health provider, and to go along to the appointment. If things escalate—if, say, your friend has a weapon—you can call 911 and request a crisis intervention team, a special police unit trained to de-escalate a mental health emergency.