CCGL9053: SUICIDE, RISKS, RESEARCH& REALITIES

Understanding And Responding To

Negative Emotions And Warning Signs:
Perspectives From Helping Professionals

Harrison Sit
Registered Educational Psychologist,
Hong Kong Psychological Society (HKPS)

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What are the warning signs that you noticed?

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Overview
How common is suicide?

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Suicide is
everyone’s business
Suicide is everyone’s business
• Undergraduate years are a high-risk period for first onset of suicidal
thoughts and behaviors (Mortier et al., 2017)
• First onset rates ranging from 4.8% to 6.4% annually

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Suicide is everyone’s business
• Among the people that individuals confide in, family members were
the most common, followed by friends and then health professionals
(Hallford et al., 2023)

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 Why would someone share
their suicidal thoughts
if they want to end their life?

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How long is a suicide thought?
• Studies using real-time monitoring technology (e.g., Kleiman & Nock,
2018)
• Kleiman et al (2017): Suicidal thoughts can
• Vary in severity considerably over short period
• Have a quick onset and differ by more than 1SD within just a few
hours
• Have a brief episode ( < 1 hour)

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Why would someone share their suicidal
thoughts if they want to end their life?
• Often having mixed motives
• The wish to die VS the wish to live
• Interviews with 11 patients hospitalised after a suicide attempt
(Galasiński & Ziółkowska, 2024)
• “Well, then I didn’t want to kill myself, perhaps sometimes. No, no, I kind of
wanted a bit. But on the other hand, I rejected it. Because on balance I didn’t
want to, I wouldn’t like to hurt her.”
• “And so, I didn’t even feel like doing it [suicide], because it was like, I was
thinking about it the whole day, like, alright, I’ll do it in the evening, I am
ready. Just like that, I was ready, it was something like thinking that it’s simply
time to do it.”

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Some incidents of impulsive suicide
• A study of 153 people with nearly lethal suicide attempts (Simon et
al., 2001)
• 24% attempted impulsively (i.e., spending less than 5 min between
suicide decision and the actual attempt)
• A Sweden cohort study of 666 hospital known cases of suicide
attempt (Beckman et al., 2019)
• 43.7% of the impulsive suicide attempts
• A study of 238 Korean people with a suicide attempt in lifetime (Jeon
et al., 2010)
• 1/3 had been unplanned
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How to identify people who
may be thinking of suicide?

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Traditional model seeing the process of suicide
• Suicide is often seen as a series of stages that become more serious
• Starting from thoughts of death to suicidal ideation, then to planning,
and eventually to attempting suicide.
• The risk of suicide tends to increase at each stage of this process
(Thompson et al., 2012)

Suicidal Suicide
Planning
ideas attempt
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But in fact, it is more dynamic…

(Bryan et al., 2020)

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Ideation-to-action Framework (Klonsky & May, 2014)

• Factors that predict thoughts of suicide ≠ Factors that predict the

transition from thinking about suicide to actually engaging in suicidal
behavior

Lock 1 Lock 2

Key 1 Key 2
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Warning Signs VS Risk Factors

Risk over much

Near-term risk longer periods of
time

(Rudd, Berman et al., 2006)

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Risk Factors
Personal Psychological Environmental
Mental illness Hopelessness Family history of suicide
History of suicidal attempt Poor impulse control Depressed parents
Self-harm behaviors Poor problem-solving skills Changes in family structure
Chronic illness/pain Poor self-concept Lack of social support
Puberty Low self-esteem Sexual and physical abuse
Sexual and gender minorities Negative thinking Bullying and victimization
Rigid thinking Loss of significant relationships
Poor family support
…. …. ….

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Protective Factors
• Access to mental health care, and being
proactive about mental health
• Feeling connected to family and community
support
• Problem-solving and coping skills
• Limited access to lethal means
• Cultural and religious beliefs that encourage
connecting and help-seeking, discourage
suicidal behavior, or create a strong sense of
purpose or self-esteem

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Warning Signs (Jeon et al, 2018)

• Before death, 80.6% of all adolescents exhibited one or more warning

signs of suicide

Verbal signs Behavioral signs Emotional signs

(86.2%) (72.4%) (55.2%)

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Warning Signs (Jeon et al, 2018)

Verbal Behavioral Emotional

• Talking about suicide or death • Changes to sleeping patterns • Displaying extreme mood
frequently and eating habits swings
• Complaining about physical • Putting affairs in order • Withdrawing or feeling
discomfort • Planning for suicide isolated
• Saying they feel worthless or • Loss of interest in personal
alone hygiene or appearance
• Asking questions about how • Acting differently than usual
to commit suicide or not completing a given task
• Speaking of longing for the • Being distracted
afterlife • Difficulty making decisions
• Talking about people who about trifles
have committed suicide • Self-harm behaviour or
• Writing down death-related substance abuse
information • Being preoccupied with
death-related music, writing
or movies
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Percentage of individuals that exhibited suggested or clear evidence of
premeditation indicators and mean number of days the indicator occurred before
suicide death (n = 131).

(Gomez et al., 2023) 25

 How to offer
immediate help to someone
having suicide thoughts?

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Steps in becoming a supporter
and connecting with community support
1. Tell
2. Ask
3. Listen
4. Keep-safe

©LIVINGWORKS safeTALK

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1. Tell
• People thinking about suicide could be inviting help in unclear ways
• Even practitioners often find it difficult to initiate conversations about
suicide (O’Reilly et al., 2016)
• Able to talk openly and comfortably about suicide

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Able to talk openly and comfortably about suicide
• Why do people avoid talking about
taboo topics?
• People attempt to avoid conversational
topics that might cause embarrassment
to themselves or to the others.
• When such topics could not be avoided,
people would indirectly discuss them
using jokes, circumlocution, obeisance
to courtesy forms, or ritual (Goffman,
1955)

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2. Ask
• Direct and unambiguous questioning (American Psychiatric
Association, 2003)
• “Are you thinking about suicide?”
• More likely to deny having suicidal thoughts when asked about it in a
negative way compared to a positive way (McCabe at el., 2017)
• E.g. “You don’t have thoughts of killing yourself, do you?”

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Try practising in your mind
• Sometimes when people say they're
1. Your worthless and pull away from their friends,
observation they might be thinking about suicide…

2. Asking • Are you thinking about suicide?

about
suicide
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Could asking about suicide
plant the idea of suicide
in someone’s mind?

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Asking about suicide increase suicidal tendencies?

• A review of the published literature in adults and adolescents, and

general and at-risk populations (Dazzi et al., 2014)
• A total of 13 papers published between 2001 and 2013
• None found significant increase in suicidal ideation
• Some showed improvement in emotional state (Gould et al., 2005;
Biddle et al., 2013)

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Asking about suicide increase suicidal tendencies?

• A meta-analysis identifying 18 studies from 2000 to 2017 (Blades et

al., 2018)
• Exposure to suicide-related content led to:
• significant, but small, reductions in suicidal ideation
• a lower likelihood of engaging in suicidal behaviour
• Asking about suicide does not increase risk (immediate & two days
later)

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How about asking about suicide repeatedly and
frequently?
• Real-time monitoring methods with smartphone (Coppersmith, 2022)
• Participants: 101 adults with active suicidal thoughts in the previous
week
• Frequently assessing suicidal thoughts was not associated with a
change in the severity of suicidal thoughts

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 How should you respond if
someone's answers about
their suicidality are vague or
not convincing to you?

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How common is recent denial of suicidal thoughts?

• A meta-analysis of 22 studies from 2000 to 2021 (Obegi, 2021)

• Respondents to an anonymous survey disclosed more suicidal
thoughts than on a non-anonymous survey
• People reporting suicidal thoughts on an app denied the experience
during a telephone interview held within 24 hours of the study’s
completion
• Average rate of denial across studies = 57% (range = 18 – 94%)

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How common is recent denial of suicidal thoughts
before suicide?
• Examining the denial in the week/month before suicide by reviewing
the patients’ responses during interview vs questionnaire
• Denial is more likely in interviews (70%) than questionnaires (41%)
• 25 – 36% denied on questionnaire the week before a suicide attempt
• 31% denied on questionnaire within one day of suicide attempt

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How common is denial of suicidal thoughts
after suicide?
• Investigating survivors of self-inflicted gunshot wounds
• 29% admitted to A&E denied their intention to die
• But more than a third did fatal acts (e.g., placing the gun in mouth)

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How to respond if someone's answers about
their suicidality are vague or not convincing?
• Many possible reasons:
• Avoid discovery
• Gross fluctuations of suicide ideas over short periods
• A disorganised state
• Their hesitance to answer truthfully is an opportunity to
inquire about their well-being and feelings regarding
suicide

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Reasons for Responding Not Accurately Among Individuals Experiencing Suicidal
Thoughts When Probed (n = 191 Total Probes)

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(Hom et al., 2017)
Reasons for Responding Accurately Among Individuals Experiencing Suicidal Thoughts
When Probed (n = 191 Total Probes)

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(Hom et al., 2017)
3. Listen
• Interviewing 20 people following a suicide thought/attempt
(Staniforth, Ali, & Adamson, 2024)
• Genuineness
• Acceptance
• Empathy
• Respect
• Care
• Compassion

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Listening without judgement
• ‘…were just nice and calm, and they just went about their normal conversation
[which] put me at ease, because I wasn’t treated as some sort of freak’
• ‘I just wanted them to say ‘ok well let’s have a meeting, let’s discuss this, let’s see
what is going on’, because I knew something was not right…and I think I just
wanted someone to listen.’
• ‘We know when someone is judging us and they may not verbally say it but we
pick up the discrete cues…they make you think there is something wrong with
you…’
• ‘…it goes back to actually listening to the person and creating an environment
anywhere where it’s clear that what you disclose is not going to be used against
you. I guess in a non-judgemental compassionate way that person gives you
time…so yeah, they need to be listening and patient and, yeah, not judge you…’

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Listening without judgement

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Empathic listening
✓Acknowledging distress:
• “I can see that things have been very difficult for you lately.”
• “I can’t imagine how you must be feeling but I can see that it is very
distressing for you.”
✓Improving hopefulness:
• “I can understand that you feel your situation is hopeless but with support
we can help you through this.”
✓Bolstering self-esteem:
• “Coming here today must have taken a lot of courage.”
✓Non-verbal communication:
• Show that you are listening by nodding, saying ‘uh huh’ and maintaining
eye contact.
✓Reflect and paraphrase:
• “You have told me that… and I can see that…”
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4. Keep-safe
• Connecting the person with support:
• “We need additional support. I would like to connect you with
someone who can help ensure your safety.”
• If you believe someone may act on their thoughts imminently or if
they have access to means of suicide, do not leave them alone
• Keep yourself safe too

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Community Resources
• 24-hour Suicide Prevention Hotlines
Organisation Hotline Service
Caritas 24-hour Crisis Line 18288 24-hour phone counselling
Mental Health Support Hotline 18111 24-hour phone counselling
The Samaritans 2896 0000 24-hour multilingual suicide
prevention hotline
The Samaritan Befrienders Hong Kong 2389 2222 24-hour phone counselling by
volunteers
Suicide Prevention Services 2382 0000 24-hour suicide prevention

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Community Resources
• Psychiatric/Psychological Services

Organisation Contact No. Service

HKU CEDARS 3917 8388 Counselling services in HKU
Headwind F2O Online registration Free online psychiatric
consultation
Hong Kong Family Welfare Society 2426 9621 Clinical psychological service to
individuals or families
Hong Kong Christian Service 2731 6227 Clinical Psychological services
Baptist Oi Kwan Social Service Mental health enquiry Rehabilitation services for
hotline: mental health patients and
2535 4135 support services for their
(Mon – Fri: 10 am – 12:30 families
pm & 2 pm – 5 pm; Tue: 7
pm – 9 pm) 50
Community Resources
• Psychological Services

Organisation Contact No. Service

LevelMind @ Jockey Club Listed out by district Free counselling and mental wellness
service for youth aged between 12 and
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Mind HK 3643 0869 Free, short-term, and remote support to
HK citizens experiencing mild-moderate
anxiety and depression or emotional
distress
Shall We Talk: Youth to Talk 2514 2280 Free short-term psychological
WhatsApp: 5164 5040 counselling for youth aged between 12
and 35
Social Welfare Department 2343 2255 The Clinical Psychology Units serve
clients with emotional or behavioural
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problems
 What if they ask you
to promise to keep this
a secret?

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Keep this a secret?
• ‘…it goes back to actually listening to the person and creating an
environment anywhere where it’s clear that what you disclose is not
going to be used against you….’ (Staniforth, Ali, & Adamson, 2024)
• Offer alternatives to secrecy. You can promise discretion, sensitivity, a
commitment to involve them in the decision-making whenever
possible/appropriate
• Do NOT promise to keep this a secret

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 What if you try to help
and they kill themselves
anyway?

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How much time had elapsed between the first
current thought of suicide and the attempt?
• A study of 105 patients after a suicide attempt (Deisenhammer et al., 2009)
• A semi-structured interview focusing on the duration

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How much time had elapsed between the first
current thought of suicide and the attempt?
• Interviews with 11 patients hospitalised after a suicide attempt
(Galasiński & Ziółkowska, 2024)
• “It was hard to take the decision, when you want to do it…but it was so
spontaneous. I was cooking dinner, I put a salad on, this and that, and
suddenly, a thought came. And within five minutes, I swallowed the tablets.”
• “Suddenly I was just looking at the tablets and I started swallowing one after
another, and then I found another pack, then a third … I took a few from each
pack, and started washing them down with beer, I drank it and then I became
dizzy.”
• “Everything was OK. Normal. I had a conversation and was about to go home.
And suddenly, I saw a table and a knife on the table, with a serrated edge, for
bread, and I cut my arm. Nothing suggested I would do it, it was an impulse”
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How much time had elapsed between the first
current thought of suicide and the attempt?
• A study of 105 patients after a suicide attempt (Deisenhammer et al., 2009)
• 97.6% stated retrospectively that they had had the possibility of contacting
somebody between the first current suicidal thought and the attempt

• The only decision within your control is whether you make an effort to
assist, or if you overlook, disregard, or evade the opportunity to provide
help!

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 Reference
and useful resources

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 Other resources
Suicide screener for friends

Always ask questions 1 and 2 Past Month

1. Have you wished you were dead or wished you could go to sleep and not wake
up?
2. Have you actually had any thoughts about killing yourself? If YES: ask questions 3, 4, 5 and 6
If NO: skip to question 6

3. Have you been thinking about how you might do this?

4. Have you had these thoughts and had some intention of acting on them? High Risk
5. Have you started to work out or worked out the details of how to kill yourself? High Risk
Did you intend to carry out this plan?
Always ask question 6 Lifetime Past 3 months
6. Have you done anything, started to do anything, or prepared to do anything to High Risk
end your life?
If yes, was this within the past 3 months?

The Columbia Lighthouse Project

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Suicide screener for friends

If YES to 2 or 3, seek behavioural healthcare for further evaluation.

If the answer to 4, 5 or 6 is YES, get immediate help:

• Call emergency or go to the emergency room.
• STAY WITH THEM until they can be evaluated.

The Columbia Lighthouse Project

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Reference
• Beckman, K., Lindh, A. U., Waern, M., Stromsten, L., Renberg, E. S., Runeson, B., & Dahlin, M. (2019).
Impulsive suicide attempts among young people–A prospective multicentre cohort study in Sweden. Journal
of Affective Disorders, 243, 421-426.

• Biddle, L., Cooper, J., Owen-Smith, A., Klineberg, E., Bennewith, O., Hawton, K., ... & Gunnell, D. (2013).
Qualitative interviewing with vulnerable populations: Individuals’ experiences of participating in suicide and
self-harm based research. Journal of affective disorders, 145(3), 356-362.

• Blades, C. A., Stritzke, W. G., Page, A. C., & Brown, J. D. (2018). The benefits and risks of asking research
participants about suicide: A meta-analysis of the impact of exposure to suicide-related content. Clinical
psychology review, 64, 1-12.

• Bryan, C. J., Butner, J. E., May, A. M., Rugo, K. F., Harris, J. A., Oakey, D. N., ... & Bryan, A. O. (2020). Nonlinear
change processes and the emergence of suicidal behavior: A conceptual model based on the fluid
vulnerability theory of suicide. New ideas in psychology, 57, 100758.

• Coppersmith, D. D., Fortgang, R. G., Kleiman, E. M., Millner, A. J., Yeager, A. L., Mair, P., & Nock, M. K. (2022).
Effect of frequent assessment of suicidal thinking on its incidence and severity: high-resolution real-time
monitoring study. The British Journal of Psychiatry, 220(1), 41-43.

• Dazzi, T., Gribble, R., Wessely, S., & Fear, N. T. (2014). Does asking about suicide and related behaviours
induce suicidal ideation? What is the evidence?. Psychological medicine, 44(16), 3361-3363. 62
• Deisenhammer, E. A., Ing, C. M., Strauss, R., Kemmler, G., Hinterhuber, H., & Weiss, E. M. (2009). The duration of
the suicidal process: how much time is left for intervention between consideration and accomplishment of a
suicide attempt?. Journal of Clinical Psychiatry, 70(1), 19.

• Galasiński, D., & Ziółkowska, J. (2024). The end of ambivalence. A narrative perspective on ambivalence in the
suicidal process. Suicide and Life‐Threatening Behavior.

• Goffman, E. (1955). On face-work: An analysis of ritual elements in social interaction. Psychiatry, 18(3), 213-231.

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Psychology, 79(12), 2768-2780.

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