Beyond 988: Real Tips for Managing Suicidal Thoughts and Self-Harm Urges

The way therapists and medical professionals are taught to help people experiencing suicidality is fear-based and minimalistic. I want to share advice for keeping people on this planet that goes way beyond the standard recommendations.

The Standard Recommendations

Most people worry that if they tell their therapist they are suicidal, they will be immediately placed on a psychiatric hold against their will and have a 3-day stay in a psychiatric inpatient unit. Of course, some people genuinely need a hospital stay to ensure that they stay alive that day.

In some cases, people are hastily hospitalized due to the provider’s lack of experience in helping people who are experiencing suicidal thinking or self-harm. The research suggests that hospitalizations are helpful in the day following a suicide attempt, but otherwise, not effective as a long-term strategy for helping people with suicidal thinking and planning. There is also some chance of being harmed while in the hospital (for example, being assaulted by staff or patients). I especially worry about children and teens being hospitalized, particularly when they are coming from a loving and safe home versus needing to be removed from an unsafe situation.

Regarding suicide hotlines, I am sure they can be helpful in the moment. The operators are available at 3am when someone is in crisis (although I have heard there can be long wait times, which is not ideal!) and their therapist is hopefully sleeping. My concerns are, one, that this recommendation is an easy out for the provider. They can think “I told the person to call 988” and feel that their work is done. Two, this is not a great long-term strategy. Someone experiencing suicidal ideation needs skills and other safe people in their life to talk about these concerns further.

Standard Therapy

For someone who is acutely experiencing suicidal planning or self-harm action, best practices would be for them to be referred to a “higher level of care” (for example, an intensive outpatient program or IOP) that provides several hours per week of therapy. One wonderful type of therapy for addressing suicidal thinking and self-harm urges is Dialectical Behavior Therapy (DBT), which includes a weekly group plus individual therapy for about 6 months. (Search here to find a DBT therapist.)

While I would love for everyone to be able to access excellent mental health care, I understand the reality that it’s just not possible for everyone. I want to lay out some strategies that someone would learn in these types of therapies so that there is more knowledge available to the people who need it and their loved ones.

Here are a bunch of examples of what we do in therapy for people experiencing suicidal ideation, online resources, and tips for loved ones.

First note: Thank you for reading this. If you are a loved one, you hopefully will gain some valuable information to support someone in your life.

If you are experiencing these thoughts and urges, know that you are so important. You are meant to be on this planet, even if you don’t understand why yet. This is a temporary dark time and there is a light at the end of the tunnel, even if you don’t see it. If you need 988 or a hospitalization, that might be a great first step, and I want you to know way more to prepare for the months and years ahead because... you’re gonna be here!

Make a Safety Plan and Share It with Someone

A safety plan is a written document outlining ways to keep you safe from harming yourself. A lot of those specific tools will be shared below. Sharing the plan with a loved one can help to make sure that someone else can help you stick to the plan. Here is an app to help with safety planning.

Talk to Someone Trusted

Social support is essential to living. If you already have a therapist, maybe your first step is admitting your thoughts/urges to them. In talking to a friend, loved one, or other trusted individual, you may feel a lot of shame and avoidance urges in admitting to suicidal thoughts, and you might be in for feelings of relief and acceptance once you have a heart-to-heart with someone who cares about you.

Just spending time with others is essential. Usually when someone is dealing with suicidal thoughts and self-harm, they are isolating. In addition to being able to talk about your feelings, it’s essential to just be spending time with people in general (of course, safe people who make you feel cared for). Call a friend, have a meetup at a coffee shop, talk to people while standing in line. If you don’t have a trusted network at the moment, the only way to get there is by starting small.

Go “Touch Grass”

I got this one from my Gen Zers. Sometimes in these moments, you may also just be spending too much time indoors in a dark, drafty room. Just changing up your environment can make a difference. Go out in the sunshine. Spend time in nature so that you can experience awe. Better yet, go outside with a friend or loved one.

Reduce Access to “Means”

You want to keep from being able to harm yourself in an impulsive moment. This might include taking actions like removing guns from your home or putting on a gun lock. You might lock up all sharp objects (razors, knives, whatever you typically use) and ask that a trusted person handle unlocking them and giving them back to you later. Your personal plan might also include reducing access to large quantities of medications or drugs and alcohol.

Tap Into Your Spirituality

Religious beliefs could be used in an unhelpful way, such as, “I’m a sinner if I hurt myself.” If rerouted from that line of thinking, though, they could be really powerful. To say something like “God created me and He thinks I’m valuable and I should be here” seems really valuable. Whatever your beliefs, there could be a way to harness them toward the goal of staying here.

Use Humor

I come from a family that processes challenging things through humor. This isn’t for everyone but might work if that’s your thing. I have a Tweet that I love that I won’t share in case it would rub anyone the wrong way, but if I read this Tweet in a dark moment, I would still laugh so hard and it would shift my perspective. Sometimes we need a good belly laugh and we don’t need to take everything to seriously. Especially if you can laugh with another person... that’s the good stuff.

Listen to Music

Now don’t listen to some super emo “my life sucks” sort of song. But if you’re someone who connects to music on a deep level, you can use that to your advantage. Make a playlist of songs that are uplifting, get you hype, or help you praise.

Write Your Reasons for Living

Get out a piece of paper and write out the reasons that you want to be on this planet. Maybe it is a small list for now, and hopefully you will be able to expand it over time. Here are some examples...

People: My parents, my cat, my best friend, my elderly neighbor who needs help carrying in groceries

Goals: I want to be an Olympic figure skater; I want to get my driver’s license; I want to make some money

Spiritual: God created me for a purpose

Other: I want to keep being able to eat cookie dough ice cream; I want to get back at my haters by being joyful

Make the list pretty, if that’s your thing. Read it, internalize it, and pull it out to read again whenever you need it.

Create a Hope Box

A hope box is a physical box holding some things that make you remember that you want to be here and that help you when you are having suicidal thoughts or self-harm urges or difficult-to-manage emotions. This can be as simple as a shoe box with items or even a list of some digital links and resources.

In my hope box, I would have ABBA’s gold album. Even if I were in the depths of despair, once Dancing Queen was playing, I’d probably have an urge to do some disco moves. I might have some photos of my family members, friends, dog, and travels. I’d have a link to Impractical Jokers and George W. Bush gaffe videos because both make me giggle. I might keep a few of the notes and cards from my family and friends throughout the years in there.

I highly recommend a physical box, but here is an app version.

Use TIPP to Manage Uncontrollable Emotions

In DBT, people learn to use “distress tolerance” skills to manage super strong emotions. One of these is called TIPP, which involves using 1-4 strategies that activate the parasympathetic nervous system (in simpler terms, they calm you down). Here is a handout and video explaining this skill.

Engage in Problem Solving

Sometimes, people are using a plan for suicide as a form of problem solving. For example, they might think that if they die, that will keep them from getting in trouble for a bad grade or help their loved ones not be burdened. I hope we can agree that suicide is not the best solution to any problem. The steps to problem solving are: 1) define the problem factually, 2) brainstorm all possible solutions, even ridiculous or silly ones, just to get the brain working, 3) choose what seems to be the best solution and maybe a top three, 4) try the top solution, 5) try another solution from the list, if the first one didn’t work. Here is an example:

Problem: I failed a really important test

Possible Solutions: Drop out of school, Hack into my teacher’s computer and change the grade, Erase my memory of the grade, Drop out of the class, Ask to retake the test, Study harder for the next test, Do extra credit assignments, Talk to my teacher about why I failed, Join a study group with classmates, End my life

Top 3 Solutions: 1) Talk to my teacher about why I failed, 2) Ask to retake the test, 3) Join a study group with classmates

As you can see, once we identify a range of options for solving our problem, suicide is not a useful strategy. Now, you might say that your problem is way more serious or harder to solve than this. I still want you to write it out like this and see what you learn.

Complete Pros and Cons

Pros and cons is an activity to help make a decision about changing a behavior. Write out all reasons for and against making a change in the matrix and then determine whether the reasons are short (ST) or long term (LT). Once you complete the matrix, review what you learned from it, write that as a statement, and then look at it as often as needed to keep up your motivation for the behavior change. Here is an example for self-harm:

	Pros	Cons
Staying the same (Keep self-harming)	·      It makes me feel better in the moment sometimes ST ·      It feels like it helps me manage strong emotions ST	·      It upsets my family LT ·      I could get really hurt LT ·      I’m not learning how to manage the emotions in other ways LT ·      It’s not a great way to treat myself LT ·      It’s kind of scary in the moment ST ·      I feel really guilty afterwards even when it’s been a while LT
Changing (Stop self-harming)	·      I’ll probably feel better about myself LT ·      I won’t have any more scars LT ·      People will be less worried about me LT	·      It will be hard to do something new in the moment ST

Lesson learned: The reasons to keep up this behavior are temporary reliefs and there are a lot of reasons to think it is way better for me long-term to change my behavior and learn other things to do when my emotions are out of control.

Notice Unhelpful Thinking Patterns

The way someone is thinking about life or their problems can be a major factor in their suicidal thoughts or self-harm urges. Take a look at the following thoughts:

“I’m a burden to my loved ones.” “I’ve probably achieved everything I can in life and everything is downhill from here.” “I’ve totally messed things up – there’s no way out of this.” “I’m a victim and I’ll never be safe again.” “My parents won’t care that I’m gone.” “I deserve a punishment.” “I’m worthless.” “I’m a screw up.”

We don’t have to get into an argument about any of these statements for any particular individual. Whether these thoughts are 100% true, 100% false, or somewhere in between, they are obviously unhelpful ways of thinking that could contribute to someone believing that harming themselves makes sense. Thinking about things in a different way could be life-saving.

Additionally, the process of thinking, such as ruminating or worrying, can be unhelpful. Whether the thought is true/untrue, helpful/unhelpful, positive/negative may not matter as much as how much time you’re spending in your own head. Using mindfulness to turn away from unhelpful thinking processes and be in the present moment can be very useful.

Improve Your Sleep Quality

Experiencing insomnia (difficulty falling or staying asleep) can make experiences with suicidal thinking even worse. There is research to show that the best psychology treatment we have for sleep (CBTi) can reduce suicidality. CBTi Coach and Sleepio are two apps that teach this type of therapy. If I had to give one sleep recommendation, it would be to wake up with the sun and get 10 minutes of sunlight directly upon awakening. It can also be helpful to ensure your sleep hygiene is good and you’re not engaging in obvious behaviors that harm sleep.

Volunteer

Helping others can get you out of your own head and help you to feel like you have a purpose. It can also put your problems into perspective. "Wow, I thought I had it bad, but now I've heard this person's story..."

Express Gratitude

Gratitude expression is one of the most consistent research-backed strategies for improving emotional wellbeing. You can even find gratitude for the tough moments. "I'm glad that I went through grief so that I can empathize with others."

Ride the Wave of Emotions

The overall goal is to learn to “ride the wave” of discomfort without hurting yourself. I have known a lot of people who are suffering but I’ve ever met someone who just 100% of the time wanted to be dead. Usually these are passing thoughts, feelings, and urges but if they are acted on, they can cause long term problems. You want to ride the wave, using as many skills as needed, until you get to the point of not wanting to hurt yourself. Here’s a stream of consciousness of riding the wave:

“I’m so mad at myself for my poor tennis performance today. I think I need to punish myself. I want to cut myself.” “Wait, I promised myself that I wouldn’t self-harm anymore. Let me go call a friend instead.” “Agh, my friend couldn’t talk very long and I’m worried she’s mad at me. Now I have an even stronger urge to cut myself! Okay, no, I’m going to try the TIPP skill to calm down.” “Hmm, I feel a bit better, but this is still kind of risky. I think I should leave my room. I’m going to sit outside and practice drawing.” “Okay, I drew, and I had a nice talk with my mom. I feel a little better about tennis now, even though it’s embarrassing to play so badly. But I also realized that I don’t like that I say I should punish myself when I don’t play well. Maybe that’s something I can learn to think of differently...”

Manage Your Grief

Maybe these thoughts are stemming from the recent death of a loved one. If so, I’m so sorry for your loss. This might feel like one thing that won’t get better, and so maybe some of the therapy skills wouldn’t apply. Here is my favorite grief visual. Even if your grief stays the same, you will grow around it, and it will feel easier at some point. Only watch if helpful, but I love this video of sisters processing their grief through humor. Some people find it helpful to process their grief in a group setting, such as GriefShare.

If you are here trying to process the death of a loved one through suicide, I’m sorry for your loss as well. Some loved ones have benefitted from joining a community of others who understand and advocating together, such as the AFSP walks.

Tips for Talking to a Loved One Who is Suicidal or Self-Harming

I think many people’s response to their friend or loved one saying “I’m feeling suicidal” would be merely “You should talk to a therapist.” I’d feel like I was being pawned off in that moment, and it seems like a nicer way of saying “That makes me uncomfortable” or “Don’t burden me with this.” Obviously, I think therapy is a fantastic option and 1) not everyone has access to therapy and 2) it’s still helpful to have a bit more to say in response to your loved one at that exact moment, even if they can eventually talk to a therapist or they will be visiting the hospital after this discussion.

You are not responsible for keeping another person from harming themselves AND your social support can make a big difference in the life of someone experiencing suicidal thoughts or self-harm urges. This can be a scary or awkward conversation to have, and you don’t have to do it perfectly to really make someone feel seen. Just providing a listening, non-judgmental ear can be so helpful.

One key skill from DBT is called validation. Validation involves expressing that you understand what someone thought, felt, or did in a situation, whether you agree with it or not. The way I teach validation is to find the emotion word that either the person said or you can guess and then build a sentence around that. Don’t be afraid to be wrong – the person can always correct you!

“I’m so upset about my breakup. I don’t think I’ll ever be happy again!”

Validation: “That totally makes sense to be really sad about your breakup.”

If you have experienced any suicidality before, it may be easy to validate someone else in their experience. If not, it may feel confusing because you genuinely don’t understand or you don’t want the person to think you’re saying what they did was okay. Here are some examples of how to validate without fully understanding and without saying the action was totally fine:

“I couldn’t stop crying about my ex. I just didn’t know what to do and so I grabbed my razor and cut my arm. It kind of distracted me for a moment because then I had a totally different pain to deal with. Now I just feel really embarrassed about it all.”

Validation: “Thanks for telling me what you were thinking. I get that you were overwhelmed with emotions and it felt like the only thing you could do at the time. It sounds like you’re feeling some shame now, and so I’m really glad that you told me about it instead of hiding inside yourself. Now that I know, I can help you with finding ways to manage those emotions in the future.”

“I just kept thinking that I’m a burden to you and the girls. I’m not the same person since I came back from deployment. Now I’m even more of a burden because I messed up shooting myself and we’ll have a hospital bill to pay and my rehab. I can’t believe this.”

Validation: “I understand you were worried because you can’t help out the girls and me the same way you used to, and I was frustrated and said some things that probably added to that. I want you to hear that you are NOT a burden to us. The girls and I love you and want you around in whatever way you can be...”

The most helpful thing is just keeping the person experiencing these thoughts from feeling like a pariah. Feeling seen and understood by another person can be so powerful. Also, remember that you don’t have the know all the answers or be the problem solver. In fact, sometimes someone just wants a listening ear and would feel invalidated if the listener just jumped straight to providing them solutions. Sometimes we do this from a place of our own discomfort. “I don’t like that you feel badly, so I want to fix it.” You can also ride the wave of your own emotions and just sit with this person in theirs without changing anything yet.

Other Resources:

I really love this: here is a site where you can read encouraging letters from others.

Here is a previous post I wrote with more information on the actual process of disclosing suicidal thoughts or self-harm urges to a therapist.

If you made it all the way here, I’m impressed! You’re taking it seriously to say “yes” to living. I hope, too, not just the opposite of dying but wholehearted, thriving, joyful, sometimes painful and challenging life! It takes time to build a life worth living, but it will be so rewarding.