Critical situations (Reading)

Often, we might have LGBTQI+ people who are contacting the chat/hotline when they are confronted with acute and immediate problems. It is very important in these critical situations for the operator to be directive. The immediate crisis requires action, less focus on the emotions, more concentration on the next steps and available options. The goal of crisis intervention is solving the immediate problem by developing an action plan and also alleviating the accumulated stress and anxiety. It is important to emphasize that not all conversations about suicidal thoughts, violence, abuse or self-harm are immediate.

If the situation is critical, the operator steps away from the more passive role and takes charge of the conversation. Sometimes individuals confront situations they have never encountered in the past. As a result, they have not developed adequate coping mechanisms to deal with them. These crises leave individuals feeling overwhelmed and powerless. For many people, these crises cause their heightened emotions to impair their ability to think rationally. During critical situations, people spontaneously turn to others for comfort, support, understanding, and protection. If the person is chatting or talking to you, then there is hope. They need your help.

The assessment of the situation is crucial. Acute and immediate situations can be:

• The LGBTQI+ person has specific plans for suicide or are in the process of a suicide attempt.
• The LGBTQI+ person is subject to domestic violence or will be subject to violence or other kinds of abuse if no help is provided for them.
• The LGBTQI+ person is severely mentally ill.

Plans for suicide or suicide attempt

On important critical situation to discuss is when the LGBTQI+ person has specific plans for suicide or is in the process of a suicide attempt. The operator should be able to identify whether the situation is immediate and acute. If the person says that they have suicidal thoughts, the operator should assess how specific these thoughts are, whether the person has specific suicide plans, and how far the person is in these considerations. Another important task is to explore how much the person is currently experiencing tunnel vision, and trying to broaden the view they currently have in a gentle and consensual way as possible.

It is important to be able to assess the immediacy of the situation based on the information you have. The factors that may increase a person’s risk for suicide include:

• Current ideation, intent, plan, access to means
• Previous suicide attempt or attempts
• Alcohol / Substance abuse
• Current or previous history of psychiatric diagnosis
• Impulsivity and poor self-control
• Hopelessness – presence, duration, severity
• Recent losses – physical, financial, personal
• Recent discharge from an inpatient psychiatric unit
• Family history of suicide
• History of abuse (physical, sexual or emotional)
• Comorbidities, especially a newly diagnosed problem or worsening symptoms
• Age, gender, race (elderly or young adult, unmarried, white, male, living alone)
• Being LGBTQI+ and a subject of homophobia, bullying, abuse

Factors that may decrease the risk for suicide are also called protective factors.  These include:

• Positive social support
• Spirituality
• Sense of responsibility to family
• Children in the home, pregnancy
• Life satisfaction
• Reality testing ability
• Positive coping skills
• Positive problem-solving skills
• Positive therapeutic relationship

Asking questions about suicidal ideation, intent, plan, and attempts is not easy. Sometimes the person will start a chat or a conversation directly with the topic of suicide, but in most cases the topic does not readily flow from the beginning. Asking about suicidal ideation and intent does not increase the likelihood of someone thinking about suicide for the first time or engaging in such behaviours. In fact, most people feel a sense of relief and support when a caring, concerned operator or professional non-judgmentally expresses interest in exploring and understanding the person’s current psychological pain and distress that leads them to consider suicide or other self-injurious behaviours.

All suicidal ideations and suicidal threats need to be taken seriously.

If the operator has some suspicion that the person might have suicidal thoughts, they might ask:

Are you feeling hopeless about the present or future? Hopelessness – about the present and the future – has been found to be a very strong predictor of suicidal ideation and self-destructive behaviours. Associated with hopelessness are feelings of helplessness, worthlessness, and despair.

If yes, ask…..

Have you had thoughts about taking your life? In most cases, suicidal ideation is believed to precede the onset of suicidal planning and action. Suicidal ideation can be associated with a desire or wish to die (intent) and a reason or rationale for wanting to die (motivation). Hence, it is essential to explore the presence or absence of ideation – currently, in the recent past, and concurrent with any change in physical health or other major psychosocial life stress.

If yes, ask…..

When did you have these thoughts and do you have a plan to take your life? Most people become suicidal in response to negative life events or psychosocial stressors that overwhelm their capacity to cope and maintain control. Hence it is important to understand what elicits suicidal thoughts and the context of these thoughts.

Have you ever had a suicide attempt? Most people who attempt suicide do not attempt again. However, about 16% repeat within one year and 21% repeat within 1-4 years. The majority of repeat attempters will use more lethal means at subsequent attempts – increasing the likelihood of increased morbidity or mortality. Approximately 2% of attempters die by suicide within 1 year of their attempt. The history of a prior suicide attempt is the best-known predictor for future suicidal behaviors, including death by suicide. Approximately 8-10% of attempters will eventually die by suicide.

Are you planning to hurt yourself now?

If yes, ask…..

On a scale of 0 to 5, how would you rate your intent now?

If the answer is 3 or above…..

Do you have the means to harm yourself now? It is important to know whether the individual has begun to enact the plan by engaging in such behaviors as rehearsals, hoarding of medications, gaining access to lethal means, writing a suicide note, etc.

As one of the aims of the chat/helpline is to prevent suicide and provide the most effective support, the operator may express concern that the persons’ life is in danger and explore immediate support options available to them (country specific).

The operator may ask the person about contacting the emergency services on their behalf.  If the person says they do not want the emergency services to be contacted, then the operator will attempt again to explore the persons’ reasons why they are actively suicidal.

If the person continues to be actively suicidal, the operator then will make another attempt to direct the person to receive emergency help. If the support seeker agrees to action being taken to prevent their suicide, the operator will explore two options with the person:

Option A

Get the support seekers’ agreement that the individual will take emergency action themselves.

The operator can inform the support seeker of the range of emergency options available to suicidal people, as follows:

• Contact the emergency services by calling 112.
• Contact suicide helplines (if available)

Option B

Get the support seekers’ agreement that the Operator will take emergency action on their behalf.

If the person would like action to be taken to prevent their suicide but does not feel able to take one of the actions identified in option A, then the Operator can offer to do the following:

• Stay on the phone/chat with the person and continue to listen to them.
• Offer to contact the emergency services on behalf of the person.

If the support seeker agrees to the Operator contacting the emergency services on their behalf, then the Operator will ask the individual the following questions and write down their responses:

• “Can you tell me where you are now?” or “Can you tell me where the emergency services can find you?”.
• “What’s the name of the last town/place you were in?” – Get address, street name, landmarks and/or specific location.
• “Can you give me your phone number to pass on to the emergency services?” – Preferably get a mobile number but any contact number is better than none as this will assist the emergency services in finding the person, particularly if they are in a remote or secluded area.
• “Can you give me your name to pass on to the emergency services?  It doesn’t have to be your real name” – This will assist the emergency services in finding the individual when they get to the location.
• “Can you tell me how and where you were planning to kill yourself?” – Important to ask so that you can find out if the person is planning to kill themselves in a manner that could be harmful to others or to the emergency services and to be able to identify the location of the person.

If sufficient details identifying the support seekers’ location are given by the person, then the Operator will agree with the support seeker to contact the emergency services on their behalf.

The operator will do the following:

1. Dial 112.
2. Inform the emergency services about the reason for calling.
3. Give your name and your contact number.
4. Give any details that the support seeker gave including their location, contact number, name and/or planned method of suicide.
5. Ask the Emergency contact to follow up immediately on your call because you are very concerned for the safety of the support seekers’ life.
6. Contact your Supervisor or Operator Leader and inform them of what has happened. It is very important for the operator to have the chance to debrief after such a stressful situation.

Threat or presence of violence

Another critical situation can be when the LGBTQI+ person is subject to domestic violence or there is a threat that they will experience some kind of abuse or violence.

Acute conversations where help is needed immediately will typically begin with an assessment of what the issue is, what the person’s exact situation is, what the risk is, and who is involved, etc. This should be followed by

• Support: “It is good that you contacted us”
• Clear feedback on what is going to happen
• Help and exploration of options: “You need help right now.” “Let us think of different options together…”

The focus can be shifted to supporting the person in assessing more specific action plans for the future.  If a support seeker expresses that they are in danger because of domestic violence or the threat of domestic violence, the operator may ask the support seeker about their ways of managing this danger.

• The Operator may express concern about the support seeker’s safety.
• The operator may ask the person about contacting 112 or the relevant organisation supporting victims of domestic violence (country specific) on their behalf.
• If the support seeker says they do not want anyone to be contacted this must be respected by the Operator. The operator in this case continues to provide support and to build rapport with the person.

If the support seeker agrees to action being taken to ensure their safety, the Operator will explore one of the following two options with them:

Option A

Option A is to get the support seekers’ agreement that they themselves will take emergency action.

The operator will inform the support seeker of the range of emergency options available to a person in danger because of domestic violence, including:

• Contact the emergency services by calling 112.
• The relevant organisation supporting victims of domestic violence

Option B

Option B is to get the support seekers’ agreement that the operator will take emergency action on their behalf:

If the support seeker agrees to the Operator contacting the emergency services on their behalf, the Operator will write down the support seekers’ responses.  If the support seeker will not provide any of this information then no follow-up action can be taken by the Operator.

If all support seeker personal details are answered by the person who contacted the chat/hotline, then the operator will agree with the person to contact the emergency services on their behalf.

The operator will do the following:

1. Dial 112.
2. Inform the Emergency Services where you are calling from.
3. Inform them that the support seeker asked that you to contact the emergency services on their behalf.
4. Give your name and your contact number.
5. Give any details that the support seeker gave including their location, contact number, name and/or details of any immediate risk/threat presented to the individual.
6. Contact the chat/hotline Supervisor or operator leader to inform them and to debrief. 

Children who seek support

All children, without exception, have the right to protection from abuse.

The purpose of a child protection policy is to ensure that appropriate action is taken when a young person under the age of 18 years is suspected of either being abused or at risk from parents, guardians, carers, adult visitors, other responsible adults or other young people.

• Physical abuse of a child is that which results in actual or potential physical harm from an interaction, or lack of interaction, which is reasonably within the control of a parent or person in a position of responsibility, power or trust. There may be single or repeated incidents.
• Sexual abuse occurs when a child is used by another person for his or her gratification or sexual arousal, or for that of others. (the age of consent)
• Emotional abuse can usually be found in the relationship between a parent/caregiver and a child rather than in a specific event or pattern of events. It occurs when a child’s developmental need for affection, approval, consistency and security are not met. Unless other forms of abuse are present, it is rarely manifested in terms of physical signs or symptoms
• Neglect can be defined in terms of an omission, where the child suffers significant harm or impairment of development by being deprived of food, clothing, warmth, hygiene, intellectual stimulation, supervision and safety, attachment to and affection from adults, and/or medical care.
• If the operator has any immediate concerns about the abuse or neglect of a child they must notify their Supervisor at the most immediate opportunity.

If the situation requires that the child has to give up their anonymity in order to get the necessary help, it is important to inform the child of this and to let them know what the consequences will be, as the child might have chosen to approach the chat helpline because they could remain anonymous. Therefore, it can make the contact very vulnerable if the operator insists that anonymity must be broken. It is important that the operator clearly informs the child so the child only breaks their anonymity with informed consent. This ensures that the child can continue to experience a certain degree of control over the situation. A lack of sensitivity to this could result in the child disconnecting or giving false information.

As an operator you should be aware that in most countries, when you know the child’s identity and you assess that the child is in immediate danger, you are obliged to inform the local authorities (“duty of care”). There may be situations where the child’s need for help is immediate, but the child does not want to get help, e.g., calling an ambulance, or being willing to provide the counsellor with the necessary information for the counsellor to get help. In such cases the counsellor must determine if there are other options for getting help that do not involve breaching the child’s confidentiality.

In some situations, the operator has to accept that it will not be possible for them to provide the help the child needs. When the person does not want to be helped by referral, please assure them that they are welcome to the chat/hotline every time they need to talk.

Summary for critical situations

1. Assess the situation’s seriousness. Is there a need for immediate intervention? Ask for facts rather than feelings.
2. Provide support.
3. Tell the person what is going to happen.
4. Wait together with the person until sufficient help has been established.
5. Contact your Supervisor immediately after such a stressful conversation to debrief.