So, yes, I am Amber Balday, and today I'm going to be presenting suicide intervention tactics to you.
So I'm just going to give a quick intro on how I ended up here talking at DEF CON about something which involves neither APT nor hacking cars.
And then we will dive right into the material.
So, first off, I would like to present some cognitive dissonance for you.
My main goal here is this won't be depressing.
So, trigger warning, this is a frank discussion of suicide and mental health, and that may be depressing for you.
If you feel ever uncomfortable in any way, I know that there are people in the room that have been affected by suicide directly in their families,
or have made attempts themselves, or are friends in some way.
If you feel uncomfortable, feel free to get up and take a breather outside.
We won't judge you at all.
So, I will also be speaking a lot in generalities and commonalities,
and that is in no way meant to say,
this is how it is for everybody.
So your experience may vary.
If you'd like to have an individual kind of chat about anything,
we'll be able to do that after the fact.
So, today, what we're going to go over is these things here.
We have a risk analysis framework,
which is how to build a profile for a person.
How to identify clues and warning signs,
which is catching red flags that might indicate some sort of brewing crisis.
How to perform situational threat assessment.
So this is how to ask questions that actually help you,
determine how to make an appropriate response.
So if something is low risk,
you would probably want to tackle it differently than someone who's in an acute crisis
that you need to get immediately to some sort of clinical setting.
And then we'll also cover some volunteer and first responder theory.
This is really where my training comes from,
which I'll tell you about in a second.
But the main point there is,
I'm doing that because we're the type of people that like information overload
and want to know how the real people do it.
So I will show you lots and lots of details on that.
But none of that is required to actually run a successful intervention.
There's very few things that are needed to talk someone down if you need to,
but also just to listen to them or to recognize risk factors out in our community.
So this isn't the kind of talk where you need to go and do five years of theory or research
so that you can actually implement it.
Although there is that much research in suicidology behind it,
the goal is to make it as transparent and usable immediately for you as possible.
So also we'll cover how to talk to another human being.
This is an important topic for the DEF CON audience.
So active listening, which is difficult.
Question phrasing.
Building trust, et cetera.
So hopefully we'll pick something up there.
So who am I and why am I standing here?
All right, I work in investment banking technology.
So this is not what I do.
I do full time.
Some of what I do involves infosec implementation.
It's certainly nothing you want to hear me stand on a stage and talk about for 45 minutes.
I also work with Girls Who Code.
I teach their tech ethics and privacy curriculum.
But my training here that's relevant is from the QPR Institute.
QPR stands for Question, Persuade, Refer.
And that's the methodology that they teach all of their responders.
They have a bunch of different training courses.
And I got involved with them by doing online crisis response,
which is the same thing as if you were to say,
hey, call the national crisis hotline,
those numbers you see posted everywhere.
But we do it online.
So it's over IM.
And I was attracted to that because I grew up on IRC.
And I'm the kind of person who would never pick up a phone
and talk to another human being when I'm in a crisis.
But I have no problem pouring my heart out to anonymous people on the Internet.
So it seemed like, you know, we have a special skill set almost
that technically we're more used to reading the cadence of an IM
or something that's written down that maybe other people don't even have.
So we might be even stronger responders than some other people.
So that's why I got involved.
But I ended up becoming a little disillusioned with it
because it turned out that I wanted to serve this community.
I mean, not exclusively, but it is really where I feel my strength lies
in being able to understand and talk to people.
And it turns out now that everyone has the Internet.
So they're all on IM.
And the people that contact the crisis centers really aren't from the Internet.
Or from Reddit or anything.
They're just regular people.
So I decided that the better idea was to take this skill set
and bring it directly to you guys.
So that we can, you know, touch everyone in that way.
I want to touch everyone. No.
In that sort of way. Woo!
If we can get everybody here to learn three or four basic steps
that they can then tell somebody,
it's actually really easy to teach people how to do this.
And it's the kind of thing you can even do at a bar.
And people find suicide fascinating.
It's kind of like that kind of morbid desire to learn about a societal taboo.
So it's actually really easy knowledge to pass on.
So I can't give you the official there.
But since normally we teach advanced theory,
the basic course is 60 minutes.
And I only have 45.
So I had to make up a title for DEF CON.
So if you want your CISSP certification afterward,
I'll try to get that for you.
So here's a couple of people.
I just wanted to front load my thank you in here.
Every time I freaked out that this didn't belong here
because I'm not dropping O-Days,
they told me to shut up and do it.
So thank you to them.
And a lot of them are here.
Okay.
So how I got here.
This is the most depressing slide in the entire presentation.
So I have a unicorn chaser for you preemptively.
There were two suicides in my family growing up
that affected me directly.
And I really come from a family of brilliant artists
and academics and engineers.
And it turns out these people are prone to depression,
alcoholism, bipolarism, and suicide.
So when my mother then several years later
was diagnosed with cancer,
I became mortified that she was going to follow the same path.
So I kind of took the nerd out
and I decided to learn everything I possibly could about it.
And that's how I ended up volunteering and why I'm here.
And she's fine now, by the way.
Yay. Thanks, Mom.
But right around the time that I was doing this
and kind of publicizing it,
the Aaron Schwartz situation happened in January.
I'm sure if you were here from the previous track,
we're all, I'm sure, aware of Aaron's suicide earlier this year.
And what surprised me was that after Aaron's death,
there were several people in the community
who actually reached out to me
and said that they were worried about their friends
and that they didn't know what to do,
they didn't know how to talk to them,
and they wanted resources from me.
And this rose a ton of red flags for me
because contagion is a very well-known,
it's a very well-known effect in the suicide community
when someone high-profile dies.
So it's actually based, it's called the Werther Effect,
which is based on a book by Van Gogh,
who also wrote Faust, if you've ever read that.
It detailed a suicide at a writing desk in Germany,
and so many people replicated it that they banned the book.
So you see this kind of over and over in clusters and communities.
The Godzilla there is Mount Mihara,
which is where they kind of throw Godzilla in to trap him.
It's actually based on a Japanese real historical location
that has been present in many, many suicides,
hundreds of suicides over the years.
And the San Francisco, the Golden Gate Bridge,
I'm sure we're all familiar with our cultural attachment to that.
So we're doing it wrong
when it comes to preventing suicide contagion in our community.
There are responsible journalism standards,
which I've kind of taken the liberty of extending to social media,
published by the CDC.
And now I kind of encourage you,
as you read various stories about suicide,
whether it's in our community or not,
to kind of see how many things they don't quite get right.
So we want to make sure that,
we always say that suicide is never the result of a single factor or event.
Sure, there might have been a trigger,
it's called a proximal event,
that pushes something into a crisis situation.
But people don't wake up one day and commit suicide.
It's just not what happens.
And if you look at the very first bullet point there,
well, not there, there,
it's committed and slashed out.
And that's because it would be really great as one takeaway
if all of us collectively could stop saying committed suicide.
That is not clinically accurate.
It's a throwback to ecclesiastical law and secular law
that does not exist in the majority of states anymore.
And instead people clinically say died by suicide,
was a victim of suicide,
killed themselves,
a whole variety of other opportunities,
other words that you can use
that don't create stigma for survivors
and don't refer to old religious heritage that we don't need.
So we also want to point out that suicide is the result of extremely complex interactions.
It's a long history of problems.
So just generally not making it seem like such an easy story to report, I guess.
So maybe we could do that a little bit better.
So it's not just Aaron.
These are computer science suicides since the 1950s,
which of course would be when we would see those start to rise.
And before that, it wasn't just computer scientists either.
We're probably a lot more familiar with artists and poets
because they tend to self-document their own destruction.
But it's just as prevalent among the highly gifted in almost any population.
But that said, the vast majority of people who die by suicide
don't have Wikipedia pages.
So while it's nice to say that we're capturing this in our research,
really this is a problem of the people that cuts across every demographic.
I will say though that you probably don't want to win a Nobel Prize for chemistry.
Okay.
So I'm just going to throw a few numbers at you
and then we're going to leave the numbers aside for the rest of the presentation.
So in America, someone dies by suicide every 14 minutes.
In China, it's every two minutes.
Overall, we're talking about the tenth most common cause of death in the United States.
That's way ahead of homicide, cancers, a whole variety of things that you might expect.
And most critically for us,
and not to exclude you,
not to exclude the ladies,
but just briefly, you're demographically safe for the moment.
We can do this by show of hands.
How many men here fall between the age range of 15 and 24?
So the younger ones in the crowd.
Okay.
So for you guys,
this is the third most likely cause of death
behind accidents and homicide.
Okay, so a little bit older.
How about 25 to 34 men?
Oh, hey, that's almost all of you.
It's second for you.
Second only to accidental death in the way that you are most likely to die.
If you look at the 45 to 54 bracket,
it's absolutely a larger number,
but we start to lose people due to natural cause and things,
so it kind of skews the data in that way.
So yeah, every year about 38,000 suicides,
more than twice the number of homicides in the country.
More than half of them involve handguns.
And not to exclude the ladies,
women are three times as likely to attempt suicide,
but men are four times as likely to die by it.
That largely has to do not with your internal failure.
That's that you choose pills which you think will be lethal but aren't,
whereas men tend to choose handguns very, very strongly,
which have very, very high lethality.
Okay.
So, oh goodness, you're going to make me drink, aren't you?
All right.
Can I borrow that microphone for a second?
So you all know the drill.
We have a tradition.
We've decided to enhance it by bringing up somebody from the audience.
But we need somebody who is a new attendee.
That's better than usual.
I like you.
Wait, you have to answer a trivia question.
Do you know the Dark Tangent's real name?
Help.
Excellent, because we don't use real names at DEF CON.
Come on up.
I'm taking this back from my time at the end.
Hurry it up.
We're on the clock here, you know.
Okay.
All right.
She's in a hurry.
Quick.
Drink.
Journey.
I'm sorry time is jumping off.
Oh, gosh.
How is it going so far?
Are you okay?
All right.
Now let's talk about clinical things.
I'm segue-independent.
Okay, cool.
All right.
So we're actually going to skip over most of the clinical stuff.
I just want to make you aware this talk isn't about the intricacies of diagnosis, but the
correlation is so strong that I would be remiss not to mention the relation to the Axis I
illnesses here.
So overall, I'm sure we're mostly aware of the drug and substance abuse at the bottom.
I just kind of want to point out that harm reduction is great for other things.
It's not great for suicide.
Sobriety is very heavily indicated in the cornerstone of a mental health management
program here.
That's because harm reduction works when your intent is not to die, but then you accidentally
die.
So if death is your end game, then harm reduction doesn't work.
So we won't really go into these guys too much, but most importantly, just pay attention
to the mood disorders at the top.
They're the most common.
If you look at the general population risk, this kind of outlines the number of times
the general population risk, if you are classified within one of these other categories.
They're mental health groups, that your chance or your likelihood of death by suicide increases.
So obviously a previous suicide attempt is kind of off the charts.
But also depression, manic depression, all of these are heavily indicated.
What you might not see on there, or you see at the bottom, I kind of just added informationally,
is all of these other medical illnesses.
People tend to think, there's a fallacy, that people think that people that are medically
ill are more likely to kill themselves.
It's really very, very small.
It's not really statistically relevant.
And, obviously, it's not.
Autism is not on here at all.
Okay.
So within our community, under diagnosis, not just in our community, but everywhere,
under diagnosis is a massive problem.
So within our community, I kind of tried to think of a few archetypes without getting
too generalized about it, that might happen.
So I'll sleep when I'm dead, I'm too busy crushing it.
This to me typifies the start-up community.
And they have something they call there the show.
And that's basically mania.
Mania is their desired state.
Depression is stigmatized.
There is a constant cycle of youth and burnout.
They're chronically underinsured.
Drug and alcohol use is trivialized.
There's a lot of intersectionality between the start-up culture and our culture here,
too, you might notice.
So that might match a few people you know.
But that's really a witch's brew for a high-risk sort of a profile.
How about, just because I'm paranoid doesn't mean they're not after me.
This sounds like under diagnosis of personality disorders, honestly.
I don't know.
If you look at the regular population, this is actually a problem with trying to find
a competent mental health professional if you work in some of the industries that we
work in.
They don't really understand you.
They don't understand the reality that you operate in.
And they might not be able to adequately or properly diagnose what is actually an acceptable
level of paranoia for the things that you're involved in.
You might also be more likely open to legal troubles as well.
I don't know.
Which can be a problem.
So if you want to learn more about any of those things, these are some of my favorite
books related to these topics that were very helpful.
Paul Quinet is the founder of the QPR Institute I mentioned earlier.
And if you are a heavily creative type and you want to read more about manic depression
in artists and how it's sometimes considered a good thing, Touched by Fire is a good one.
So all of this stuff is on the CDs and everywhere.
So for us, if we self-diagnose.
Which we do.
And then we think we're PhDs in psychology because we can use the DSM-5 and we go online.
And we tend to use these unilateral kind of like we'll post a forum post or we talk to
people.
But not ‑‑ we don't have one‑on‑one face time.
So we want to get away from that.
So this is like the online intervention that I talked about before.
30% of callers to suicide hotlines hang up.
We get a lot higher retention rate.
With online.
It's more anonymous for certain values of anonymity.
Mostly they don't track you just by policy and because they really don't know how to
do that.
Kind of hinders their ability to do statistical analysis afterward.
But the efficacy of the online is pretty much equivalent with a hotline.
The training is great.
They are a very good resource.
But like I mentioned earlier, your pairing is luck of the draw.
So we're bringing it to you.
Now, what's the difference between intervention and what I like to call a friendtervention,
which you're probably much more likely to do?
In an intervention setting, it's really not that hard.
The person comes to you.
You know they're in a crisis.
They want to tell you their problems.
They assume that you know what to tell them.
And then you're done.
And you can walk away.
There's enforced anonymity.
Actually, you're not allowed to give them your name, you're not allowed to have a follow‑on
relationship.
In a friendtervention, you might need to initiate.
You might be the one that notices there's something wrong and that could harm your relationship.
Your friend sees you as a peer.
Maybe they don't get better over time and you start to lose credibility.
Really that's why the ultimate end game is not to become your friend's counselors unless
you want to do that professionally.
You want to get them the actual help that they need.
So we need to get people to go back to really accepting professional help.
And it's very hard.
For our community especially.
Because a lot of us have had really bad experiences in the past with people that didn't understand
us or medication that didn't work.
And the medication in the last 20 years has gotten a lot better.
About 60 to 80% of people who have depression, once you find the right therapy, it will actually
help you and your risk dramatically goes down.
But you kind of have to trust in that process and then do a lot of work yourself.
So we need to keep encouraging people to open up and seek help.
But let's start proactively screening and responding.
So how are we going to identify risk?
There's a few different types of clues that you want to look for.
Direct verbal cues.
This is relatively obvious.
I wish I were dead.
If I don't get a boyfriend soon, I'm going to throw myself off a bridge.
Pretty obvious.
Often encoded as jokes.
So keep your eyes out for that.
Indirect.
I'm tired of life.
My family would be better off without me.
Or pretty soon you won't have to worry about me.
These ones are big red flags.
They're like little testers that people throw out there to see if anyone is actually
paying attention to them.
Behavioral.
Maybe they just seem depressed now.
That's kind of important.
If they get their affairs in order, they give stuff away or they relapse if they were into
drugs and alcohol before.
Or a sudden interest in religion.
Huge red flag.
So I want to watch out for that.
And situationally.
Trigger events.
So if you lose a job or a relationship.
You're diagnosed with a disease.
You suddenly are being prosecuted by the federal government.
These things are obviously huge, huge situational risks.
So you want to watch for red flags and then act when you see them.
So take them all seriously.
And here's just two common myths.
If somebody is talking about suicide, they won't do it.
Not true.
And if someone is ‑‑ if you're talking to someone about suicide, you're not going
to put the idea in their head.
You're just not that powerful.
And I guarantee you if you're that worried about your friend, they probably already thought
about it themselves.
So seize the day.
All right.
So this is a big wall of text.
I understand that.
But it's just kind of to take away the high points from this.
This is how you form an actual risk profile for a person.
This is something that you carry with you your whole life.
So it doesn't really change day to day.
It's about who you are and the various kind of baggage you've picked up over the course
of your life.
Some of it might be changeable, like the environmental factors at the bottom.
So maybe you move to a new place.
Where the sociopolitical climate is more accepting of who you are.
That might lower your risk.
Some of your personal and psychological issues, this is kind of ‑‑ I think one time I
called this lint on the sock of life.
And people enjoyed that.
So I go with that now.
So these are the things that you cannot be unseen.
But we just have to learn to try to cope with them.
And then biologically, this is stuff that really makes you who you are.
So this would be your mental illnesses, those things you carry with you.
That's really the foundation of your risk profile.
And then you have the proximal risks.
So these are the triggers that we were talking about before.
This is the stuff that if you are newsworthy enough, they will say is why you killed yourself.
So it's a relationship crisis.
It's public shame.
It's losing money.
It's whatever the event is that pushes you over the edge.
But what's most important is that it's how important that is to you.
It's your perceived level of loss.
All losses are real.
And one interesting note is that one thing that's not on here is any sort of risk or
protective factor is your wealth.
Absolutely irrelevant.
A relative loss of financial stability is very bad.
But having a lot of money does not in any way protect you against suicide risk.
So as we move across the way, there's an increasing sense of hopelessness, which is pretty much
the one thing we really want to try to combat.
We are trying to provide hope.
And give people a sense of the future is the most important thing.
And then you have a wall of resistance.
These are the protective things that are pushing back, that are telling ‑‑ that are keeping
you safe.
Once that's broken through, then you have the wall of death over there.
So the resistance, these are the things that are protecting you, are pretty obvious.
I mean, these are the things that we say, you know, make us happy.
We want to have all of these things.
Again, money not on the list.
But if you look ‑‑ there's a few things.
Two, like the AA sponsor, the sobriety, again, that's as part of a mental health plan that
requires those items.
But strong relationships, good health, a positive therapeutic relationship with a counselor,
it's not rocket science.
But you do want to check them off when you're talking to people mentally and know whether
or not they're totally isolated or whether they have somebody to talk to.
So oh, my God, oh, shiz, now what?
I just realized that I think my friend might be suicidal.
So here's the process.
You find a safe place to talk.
You want to set aside a little bit of time.
Best face‑to‑face.
It doesn't have to be.
You build rapport and trust.
That's the talking to a human thing that we mentioned before.
So we'll cover that in a second.
You're going to ask the suicide question.
This is the most critical step, and it's where you actually ask directly someone if
they are thinking about, have they considered, are you feeling suicidal?
It's very important to ask this as directly as possible.
You can kind of round about it in a have you thought about not waking up?
You don't want to get too euphemistic with it.
We'll actually cover different ways to ask the question in a second, but this is probably
the hardest step and the one that actually saves the most lives.
People are just waiting for someone to ask, really.
So once you ask the question or you're talking to them, you just shut up and listen for a
little bit.
And while you're listening, you're assessing the threat level of their current situation
based on a framework that we'll present in a second here.
Okay.
So you're doing active listening.
So you're responding to what they're saying.
You're asking relevant questions.
You're leading them a little bit around things that you want to know, but mostly just giving
them space to, like, brain dump.
And throughout that kind of organic process, you are determining whether they're a low
risk, moderate risk, super high risk, we have to act right now.
And then once you've determined which level they are, you'd be able to implement an appropriate
response plan.
Most importantly.
Or usually we want to get them into the professional help, like I mentioned before.
You don't want to stop with you being the last line of defense.
You want to get them somewhere that's going to have follow‑on treatment and that they
can keep going to beyond you.
So and then you want to follow up.
You don't want them to feel abandoned.
You want to check in and just let them know that somebody's there and somebody cares.
Often people feel so crushingly alone that just having anybody text them can brighten
an entire day and really change their mind.
So.
I usually get asked this question, so I just kind of throw this one in there.
What are my reporting obligations legally if I find out a friend is suicidal?
Basically none.
You don't legally have to do anything unless you're actually getting paid to evaluate their
mental state.
If you're a teacher, a guidance counselor, a social worker, there's kind of other obligations
you would know about that if it was your job.
But in general, as a good Samaritan, if you're acting in good faith, you will be fine.
Okay.
So also the reverse of this, people often ask, like, let's say there's a break‑up
and somebody storms out and says, you know, if you don't come back to me or you don't
do X, Y, Z or whatever, I will kill myself.
And then you don't do it.
You don't want to see them again and they actually go through with it.
Are you culpable?
Are you responsible in some way?
And the answer is no, absolutely not.
You didn't really have anything to do with it.
You can't control them.
There's usually a lot of survivor guilt in those sorts of cases.
But no.
Legally.
Legally you don't have an obligation to protect them.
If you know what to do, it's certainly great to follow the framework we're going to talk
about.
But what's most important is that you know that it's ‑‑ that you get out there
and actually say something and do it and activate the plan.
So building rapport.
This is Uma Thurman's, do you listen or do you wait to talk?
And Vincent Vega's, well, I have to admit, I wait to talk.
But I'm trying to learn to listen.
So that's how I always explain active listening.
If you're a real film buff, you'll know that it's not actually from this still.
It's from the director's cut.
But I couldn't get that screen cap.
So okay.
It's the important thing.
So building rapport.
What's constructive?
What's constructive is asking one question at a time.
Give the person time to respond.
This is a little counterintuitive.
But if you repeat back to them what they just said, it makes them feel understood and heard.
People that are in an acutely suicidal state or even just a very depressed state, they
think like they have blinders on.
And research has been done to give them sets of math problems or have them do various cognitive
functional skill tests that you just don't perform as well.
You can't see a variety of options in the way that you normally would.
So your thinking is actually impaired into this kind of unilateral rut where you think
there's only one way out and one thing that you can do.
So it's very important to get people to break out of that and say, you know, it's like this
now but maybe it hasn't been this way all the time.
Tell me how you feel and let me show you that I understand what you're saying.
So say when you don't understand.
Don't ever say you do understand when you don't.
They catch on to that very quickly.
And ask open-ended questions.
Let them respond.
So obviously the opposite of that would be destructive things.
Active listening is not social engineering.
It's kind of the takeaway from this.
Yes, you are maybe filling out a threat assessment.
Yes, you are thinking about what's going on.
What they're talking about.
But that's kind of what people are supposed to do all the time when they're in conversations.
You're not actually manipulating an outcome.
And most importantly, because of that, the inhibited ability to perform cognitive functions,
all of the really cool Socratic rational logical arguments that you can step them through will
absolutely fail.
People do not respond to rational arguments when they're in that sort of state.
What you want to do is create a buffer.
A buffer zone.
A bubble where they can get through a crisis because it will eventually end.
Where they are safe.
And then once that's done and they kind of get back to a more clear way of thinking.
Almost like if you're out with somebody and they're like drinking and you can't talk to
them anymore.
You have to get them through that space and then you can confront their problems.
You can use cognitive behavioral therapy is pretty much the state of the industry to confront
people's misperceptions and change their world view.
But you're not going to be able to do that when someone is in the middle of a crisis.
Okay.
So separating feelings from states of being.
This is actually a great slide because this is something you can do on yourself all the
time.
That you might not ‑‑ it's one of those things you don't really think about or hear
yourself say.
But if you become aware of it, it can actually start to kind of change the way that you also
perceive the world.
So stop saying you are so many things.
Like I am lonely.
I am a mess.
I ‑‑.
angry. It's this sense of isness that becomes immutable and becomes who you are. It's like
when you introduce something, they are nice, which is the worst possible word because it
means nothing. But they are smart. You accept that this person is that thing and it's never
going to change. So if you change that to a simple I feel that right now, but I could
change that, it might change in the future, this gives you wiggle room to be able to
change the way that you think about things. So it's a pretty good tactic.
And then this slide is a slight deviation and it's another intentional wall of text.
But I just wanted to point out, this is one I hear around here all the time. I'm so burnt
out. And it's another thing that really means nothing. It's euphemistic and we all use it
to say I'm stressed, I'm troubled, I don't want to deal with it. But you don't know.
It could mean anything. So when ‑‑ you know, I call this the ten of the ten. The
beer therapy. But you go out and you have a couple beers with people and then somebody
inevitably will pull out the oh, I'm so burnt out line and then you talk about how much
you're smarter than your employer and then everyone goes home.
But really, if you dig down into that a little bit, you know, I feel exhausted from working
all the time. Okay, you're getting somewhere. No, dig deeper. Get somebody to express anger
and frustration. Now that's maybe a little more relevant. Okay, if you can get under
that and actually find out what they're afraid of that's making them feel that way, then you
can actually confront them. You can actually confront them. You can actually confront them.
And get them to change something that will make them feel less burnt out. So you can
probably read this one later. But it's kind of the progression of extracting that information.
So bringing it up is the S question that I mentioned earlier. This is ‑‑ so we're
assuming at this point that you found a safe space. You're talking to your friend or whoever
this is. You've assessed that they are at risk. You're concerned about them. You think
they trust you. And now you're ready to ask.
You can ask directly. Some of the things that you said made me think that you are thinking
about suicide. Am I right? This is probably one of the less awkward ways to ask, but you
can kind of figure it out for yourself. Indirectly, have you ever wished that you just didn't
have to deal with all of this anymore? The point is you can actually practice and find
a statement that feels good for you. It's really weird how difficult it is to find something
that you can utter with. Which is ‑‑ what was it? You're putting it on the wall. You're
without it catching in your throat. It's almost like when you first start talking about sex
or have to ask someone about contraception for the first time. You might be able to just
talk about all of these things in public or other settings, but you put someone one on
one and you make them ask a vulnerable question like that and it's really, really hard. But
you've got to suck it up and do it. And if you can't and you're that concerned about
somebody, you need to find someone who can. So don't say, this is the one thing that I
will say don't. Everything else, there's not really a wrong way to do things usually. People
are very concerned about what don't I say, like you're going to say the magic thing that
sends them over the edge. Don't worry about that. But don't ever say, you're not thinking
about doing anything stupid, are you? This is like the worst. First of all, you've delegitimized
all their feelings. If they actually are suicidal, you've told them that that's like a dumb
idea. And you're asking a negative response where it sounds like you're basically saying
don't bother me with your problems. You're not going to get a yes to this question ever.
So don't do that. All right. So depending on their response, and this is what you're
looking at here is a screen shot of what's actually on the CD. This is the threat assessment
framework that volunteers actually use to go through and check off all these boxes.
I know it's really little. We're going to zoom into the sections in a second.
You don't have to check off every box in order to do a successful intervention. This is just
the information overload that I know everyone loves. So once you get a yes to this sort
of question, now you're doing a threat assessment. First, immediate state. This is probably more
relevant to volunteers when they pick up the phone. But is a suicide already in progress?
If yes, you call 911. You can't handle that yourself. Are they currently under the influence
of drugs and alcohol? Are potential suicide methods nearby? Usually you can't convince
someone to give them up right away. There's a very long trust building process there.
But eventually they will. And also self‑harm, is their self‑harm in progress? Is it just
completed? Is it part of their world view? Whatever. So that's the first triage that
you do. But we're going to assume in your intervention that it's not this critical. Suicidal ideation and intent. This is really the meat of what you're looking for.
So are you currently suicidal? Are you having suicidal thoughts recently? In the last two
months is about the buffer zone. Was the person asked directly the suicide question?
We track that. So if this current intent exists, is it ‑‑ do you have a plan? Do you have
a method? Do you have easy access to that? So the more concrete someone's idea or plan
is, the higher the threat. Obviously, if you say, yeah, I'm going to go get myself some
of my dad's gun and you have that gun and you know where ammunition is and you have
all these things in order, that is a very critical situation. If somebody says, yeah,
I don't know, I maybe thought about pills but I probably don't have enough and I don't
really know, but I just don't want to be here, the risk is lowered. It doesn't mean
we walk away, obviously, but it's a different sort of situation.
So capability and desire is how strongly or how likely you are to actually execute on
the plan that you've talked about. So have you made prior attempts? Remember the early
graph, that's the strongest indicator of future attempts. Have you made rehearsals,
which is not quite an attempt but where you kind of play with the method? There's an entire
addiction underlying like psychology to suicide that we don't really have time to talk about,
but it becomes kind of like a safety blanket that people use in an escapist sense to go
off into a fantasy land where their problems don't exist anymore. So kind of digging down
into how much they've brought that out of the fantasy world and into the real world.
And then you just document what's wrong, why now, why not tomorrow, and why not now.
What are the buffers? You want to start eliciting the good stuff. And who else is involved?
So who else can you get in there? You really don't want to try to tackle this alone if
you don't have to. So risk indicators, this is your desire, intent and capability kind
of ‑‑ this builds the profile. This is where you find out is someone feeling hopeless
or are they feeling lonely? Do they feel like a burden to their family?
This is the core of the standard archetypes that you'll see. Their intent, again, would
be if it's in progress, you've already called 911. And then their capability, this is kind
of like a check box to some of the questions that we were describing before. But just you
kind of learn to kind of speed read, I guess, the various check boxes and develop a profile
or an archetype of various types of people. I mean, obviously all of our lives are individual,
but we do fall into different kind of categories, I guess, so ‑‑ and then your buffers. Internal
buffers always better than external buffers. If you can cope with stress, spiritual beliefs
of any sort of a sort, it doesn't matter what it is, tend to be a protective factor.
If you feel like you have a purpose in life or if you're planning for the future is a
big one. You know, I remember talking to someone and then it seemed very critical and then
they said, well, God, I guess next year we're just going to have to do it differently. And
like for the planning event, I was like, oh, okay, well, I guess that's ‑‑ that's
pretty far away. So I guess, you know, risk, lower, good. So and then external is your
supporting relationships, your community bonds, your people connections. We may feel
isolated just because we sit alone behind our computer every day, but that doesn't mean
that we're not part of a strong community. It doesn't mean we don't have people to talk
to. And it doesn't mean that we don't have strong relationships interpersonally and people
that are there for us.
Okay. And then outcomes and next actions. This is the GTD portion of the intervention.
So you never walk away from a meeting without having your next actions defined and someone
who is responsible. So you want to document that this person was persuaded to accept assistance,
who they're going to talk to, any professional referral details, and then make sure that
they've made a commitment to safety. So a commitment to safety is a commitment to safety.
is really critical if you're going to let someone out of your sight. This is where the
person agrees to not self‑harm, to not use drugs and alcohol and to not kill themselves
until you're getting help and until you've had, you know, more time to adjudicate their
situation. It's basically a safety bubble that they're agreeing to. And it's critical
because we just can't keep them safe. People are incredibly determined. And we cannot change
their minds and we cannot protect them entirely all the time. There are people in, like, locked
psych wards that find incredibly creative and bizarre ways to kill themselves when they
are determined to do so. So it's best not to try to lock them down. It's best to try
to get that internally. And sometimes it takes quite a while. So here's a threat assessment.
Okay. So at this point we've walked through all of the risk profiling. You've got a good
idea of what's going on with the current situation, the current crisis. And you're ready to make
a call. Is it high risk, moderate risk, low risk?
What's most important from this slide, again, it's kind of a lot of text on this one, but
this is also on the slide deck that's published. So you can kind of use it.
But generally the people that you will encounter are not going to be high risk. They probably
won't even be moderate risk. When you do a friend intervention, it will feel incredibly
critical to you and people will feel very life and death. But when you actually fill
out that rubric or that form, and that's why it's great to have these clinical assessment
tools, you'll see that maybe what seems like an ungodly life and death really isn't a plan
that's been made.
Maybe it really is just more of a kind of nebulous idea they're having.
So you're most likely statistically to end up in a low risk situation. So in that case,
you want to get somebody safe, you want to get them a referral, and then you can move
on from there.
If you ever do actually have a moderate or high risk situation, there is kind of a progression
through voluntary ‑‑ through an ER system, through voluntary commitment, through involuntary
commitment.
It can become kind of very legally feisty, so we don't really have enough time to deal
with that.
But if you need any sort of details on that, I'm happy to talk to you about it. But it
really varies incredibly based on your geography. So really, it could be anything, honestly.
Some states have great systems. Most of them do not.
So you've accepted ‑‑ you've persuaded the person in crisis to accept your help in
getting better help.
You've established a commitment to safety. You've established a commitment to safety.
You've got a safe space where they can ride it out for the next few hours. And now you're
going to make a follow‑up plan.
So you want to enlist other people. Keep them around. You want to keep the person that's
in crisis from being alone. You want to get them online resources or reading material
for the future maybe. But most importantly, you want to get them towards professional
care. And also, you can move towards building a crisis plan with them.
So this is kind of the end of my presentation. I hope you enjoyed it. If you have any questions,
kind of towards the end here, this is ‑‑ this is something a lot of people haven't seen
before. And that's really kind of disappointing because it's really a critical part of any
mental health strategy. And it's something you can build for yourself.
So a crisis plan is something that you make proactively when you're not in a crisis.
You identify your personal triggers, your warning signs, stuff that tells you personally
that a crisis might be developing. Your goal is to start outsmarting your own brain and
recognizing when your brain is telling you that it needs to go into crisis mode and
just telling it to stop. It's actually very effective. And one of the books that I pointed
out earlier on the slide with all the covers is called How I Stayed Alive When My Brain
Was Trying to Kill Me. And it's a story of a woman and her multiple attempts. And she
finally implemented this crisis plan. She said she had printed out copies, had them
all over her house, on her fridge, in her wallet, had given them to her friends that
were on the to call list, and just like inundated herself with this and refused to do anything
but follow these action steps. And that was what finally got her to be able to deescalate
herself rather than constantly having to refer on crisis services.
So there's an example that's kind of filled out. I don't know if you can read it from here.
But that's kind of what it looks like. And then there's a blank template that you can
fill out on the CD. So the crisis plan is really critical for a crisis plan because
it's critical for ongoing maintenance and for ‑‑ I don't know how to describe that.
It really helps you have an anchor for yourself. So I know we're kind of rolling towards the
end. So tactical crisis response information. These are kind of some slides I just wanted
to include toward the end for reference later. So you, 911, a current or past therapist,
a hospital or counseling center, there's hotlines. This is all, like, right now. This is all,
like, reference stuff that you can look at. If you want to get involved in discussions,
there's stuff ‑‑ there's some channels on IRC. There's some subreddits. Our suicide
watch is actually a really good one. Our suicidology is more ‑‑ has an academic
slant. And then there's a few sites that I tried to find some ones that were more
technically oriented. I've talked to a couple people that had started projects that kind
of rose and died. So if anybody would like to work on this. This presentation is actually
about half the length of what I had presented previously at source. So there's just tons
and tons of material. So it might be useful to maybe modularize it and get it up there
so you can kind of dig down deeper into it. And then education and advocacy, these are
places that ‑‑ these should be your first line of defense if you ever have to hand out
resources. Most of these organizations started in the 70s. It's a very, very kind of nascent
area of study, surprisingly. But, I mean, I guess that's due to our cultural things.
And then these are references about all the other stuff that's in here. And I have questions.
So thank you. I just ‑‑ before that, I just want to ‑‑ I want to thank everybody.
Okay. Clap. Fine. Thank you. So I just want to thank everybody for taking the time to
come learn about this. And I hope that you actually feel like you got some actual knowledge.
And can outline these steps. And that you walk out if you're not depressed but hopeful
about the change that we can make for each other. So I'll do Q and A ‑‑ I mean,
I didn't see anybody hold any things up. But I can do Q and A in here if we have time
or outside. Does anybody have, like, a counter? Do they actually give me extra time for this?
Because I'm running a counter right here. I'm not just making this up.
Okay. So does anybody have any questions or anything they want to ask? Yeah. Go ahead.
Odd, almost ethical sort of question. I'll skip over the details. But a friend of mine,
she ‑‑ her life, from a very objective standpoint, sucks. She's got chronic mental
illness, cannot hold a job because of it. She's sort of skating the edge of homelessness,
this sort of thing. Your question is what ‑‑ how do I feel
about rational suicide? That is your question. Yes.
Okay. Okay.
That is one of the slides that was removed from the 90 portions. There was a whole things
we can talk about at happy hour. Right to die stuff, rational suicide, there is absolutely
a case for that. It falls into a very different category than the things that you see here.
Generally the tenets of a rational suicide plan involve terminal illness, support from
your friends and family, premeditation, and a general comfort that everyone feels about
the decision. And in that case, I mean, personally, I think
I'm not against that at all. It's very different than people who say, I have free will, and
I should have the right to decide this for myself. That may be the case, but as we talked
about before, your brain is not functioning in the same way that it would normally.
And like I mentioned at the beginning about the number of attempts to completions, there
are 15 attempts for every completion. That doesn't mean that every person attempts 14 times and then completes. No.
Because the vast majority of people attempt once, do not complete suicide and never try
it again and are incredibly glad about that.
If those people were to have, you know, through pure chance, had a different outcome, we never
know whether or not people actually are satisfied with that.
And that's the problem with calling things successful and failed.
And also you're never going to have a successful attempt.
You only have failed attempts.
So it doesn't really work.
And that tends to also alienate other survivors.
So we should also try to get rid of the success, fail, committed.
Yeah.
There's a mic thing.
Yeah.
Sorry, Aaron.
It's a meritocracy.
Okay.
Yeah.
So I have a couple of family members that have had attempts or have talked
about feeling suicidal.
And they've got ‑‑ they have some professional help.
But I feel kind of ‑‑
I feel kind of helpless as to how to support them as a family member besides being encouraging.
And also what to do when ‑‑ they both like to talk a lot.
So it's hard for me to balance.
How do I know when ‑‑ how to support them when most of the time they just, regardless
of how they're feeling, they just want to talk and talk and talk.
That's kind of like the emotional exhaustion with the front intervention that I was pointing
out.
Yeah.
And the difference with having a ‑‑ being a real counselor is you have office hours
and you can sit when you can and cannot speak with people, which you can't do with your
family even when they're not suicidal.
I would say that the crisis plan is the best way to start enforcing that.
Because if you're a step on the crisis plan, you want to hope that all of the other steps
have been completed before that point.
So did you already, you know, go walk your dog?
Did you already journal today?
You know?
So starting to take back part of your time and enforcing that your time is valuable there.
But that you are there.
But you're like ‑‑ you're an escalation.
You're not level one support.
You're supposed to be like level two or three support for them.
And you want to make sure that they're doing the other things first, which isn't always
easy to enforce.
But if you make it seem like you're working with them and that way you can ‑‑ you
know when they call that it's valuable, they're more likely to work with you.
Thank you.
Yeah.
If that helps.
Yeah.
Hello, everyone.
Hello.
So for those of you who don't know, my name is RenderMan, and about February I went on
a bit of a Twitter rant and forum ‑‑ DEF CON forums post that I am dealing with depression
as much in our community does.
Honestly, it's the fact that we've got this huge community that we need to really destigmatize
reaching out.
And, you know, we've lost some really notable people, but there's a lot of people we haven't
heard about.
Absolutely.
And, really, I think we need to have an attitude shift, particularly within these communities.
That's something we can control.
To destigmatize depression and reaching out and, you know, taking that hand and getting
that help that you need.
So ‑‑ Absolutely.
I completely agree with that.
In a way, we are kind of progressively ahead of other communities, which I know sounds
a little counterintuitive, but because, I mean, we're here, we're doing this, and we
do talk to each other, I think that the stigma ‑‑ it perpetuates all of society, really.
If you start ‑‑ if you look back through especially the mental health industrial complex
since the turn of the century, we have done some really terrible things to people.
We stigmatized it intentionally.
In the 1800s, you know, suicides were not buried on religious grounds.
In England, the word coroner actually derives from the person whose job it was to decide
whether or not a death was a suicide, because if it was, your family forfeited all of your
assets and property to the crown, and it's a derivation of the etymology of crown, so
the coroner.
Yep.
Okay.
And we're done.
I'll go back there if anybody wants to talk.