How Would You Talk to the Person on the Roof? A Response to H. Omer and A. Elitzur

How Would You Talk to the Person on the Roof?
A Response to H. Omer and A. Elitzur

Dr. Ze'ev Bergman and staff, Institute for Family Therapy, Jerusalem

"What would you say to the person on the roof", by Avshalom Elitzur and Haim Omer, is an illuminating and important article, in its attempt to provide advance resources with which a helper can assist suicidal individuals and extricate them safely from their predicament.

At the same time, the authors consider their text preliminary, requiring further examination and calling for corrections and amendments. We have accepted this challenge, held comprehensive discussions, and hereby present our views:
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General Approach

The Helper’s Position

The desired outcome of this crisis is clear: bringing the suicide down from the roof. However, the answer to the question, which approach should the helper use to achieve this goal, is far from obvious. Theoretically the helper may think of the following approaches.

1. The Authoritative-Charismatic Approach offers a set of arguments and examples intended to persuade the suicide to abandon his or her objective.

2. Respecting The Suicide’s Decision, an approach which states, in essence: "If you've made up your mind to end your life, there is no force on earth that can prevent you from doing so. Therefore, the decision is entirely in your hands."

3. The Empathetic Approach underscores the emotional involvement of the helper - and possibly others caught up in the event – and states plainly that the helper does not want the suicide to die.

4. Identifying-Challenging Approach, put forward by the authors, attempts to describe to the suicide the extent of his or her despair, and then challenges the suicidal decision.

Each of these approaches has its advantages and disadvantages, and it is clear that each approach must be applied specifically to the suicide presently on the roof. However, the helper cannot know ahead of time which of these approaches will dissuade the suicide. Also, it may be necessary to move from one position to another, based on the developing situation. For instance, it is possible that the Empathetic Approach will become more dominant as the crisis develops, and so one should not rule out cautious and exploratory use of each approach, gauging the reaction of the suicide to determine which to pursue.

For instance, it is possible that after a while, the helper will feel that expressions of his involvement in the suicide’s life, and his empathy towards him, will not be construed as false, and so he should make repeated use of them.The helper should be given a wide range of options so that he is able to choose a combination most appropriate to him, to the suicide or to the situation at hand.

Interacting With the Suicide

We share the authors’ principal assertion that the suicide’s motivation to commit suicide is not his sole motivation. A person who intends to kill himself will commit the act efficiently, and in private and will not call for help. Making the act public is in itself a cry for help and indicates additional motivations, which are opposed to the suicidal objective.

The authors’ central claim for presenting the voice of the suicide is an identification with his position. However, excessive descriptions of the suicide's pain and suffering in the dissuading texts- particularly the abundance of sympathetic language, may be construed as a validation and not merely an acknowledgment of the suicide's viewpoint. In this case we may very well bring about the suicide’s death, rather than save his life. If the suicide perceives the helper’s message through his own Tunnel Vision, he is liable to link these messages to the ideas reverberating in his mind and jump to his death. For this reason, we propose a constant and unambiguous reiteration of the fact that these are the thoughts and feelings of the suicide and to emphasize, throughout the text, the presence of that other voice within him- the voice of life.

Furthermore, the helper must convey unequivocally that although he sympathizes with the suicide, he is not in agreement with him. Thus, for example, on page 14, Omer and Elitzur write: "Ron, I believe I know where you are, what kind of bind you're in, how pointless it all seems, how low you’ve sunk. But it’s not as though your life has been a picnic. I truly believe that if you could find another solution, you would not choose to die. In this regard, your intention is honorable. I respect it because I believe that if you could, you would choose otherwise."

In this text there is excessive identification and insufficient expression of a desire to live. Therefore, what we propose is this: "Ron, you feel that there is no hope, that others- myself included- cannot understand the extent of your despair. You may be right, although I am trying as best I can. It is possible that anyone else in your place would reach the same conclusion. But it just may be that your anguish is preventing you from seeing all the possibilities."

These practical conclusions stem from a wider perspective which views the inherent asymmetry between helper and suicide, accepts it as given and does not try to bridge this divide. Furthermore, the suicide does not need someone who identifies with him, in other words, an individual as despondent as himself. Rather, he requires someone whose personality is distinct from his own, who is in a dissimilar mental state and comes to him with a message. This message must be made up of two parts: First, an understanding (and not an identification) of his state of mind. And second, an external expression of the suicide's other voice- the voice that speaks of his desire to live.

Presenting himself in this way, the helper can be genuine and pragmatic, and will not need to find within himself the (nonexistent) identification with the Suicidal individual. The suicide can understand this approach and accept it. By standing on the roof, he is saying, in essence, that he has been waiting for someone to save him, and so he will be receptive to this approach.

On page [-], the authors write: "I also want to tell you that, while I’ve been speaking about all the reasons you may have for committing suicide, and the terrible pain you’re in, I feel that some of your despair and helplessness has somehow even managed to be passed on to me." The authors themselves appear uncomfortable with these lines, most likely because they sense that the suicide would not trust the helper’s empathy. The three reservations in their phrasing - somehow; even and manage - prove this point.

The Plight of the Suicide and the Plight of the Rescuer

In the crisis described here, there are two people in distress; the suicide, and the helper. However these are very different forms of distress and it is important to distinguish between them. The suicide seeks to end his life due to the hardships he has experienced; And the helper is in distress because he has been removed from the normal flow of his life and confronted with a complex situation, both personal and professional. He is required to perform in public a task which is typically carried out intimately and with discretion. He has not had the opportunity to study the personality of the suicide and the circumstances that have led to his decision. Time is against him, and failure could prove fatal.

The plight of the helper is mentioned only once in the dissuading text of Omer and Elitzur: "At this moment I am terrified of the act which you want to carry out." This is an authentic statement because it speaks emotionally of the helper’s genuine distress and not rationally of the suicide's suffering. Making use of his own plight, which stems directly from the suicide's, increases the helper’s credibility, both because he is communicating his own inner state, and because he is speaking the minds of all those for whom the suicide's death would be devastating.

This foreseeable strain on the helper makes it necessary to prepare him well in advance and give him the resources to carry out his task. We should prepare him as well as protect him. Preparation implies we must ensure that the helper is best-equipped to handle the situation. Protection implies that he be able to justify his attempts, whether in his own eyes or in the eyes of others if his rescue attempt fails.

In order for the helper to defend himself, it is important that he knows, ahead of time, that success is not guaranteed in every instance. What is required of him is to do the best he can, and be aware that no demands are being made on him to succeed in each case.. This understanding is also helpful prior to the rescue attempt because it reduces the stress on the helper and allows him to make the most of his skills. Substituting an identifying approach with one that expresses an understanding of the suicide's position may also help to reassure the helper, asking of him only the simple act of empathizing with a fellow man, rather than identifying with the suicide’s extreme mental state.

As for the helper’s preparation, it must be asked, what are the “tools” with which the helper approaches the suicide. We believe that his “tool-kit” includes everything he has learned about life and all that he believes in. In some cases, it is his strong belief in the sanctity of life. In others, a deep conviction in our constant need to choose and our ability to make the right choices. Or it may be the helper’s inner conviction in his ability to understand people, to join and to lead them.

It is only this kind of narrative, one that arises from within himself, that will allow the helper to persuade the suicide to abandon his goal.

For this reason the helper should rely on his inner resources rather than adhering to a prepared text. All we can do is offer advice. If it suits you, use it. If it sparks an idea, pursue it in your own way. And if it does not appeal to you, disregard it. One example of this type of advice is Omer and Elitzur’s idea of the personification of Death, which seduces the “weak” into abandoning life and committing suicide.

Another guideline is relating to the ascent to the roof (the cry for help) as the pivotal step taken by the suicide. The helper can then point out to the suicide that he has already succeeded in expressing his suffering and making it known to those who should be aware of it. Through this kind of language the helper can convey an understanding and even an appreciation of the suicidal act, with no need to fabricate a non-existent identification with the suicide. Emphasizing the call for help as the suicide’s objective also conveys to him the message that his act has been completed, and that there is in fact no need for him to jump.

The following is an example of a text which makes use of this approach: "You are up there on the roof, feeling lonely and disconsolate. You went up there because you saw no other option. When you tried to communicate your suffering you felt that no one was listening, and when your pain became intolerable you felt you could no longer bear it, and so you climbed up on the roof. Now that you are up there, everyone around you, including myself, understands how hard it is for you. We realize that we can no longer ignore you. Perhaps we should have listened to you sooner, but when we didn't, you decided on a course of action that would force us to take notice. In that regard, you have achieved your goal; we all understand how hard it is for you and how ignorant we were of your pain."

Another approach, which is certainly not appropriate for all suicidal people and yet may be suitable for those whose exhibitionist traits are apparent, is the idea of employing the dramatic themes of the event and taking advantage of the helper’s skills as a director to prevent the suicide from jumping. helpers who engage in psychodrama, may use these skills to communicate to the suicide: "There are many people standing around you and looking up at you, and they are all frightened of the step you are about to take. They are praying that you choose not to jump. You are the center of their attention now, you are the hero of this story, and it is in your hands to bring about a happy end. Everyone will applaud you if you decide to come down off the roof."

Other technique is the organizational approach to treating shell shock, used in the Israel Defense Force. This is an Authoritative approach that stresses the confused and disoriented state of the suicide, and organizes the situation for him. This type of helper is like Clint Eastwood in "Dirty Harry", though he adds to it a confrontational and provocative approach that most helpers may find daunting.

General Guidelines for Creating the Narrative

Several guidelines can be drawn from the General Approach for creating a narrative for a specific suicide:

1. Gathering the Utmost Information. Basic facts which can be rapidly gathered from the alerting party can be invaluable in creating the narrative. (For example, it would be pointless to discuss dropping out of officer-training with a person contemplating suicide due to a failed love affair). On the other hand, it is clear that lost time can be critical, and so this phase should be as brief as possible.

Occasionally however there are moments that can be utilized, such as the time it takes to get from the helper’s car to the scene of the event. Then questions such as these should be asked: a) The name of the individual attempting suicide. b) Reasons for the attempt. c) Is this the first attempt. d) Anything the suicide may have already said since the beginning of the event. e) Others who might be alerted (i.e. relatives, friends) in order to assist with the rescue.

Another option is to engage the alerting party (whether superior, commanding officer or close friend) to remain at the helper’s side and provide instructive responses to the questions aimed at the suicide. In this way the helper can increase the time frame during which he receives information about the suicide.

2. Modularity. While the authors do not consider their work definitive, they put forth a complete narrative that does not allow for changes. We believe that it is vital for the helper to understand that there can be a range of narratives which may change based on the conditions, the suicide's responses and the events that unfold at the scene.
3. Pacing and Leading The authors' concept of beginning with identification and moving towards confrontation is a variation on the approach known as Pacing and Leading, common in hypnotherapy. One of the benefits of this approach is the subtle and almost imperceptible shift from pacing to leading, which may be put to use by the helper in these situations as well. Shifting from articulating the understanding of suicide's intention to his dissuasion from the suicidal objective should be done in a seamless and consistent manner.. The helper should incorporate references from the suicide's own verbal and non-verbal reactions, revising the text even as it is being created.

For example: The helper: "Even if you are angry at your loved ones there must be someone among them whom you do not want to hurt." When the response to this is a denial, or apparent dissatisfaction, it is best not to follow this course. If, on the other hand, the suicide appears attentive, it should be pursued. Here it may be useful to demonstrate an approach mentioned previously in the context of Information gathering: "Who are the people dearest to you?" If there is no reply from the suicide, the alerting party may answer for him: "He loves his little sister.." The helper can then use this information to pursue this topic.

4. The Length and Complexity of the Texts The texts created by Omer and Elitzur are somewhat lengthy and complex. It would seem that putting forward this kind of presentation can be useful for distracting the suicide from carrying out his objective (similar to the Confusing Technique of Milton Erickson). However there is the risk that the suicide will simply stop listening. If we want to get the suicide’s attention, the messages conveyed to him must be simply phrased, uncomplicated, succinct and appeal to the emotions rather than the intellect.

5. Diversity vs. Repetition. The authors' text offers a diverse approach. It puts forward such an excess of arguments that even reading the article requires considerable effort. There is the risk that an individual under stress, suffering from tunnel vision, might react to this abundance as though to an annoying drone and come to disregard it completely. Conversely, if a few concise points are put forth, recurring in a variety of ways and yet employing simple, emotional language, it is possible that the suicide will take notice and listen.

The case for a diverse approach states that it is impossible to foresee what will attract the suicide's attention, and so it becomes necessary, at the onset of the event, to try a wide variety of arguments. But when the helper finds that he has caught the suicide's attention with a few specific arguments, he should focus only on these and adhere only to them.

6. Simulated Dialogue. The text presented by Omer and Elitzur is virtually devoid of questions, the assumption being that the suicide will not respond to questioning. This is not always true. However, even if one does adopt this stringent hypothesis, it may be beneficial for the helper to pose both true questions as well as rhetorical ones and to answer them himself. If the suicide responds, then the helper has created a dialogue, which greatly improves his chances of dissuading the suicide from jumping.

If there is no response from the suicide, this can still serve as a reflection of his inner conflict ("You're wondering if there is any reason to go on living like this.."), and also as an opportunity to answer for him ("On one hand you feel as though there is no point in living, that this is the end, but on the other hand you have doubts.."). While asking these questions, the helper can observe the suicide to determine which of the questions and answers appeal to him.

7. Discussing the Interaction (whether it exists or not), between the suicide and helper, can serve to personalize the narrative. Here are two examples:

a) The helper: "I've said some things to you and I believe you’ve been listening. At the moment I think it's difficult for you to reply, and to talk to me. It's possible that you're too focused on yourself and on your suffering. Nevertheless, I will not give up, I will stay with you and wait patiently until you feel you can talk to me.

b) The helper: "When I spoke about your younger sister Yael you remained quiet, but I noticed that you turned your head towards me for a second. This leads me to believe that even though you think the world looks bleak and pointless, you do not want to hurt your sister. Even in the state you're in, something is still present in you that enables you to think about her and care for her. And that something, as insignificant as it may be, could, at a different point in time, become quite significant."

8. Attrition As we know, extreme mental states are temporary. No-one remains on a roof for twenty four hours. After long periods of time in an extreme mindset, attrition sets it. Should a helper strive for this intentional prolonging of the crisis, so that the suicide eventually comes down from the roof instead of jumping from it? There is no clear answer, and so it is important to identify the conditions under which this becomes the case. If this has been indicated - either beforehand (for example, if the suicide had gone up to the roof on a previous occasion and sought a way down) or during the event- then the helper must consider the option of attrition and try to prolong the episode in order to increase its chances of success.

9. Confrontation. This term, used by the authors, is inappropriate, because we do not confront the Suicidal individual. We simply recognize that which the suicide has been able to grasp throughout his life but can now no longer grasp - that he wants to live and that there is meaning to his life – and it is this desire which we are now expressing.

10. Making Realistic Promises. We believe that promising the suicide a practical course of treatment is unproductive. If the suicide is in a state of life-threatening anguish, this type of assurance may seem to minimize the magnitude of his suffering, in its reduction into practical, bureaucratic steps. If the suicide is on the roof in an attempt to elicit these kind of assurances, his sole objective once he comes down will be to redeem them, and infuse them with as much content as possible. In this case there is high likelihood that the helper will be perceived as a liar and a fraud. For this reason it is best not to enter this type of “minefield”.

11. Alienating and Accusing Language. Omer and Elitzur use in their text terms such as Totalitarian and Inquisition, and names like Buber and Wittgenstein, language which conveys detachment and condescension. They also attribute to the suicide a desire for vengeance, (“You become the executioner of your loved ones who remain behind.) This type of language should be avoided. Also, bringing up the joys of life is irrelevant. It is enough that we save the suicide from death.

In Closing

The final segment of Omer and Elitzur's text remains inconclusive. Once a helper feels that he has been able to connect with the suicide on a personal level, it is best to translate this into action and assist him in coming down from the roof. Thus, he might say: "Now that you've succeeded in getting your message across and we see the extent of your suffering, why don’t you give us the chance to change the way we've treated you. I am going to move closer to you and help you come down." Obviously, the helper must take appropriate caution and withdraw if the attempt places the suicide in jeopardy. Conversely, faced with a disorientated and uncontrollable individual, a helper would do best to offer a realistic way to end the incident.