So here's what I understand about suicidality; not as a professional, but as someone who's been around suicidal people more than she'd like and so had to either get good at dealing with it or start having a breakdown.
Not all suicidality is immediate; there's a really big difference between wanting to die and planning to. There's a whole spectrum in there of complicated feelings, loss of control, loss of ability, loss of being able to cope. There's a reason doctors, if they're competent, ask if there's a plan. It's grey, and understandably some play it safe; the good ones can deal with the grey area. When we try to help someone who's suicidal, especially one the system is likely to fail, we have to respect this grey area.
There's three major ways suicidality shows itself. Four if you accept dying as an acceptable remedy to intolerable pain.
First, planned suicide, usually after a long down spell, often accompanied by being cheerful. And often giving away stuff, etc. The warning signs are almost all positive seeming. That one is super hard. Seriously. It doesn't come out of the blue, but it surprises the hell out of people. Watch out for people getting better for no reason -- same shit in their lives, no steps to improve it, but one day it's blue sky, all better... go stay with them. Go connect. But it's a rough ride if it happens.
Then there's "I'm hurting and I just want it to stop" suicidality. That is usually desperate, but not focused. Self harm is a more usual result. Risk goes up with the lethality of the methods available: having guns in the house means that a moment of desperation can be life-ending. Knives are rarely fatal, but someone can end up with nasty scars. Scissors, paperclips, staples ... the list is so long for things that can leave someone bloody, frustrated, hurting and alive, it's not worth mitigating. If the drive is there, it can happen. If it's not fatal, it can turn out okay.
So encourage risk reduction. Even harsh behaviors like cutting are a win over suicide. Get someone to sleep is the best.
That's where connection helps. Someone to talk to, distraction with movies or silliness. Eating. Change of scenery. Friend visiting. Even though they don't usually want anyone near.
It's also exhausting. Constancy over depth of intervention is a win. Daily check-ins. Remind yourself it's not a big bang coming, but increasing desperation that drives suicide in this case. So it's a marathon, not a single moment to save someone. Something's gone wrong, and it's only support that is going to let things sort themselves out.
And then there's manipulative suicidality. Take it like the above case, but watch out for being taken advantage of. Usually, there's other manipulation in the past. If you're someone who's vulnerable to the person who ends up in this state, be careful. Better to enlist more neutral folks to help out. The suicidality may be real, but so can the manipulation.
But it's counter-intuitive but even encouraging someone to do a harmful thing like cutting if it's a real alternative can make sense. Running until exhaustion, anorexic behaviors, hyperfocus on a task to the point of potential damage. All of those are better than suicide. If it's anxious-hyper suicidal feelings in particular, activity can help. Not all ups are positive for people, and for some people that's when they're in the worst of it, with the depression as the relief.
The overall theme, though, is anything to give a sense of both control and support.
"I brought two meals. Pick one, we'll eat together"
"I don't think you're a bad person. You're having a hard time."
"I'll still love you with some scars."
Too much empathy is only alienating. "I get it, I've been down sometimes too" is so unlike the desperate feeling of being suicidal. Don't go there. You haven't been there unless you've been suicidal too. It's not a gentle feeling, it's visceral, desperate, completely overwhelming.
Any evidence that you'll be back regularly helps. Even if virtual.
"See you tomorrow night?"
Helps build trust. Avoids abandonment issues.
And anything to mitigate the reason for suicidality helps too. House cleaning is a huge one. Help get a sense of control of the environment back -- depression wrecks your ability to function, and having to struggle to get back to baseline makes it all the more overwhelming. But be careful you don't undo those unhealthy-but-better-than-suicide coping mechanisms. But showing up, doing the dishes, taking out the trash, and tidying the bathroom? That can be the difference for someone.
What do you say if someone is dealing with being suicidal and feels alone? "Talk to me."
Time box it to stay healthy. This isn't an acute intervention. You won't make suicidality go away in a day. Nor likely in a week or even a month. You'll exhaust yourself trying to fix it right away. If there is someone to trade off with, yay! An hour from one person in the morning, an hour from a other at night? That's a huge, stable, life-giving support, with a bounded cost to the people providing it.
And then there is the encouraging to get help. Get on the waiting lists for treatment. And if they need a buddy to go with them, try to help them get that. The system is terrifying and really hard to navigate when anxious and depressed. Outcomes are vastly better with an advocate -- not controlling the person's life. Never control. Yield control as much as possible. Sometimes simplify the options or restate them simply, but the goal is to make getting choices in the hand of the suicidal person achievable.
Be careful with family and friends. Only actively supportive people should be told that someone is suicidal: there's a lot of things not to do in this document, and in addition, betrayal of privacy and control sucks. Sometimes it's positive to break the shame cycle that keeps people from being connected and healing, but it's a lot like coming out, but only during a crisis, and so twice as fraught.
But aside from acute moments of crisis, suicidality is usually chronic, not needing immediate and acute intervention. People screw that up all the time and the ensuing loss of control is devastating to the person suffering. But it takes guts to be helpful with that with how suicidality is portrayed as an immediate crisis. Suicidality is a symptom. Potentially deadly, but not the point.
The specifics are different for trans folks.
Affirming identity and frustration. Reducing pressure to conform immediately. Fears over coming out to family and coworkers. It's fraught because the pressures society places on us to conform are devastatingly intense sometimes. Threat of violence is real, and even when imagined, devastating and can cause PTSD.
The specifics are different for Black folks.
Don't call the police. Be careful with official responses, including calling the ambulance. Do everything possible to make sure the person you're calling to help will be not treated as a threat. Police violence when called for mental health issues is a possibility anyway but is vastly more likely to affect Black folks. Call for community support and do the extra work to find it. Ask if there's a church, community group, group of friends, anything that can be brought in. Arrange rides to the emergency room or psych hospital intake in personal vehicles. If you are with someone who's chronically suicidal, develop plans for this in advance as best you can and write it down.
A final word.
Be aware of who is a mandated reporter. Most states make teachers, counselors and sometimes even clergy and other professionals into mandated reporters. Someone who is actively suicidal can have all control stripped away, and then be held in an inpatient psych unit for 72 hours. What happens after those hours depends on the state and the patient, but the loss of control can be devastating, and so it is much, much better to have it be chosen to go to the inpatient unit than have it forced upon someone.
In addition, many places, any of law enforcement, firefighters, EMTs and ambulance personnel, doctors and therapists have the power to refer for a 72 hour hold for "potential harm to self or others", including the use of illegal substances.
To do:
For section 1, kinds of official response; what to do with recklessness and semi-accidental overdoses of only possibly-lethal pills
For section 2: how involuntary vs voluntary works (and how there's not a ton of difference initially)