Assessing Suicidal Ideation

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Newer therapists tend to get really nervous when it comes to assessing suicidal ideation. One distressing thought is that bringing up the topic might somehow implant a stronger desire to commit suicide in their client.  Another distressing thought is that bringing up the topic might somehow make things awkward and hinder the burgeoning therapeutic alliance.

But neither of these fears are founded. The truth is that asking about suicidal ideation isn’t telling anyone to do anything. If someone isn’t feeling suicidal asking them about it won’t change that fact and the conversation can move on. If they are feeling suicidal asking them about it not only shows concern but also isolates the most pressing problem right away and allows for immediate intervention, while feeling awkward and therefore letting the question slide leaves the most important piece of the puzzle off the table.

Depression is a dark and lonely place. Suicidal ideation is a dark and lonely place. We’re all taught in our society to buck up, to be individualistic, to put a smile on our faces, to be normal, to fight through it. We don’t want to burden friends or family with our dark thoughts. Many of us have no idea how to even put these thoughts into words.

So rather than being awkward or hindering the therapeutic alliance, when suicidal ideation is present and it’s asked about in a non-judgmental, open way the bond immediately strengthens. There’s someone willing and able to listen to this threatening, dangerous material and there’s no threat of reprisal or humiliation? That’s a liberating feeling for people who are currently feeling pressed further and further into a corner with no apparent way out.

As therapists, the subjects we bring up only get awkward if we make them awkward. Our clients take many of their cues from us. So if we can learn to talk about the threatening, dangerous, embarrassing, awkward material openly and honestly they quickly learn to model that behavior and do the same.

When assessing for suicidal ideation, a good place to start is just to ask frankly if the client has ever felt suicidal or is currently feeling suicidal and if so how much on a scale of 1-10 where 1 is very little and 10 is that suicide is imminent. As the professional the task is to try to come to an objective appraisal based on that subjective number scale. The way to do this is to figure out what if any plan they have and how specific that plan is. Conditional questioning can be used, like “If you were to attempt to kill yourself how do you think you’d do it? Where would you go? When would be the best time?” The more specific the plan the more pressing the problem. So for example, “I would do it by hanging myself at night when my parents were out of the house this Valentine’s day” is a blaring red alert. “I’ve never really thought about what I’d use to do it or where I’d go” is on the other end of that alert spectrum.

Regardless of where they end up on that scale of 1-10, it’s a good idea, if they are feeling suicidal at all or ever have, to draw up a contract with them that you can both sign where they promise to go through certain procedures if they’re feeling suicidal, like listing the good reasons to stay alive, calling a help line, reaching out to friends, calling you, setting up an appointment, checking themselves into a psychiatric ward, etc. These contracts are more powerful than you might think. As social animals we have that cognitive bias in our DNA that when we commit to a social contract we need to follow through with it. And if you think the risk is high enough that suicide is imminent this falls under immediate danger to self and others and it’s your ethical and professional responsibility to get them checked into a psychiatric ward where they can get the immediate help they need. This is another area where newer therapists worry that taking this step would ruin the therapeutic alliance but the opposite is usually true. Once the crisis is past the feeling is usually profound gratitude that someone cares enough about them to get them the help they need.

Suicide is a scary topic. It needs to be approached with great care and consideration. But we should never let the fear keep us from asking the important questions, questions that have the potential to greatly speed up the healing process, not to mention save lives. Assess suicidal ideation in a frank, non-judgmental, open way and you’ll get the honest answers to help you come to the correct diagnosis so that you can craft the correct treatment plan.

Suicide Prevention Hotline: 1-800-273-TALK (8255)