Welcome back to my series Making Sense of Suicide. I’ve previously talked about why we need to talk about making sense of suicide more, and I reviewed key theories to provide the needed framework for understanding suicidal ideations and related behaviors. Now I’ll be talking about the common fears clinicians face when dealing with suicidality. Specifically, fears associated with asking about suicide and doing a suicide risk assessment.

This feels particularly salient as September is Suicide Prevention Month. As a society we are talking more and more about understanding and helping to prevent suicide. And we have a long way to go. To that end, and in recognizing this topic requires much more than a few blog entries, I’ll be facilitating a Making Sense of Suicide Workshop on October 26, 2024 in Tucson, Arizona. You can find out more and sign up here.

Common Clinician Fears

There are two big fears I’ve observed when it comes to conducting a suicide risk assessment. The first is that if you ask about suicide, you risk triggering thoughts of suicide that weren’t there before. The second is that if you start asking about it, you won’t know what to do with what you hear. Both of these fears can result in assessing suicide as quickly and minimally as possible or even avoiding it all together.

Creating Suicidal Thoughts

The first fear is just not true. You cannot create suicidal thoughts just by asking about them. Having a clinician ask, “given everything you are going through, is suicide something that has come up for you?” will not inspire the client to go, “you know, I hadn’t but now that you mention it, that actually seems like it might be a good idea.” Part of this fear stems from concerns that suicide can be “contagious”.

This is a tricky concept, because while you can’t “catch” suicide, your risk does increase from exposure to suicidal behaviors and deaths by suicide. This is the acquired capability part of Joiner’s Interpersonal Theory of Suicide. Witnessing, or experiencing for yourself, suicidal behaviors changes how you relate to and understand suicide. It becomes a more tolerable, acceptable, and viable option for coping. This learning will not occur from a clinician asking if such thoughts are already present. Particularly, if they are asking the questions directly, compassionately, and skillfully. More on that in a second.

Fear of Making a Mistake

This brings us to the second fear of not knowing what to do. Which can be because you factually do not know what to do (hopefully this series will help with that!). It can also correlate to the fear of making a mistake, of not hospitalizing someone who really needs it, of not asking the right question and missing something, of feeling responsible if the worst case scenario happens. Unfortunately, these fears can lead to the desire to avoid doing a thorough suicide risk assessment and instead deferring to the generic “are you having any thoughts of hurting yourself and others” question and leaving it at that.

The problem with this question is:

• It is way too broad.
  • For example, the client may not want to hurt themselves though they do want to die.
  • Or, they may not want to die and are engaging in self-harm.
• The clinician can come off as:
  • Not wanting to really engage in this topic and just wanting to check-the-box.
  • Assuming the answer is no.
• It is too easy for the client to say no because:
  • They may also want to avoid the topic.
  • They can sense the clinician is asking the question in a checking-the-box kind of way.
• It puts the onus on the client:
  • To challenge shame and fear that may be present.
  • To get more specific.
  • To label the nuances of their experience – for which they may or may not actually have the words.

What should we be asking?

As I modeled above, “given everything you are going through, is suicide something that has come up for you?”, I like to ask about suicide in a global, non-judgmental, way. This approach normalizes that suicide may be present. It sets the stage that I am open to talking about it and I want the client to feel comfortable in the process. I am also taking a neutral stance. I am approaching suicide dialectically in that I’m going to be both matter-of-fact and also compassionate.

And the assessment doesn’t stop there. Even if suicidal ideations aren’t present now, I’m going to ask if they ever have been. If so, what did that look like? Did the thoughts ever translate into action? What helped the thoughts resolve? And so on. I’ll go over the nuts and bolts of this in a future post.

In Conclusion

We have to guide the conversation. And we have to get specific (again, more on this to come). This initially opens the door to potentially scarier conversations and harder clinical decisions. Ultimately, however, a thorough suicide risk assessment can help us feel more confident in our decision-making and in the care we are providing. And we are giving our clients a tremendous gift; the gift of them being able to be fully honest and open about the depths of their pain and suffering without judgment, shame or blame, or punitive treatment planning.

For Clinicians: I hope if you have held these fears that they are starting to be allayed. I know I haven’t given you much yet in terms of what to actually do, and I promise, it’s coming! In the meantime, what do you notice when it is time to do a suicide risk assessment? Are you hesitant? Shying away? Have you ever been taught how to do a suicide risk assessment? Or how to treat suicide? What comes up for you in these moments? Whatever it is, it’s normal! And some extra support would be warranted. That’s where training, supervision, consultation, and maybe even our own therapy come in.

For Those Seeking Healing: If you have ever had an ineffective or negative encounter with a provider around suicide, I see you. It happens far too often. And on behalf of the field, I am sorry you’ve had these experiences. As I will always remind you, these posts do not equate to emergency interventions or therapy.  Please call 9-8-8 or go to your local emergency room if you are in crisis.