To help a person deal with suicidal thoughts, you first need to know they have them. The challenge here is that many people who seriously consider suicide do not tell their therapist, at least not fully.
What To Do?
Shawn Shea, M.D., a psychiatrist and expert on suicide risk assessment, has described excellent techniques for eliciting disclosures of suicidal ideation from potentially reluctant clients. (His book, The Practical Art of Suicide Assessment, is a must-read for clinicians.) These techniques include:
- Shame attenuation
- Gentle assumption
- Symptom amplification
- Denial of the specific
- Behavioral incident
This technique involves making clear from the outset that it is essentially normal to think of suicide at one time or another. To convey this, you might allude to other clients who have experienced similar pain, hopelessness, or difficult situations and thought of suicide as a result.
Example: “Some of the people I work with who have severe depression get to feeling so hopeless that they think of ending their life. Do you ever have thoughts of suicide?”
Many people who want to die by suicide feel ashamed of such desires. They may have grown up with religious teachings that said suicide is a sin. Or maybe they believe that people who think of suicide are selfish or weak. Maybe they fear that thinking of suicide means they are defective or “crazy.”
Shame attenuation may help people feel less condemning of themselves and of their suicidal thoughts. This technique is similar to normalization, only that you convey that the client’s situation itself makes it understandable that suicide might be considered as an option. This does not mean that you condone suicide as an option, only that you can see how it can make sense to the client.
Example: “You’ve described an enormous amount of painful problems that you are going through. With all the pain that you feel, have you ever just wished that you were dead?” followed by, “Do you ever think of killing yourself?”
Sometimes, when asked a difficult “yes-no” question, the hardest part is saying yes. It can feel like an admission or confession – of having done something wrong. To avoid this obstacle to disclosure, the technique of gentle assumption calls for the therapist to act as if the client has already acknowledged feeling suicidal. That way, the therapist can ask questions to determine if such suicidal thoughts actually exist.
Example: How many times in your life have you ever thought of killing yourself? How many times recently?
This technique has been used in sex research. According to a report by the Kinsey Institute, more people were willing to talk with researchers about masturbation if they are asked “How old were you when you first started masturbating?” instead of “Do you masturbate?” This question makes the assumption that yes, of course people masturbate. No shame there. It really does matter how you ask questions.
The task of the clinician is not only to determine whether the person is thinking of suicide, but also how often and how intensely.
Example: How often would you say you think of suicide a day, 30 times? 40 times?
By exaggerating how frequently or intensely the person thinks of suicide, this question can also be asked in a manner that helps the person to feel less ashamed or stigmatized about having suicidal thoughts. If a very large number is proposed, it sends the message that smaller amounts are not so unusual. It also makes it easier for the client to say they think of suicide many times a day. For example, someone may be embarrassed to admit they think of suicide 10 times a day until they hear this much larger number, which makes 10 times sound like not so much.
Denial of the Specific
This technique involves going from the general to specific. Instead of merely asking the person if he or she has suicidal thoughts, now you ask whether they have considered attempting suicide in several specific ways:
Example: Have you ever thought of shooting yourself? Taking an overdose of pills? Hanging yourself?
This technique is especially useful when a person reports no suicidal thoughts, or only one method of suicide under consideration. Although the person might be irritated when you ask a question that was already seemingly answered, in reality many people who say “no” to suicidal thoughts do go on to endorse a specific method.
For this technique, you ask very specific questions about the person’s behavior in response to stress, pain, hopelessness or other difficult emotions or situations that might trigger suicidal thoughts. You seek to understand concrete facts, specific feelings, and actions that the client took next. By breaking the client’s experience down into very specific details, you help strip away any vagueness or subjective distortions that might obscure the client’s true experience.
Example: When your boyfriend told you he was breaking up, what did he say? What did you do next? What did you feel? Then what happened?
No assessment technique is perfect, and some people who want to die by suicide simply will not reveal their thoughts and plans. Still, these techniques can help convey to a person that thinking of suicide does not mean they are a bad person or doing anything wrong. And the techniques help make it easier for the client to speak about what, for too long, may have been unspeakable for them.
For More Information:
The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors, by Shawn Christopher Shea. (2002). Published by Wiley & Sons, Inc.
See, too, www.suicideassessment.com. This is the website for Dr. Shea’s group, the Training Institute for Suicide Assessment and Clinician Interviewing.
© Copyright 2013 Stacey Freedenthal, PhD, LCSW, All rights Reserved. Written For: Speaking of Suicide
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LAST REVISION: September 2, 2015