Uncovering Suicidal Thoughts

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?

First: Ask the question. Don’t shy away from asking if the person is having suicidal thoughts. Use direct language, such as “Do you have thoughts of suicide?” or “Are you thinking of killing yourself?”

Avoid euphemisms. Don’t ask only if they are thinking of harming or hurting themselves, because not all self-harm is suicide, and not all suicidal people view suicide as hurting themselves. (Think about it: To them, they may be ending their hurt.) Using a euphemism conveys that you consider suicide too taboo to talk about it directly. Break the taboo.

Shawn Shea, M.D., a psychiatrist and expert on suicide risk assessment, has described excellent techniques for asking about suicidal ideation. These validity techniques are designed to elicit valid information about stigmatized topics such as suicide, sex, and substance use. (His book, The Practical Art of Suicide Assessment, is a must-read for clinicians.) Validity techniques include:

  • Normalization
  • Shame attenuation
  • Gentle assumption
  • Symptom amplification
  • Denial of the specific
  • Behavioral incident

Normalization

This technique involves making clear from the outset that it is essentially normal to think of suicide in some contexts. 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?

Shame Attenuation

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 blames the situation, not the person, for their suicidal thoughts. 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 think of killing yourself?”

Gentle Assumption

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 say they masturbate if researchers asked them, “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.

Symptom Amplification

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, 20 times? 30 times?”

By exaggerating how frequently or intensely the person thinks of suicide, this question can help 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.

(Unrelated to suicide, I witnessed this phenomenon in action recently when a friend was embarrassed about how many boxes of Girl Scout cookies she’d purchased. In a group conversation, people threw out numbers: “What, did you buy 20?” Someone else asked, “30?” My friend said, “Y’all are making me feel less bad about how many I bought. I got 8 boxes.”)

Denial of the Specific

This technique involves going from the general to specific. You ask an overarching question about suicide or a related construct, and then if the person says no, you get more specific.

Example:

Clinician: “Have you made any preparations for suicide?”

Client: “No.”

Clinician: “Have you written a will?”

Client: “No.”

Clinician: “Have you written a suicide note?”

Client: “Well, yes, but only on my phone. I haven’t printed it out or anything.”

Although the person might be irritated when you ask a question that was already seemingly answered, in reality many people who say “no” to a general question say “yes” when the question is asked about specifics.

Behavioral Incident

For this technique, you ask very concrete questions about situations that might trigger or exacerbate suicidal thoughts. You seek to understand facts and the person’s thoughts, feelings, and actions in response. 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: “Can you walk me through what happened the night you almost attempted suicide?” And later: “What did you do next?” or “What did you feel next?” or “What did you think next?”

In an example of someone who says they wanted to take pills: “Did you get the pills out? Did you put them in your hand? What did you do next? (Of course, allow time for the person to answer, listen, and maintain a conversational, not an interrogational, stance.) 

Summing Up

No assessment technique is perfect, and some people who want to die by suicide simply will not reveal their thoughts and plans. Still, these validity techniques can help convey to a person that you will not judge them for thinking of suicide. And the techniques help make it easier for the client to speak about what, for too long, may have been unspeakable.

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.

You can hear an interview with Dr. Shea here, conducted by Jonathan Singer, Ph.D., for the Social Work Podcast.

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. Photo purchased from Fotolia.com

LAST REVISION: March 11, 2021

Stacey Freedenthal, PhD, LCSW, is the author of “Helping the Suicidal Person: Tips and Techniques for Professionals,” a psychotherapist and consultant, and an associate professor at the University of Denver Graduate School of Social Work.

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