Nearly everyone agrees that asking clients directly about suicide is the right thing. However, because every client situation is unique, there are also many different strategies for asking about suicide. In this short excerpt from Clinical Interviewing, we discuss how to bring up suicide using information from outside of the counseling or assessment session.
Using Outside Information to initiate Risk and Protective Factor Assessment
Outside of the formal suicide assessment interview, three main sources of information can be used to initiate a discussion with clients about suicide risk and protective factors:
- Client Records
- Assessment Instruments
- Collateral Informants
If available, your client’s previous medical or mental health (med-psych) records are a quick and efficient source for client risk and protective factor information. Many risk factors listed in this chapter won’t be in your client’s records, but you should look closely for factors, such as: (a) previous suicide ideation and attempts; (b) a history of a depression diagnosis; and (c) familial suicide. After your standard intake interviewing opening and rapport building, you can use the records to broach these issues.
I saw in your records that you attempted suicide back in 2012. Could you tell me what was going on in your life back then to trigger that attempt?
When exploring previous suicide attempts, it’s important to do so in a constructive manner that can contribute to treatment (see Case Example 10.2). Using psychoeducation to explain to clients why you’re asking about the past helps frame and facilitate the process.
The reason I’m asking about your previous suicide attempt is because the latest research indicates that the more we know about the specific stresses that triggered a past attempt, the better we can work together to help you cope with that stress now and in the future.
Don’t forget to balance your questioning about previous suicide attempts with a focus on the positive.
Often, after a suicide attempt, people say they discovered some new strengths or resources or specific people who were especially helpful. How about for you? Did you have anything positive you discovered in the time after your suicide attempt.
It may be difficult to identify protective factors in your client’s med-psych records. However, if you find evidence of protective factors or personal strengths, you should bring them up in the appropriate context during a suicide assessment interview. For example, when interviewing a client who’s talking about despair associated with a current depressive episode, you might say something like:
I noticed in your records that you had a similar time a couple years ago when you were feeling very down and discouraged. And, according to your therapist back then, you worked very hard and managed to climb back up out of that depressing place. What worked for you back then?
Strive to use information from your clients’ records collaboratively. As illustrated, you can use the information to broach delicate issues (both positive and negative).
Traditionally, previous suicide attempts are considered one of the strongest predictors of future suicidal behaviors. However, as with all risk factors, previous attempts should be considered within the idiosyncratic context of each individual client. Case example 10.2 provides a glimpse of a case where a previous attempt ends up serving as a protective factor, rather than a risk factor.
Case Example 10.2
Exploring Previous Attempts as a Method for Understanding Client Stressors and Coping Strategies
Exploring previous suicide attempts is an assessment process. It can illuminate past stressors, but it’s equally useful for helping clients articulate past, present, and future coping responses.
Therapist: You wrote on your intake form that you attempted suicide about a year and a half ago. Can you tell me a bit about that?
Client: Right. I shot myself in the head. It’s obvious. You can see the scar right here.
Therapist: What was happening in your life that brought you to that point?
Client: I was getting bullied in school. I hated my step-father. Life was shit, so one day after school I took the pistol out of my mom’s room, aimed at my head and shot.
Therapist: What happened then?
Client: I woke up in the hospital with a bad fucking headache. And then there was rehab. It was a long road, but here I am.
Therapist: Right. Here you are. What do you make of that?
Client: I’m lucky. I’m bad at suicide. I don’t know. I suppose I took it to mean that I’m supposed to be alive.
Therapist: Have you had any thoughts about suicide recently?
Client: Nope. Nada. Not one.
Therapist: I guess from what you said that getting bullied or having family issues could still be hard for you. How do you cope with that now?
Client: I’ve got some friends. I’ve got my sister. I talk to them. You know, after you do what I did, you find out who really cares about you. Now I know.