I’ve been contemplating whether anyone likes to go for medical examinations. I’m thinking of colonoscopies, dental exams, mammograms, stress tests, blood draws, and other more or less routine examinations of physical functioning. I’m guessing most people don’t like these procedures much, even though medical examinations provide important information and can contribute to our good health and well-being.
Why are medical and physical assessments so darn unpleasant? One part of the unpleasantness is probably the intrusiveness. Assessments are all about gathering information; medical assessments involve gathering information about things that trigger vulnerability. Sometimes we have to be naked while we let strangers look at us and poke and prod our bodies. Even worse, medical examinations generally focus on our flaws, our weaknesses, and potential illness or disease. Whether we’re stepping on the scale in front of the medical technician or being asked, “How much alcohol do you drink?” insecurities and defensiveness can get activated. Two weeks ago when I got weighed at the doctor’s office, I wanted to complain, “Hey. That’s not right. Your scales are off. At home I weigh at least 6 pounds less than that!” What stopped me? The realization that complaining about my weight might look and sound even worse than just accepting the number. . . and so I kept quiet about my opinion. Partly–as one of my former grad students would say–we’re all about impression management.
If physical examinations trigger insecurity and vulnerability, just imagine what gets triggered in the mental and emotional domains. While at the medical office I got asked items from the PHQ-9 and GAD-7. I said “No” to every symptom, explaining, “Hey. I know all about these assessments and have written articles about them.” My med tech person wasn’t especially interested. I suspect, given her devotional attention to the computer screen, that she might not have been super-interested even if I had complained of depression or anxiety symptoms. But that’s speculation. She might have turned to me and tuned in like an empathic laser.
Nowadays, everybody is supposed to be on the alert and, if needed, ask about suicide. This idea, although theoretically great, doesn’t work all that well in reality. During a recent integrated behavioral health (IBH) training I learned of an IBH program that’s now devoting a whole three minutes to suicide assessment. Oh my. No wonder, based on a meta-analysis of 70 studies, about 60% of people who died by suicide, denied suicide ideation when asked by a general practitioner or psychiatrist (McHugh et al., 2019).
In an early version of the assessment chapter of our upcoming book on suicide assessment and treatment, I jumped headlong into the problems with suicide assessment. I figured, if answering questions about weight or alcohol consumption activate vulnerability and defensiveness, getting asked, “Have you thought about suicide?” likely stokes even greater insecurity and potentially stimulates even more evasiveness.
My early draft section on what’s wrong with suicide assessment, got substantially re-worked, maybe because some people thought I should be nicer, and maybe because I agreed with those people. However, right here on my very own blog I don’t necessarily have to be nicer. You all can tell me if I’m being too mean.
But before we get lost in my not-quite-ready-for-prime-time text below, here are my general conclusions.
1. Although questionnaires are fine for gathering information, if people are suicidal we need to rely on clinical interviews, rather than questionnaires.
2. We should ask about strengths, and not just problems (like the PHQ).
3. We should use normalizing questions (as I’ve written about before). We also need to train people how to use normalizing questions.
4. We should ask with kindness, compassion, and empathy . . . and be prepared to spend more than three minutes on the topic. We also need to train people on how to spend more than three minutes on the topic.
And finally . . . here’s the excerpt.
Currently, in the United States, more professionals are conducting more suicide screenings and suicide assessments than ever before in the history of time. This fact begs the question: If we’re conducting more suicide screenings than ever, why are suicide rates continuing to rise? Could it be possible that suicide screenings increase suicidality?
Traditional responses to this question include:
- We don’t know why suicide rates continue to rise despite prevention efforts
- Asking about suicide doesn’t cause or increase suicidality.
For many years suicide researchers and practitioners have emphasized that asking about suicide doesn’t increase suicidality. Everyone in the suicidology field teaches that clinicians, paraprofessionals, and concerned non-professionals should ask directly about suicide ideation. We agree with this stance. The unanimous message is:
Clinicians should ask directly about suicide. Asking directly doesn’t increase risk or put the idea into the client’s head. Most clients either accept questions about suicide as a standard mental health practice, or feel relieved to be asked about suicide.
Despite our agreement with the philosophy of asking directly, all too often, when we’ve witnessed the question being asked, we’ve seen it asked badly. In one case, as a part of a mental status examination, we saw a social worker ask an elderly man, “Have you had thoughts about suicide?” The man responded, “I don’t know.” The social worker rephrased the question, “Do you think about death and dying?” Again, the man said, “I don’t know.” The social worker moved on. There was no follow up.
In another case, we listened as a nurse used a suicide assessment protocol during an initial interview. She asked a question from item 9 of the Patient Health Questionnaire-9 (PHQ-9): “Have you had thoughts that you would be better off dead, or of hurting yourself?” The patient said, “Yes.” Then, much to our surprise, the nurse simply asked another question. There was no empathy. There was no compassion. The nurse looked back at her clipboard, made a note, and continued asking questions from a script. Apparently the script didn’t include a box for checking off empathy or compassion.
Over the past decade we’ve repeatedly been asked to consult with schools on their suicide assessment and referral process. All too often we’ve heard from exasperated school counselors and school psychologists about how much they hate trying to interpersonally engage potentially suicidal students using a risk factor checklist or questionnaire items. School professionals complain about rigid procedures that result in referrals to the local hospital emergency department and end in ruptured therapeutic relationships.
Beyond these less-than-optimal scenarios, there’s empirical evidence indicating that suicide assessment procedures don’t always have neutral or positive effects. Harris and Goh (2017) conducted a randomized control trial evaluating the emotional effects of a suicide assessment protocol on Singapore residents. Although they reported no evidence for iatrogenic effects, 24% of participants experienced increased negative affect following administration of the Suicide Affect-Behavior-Cognition scale (Harris et al., 2015). Using a similar protocol, a Dutch research team reported similar results (de Beurs, Ghoncheh, Geraedts, & Kerkhof, 2016). After responding to 21 items from the Beck Scale for Suicide Ideation (BSSI, **), participants generally reported increased negative affect. In particular, about 15% of the BSSI group had substantially negative affective responses to the BSSI items.
We have no doubt that the social worker, the nurse, and the school districts featured in the preceding examples of poor suicide assessment were well-intended. For many reasons—including anxiety, lack of professional training, client hostility, fears of liability, or countertransference reactions—professionals often engage poorly with suicidal clients. We’re also certain that most of the time, clients view questions about suicide as necessary, and sometimes consider queries about suicide a welcome relief. However, we also believe, as in the two research examples, that repeated questioning about depression, suicide, anxiety, insomnia, and other aversive symptoms—without a skilled clinician to collaboratively explore depressive symptoms and reorient clients toward strengths and positive experiences—can activate negative affect. These reasons—and more—have convinced us that mental health and school professionals can do better than simply administering the PHQ-9, the BSSI items, and following a checklist when evaluating for suicide. Instead, professionals should balance their questioning, follow-up sensitively to clients’ responses, and validate that suicidal thoughts are a natural reaction to painful emotions and disturbing situations. All this points to the need to view suicide assessment differently; instead of adopting an authoritative assessment role, we encourage you to apply the principles of therapeutic assessment when conducting suicide assessment interviews.
Despite our critique of how suicide assessment is practiced, we strongly recommend that you follow the usual guidance, and ask directly about suicide ideation. We just want to add, you should do it right. The rest of this chapter is all about how to weave in therapeutic assessment principles so you can do suicide assessment right.
As always, let me know what you think. I promise to be nice.