Just for fun, here’s a photo of a page from our Suicide Assessment and Treatment Planning book. This page is the lead in to a section that focuses in on how to work with clients who are suicidal, but whom also may be naturally also experiencing irritability, hostility, and hopelessness. For info, go to the publisher, ACA: https://imis.counseling.org/store/detail.aspx?id=78174
The following is another excerpt from a chapter I wrote with my colleagues Roni Johnson and Maegan Rides At The Door. This excerpt focuses on ways in which clinical interviews are used as assessment tools. The full chapter is forthcoming in the Cambridge Handbook of Clinical Assessment and Diagnosis. For more (much more) information on clinical interviewing, see our textbook, creatively titled, Clinical Interviewing, now in its 6th edition. If you’re a professor or college instructor, you can get a free evaluation copy here: https://www.wiley.com/en-us/Clinical+Interviewing%2C+6th+Edition-p-9781119215585
The clinical interview often involves more assessment and less intervention. Interviewing assessment protocols or procedures may not be limited to initial interviews; they can be woven into longer term assessment or therapy encounters. Allen Frances (2013), chair of the DSM-IV task force, recommended that clinicians “be patient,” because accurate psychiatric diagnosis may take “five minutes. . .” “five hours. . .” “five months, or even five years” (p. 10).
Four common assessment interviewing procedures are discussed next: (1) the intake interview, (2) the psychodiagnostic interview, (4) mental status examinations, and (4) suicide assessment interviewing.
The Intake Interview
The intake interview is perhaps the most ubiquitous clinical interview; it may be referred to as the initial interview, the first interview, or the psychiatric interview. What follows is an atheoretical intake interview model, along with examples of how theoretical models emphasize or ignore specific interview content.
Broadly speaking, intake interviews focus on three assessment areas: (1) presenting problem, (2) psychosocial history, and (3) current situation and functioning. The manner in which clinicians pursue these goals varies greatly. Exploring the client’s presenting problem could involve a structured diagnostic interview, generation and analysis of a problem list, or clients free associating to their presenting problem. Similarly, the psychosocial history can be a cursory glimpse at past relationships and medical history or a rich and extended examination of the client’s childhood. Gathering information about the client’s current situation and functioning can range from an informal query about the client’s typical day to a formal mental status examination (Yalom, 2002).
The psychodiagnostic interview is a variant of the intake interview. For mental health professionals who embrace the medical model, initial interviews are often diagnostic interviews. The purpose of a psychodiagnostic interview is to establish a psychiatric diagnosis. In turn, the purpose of psychiatric diagnosis is to describe the client’s current condition, prognosis, and guide treatment.
Psychodiagnostic interviewing is controversial. Some clinicians view it as essential to treatment planning and positive treatment outcomes (Frances, 2013). Others view it in ways similar to Carl Rogers (1957), who famously wrote, “I am forced to the conclusion that … diagnostic knowledge is not essential to psychotherapy. It may even be … a colossal waste of time” (pp. 102–103). As with many polarized issues, it can be useful to take a moderate position, recognizing the potential benefits and liabilities of diagnostic interviewing. Benefits include standardization, a clear diagnostic focus, and identification of psychiatric conditions to facilitate clinical research and treatment (Lilienfeld, Smith, & Watts, 2013). Liabilities include extensive training required, substantial time for administration, excess structure and rigidity that restrain experienced clinicians, and questionable reliability and validity, especially in real-world clinical settings (Sommers-Flanagan & Sommers-Flanagan, 2017).
Clinicians who are pursuing diagnostic information may integrate structured or semi-structured diagnostic interviews into an intake process. The research literature is replete with structured and semi-structured diagnostic interviews. Clinicians can choose from broad and comprehensive protocols (e.g., the Structured Clinical Interview for DSM-5 Disorders – Clinician Version; First et al., 2016) to questionnaires focusing on a single diagnosis (e.g., Autism Diagnostic Interview – Revised; Zander et al., 2017). Additionally, some diagnostic interviewing protocols are designed for research purposes, while others help clinicians attain greater diagnostic reliability and validity. Later in this chapter we focus on psychodiagnostic interviewing reliability and validity.
The Mental Status Examination
The MSE is a semi-structured interview protocol. MSEs are used to organize, assess, and communicate information about clients’ current mental state (Sommers-Flanagan, 2016; Strub & Black, 1977). To achieve this goal, some clinicians administer a highly structured Mini-Mental State Evaluation (MMSE; Folstein, Folstein, & McHugh, 1975), while others conduct a relatively unstructured assessment interview but then organize their observations into a short mental status report. There are also clinicians who, perhaps in the spirit of Piaget’s semi-clinical interviews, combine the best of both worlds by integrating a few structured MSE questions into a less structured interview process (Sommers-Flanagan & Sommers-Flanagan, 2017).
Although the MSE involves collecting data on diagnostic symptoms, it is not a psychodiagnostic interview. Instead, clinicians collect symptom-related data to communicate information to colleagues about client mental status. Sometimes MSEs are conducted daily or hourly. MSEs are commonly used within medical settings. Knowledge of diagnostic terminology and symptoms is a prerequisite to conducting and reporting on mental status.
Introducing the MSE. When administering an MSE, an explanation or role induction is needed. A clinician might state, “In a few minutes, I’ll start a more formal method of getting … to know you. This process involves me asking you a variety of interesting questions so that I can understand a little more about how your brain works” (Sommers-Flanagan & Sommers-Flanagan, 2017, pp. 580–581).
Common MSE domains. Depending on setting and clinician factors, the MSE may focus on neurological responses or psychiatric symptoms. Nine common domains included in a psychiatric-symptom oriented MSE are
- Behavior/psychomotor activity
- Attitude toward examiner (interviewer)
- Affect and mood
- Speech and thought
- Perceptual disturbances
- Orientation and consciousness
- Memory and intelligence
- Reliability, judgment, and insight.
Given that all assessment processes include error and bias, mental status examiners should base their reports on direct observations and minimize interpretive statements. Special care to cross-check conclusive statements is necessary, especially when writing about clients who are members of traditionally oppressed minority groups (Sommers-Flanagan & Sommers-Flanagan, 2017). Additionally, using multiple assessment data sources (aka triangulation; see Using multiple (collateral) data sources) is essential in situations where patients may have memory problems (e.g., confabulation) or be motivated to over- or underreport symptoms (Suhr, 2015).
MSE reports. MSE reports are typically limited to one paragraph or one page. The content of an MSE report focuses specifically on the previously listed nine domains. Each domain is addressed directly with at least one statement.
Suicide Assessment Interviewing
The clinical interview is the gold standard for suicide assessment and intervention (Sommers-Flanagan, 2018). This statement is true, despite the fact that suicide assessment interviewing is not a particularly reliable or valid method for predicting death by suicide (Large & Ryan, 2014). The problem is that, although standardized written assessments exist, they are not a stand-alone means for predicting or intervening with clients who present with suicide ideation. In every case, when clients endorse suicide ideation on a standardized questionnaire or scale, a clinical interview follow-up is essential. Although other assessment approaches exist, they are only supplementary to the clinical interview. Key principles for conducting suicide assessment interviews are summarized below.
Contemporary suicide assessment principles. Historically, suicide assessment interviewing involved a mental health professional conducting a systematic suicide risk assessment. Over the past two decades, this process has changed considerably. Now, rather than taking an authoritative stance, mental health professionals seek to establish an empathic and collaborative relationship with clients who are suicidal (Jobes, 2016). Also, rather than assuming that suicide ideation indicates psychopathology or suicide risk, clinicians frame suicide ideation as a communication of client distress. Finally, instead of focusing on risk factors and suicide prediction, mental health professionals gather information pertaining to eight superordinate suicide dimensions or drivers and then work with suicidal clients to address these dimensions through a collaborative and therapeutic safety planning process (Jobes, 2016). The eight superordinate suicide dimensions include:
- Unbearable emotional or psychological distress: Unbearable distress can involve one or many trauma, loss, or emotionally disturbing experiences.
- Problem-solving impairments: Suicide theory and empirical evidence both point to ways in which depressive states can reduce client problem-solving abilities.
- Interpersonal disconnection, isolation, or feelings of being a social burden: Joiner (2005) has posited that thwarted belongingness and perceiving oneself as a burden contributes to suicidal conditions.
- Arousal or agitation: Many different physiological states can increase arousal/agitation and push clients toward using suicide as a solution to their unbearable distress.
- Hopelessness: Hopelessness is a cognitive variable linked to suicide risk. It can also contribute to problem-solving impairments.
- Suicide intent and plan: Although suicide ideation is a poor predictor of suicide, when ideation is accompanied by an active suicide plan and suicide intent, the potential of death by suicide is magnified.
- Desensitization to physical pain and thoughts of death: Fear of death and aversion to physical pain are natural suicide deterrents; when clients lose their fear of death or become desensitized to pain, suicide behaviors can increase.
- Access to firearms: Availability of a lethal means, in general, and access to firearms, in particular, substantially increase suicide risk.
(For additional information on suicide assessment interviewing and the eight suicide dimensions, see other posts on this site).
This past month I worked on revising our Suicide Assessment chapter from our Clinical Interviewing (6th edition, 2017) textbook so it could function as a stand-alone continuing education course. The continuing education course is finished and now available online.
The Learning Objectives include:
This is a beginning to intermediate level course. After completing this course, you will be able to:
- Explore your own personal reactions to suicide and identify four clinician self-care strategies.
- Discuss and debunk four common and unhelpful myths about suicide.
- Describe evidence-based risk/protective factors, warning signs, and cultural issues and how they can be used to deepen empathic understanding of suicidal clients.
- Identify components of suicide theory that contribute to and guide suicide assessment.
- Provide a comprehensive suicide assessment interview based on a social constructionist model.
- Engage in decision-making with suicidal clients.
If you’re interested, here’s a link to the list of courses on ContinuingEdCourses.Net, with the Suicide Assessment course at the top of the list: http://www.continuingedcourses.net/active/courses/courses.php
And here’s a link that takes you deeper . . . all the way to the brand new 3 hour course, go here (I think you can read it for free and only have to pay to take the quiz and get CE credits): Suicide Assessment For Clinicians: A Strength-Based Model
Of course, if you’re interested in a three-part (7.5 hours total) continuing education video experience, here’s your link to Psychotherapy.net: https://www.psychotherapy.net/video/suicidal-clients-series
Have a great day . . . and keep on learning!
As you probably know, suicide rates are and have been on the rise. Here’s what the Centers for Disease Control said several months ago: “From 1999 through 2017, the age-adjusted suicide rate increased 33% from 10.5 to 14.0 per 100,000” (CDC, November, 2018).
Although the CDC’s report of a 33% increase in the national suicide rate is discouraging, the raw numbers are even worse. In 1999, an estimated 29,180 Americans died by suicide. As a comparison, in 2017 (the latest year for which data are available), there were 47,173 suicide deaths. This represents a 61.9% rise in the raw number of suicide deaths over the past 17 years.
Along with rising suicide rates, there’s also a palpable rise in anxiety and panic among mental health and healthcare professionals, teachers, and the public. Even though suicides still occur at a low rate (14 per 100,000), it’s beginning to feel like a public health crisis. We don’t have much evidence that current intervention and prevention efforts are working, and the continued tragic outcomes (about 129 suicide deaths each day in the U.S.) are painful and frustrating.
The purpose of this post is simply to offer resources. I’ve been working in this area for many years; my sense is that having additional resources to help professionals feel more competent can reduce anxiety and probably increases competence. Here are some resources that might be helpful.
- In 2017, I published an article on suicide assessment in Professional Psychology. Here’s a pdf of that: SF and Shaw Suicide 2017. In 2018 I published an article in the Journal of Health Service Psychology. The purpose of the 2018 article was to be more practical and provide clear ideas about how psychological providers can be more effective in how they work with clients or patients who are suicidal. You can click here to access a pdf of the article. Conversations About Suicide by JSF 2018
- I’ve been working with some of my doctoral students on alternatives to the traditional (and failed) approach of using client risk factors to categorize or estimate suicide risk. One product of this work is an evidence-based list of eight potential suicide dimensions. These suicide dimensions can be used with other models (e.g., safety planning) to guide collaborative treatment planning. To see a description of the eight dimensions and a treatment planning form based on the eight dimensions, you can click on the following links. Suicide TPlanning Handout Suicide TPlanning Handout Blank
- Barbara Stanley and Gregory Brown developed the “Safety Planning Intervention.” For information about their intervention and access to their safety planning form, you can go to their website: http://suicidesafetyplan.com/Home_Page.html
- Along with Victor Yalom and some other contributors, this past year I helped produce a 7.5 hour professional training video titled, Assessment and Intervention with Suicidal Clients. You can buy this 3-part video series through Psychotherapy.net and can access a preview of the video series here: http://www.psychotherapy.net/video/suicidal-clients-series
- I’m a big fan of David Jobes’s work on the collaborative assessment and management of suicide. You can check out his book on Amazon: https://www.amazon.com/Managing-Suicidal-Risk-Second-Collaborative/dp/146252690X/ref=sr_1_1?crid=29DN6ZM2BUCV3&keywords=david+jobes+suicide&qid=1551837394&s=gateway&sprefix=david+jobes%2Caps%2C177&sr=8-1
- Later this spring and this fall, in collaboration with the Big Sky Youth Empowerment Program and the University of Montana, I’ll be offering several low-cost six-hour training workshops in four different Montana locations. These trainings will include research data collection, as well as an opportunity to participate in follow up booster trainings—booster sessions that will happen about three months after you attend an initial six-hour session. If you’re interested in participating in these Montana Suicide Assessment and Treatment Planning Workshops, you can email me, send me your email via a comment on this blog, or begin following this blog so you don’t miss out when I share the dates, times, and locations, and registration information in an upcoming post.
I hope this information is helpful to you in your work with clients struggling with suicide. Together, hopefully we can make a difference.
The following material is adapted from an article in the Journal of Health Service Psychology. You can access the whole article here: Conversations About Suicide by JSF 2018
My favorite suicide assessment procedure is to ask about suicide in the context of a mood assessment (as in a mental status examination). This procedure utilizes a scaling question to explore patient mood and possible suicide ideation (Sommers-Flanagan & Shaw, 2017). As you read through these steps, think about how you might apply this procedure with a recent or current patient of yours.
- Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; patients can say “no,” but rarely do.)
- I’d like you to rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. Zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood (you might hold your hand up high to illustrate the top of the scale). A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now? (Each end of the scale must be anchored for mutual understanding.)
- What’s happening now that makes you give your mood that rating? (This is what psychoanalysts call binding affect; it links the internal mood to an external situation.) At this point, you might ask questions to have your patient elaborate, in greater detail, the reason for the current mood rating.
- What’s the worst or lowest mood rating you’ve ever had? (This question informs you about the patient’s lowest lows.)
- What was happening back then to make you feel so down? (This question binds the sad affect to an external situation; it may lead to discussing previous attempts.) Again, you might take time here to explore a previous attempt, in an effort to understand the (a) dynamics that led to it, (b) the seriousness of suicide intent, and (c) what happened to help the patient live and be with you to work on suicide.
- For you, what would be a normal mood rating on a normal day? (You can insert this question at any point where it fits. Often, the best point is after the first mood rating because patients will immediately tell you whether they’re a little more up or a little more down than normal. The purpose is to get your patients to define their normal.)
- Now tell me, what’s the best mood rating you think you’ve ever had? (The process ends with a positive mood rating.)
- What was happening that helped you have such a high mood rating? (The positive rating is linked to an external situation.)
This procedure is a general map that can be used more or less creatively. No doubt, when you start the process with an individual patient, there will be opportunities to stray from the procedure. For example, when exploring the low end of her mood, your patient may begin sharing a traumatic experience. If so, you are at a key choice point. Should you continue with the next step in the procedure or focus in more detail on the trauma? Either option may be appropriate and will depend on one or more of the following factors:
- Based on your best judgment, does your client want to talk about trauma in more detail? If so, you should move in that direction and come back to the procedure later.
- Do you have time to immediately explore the trauma? If not, then you should say so and let your patient know that when you do have time, you will be interested in hearing details.
- Do you sense that your rapport is minimal and your client is uncomfortable sharing details? If so, then the best option is to continue with the procedure, making a mental note to check back later when your client is more comfortable.
Numbers can be useful in rating patient mood, but because every patient is unique, the meaning of specific numbers will be subjectively variable. I have interviewed teenagers and young adults who emphasize their distress by saying something like, “I’m a negative three!” Despite the fact that having a negative three rating on the suicide scale indicates—in a quantitative sense—suicide certainty, these patients are typically making a point, and may or may not be an especially high suicide risk. In contrast, I have also worked with cases where adult patients burst into tears and admit to suicide ideation after giving themselves a current mood rating of 8 or 9. One patient who rated herself as “9” explained that she always thought of herself as being a 10. For her, anything outside of a perfect mood rating as terribly disturbing.
Several of my supervisees who work with teenagers have creatively transformed the scaling method to eliminate numbers. One supervisee engaged a patient in mood scaling using musical genres. After a collaborative conversation, they established that listening to opera 24/7 was equivalent to zero and imminent suicide, while listening to heavy metal was a solid 10. When working with a middle school boy, another former student used Yoga as zero and pizza as 10. The point of these examples is that practitioners can collaborate with patients to identify a method to discuss mood. Collaborative rating systems makes the method personally meaningful to the patient; it also involves interpersonal connection, implying that the assessment method has become simultaneously therapeutic.
The mood scaling procedure offers several advantages. First, it is a process that facilitates engagement, and engagement or interpersonal connection is central part of suicide interventions. Second, when patients bind their low and high moods to concrete external situations, you gain knowledge about the themes and triggers that lift and depress your patient’s mood. Third, as illustrated in the case where a client begins talking about trauma, the mood scaling procedure can be abandoned (temporarily or permanently) in favor of more salient therapeutic opportunities. Fourth, mood scaling flows smoothly into safety planning or other suicide interventions (e.g., “When you say that being a zero always involves you being alone, it tells me that one thing we should talk about now or later is how you can reach out to others, and we should talk about who you want to reach out to, during those times when you’re feeling like a zero. It also tells me that we should talk some more about other methods you can use to move from a zero to a one.”).
One final note: The mood scaling technique is an indirect method for assessing suicidality. As such, it is not a replacement for using a normative frame and asking directly. In fact, you should be thinking about if and when you will weave asking directly into your mood scaling process. For example, if your client says “I’m a 3” you might follow that with a normative-based direct question: “It’s not unusual for people who rate themselves as a three to sometimes have thoughts about suicide. Has that been the case for you?”
Hey Blog Readers.
For those of you who might be interested, I just published a new article on suicide assessment and interventions in the Journal of Health Service Psychology. The article title is, “Conversations about suicide: Strategies for detecting and assessing suicide risk.” The article is designed to help practitioners who work or may find themselves working with suicidal clients.
Here’s a link to the article: Conversations About Suicide by JSF 2018
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.
Spring is coming to the Northern Hemisphere. Along with spring, there will also be a bump in death by suicide. To help prepare counselors and clinicians to talk directly with clients about suicide, I’m posting an excerpt from the Clinical Interviewing text. The purpose is to help everyone be more comfortable talking about suicidal thoughts and feelings because the more comfortable we are, the more likely clients are to openly share their suicidal thoughts and feelings and that gives us a chance to engage them as a collaborative helper.
Here’s a link to the text https://www.amazon.com/Clinical-Interviewing-Video-Resource-Center/dp/1119084237/ref=asap_bc?ie=UTF8
And here’s the excerpt:
Exploring Suicide Ideation
Unlike many other risk factors (e.g., demographic factors), suicide ideation is directly linked to potential suicide behavior. It’s difficult to imagine anyone ever dying by suicide without having first experienced suicide ideation.
Because of this, you may decide to systematically ask every client about suicide ideation during initial clinical interviews. This is a conservative approach and guarantees you won’t face a situation where you should have asked about suicide, but didn’t. Alternatively, you may decide to weave questions about suicide ideation into clinical interviews as appropriate. At least initially, for developing professionals, we recommend using the systematic approach. However, we recognize that this can se0em rote. From our perspective, it is better to learn to ask artfully by doing it over and over than to fail to ask and regret it.
The nonverbal nature of communication has direct implications for how and when you ask about suicide ideation, depressive symptoms, previous attempts, and other emotionally laden issues. For example, it’s possible to ask: “Have you ever thought about suicide?” while nonverbally communicating to the client: “Please, please say no!” Therefore, before you decide how you’ll ask about suicide ideation, you need the right attitude about asking the question.
Individuals who have suicidal thoughts can be extremely sensitive to social judgment. They may have avoided sharing suicidal thoughts out of fear of being judged as “insane” or some other stigma. They’re likely monitoring you closely and gauging whether you’re someone to trust with this deeply intimate information. To pass this unspoken test of trust, it’s important to endorse, and directly or indirectly communicate the following beliefs:
- Suicide ideation is normal and natural and counseling is a good place for clients to share those thoughts.
- I can be of better help to clients if they tell me their emotional pain, distress, and suicidal thoughts.
- I want my clients to share their suicidal thoughts.
- If my clients share their suicidal thoughts and plans, I can handle it!
If you don’t embrace these beliefs, clients experiencing suicide ideation may choose to be less open.
Asking Directly about Suicide Ideation
Asking about suicide ideation may feel awkward. Learning to ask difficult questions in a deliberate, compassionate, professional, and calm manner requires practice. It also may help to know that, in a study by Hahn and Marks (1996), 97% of previously suicidal clients were either receptive or neutral about discussing suicide with their therapists during intake sessions. It also may help to know that you’re about to learn the three most effective approaches to asking about suicide that exist on this planet.
Use a normalizing frame. Most modern prevention and intervention programs recommend directly asking clients something like, “Have you been thinking about suicide recently?” This is an adequate approach if you’re in a situation with someone you know well and from whom you can expect an honest response.
A more nuanced approach is to ask about suicide along with a normalizing or universalizing statement about suicide ideation. Here’s the classic example:
Well, I asked this question since almost all people at one time or another during their lives have thought about suicide. There is nothing abnormal about the thought. In fact it is very normal when one feels so down in the dumps. The thought itself is not harmful. (Wollersheim, 1974, p. 223)
Three more examples of using a normalizing frame follow:
- I’ve read that up to 50% of teenagers have thought about suicide. Is that true for you?
- Sometimes when people are down or feeling miserable, they think about suicide and reject the idea or they think about suicide as a solution. Have you had either of these thoughts about suicide?
- I have a practice of asking everyone I meet with about suicide and so I’m going to ask you: Have you had thoughts about death or suicide?
A common fear is that asking about suicide will put suicidal ideas in clients’ heads. There’s no evidence to support this (Jobes, 2006). More likely, your invitation to share suicidal thoughts will reassure clients that you’re comfortable with the subject, in control of the situation, and capable of dealing with the problem.
Use gentle assumption. Based on over two decades of clinical experience with suicide assessment Shawn Shea (2002/ 2004/2015) recommends using a framing strategy referred to as gentle assumption. To use gentle assumption, the interviewer presumes that certain illegal or embarrassing behaviors are already occurring in the client’s life, and gently structures questions accordingly. For example, instead of asking “Have you been thinking about suicide?” you would ask:
When was the last time when you had thoughts about suicide?
Gentle assumption can make it easier for clients to disclose suicide ideation.
Use mood ratings with a suicidal floor. It can be helpful to ask about suicide in the context of a mood assessment (as in a mental status examination). Scaling questions such as those that follow can be used to empathically assess mood levels.
- Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; clients can say “no,” but rarely do.)
- Please rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. In fact, zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood. A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now? (Each end of the scale must be anchored for mutual understanding.)
- What’s happening now that makes you give your mood that rating? (This links the mood rating to the external situation.)
- What’s the worst or lowest mood rating you’ve ever had? (This informs the interviewer about the lowest lows.)
- What was happening back then to make you feel so down? (This links the lowest rating to the external situation and may lead to discussing previous attempts.)
- For you, what would be a normal mood rating on a normal day? (Clients define their normal.)
- Now tell me, what’s the best mood rating you think you’ve ever had? (The process ends with a positive mood rating.)
- What was happening that helped you have such a high mood rating? (The positive rating is linked to an external situation.)
The preceding protocol assumes clients are minimally cooperative. More advanced interviewing procedures can be added when clients are resistant (see Chapter 12). The process facilitates a deeper understanding of life events linked to negative moods and suicide ideation. This can lead to formal counseling or psychotherapy, as well as safety planning.
Responding to Suicide Ideation
Let’s say you broach the question and your client openly discloses the presence of suicide ideation. What next?
First, remember that hearing about your client’s suicide ideation is good news. It reflects trust. Also remember that depressive and suicidal symptoms are part of a normal response to distress. Validate and normalize:
Given the stress you’re experiencing, it’s not unusual for you to sometimes think about suicide. It sounds like things have been really hard lately.
This validation is important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they’re a social burden (Joiner, 2005). Your empathic reflection may be more or less specific, depending on how much detailed information your client has given you.
As you continue the assessment, collaboratively explore the frequency, triggers, duration, and intensity of your client’s suicidal thoughts.
- Frequency: How often do you find yourself thinking about suicide?
- Triggers: What seems to trigger your suicidal thoughts? What gets them started?
- Duration: How long do these thoughts stay with you once they start?
- Intensity: How intense are your thoughts about suicide? Do they gently pop into your head or do they have lots of power and sort of smack you down?
As you explore the suicide ideation, strive to emanate calmness, and curiosity, rather than judgment. Instead of thinking, “We need to get rid of these thoughts,” engage in collaborative and empathic exploration.
Some clients will deny suicidal thoughts. If this happens, and it feels genuine, acknowledge and accept the denial, while noting that you were just using your standard practice.
Okay. Thanks. Asking about suicidal thoughts is just something I think is important to do with everyone.
On the other hand, if the denial seems forced, or is combined with depressive symptoms or other risk factors, you’ll still want to use acknowledgement and acceptance, but then find a way to return to the topic later in the session.
Way back in 1990, a university book salesman came by my faculty office at the University of Portland. He was trying to sell me some textbooks. When I balked at what he was offering, he asked, “Do you have any textbook ideas of your own?” I said something like, “Sure” or “As a matter of fact, I do.” He handed me his card and a paper copy of Allyn & Bacon’s proposal guidelines.
Not having ever written a book, I never thought they’d accept my proposal.
They did. But after three years, A & B dropped our text.
Lucky for us.
Two years later, Rita and I decided to try to resurrect our Clinical Interviewing text. We polished up a proposal, sent it out to three excellent publishers, and immediately got contract offers from W. W. Norton, Guilford, and John Wiley & Sons.
We went with Wiley.
Here we are 18 years later in the 6th edition. It’s been fun and a ton of work. Over the past five years we’ve started recording video clips and interviewing demonstrations to go along with the text. For the 6th edition, we got some pretty fantastic reviews from some pretty fancy (and fantastic) people. Here they are:
“I’m a huge admirer of the authors’ excellent work. This book reflects their considerable clinical experience and provides great content, engaging writing, and enduring wisdom.”
—John C. Norcross, Ph.D., ABPP, Distinguished Professor of Psychology, University of Scranton
“The most recent edition of Clinical Interviewing is simply outstanding. It not only provides a complete skeletal outline of the interview process in sequential fashion, but fleshes out numerous suggestions, examples, and guidelines in conducting successful and therapeutic interviews. Well-grounded in the theory, research and practice of clinical relationships, John and Rita Sommers-Flanagan bring to life for readers the real clinical challenges confronting beginning mental health trainees and professionals. Not only do the authors provide a clear and conceptual description of the interview process from beginning to end, but they identify important areas of required mastery (suicide assessment, mental status exams, diagnosis and treatment electronic interviewing, and work with special populations). Especially impressive is the authors’ ability to integrate cultural competence and cultural humility in the interview process. Few texts on interview skills cover so thoroughly the need to attend to cultural dimensions of work with diverse clients. This is an awesome book written in an engaging and interesting manner. I plan to use this text in my own course on advanced professional issues. Kudos to the authors for producing such a valuable text.”
—Derald Wing Sue, Ph.D., Professor of Psychology and Education, Teachers College, Columbia University
“This 6th edition of Clinical Interviewing is everything we’ve come to expect from the Sommers-Flanagan team, and more! Readers will find all the essential information needed to conduct a clinical interview, presented in a clear, straightforward, and engaging style. The infusion of multicultural sensitivity and humility prepares the budding clinician not only for contemporary practice, but well into the future. Notable strengths of the book are its careful attention to ethical practice and counselor self-care. The case studies obviously are grounded in the authors’ extensive experience and bring to life the complexities of clinical interviewing. This is a ‘must-have’ resource that belongs on the bookshelf of every mental health counselor trainee and practitioner.”
—Barbara Herlihy, PhD. NCC, LPC-S, University Research Professor, Counselor Education Program, University of New Orleans
You can check out the text on Amazon https://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1119215587/ref=dp_ob_title_bk or Wiley http://www.wiley.com/WileyCDA/WileyTitle/productCd-1119215587.html or other major (and minor) booksellers.