Subtly Raising the Topic of Suicide

“Metaphor is one of thought’s most essential tools. It illuminates what would otherwise be totally obscure. But the illumination is sometimes so bright that it dazzles instead of revealing.”

Alasdair Gray
from the novel,
Lanark: A Life in 4 Books

Subtly Raising the Topic of Suicide

TISA Description of the Problem: 99 out of 100 times, I find that the best way to raise the topic of suicidal ideation is in a sensitive, direct, and unambiguous fashion. One of my favorite ways is to use a type of question called a “shame attenuation” which I described for the first time in the book Psychiatric Interviewing: the Art of Understanding. When applied to sensitively raising the topic of suicide, it allows the interviewer to cue directly off of the client’s pain in a naturalistic fashion as, “With all of your pain, have you been having any thoughts of killing yourself?” In the following clinical interviewing tip from a recent workshop participant in a week-long series of pod trainings on the CASE Approach in New Jersey, a nice way of raising the topic of suicide, in an indirect fashion, was given to me. It is nice to have this interviewing technique in ones “tool kit” for use in specific occasions as outlined below.

Tip: Occasionally, one may intuit that the engagement with a client is so tenuous, that raising the topic of suicide directly might result in disengagement. Although rare, this situation may arise with an extremely timid client, stigmatized client, or with an adolescent who does not want to be in the room and is being cagey. In such instances I have found the following to be very effective :

“With all of the pain you have been having, do you sometimes wish that you could just close your eyes and not wake up?”

I have been pleased with how often clients pipe up with comments like, “Absolutely, I feel that way almost every day. Sometimes I pray that God will take me while I’m asleep.” They sometimes add comments like, “Yea, that’s why I sometimes think I should just kill myself and get this all over.”

If the client doesn’t raise the topic of suicide after this question, I always follow-up with something like, “In that regard do you ever have thoughts of killing yourself?”

TISA Follow-up: This is a nice way of subtly raising the topic of suicidal ideation. Seldom do I need to use an indirect technique, but when I do, this specific question is useful and can help preserve a fragile therapeutic alliance. Keep in mind, that if this indirect question does not result in the topic of suicide being discussed, in my opinion the clinician must follow-up with a direct method as described above.

Tip provided by:

Unidentified workshop participant (please contact me if
you provided the tip, so I can acknowledge you)
New Jersey, school counselor pod trainings, Dec. 2010