SCL1201 - SECTION 3: SUICIDE ASSESSMENT: QUESTIONS TO INCLUDE
In conducting a thorough assessment of a client's risk for suicide, there are a number of areas that must be examined related to the formula we have just presented. The clinician will gather information from a number of sources. Prior case history for a client may provide some of that information. Family and friends may have other important facts to share about the client's actions, thoughts and feelings. The client's behaviors in the assessment interview may provide clues to his/her state of mind and risk of suicide. All of these sources must be scrutinized carefully for clues concerning the client's motives and motivations for suicide.
By far the most usual source of information about the client's state of mind, however, will come from the client. This part of the assessment process will consist of asking the client direct questions about his/her mood, thoughts, feelings, and perceptions related to any intention to commit suicide. This section, therefore, will start with an overview of what questions should be included in the suicide assessment interview, with additional discussion of the process in which these questions should be included. We will list all the questions on printable pages, with examination of the material to follow.
1. Have you had any thoughts of death or suicide before? Are you having them now?
2. How often have you had these thoughts? How persistent have the thoughts been? Are they fleeting thoughts you have once in a great while, do you have them on a regular basis, or do you have them all the time?
3. Do you have these thoughts only under certain circumstances? If yes, what are those circumstances? Are those circumstances happening right now?
4. Are the thoughts increasing, decreasing or staying the same? Can you tell me how that happens?
5. Do the thoughts include actively hurting yourself, or just thinking about harm or death coming to you?
6. Are you currently intending to harm or kill yourself?
7. Do you have a current plan to harm or kill yourself? What are the details of that plan?
8. Have you rehearsed your plan, or put any part of it in motion? Have you hurt or mutilated yourself before?
9. Have you had any times before when you tried to go through with a plan to harm or kill yourself?
10. Do you have the means to go through with your plan to harm or kill yourself? (Gun, pills, etc.)
11. If you don't have the means, do you have a plan to secure the means?
12. What is your attitude towards suicide?
13. What reasons do you have to die? In what ways do you think killing yourself will make things better?
14. What reasons do you have to live? What things stand in the way of you committing suicide?
15. How have you managed to stop yourself from committing suicide before?
16. Is there anything different in your life right now that contributes to your current feelings of wanting to harm yourself? Are there any additional difficulties you anticipate that could make this worse? Better?
17. Who could be helpful to you in managing what is happening right now?
18. Have you had any recent losses that have been hard for you to handle? Do you anticipate any important losses in the future?
19. Are you currently using drugs or alcohol? Have you had any problems controlling your use of drugs or alcohol?
20. Have you had any history of problems making good decisions or controlling your behaviors?
21. Has anyone in your family ever committed suicide or tried to commit suicide? How does this affect your thinking about suicide?
22. Do you ever feel completely isolated from other people? Has this gotten better or worse recently?
23. Do you have any medical problems that make things worse right now, like pain or illness? How much does this affect your wanting to live?
24. Is there any history of serious emotional or psychological problems in your family? Have you had any serious emotional or psychological problems that have made your life more difficult?
Question 1 and first follow-up question:
Have you had any thoughts of death or suicide before? Are you having them now?
With the first question, the clinician is looking to introduce the subject of suicide, and get some first indication of whether suicidality will be an issue for the client. Particularly in cases where the clinician does not have an established therapeutic relationship with the client, this first question should be presented as respectfully and gently as possible. Where the client acknowledges some prior suicidal thought, the clinician moves to the present with the first follow-up question.
Where the clinician gets an indication that the client may have more to say at this starting point, an additional follow-up question - more open ended in nature - may be asked:
Can you tell me more about this?
Question 2 and follow-up questions:
How often have you had these thoughts? How persistent have the thoughts been? Are they fleeting thoughts you have once in a great while, do you have them on a regular basis, do you have them all the time?
The second question begins to ask the client about his/her motivation for suicide by examining the degree to which the suicidal thought is present. Where the suicidal thoughts are present to a great degree, the clinician can assume that the pressures propelling the client towards suicide are stronger.
Again, the clinician may ask the same open ended follow-up question to gather additional information from the client:
Can you tell me more about this?
Question 3 and follow-up questions:
Do you have these thoughts only under certain circumstances? If yes, what are those circumstances? Are those circumstances happening right now?
The third question and its first follow-up open the examination of motives by asking the client to describe the circumstances under which the suicidal thought comes forth. This also begins the process of looking for points of impact to direct the therapeutic process. The circumstances that create the suicidality inform the interventions to change those circumstances and decrease the suicidality.
The second follow-up question comes back to the question of motivation by asking the client if the circumstances are occurring in the present. This will help the clinician know if the pressures that lead the client towards suicide are presently in the client's life.
Question 4 and follow-up question:
Are the thoughts increasing, decreasing or staying the same? Can you tell me how that happens?
With the fourth question, the clinician continues to look for the client's motivation, to see whether the pressures are increasing or decreasing. The follow-up question asks the client for information that may direct the clinician to both some understanding of the client's motives and towards some potential interventions to improve the client's state of being.
Do the thoughts include actively hurting yourself, or just thinking about harm or death coming to you?
Question five begins the somewhat deeper analysis about the client's motivation to commit suicide. Persons who are depressed, but not particularly inclined towards suicide are likely to have vague thoughts about dying, but not of being the instrument of their own death. This question looks to make this distinction in the client's thought process. Where the client acknowledges thoughts of harming him/herself, the risk level is assumed to be higher.
It is advisable to follow this question with the same open ended question we have used before:
Can you tell me more about this?
Are you currently intending to harm or kill yourself?
Question six is a direct inquiry into the intent of the client to commit suicide. It is a question that must be addressed, but it is also a question that will test the clinical skills of the person asking it. It must be asked at the right time, in the right way, in the proper context with regard to everything else that is occurring in the assessment session. There are so many emotions that are likely to be aroused in such a direct inquiry into the client's state of being that great care must be taken.
Again, the clinician can follow this question with our same open ended question, and allow the client to provide more undirected information that may tell the clinician a great deal about the client's overall state of being:
Can you tell me more about this?
Question 7 and follow-up question:
Do you have a current plan to harm or kill yourself? What are the details of that plan?
Question seven pursues the question of intent to the next level. When a client has a clear plan to kill him/herself, the motivation level must be assumed to be higher, and the client may be seen at greater, or more imminent, risk. In asking for the details of the client's plan to kill him/herself, the clinician can both gather information about the seriousness of the plan, and begin to discern what steps must be taken to prevent the client from following through with the plan.
Question 8 and follow-up question:
Have you rehearsed your plan, or put any part of it in motion? Have you hurt or mutilated yourself before?
Question eight continues the inquiry into the question of intent and takes it to the next level. A client who has set into motion any part of a suicide plan, or who has hurt or mutilated him/herself before, has moved from the thinking and feeling stage to the action stage. This represents a significant increase in the level of risk. Not only does this show the capacity of the client to move to action, it also means that a threshold has been crossed. Until a self-harmful action has been undertaken, the client is uncertain about the meaning and impact of that action. There is a certain mystery and power that naturally makes the person anxious about taking that first step. When the threshold is crossed, the mystery loses it power.
The clinician may want to take a good deal of time in helping the client examine these issues.
Have you had any times before when you tried to go through with a plan to harm or kill yourself?
Question nine continues to assess how much the resistance threshold has been crossed. The closer the client has come to putting in motion a potentially lethal plan, the more the resistance has been reduced. This means that the client will be at greater risk if he or she reaches a point in time when the motivation to commit suicide will be very high.
The clinician may again choose to ask a number of follow-up questions in this area to gather as specific information as possible about the client's plan to commit suicide. This will continue to inform the treatment planning.
Do you have the means to go through with your plan to harm or kill yourself? (Gun, pills, etc.)
Question ten directly raises the issue of means. It is a logical continuation of the line of questioning that would have been started with questions 8 and 9. As has previously been mentioned elsewhere in this training, if ready means are available to a suicidal client, the level of risk rises significantly. The clinician should spend some time in thoroughly investigating the client's access to means.
In particular, the clinician should always ask the client directly if he/she has easy access to a gun. If there is a gun in the client's home, or any other place where the client can access a gun in private, this must be noted. Steps may need to be taken to remove the easy access to the gun if the client appears at all motivated to move towards suicidal action.
If you don't have the means, do you have a plan to secure the means?
Question eleven is a logical extension of question ten. In asking this question, however, it is important for the clinician to be very cautious. Some clients may not have developed a clear idea about how they wish to commit suicide. The clinician is likely to have a very clear sense about possible ways to commit suicide. It is important that the clinician not pass this information on to the client in the course of asking questions, and thereby inadvertently provide to the client detailed instructions or creative new ideas about how to commit suicide.
What is your attitude towards suicide?
Question twelve is designed to elicit from the client information about values that would either encourage or inhibit suicide. The client may have values that help create resistance to the idea of suicide. The clinician can utilize this therapeutically by supporting those values to help the client resist acting on his/her suicidal thoughts. The client may also have very complicated thoughts and ideas that are raised by this question, or values that are very muddled and unclear. This may present an opportunity to the clinician to insert values that are more oriented towards resisting suicide.
Question 13 and follow-up question:
What reasons do you have to die? In what ways do you think killing yourself will make things better?
Question thirteen begins the difficult process of trying to understand the client's motives for committing suicide. These simple questions must not be viewed as the ending point, but rather the starting point for engaging with the client in the long and difficult task of understanding the complex reasons the client has reached this point.
These questions are liable to provide the clinician with some information about the key stresses and obstacles experienced by the client. They may also reveal whatever distortions may exist in the client's thinking concerning the use of suicide as a solution to these stresses. The clinician must carefully balance the dual tasks of allowing the client to provide a full and clear picture of these distortions while beginning to correct the more dangerous distortions as part of the therapeutic process.
Question 14 and follow-up question:
What reasons do you have to live? What things stand in the way of you committing suicide?
Question fourteen is a good follow-up question to question thirteen, as it moves from a study of the reasons to die to an examination of the reasons to live. This question begins to search for points of resistance to suicide in the client's life. Raising this question both informs the clinician's planning for undertaking interventions that support the client's strengths and connections to the world, and makes immediately present to the client the fact that those strengths and connections exist.
How have you managed to stop yourself from committing suicide before?
Like question fourteen, question fifteen looks both for practical information that will help the clinician in treatment planning to prevent suicide, and seeks to reinforce to the client resistances to suicide in the client's life.
Question 16 and follow-up questions:
Is there anything different in your life right now that contributes to your current feelings of wanting to harm yourself? Are there any additional difficulties you anticipate that could make this worse? Better?
Question sixteen is also concerned with looking for points of impact to address in the course of treatment planning with the client around suicidality. It also follows up on the investigation into motives for suicide. Since the question is somewhat more concrete in nature, it may be a substitute of sorts for question 13, which asks clients - but more abstractly - to describe their reasons for wanting to live or die.
The follow-up questions here also point to an important part of the overall assessment and treatment process. Many of the questions are directed towards events of the past, from which the clinician would try to predict events of the future. The client may also be invited to help the clinician anticipate future problems - as well as future improvements - so that the helping process will be protective over time.
Who could be helpful to you in managing what is happening right now?
Question seventeen begins to address the nature of the client's support system - from the client's perspective. When support systems are viewed as useful by the client, they can be utilized to help increase the client's resistance to suicide. It must be remembered, of course, that support systems may also have very complex relationships with the client - at times viewed as supportive, at times viewed as antagonistic. The client may also have misperceptions about his/her support system that must be evaluated independently by the clinician.
We will discuss this issue in some detail later in this training, so we will not continue it here.
Question 18 and follow-up question:
Have you had any recent losses that have been hard for you to handle? Do you anticipate any important losses in the future?
Question eighteen continues to look for an understanding of the client's motives for considering suicide. Since losses are a frequent trigger for clients becoming suicidal, this question has been added to remind the clinician to help the client examine this area.
Anticipated future losses may be just as significant a contributor to suicidality as losses that have already occurred, and therefore must be examined with the client. In this regard, it is important to remember that the client may or may not have a clear sense of whether the losses will or will not come to pass. The clinician must remember to consider future losses - their potential for occurring and their meaning - from the client's point of view. Where there are misperceptions, the therapeutic work can become engaged in helping to clear up those misperceptions.
Question 19 and follow-up question:
Are you currently using drugs or alcohol? Have you had any problems controlling your use of drugs or alcohol?
Question nineteen has been included to remind the clinician to look for the presence of substance abuse problems in the suicidal mix. Figures compiled over many years demonstrate a very high correlation between substance misuse and suicide, particularly among certain demographic groups. Where there are numerous other precipitating factors that might explain the suicidality, it may be easy for the clinician to forget to assess the client for substance abuse problems.
The very nature of substance misuse is such that it can create a very significant decrease in any client's resistance to suicide. Substance misuse affects both judgment and impulse control in ways that increase risk to a very high degree. This question should always be included in an assessment for suicidality, and can serve as a starting point for a more thorough substance abuse assessment where evidence suggests that substance abuse may be contributing to the client's problems.
Have you had any history of problems making good decisions or controlling your behaviors?
Impulse control problems also correlate with suicidality to a significant degree, particularly with younger suicidal clients. For this reason, it is important to include question twenty in this assessment process. If the client describes a long history of problems with impulse control, particularly where violent or self-destructive behaviors are concerned, the clinician should take special precautions to err on the side of safety when considering what level of care will be required to protect the client.
Question 21 and follow-up question:
Has anyone in your family, or any one you care about, ever committed suicide or tried to commit suicide? How does this affect your thinking about suicide?
When a family member, or someone admired or liked by the client, has committed or attempted suicide, it may increase suicide risk in two ways. First, it may indicate the presence of painful experiences for the client, or significant problems in his/her relationships. Second, it means that suicidal behavior has been modeled by someone whose behaviors the client has watched and studied. This can create the perception of suicide as something possible, perhaps even something to be considered.
The correlation, however, is not exact or simple. It is also possible that suicide will be less likely, since the client has experienced what it is like to be a witness to the suicide or attempted suicide. He/she may understand the pain that is felt by such a witness, and may not want to create that kind of pain for others. This question, like all others, must be viewed in its total context.
Question 22 and follow-up question:
Do you ever feel completely isolated from other people? Has this gotten better or worse recently?
Question twenty-two continues to examine the client's perception of his/her support system. Clients with few or no social connections have an increased risk for suicidality. Elderly clients, who have experienced the gradual passing away of the pieces of their support networks, can be at particular risk for suicide the more socially isolated they feel.
Suicide by elderly clients may also be conducted in manners that are not immediately obvious to the clinician. At times, the client may simply stop eating, or stop engaging in self-caretaking behaviors, the net result of which is a gradual wasting away towards death. Treatment planning for these particular issues will often involve the addition of services outside of traditional psychotherapeutic interventions.
Question 23 and follow-up question:
Do you have any medical problems that make things worse right now, like pain or illness? How much does this affect your wanting to live?
Another correlation can be found between chronic pain or illness and suicidality. The client may view suicide as a reasonable alternative to the prospect of unremitting pain or suffering. In such cases, the clinician enters into difficult moral and ethical territory. It is not necessary for our purposes to attempt to resolve these moral and ethical questions here. What is important is for the clinician to be aware of the need to examine this question in light of the client's motives for considering suicide.
Question 24 and follow-up question:
Is there any history of serious emotional or psychological problems in your family? Have you had any serious emotional or psychological problems that have made your life more difficult?
The final question from our list is concerned with searching for mental or psychological illness in either the client's life, or in the client's family history. This question is once again suggested from an understanding of what factors correlate with suicidality. Mental illness is present in a very high proportion of suicide attempts, both unsuccessful and successful.
It is not expected that the clinician will be able to gather a clear and unassailable sense of the nature and extent of a client's mental illness or well-being in the course of a single interview. This assessment process will occur over time, as will the overall assessment of the client's suicide risk. It must be viewed as a work in progress.
These questions, by themselves, are not enough to constitute a thorough client assessment in this area, but should rather be included as foundation elements in any comprehensive assessment process. It is very likely that the responses to any individual question may direct the clinician towards further investigation in areas that may not be covered here. The willingness to follow the lead of the client to the most relevant data is simply part of the assessment process. The clinician should not view him/herself as being held a slave to the sequence of questions presented here. What is more important is that all the relevant information be gathered in a way that is most helpful to the client.
This concludes this section. In our next section, we will look at some of the other information that must be gathered as part of the assessment process.
Men are responsible for 79% of all suicides in the United States.
Source: Centers for Disease Control
Access to firearms is associated with a significant increase in risk for suicide.
Source: National Alliance for Mental Illness (NAMI)
Only half of all Americans experiencing an episode of major depression receive treatment.