Suicide Prevention Begins With Asking the Question

It’s hard for most medical professionals to ask whether a patient has ever considered or attempted suicide, and whether they are considering it currently. Many doctors and nurses haven’t been trained to do this, don’t know what to look for, and don’t know how to create an effective suicide prevention plan. As a result, they shy away from asking, “Are you thinking of killing yourself?”

It might be somewhat less scary to say, “Are you thinking of hurting yourself?” or “I hope you’re not thinking of killing yourself,” but these aren’t nearly as effective. The former introduces euphemisms into the conversation, which lead people to talk around the problem, while the latter alludes to the helper’s discomfort in talking about suicide, which discourages openness and honesty.

Asking directly about suicide can relieve the anxiety of a suicidal person who has been afraid to talk about how he or she is feeling. The person now has permission to unburden themselves.

When he or she does, counselors assess the immediate risk—is an attempt imminent or is the person ideating at this point? They probe, ask more questions, determine what supports the individual has, and discuss potential options that lead to a plan.

One of the phrases that is voiced sometimes by helpers to encourage suicidal people to develop a different mindset is, “Suicide is a permanent solution to a temporary problem.” This is something that I said more than once early in my career, before I learned that it’s flawed. It may apply to some youths who are depressed and contemplating suicide, but it’s less applicable to older people for whom there is an irreversible decline in mobility, vision, hearing, physical health, mental health, and friends. In addition, a professional career might be winding down or have ended, resulting in fewer connections, reduced finances, and diminished self-esteem. These are permanent challenges, not temporary ones, and the depression that sometimes results from them isn’t easily lifted.

One question worth asking of someone with suicidal thoughts is whether suicide scares them or comforts them. Thinking about suicide can be comforting to people who feel trapped in their own self-described hell. They know that if the pain becomes unbearable, they have a way out.

What helpers try to do is expand the person’s perspective. They talk about who will find their body, loved ones who will be left behind, and the potential lessening of the person’s pain over time. Individuals continue to have the freedom to make their own decisions, including the decision to end their life, but options are presented.

In Definition of Suicide, Edwin Shneidman describes counseling a college student who was single, deeply religious, and pregnant. The woman was overcome with shame, and decided to kill herself.

“I did several things,” Shneidman said. For starters, he took out a piece of paper and began to “widen her blinders.” The conversation started with Shneidman saying that the woman could have an abortion locally, to which she replied, “I couldn’t do that.” He said that she could go elsewhere and have an abortion, and she said, “I couldn’t do that.” He suggested that she could bring the baby to term and keep it, prompting the same response, “I couldn’t do that.” Alternatively, he said, she could have the baby and adopt it out. Again the woman said, “I couldn’t do that.” Shneidman said that they could get in touch with the young man involved, or involve the help of the woman’s parents, and the woman said, “I couldn’t do that.” He ended the listing of possible options by saying that she could always kill herself, but there was no obvious need to do it that day. The woman, for the first time, was silent.

“Now,” Shneidman said, “let’s look at this list and rank them in order of your preference, keeping in mind that none of them is perfect.’”

The very making of the list had a calming effect. “Within a few minutes,” Shneidman says, “her lethality had begun to de-escalate. She actually ranked the list, commenting negatively on each item. What was of critical importance was that suicide no longer was first or second. We were then simply ‘haggling’ about life—a perfectly viable solution.”[1]

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.