Gathering Information for a Suicide Assessment

This is the second post in a three-part series.

In the first post of this series, I introduced a Framework to Guide Suicide Assessment based on the Four Core Principles used by 988 centers nationwide. Here, I will explore how, while considering this framework, you can begin to gather the information needed for your full assessment, focusing on how to ask about suicide, listen to your client’s story, and clarify missing pieces of your assessment.

Ask

Talking to clients about suicide is stressful, even for the most experienced clinician. I have worked in the field of suicide prevention for over 25 years and yet still experience a moment’s pause before the word "suicide" comes out of my mouth. It’s just not easy. But whenever you have any concerns about suicide, you must ask about it, and you must ask directly:

Are you thinking of suicide?

Are you thinking of killing yourself?

Practice these questions. Use the word “suicide”—say it out loud when alone or practice these questions with colleagues. Any way that helps increase your comfort in asking about suicide, without hesitation, is valuable.

During an intake, it is often easier to ask about suicide since it is expected that you will be gathering information about your client’s history and current needs. While many clinicians use suicide screeners, such as the ASQ5 or the C-SSRS, I have found that most clinicians in private practice do not use these tools, so it is helpful to plan your questions in advance. As a general intake question, you can ask:

Have you had any thoughts of suicide in the last few months/days, including today?

You want to know about lifetime risk—but you also want to know about today, right now. The reason not to do just one or the other, and to also phrase the question to include recent months/days, is that many people feel safer acknowledging previous thoughts or behaviors rather than discussing the more immediate situation. Other questions you can ask include:

Have you ever had thoughts of suicide/killing yourself?

Have you ever attempted to kill yourself?

Have you EVER taken any action to harm yourself, including today? [This last clarification can be especially relevant in remote sessions, where it can be unclear if a client has already ingested pills or undertaken any action to harm themselves.]

If your client acknowledges a suicide attempt history, be sure to ask about details of the attempt. It is important to begin to understand the lethality and their feelings on surviving. It can also be useful to know about interrupted or aborted attempts that a client may not consider reporting.

During ongoing work with clients, talking about suicide can be much more challenging. You may have been working with a client for some time—even someone with no history of suicidal thoughts—when the need to address the issue arises. Here, it is good to remember that, as difficult as it may be for you, it is likely significantly harder for your client. They may fear your reaction or judgment, or that you will no longer want to work with them. They may worry about involving others or that you will jump to hospitalization. For some, this may be the first time they have expressed their thoughts of suicide and your job is to provide a safe and nonjudgmental space for them to explore these thoughts as you work to ensure safety.

Given that clients could be reluctant to bring up the issue of suicide, it is also essential that you “listen for invitations”—where your client offers an opening to begin the conversation. Invitations to talk about suicide come in many forms. Of course, there are some clearer indications reviewed in risk factors—maybe they have had a decreased mood or seem hopeless. But not everyone with thoughts of suicide will look as you may expect. Invitations, therefore, could just sound like statements, such as:

It's all too much for me. I can’t go on like this.

All of my problems will end soon.

No one can do anything to help me now.

These could well be invitations to you to ask them about how they are feeling—and whether they are having thoughts of suicide.

When you say your problems will end soon, what do you mean by that?

Do you mean you are having thoughts of killing yourself?

Be mindful of phrasing and avoid negative statements—You’re NOT thinking of killing yourself, are you?—which, as you can imagine, sends a clear message that this is not what you want to hear.

Listen

Then there is the moment when your client replies:

Yes, I am thinking of suicide.

Acknowledge what your client has said and ask:

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Can you tell me more about that?

Let your client tell their story. Let them describe their thoughts of suicide—are they fleeting? Intrusive? Distressing? How does it feel to have these thoughts? For some people, thoughts of suicide occur all the time; they carry them like a safety blanket—"I can handle this, and if anything goes wrong I can just kill myself"—but they have never really had any active intent (no less important in terms of safety planning). What does this person do when these thoughts arise?

It can be useful to ask your client:

What stops you from killing yourself?

In listening to their story, you are gathering information that can inform your assessment and safety plan and, while you will likely hear many reasons for dying, it is important to tune in to what may also be reasons for living. As strongly as someone may feel about dying, something has kept them alive to this point, and some level of internal ambivalence is likely why they are talking to you today.

A Note on Ambivalence

Ambivalence in the context of suicide refers to the simultaneous experience of conflicting thoughts and feelings about living and dying. It is a very complex and very common occurrence for those who are contemplating suicide, and understanding this concept is extremely important.

Ambivalence often involves a deep struggle between the desire to escape pain and the desire to live. A person may feel hopeless and despairing yet also experience moments of connection, purpose, or love. This internal conflict is not only distressing but also difficult to express.

Ambivalence can be seen most acutely when someone walks into your office and tells you they are having thoughts of suicide. No one likely forced this person to come and tell you this, and so while there may be one part of your client that wants to die, there is another part that is right in front of you and asking you to help them live.

Your client’s AMBIVALENCE is your OPPORTUNITY.

Clarify

As you listen to your client's story, it is important to remember the Four Core Principals of Assessment and clarify any missing pieces. Ask yourself:

Is there evidence of intent and capability?

What buffers (safety measures) are in place?

Four Core Principles of Suicide Assessment

Source: 988 Suicide & Crisis Lifeline Safety Assessment

Clarify Intent: What else do I need to know about my client’s intent to act on their thoughts of suicide? Did they clearly express an intent to die? Have I heard all I need to know about any method that has been considered or plans made?

Clarify Capability: What do I know about their history of attempts or self-harm? Do they seem dysregulated or intoxicated? Are they sleeping? In particular, what do I know about their access to lethal means? Does this person own a gun?

Clarify Buffers: What do I know about my client’s support system? Do they live alone? Who do they talk to about their thoughts of suicide? Have I heard them express any reasons for living?

Once you have gathered what you need, it will be time to formulate the degree of risk you believe to be present and, based on that, begin to plan how you will help your client stay safe. In my final post on assessment, I will explore the process of formulating risk and how we use this to plan with our clients for safety.