Module 3: Talking about suicide Risk: How you ask makes a difference

Easing into the topic:
Suicide-related Issues and Suicidal ideation and behavior

How you begin to ask about suicide itself will depend on the context of your discussion and the existing relationship with the person with whom you are talking.

Asking about Risk Factors, Triggering Events, and Warning Signs

Risk Factors, Triggering Events, Warning Signs

Again, there isn’t a single “right” way to introduce the topic. Sometimes, after establishing rapport, you might start right in because it will be evident that the person is open, is suffering, and is in need of help; however, the most common way to start into a discussion of suicide risk is to ask about sadness, life events, or other suicide-related risk factors, warning signs, and triggers.

Asking about these factors serves the triple purpose of helping you understand influences in the person’s life, providing you with a connection to move the conversation deeper toward suicide itself if warranted, and providing you with information that can help if you need to think about ways to protect the person.

Although over time you will become confident and competent in asking about the range of issues in the table above, a good set starting point is:

“Have you been feeling sad or unhappy?
A “yes” response will confirm that the person has been feeling some depression.

“Do you ever feel hopeless? Does it seem as if things can never get better?”
Feelings of hopelessness are often associated with suicidal thoughts and may be a significant risk factor

Moving from a discussion of a risk factor, such as sadness, to a more stigmatized topic such as suicide can sometimes happen surprisingly easily once the person open’s up; however, in many cases, such a transition can remain difficult and often relies heavily on your interpersonal skills.

Asking about Suicidal Thoughts, Desires, and Behaviors: Getting to “The Question”

Asking about related risk factors, triggering events, or warning signs can serve as a natural introduction to asking about suicide itself. Moreover, normalizing, acknowledging emotions, pointing to a known behavioral change, or a combination of these can help you segue into a discussion of suicidal thoughts.

Although you may approach the question from multiple ways, as will be discussed next, there are two basic questions:

“Do you find yourself wishing you were dead?”
A “yes” response indicates a desire to be dead but not necessarily thoughts of suicide.

Many depressed people say they think they’d be better off dead and wish they’d die in their sleep or get killed in an accident. However, most of them say they have no intention of actually killing themselves.

Also, morbid thinking, thoughts of death, even suicidal thoughts, are one of nine clinical symptoms of depression, and many individuals are actually relieved when they understand this.

“Do you ever have any actual suicidal thoughts? Do you think about killing yourself?”
A “yes” indicates an active desire to change their circumstances or suffering, often with the only way the can think of to do this being to kill themselves. This is a serious situation. It is appropriate to ask the individual about the frequency, duration, and intensity of the thoughts, especially, what was the most intense suicidal thoughts he or she ever experienced?

Although these are straightforward, how you ask them is very important, and doing so while acknowledging and normalizing the person’s thoughts, feelings, and observed behaviors can make it far more likely he or she will increase their trust and answer honestly about the issues.

1. Normalizing the question (e.g. “I ask everyone this question just to check in”) or normalizing their feelings if they have already reticently shared negative emotions or suicidal ideation (e.g., “Many people have thoughts of death, and some think of suicide when they are depressed”) might ease the discomfort of asking. Another way to ask would be “Often people will feel so badly that they may wish to not be here anymore – have you experienced anything like that?” Normalizing the question is an especially useful tactic when you feel as though asking about suicide too early might cause the faith member to disengage.

2. Acknowledging emotions. You can begin the discussion by acknowledging an evident sadness or change in demeanor, and empathically expressing your concern about the person’s well being.
Start with: “I’m concerned about how you are doing. Have you been feeling sad lately?”
Followup: “Have you felt so sad that you wished you were dead?”
Or: “Do you sometimes feel so bad you think of suicide?”

3. Acknowledge Behavior. Another way to approach someone is to point out a specific change in their behavior, versus their affect or demeanor. Actions, like the warning signs and behavior changes can be harder for them to dismiss as something that you have misinterpreted compared to changes in their emotions or demeanor.
“I’ve noticed that you have been behaving/acting differently lately. For example…
Or “Someone noticed you have been….”

4. Normalizing to the Faith Members Situation. Often the best approach is to normalize suicidal thoughts to the person’s specific situation. This combines the benefits of normalization (that other people have these thoughts and that you ask others about them) with the benefits of acknowledging this specific person’s emotions and behaviors (“I understand what you are going through). By combining them, you can say things like “sometimes people in your situation feel hopeless, like they want to die, or even have thoughts of killing themselves.  Have you had any thoughts like these?”

This acknowledges something about the person while at the same time normalizing the topic and making it easier to talk about. That is, it establishes that other people in situations just like the faith member’s may have these thoughts, and that’s okay, let’s talk about them.

“People with the problems/stressor/losses that you’ve been facing sometimes feel like they don’t care whether they live or not. Do ever find yourself feeling that way?”

“It’s not unusual for people in your situation (whatever it is) to begin to lose hope, think about wanting to die, or even think about suicide; I’m wondering if you’ve had any thoughts like that?”

Try to tie the specific details you now know about the person, with the normalizing phrases. Remember, the goal here is to make it easy for the person to be honest—it’s not unusual for people in their situation to have the experiences he or she is having, and its okay to talk about it with you.

There is no one right approach. If you know something about the person’s situation, start with normalizing to that situation. If the answer is no, then circle back and ask about specific emotions and behaviors as an entry to asking again about suicidal thoughts. It’s always a good idea to ask two or three different ways, especially if there are warning signs (agitation, anger, etc).

Let’s look at 3 examples of seguing to the asking about suicide. How does each faith leader handle moving to the topic? Do you think they did so effectively? How are the 3 cases similar and how are they different? Under what conditions might you be able to use the strategies depicted and how might you do it differently?

Easing into the Topic: Case Videos

Bishop Young & Nathan

Nathan Dodd, 29-year-old African American male, grew up religious but hasn’t gone to church since the day he graduated high school and left home. Despite having known he was gay since he was a teenager, and having dated men seriously for five years, he only recently came out to his family.

Reverend Molock & Allie

Allie Werner, 25-year-old Caucasian female, graduated from college two years ago with a degree in art history, her long-time passion, and despite great opposition from her parents, both high-profile lawyers. She’s the only child of successful parents, and grew up under intense scrutiny and pressure. Allie and her parents have been estranged since they cut off her funding for college during her Junior year. She’s blown off steam with drug use and some alcohol abuse since she was a teenager.

Father Certain & Jasper

Jasper Collins is a 57-year-old Caucasian male. He has been married to Harriet for 30 years. The couple has two children, Jason (age 29) and Sarah (age 18). Jason lives out of state and Sarah, who recently joined the military, also lives out of state. Jasper and Harriet go to an Episcopal church regularly, and Harriet is involved in several church activities.

There is never a good reason not to ask about suicidal thoughts. The question becomes how.  For example, with someone with whom you do not have an established relationship, someone who is reaching out, you might suspect something but be reticent to ask in an initial meeting for fear they will not return. In this case, using the normalization technique allows you to convey that you ask everyone this question in order to make sure everyone is safe. How are you? Have you had any thoughts about killing (or about hurting) yourself?” If you don’t ask, you can’t know, and if you don’t know, you cannot help.

The key things you want to know at this point are whether or not the person has had or is having suicidal thoughts and whether they want to die. That is, you want to know about their suicide-related thoughts and emotions, two obviously connected but often quite different things.