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

Skills and Strategies for Engaging in Dialogue About Suicide:
Just Ask!

How you approach a discussion in general makes a big difference when it comes to sensitive topics like mental health and suicide.

So, before addressing the specifics of discussing suicide risk, ideation, and behavior, there are general strategies you can take generally to make such conversations flow more smoothly. Some of this section may very well be well-known to you, but it merits some review, if only to serve as a reminder of its importance for suicide specifically: its dialog, not directives; brainstorming, not solution providing; and commitment elicitation. Discuss, brainstorm, seek commitment.

Person-centered discussion.

These three principles all emanate from the idea that you are there to help the person define their own problems and find their own solutions. A person-centered approach seeks first to understand, then to walk side by side in seeking solutions, solutions to which, in small and large steps, the faith member can commit to action.

Dialogue versus Directives

Engaging in dialogue about suicide can be difficult. Knowing how to ask questions and how to respond to answers is often just as important as exactly what you ask about.

Similar to how you likely already engage faith members in discussions of faith, theology, or personal spiritual well-being, a discussion about suicide risk should be exactly that: a discussion, or a dialogue between you and your faith member.

Remember that your initial goal is to help the person make the unobservable observable by talking about it. To do that well, we cannot put our own words or ideas into the person’s head. Instead we have to ask open-ended questions, listen to the responses, clarify what we hear and move forward.

Pastor Mollock & Allie

An example from the Pastor Molock and Allie Warner conversation is when Pastor Molock says, "There's no judgment here. I'm asking all these questions in so much detail because I care about you, and I'm concerned about you."

Open-ended, non-judgmental questions and active listening

You should acknowledge the person’s courage for talking about such difficult emotions. Remind them that they don’t need to be embarrassed or ashamed (“I know this must be difficult to talk about, and I’m so glad you can share this with me”).

Asking open-ended questions, and listening actively, takes time and patience, but it is important. It is often more important to listen without judgment to someone who is willing to open up to you than it is to give advice. You may need to give them a long time to respond – it is common for individuals who are depressed to show pauses in their dialogue.

Silence is hard, but important.

The temptation is to fill the silence by talking when a situation is uncomfortable; however, allowing the silence to settle also may spur the person to open up.

While engaging with someone in a discussion of suicide or other emotionally charged issues, there are some straightforward principles that you likely already use:

  • Give your full attention, and make eye contact.
  • Speak only when the other person has finished or when you are asked a question.
  • Be non-judgmental — do not debate about the value of life or ideas/thoughts of suicide.
  • Never dare someone to kill him/herself.
  • Don’t ask “why” someone has decided to kill himself in a challenging way that could encourage defensiveness.
  • Don’t act shocked or disappointed — this creates distance.
  • Respect confidentiality, but do not promise it.

Suicide is almost always motivated by psychological pain, which is also called Psychache. It is similar to an intense, chronic physical pain, and the wish to end that pain. As such, you can always show compassion and empathy for the despair and pain the person is feeling, without needing to approve of the “solution” to the pain that they are contemplating. Indeed, you are trying to help the person recognize that they have other options for solving their problems and finding relief from their suffering.

A word about confidentiality

We all know that confidentiality is important in gaining someone’s trust. You are probably very careful to respect the confidentiality of those you advise. However, it will be important to involve others (family and mental health providers) in the ongoing mental health treatment that may be required to prevent a suicide. Don’t be the only person who knows someone else is thinking of suicide. You will need to involve their friends and family members to help keep them safe. You may need to say to someone “Normally, I keep what people say to me in strict confidence. But in some situations, I have to ask for help from others to be able to protect someone’s life.  Based on what you have shared with me, I think you are at risk, and I want to have others helping us keep you safe. I think this is an urgent situation where we need to decide who else can help us keep you safe. Is there anyone you can think of that could help us?”  You can then bring them in, or connect with them on speakerphone, for example. This probably deserves more attention especially since we want them to talk to the faith member first, to really try to use person-centered counseling to get them to suggest involving others…

Given your experience with tough, complex, and often highly emotionally laden conversations, the concept of maintaining a conversational dialogue may seem self-evident; however, there are some ways that conversations can easily devolve into directives, where you may end up telling the person you are concerned about what you think and what you want them to do. Moreover, it’s not always obvious when this happens.
One way this can happen is when you try to get confirmation of something you have heard. You may restate the situation, which is an excellent thing to do, but then you may not ask them to actively endorse your restatement—assuming that if the person does not disagree then you must have gotten it right. However, much of the time people are simply not willing to disagree. So, let’s look at an example:

“From what I can tell, you are experiencing some traumatic events, but are working through them, and feel a little down, but you haven’t had any suicidal thoughts, that’s good. I’d like to talk to you more about your sadness.”
 
This person does not ask the faith member to confirm the summary. Bonus, this person also ‘closed the door’ on the conversation by expressing relief about the suicidal thoughts—more on that later.

“From what I can tell, you are experiencing some traumatic events, but are working through them, and feel a little down, but you haven’t had any suicidal thoughts.”
“Is that correct?”
“Okay, and you have not had any thoughts of killing or even harming yourself?”

Some key principles to remember are:

  • Ask open-ended questions
  • Listen actively and empathetically
  • Repeat back what is said and get confirmation of your understanding

Brainstorm Solutions and Next Steps

In addition to asking open-ended questions, and being sure you get active confirmation of your understanding, there is a related concept that applies more to working toward solutions and determining next steps.

Let’s say you just determined that the person has had suicidal thoughts but has no plan and isn’t likely to act on them in the near future. They are not at high-risk and you would like to see them more often, so you say,

“I think we should increase how frequently we touch base, I’d like you to come in every week, about the same time. Okay?”

While this may be a good idea, it would be better if you help the person you are concerned about brainstorm solutions, to get them to better “buy into” and take responsibility for their well-being. Regardless of whether you are concerned about something as important as deciding to accept a referral, to be hospitalized, or simply setting your next discussion, if you can get the faith member to mention the solution rather than you telling them, then they will be more strongly committed to the action.

“So, what are some steps we might take to help keep you safe?”

“How do you think today’s conversation went?”
“Ah, me too, would you like to continue the discussion?”

Then work together on “how often,” “what manner,” and so on.

Similarly, as will be discussed in much greater detail in the next module on handling risk, if you have determined that the person is at some level of risk. Ask them how they think they can better protect themselves, and how you can help. The goal with person-centered counseling such as this is help people themselves suggest good practices for being safe. Your goal is to help them work toward the things that might be effective, not to solve the problems for them. As in that familiar saying “It is better to teach a person how to fish than to just feed him a fish for today,” we want to help people learn how to help themselves for the long term.

Many things can help someone be safe. Some are grounded in faith, some involve healthcare providers, especially cooperation with mental health professionals, yet others may involve family, friends, or other steps to remove risk. A balanced approach, involving faith, mental health, and other family and friends is usually best, not relying too much on any one way to increase safety. A veteran once told a clinical psychologist, “I tried to give it to God like they told me, and God just gave it back.”

Again, by helping them work out their own next steps, they are far more likely to be committed to those steps than if you simply suggest solutions.

Eliciting Commitment

Finally, let’s discuss the issue of getting commitment from the faith member. One strategy that has been shown time and again to increase participation in different actions is to elicit commitment. This sounds somewhat complicated but is in fact the simple strategy of getting the person you are concerned about to actively and affirmatively endorse whatever next steps you have agreed upon.

“Will you come see me tomorrow, at 12pm?”
“Yes, I will.”

This is likely to be more effective and will receive better follow through than something like “This has been a good conversation, and I think we should continue the dialogue, let’s meet again tomorrow at noon.”

Eliciting commitment flows naturally from brainstorming solutions together. If you have guided people to themselves suggest next steps that line up with what you have in mind, whether that is to come in more frequently, to accept a phone call, or even to go with you to a community mental health care provider, then it is a short step for them to re-affirm that they will in fact do those things.

Safety plans and eliciting commitment.

A “safety plan” is a plan, an agreement, you work out with someone who is at risk. It is a means of reducing risk. Module 4 of this course addresses safety plans and other steps you should take with at-risk faith members.

Just Ask

Although there are important ways to improve the likelihood that someone will trust you, will open up, and will discuss suicidal risk and thoughts with you, the vital thing is to ask. Suicide is still a taboo subject in our culture, and not often openly discussed. Because of that, asking people if they are thinking about suicide may feel awkward or invasive.

Research shows that asking about suicide DOES NOT put the idea in someone’s head who otherwise was not thinking of taking their life, and it does not increase in any way the likelihood that she will attempt or complete a suicide in the future.

Many people who are asked if they are thinking of suicide appreciate being asked and have a great desire and need to talk about their feelings. In fact, a recent study found that research participants generally felt less suicidal when being asked in detail about their suicidality (Cukrowicz, Smith, & Poindexter, 2010).

Talking about suicide with someone will not increase risk, and, in fact, is likely to decrease the chance that someone will attempt suicide by helping them to know that someone else has noticed and cares enough to ask!

If for any reason you suspect something is going on, then ask!

The next sections of this module will address how you can establish rapport before asking about suicide, how to ease into asking about suicidal risk and thoughts, and how to respond to answers. That is, the next module is about how to just ask.

From this section, some key principles to remember are:

  • Ask open-ended questions
  • Listen actively and empathetically
  • Repeat back what is said and get confirmation of your understanding
  • Work with the person to generate solutions rather than telling them what to do
  • Elicit a commitment to a particular positive action or plan
  • And, in the end, when in doubt, be sure to ask