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

Bringing it together, a suicide conversation ‘template’

As we have stressed over and again within this module, discussion of suicide risk should not be regimental; it should not feel like an interrogation, which can happen if you run through a mental ‘checklist.’ Rather it is exactly that: a discussion. There has been a lot of information in this module, and you may feel a little lost. That is perfectly okay: suicide is a complex problem!

There is, however, as you recall, a general structure to a conversation about suicide.

flow chart

As you start to learn how to discuss suicide risk with faith members, there are some key questions that can guide you through the general flow of the discussion. They are scattered throughout the sections above and are brought together into one ‘template’ here. The National Alliance on Mental Illness (NAMI) recommends asking the following questions to better understand a person’s suicide risk. These provide a sort of ‘conversational template’ for engaging in dialogue with faith members about whom you are concerned.

For each of these, you should think about where each would live in a conversation; how  each connects into the risk factors, warning signs, triggering events, and protective factors; and what you would respond to your faith member’s responses—that is, what would you do next?

“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.

“Do you have thoughts of death? “
 
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?

“Do you have any actual plans to kill yourself?”
 
If the answer is “yes,” ask him to describe his specific plans. Make note of the method used in the plan (E.g., Hanging, Jumping, Pills, gun)? Ask if he has done anything to start implementing the plan (e.g., having bought a rope or a gun, collected pills, sat holding the gun, tied the rope, held pills in the hand, searched for methods online) The risk becomes greater as the plans are clearer and more specific, when they have made actual preparations, and when the method they have chosen is more lethal.

“When do you plan to kill yourself?”
 
If the suicide attempt is a long way off (say, in five years) danger is clearly not imminent. If they plan to kill themselves soon, the danger is grave.

“What would you be accomplishing if you killed yourself?”
 
What are the person’s reasons for dying by suicide? If the person says that people would be better off without them, and if they have no deterrents, a suicide attempt is much more likely.

“Is there anything that would hold you back, such as your family or your religious convictions?”
 
A person who can describe compelling reasons for living (not attempting suicide) is of relatively lower risk than someone who cannot answer the question.

“Have you ever made a suicide attempt in the past?”
 
Previous suicide attempts indicate that future attempts are more likely. Even if a previous attempt did not seem serious, the next attempt may be fatal. All suicide attempts should be taken seriously. Suicidal “gestures” can be more dangerous than they seem, since many people do kill themselves on subsequent attempts.

“Would you be willing to talk to someone or seek help if you felt desperate? With whom would you talk?”
 
If the person who feels suicidal is cooperative and has a clear plan to reach out for help, the danger is less than if they are stubborn, secretive, hostile, and unwilling to ask for help. The development of a plan to protect the person, a safety plan, will be covered in a later module.

In Order?
Although throughout this module we have stressed that there isn’t a cookie cutter ordering of questions, we include these questions and the suggestion of doing them “in order” to give you a place to start. In the long run, however, your experience will guide you in selecting and ordering questions during a particular discussion.

There are, as you know from the first two modules of this course, many more risk factors, warning signs, and triggering events that you can learn to weave into the conversation. Your developing ‘clinical judgment’ will allow you to know when to add these over time; however, the above list will get you started for a wide range of situations.
You definitely do not want to read these off like a checklist. Weave them smoothly into the flow of conversation. If the person you are talking to feels like you are drilling them or holding them up against a checklist, they may shut down and disengage, lowering the level of rapport you established previously.

Let’s take a look at some of these questions woven into a discussion.

  • How did the faith leader established rapport?
  • How did introduce the topic of suicide into the conversation?
  • What risk factors, triggering events, and warning signs did s/he ask about?
  • Which were present?
  • Did the faith leader use active listening skills?
  • Which ones and how well?
  • Did the faith leader elicit a commitment from the faith member to take a next step?