Interviewing the SuicidalInterviewing the Suicidal

Gary M. Leu, School Gary M. Leu, School PsychologistPsychologist

Davis School DistrictDavis School District

Before the Interview:Before the Interview:Overcoming the Taboo Against Talking Overcoming the Taboo Against Talking About SuicideAbout Suicide

• We must first make sure that the interviewer wants to ask the questions – consciously and “unconsciously.”

• The most important myth to address is that asking about suicide will “give the client ideas.” NOT TRUE!– I have never heard of this happening.– There is no data to support this myth.– Suicide is no secret – people already

know about it. Even young children know about it.

– Suicide is extremely hard to do. It involves more than getting an “idea.”

– By matter-of-factly exploring suicide we can give the healthy message, “Suicidal thinking is no longer a “sin” to be hidden, it is a problem to be solved.

Client Biases & FearsClient Biases & Fears

• “Leakage Myth”: during the interview, suicidal clients will “leak” evidence of their underlying struggle either verbally or non-verbally– Many do. Enough don’t.

• Few topics are more shame producing or taboo conversationally than suicide.– Culturally a hot topic; personally a

taboo topic.

Client Biases & FearsClient Biases & Fears• Resistances to sharing a suicidal

thought. The client:– Feels it is a sign of weakness and

is ashamed.– Feels that suicide is immoral or a

sin.– Feels that discussing suicide is

taboo.– Is worried they’ll be perceived as

“crazy.”– Fears they’ll be “locked up” if

they admit it.– Truly wants to die and wants to

keep it secret.– Does not think anyone can help.

Client Biases & FearsClient Biases & Fears• “Normalization” can help bypass the

above resistances.– When the topic is first broached we try to

dismantle the fears of being perceived as crazy, weak, or immoral.

– It is a gentle lead-in to a discussion of any sensitive topic.

– It lets clients know other people have had similar thoughts, feelings, or pains.

– “When people are feeling extremely upset they sometimes have thoughts of killing themselves. Have you ever had any thoughts of wanting to kill yourself?”

Interviewer Biases & FearsInterviewer Biases & Fears

• Interviewer biases are even more dangerous to the client. These should not find their way into the dialog.

• Attitudes about suicide are often interpreted as moral disapproval.– If this happens as a result of tone,

voice, or body language, the client will “shut down.”

• Self-exploration of one’s biases and fears is an on-going process.

• Let’s look at the list of client fears with a “twist”:

Interviewer Biases & FearsInterviewer Biases & Fears• To reveal bias(es), ask yourself, “Do

I…”– Feel suicide is a sign of weakness in

which people should feel shame?– Feel that suicide is immoral or a sin?– Feel that discussing suicide is taboo?

•Have you ever asked someone you know outside of work about their suicidal ideation? If “No,” the topic may be taboo on some level.

– Feel that someone would have to be “crazy” to consider suicide?

– Tend to overreact to the presentation of suicidal ideation? (e.g., call the police or send to the hospital too quickly)

Interviewer Biases & FearsInterviewer Biases & Fears• More penetrating questions:

– Have I known anyone (family or friend) who has committed suicide?•How did I feel then? How do I feel now?

Do I feel it was the right thing to do? How does that suicide affect the way I approach an interview? When I ask about suicide, do I ever have images of that person?

– Have I ever thought of taking my own life?– Under what exact circumstances, if any, do

I picture myself considering suicide as a viable option?

– If a significant other or one of my children killed themselves, how would my life be different?

– What will I say if a client asks me, “Do you believe it is okay to kill yourself.”

Interviewer Biases & FearsInterviewer Biases & Fears• “Countertransference” issues:

– Knowing about suicide can create a mess for ourselves. (e.g., more time, inconvenience, dealing with difficult people, etc.)

– Knowing about it creates anxiety – which humans are programmed to avoid. (e.g., worry about the safety of the client, worry about our decision's).•It stresses us at work and at home.

– The clinician may not want to be aware of a worrisome situation.•“You’ve not thought about… have you? Well, good.” = Clear message to the client on how the question should be answered.

Interviewer Biases & FearsInterviewer Biases & Fears• The displeasure of stumbling upon

suicide ideation and the resulting increased anxiety can generate:– Irritation, resentment, or more intense

negative reactions.•Personality disorders can generate

malice or aversion, especially with prolonged exposure.

– Brief assessments done sloppily.– Anger toward suicidal clients.– Non-verbal cues to clients that the

clinician is not comfortable with the topic.

– Flip expression of, “You can’t predict suicide, so don’t get too bent out of shape about it.”

Interviewer Biases & FearsInterviewer Biases & Fears• What if… in the course of our careers,

we develop suicidal ideation ourselves?– Ethical issues! How do we work with

clients?– May at first feel guilty.– To avoid guilt, may avoid talking about

the subject.– The clinician may convey an “ill at ease”

quality that may convey that suicide is not safe to talk about.

– The clinician may “unconsciously” steer the client toward the therapists own leanings to validate his or her own decision.

– We are likely to not be 100% attentive when the client is discussing their suicidal issues.

Interviewer Biases & FearsInterviewer Biases & Fears• It is foolish to think that clinicians

won’t ever develop suicidal thoughts or that they won’t impact the quality of their work.– The clinician cannot likely subjectively

determine this impact – an outside opinion is needed.

• The clinician should seek mental health intervention (for the sake of self & clients).

• The clinician should seek out a weekly supervisor/consultant who can more objectively determine the impact of the clinician’s condition upon on-going cases.

ConclusionConclusion

• Realizing that suicide carries many cultural biases and how those biases impact the interviewer is important in providing good care.

• To the extent possible, biases should be realized and their impact upon the interview of a suicidal person needs to be brought to a minimum.

• Professional consultation and/or treatment may be needed to successfully cope with the issues surrounding suicide.