Assessing suicide risk is a fundamental skill for all psychiatrists. Early in training we are taught to look for prior attempts, family history of suicide, related psychiatric diagnoses (such as depression, psychosis, or substance abuse), symptomatology, and medical comorbidities, as well as demographic risk factors such as age, race, marital status, and religion.
This tendency to focus on data, document risks factors, and differentiate between ideation, intent, and plan may cause us to overlook why a patient wants to commit suicide, however. And rapid-fire questioning—particularly about suicide—can compromise rapport and leave the patient feeling alienated.
Positive inquiry
I always end the suicide risk assessment component of the interview by asking, “What keeps you from killing yourself?” Patients’ responses to this question often reveal compelling reasons why they do not want to harm themselves, including meaningful relationships or religious beliefs.
Examining these so-called protective factors—or the lack thereof—in conjunction with the overall clinical picture often can help clarify the patient’s risk of suicide. When patients identify factors that prevent them from committing suicide, such as a relationship with a loving spouse or a religious conviction, I am inclined to use a more liberal treatment plan, such as immediate outpatient follow-up, rather than a more conservative approach, such as inpatient hospitalization.
Asking a supportive question helps to end difficult discussions on a positive note. After talking about ways a patient has thought about ending his or her life, for example, I can use a protective factor as the endpoint to the suicide risk evaluation before segueing into other questions.
Supportive interviewing embodies a framework of inquiry in which mental health clinicians can gather valuable information and at the same time build up the patient’s psychological defenses. This line of questioning does not guarantee a successful suicide-risk assessment. However, focusing on protective factors ensures that these difficult conversations—often undertaken when patients are under extreme stress—accomplish more than simply gathering data.