By Dr David Laing Dawson
I have written a blog before about suicide prevention, about many of the things we do that don’t really make a difference, and about where we could and should put our resources if we want to make a difference. But this is a blog about suicide prevention on the ground.
We can talk about suicide prevention in general terms but the one and only time a health care clinician can actually prevent a suicide is when an at-risk individual is sitting in front of him or her. Your patient, new or known to you, at your office, in your clinic, at the hospital.
Some emergency and rapid response services have mandatory checklists. Most clinicians are taught to always ask the question. Many family doctors are fond of using a self-test for depression with questions like “Do you think of suicide?” with check boxes ranging from “all the time” to “never.” And many clinicians contract with patients – that is they extract a verbal agreement from their patients to not harm themselves, at least not before calling.
My suspicion is that these activities provide a false sense of security for the clinician and do not necessarily make any difference to the outcome.
- While asking and focusing on the checklist questions and filling in the boxes, and taking notes, a clinician may well miss what I will discuss later.
- The direct question about suicide intent and suicide ideation yields far more false-positives than useful and truthful answers, to say nothing of a few false negatives.
- How we answer those self-test questions depends more on how we want to present ourselves to the doctor than a realistic appraisal of mental state, especially when it comes to the question of frequency and future behavior.
- And contracting with patients poses two problems: one is that it does not work. The other is a logical fallacy: If the clinician truly thinks that the only thing preventing his or her patient from killing himself is a private promise that he won’t, a promise that he won’t let the clinician down, then that patient should be in hospital. And clinicians who contract in this way should think hard about the boundaries, the limitations, the nature and impermanence of the professional therapeutic relationship.
But day to day, mental health clinicians are faced with the difficult decision to act or not, with the anxiety of predicting human behaviour, in this case with a lethal outcome if they get it wrong.
Let me share with you what both good and bad experiences have taught me:
Rule 1: Be present when seeing a patient, be there, in the room, focused and attentive.
This may require, in many situations, a clearing of the head before entering the room, making sure other loose ends have been taken care of and are not nagging you. It requires an ability to be present in that room no matter how slow, painful, distasteful, or even boring the encounter is, or how many distractions insinuate themselves . And it requires you to stay away from your computer screen, not take notes, and be quiet.
Rule 2: Talk less. Empathy, the ability to experience what the other is experiencing requires silent observation, watching the eyes and mouth, the movement and posture, listening to the tone, the cadence, the intensity, the timbre, the intention of the spoken word as much as the content.
Rule 3: Without directly asking, listen for the presence or absence of future references in your patient’s words, something he or she plans for next week, next year, tomorrow.
Rule 4: And lastly, watch for, listen for, let yourself experience, the presence of two emotions, the congruence of these two emotions if they are present:
Despair/hopelessness plus dread/anxiety.
If both of these are present this patient is high risk for suicide. And to know these are both there, residing in your patient today, you have to be there yourself, attentive, present, open, receptive.