Suicide Prevention – Thoughts For Practitioners

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.

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9 thoughts on “Suicide Prevention – Thoughts For Practitioners

  1. As always Dr Dawson shows sensitivity, knowledge and wisdom all cemented together with a liberal dash of practical application. A simple but vital guide to the interviewing process, suicide risk or not.

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  2. Outstanding insights. Some of the points, such as the one on contracts, deserve their own blogs.
    The only thing I would add to the conclusion about despair/hopelessness plus dread/anxiety is the dynamic of irrational anger/hatred. Some people reason that committing suicide will somehow vindicate their grievance or make someone suffer.

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  3. As usual Dr. Dawson is sensitive and aware and truthful about the difficulties of prediction.

    I would echo his thoughts 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.

    A psychiatrist can only do the best he can. The fifteen minute appointment often scuttles that. Patricia Forsdyke.

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  4. A clinician must know the person’s situation; if he or she is in a critical situation that appears to have dire consequences then this should set off alarm bells. The anxiety and dread plus hopelessness in the context of a dreadful situation is a trigger for suicidal acts. Context is always vitally important

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  5. “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”

    I’m sure many doctors are aware of the tenuous nature of “contracting”, but with a national bed crisis in the UK, how many doctors can alleviate their anxiety and ensure the safety of a potentially suicidal patient by hospitalising them? Many cannot even offer the most basic of follow up support. It leads me to think that the dismissive attitudes that many psychiatrists seem to take over analysing suicidal thoughts is in part based on the premise that you cannot keep somebody safe when there is no safe place to offer them. Home Treatment Teams have a generally disastrous reputation, and seem to salve their own consciences about patient safety by obsessively repeating “distraction” mantras to an often very distressed person in times of crisis. I have said it before and I will say it again, nobody in crisis needs to be told to drink tea/have a bath. If you are in crisis, chances are you have had a cup of tea, and had a bath, and/or you KNOW it will not help. Interestingly, refusing to acknowledge the helpfulness of these suggestions leads to suicidal people being branded as “manipulative”, “dramatic” and “attention seeking”. A very good article as usual 🙂 but in practice, I wonder if the solutions to problems like these actually exist in modern (British) mental health care.

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  6. I’m glad to see this more compassionate effort.

    But I still question the motivation of suicide prevention. I still don’t see how SP is anything less than rape, a disregard of bodily autonomy and curing people of their thoughtcrime. Nobody born with choice. All life is forced upon us, so why do we prevent people from rejecting a life they didn’t ask for?

    Also, suicide prevention actually encourages suicides. In suicide networks, nothing is more hated than suicide prevention itself.

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  7. unless we use scientific methodology to find cures for neurological diseases we can not prevent suicide. Even if we persuade or save a patient from suicide one time, it is not the solution. And even the most compassionate psychiatrist (like Dr. Dawson) cannot permanently “cure” this aspect of serious brain diseases anymore than he/she can cure” anosognosia “( a symptom of schizophrenia where the patient is unable to understand that he/she is seriously ill.)

    Lists of how to deal with possible suicides have no evidence that this personal attention of the psychiatrist prevents suicides.

    All out scientific research to find root causes for these diseases is the only solution for all neurological diseases’, if we are to eradicate their awful symptoms–including suicides.

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