Thread by @SFreedenthal

Many therapists don’t know what they don’t know about #suicide risk assessment.

A thread.

1/20

Some MH prof’ls got upset w/me this week for saying in the NYT that some therapists don’t ask about suicidal ideation, even w/depressed clients.

The psychologist who started the pile-on said he asks abt thoughts of “harming yourself.”

That’s NOT asking suicidal thoughts.

2/20

Sure, you might consider harming oneself to be suicide, & suicide to be harming oneself. That’s bc suicide is so taboo that we’ve created euphemisms for it.

But not all self-harm is suicide, & not all suicidal people see suicide as self-harm.

3/20

Self-harm can include many things that are NOT suicide: cutting w/NO suicidal intent, head banging, burning oneself w/cigarettes, pulling hair out, etc.

medlineplus.gov/selfharm.html

4/20

Many suicidal people don’t view suicide as self-harm. They view it as self-deliverance.

In their eyes, suicide isn’t hurting themselves.

In their eyes, suicide ends the hurt.

5/20

It can seem like I'm nitpicking about semantics, I know. Definitions aside, everyone knows “harm yourself” & “hurt yourself” are code for “kill yourself.”

So what’s wrong w/using code?

6/20

What’s wrong w/using code for suicide is it perpetuates the idea that asking, talking, & thinking about suicide are shameful & bad.

It treats suicide as unspeakable — that which must not be named.

Therapists, of all people, should be able to name suicide & speak of it.

7/20

"When asking about suicide, be direct. Use specific wording such as 'kill yourself,' 'suicide,' or 'take your life.' I don't think lethality inquiries are any place to risk misunderstandings.” —Shawn Shea, MD, Practical Art of Suicide Assessment

8/20

If therapists won’t talk directly & specifically about suicide, how can we expect clients to?

9/20

If you want to know if someone is thinking of harming (hurting) themselves, by all means ask if they’re thinking of harming themselves.

But if you want to know if someone is thinking of suicide, ask that.

10/20

Asking about suicidal thoughts means asking about suicidal thoughts.

Examples:

“Do you have thoughts of suicide?”

“Are you thinking of killing yourself?”

“Do you want to end your life?”

11/20

If you want to know about self-harm and suicide, great. Ask if the person is having thoughts of self-harm or suicide. But ... name suicide. Be clear. And then talk separately about suicide. 12/20

There are cultural considerations. In some cultures, talking about suicide or death in general is considered or disrespectful or even forbidden. But ... the suicidal mind doesn’t submit to taboo.

Not talking about suicide doesn’t = not thinking about suicide.

13/20

Even in cultures where speaking of suicide is verboten, suicidal thoughts still come.

Shouldn’t people who experience them have someone they can talk to about them, w/out rebuke?

14/20

I give other advice on how to ask about suicidal thoughts on my website, using validity techniques described by psychiatrist Shawn Shea. 15/20

speakingofsuicide.com/2013/05/15/unc…

A suicide risk assessment shouldn't be an interrogation. It can and should be a conversation. Even if you're required to use a specific protocol such as the Columbia Scale, you can still invite the person to tell you the story of how they came to think of suicide.

16/20

This thread is not intended to convey that ALL therapists don't talk openly and directly w/clients about suicide. Of course it's not all therapists.

But SOME therapists don't.

DM if you'd like some research citations to back this up.

17/20

If you're reading this bc you have suicidal thoughts & want to see a therapist, good help is available. But you might need to look for it. 18/20

speakingofsuicide.com/2013/07/22/the…

By the way, I typed this thread out on my iPhone, which does NOT like talking about suicide. Some autocorrects that I had to change:

“Are you having social thoughts?”

“I wanted to to Jill myself.”

“Are you thinking of filling yourself?”

19/20

Have you really made it to the last tweet in this hellaciously long thread about suicide assessment? You deserve a cat photo for your time. Thanks for listening!

20/20