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The Initial Suicide Treatment Interview

Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

You will likely be asked many probing questions during your first visit to a psychotherapist's or psychiatrist's office. Common questions are designed to help the interviewer (often the doctor or therapist who will be treating you, but sometimes not) to understand your background and history, and presenting symptoms. These questions may include:

  • Why you are seeking help at this time?
  • What is your understanding of the nature of your problems?
  • What are your symptoms? (headaches, sleep and eating disturbances, etc.)
  • How your problems have affected your life?
  • Demographic information (your age, educational background, etc.)
  • Social information (marital and relationship status, occupational status, legal history)
  • Past history of mental and physical health conditions and treatments
  • Past and present substance abuse history and treatments
  • Past and present history of abuse or neglect, and/or exposure to trauma
  • History of past suicide attempts and treatment history (and history of past suicides/ suicide attempts and mental illness in your family)
  • Information on recent life changes and stressful events

list with boxes checkedThe interviewer should spontaneously ask you specific and detailed questions concerning your suicidality, but sometimes this important question gets overlooked. If this happens, be sure to volunteer that you are feeling suicidal. Please do not be ashamed about feeling suicidal. Having suicidal feelings does not make you a "loser" or any other negative name you might come up with as a label for yourself. Many people feel suicidal and many people come close to acting on their suicidal urges. Your interviewer has talked with many patients who are coping with suicidal urges before hearing your story, and will very likely continue to hear similar stories long after you are feeling better. Your information is unlikely to shock or surprise the interviewer, or cause him or her to think less of you.

Assessment of Suicide Risk

Assuming you've been honest regarding your suicidal ideation, the interviewer will shift to assessing your current level of suicide and self-harm risk. If you do not presently have a specific plan or easy access to a method for committing suicide, the interviewer may conclude that your present risk for suicide is not high. Just because you have been classified as lower suicide risk does not mean that your pain is not real or that your condition is not serious. The psychotherapist is simply determining your risk level in order to determine the most effective and safest course of treatment to offer you. As mentioned before, high risk patients are typically asked to enter the hospital because they are likely to be a danger to themselves if they are not temporarily confined to a safe environment. Lower risk patients are offered outpatient help.

During the risk assessment phase of your interview, the interviewer is likely to touch upon the following questions:

  • Why are you thinking about suicide now?
  • Do you have a specific plan?
  • If so, how and when will this occur?
  • What are some options for coping besides suicide?
  • Have you ever felt this way before? If so, what did you do avoid suicide?
  • Do you hear voices telling you to harm or kill yourself?
  • Are you depressed, or have you been depressed until recently?
  • Have you been giving away personal possessions?
  • Is the anniversary of a loss (e.g., death of someone) or any other significant date (birthday, holiday) approaching?
  • Have you been avoiding or withdrawing from others?
  • Have you recently made a will or other arrangements for your death?
  • Have you recently experienced any significant losses (such as losing a job, home, significant person to death or divorce, or financial investment)?
  • Are you terminally or chronically ill?
  • Are you currently under the influence of alcohol or other substances? Do you use alcohol and/or other substances on a frequent basis?
  • Have you ever been told that you take too many risks or are impulsive?

Even if you are not currently suicidal, but you have had previous suicidal thoughts or attempts, the interviewer may still ask the above questions to determine your level of risk. You may expect to hear these questions repeated during later therapy visits as a way of monitoring your risk level over time.

Confidentiality

Ordinarily, the information you share with a doctor concerning your health, both physical and mental, is kept confidential and secret. However, this is typically not the case when it comes to suicide. By law, if you are an acute suicide risk, your therapist or doctor must "break confidentiality" and share information concerning your condition with other professionals (and possibly with the police and court system) so as to keep you safe. If you express clear suicide intent, and describe a specific plan of high potential lethality (e.g., using a gun, jumping from a high place, cutting your wrists or drinking poison), and you have access to the means by which to act on your plan your psychotherapist or doctor may:

  • Remove the planned means of suicide.
  • Help you generate possible alternative coping strategies other than suicide.
  • Consult with your psychiatrist (if you have one), their supervisor (if they work in an agency), a crisis worker (in person or by telephone) or a colleague to help keep you safe.
  • Help you to develop a crisis safety plan.
  • Stay with you until your crisis has subsided.
  • Facilitate your hospitalization or other residential crisis placement.

No therapist or doctor wants to hospitalize their patients. Rather, it is their goal, in general, to want to help patients remain in as high functioning a circumstance as possible. Your therapist will hospitalize you only if that seems necessary. Otherwise, if you are judged safe to return home, he or she will likely help you develop a suicide safety plan, or a plan for keeping yourself safe. This plan may be written or verbal, and will likely include things you can do to help ensure your safety if you start feeling suicidal again. Here's an example of information included in such a plan:

  • a list of your strengths and skills for dealing with stressors
  • examples of common triggers for suicidal thoughts (i.e., a list of events that often make you feel overwhelmed by suicidal feelings) and some options for dealing with those specific triggers
  • other suggestions for how to deal effectively with suicidal feelings (e.g., "if I start thinking about killing myself again, I will listen to some good music, or call my best friend, or go jogging so as to distract myself and help myself feel better. If I still feel suicidal, I will call a crisis number {provided by the therapist - either the therapist's emergency number, or the number for another crisis service} or I will go to the nearest hospital emergency room").

As part of this plan, a therapist may also ask you to sign a no-suicide contract, which is your written statement promising not to attempt suicide before the next office visit on a specified date. This type of strategy was recommended as a best-practice to therapists not all that long ago. However, more recent research suggests that boiler-plate (i.e., non specific) no-suicide statements are not particularly effective in keeping people safe. The newer recommendation to therapists dealing with suicidal patients is that they develop a detailed safety plan (as described above) that is personalized for each patient.

Keep copies of your suicide safety plan (and, if relevant, your no-suicide contract) on your person (in your purse or wallet) so that you can refer to them if you find yourself starting to feel suicidal again. It is nice when copies of your plan are shared with the other therapists and doctors you are working with, so that all of your professional helpers can be on the same page with regard to your care. However, these days, communication between doctors is often scarce. For practical and confidentiality reasons, do not assume that one doctor knows what your other doctors know. If you call for further crisis assistance, and are helped by someone new or someone who doesn't know about the work you've already done, be sure to bring them up to date.

During the initial treatment (and subsequent meetings), you will also be asked other questions about your mood, behavior, and ability to function in daily life. These questions are necessary to determine whether your suicidal thoughts and feelings are connected to a mental disorder. Based on your responses, you may be given a diagnosis of a specific mental disorder (or, you may have been given a diagnosis if you were hospitalized for your suicidality). Although you may feel embarrassed or angry at being labeled, an accurate diagnosis is an important part of understanding the nature of your problems and how they may best be treated. For example, as mentioned previously, depression is a frequent trigger of suicidal thoughts. If a clinician knows that you are depressed, he or she can tailor your treatment to actively decrease your depression. Exactly how your diagnosis is treated will depend on your particular circumstances, characteristics, strengths and preferences, and on the methods that your therapist and doctor have been trained to use for your condition.