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Section 26
Communication Strategies for Talking
about Lethal Means

Question 26 | Answer Booklet | Table of Contents

When initiating conversations with patients about suicide-related topics, including lethal means, there are a number of ways that this can be done including directly asking the patients about suicidality as part of the routine intake interview or asking about suicide within the context of other relevant variables. Clinicians are advised to show empathy and build rapport with the patient when asking that patient about suicide and suicide-related topics, such as lethal means.

Showing Empathy and Building Rapport with the Patient
Suicidal patients’ speech content can become singularly and profoundly negative which can naturally affect the clinician and cause you to react in was that are positive and encouraging, but lacks empathy. Some of these types of responses can include:

  • This too shall pass.
  • Suicide is a permanent solution to a temporary problem.
  • Let’s focus on what’s been going well in your life.

These types of responses can cause a problem because if these are used to counter patient negativity, patients may come to a conclusion that the clinician “doesn’t get them,” and will hold on more strongly to their negative perceptions. In this case, using empathetic reflections can help the clinician to connect to the patient’s unbearable distress and depressive symptoms.

The “completely miserable and hopeless” reflection can be useful to the clinician in two different ways: First, this type of reflection demonstrates the clinician’s willingness to be with the patient in the middle of the patient’s despair; Second, this type of reflection could function as an amplified reflection, meaning that the patient could respond with talk of positive change.

When the clinician also uses validation and reassurance, this can also facilitate rapport with the patient. When using this type of conversation, it is important to remember that as long as your response is authentic, using immediacy or brief self-disclosure is a type of validation strategy that can deepen the alliance between the clinician and the patient.

Sometimes suicidal patient can become extremely irritable and can cause difficulties in the clinician developing rapport with the patient. Irritable patients can provoke negative emotional reactions from the clinicians. In this case, using a three-part response is recommended: 1) reflective listening, 2) gentle interpretation, and 3) a statement of commitment to keep working with and through the irritability.

Asking Directly about Suicide Ideation
Asking patients directions about their suicide ideation can trigger the patient to have clinician anxiety and can the clinician to have difficulty in finding the right words for the patient to give an honest and open patient response. Using a balance of positive and negative questioning is recommended, in other words, if you ask the patient about sadness, it is also important to ask the patient about happiness.

Mood Scaling with a Suicide Floor
This strategy uses a scaling question to explore patient mood and possible suicide ideation. This strategy is a like a general map that can be used more or less by the clinician, who uses their judgement to judge which direction to take the conversation with the patient. The numbers in the rating scale can be useful in rating the patient’s mood, however, the numbers will be variable subjectively because every patient is unique.

This strategy offers several advantages for clinicians. First, it is a process that facilitates engagement, and this engagement or in other words, interpersonal connection, is a central part of suicide interventions. Second, when patients are able to connect their low and high moods to concrete external situations, the clinician is able to gain the knowledge about the triggers that lift and depress the patient’s mood. Third, the mood scaling procedure can be abandoned (either temporarily or permanently) in favor of other opportunities. Fourth, the mood scaling can flow smoothly into safety planning or other suicide interventions through opening a discussion.

There are a number of conversation strategies that the clinician can utilize in order to open up the discussion of suicide and suicide ideation, including conversations about lethal means, with the patient. The list above is not all inclusive and is subject to the clinician’s judgement as to which strategy he or she might believe would be the better option for their patient.

- Sommers-Flanagan, John Ph.D. Conversations About Suicide: Strategies for Detecting and Assessing Suicide Risk. National Register of Health Service Psychologists. Winter 2018.

QUESTION 26
What is a three-part response that is recommended for clinicians to use with patients who are extremely irritable? To select and enter your answer go to Answer Booklet.

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