Assessing Suicidality: Beyond Issues of Don’t Ask Don’t Tell

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In a recent post, I wrote that 1.7 million Americans attempt suicide every year, and many people who think about ending their lives don't tell anyone.

People may hesitate to openly share their thoughts to end their lives for a host of reasons. A taboo subject such as this (Al-Halabi et al., 2021; Hales-Ho & Timm, 2023) can elicit profound levels of shame, embarrassment, and vulnerability, and these feelings can be associated with clients and patients pulling back from discussing suicidal ideation openly and candidly (Farber et al., 2019). They may feel that suicide is immoral or a “mortal sin.” They may not believe that anyone or anything can help them.

Researchers have found that a majority of adult clients report they did not disclose their suicidal ideations to anyone, including therapists and other healthcare professionals (physicians, nurses, etc.) (Calear & Batterham, 2019). So, sometimes people do not tell, but do professionals consistently ask?

Physicians and clinicians sometimes fail to inquire about suicidal ideation with their patients and clients because of hectic work schedules, lack of awareness, or reluctance to broach this taboo subject (Vannoy & Robins, 2011). As many as 40 percent of professionals report being “very or somewhat uncomfortable” conducting an assessment of the level of acuity and risk of suicide (Shahidullah et al., 2020, p. 176). Bommersbach et al. (2018) found that health providers screened less than half of people who committed suicide in the year before their death, that less than 60 percent of these people ever endorsed suicidal ideation, and that none did at final appointments, calling into question screening practices and effectiveness. So, this represents the “don't ask” component of “don’t ask, don’t tell” regarding suicidal thoughts. But what about the 46 percent of folks (Hallford et al., 2023) who do disclose suicidal ideation?

I was talking with a young man this past week. He disclosed he’d indicated on the intake form at a healthcare service provider “medium to high” on thoughts of suicide and self-harm on several occasions. He’d also ticked an increase in substance use on the form in conjunction with his endorsement of suicidal ideation. There was no follow-up whatsoever. This brings up another issue around suicidal ideation assessment: Not only do professionals sometimes not ask, and sometimes patients/clients do not tell, but when patients/clients do tell, healthcare professionals can fail to follow up.

Discomfort with suicide assessment and disclosure cuts both ways. Researchers (Bennett, 2018; Bryan et al., 2017) have concluded that although individual providers do receive training at some point in the assessment of risk, a lack of well-defined, systematic screening and protocols reduces the effective utilization of these requisite skills.

This constitutes a serious problem in accurate assessment and effective service provision. Having a reliable and valid means of acquiring the necessary data to make good clinical decisions is crucial and would enhance the safety of clients and their families (Killian, 2024). I undertook a research project to develop a subtle screening of suicidal ideation to rectify this pressing issue in the assessment of suicidal ideation and the provision of effective healthcare interventions. I will report the results of this study in my next post.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 contact the 988 Suicide & Crisis Lifeline by calling 988, or the Crisis Text Line by texting HOME to 741741. To find a therapist near you, see the Psychology Today Therapy Directory.