Student NT editor Heather Phelan shares her advice for discussing suicide with patients.
Mental health nurses get a lot of flack.
My classmates studying other fields of nursing love to make fun of me for never dressing wounds, doing ECGs, or giving injections.
On my last placement, I did one day of outreach on a medical ward, and they were completely baffled as to why I’d never removed a cannula or emptied a catheter bag.
I try to explain to people that as mental health nursing students, the skills we learn are often more abstract – how to build up a therapeutic relationship with a patient, assessment skills and de-escalation skills – but they’re always left looking a little confused as to what we do all day.
Then two famous public figures killed themselves within a week, and suddenly people were asking me what to do when a patient comes into a medical ward saying they’re thinking about suicide.
These tips are not a definitive guide to assessing a patient’s suicidal risk – for that, you need to speak to your mentor. But these tips are for the people who find themselves uncomfortable around a suicidal patient, who don’t quite know what to ask, who aren’t sure what they can do for their patient, for how to start the conversation and keep it going.
“Don’t be afraid to say the word ‘suicide’”
Broaching the subject
The best advice my mentors gave me was this: don’t be afraid to say the word “suicide”.
While I was beating around the bush, asking my patient if they had had thoughts about “leaving it all behind” and “running away from it all”, my mentor would just ask: “Have you been having thoughts about harming yourself?” Then the patient is most likely to give a yes or no answer – making things clearer for you.
Personally, I find it easier to lead into that question: “You’ve mentioned you’re feeling quite down and hopeless. Can you tell me if you’ve been thinking about harming yourself?”
Gaining more information
Once the patient has confirmed their suicidal thoughts, you want to get more information about this from them.
Asking them, “how long have you been feeling this way?” or “have you ever felt this way before?” gives you some context to their low mood, and will hopefully lead to a conversation about what triggered the suicidal thoughts, and what’s going on in their life that has lead them to this point.
“You can’t fix it in one conversation”
Validating their feelings
I think the fear of talking to suicidal patients comes from feeling like you need to fix it.
When a patient comes in with a broken arm, you know what to do to get them better. But you can’t get rid of suicidal thoughts with a bandage or an IV. You have to alleviate yourself of that responsibility.
If a patient comes to you with suicidal thoughts, you can’t fix it in one conversation. What you can do is help them feel listened to, and give them the opportunity to talk about what’s bothering them.
It is about letting them talk – you don’t need to be saying a whole lot. Simple phrases such as “that must have been difficult” and “sounds like you’ve been having a tough time” validate what the patient is feeling and give you something helpful to say if you’re feeling awkward or uncomfortable.
Identify any protective factors
Protective factors are aspects of a patient’s life that will stop them from harming themselves. This might be a pet that they need to look after, or children who need their parent.
I had one patient who expressed suicidal intentions, but said he would never go through with them because he wanted to make sure he could take care of his cat.
To find this information, you can ask the patient if they have any family, who is in their social circle, who lives at home with them or how they spend their day. This will highlight any hobbies, loved ones or goals that will stand between a patient and their suicidal thoughts.
“The patient has probably heard this all before, and when you’re feeling suicidal, it’s difficult to feel optimistic”
Don’t try to cheer them up
It is completely in our nature to try to find the positive in this situation. When a patient comes to you with suicidal ideation, it feels entirely natural to tell them that they have a lot to live for, that things will get better and that they have their whole future ahead of them.
But the patient has probably heard this all before, and when you’re feeling suicidal, it’s difficult to feel optimistic.
Telling the patient anything along these lines tends to shut down the conversations and stifle their feelings – it can make them feel like they can’t talk about what they’re feeling, and that they should be focusing on the positive.
You want to create a space where it’s okay for them to talk about their darkest moods, because sometimes, that’s what someone needs most of all.