A discourse analysis of suicide ideation assessment among first year health professional students enrolled in a communications course


  • Trena Paulus East Tennessee State University, USA
  • Hebah Al-Khateeb University of Tennessee, USA
  • Jessica Lester University of Indiana, USA
  • Rick Hess East Tennessee State University, USA
  • Alicia Williams East Tennessee State University, USA




Communication skills, objective structured clinical examination, standardized patients, suicide assessment


Background: Suicide risk assessments require a complex set of skills around a sensitive matter which can be difficult for providers. Aim: Research investigating communication techniques and the language choices used to assess for suicide ideation is limited. Methods: We analyzed 121 video-recorded and transcribed final exams from a communication skills course for first year health professional students to identify patterns and variation in the language choices made to assess for suicidal ideation in standardized patients exhibiting symptoms of depression.  Results: We found that 66 of the 121 (55%) interviews included a suicide assessment. We noted key patterns and variation around when the assessments took place (while exploring depressive symptoms or as a topic shift), how they were prefaced (with ubiquity statements, normalization statements, or expressions of care and concern), and how the question itself was structured (with a negative preference structure, in a non-polar format, or ambiguously). Conclusions: Assessing for suicide is a delicate task for both patients and providers, both of whom may be reluctant to engage around the topic. Utilizing normalization statements as well as statements of care and concern is a good approach to assess suicide idation while exploring depressive symptoms.


Airey, N. D., & Iqbal, Z. (2020). Are clinicians confident in the risk assessment of suicide?: A systematic literature review. Archives of Suicide Research, 1–13. https://doi.org/10.1080/13811118.2020.1792019

Bernert, R. A., Hom, M. A., & Roberts, L. W. (2014). A review of multidisciplinary clinical practice guidelines in suicide prevention: Toward an emerging standard in suicide risk assessment and management, training and practice. Academic Psychiatry, 38(5), 585–592. https://doi.org/10.1007/s40596-014-0180-1

Brown, P., & Levinson, S. (1978). Universals in language usage: Politeness phenomenon. In E. Goody (Ed.), Questions and politeness: Strategies in social interaction (pp. 56-289). Cambridge: Cambridge University Press.

Cegala, D. J., & Broz, S. L. (2002). Physician communication skills training: A review of theoretical backgrounds, objectives and skills. Medical Education, 36(11), 1004–1016. https://doi.org/10.1046/j.1365-2923.2002.01331.x

Centers for Disease Control. (n.d.). Suicide prevention. Retrieved June 17, 2021, from https://www.cdc.gov/suicide/facts/index.html.

Dazzi, T., Gribble, R., Wessely, S., & Fear, N. T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361–3363. https://doi.org/10.1017/S0033291714001299

Epstein, R. M., Franks, P., Fiscella, K., Shields, C. G., Meldrum, S. C., Kravitz, R. L., & Duberstein, P. R. (2005). Measuring patient-centered communication in patient–physician consultations: theoretical and practical issues. Social science & medicine, 61(7), 1516-1528. https://doi.org/10.1016/j.socscimed.2005.02.001

Floyd, M., Lang, F., Beine, K. L., & McCord, E. (1999). Evaluating interviewing techniques for the sexual practices history. Use of video trigger tapes to assess patient comfort. Archives of family medicine, 8(3), 218–223. https://doi.org/10.1001/archfami.8.3.218

Ford, J., Thomas, F., Byng, R., & McCabe, R. (2020). Asking about self-harm and suicide in primary care: Moral and practical dimensions. Patient Education and Counseling, 104(4), 826–835. https://doi.org/10.1016/j.pec.2020.09.037

Goffman, E. (1967). Interaction ritual: Essays on face-to-face behavior. New York: Anchor Books.

Hawgood, J. L., Krysinska, K. E., Ide, N., & De Leo, D. (2008). Is suicide prevention properly taught in medical schools? Medical Teacher, 30(3), 287–295. https://doi.org/10.1080/01421590701753542

Heritage, J. (2010). Questioning in medicine. In A. F. Freed & S. Ehrlich (Eds.), “Why do you ask?” The function of questions in institutional discourse (pp. 42-68). New York, NY: Oxford University Press.

Heritage, J., & Robinson, J. D. (2011). ‘Some’ versus ‘any’ medical issues: Encouraging patients to reveal their unmet concerns. In Applied conversation analysis (pp. 15-31). Palgrave Macmillan, London.

Jefferson, G. (2004). Glossary of Transcript Symbols with an Introduction. In Conversation Analysis: Studies from the First Generation (1st ed., pp. 12–31). John Benjamins Publishing Company. http://liso-archives.liso.ucsb.edu/Jefferson/Transcript.pdf

Jenkins, L., Cosgrove, J., Ekberg, K., Kheder, A., Sokhi, D., & Reuber, M. (2015). A brief conversation analytic communication intervention can change history-taking in the seizure clinic. Epilepsy & Behavior, 52, 62-67. https://doi.org/10.1016/j.yebeh.2015.08.022

Kiyimba, N., Karim, K., and O’Reilly, M. (2017). The use of why questions in child mental health assessments. Research on Children and Social Interaction, 1(2), 222-242. http://hdl.handle.net/10034/620953

Lake, C. R. (2008). How academic psychiatry can better prepare students for their future patients: Part I: the failure to recognize depression and risk for suicide in primary care; problem identification, responsibility, and solutions. Behavioral Medicine, 34(3), 95–100. https://doi.org/10.3200/BMED.34.3.95-100

Law, M. K., Furr, R. M., Arnold, E. M., Mneimne, M., Jaquett, C., & Fleeson, W. (2015). Does assessing suicidality frequently and repeatedly cause harm? A randomized control study. Psychological assessment, 27(4), 1171–1181. https://doi.org/10.1037/pas0000118

Lester, J. N., & O'Reilly, M. (2019). Applied conversation analysis: Social interaction in institutional settings. Thousand Oaks, CA: Sage.

Lester, J. N., & Paulus, T. M. (2014). “That teacher takes everything badly”: Discursively reframing non-normative behaviors in therapy sessions. International Journal of Qualitative Studies in Education, 27(5), 641-666. https://doi.org/10.1080/09518398.2013.805446

Luoma, J. B., Martin, C. E., & Pearson, J. L. (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. The American Journal of Psychiatry, 159(6), 909-916. https://doi.org/10.1176/appi.ajp.159.6.909

Maynard, D. (1991). The perspective-display series and the delivery and receipt of diagnostic news. In D. Boden & D. H. Zimmerman (Eds.), Talk and social structure: Studies in ethnomethodology and conversation analysis (pp. 164-194). Cambridge: Polity Press.

Maynard, D. W., & Heritage, J. (2005). Conversation analysis, doctor–patient interaction and medical communication. Medical education, 39(4), 428-435. https://doi.org/10.1111/j.1365-2929.2005.02111.x

McCabe, R., Sterno, I., Priebe, S., Barnes, R., & Byng, R. (2017). How do healthcare professionals interview patients to assess suicide risk? BMC Psychiatry, 17(1), 122. https://doi.org/10.1186/s12888-017-1212-7

Miller, P. K. (2013). Depression, sense and sensitivity: On pre-diagnostic questioning about self-harm and suicidal inclination in the primary care consultation. Communication & Medicine, 10(1), 37–49. https://doi.org/10.1558/cam.v10i1.37

Mospan, C. M., Hess, R., Blackwelder, R., Grover, S., & Dula, C. (2017). A two-year review of suicide ideation assessments among medical, nursing, and pharmacy students. Journal of Interprofessional Care, 31(4), 537–539. https://doi.org/10.1080/13561820.2017.1301900

Nock, M. K., Millner, A. J., Ross, E. L., Kennedy, C. J., Al-Suwaidi, M., Barak-Corren, Y., Castro, V. M., Castro-Ramirez, F., Lauricella, T., Murman, N., Petukhova, M., Bird, S. A., Reis, B., Smoller, J. W., & Kessler, R. C. (2022). Prediction of suicide attempts using clinical assessment, patient self-report, and electronic health records. JAMA Network Open, 5(1), e2144373. https://doi.org/10.1001/jamanetworkopen.2021.44373.

Norrish, M. (2009). The effectiveness of a vignette approach to teaching suicide risk factors: An Omani perspective. Medical Teacher, 31(11), e539–e544. https://doi.org/10.3109/01421590902849511

O’Reilly, M., Kiyimba, N., & Karim, K. (2016). “This is a question we have to ask everyone”: Asking young people about self-harm and suicide. Journal of Psychiatric and Mental Health Nursing, 23(8), 479–488. https://doi.org/10.1111/jpm.12323

Pino, M., Parry, R., Land, V., Faull, C., Feathers, L., & Seymour, J. (2016). Engaging terminally ill patients in end of life talk: how experienced palliative medicine doctors navigate the dilemma of promoting discussions about dying. PLOS ONE, 11(5), e0156174. https://doi.org/10.1371/journal.pone.0156174

Polihronis, C., Cloutier, P., Kaur, J., Skinner, R., & Cappelli, M. (2020). What’s the harm in asking? A systematic review and meta-analysis on the risks of asking about suicide-related behaviors and self-harm with quality appraisal. Archives of Suicide Research, 1–23. https://doi.org/10.1080/13811118.2020.17938.

Potter, J. (2004). Discourse analysis. In M. A. Hardy & A. Bryman (Eds.), Handbook of Data Analysis (pp. 607-624). London: Sage.

Quirk, R., Greenbaum, S. , Leech, G., & Svartvik, J. (1985). A comprehensive grammar of the English language. London: Longman.

Robinson, J. D., & Heritage, J. (2016). How patients understand physicians’ solicitations of additional concerns: implications for up-front agenda setting in primary care. Health communication, 31(4), 434-444. https://doi.org/10.1080/10410236.2014.960060

Sacks, H. (1992). Lectures on conversation. Blackwell.

Sacks, H., & Schegloff, E. (1979). Two preferences in the organization of reference to persons conversation and their interaction. In G. Psathas (Ed.), Everyday language: Studies in Ethnomethodology. (pp. 15–21). Irvington Publishers.

Sands, N. (2004). Mental health triage nursing: An Australian perspective. Journal of Psychiatric and Mental Health Nursing, 11(2), 150–155. https://doi.org/10.1111/j.1365-2850.2003.00697.x

Shea, S. C. (2017). Psychiatric interviewing: The art of understanding (3rd ed.). Elsevier.

Shea, S. C., & Barney, C. (2015). Teaching clinical interviewing skills using role-playing: Conveying empathy to performing a suicide assessment. Psychiatric Clinics of North America, 38(1), 147–183. https://doi.org/10.1016/j.psc.2014.10.001

Sommers-Flanagan, J. (2018). Conversations about suicide: strategies for detecting and assessing suicide risk. Journal of Health Service Psychology, 44(1), 33–45. https://doi.org/10.1007/BF03544661

Sommers-Flanagan, J., & Shaw, S. L. (2017). Suicide risk assessment: What psychologists should know. Professional Psychology: Research and Practice, 48(2), 98–106. https://doi.org/10.1037/pro0000106

Stene-Larsen, K. & Reneflot, A. (2019) Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scandinavian Journal of Public Health. [Online], 47(1), 9–17. https://doi.org/10.1177/1403494817746274

Vickers, C. H., Lindfelt, C., & Dodd-Butera, T. (2016). Repetition in the health history segment of Spanish language clinical consultations: A conversation analysis. Nursing Research, 65(4), 306-317. https://doi.org/10.1097/NNR.0000000000000166

Wood, L. A., & Kroger, R. O. (2000). Doing discourse analysis: Methods for studying action in talk and text. Thousand Oaks, CA: Sage.




How to Cite

Paulus, T., Hebah Al-Khateeb, Jessica Lester, Rick Hess, & Alicia Williams. (2023). A discourse analysis of suicide ideation assessment among first year health professional students enrolled in a communications course. Qualitative Health Communication, 2(1), 73–89. https://doi.org/10.7146/qhc.v2i1.133566