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The Question Every Suicide Screen Should End With
One of the advantages of practicing psychology for many years is that your assessments gradually evolve. New research changes how you think, difficult cases challenge long-held assumptions, and occasionally one simple question changes the way you conduct every evaluation thereafter.
For me, that evolution continued while reviewing 30 randomly selected, documented school attack cases from a database of school shootings (Riedman, n.d.) as part of my research and our work with the HomicideZero training program.
One finding immediately stood out. In 15 of those cases, the attacker demonstrated evidence of suicidality before engaging in homicidal violence. The sequence caught my attention because it suggested something I had not fully appreciated earlier in my career. In these individuals, despair appeared first. Over time, thoughts directed inward became accompanied, or in some cases displaced, by thoughts directed toward others, often in the context of an escalating grievance.
The case series is relatively small, and it should not be overinterpreted. Most individuals experiencing suicidal thoughts never become violent toward others. Nevertheless, the broader targeted violence literature has reached a similar conclusion: in a subset of offenders, suicidality and homicidal ideation overlap in clinically meaningful ways (e.g., Vossekuil et al., 2004; U.S. Secret Service National Threat Assessment Center [NTAC], 2019, 2021; Meloy & Hoffmann, 2021).
Reviewing these cases changed the way I think about suicide assessment.
It also led me to ask a question I now believe deserves a place in nearly every comprehensive suicide evaluation:
When the despair is in the room, have we asked where else the thoughts are pointing?
A Habit I Rarely Observed
Throughout my career, I have observed clinicians conduct thoughtful and thorough suicide assessments. They ask about suicidal ideation, intent, planning, previous attempts, protective factors, and access to means. These conversations are often compassionate, structured, and clinically sound.
Then, almost without exception, the assessment ends.
Not because clinicians are careless, but because the screening instruments often end there as well.
Looking back, I suspect many of us, including myself early in my career, viewed suicide assessment and violence assessment as two separate clinical conversations. One addressed danger to self. The other addressed danger to others.
Experience and the targeted violence literature have gradually convinced me that this distinction is sometimes too neat.
Retrospective investigations of targeted attacks consistently demonstrate that some individuals simultaneously struggle with profound despair, perceived injustice, humiliation, anger, and violent fantasies (Vossekuil et al., 2004; NTAC, 2021). Those experiences do not always occur independently. In some individuals, they appear to interact with one another over time.
That realization changed one small part of my own assessment process.
One Additional Question
Today, whenever I complete a comprehensive suicide assessment, I routinely ask one additional question.
After discussing thoughts of self-harm, I simply say,
"Sometimes when people are hurting this much, their thoughts aren't only directed toward themselves. Have you had thoughts about seriously harming someone else?"
There is nothing dramatic about the question.
It is asked with the same calm, matter-of-fact tone as every other component of the interview.
It is not an accusation.
It is not based on an assumption.
It is simply another attempt to understand the patient's experience as completely as possible.
Interestingly, I have found that asking directly rarely damages rapport. If anything, patients often appear relieved that someone is willing to discuss thoughts they have not known how, or whether, to disclose. Research examining collaborative approaches to suicide assessment similarly suggests that direct, respectful questioning does not increase suicidal or violent ideation and may strengthen therapeutic engagement.
When the Answer Is "Yes"
The value of the question lies not simply in identifying homicidal ideation but in changing the formulation that follows.
A positive response naturally leads to additional assessment.
- Who is the intended target?
- How long have these thoughts been present?
- How specific are they?
- Is there intent?
- Has planning occurred?
- What circumstances intensify the thoughts?
- Are weapons accessible?
These are familiar questions. They closely parallel the structured follow-up clinicians routinely conduct after discovering suicidal ideation.
The assessment also broadens beyond the individual.
Is the identified person someone the patient continues to encounter? Have concerning statements been communicated to friends, family members, coworkers, classmates, or online contacts? Has anyone observed behavioral changes that, when considered together, suggest escalating risk?
One of the most consistent lessons from targeted violence investigations is that important warning behaviors are often recognized by different people but never assembled into a coherent picture until after violence occurs (NTAC, 2019, 2021). Comprehensive assessment requires connecting those observations before a crisis develops rather than afterward.
Treatment planning also changes.
Hopelessness remains an important focus, but clinicians must now also understand the grievance, cognitive distortions, perceived injustices, interpersonal conflicts, and other factors contributing to thoughts of violence toward others. Although these processes frequently overlap, they often require different therapeutic interventions.
Document What You Learned
Over the years, I have become increasingly convinced that asking difficult questions deserves equally thoughtful documentation.
A note stating,
"Patient reports thoughts of harming others,"
provides little guidance to the next clinician.
By contrast,
"Reports recurrent thoughts of harming a specific classmate beginning approximately four months ago following repeated experiences of perceived humiliation. Denies current intent or plan. Reports firearm present in the home but states it is stored in an unlocked bedroom closet. Identifies parents and school counselor as supportive adults."
creates a much clearer clinical picture.
Good documentation distinguishes observations from interpretations, preserves meaningful contextual details, and provides information that supports continuity of care, consultation, and future decision-making.
An Important Qualification
One lesson from reviewing targeted violence cases is equally important.
The relationship between suicidality and targeted violence is not symmetrical.
Many individuals who die by suicide never express thoughts of harming another person.
Conversely, some individuals who pose substantial violence risk report no suicidal ideation whatsoever, believing their contemplated violence to be justified rather than despair-driven.
Accordingly, I do not view bidirectional screening as a predictive shortcut.
Rather, I view it as one component of comprehensive violence-risk assessment, alongside evaluation of grievances, warning behaviors, leakage, access to weapons, psychiatric symptoms, psychosocial stressors, protective factors, and other empirically supported indicators.
Like every clinical interview question, it contributes one piece of a much larger formulation.
One Lesson That Changed My Practice
If there is one practical lesson I would pass on to psychologists, counselors, psychiatrists, and other mental health professionals, it is this:
Every suicide assessment should include a brief inquiry regarding thoughts of harming others.
Every violence-risk assessment should include questions regarding suicidal ideation.
Those two questions acknowledge an important clinical reality: although self-directed and other-directed violence are distinct phenomena, they sometimes coexist. When they do, recognizing that overlap may substantially influence formulation, safety planning, consultation, and intervention.
The addition requires less than a minute.
Occasionally, it changes the entire direction of the assessment.
Clinical Pearl: Bidirectional Screening Principle. Every suicide assessment should briefly evaluate thoughts toward others, and every violence-risk assessment should evaluate thoughts toward the self. Neither question predicts violence by itself, but together they provide a more complete understanding of risk and may identify clinically significant information that would otherwise remain undisclosed.
References
Cornell, D., & Sheras, P. (2006). Guidelines for responding to student threats of violence. Sopris West.
Meloy, J. R., & Hoffmann, J. (Eds.). (2021). International handbook of threat assessment (2nd ed.). Oxford University Press.
National Threat Assessment Center. (2021). Averting targeted school violence: A U.S. Secret Service analysis of plots against schools. U.S. Secret Service, Department of Homeland Security.
National Threat Assessment Center. (2019). Protecting America's schools: A U.S. Secret Service analysis of targeted school violence. U.S. Secret Service, Department of Homeland Security.
Riedman, D. (n.d.). K–12 School Shooting Database. Retrieved July 22, 2026, from https://k12ssdb.org
Vossekuil, B., Fein, R. A., Reddy, M., Borum, R., & Modzeleski, W. (2004). The final report and findings of the Safe School Initiative: Implications for the prevention of school attacks in the United States. U.S. Secret Service and U.S. Department of Education.
Sources and further reading: Vossekuil et al. (2004) Safe School Initiative; NTAC (2019, 2021); Meloy & Hoffmann (2021) International Handbook of Threat Assessment; Cornell & Sheras (2006); Riedman K–12 School Shooting Database