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| Practical Tips for Eliciting Suicidal Ideation |
| Feature Articles - Research/Scientific | |
| Friday, 30 November 2001 | |
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Suicide is ubiquitous. It honors no boundaries. For substance abuse counselors the assessment of suicide risk is often a daily task. Whether the client is young or old, rich or poor, a quiet recluse or an infamous Hollywood star, the shadow of suicide is often a player - a final solution that, if chosen, ends the play. As clinicians we are far from immune to its draw. Many of us have been touched by suicides among our friends, family members, and colleagues. Contemplation of suicide may even be a part of our own past or future history. There are a variety of factors with substance abuse clients, ranging from shortened length of stays in rehabilitation centers to the presence of comorbidity with other mental disorders that can complicate the assessment and treatment of suicidal risk. In addition, for most people the topic of suicide is profoundly taboo and is often viewed as a sign of serious psychological or spiritual weakness. Many patients with suicidal ideation may not spontaneously provide such ideation unless directly asked and some downplay the severity of their ideation unless the interviewer sensitively, yet tenaciously, pursues an effective line of questioning. Before exploring some interviewing techniques that may help us to approach the daunting challenge of suicide assessment, it is of value to note the complexity of the process. Suicide assessment consists of three different tasks: 1) the elicitation of suicidal ideation from the client (corroborative sources are also sometimes critical), 2) the gathering of known risk factors (such as age, sex, use of alcohol, family history of suicide, presence of agitation or psychosis), and 3) the clinical decision-making itself, in which the clinician weighs the acute danger facing the client using the knowledge gained in steps one and two. Valuable literature exists devoted to the latter two aspects of suicide assessment - delineating risk factors and the art of clinical decision-making. This literature consists of empirical research and practical clinical wisdom. In contrast, until recently, substantially less has been written concerning specific interviewing techniques and strategies for eliciting suicidal ideation itself, other than to remind the reader that such questioning should be conducted while providing some sample questions. But there is little doubt that two clinicians, after exploring suicidal ideation in the same client, can walk away with a surprisingly different database, depending upon the exact wording of the questions, the sequencing of the questions, and the degree to which the client felt safe with the interviewer asking the questions. Consequently, in this article we shall focus solely on the art of eliciting suicidal ideation, examining a specific interview strategy called the CASE Approach. For the interested reader the other two critical aspects of suicide assessment - the elicitation of risk factors and the process of clinical formulation - are thoroughly explored in The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors (Shea, 1999). The CASE approach The language of suicide is defined by specifics. In the last analysis the final steps towards suicide lie along a common path. The client must choose a method and plan its successful implementation. The degree with which the counselor becomes familiar with this language, its nuances and accents, is the degree with which the clinician will be granted entrance into the client's world of suicidal thought. Clinicians must become both adept and comfortable with asking explicit questions about implicit plans. No detail in the planning is too small, for the degree with which the client has thought out the details may reflect the degree with which the client is about to act upon them. When functioning as the sole provider of care, the substance abuse counselor may be the only professional available to uncover the first signs of suicidal potential. Even when working with other professionals - perhaps a psychiatrist providing medication for a comorbid depression - it is the substance abuse counselor who may be seeing the client the most frequently. In such situations it is often the substance abuse counselor who may have forged the most enduring and safe relationship with the client, and it is the power of this relationship that may provide the opening for the client to share his or her suicidal ideation. It becomes critical that the client and counselor feel comfortable talking about the client's suicidal thoughts during ongoing counseling, for such thoughts can then be productively shared with other team members for treatment planning and further assessment of risk. In this regard there are four contiguous time frames (see Figure 1, below) that may provide pivotal information regarding a patient's history of suicidal thoughts and actions: 1) presenting suicide attempt, gesture, or ideation if present, 2) any recent suicidal ideation and behaviors (over the preceding eight weeks), 3) past suicidal ideation and behaviors, and 4) immediate suicidal ideation and plans for the future. An easily learned and time-efficient strategy for asking questions in these four areas, all of which are important in helping the substance abuse counselor to determine the urgency of intervention and possible need for referral, has been developed - the Chronological Assessment of Suicide Events (CASE Approach). In the CASE Approach the term "suicide event" is used in the broad sense of any suicide attempt, gesture, thought, or death wish. The CASE Approach provides concrete suggestions about what questions may be most useful in delineating suicidal ideation and what questions are more likely to be a waste of time. The CASE Approach is not presented as the "right way" to elicit suicidal ideation. It is presented merely as "a way." Clinicians can directly adopt the entire approach or only those parts they find most useful to their styles. The approach is not intended to be a "cookbook" way of interviewing. Its purpose is to encourage clinicians to discover their own way of strategically eliciting suicidal ideation. It should be emphasized that the CASE Approach in clinical practice is adapted to the unique needs and personality traits of the individual client. Thus the CASE Approach strategy described below might be altered markedly with a client who might want to manipulate himself or herself into a hospital or might have borderline personality traits where "suicide talk" is used for manipulative purposes. In this article space considerations prevent us from exploring all four of the time frames of the CASE Approach. Instead we will focus upon one of these areas, the Region of Recent Suicide Events, which includes suicidal ideation over the past eight weeks. An article (Shea, 1998) that outlines the recommended strategies for all four time frames of the CASE Approach can be found at the web site for the Training Institute for Suicide Assessment and Clinical Interviewing (www.suicideassessment.com). Common interviewing traps We will focus on the region of recent suicidal ideation for two reasons: 1) Substance abuse counselors are often in the difficult position of seeing patients for assessment who have had significant suicidal ideation during the previous two months. Indeed the immediate referral for substance abuse treatment often follows on the heels of a consequence of substance abuse such as an arrest for driving under the influence or dismissal from a job - the exact type of crises that can precipitate suicidal thinking. 2) The exploration of the region of recent suicidal ideation is fraught with easily "tripped" traps. Even referring mental health professionals can make mistakes while exploring in the treacherous region of recent suicidal ideation. Thus it is quite possible that the referring clinician, whether it be a mental health professional, primary care physician, or an emergency room clinician may not have "the whole story." Four major factors complicate the elicitation of recent suicidal ideation: 1) Suicidal ideation, planning, and intent often fluctuate, sometimes dramatically. A patient who presents with no or mild ideation in the past week may have had severe ideation, or even suicide gestures, in the past two months depending upon fluctuating factors such as the natural course of a psychiatric disorder, the intermittent use of alcohol and drugs, or changes in stressors. 2) Because of the taboo nature of the topic, many clients will downplay the extent of their recent planning for fear of looking inadequate or weak. 3) Some clients fear that if they share any specific plans they will be "locked up" or sent "to see a shrink." 4) It is surprisingly easy for clients and clinicians to miscommunicate on suicidal issues, especially if the clinician asks for patient opinions as opposed to facts or behaviors. Perhaps the best way to introduce the interviewing traps awaiting the unwary clinician is with a clinical presentation. Let us suppose that we have a client referred for a substance abuse evaluation (see Figure 2, above). Initially, the client had called a community mental health center requesting assessment for drinking and depression. An initial intake was set-up at the center. During this intake the mental health professional uncovered significant drinking problems and referred the client to our center for outpatient assessment and treatment. Let's put some flesh on our imagined client. Jim is a 31-year-old male with a longstanding history of alcohol dependence. He goes through brief, intermittent periods of being dry but invariably returns to his drinking. Over the years Jim has experienced an occasional run-in with the law and he has an inconsistent job history. He also has had a volatile relationship with a woman who truly loves him, but she has "just about had it" with his drinking behaviors. They frequently argue and domestic violence has erupted on several occasions. Let us now reexamine the referral situation as it could have unfolded. To do so we will need to return in time to about two months before the appointment in which we are providing an assessment for Jim. At point A in Figure 2 Jim, who has been drinking heavily, has had a major argument with his girlfriend, whom we shall call Jennifer. She storms out saying, "That's it. I'm outta here. I'm done with you." Over the course of the next several hours, while drinking heavily, Jim periodically gets a handgun out, loads it, and places it in his mouth and clicks the safety off. At one point, during which he has returned the gun to his bed stand, his girlfriend returns offering one more chance, "Look I really love you, but you have a serious drinking problem. I'll give you one more chance, but you have to call for an appointment tomorrow morning or I'm gone." Jim bursts into tears of gratitude and his suicide potential immediately plummets. The next day, he does not call. Arguments ensue. Jennifer once again storms out announcing that the relationship is over. Jim's drinking intensifies and at one point he finds himself once more gun in hand, bullets loaded (point B in Figure 2). Three hours later a reluctant Jennifer, bound by a genuine sense of compassion, as well as her own problems with dependency, returns one more time offering to stay but only, "If I'm there tomorrow when you call and I hear you set up the appointment myself. And I'm not kidding, if you don't follow through this time I'm gone and I'm never coming back." Jim once again bursts into tears and promises to make the much-needed call. This time he makes the call. Jim requests an assessment for his depression adding, "and I think I may have some problems with drinking." The intake coordinator at the community mental health center comments, "Let me see here, wait just one minute, oh yea, looks like I got something for you in about, let me see, six weeks. Can you make that on May 21 at 3:00 p.m." Jim says "great" and has himself a six-week wait. The six weeks go very well indeed. Jim doesn't drink a drop. Jennifer is thrilled both at his abstinence and his follow-through on getting an appointment. Jim has six of the best weeks of the last ten years of his life. The mental health therapist, our eventual referral source, does a nice job of interviewing (point C in Figure 2). She uncovers the alcohol dependence and feels it may well be the primary problem, the depression being secondary. Screening for suicide she asks, "Have you been having any suicidal thoughts recently?" Jim, who currently is now feeling on top of the world, answers without any hesitancy, "No." Being thorough, our clinician asks, "Have you ever tried to kill yourself?" Jim pauses and then continues, "Well, back in college I tried once, but it was silly. I took a tiny overdose when a girlfriend jilted me." The clinician follows up, "Tell me more about that." Unwittingly the clinician has steered the interview to a distant suicide event and the much more pressing recent suicidal behavior related to the gun has been completely skipped over. The mental health professional will thus make a referral for substance abuse treatment without providing even a hint to the substance abuse counselor that this client had a loaded gun in his mouth, with the safety off, about six weeks earlier. Which brings us to the present - Jim is sitting in our office for his initial substance abuse assessment (point D in Figure 2). Not infrequently Jim's records may not have been sent yet, but even if they had been sent, they would contain no record of the recent gun incidents. Even if the referring mental health professional had conscientiously called the counselor, the referring clinician would relay no suspicion of immediate dangerousness, for he or she would have had no knowledge of it. But this client is a literal powder keg. If two weeks after the initial substance abuse assessment (point E in Figure 2) an old drinking pal of Jim's turns up and Jim hits his old watering holes, Jennifer may stand her ground and leave for good. Later that night, Jim will become a statistic. The suicide will have occurred on the substance abuse counselor's "watch" and everyone will wonder what went wrong. To avoid such outcomes, it is critical to carefully assess each client's suicide potential both at the beginning of substance abuse counseling and when indicated during ongoing counseling. Not only is it important to ask about suicide, it is important to ask in a fashion that optimizes the likelihood that the client will share valid information. In the example, even if the substance abuse counselor had inquired about suicide, but had done so with the same type of questions that the original mental health professional had used, the outcome would probably have been the same. Foundation principles and validity techniques In the CASE Approach, if the client presents having experienced suicidal ideation or behavior in the previous several days, this material is carefully explored in the Region of Presenting Suicide Events. After completing this exploration, or in those instances in which the client has no presenting suicidal ideation, the counselor can begin to explore the Region of Recent Suicide Events (the previous two months). The goal in this time frame is to determine the following facts: 1) Which specific suicide plans had been contemplated? 2) How far the client had taken actions on these plans? 3) How much of the client's time had been spent on these plans? The usefulness of this information is solely dependent upon the degree with which clients openly share their suicidal thought. In this regard validity is the cornerstone of suicide assessment. Consequently the design of all four time frames of the CASE Approach was built upon previous work by interviewing experts regarding specific "validity techniques." The following four validity techniques - the behavioral incident, gentle assumption, symptom amplification, and denial of the specific - were not developed with suicide assessment per se in mind. They were devised to increase the likelihood of receiving a valid response to any question which might raise sensitive material for the client from antisocial behavior to a sexual abuse history. Behavioral incident A client may provide distorted information for any number of reasons including anxiety, embarrassment, protecting family secrets, unconscious defense mechanisms, or conscious attempts at deception. These distortions are more likely to appear the more the interviewer asks a client for opinions rather than behavioral descriptions of events. Behavioral incidents, originally described by Gerald Pascal (Pascal, 1983), are questions that ask for specific facts, behavioral details, or trains of thought such as, "How many pills did you take?" or which simply ask the patient to describe what happened sequentially, as with "What did you do next?" By using a series of behavioral incidents of the latter style, the counselor can sometimes help a client to enhance validity by recreating step by step the unfolding of a potentially taboo topic such as a suicide attempt. As Pascal states, in general, it is best for clinicians to make their own judgment based on the details of the story itself rather than relying on patients to proffer "objective opinions" on matters that have strong subjective implications. Some typical behavioral incidents follow: Prototypes: 1) Did you put the razor blade up to your wrist? 2) When you say that "you taught your son a lesson" what did you actually do? 3) Has anyone ever asked you for your car keys because they were afraid to let you drive because of your drinking? 4) What did your father say then? 5) Tell me what happened next? Clinical Caveat: Behavioral incidents are quite time-consuming. Obviously the counselor must pick and choose when to utilize behavioral incidents, with a heavy emphasis during sensitive areas such as drug abuse, domestic violence, and suicide assessment. Gentle assumption Gentle assumption, originally delineated by Pomeroy, Flax, and Wheeler (Pomeroy et al., 1982) for use in eliciting a valid sex history, is used when a clinician is suspicious that a patient may be hesitant to discuss a taboo behavior. With gentle assumption, the clinician assumes that the potentially embarrassing behavior is occurring and frames his or her question accordingly using a gentle tone of voice. In uncovering a valid sexual history, it was discovered that questions such as, "How frequently do you find yourself masturbating?" were much more likely to yield valid answers than, "Do you masturbate?" If the clinician is concerned that the patient may be potentially disconcerted by the assumptive nature of the question, it can be softened by adding the phrase "if at all" as with, "How often do you find yourself masturbating, if at all?" If engagement has gone well and an appropriate tone of voice has been used, patients are seldom bothered by gentle assumption. Prototypes: 1) What other types of vandalism have you been involved in? 2) How many times a week do you and your wife argue? 3) How many jobs have you been fired from in your lifetime? 4) What other ways have you thought of killing yourself? Clinical Caveat: Gentle assumptions are powerful examples of leading questions. The clinician must use them with care. They should not be used with clients who may feel intimidated by the clinician or with clients who are trying to provide what they think the clinician wants to hear. They are inappropriate with most children, when they could lead to the relating of false memories of abuse. Denial of the specific After a patient has denied a generic question it is surprising how many positives will be uncovered if the patient is asked a series of questions about specific entities. The technique of denial of the specific (Shea, 1988) appears to jar the memory of the patient, and it also appears to be harder to falsely deny a specific as opposed to a generic question. Examples of denial of the specific, concerning drug abuse, would be a series of questions such as: "Have you ever tried cocaine?"; "Have you ever dropped acid?"; "Have you ever used speed?" Prototypes: 1) Have you thought of shooting yourself? 2) Have you thought of overdosing? 3) Have you thought of hanging yourself? Clinical Caveat: It is important to frame each denial of the specific as a separate question, pausing between each inquiry and waiting for the patient's denial or admission before asking the next question. The clinician should avoid combining the inquiries into a single question such as, "Have you thought of shooting yourself, overdosing, or hanging yourself?" A series of questions combined in this way is called a "cannon question." Such cannon questions frequently lead to invalid information, for clients only hear parts of them, or choose to respond to only one question in the string. Symptom amplification This technique is based upon the observation that clients often minimize the frequency or amount of their disturbing behaviors. When using symptom amplification this minimizing mechanism is bypassed by setting the upper limits of the quantity in the question at such a high level that, when the client downplays the amount, the clinician is still aware there is a significant problem (Shea, 1998). For a question to be viewed as symptom amplification, the clinician must suggest an actual number. For instance, when a clinician asks, "How much liquor can you hold in a single night, a pint, a fifth?" and the patient responds, "Oh no, not a fifth, I don't know, maybe a pint," the clinician is still alerted that there is a problem despite the patient's minimizations. The beauty of the technique lies in the fact that it avoids the creation of a confrontative atmosphere to the interview, even though the client is minimizing behavior. It is worth repeating that symptom amplification is utilized in an effort to determine an actual quantity. It always involves the interviewer suggesting a specific number, set high. Prototypes: 1) How many times have you tripped on acid in your whole life, thirty, sixty, more than eighty times? 2) How many physical fights have you had in your life, twenty, forty, fifty? 3) On the days when your thoughts of suicide were most intense, how much of the day did you spend thinking of killing yourself, fifty, eighty, ninety percent of the day? Clinical Caveat: Be sure that you do not set the upper limit at such a high number that it seems absurd or creates the appearance that you don't know what you are talking about. Strategic exploration of recent suicidal ideation Let us look at a strategy that naturalistically weaves the above validity techniques into a conversational flow while exploring recent suicidal ideation. The counselor should feel free to adapt this strategy to the unique needs of each client and clinical setting. As mentioned earlier there is no cookbook approach that is correct. But I believe consistent use of the following principles can often enhance the clinician's ability to rapidly and reliably uncover suicidal ideation. One might wonder why it is important for a substance abuse counselor to uncover the full extent of suicidal planning, once the counselor has already "heard enough" to know that a referral should be made to a mental health professional for further risk assessment. Although not immediately obvious, I think the answers are compelling: 1) Sometimes persistent questioning will uncover surprisingly serious ideation or even grounds for involuntary commitment, information that may suggest the need for immediate intervention. 2) At the end of the interview, especially with a new client, the client may balk at referral to a mental health professional. At such a juncture, it is the grounds for commitment that may serve as the only effective leverage point for ensuring that the client follows through with the potentially life-saving referral. 3) During the interview with the subsequent clinician, the client may innocently not relay critical information. More ominously the client may purposefully choose not to share this information from fear of stigmatization or concerns of an intervention such as hospitalization or involuntary commitment. If the referring counselor has uncovered such critical information, it can be relayed to the next clinician. Having run a psychiatric emergency room, I can readily vouch that clients sometimes "clam up" once they enter the emergency room setting. 4) In a similar vein, whomever first uncovers suicidal ideation, especially if the client is also feeling intense pain at the time of sharing, will sometimes have the best chance at uncovering the true extent of the suicide planning. This is particularly true when there is a strong therapeutic alliance as is often the case with ongoing substance abuse counseling. In a standard substance abuse referral, the client does not typically present with intense suicidal ideation or with a suicide attempt in the past 48 hours. When clients do present in such a fashion, suicidal ideation is often easily broached, in fact, it is frequently raised by the client itself. At such a point the counselor would proceed to explore the Region of Presenting Suicide Events. When done exploring this region, the clinician would go on to explore the time frame of our focus in this article - the Region of Recent Suicide Events. As was the case with Jim, the client we used earlier as a classic example of missed recent suicidal ideation, the more typical client does not have an immediate suicide event to share with the interviewer. Thus it becomes the responsibility of the counselor to somehow broach the topic of suicide in a graceful and natural fashion. One unobtrusive method of raising the topic of suicide, without concurrently raising the patient's feelings of shame, is to normalize the topic for the patient, as with "You know, Mike, a fair number of my clients, when they are feeling as stressed out and depressed as you have been feeling, tell me that they sometimes get thoughts of killing themselves. I'm wondering if you've been having any thoughts like that over the past two months?" If the client denies any suicidal ideation I always ask again with a question that invites the client to share even subtle suicidal ideation such as, "Once again, over the past two months, have you had any thoughts of killing yourself, even if fleeting in nature?" In those instances in which the counselor uncovers suicidal ideation, it is now time to carefully begin an exploration of recent suicidal ideation over the past two months. Let's take a look at our strategy as it now unfolds (see Figure 3, page 21). If the client admits to thoughts concerning a specific method, the clinician uses a series of behavioral incidents to establish the extent of action taken in implementing the plan. The power of a series of behavioral incidents to uncover valid information can be easily demonstrated. Let us picture two different counselors trying to ferret out how close a client has come to committing suicide. Having already shared that he keeps a gun in his house, the client comments, "I was thinking of shooting myself about a week ago." Our first clinician asks an opinion-oriented question, "How close do you think you came to doing that?" The second clinician asks a series of behavioral incidents: "Have you ever gotten the gun out while thinking about using it to kill yourself?"; "Have you ever loaded the gun while thinking of killing yourself?"; "Have you put the gun up to your body or head?"; "Did you take the safety off?"; "How long did you hold the gun there?"; "What stopped you from pulling the trigger?" The latter clinician will probably obtain a much clearer idea of how close to suicidal action the client had actually come. There exist numerous reasons that a client experiencing suicidal ideation may minimize his or her own dangerousness, not the least of which are shame, denial, and fear of intervention including involuntary commitment. Opinion-oriented questions invite such minimizations. In contrast, when the clinician uses a series of behavioral incidents, the clinician is inviting "the telling of a story." As the patient becomes more animatedly involved in this telling, defenses may fall and valid information may more readily surface. By persistently, yet gently using a series of behavioral incidents, the clinician is essentially helping the client to create a step-by-step "verbal videotape." If the client skips a step, the clinician can ask the client to go back until the picture is clear as to what truly transpired. In this fashion the clinician can feel more confident that an accurate picture of the client's suicidal intent is emerging. With some clients the process of replaying their physical actions triggers an associated retracing of their thoughts, especially their thoughts related to the weighing of the pros and cons of proceeding with a suicide attempt. Even if the client does not spontaneously share such thoughts, this juncture of the CASE Approach provides an opportune time to hunt for them with questions such as, "As you were holding the razor blade to your wrist, what were your thoughts about the pros and cons of proceeding to kill yourself?" Once the clinician has explored the extent of action taken with the client's first suicide method, gentle assumption is employed to establish another method, if indeed one exists. This second method is then explored using behavioral incidents in exactly the same manner as before. The interviewer continues this use of gentle assumptions with follow-up behavioral incidents until the client denies any other methods. At the point when the use of a gentle assumption yields a blanket denial of other methods, the clinician utilizes denial of the specific in a small series. This technique can be surprisingly effective at uncovering previously denied suicidal material, for each time the client answers a denial of the specific, the clinician has the opportunity to look for evidence of ambivalence or deceit. The interviewer doesn't "drive this technique into the ground" with an exhaustive series of suicide methods, but simply asks for any unmentioned methods with which the client would already be familiar - being common methods of suicide in the client's own culture. By way of example, if the patient has talked about overdosing, guns, and driving a car off the road, the counselor may employ the following short list of denials of the specific, pausing after each one for an answer: "Have you thought about cutting or stabbing yourself?"; "Have you thought about hanging yourself?"; or "Have you thought about jumping off a bridge or other high place?" As before, if a new method is uncovered, the clinician uncovers the extent of action taken by asking a series of behavioral incidents. A clinical example highlights the usefulness of using denials of the specific. A case was presented to me in which a client committed suicide. The clinician was quite experienced and knew the client well. The client was a young adult male with a difficult case of schizoaffective disorder. During intense episodes of demoralization, he would sometimes attempt an overdose, the only method he had ever used. At the end of the session in question, the therapist intuitively felt uneasy. She asked the client as he was about to leave, "John, are you thinking of overdosing?" Without hesitancy he answered "No." Later that night he was found dead from a gunshot wound. If this client had been questioned about guns specifically, as part of a series of denials of the specific, it is possible that he still would have lied and the result would have been no different. On the other hand, perhaps he would have given a nonverbal leak to his suicidal intent - an uncharacteristic pause for example - at which point the clinician might have asked, "John, you look hesitant. Are you having any thoughts, even if fleeting in nature, of shooting yourself?" If John was experiencing the ambivalence that so many suicidal clients have, he might have broken into tears and subsequently shared the plan. The CASE Approach does not guarantee that a client will share suicidal planning. But it is designed to optimize the likelihood that such planning will be shared. After establishing the list of methods considered by the client and the extent of action taken on each method, the clinician hones in on the frequency, duration, and intensity of the suicidal ideation with a question such as: "Over the past six to eight weeks, how much time do you spend on your bad days thinking about killing yourself?" It is here that symptom amplification may be of value by adding, "you know, sixty, seventy, ninety percent of the day?" The above strategy is easy to learn and simple to remember. It also flows imperceptibly for the client, frequently increasing engagement as the client is pleasantly surprised at how easy it is to talk to the clinician about material that had frequently been shouldered alone as a topic of shame. It also becomes apparent from the questioning that the interviewer is quite comfortable talking about suicide and has clearly discussed it with many others, yet another shame reducing metacommunication. Perhaps even more importantly, the clinician has conveyed that he or she will neither overreact or underreact to a discussion of suicidal thoughts in the future. This sense of interpersonal safety may go a long way towards ensuring that any dangerous suicidal thought will be shared by the client in the future. To see a clinical demonstration of the CASE strategy as described, please refer to the sidebar on page 18, where a transcript from a complicated suicide assessment has been reproduced. The client is being evaluated for possible outpatient care in a crisis group. While delineating the Region of Presenting Suicide Events she had shared thoughts of overdosing and shooting herself. In the sidebar you will see my exploration of the Region of Recent Suicide Events, carefully hunting for evidence suggesting acute dangerousness versus evidence supporting current safety such as the client having a powerful reason for living. At this point we have completed our look at some of the specific interviewing techniques that may be of immediate value to the substance abuse counselor faced with the complex responsibility of uncovering suicidal ideation in settings such as substance abuse clinics or rehabilitation centers. The pace is formidable in such settings, and the stakes are high. In the last analysis there is probably no right method to the art of eliciting suicidal ideation. But there is a value in consciously employing a specific interview strategy, becoming familiar with the subtle nuances of its questions and the implications of how our clients answer those questions. Suicide is an all too common ending to clients struggling with recovery, especially during periods of relapse. Hopefully, the techniques and strategies outlined in this article can help us to spot those clients about to choose suicide. Such recognition may ultimately allow us to provide them with a chance to discover a different choice - a choice filled with both hope and the promise of a future worth living. Sections of this article have been adapted from The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors courtesy of John Wiley & Sons, Inc. Shawn Shea, MD, a former director of an outreach dual diagnosis team, is the author of The Practical Art of Suicide Assess-ment: A Guide for Mental Health Professionals and Substance Abuse Coun-selors. A recipient of an Outstanding Course Award from the American Psychiatric Association, he has presented at many national venues including the Cape Cod Symposia. He is currently the Director of the Training Institute for Suicide Assessment and Clinical Interviewing (www.suicideassessment.com) and an Adjunct Assistant Professor of Psychiatry at Dartmouth Medical School. References Husain, S.A. (1990). Current perspectives on the role of psychosocial factors in adolescent suicide. Psychiatric Annals 20: 122-127. Jacobs, D.G. (1999). The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco, CA: Jossey-Bass Publishers. Maris, R.W., Berman, A.L., Silverman, M.M. (2000). Comprehensive Textbook of Suicidology. New York, NY: The Guilford Press. Murphy, G.E., Wetzel, R.D., Robins, E., McEvoy, L. (1992). Multiple risk factors predict suicide in alcoholism. Arch Gen Psychiatry 49: 459-463. National Institute of Mental Health: Suicide Fact Sheet (based upon completed suicides in 1997) August 2001, www.nimh.nih.gov/research/suifact.htm. Pascal G.R. (1983). The Practical Art of Diagnostic Interviewing. Homewood, Illinois: Dow Jones-Irwin. Pomeroy W.B., Flax C.C., (1982). Wheeler C.C. Taking a Sex History. New York: The Free Press. Roy A. (1995). Psychiatric emergencies, suicide. In: Kaplan HI, Sadock BJ, eds. The Comprehensive Textbook of Psychiatry, 6th ed. Baltimore, Maryland: Williams and Wilkins; 1739-1752. Shea S.C. (1988). Psychiatric Interviewing: The Art of Understanding. Philadelphia: W.B. Saunders Company. Shea S.C. (1988). The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors. New York, NY: John Wiley & Sons, Inc. Shea S.C. (1998). The chronological assessment of suicide events: A practical interviewing strategy for the elicitation of suicidal ideation. J Clin Psychiatry (Supplement 20) 59:58-72. Shea S.C. (1999). Psychiatric Interviewing: The Art of Understanding, 2nd Edition. Philadelphia: W.B. Saunders Company. sidebar1 Illustration of the Exploration of Recent Suicide Events as Described on Pgs. 20-24 At this point, the clinician has just completed an exploration of the Region of Presenting Suicide Events - the first region explored in the CASE Approach - and is about to enter the Region of Recent Suicide Events over the last two months: Clinician: Now before this time, over the last two months, have you gotten the pills out in your hand and dumped some of them out and thought of overdosing right on the spot? Client: A little while ago I thought I was going to cut my wrists. I was in the bathroom, I had the warm water running, and I knew I had to cut up my arm and not across my arm. I had the razor out. And I didn't do it. I don't know why. Clinician: I was going to say what do you think stopped you? (behavioral incident) Client: I don't know. I wasn't crying. I was home all alone. I just kind of thought about the mess it was going to make and my son would probably be the first one home. Clinician: Okay. So, you didn't want him to see it. Client: No. Clinician: Now did you actually touch the razor blade up against your wrist? (behavioral incident) Client: No. I don't think so. I took it out of the paper, and I set it on the sink. Clinician: Okay how long did you think about this? How long were you sitting there? (behavioral incident) Client: I was probably there for a while. Probably a half hour or so. I was thinking is this really worth what I'm going to do to the kids? You know I don't want anyone else raising my kids. Clinician: Right. Client: And I've seen a lot of suicides being an EMT, and I've seen what it can do to people and their families and everything. It's so stupid. I don't want to do this. Clinician: True. It is devastating for those who are left behind. That is an important thing for you to remember. It can help you to not do it. I am just a little bit confused. The knife incident, was it recent or when did that happen? (behavioral incident) Client: It was about three months ago. Clinician: So the incident that brought you here was the idea of overdosing and shooting yourself, and that you shared it with your friend. Client: Yea. Clinician: Have you written letters? (behavioral incident) Client: Yes. Clinician: Did you work on your will or anything to make sure . . . . ? (behavioral incident) Client: The will was all up-to-date. Clinician: Now, lets talk a little bit more about that, in this last six to eight weeks, one thing that you thought about was cutting yourself. What other ways did you think of killing yourself? (gentle assumption) Client: Really none. I mean there are so many options. Sometimes I drive down the road and think it would be so easy just to run into a telephone pole but then you don't have the guarantee that you are going to die for one thing, and it just makes more hardship on your family. Clinician: Now did you ever specifically get into a car with the intention of driving off the road? (behavioral incident) Client: No. I got in the car with the intention of not knowing what I was going to do, but not necessarily with that in mind. Clinician: What other ways have you thought of killing yourself? (gentle assumption) Client: Really that's all. I would never hang myself. I saw a lady that had been hung and it was really disgusting. Clinician: You said you would never do it. Did you think about it and rule it out or....? (behavioral incident) Client: Well it was there but it was just (pause) I would not do it. It was an option. Clinician: Did you ever get a rope out? (behavioral incident) Client: No. Clinician: What other ways? (gentle assumption) Client: I don't think there were any other ways. Clinician: Did you ever think about... (pause) You mentioned shooting yourself. What about carbon monoxide poisoning or anything like that? (denial of the specific) Client: No. We don't have a garage. So there's no place to do that. Clinician: Did you ever think about jumping off a building? (denial of the specific) Client: No that would hurt. I'm not a great one for pain. (she smiles) Clinician: How about driving your car into traffic? (denial of the specific) Client: Nope. Clinician: Okay. Good. You had mentioned cutting yourself. Have you ever thought of stabbing yourself or anything like that? (denial of the specific) Client: No. Clinician: Now, how much time do you think.... if we look over the last couple or say six weeks, on a given day, how much time do you think you spent thinking about killing yourself? (behavioral incident) Client: A lot. More than usual. Clinician: Two minutes a day? Three hours a day? Ten hours a day? (symptom amplification) Client: It just seems to be in my thoughts. I don't really know how much time I actually spent. The day that I wrote the letters and stuff, it was over the course of, like, a week I guess, and it was every day. It was every day I thought of it. I woke up in the morning thinking about whose letters I had to write, but umm..... Clinician: So it was very much on your mind and just wasn't an impulse. Client: Oh no, it's been there. Clinician: What about in the past, have your ever attempted to kill yourself? The clinician is now gently moving the client into the Region of Past Suicide Events - the third region of the CASE Approach. sidebar2 National Depression Screening Day At this time of the year, it is interesting to note that contrary to popular belief, more people do not commit suicide during November and December - the classic holiday season - than during the rest of the year. In fact, the suicide rate is at its lowest during November and December with spring, usually April or May, as the time of year when most suicides tend to occur. Nevertheless, the holiday season can be stressful and harrowing - families that rarely see each other gather together and tensions may arise; people reflect on the year and may feel disappointed, lonely or sad. It is important to acknowledge these issues and recognize when there is a need for help. Community-based screenings, such as National Depression Screening Day, can play an important role. Screenings can identify symptoms of depression and suicide and provide the first step towards proper diagnosis and treatment. National Depression Screening Day incorporates a specific suicide intervention strategy called SOS: Signs of Suicide. SOS encourages friends, and family members surrounding the person in need to ACT - Acknowledge the situation, Care for your friend or loved one, and finally Take them to a mental health professional. Suicide intervention, at any time of year, is necessary. It is important to recognize that mental health screenings can identify persons at risk for mental illness and encourage those at high-risk to pursue a complete psychiatric evaluation. Proper treatment that may include medication and/or psychotherapy provides the best way to alleviate depression and diminish the possibility of suicidal behavior during the holidays or at any time of the year. For more information on National Depression Screening Day and the SOS: Signs of Suicide, please visit http://www.mentalhealthscreening.org/depression.htm Douglas G. Jacobs, MD, is an Associate Clinical Professor of Psychiatry at Harvard Medical School and founder of Screening for Mental Health, Inc., a national non-profit devoted to mental health education and screening.              |
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