Shawn C. Shea, MD, a psychiatrist and seasoned writer, creates books and articles focusing on topics readers might expect from him. Psychiatric topics are generally not experienced as literature, much less the type of read that one might pull down from a shelf for a lazy afternoon in front of the fireplace. But when Shea writes, the unexpected happens: readers, while gaining copious amounts of valuable clinical insight, find themselves having a relaxing and enjoyable time doing so.

This review focuses on The Practical Art of Suicide Assessment, A Guide for Mental Health Professionals and Substance Abuse Counselors, now in 2nd Edition. However, I want to make readers aware of his first publication, Psychiatric Interviewing: The Art of Understanding, also in 2nd Edition, which is a remarkably concise and valuable body of information for clinicians at any level in any area of specialty.

That said, you may be asking, “Can we as addiction counselors perform psychiatric interviews?” This very fair question brings us into the area of ethics regarding our scope of practice, not to mention whether we are “qualified” in the same manner that a psychiatrist is. In reference to our specialty of counseling addictive disorders, I feel compelled to share some critical thoughts regarding scope of practice. Based on his writings, it is clear that Shea is, as are many clinicians, trained at the highest level and licensed to diagnose and treat psychiatric disorders as an appropriate part of their scope of practice. An important consideration, however, is: although anyone may choose to read and learn about advanced assessment and treatment skills, is the application of such skills appropriately within one’s scope of practice if they are licensed and certified addiction counselors without advanced degrees such as MD or PhD?

My sense is that it is unethical not to make every attempt to identify disorders and circumstances that complicate our clients’ recovery from primary addictive disorders. Addiction counselors are a frontline defense facing altogether too many valuable opportunities to intervene on suicidal intentions or dual diagnosis to simply not do so. While identifying additional risk factors, we must know the exact point at which attempting to treat co-existing disorders is outside of our scope of practice and that we must make appropriate referrals. This is a critical question for ongoing discussion, one that I pose in general to the reader, and challenge the author to respond to (see response on page 71).

Few professionally trained clinicians have not been exposed to a basic suicide assessment class or workshop — and rightly so, for in the United States, a suicide is completed approximately every 20 minutes. When confronted with the suspicion of client suicidal ideation, many would reel off three, maybe four or five “party-line” questions such as: Are you thinking of committing suicide? Do you have a plan? Are the means readily available? How lethal? When? Where? Because these questions have been drilled into many of us, we may feel they serve us adequately as a necessary tool to intervene on suicidal intent; but, after reading Shea’s book, these “tools” are certainly an unacceptable minimum and are clearly a basic entry point for the observation of suicidal intent and risk.

When Shea discusses suicide assessment, he does far more than relate to a few questions for the client. He also turns questioning inward: “I feel that all mental health and substance abuse programs should have a brief course or seminar in which the topic of suicide is explored intimately, from its etiologies to our own biases and beliefs about it” and perhaps our own ideation (p. 118). Shea’s book is more than a brief course. Especially valuable is his exploration into our potential for not wanting to uncover suicidal intent in a client. He discusses phrasing and sequencing of our questions: “The elicitation of suicidal ideation is an art in which our questions are brushes, our facial expressions are pigments, and our canvas is the relationship we jointly create with our client” (p. 112).

It is difficult to relate in a media review to what Dr. Shea is presenting in his book because there is such value in every word. Moreover, I experienced the tendency to overlay other instances to which his theories would apply given their universality, such as the denial of addiction. When speaking of adolescent suicides on a Native American reservation, Shea relates that a pastor “described suicide as a way of bringing order to a society where everything is basically out of control... It’s a tiny fraction of dignity in a world that doesn’t make sense” (p. 43). And, when relating to the suicide of Kurt Cobain he describes the musician as relating to four cognitive distortions: (1) overgeneralizations, (2) catastrophization, (3) self-denigration, and (4) black-or-white view of the world. Are we observing addiction, suicidal tendencies, or both? The Practical Art of Suicide Assessment increases our awareness on so many levels.

Chapter Five is entitled “Validity Techniques: Simple Tools for Uncovering Complex Secrets.” It is at this point that the usefulness of this book moves into high gear. More straightforward tools are introduced. The chapter begins with the sentence, “Validity is the cornerstone of suicide assessment.” The validity techniques are: (1) behavioral incident, (2) shame attenuation, (3) gentle assumption, (4) symptom amplification, (5) denial of the specific, and (6) normalization. These techniques are masterfully taught and are put to use in Chapter Six, “Eliciting Suicidal Ideation: Practical Techniques.” It is here that the Chronological Assessment of Suicide Events (CASE) Approach is introduced. The chapter builds on a two-stage framework; methods are discussed for naturally and unobtrusively setting the stage for raising the topic of suicide, and the effective utilization of the CASE Approach, which explores four regions.

1. The presenting suicidal ideation and behaviors,

2. Any recent suicidal ideation and behaviors (over the proceeding eight weeks),

3. Past suicidal ideation and behaviors,

4. Immediate suicidal ideation and future plans for its implementation.

This chapter employs several case scenario/role play events, which make the learning come alive. Suffice it to say that the contents of this chapter are very important; you really have to read it! Having said that, note that Dr. Shea’s Training Institute for Suicide Assessment and Clinical Interviewing (TISA) has a wonderfully informative Web site (www.suicideassessment.com), which is full of links, articles, and a publication presenting CASE in great detail is available as a link from his Web site.

I encourage you to have this book in your library. It is an invaluable reference. If you need further convincing, check out the Web site. The second edition includes several helpful appendixes that one will not find in the first edition. Appendix A is “How to Document a Suicide Assessment,” and Appendix B is “Safety Contracting Revisited: Pros, Cons, and Documentation.” If you’re reading a first edition, find a second because these two additions are extremely valuable and worthwhile. There is also an Appendix C, “A Quick Guide to Suicide Prevention Web Sites.”

Earlier, I mentioned Psychiatric Interviewing: The Art of Understanding and wish to refer to it again. I have been using the information in this book since its publication. Not only does it offer a wealth of information about the assessment of psychiatric disorders but it is also an abnormal psychology book. The most valuable chapter covers working with client resistance, redefining it as a point of engagement and not in the negative way we usually do. Shea works with the core pain of the client, which draws us into the clients’ world; and once our understanding of their experience is heightened, we may flow with their resistance instead of fighting it. Again Shea exhibits his understanding of the two worlds of clinician and client, explaining the dance of being more “with” or more “against” a client’s resistance and constantly flowing back and forth on this continuum. “Even direct conversation is, at best, a second generation copy of internal experience” (p. 126). All of Shea’s writing is incredibly insightful. I hear his next book is nearing completion, and its focus is happiness. I can’t wait!

Lindsay E. Freese, MEd, MAC, LADC ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) is Professor of Human Service at the New Hampshire Community Technical College in Concord, NH. Over the past 20 years, he has worked in private practice and both clinically and administratively in residential programs. He is a past president of the New Hampshire Alcoholism and Drug Abuse Counselor Association.

A response from Dr. Shawn C. Shea
Concerning the skills needed to elicit suicidal ideation and uncover risk factors (as is the case with primary care clinicians) our goal is to help all substance abuse counselors be well trained for, as Mr. Freese notes, providing a frontline defense. Moreover, both with clients who solely have a substance abuse disorder and those who are dually diagnosed with another psychiatric disorder, suicidal ideation can appear at any time. Counselors need to be prepared to screen for it. When ideation is uncovered, a prompt consult with a mental health professional can help ensure that a sound assessment is undertaken for the severity of the suicidal risk, the presence of a comorbid psychiatric disorder, and the design of the most appropriate ongoing assessment of risk and treatment planning.

Second, when substance abuse is present, comorbidity with other psychiatric disorders is not the exception — it is closer to the norm. In the Epidemiologic Catchment Study, 75 percent of daily substance abusers had a comorbid psychiatric disorder. Consequently, it makes sense where possible to have any person being treated for substance abuse evaluated by a mental health professional to perform a differential diagnosis using the DSM-IV-TR. When such referral is not readily available, then the more knowledge the counselor has on the presentation of various psychiatric diagnoses, the better equipped the counselor will be to promptly refer those clients most likely to have such disorders.

Shawn Shea, MD, is 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. The former director of an outreach dual diagnosis team, he is also author of Happiness Is, Unexpected Answers to Practical Questions in Curious Times (Health Communications, Inc., 2004) available later this month.

This article is published in Counselor,The Magazine for Addiction Professionals, October 2004, v.5, n.5, pp. 70-71.

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