For many clinicians, there is the assessment phase of treatment and then there is the treatment phase of treatment. When the clinician is in the suicide as-sessment mode, there can often be little room for positive movement because the focus is on preventing something negative. Conversely, clinicians can have great difficulty when they are in the treatment mode and are interrupted by a distraught patient in a suicidal crisis requiring assessment activity. This dis-tinction comes from the traditional medical model, which requires that a for-mal operating diagnosis be made before appropriate treatment can begin. But does the traditional model work in the care of suicidal patients? Certainly this approach is necessary when major mental illness is present and appropriate medication selection is needed. However, most suicidal patients need both a diagnostic assessment and an intervention that starts at first contact. For this reason, you should use the assessment process as part of, rather than distinct from, treatment proper.
Take, for example, the initial interview with a suicidal patient. In the fol-lowing two vignettes, we demonstrate prevention-focused assessment and treatment-focused assessment. While reading them, think carefully about the emotional tone created in each sequence.
Prevention-Focused Assessment
Therapist: I understand from what you’re telling me that you’re under a lot of stress on the job and your marriage isn’t going well either. You’re ob-viously pretty depressed. ... Have you been thinking about suicide?
Patient: Well, I’ve had some thoughts like that.
Therapist: Can you tell me how seriously you’re thinking about it?.. . By that I mean do you have a specific way that you would do it?.. . Do you think about it pretty much daily?
Patient: I’ve been thinking about it quite a bit lately but I’m not sure I’d ac-tually do it.
Therapist: Do you have a method or plan about what you would do?
Patient: I usually imagine driving my car through a curve up in the moun-tains.
Therapist: Have you actually driven your car around that curve and imag-ined that you went straight?
Patient: Yes, I drive that road quite a bit as part of my job, and, sometimes, I imagine that I just end it all. That way, my wife and kids would get my life insurance. At least that way, they’d have something positive to remember me by.
Therapist: So you’ve been having these thoughts more often lately, is that right?
Patient: Yes, but it’s not something I think about all the time; just when I’m having a lousy day. I have had quite a few lousy days lately.
Therapist: Well, I’m hearing some things that make me concerned that you might actually try to kill yourself if you had a real bad day. I’m wondering. .. . Would you be willing to make an agreement with me that you will not try anything like that without first calling me to talk about it? I’d like us to agree that you won’t try anything like this for the time being while we work on your problems.
Patient: I suppose I can agree to that.
Treatment-Focused Assessment
Therapist: You’ve told me that you’ve got some pretty big problems in your life right now, including problems with your job and your marriage.
Sometimes when people feel like there are no solutions to problems like these, they begin to think about suicide as one way to take care of the problem. Have you thought about suicide as one way of solving these problems?
Patient: Well, I’ve had some thoughts like that recently.
Therapist: When you think about suicide as an option here, what specific as-pects of the problem do you think would be solved if you killed your-self?
Patient: Well, I wouldn’t have to go work and deal with my crummy super-visor; if I were dead, then my wife and I certainly couldn’t argue as much as we have.
Therapist: So, the thing that you imagine being better if you committed sui-cide is that you wouldn’t have to participate in these conflicts, for ex-ample, with your boss or with your wife. Another way of saying this is that suicide might help you with the problem of feeling bad as a result of these interactions. Suicidal thinking or behavior serves the purpose of helping you gain control over these unwanted feelings. Does that make sense?
Patient: Yeah, I suppose I’ve just about had it with feeling frustrated and an-gry all the time, and very little I’ve tried gets rid of it. As many times as I’ve tried to approach the situation more positively, I’m just getting to believe that nothing is really going to make a difference.
Therapist: So, in addition to feeling bad, frustrated, and angry about what these interactions do to you, you’re also getting pessimistic that any-thing you do to solve the problems is going to work, is that right? It sounds like the more you try to ratchet down on these painful feelings, the stronger they get. As they get stronger, you get more desperate in your search for some way to control them. Suicide might be one tactic that would help you gain that kind of control.
Patient: Yeah, I guess it is my last resort, and I feel like I’m getting to that point now.
Therapist: Before you get to that point, would it make sense for us to work together to explore what you’ve actually done to try to solve the prob-lem of feeling you have no emotional control and to see if we can come up with something that might work better and doesn’t involve you having to be dead?
Patient: I suppose I can agree to that.
These two vignettes show a contrasting style of approaching the patient’s suicidality. Table 4–3 summarizes contrasting strategies generated by the as-sessment-only versus the assessment/treatment-oriented model. In the more assessment-focused vignette, the therapist is most interested in collecting data about the suicidal behavior per se and trying to determine risk. The implicit focus of the interview is to prevent the occurrence of suicide by examining the patient’s intent. In this approach, very few concepts that are integral to prob-lem-solving treatment have been used. In a sense, the issue of suicide is on center stage and is the problem that the therapist is going to focus on.
Conversely, a therapist using the treatment-focused approach is more likely to validate and understand the patient’s suicidal ideation and increasing suicidal intent. Moreover, the issue is reframed in the context of emotional control and avoidance and problem-solving behavior. The effect is to legiti-mize the occurrence of suicidal ideation as a response to developing pessi-mism, frustration, and anger while keeping the door open that other solutions might be available. Although the therapist is asking the patient to defer the decision to commit suicide until other problem-solving options have been ex-amined, this step certainly is not the primary clinical intervention. The ther-apist has gleaned much information about the patient’s affective state and the
Assessment of Suicidal Behavior and Predisposing Factors81 Clinical issue Assessment/risk oriented Assessment/treatment oriented
1. Focus of session Assess and manage suicide risk Reframe suicidality as problem solving 2. Importance of knowing suicide risk
factors
Very important, central part of interaction
Less important, collected in problem-solving context
3. Importance of assigning “reliable risk” Central to type and frequency of treatment
Less important, suicide potential is not predictable
4. Risk management concerns Very high, focus on risk factors, be prepared to take strong steps to protect patient
Low, suicidal behavior per se cannot be prevented; focus on patient’s underlying problems
5. Stance regarding ongoing suicidal behavior
Prohibitive, requires ongoing detection and prevention
Anticipated, forms a basis for collecting data about problem solving
6. Legitimacy of suicidal behavior It is the problem; the goal is to get rid of it
It is a legitimate but costly form of problem solving
7. Time allotment for discussing suicidality Much more session time Much less session time 8. Prevention orientation Most strategies built around
preventing suicidal behavior
Fewer prevention strategies
patient’s willingness to accept negative emotions and general problem-solving style by not focusing on the issue of suicidal behavior. When a patient is acutely suicidal, approaching the problem from this angle immediately reassures the patient. This approach not only validates what the patient believes is an ab-normal, stigmatized event (i.e., thinking seriously about suicide) but also be-gins to create some perspective on how people come to consider suicide an option. Although the therapist is still able to gather relevant information about the patient’s suicidal intent, the general flow of the session is much calmer and more accepting of the patient’s suffering and frustration.
Whenever possible, you should attempt to use acceptance-based problem-solving reframing when discussing suicidal ideation or suicide intent. Ideation refers to the act of thinking about suicide, whereas intent represents the pa-tient’s developing commitment to engage in some sort of overt behavior. It is important to understand that the movement from ideation to intent is ably based on certain types of cognitive appraisals of suicide as a useful prob-lem-solving device. Thus probprob-lem-solving language blended with a recasting of the patient’s basic agenda (to eliminate unacceptable feeling states) is enor-mously powerful in that it links the patient’s prior experience of low-intent ideation with current higher intent as a form of problem solving. The shift from mild ideation to serious intent is scary for the patient and is often inter-preted as evidence of being out of control. When you are able to explain this type of experience in a simple yet credible model, basic features of an acute sui-cidal crisis are being addressed even while the assessment is being conducted.
If you can at the same time validate and normalize intense suicidal ideation while shifting the focus to problem solving and tolerance of emotional pain, there will often be an immediate reduction in suicidal intent and ideation.