The Delicate Art of Eliciting Suicidal Ideation About the ...€¦ · The Delicate Art of Eliciting Suicidal Ideation About the Speaker ... One completed suicide in America every

Speaker: Shawn Christopher Shea, M.D.

The Delicate Art of

Eliciting Suicidal Ideation

About the Speaker

Shawn Christopher Sliea, MD

Director, Training Institute for Suicide Assessment

and Clinical Interviewing (TISA)

www.suicideassessment.com

Commercial Associations: None

I SUICIDE ASSESSMENT PROTOCOL I

Ri81< and Suicidal Ideation I

Rrotective Factors and Intent

I '· -.. ; (l .::... .. ,

Clinical Fwmulation

of Risk

1

Equation of Suicidal Intent

Real =

Stated 9 Reflected 9 WithheldIntent = Intent Intent Intent

Chronological Assessment of Suicide Events

I Past i,¢:J Recent y i Presenting Immediate j �Y.!".!,t�j -�Y.�n!s._ l __ §y��t�- ... Events _I

(2 Months)

Equation of Suicidal Intent

Real = Stated 9 Reflected 9 WithheldIntent = Intent Intent Intent

2

Chronological Assessment of Suicide Events

��;_;��:Q ��;;�;J Qt�;�;;."� l'y_�;�ti:�:I (2 Months)

Puzzle Piecies Needed for the Region of Presenting Events: Overdose as an Example

1 ) What kind of .pills

2) How many pills

3) How many pills left in the bottle (Phantom Number)

4) Immediate trigger

5) Where were they taken

6) Likelihood of rescue

7) Lethality (Real and perceived lethality)

Puzzle Pieces Needed for the Region of Presenting

Events: Overdose as an Example (cont.)

8) Impulsive versus planned

9) Drugs and/or alcohol involved

i 0) How did the person feel about the attempt failing

11 ) Whet stopped the person

12) What happened afterwords (the denouement)

3

l SUICIDE ASSESSMENT PROTOCOL I

Risk and Protectivli Factors

Suicidal Ideation Iand Intent

Clinical Formulationof Risk

Puzzle Pieces Needed for the Region of Presenting Events: Overdose as an Example (cont.)

8) Impulsive versus planned

9) Drugs and/or alcohol involved

10) How did the person feel about the attempt failing

11 ) What stopped the person

12) What happened afterwords (the denouement)

Chronological Assessment of Suicide Events

[?� y -��:�;,:_ y r�;��;�"9. l���:��t

�:I (2 Months)

4

Equation of Suicidal Intent

Real - Stated 9

Reflected 9Withheld

Intent = Intent Intent Intent

Validity Techniques for Exploring Sensitive Topics Once Raised

1) Behavioral Incident

2) Gentle Assumption

3) Denial of the Specific

4) Catch-All Question

5) Symptom Amplification

Exploring the Region of Recent Events

S-1

GA

S-2 --l> B! ___,. B! - Bl

GA E

S-3 --l> Bl - Bl --+ Bl

GA E

i

8> Continued

5

Validity Techniques for Exploring Sensitive Topics Once Raised

1) Behavioral Incident

2) Gentle Assumption

3) Denial of the Specific

4) Catch-All Question

5) Symptom Amplification

Exploring the Region of Recent Events

OS

! S-4--+ Bl - Bl --+ Bl

·-----�-OS c-

OS CaQ

Equation of Suicidal Intent

Real = Stated9

Reflected 9 Withheld

Intent = Intent Intent Intent

6

Workshop Outline: "The Chronological Assessment of Suicide Events: A New Interviewing Strategy for Eliciting Suicidal Ideation (CASE Approach)"

Workshop Leader : Shawn Christopher Shea M.D.

I) Introduction: "The Art of Suicide Assessment"A. Prevalence of Suicide

1. One completed suicide in America every 15 minutes2. In 2010, there were 38,364 completed suicides for the year3. Tenth leading cause of death across all ages4. Third most common cause of death in 15-24 year olds (follows

accidents and homicide) 5. Second leading cause of death in 25-34 year olds.6. From 1952-1992 the rate of suicide tripled in the age group of 15-24

year olds. In 2010, there were 4600 deaths in this age group. 7. In 2010, 267 children from the ages of 10-14 killed themselves8. Estimated that close to one-half million adolescents and young

adults perform suicide gestures or attempts per year

B. Key clinical skill for both mental health professionals and primary careclinicians.

1. Roughly 50% of people who go on to kill themselves have seen aphysician within 1-2 months, usually a non-psychiatrist

C. Suicide assessment is composed of three discrete processes1. The elicitation of suicidal ideation and intent2. The elicitation of statistical risk factors3. Clinical decision making based upon factors such as the severity of

the suicidal ideation and the presence of suicide risk factors

D. Complementary interplay between the CASE Approach and the Columbia-Suicide Severity Rating Scale

II) "CASE Approach" (Chronological Assessment of Suicide Events)(Please Refer to Illustration 1)

A. Presenting Events (gesture or attempt)1. phenomenology of attempt

a. trigger "event" if presentb. plan (including such factors as lethality of suicide agent,

likelihood of being discovered, letters to family and will, and familiarization with practical employment of plan)

c. actions taken on plan (what pills? how many? etc.)

2

d. presence of alcohol/drugs and degree of impulsivitye. degree of hopelessnessf. what stopped the patient if anythingg. how were they foundh. attitudes and behaviors after being found

2. use of behavioral incidents to create a "verbal videotape"

B. Recent Events (last 6-8 weeks)1. Flexibly utilizing gentle assumption, denial of the specific,

and behavioral incidents 2. Specific Interview Strategies

Strategy I: (Refer to Illustration 2) Sequentially uncover a methodusing gentle assumption or denial of the specific. After each method is uncovered immediately delineate the actions taken on the method using a series of behavioral incidents. After all methods are uncovered and explored, assess the combined frequency, duration, and urgency.

Strategy II: Uncover all methods using gentle assumption and denial of the specific. Return to each individual method and assess the

actions taken using a series of behavioral incidents. After all methods are uncovered and explored, assess the combined frequency, duration, and urgency.

3. Flexibly adapt the system to the unique needs of the patient

C. Past Events1. most serious attempt (review method, degree of lethality and

similarity to current presentation with regard to stressors and situational factors)

2. most recent attempt3. number of attempts

D. Immediate Events1. Now and Next2. immediate intention3. assessment of hopelessness4. role of "safety contracts"

a. limitationsb. use as assessment tools more than as deterrents

E. Video demonstration

s, I

GA

I

CAQ

I I SA

FIGURE 2-2. Prototypic exploration of the region of recent suicide events. Should be flexibly adapted in response to cli­ent's answers and clinical presentation. BI=behavioral incident; CAQ=catch-all ques­tion; DS=denial of the specific; GA=gentle assumption; S=suicide method; SA=symptom amplification. Solid outlined bar indicates cli­ent denial of suicidal ideation.

Suggested Readings: The Delicate Art of Suicide Assessment

Shawn Christopher Shea, M.D.

1. Berman, A.L., Jobes, D.A., and Silverman, M.M.: Adolescent Suicide: Assessment

and Intervention. Washington, DC, American Psychological Association,

2005.

2. Bongar, B., Berman, A.L., Maris, R.W., Silverman, M.M., Harris, E.A., and

Packman, W.L.: Risk Management with Suicidal Patients. New York, The

Guilford Press,1998.

3. Busch, K.A., Clark, D.C., Fawcett, J., and Kravitz, H.M.: Clinical features of

inpatient suicide. Psychiatric Annals 23: 256-262, 1993.

4. Chiles, J.A., Strosahl, K.D.: The Suicidal Patient: Principles of Assessment,

Treatment, and Case Management. Washington, DC, American Psychiatric

Press, 1995.

5. Clark, D.C.: Suicidal behavior in childhood and adolescence: Recent studies

and clinical implications. Psychiatric Annals 23: 271-283, 1993.

6. Ellis, T.E., Newman, C.F.: Choosing to Live: How to Defeat Suicide Through

Cognitive Therapy. Oakland, CA, New Harbinger Publications, Inc., 1996.

7. Fawcett, J., Clark, D.C., and Busch, K.A.: Assessing and treating the patient

at risk for suicide. Psychiatric Annals 23:245-255, 1993.

8. Fremouw, W.J., de Perczel, M., Ellis, T.E.: Suicide Risk: Assessment and

Response Guidelines. New York, Pergamon Press, 1990.

9. Jacobs, D.G.: The Harvard Medical School Guide to Suicide Assessment and

Intervention. San Francisco, Jossey-Bass Publishers, 1999.

10. Jamison, K. R.: Night Falls Fast. New York, Alfred A. Knopf, 1999.

11. Jobes, D. A.: Managing Suicidal Risk: A Collaborative Approach, New York, The

Guilford Press, Inc., 2006.

12. Joiner, T.: Why People Die by Suicide, Cambridge, Harvard University Press,

2005.

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13. Maltsberger, J. T.: Suicide Risk: The Formulation of Clinical Judgment. New York,

New York, University Press, 1986.

14. Maris, R.W., Berman, A.L., and Silverman, M.M.: Comprehensive Textbook of

Suicidology. New York, New York, The Guilford Press, 2000.

15. Patterson, W. M., Dohn, H. H., Bird, J., and Patterson, G.: Evaluation of

suicidal patients: The SAD PERSONS scale. Psychosomatics 24:343-349,

1983.

16. Posner K., Brown, G., et al: The columbia-suicide severity rating scale:

initial validity and internal consistency findings from three multisite

studies with adolescents and adults. Am J Psychiatry 168(12):1266-1277,

2011.

17. Shea, S.C.: "Exploring Suicidal and Homicidal Ideation" In The Psychiatric

Interview: The Art of Understanding, 2nd edition. Philadelphia. The

Saunders Company, 1998.

18. Shea, S.C.: The Practical Art of Suicide Assessment, (expanded paperback edition)

Stoddard, NH. Mental Health Presses, 2011.

19. Shea, S.C.: The chronological assessment of suicide events: A practical

interviewing strategy for the elicitation of suicidal ideation. Journal of

Clinical Psychiatry (supplement 20) 59: 58-72, 1998.

20. Shea, S.C.: The delicate art of eliciting suicidal ideation. Psychiatric Annals 34:

385-400, 2004.

21. Shea, S.C., Barney, C.: Macrotraining: A "how-to" primer for using serial

role-playing to train complex clinical interviewing tasks such as suicide

assessment. Psychiatric Clinics of North America, June, e1-e29 on web at

www.psych.theclinics.com , 2008.

22. Shea, S.C.: Suicide Assessment: Part 1: Uncovering Suicidal Intent—A

Sophisticated Art. Psychiatric Times, December, 2009 on web at:

www.psychiatrictimes.com/display/article/10168/1491291

.

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23. Shea, S.C.: Suicide Assessment: Part 1: Uncovering Suicidal Intent— Using

the Chronological Assessment of Suicide Events (CASE Approach).

Psychiatric Times, December, 2009 on web at:

www.psychiatrictimes.com/display/article/10168/1501845

24. Reed, M. & Shea, S.C. Suicide Assessment in College Students: Innovations in

Uncovering Suicidal Ideation and Intent: Understanding and Preventing College

Student Suicide, Lamis, D. and Lester, D. (eds.), Charles Thomas Publishers, 2011.

25. Shea, S.C. The Interpersonal Art of Suicide Assessment: Interviewing

Techniques for Uncovering Suicidal Intent, Behaviors, and Ideation. Simon, R.

and Hales, R. (eds.) : Textbook of Suicide Risk and Assessment, Second Edition,

American Psychiatric Publishing, Inc., 2012.