- OK, here we go.
So, what do you look for in a suicidal person?
We've talked about risk factors,
but some things to consider.
Are there recent, is there a recent
loss of interest in activities that
were previously enjoyed?
Is there this sort of increased anhedonia?
A decrease in social interactions.
This is true for adolescents
as well as for adults.
Complaints of pain that don't respond to treatments.
So is somebody complaining of pain
that doesn't respond to treatment.
Again, that sort of unremitting pain
that can't be managed physically.
The experience of a significant loss,
as we were just talking about,
somebody who's experienced a significant loss
of a spouse or a loved one.
And the loss of a loved one, that grief,
the feeling of emptiness and the feeling
of pain, is completely normal.
Where it becomes concerning is
if it goes for, you know, three months or longer
where the intensity of that pain
increases the likelihood that somebody's
gonna act on their thoughts of suicide.
So the initial loss, often people,
people will not likely commit suicide,
statistically anyway,
within the first month of a significant loss.
But, if the feelings continue
and you see behaviors that indicate
suicidality beyond that first month,
that's when you should really become concerned,
and begin to pay attention closely to that.
So, feelings of hopelessness,
we've talked about stockpiling medication
and creating other lethal methods
or obtaining other lethal methods,
and obviously making verbal statements or cues
about thinking about suicide or about things like,
you know, everybody would be better off without me.
There's really no reason for me to go on living,
not necessarily making overt statements about a plan,
but making kind of statements
in the conversation about cues.
So there are a couple things that people ask
themselves, according to Sean Shea,
before, and they have to resolve these questions
before they actually
commit suicide.
The first one is, "Will it work?"
So for whatever it is that they're struggling with,
will it put an end to my pain?
Will it solve the problems
that I have?
The other question that they have to answer
is whether or not it's the right thing to do.
So, will it work and is it the right thing to do.
Is it the right thing to do,
according to my religion?
Are there religious factors that will
prevent me from committing suicide?
Is it the right thing to do according to my
beliefs about my family?
As skewed as those may be,
about what the survivors will experience
in your case, what was the husband thinking
when he was planning the suicide and knew
that he would be leaving his children without a parent
after the death of his wife.
His thinking was probably
skewed in some way by his grief,
or by something else that was happening for him,
so his judgement, his thinking was not clear,
his judgement was impaired in some way.
my guess would be.
Now whether or not he had alcohol
or other substances on board when he
did this, you know, would be a question
that you'd wanna have.
So, does what I'm going to do substantially
violate my beliefs about religion
or family or culture.
So these are all things that we've talked about
pretty much all along, but I'm just gonna
throw these up here so that you
have a chance to see them.
Shea uses acronym SAD PERSONS and NO HOPE
and there's actually
a SAD PERSONS kind of scale
that emergency departments, some emergency departments
have modified and are using
to assess risk, so I'm gonna pass that around,
but thinking about, what're the statistical facts
risk factors around sex, age, depression.
Sex, more men commit suicide than women,
more women attempt than men.
Age, again, looking at statistically
where the risks are, at 25 to 55
is certainly a risky time, but after 65
and especially after 75 for men,
the risk increases significantly.
Previous attempts, and again,
pass this out, sort of a pathway to suicide
how people make decisions and how they sort of practice
so people are likely to begin to think about suicide,
and then they begin to plan, and then practice
a little bit, the suicide.
Oftentimes the practicing leads to an attempt,
which may be unsuccessful,
often is unsuccessful, which leads to
more practicing and more thoughts,
and you see that it kind of becomes this whole pathway
towards a successful suicide.
Not unlike when somebody is cutting,
for non-suicidal reasons,
and then they keep cutting and cutting
and then cut deeper and deeper and deeper.
In terms of suicidal practicing,
people tend to practice with more lethal methods
as they go along.
So they find that one thing doesn't work,
but it brings them closer.
They start out with, try turning on the gas
in their apartment and going to bed,
gassing the stove.
Well, that didn't work,
and then they may try overdosing.
Well, they slept for a long time and they threw up
but that didn't work.
So the next thing is maybe attempting hanging.
So they often will go to more and more
lethal methods as they go to the practicing phases.
Loss of rational thought, alcohol abuse,
rational thought loss, social supports lacking.
No spouse or partner, again,
leads to isolation.
The NO HOPE acronym I think is important to consider.
The person may not have a framework for meaning
there may be no framework for meaning for them,
again, that sort of anhedonia.
An overt change in their clinical status,
again, somebody who suddenly presents very differently
in a session, where in the past you've been concerned
about their ideation, and then suddenly,
doesn't seem to be concerning.
That's the time when you really
wanna check for risk.
A hostile environment, somebody who's living
in a hostile environment, or is experiencing
a hostile environment, a domestic violence situation,
is certainly one.
And domestic violence situations confound
the clinical interview as well.
So someone, especially if you're doing
a crisis evaluation or assessment on somebody
you don't know, if they're in a violent living situation
or a hostile living situation,
and they don't have a relationship with you,
they're not likely to necessarily disclose that to you
or fully disclose that to you.
You may miss that as a risk factor,
so it's important to consider what their
living environment is.
Folks who were out of the hospital recently,
why would that be true?
And that's true for both psychiatric
and medical admissions, why would somebody
who's out of the hospital recently be a risk?
- [Voiceover] Lack of structured environment.
- Lack of structured environment,
so they've been in a hospital,
they've had structure, they've had attention.
Anything else?
- [Voiceover] There's nobody taking care of them.
- Right, there's nobody there taking care of them.
In the hospital you're getting three meals a day,
probably, you're getting attention,
you've got at least somebody coming in
and taking your temperature,
or giving you your medication.
There may be, if you're in a psychiatric unit,
you've got groups, you've got connections.
So coming out of the hospital,
that first week especially out of the hospital,
is that time when people are really at
a high risk for suicide.
It also may be that, you know,
the medication that they're on hasn't started
to work yet, and obviously
with shorter and shorter hospital stays,
that's the case often.
We could do a whole course on documenting
for medical necessity in cases like that,
because that really is critical.
And again, it's part of, you know,
if you're working in a hospital,
and you're dealing with the managed care organizaton
that's giving you two days, three days maybe
for an admission, and then you're having to do
concurrent reviews and they're really pushing back,
for somebody who's doing well in the hospital,
it's pretty tough to justify not discharging them.
They're going to groups, they're eating,
they're participating in all the things
that they need to in their treatment.
So they need to leave the hospital, right?
More and more, who, did you do the partial hospitalization?
More and more often, what I'm finding is that,
and I think partial hospitalization
is a great level of care,
but up until about four months ago,
one of the programs I oversaw was
a partial hospitalization program,
and more and more often, insurance companies are
less likely to give lots of time
for partial hospitalization. - [Voiceover] Five days.
- Five days, right, right!
- [Voiceover] After they've had a three day hospital stay.
So they're in the hospital for three days,
they go into partial for five days,
maybe then an IOP, if there's an IOP
that's appropriate for them for another, right.
So what you end up with is this sort of
process by which the person never really
gets the care that they need,
they never really stabilize, and
all of it is, from my perspective,
economically driven.
So there are certainly ways to document
for medical necessity in situations
when you have concern about risk,
but you really have to delve into the assessment piece.
So what do we do for a suicide assessment,
what is that composed of?
The first thing you want to do is,
you're looking at the elicitation
of high risk behavior or intent.
Again, thinking about the statistical risk factors,
what are the factors that this person has in their life
that puts them at risk for suicide?
You want to make a clinical decision
based on the risky behavior and the intent,
and the statistical risk factors.
As to the severity of the presence of suicide
risk factors, the severity of the ideation,
one of the things in an assessment
that you're really looking for is,
so, here are these risk factors, right?
And some people have a lot of risk factors,
but they also have a tremendous number of
protective factors as well,
and you sort of have to balance the two.
There's a formula that I probably
should have provided to you, but if you're interested
email me and I'll send it to you.
There's a formula to kind of look at
weigh the two protective factors and risk factors,
in terms of doing an assessment.
So somebody who has high protective factors
and moderate risk factors
is at a lower risk of suicide than someone
who has moderate suicide risk factors
and low protective factors.
So you're really looking at the risk behavior
and intent and the risk factors that exist.
So when you're, the components of,
what makes up an assessment,
are, first off, identifying
and detecting those predisposing factors,
the statistical risk factors,
elucidating potentiating factors.
So what are the potentiating factors in
a case when somebody has
you know, other risk factors?
Well, a potentiating factor might be
let's say that you have a guy who's
depressed, risk factor,
who's substance abusing, risk factor,
whose spouse just died, potentiating factor.
The death of his spouse isn't necessarily
a risk factor in every case, but in this case
it's a potentiating factor that makes it worse.
The substance abuse can be a potentiating factor
in some cases.
Legal issues are a potentiating factor,
especially in individuals who have a history
of involvement with the courts,
and particularly a history of incarceration.
It's not unusual to hear somebody who's
been incarcerated say, "I will never
"go back to jail again."
And then they get arrested for something,
and then they end up going to court,
and they're facing, you know,
prison time or jail time.
That is a significant potentiating
factor for their risk.
There was an incident a couple of years ago
in Brattleboro, Vermont.
Individual was going to court,
he'd been imprisoned at a point in time
years ago, said he would never go back to jail,
his mother, he and his mother were
going into the courthouse and he shot himself
on his way into the courthouse.
That's an incredibly important thing to consider,
and one that often clinicians miss.
They don't necessarily think, you know,
it's one of those things on an assessment,
do you have any legal issues that you're
concerned about, pay attention to that
'cause it's important, there's a reason that's there.
Conducting a specific inquiry,
a specific risk inquiry.
So actually having the conversation
with that individual, engaging in a conversation
with the patient or the client,
and doing it in a way, we'll talk about this
in a few minutes, that really connects with them,
using some therapeutic rapport techniques
to pull them in.
Your basic empathic skills.
I'll talk about how not to engage
in a conversation when you're evaluating for risk
especially with somebody you don't know,
and how to do it, because there are
ways you don't wanna engage.
Determining the level of intervention.
Part of an assessment, part of a
big component of the assessment,
is once you've got that information
OK, what's next, what's the intervention gonna be?
Sometimes we miss that.
We'll do a pretty good job here,
but we don't really get to the interventions
in the assessment.
You wanna look at the competence
of the individual, you know,
what's the nature of the therapeutic alliance
that you have with them.
Is this the first time you've met them
or is this somebody you've been working with for years?
Their competence is something that, although
you might not legally be able to determine
if you're not a psychiatrist or a psychologist
who's evaluating competency,
but you, as a clinician, have a sense
of what competence looks like, right?
There are things that you're looking for,
behaviors that you're looking for,
that help you recognize whether
somebody's making a competent decision themselves.
And then, finally, you wanna plan
the nature and the frequency of the re-assessment.
OK, so, you've got an intervention,
when do we have to re-assess again?
In the case of the Lucy suicide,
even if he had been seen by a psychiatrist at the VA,
there wasn't any sense of what the re-assessment
needed to be, how often did he need to be seen.
This is true particularly in prison situations,
jail situations, where somebody may be
considered at risk, but they're not
checked except every hour.
So for somebody that's at a high risk setting,
and they're not on 15 minute checks
or five minute checks, that's a concern.
You have to think about the frequency
of the re-assessment.
Finally, the most important thing, I think,
is to make sure that you document the assessment,
because without writing it down, it didn't happen.
I can't tell you the number of court cases
that I've been made aware of where
it really hinged on, the court hinged on
the appropriateness of the documentation
of the risk assessment by the clinician.
So if you're doing an assessment,
make sure that you document that.
In an assessment, there's sort of, you know,
these four phases that seem to exist.
There's the engagement, rapport, development phase,
where you're entering into that client's
or that person's life.
It may be with somebody that you've been
working with for a long time,
so you may have already established that rapport
over a long period of time.
If you've been working with somebody for three years,
hopefully you have a rapport with them.
If it's somebody that you've, you're walking
into an emergency department as a crisis clinician,
and you've never seen this person,
you have about, I think, 45 seconds to make,
to establish rapport
with that individual.
People look at me like, 45 seconds, are you kidding?
No, you really have about 45 seconds.
Do you feel like that's probably
true from your experience in crisis?
You walk in, and how you connect with that individual
in that first minute is incredibly important
and will basically set you up for
either being able to have a valid assessment
or for you to be likely not to get
the information that you really need
to create a valid assessment of suicidality.
We'll talk about that engagement piece
in a minute.
The second phase is around information gathering.
You're kind of doing the detective work
during this time, you're getting information,
you're developing that tapestry that Sean Shea says
the events, you're sort of making connections
between what happened after you did
this and this and this,
and then you're using that information,
and the statistical risk factors that you know
from the gathering of information to evaluate the risk,
and then you're making recommendations for action.
This is really the kind of crisis evaluation
that happens in emergency departments all the time,
in medical units and medical floors where,
you know, a crisis clinician or a hospital clinician
is called in to do an assessment in an ICU.
So that's kind of how I see it, anyway.
Let's talk about this case for a second.
So this is Mr. Jackson, he's a 65 year old
widowed African American male, he's a Vietnam
war vet with diabetes and recent diagnosis
of Stage IV adenocarcinoma, which has
metastasized to the liver.
He arrived at the emergency department by ambulance
following a benzodiazepine overdose at home,
where he was found confused and lethargic by a neighbor
who had stopped to check on him.
The ED nurse screens Mr. Jackson for suicide risk
using a modified SAD PERSONS scale,
which triggers the need for a psychiatric consult.
Following his medical clearance in the emergency department,
the hospital's crisis team worker is asked
to evaluate Mr. Jackson's suicide risk.
The clinician arrives at Mr. Jackson's gurney,
which is against a wall in the hallway
of a busy department.
He is dressed in a standard hospital johnny.
As she approaches him, her pager begins to chirp,
suggesting that an important call is waiting.
You kinda get the scenario, right?
Here's this man, who's got some medical concerns,
who is African American, we don't know
anything about the community that he's living in,
but he's a veteran, and the hospital
emergency department that he's in is busy,
so he's been sort of pushed up in a gurney
against the wall, waiting for a psych consult.
If you don't believe this is a real scenario,
it is, and this happens all the time,
Especially with psychiatric patients, "psych" patients,
"your" patients, right?
Because emergency departments are inundated
with mental health patients.
It's, I don't use the work epidemic lightly,
but, in some communities,
there is an epidemic of behavioral health,
mental health patients, being untreated
or maltreated in emergency departments,
and often it's, put 'em against the wall,
let 'em sit there, somebody will get to you later.
So here we have this scenario, right.
Clinician comes in, her pager goes off,
and this is scenario one,
this is her first engagement.
- [Voiceover] Is she white?
- She is white, yes, thank you.
The clinician begins by offering Mr. Jackson
her agency's privacy statement, patient rights,
and several incomplete "authorizations
"to exchange information."
Appearing distracted by her pager, she states
to Mr Jackson, "I'm from the crisis team
"and I need to ask you some questions.
"Would you please review and sign these documents
"and I'll be back after I take this call?"
(astonished chatter)
Again, you think I'm kidding?
I'm not, all right.
I ran a crisis team for eight years.
This is not an unusual situation in a busy
emergency department, even for well-trained clinicians
to approach a situation like this.
They're stressed, we're all stressed.
The doctor's saying, "Get that patient out of here,
"I don't want him here.
"This is the third time he's been here this week,
"get him out, have him sign a safety contract."
So this kind of response, while seeming
really inappropriate, is not necessarily unusual.
A more appropriate response is that
although her pager is sounding, the clinician
silences it and opens her initial contact with,
"Hello, Mr. Jackson, my name is Sue,
"I'm gonna spend the next 45 minutes or so meeting with you
"to discuss some issues that may have
"brought you to the medical center.
"I'm sure this is a difficult time for you,
"and I'm here to help.
"I'd like to get started right away,
"but I recognize that meeting here in this
"busy hallway may not feel very conducive to assuring
"your privacy or for our ability to have
"a productive conversation.
"I wonder if I could take a few minutes to see if there is
"a room or space in the vicinity that is quieter.
"In the meantime, I'll see about getting a blanket
"and check to see if I can get your clothes
"returned to you so that you'll feel more comfortable.
"While I step away, I've got a couple items that
"you may want to read.
"At the end of our conversation I'll go over them
"in more detail and help you complete the documents
"we'll need to make sure we can, so that we can
"make sure that you'll get any additional services
"as quickly as possible."
45 seconds,
for that engagement.
Is there a difference between how that patient
feels in terms of the engagement
in scenario one from scenario two?
Scenario two isn't perfect, either.
There are areas that she could improve on in that,
but scenario two
evidences empathy,
it evidences a recognition for the
individual patient's
sense of self,
and for his work,
and the fact that he may be sitting there
embarrassed in a johnny, if you've ever worn
a johnny in a hospital ER you kind of know.
It's embarrassing.
So she's really addressing some of those issues.
Gender, culture, race, status,
that are really important to developing
that therapeutical rapport.
So she's doing the same thing,
although she's not saying he has to sign these forms,
she's doing almost exactly the same thing,
because she's gonna leave the room,
she's gonna do all the things she said,
she's gonna check her pager, too,
and answer that call,
but then when she comes back, she's
gonna have a different relationship with the patient.
That, that's that first phase, that engagement
rapport phase.
The next phase in terms of getting information
from the patient or from the individual, from the client,
that delving into, investigating
what's happening,
That's the most important, most critical phase
in terms of the information gathering
and assessing the risk.
I like to think, I like to use different techniques
in terms of how I do that investigation,
and I think about it really as, "What am I going to do
"or ask to get the most valid formation I can
"from that individual that's sitting across from me?"
And how can I do that as quickly
as I possibly can, right?
One of the things I'm gonna do is
I'm gonna hypothesize about what risk behaviors,
what risk factors exist, and I'm gonna try
and make it easier for that person
by hypothesizing, by guessing, making some guesses
or just maybe some assumptions about
the situation that they're in.
That's gonna allow them to open up more to me.
I'm gonna standardize risk factors or behaviors
within expected norms.
It wouldn't be unusual in a situation like this
for you to feel this.
It's not unusual for someone whose,
whose spouse recently passed away to be having some
thoughts of suicide, I wonder if you can
talk more about whether you've
been having those thoughts of suicide.
Exaggerating the risk factors or symptoms
of the behaviors.
Sometimes in conversation, in kind of doing
that information gathering, you have to exaggerate
to get real information.
This is especially true when you're dealing
with substance abuse.
If you say to somebody, "Do you drink?"
Or, "How much do you drink?"
They may not give you a valid answer.
But if you say to somebody,
"What do you drink, a couple quarts a day?"
(laughs) No, I only drink a quart a day,
or I only drink a pint a day.
So you're exaggerating, which allows them
to feel more comfortable giving you real information.
Itemizing each factor or behavior
is another way of gaining information.
Gee, Mr. Jackson, do you ever think about suicide?
Oh, no, I never think about suicide.
Oh, really, OK.
Do you ever think about cutting yourself?
No.
Do you ever think about taking an overdose?
Well, yeah, there was that one time,
I did think about taking an overdose.
How about shooting yourself?
Have you ever thought about shooting yourself?
Oh yeah, I'm a Vietnam vet, I think
about that all the time.
So it's easy to deny sort of the broad,
general question, it's harder to deny
those specific questions when you go through
and kind of itemize each one.
So these are just techniques that
I like to use to help develop
the relationship and help develop
the information that I'm getting
and make it more valid.
The last one is the Columbo technique,
anybody old enough like I am
to remember who Columbo was?
(classroom murmurs)
Columbo was, well, I'll talk about Columbo in a minute.
So hypothesizing, let's just talk a little more
broadly about that.
Hypothesizing that a risk factor may be present,
or that some concerning behavior or thoughts
are present, is an empathic technique that allows
the patient to open up and feel less ashamed
at what is assumed by the clinician to have occurred.
Guessing about whether somebody has,
is feeling suicidal, is not going
to make them suicidal.
Guessing that someone is having, you know,
teenagers are having sex, is not going
to make them have sex, it's the same thing.
Guessing that somebody's suicidal
is not going to make them suicidal.
In most cases, guessing that someone is suicidal
and saying that, and asking them questions
around that, allows them to open up the conversation.
If they don't, if they're not suicidal,
and you've used some of the other techniques
to kind of clear that up,
then they're not gonna pay any attention to it.
They're not gonna accuse you of being
inappropriate in your conversation with them.
Using hypotheses can be very helpful.
Standardizing the risk factor, the technique used
to really help put the patient at ease.
It's an effective tool for establishing
rapport and alliance.
With the clinician's suggestion that it may be
a standard experience to have thoughts of suicide,
the behavior becomes less shameful
and anxiety producing.
Remember, part of what we're doing is
we're attenuating the shame that exists for folks
when they are feeling suicidal,
or attenuating the shame that brings them
to the point of being suicidal.
So if you can standardize risk factors,
that can be a technique that's helpful.
Exaggerating the risk factors,
I talked about already in terms of substance abuse
but with Mr. Jackson here, Sue says,
"I'm feeling like it would be helpful for me
"to understand how often you've attempted suicide.
"I'm guessing you might have tried to kill yourself
"more than 20 times, is that right?"
"Are you kidding, I've only done this
"three times before yesterday."
So she set sort of a higher level than what
she would've assumed he probably actually
experienced, based on what she had gotten
in terms of history prior to this,
and then he was able to more,
less shamefully and more openly talk about
exactly how many times he had tried.
Itemizing factors and behaviors I talked about.
Just delving for clear, concrete responses
to clear, concrete questions.
That helps to really get people to be honest.
"How often do you use drugs?"
"Well, I don't use drugs."
"Well have you ever used drugs?"
"No, I've never really used drugs before."
OK, all right, so you go on a little bit further,
then you come back and say, "So, I'm wondering,
"at any point in time have you ever used cocaine?"
"No, I've never used cocaine." "Ever used heroin?"
"No, I've never used heroin." "Ever smoke marijuana?"
"Oh yeah, I smoke marijuana everyday."
"OK, let's talk about that."
Maybe he doesn't think of that as a drug.
Maybe that's his medicine.
So, getting specific answers
to specific concrete questions can be very helpful.
And then the Columbo technique.
This is, I have to say this is my favorite.
So if you've seen Columbo, and I'm hoping that
this link will work, Columbo was this,
Peter Falk played Columbo back in the 1970's,
and he had this technique when he was
doing an investigation, of always coming back
in the conversation to something that happened
or something that he heard or maybe misheard,
or maybe he was concerned about the person being
dishonest in the conversation,
but he let it go during the interview.
But then he went back and asked another question about it.
He had this way of, like, he'd get to the door,
and he'd go, "Oh, y'know, just one more question,"
and he'd go back and ask the question,
and you know, Columbo always got his criminal.
So I kind of have this affinity for Columbo
because it's something that I find can be
very useful.
You kind of get it, right?
It's his sort of style of, you know,
engaging around asking questions
that takes the one down kind of position,
which I really find to be
helpful, at least in my assessment technique.
I want to take a one down position,
I don't wanna be the expert, I really want
to be able to take the position of
the person that I'm interviewing has way more information
about themselves than I have.
My job is really to try and just delve
into that and get it from them.
I really want them to be able to tell me
what it is that's troubling them
that brings them to that point of feeling suicidal.
And that's one way of doing that.
Going back and asking questions in different
ways can be very helpful.
My guess is that this is not new material
for folks because this is probably
what you do all the time.
It's giving you maybe just a little
different frame of reference.
So, Shea talks about
the process of how you go about structuring,
not structuring the interview,
but the timeline, the frame that you use in the interview.
What he has found is that if you start
with the presenting problem, let's say
the presenting problem that's coming to you
is that the person has had, or is considering
very seriously, suicide.
So starting with the presenting problem
and then going backwards to recent events
and past events, and then going forward
to immediate events, is the best way to get
the most valid information.
Rather than doing what we often do, which is
maybe start with recent events, the presenting problem,
immediate events, past events, or some form of that.
Or starting with past events and going forward,
starting with the presenting problem
and working backwards is the way that you
develop the therapeutic relationship.
You begin with the presenting
suicidal/high risk ideation and behaviors,
that's the presenting problem.
You go back and talk about anything recent,
any recent high risk behaviors or ideation that occurred
over the preceding, let's say, two months.
So this is what you're bringing in today,
let's talk about that for a couple of minutes.
What happened today that brought you in?
So over the course of the last two months,
have you found yourself being in a situation
that's similar to this?
What kind of things have led up to that?
Then, the remote suicidal/high risk ideation and behaviors.
You know, two months ago you were feeling depressed,
but you weren't quite at the point where you
did what you did today, how about
back in your last three or four
or 10 years?
Were there other times when you felt like this?
Were there other times when you made attempts?
Have you done anything in the past
that's been similar to what you did today?
And then, ending with, the immediate suicidal
high risk and future plans for its implementation.
Before you get into, what're your plans
for committing suicide tomorrow,
or what're we concerned about for tomorrow,
you build up a relationship, and you've got this
perspective on their history to use
in the discussion with them about
what's happening next.
Because often if you go from now to next,
immediately, which often happens,
without getting into what happened way back then,
then the person isn't gonna feel
willing to give you the information that's valid.
You don't have that relationship built up.
But if they've already talked about what happened
six years ago, and what happened two months ago,
and what happened today,
they're a lot more likely to tell you
about what their future plans are for their risk.
Does that make sense?
It takes more time, and it's a little different
way of thinking about doing it,
but if you can structure the interview in that way,
I think what you'll find is you'll get
much more valid information.
That extra five or ten minutes that it takes
to go back and do the remote history piece,
and then go to the immediate and future
will work better.
The other thing with any of these techniques,
and a book that I would recommend you buy
or at least look at is Sean Shea's
"The Practical Art of Suicide Assessment",
which is a really great handbook
for doing risk assessments,
and a lot of these ideas and techniques are kind of
derived from that.
But what he says is, the more you practice this,
the easier it becomes, and then it becomes
almost a part of your interview style.
And for me, when I'm doing a risk assessment now,
I find that I can go through the assessment
very quickly, and structure it in this way,
get really valid information,
and I can usually have a really good picture of risk
within 30 minutes for somebody that I don't know.
But I think the more you play with the questions
and the more you sort of develop your own style
the easier it gets.
In terms of using the case approach,
what specific information would give the clinician
the most accurate picture of the seriousness
of a presenting gesture or an attempt?
What information would alert the clinician that
hospitalization might be necessary?
The answer really is in the process of entering
the client's world at the time of the suicide attempt
and understanding how the client feels about the fact
that he or she did not die.
Part of what you wanna do, especially
in high risk patients that have had an attempt,
is to try to get into their world.
Understand what it was that was going on for them
at that time.
Often, they don't even know.
They may not be able to articulate it right away,
so using this approach of going back
and talking through time, allows you
to help not only you enter their world,
but allows them to kind of deepen
their understanding of what happened.
It's sort of remarkable
how it just begins to bubble up
in the conversation, the client will begin to say,
"Oh yeah, gosh, this is what it was like
"when I did this three years ago.
"This is exactly how I was feeling then."
I'm not talking about treatment at all,
I'm just talking about assessment.
Treatment's different, a whole 'nother area.
So entering into the client's world.
How did the client try to kill himself?
What was the method that was used?
You wanna know that.
How serious was the action taken with this method?
To what degree did the client intend to die?
Were there risk/rescue factors?
It's always important to know what the rescue factors were.
Was the rescue factor that, you know,
the individual had his cell phone on him,
so he or she was going to call
for help?
There's a case I was aware of recently where
individual went to a beach, took an overdose,
and he was going to call his partner,
and his cell phone was dead.
So that rescue factor was gone.
So all you had, then, was risk,
because he was in a remote location on an island,
and he was very lucky that he was found
before he died.
But that's the kind of information you want to know.
What're the rescue factors that were in place?
How does the client feel about the fact that
the attempt wasn't successful?
How well-planned was the attempt,
and did alcohol and drugs play a role in the attempt?
And so on, and you can kind of see.
A good question to ask for somebody,
especially somebody who really was hoping to die,
where is it here...
Why did the attempt fail?
How was the client found and how was help summoned?
Because that's often, clients who have
made a serious attempt,
it's important for you and for them
to know why the attempt failed,
what happened that caused that to fail.
Because you can imagine that, their next attempt
if they have an opportunity to attempt again,
will avoid that failure.
It's that practicing piece.
They'll get better at it so that they avoid
whatever mitigating circumstances
kept them from being successful.
So what're some of the clinical gremlins
for the complicating assessment?
Inconsistent data.
Inconsistent data can come from that
intoxicated patient that comes in,
and tells you one thing, and then three hours later
the story's completely different.
Inconsistent data can come from
you know, just the individual's mental state,
whether they're psychotic or not,
so it's important if you don't know the person
to try and get as much history on them before you
go into the interview as you can.
Fluctuations in the client's clinical condition
sort of complicate the assessment.
And then social supports.
Are they in a safe or hostile environment?
Do they feel comfortable being on the gurney
at the edge of the wall,
in their johnny, versus being in a interview room
that is certainly easier to be open
and honest in.
So real quickly, I want to talk about
contracting for safety.
I said a little bit about this earlier,
doing a safety contract as it was designed
originally, back in 1973,
was really to be used as part of the therapeutic
process for long-term psychoanalytic patients.
It still can be used in that way for folks
that you're working with on a longer term.
It's really part of the treatment plan,
it's part of the treatment approach with them.
And, you know, if you're using DBT,
you know that sort of contract piece is
really important in the DBT process.
As it's used today, it's primarily for
providing comfort to the treating professional.
It's a little cynical, but it's been
my experience that that's the case.
It's often used to discharge responsiblity
as well as discharge the patient.
It really has very little value in that case.
So if you're gonna use a safety contract,
it really should be part of an ongoing
dialog with the client, the benchmark
to be used in each session or meeting.
The benchmark is where are you in terms
of the safety contract, where are you today
versus how you were last week.
What do we need, are there things we need to tweak,
are there things we need to add or change
to make sure the safety contract still is
operational and still works.
It's best used when you have
a therapeutic alliance with the consumer.