The Practical Art of Suicide Assessment

It is always interesting to read about the right way to do things from authors that acknowledge nothing is foolproof.  The Practical Art of Suicide Assessment explains a process – one which admittedly doesn’t have empirical support.  It also acknowledges that our ability to predict short-term risk of suicide is poor.  (“Current research shows that clinicians have little ability to predict imminent suicide.”)  Like many things, this is a book I purchased but hadn’t read until a recommendation by Skip Simpson – the one discussed in The Suicide Lawyers.  While I knew that there wasn’t any clinician (much less framework) that could consistently and accurately predict suicide risk, it was a good thing to inspect a standardized process – that one could support in court if that ever became necessary.

The Promise

The goal is clear: we want to identify those at risk for suicide and provide care for them.  However, Shea states, “It has always been hoped that risk factors, if studied collectively in a specific client, would also serve as reliable risk predictors alerting the clinician to an immediate danger of suicide.  Such is not the case.”  Later, Shea identifies the core challenge: “We do not know for certain what is going on in our client’s mind.  We never will.”

While there are things to be learned from improving the assessment of patients for suicidal risk, we cannot fool ourselves into thinking that the process is foolproof – or in some sense ever will be.

Chronological Assessment of Suicide Events (CASE)

The core of the book is explaining the CASE approach, which involves a structured interview.  That is, there are a series of areas, phases, or questions that are intended to be asked.  It’s a framework designed to help a clinician ensure they’re not missing anything.  Much like The Ethnographic Interview approach that is recommended for anthropologists, it has no forms to fill out and recognizes the dynamic unfolding of conversations.

The use or non-use of forms is problematic.  Shea makes the point that without forms, you can focus on the client.  However, without forms, it’s also almost impossible to not drop something.  Approaches like CAMS, explained in Managing Suicidal Risk, explicitly use a joint form that the patient and clinician work together on to ensure fidelity, accuracy, and collaboration.  It’s my strong belief that this is a much better approach than having the clinician do an interview without the support of a memory, documentation, and understanding confirmation aid.

Stage 1: Setting the platform

In the show before the show, Shea recommends preparing for the CASE part of the interview by building rapport and setting expectations.  It’s called therapeutic alliance or therapeutic environment.  A more detailed understanding of this concept is in Motivational Interviewing, and support for the efficacy can be found in The Heart and Soul of Change.

Stage 2: The CASE Approach

The CASE approach itself has four regions.  They are intended to be addressed sequentially.

Region 1: Presenting Events

The patient’s current condition, including their suicidal feelings, death wishes, ideations, plans, intent, and actions.

Region 2: Recent Events

The items that preceded the presenting events, including immediate or imminent danger in the patient’s method of choice, time spent contemplating the method of choice, and actions taken on the method of choice.

Region 3: Past Events

A review of a patient’s past suicide attempts.

Region 4: Immediate Events

This region captures the patient’s thoughts and intentions concerning suicide that come up during the interview itself.

Ideation to Death

There’s a general belief in the suicide prevention space in an ideation to action framework.  This framework says that first people think about it, then they do it.  Shea states, “Roughly less than one percent of people who have had suicidal ideation go on to kill themselves.  This is an extraordinarily important number.  It is a measure of hope.”  Shea vastly overestimates the percentage of people who die by suicide as a ratio of those who have suicidal thoughts.  If we assume that 1/3 of the population considers suicide (which is conservative based on the research), it’s easy to see that the number who go on to die cannot be 1%, because the base rate is roughly 14 per 100,000.  At 1%, those only considering suicide would be 3,333:100,000.  Clearly, it’s substantially less than 1% of people who have suicidal thoughts die by suicide.

Causes

Consistent with the fluid vulnerability theory of suicide, Shea believes that suicide is triggered by external stressors, internal conflict, and neurobiological disfunction.  (See BCBT-SP for the fluid vulnerability theory of suicide.)  Despite the coherence, it’s difficult to understand the mechanisms of internal conflict – and therefore hard to predict the probability of suicide.

Fear of Suffering

There is a fear of death that is inherent to humans.  (See The Denial of Death and The Worm at the Core.)  However, as The Top Five Regrets of the Dying implies, death isn’t the largest fear.  Shea recounts the testimony of an elderly person who answers whether he fears death.  “No. I fear suffering. The older one gets, the greater the likelihood that one will be kept alive without purpose.”  This is one of the reasons why people want the option of suicide – even if they don’t intend to use it.  (See Undoing Suicidism.)

Making Your Way in the World Today Takes Everything You Got

The opening song to Cheers contains the lyrics, “Making your way in the world today takes everything you got, taking a break from all your worries sure would help a lot.”  That’s the way that some people with suicidal ideation think.  Shea says, “Consequently, the common vicissitudes of daily living may present these clients with a bewildering array of unbearable pains.”  He insists, “Most people do not kill themselves in response to a single, catastrophic stressor. It is the stress of living with oneself that more often leads to despair.”

I don’t agree here.  While there are too many lives lost after a long period of pain, there are also those whose journey to suicide is very short.  (See Myth: Suicide is Never Decided Suddenly.)

Swing of Suicidal Ideation

While defining the art of prediction of suicide, Shea also argues against its efficacy.  “Within the span of five minutes, Anna went from feeling wonderful to feeling suicidal. That’s how quickly such a descent into a suicidal maelstrom can occur when fed by a borderline rage created from a bevy of cognitive distortions.”  This statement is supported by research that demonstrates that suicidal ideation intensity can vary quickly and rapidly.

Involuntary Commitment

The greatest fear in disclosure of suicidal ideation is the fear of institutionalization.  There are good reasons for this fear.  Shea exposes the validity of this fear with, “In this type of questioning, besides determining lethality, the clinician is searching for information that would fulfill involuntary commitment criteria.”  As innocuous as it may sound, it’s problematic.  It subtly signals to the patient that the clinician isn’t necessarily looking out for their best interests – they may be protecting themselves from a future lawsuit.

This is particularly challenging when we look at the evidence (or lack of evidence) on the inpatient commitment process.  (See Myth: Inpatient hospitalization is best for people with suicidal ideation.)

Environmental Factors

Shea explains why we need to look beyond the individual for risk: “Suicide is often an interpersonal phenomenon. As we saw with Jimmy, an evaluation of suicide risk involves not only consideration of the identified client but also assessment of the people surrounding the identified client.”  He’s right that some people have environments around them that protect them and help them to avoid suicide attempts.  Other environments are not so friendly.

The environments that people find themselves in can be a huge factor for whether they’re at risk or not.

Indicators

Looking for indicators of risk is good – but expecting them is not.  Consider Shea’s comment, “Perhaps the most important indicator that Kell is probably not imminently suicidal is the fact that she denies current suicidal intent and has no organized plan to harm herself.”  The missing piece of this is “that she has disclosed.”  As mentioned earlier, you cannot know what is in the mind of a client.  We cannot know what they are or are not thinking.

Relying on a few indicators to be present – and shared – means that many people will slip by.

Suicidal Risk Is Messy

Shea admits that clinicians are wary of asking about suicidal intent, saying, “If we uncover serious suicidal intent, we are potentially creating a mess for ourselves.”  The “mess” is, of course, the additional work to assess their imminent risk – requiring institutionalization, enhanced documentation, and the time necessary to stabilize the patient if inpatient hospitalization isn’t called for.

While it’s appropriate to recognize the extra work, people are worth it.

Documentation

Shea recommends seven principles for suicide assessment documentation to keep clinicians out of trouble.  They are reproduced here:

1. Good clinical documentation is the primary shield against malpractice litigation.
2. There can be no good clinical documentation, unless there has first been good clinical care.
3. Even if good clinical care has been provided, if there is poor documentation then the risk of malpractice litigation rises steeply.
4. There are two types of poor documentation:
   • The clinician didn’t document the assessment.
   • The clinician did document the assessment, but documented it poorly.
5. The first legal purpose of a sound written document is to keep the clinician out of court.
6. The second legal purpose of a sound written document is to effectively defend the clinician if the case goes to court.
7. The most important reason to write a sound written document is to convey information to other professionals that may help the care of the client or may serve as a quality assurance checklist for the clinician which, if done effectively, will also result in a sound legal document.

In the end, the right thing for a clinician to do is to create appropriate documentation.  It’s the best defense against a lawsuit and a judgement.  This is true even given the limitations in The Practical Art of Suicide Assessment.