From a psychodynamic perspective, a curious paradox can arise. If a patient believes that suicide is a sign of weakness or a sin, unconscious defense mechanisms (such as denial, repression, rationalization, or intellectualization) may create the conscious belief that the patient’s intent is much less than it actually is. When asked directly about his suicidal intent, this patient may provide a gross underestimate of his potential lethality even though he is genuinely trying to answer the question honestly.
From a phenomenological perspective, it is not surprising that some seriously suicidal patients may relay their actual intent in stages. Whether evaluating such patients in an ED or on a crisis line, one would expect that the patient would share some information, see how the clinician responds, then share some more information, reevaluate “where this session is going,” and so on.
Indeed, patients with serious suicidal intent who are trying to decide how much to reveal may share information about a mild overdose while consciously withholding their main method of choice (such as a gun, for they are well aware that once they share information about the gun it may be removed) until they arrive at a decision during the interview that they do not want to die. At this point, they may feel safe enough to share the full truth with the clinician.
Reflected intent: one of the master keys to unlocking real intent
Reflected intent is the quality and quantity of the patient’s suicidal thoughts, desires, plans, and extent of action taken to complete the plans, which reflect how much the patient truly wants to commit suicide. The extent, thoroughness, and time spent by the patient on suicidal planning may be a better reflection of the seriousness of his intent and the proximity of his desire to act on that intent than is his actual stated intent.
Such reflections of intent may prove to be life-saving pieces of the suicide assessment puzzle. The work of Thomas Joiner10,13 has provided insight into the importance of acquired capability for suicide (eg, intensive planning, multiple past attempts) as a reflection of the seriousness of intent and the potential for action.
A wealth of research and theory from an unexpected source—motivational theory—can help us better understand the importance of reflected intent. Prochaska and colleagues’14,15 transtheoretical stages of change—precontemplation, contemplation, preparation, action, and maintenance—helped lay the foundation from which Miller and Rollnick’s16,17 influential work on motivational interviewing arose. When it comes to motivation to do something that is hard to do but good for oneself (eg, counseling), the extent of the patient’s goal-directed thinking and his subsequent actions may be much better indicators of intent to proceed than his stated intent. In short, the old adage “actions speak louder than words” appears to be on the mark in predicting recovery behavior.
A patient in alcohol counseling may tell the counselor all sorts of things about his intent to change. Nevertheless, it is the amount of time he spends thinking about the need for change (reading the literature from Alcoholics Anonymous [AA]), arranging ways to make the change (finding out where the local AA meetings are), and the actions taken for change (finding someone to drive him to the meetings) that, according to Prochaska’s theory, may better reflect the intent to change than the client’s verbal report.
Motivational theories are usually related to initiating difficult-to-do actions for positive change. But they may be equally effective for initiating a difficult-to-do action that is negative, such as suicide. (Joiner10,13 has pointed out that suicide can be quite a difficult act with which to proceed.) Once again, the amount of time spent thinking, planning, and practicing a suicide attempt may speak louder about imminent risk than the patient’s immediate words about his intent.
Pitfalls of an incomplete elicitation of suicidal ideation
Premature crisis resolution. Arguably, the single most important task in a suicide assessment, whether in a face-to-face interview or on the phone, is to estimate the immediate risk of suicide and to triage safely with appropriate follow-up. Much of this determination of risk is contingent on an accurate estimate of the patient’s suicidal intent. However, significant errors can be made, whether a clinician is in an ED or manning a crisis line.
Picture a patient who mentions suicidal thought and openly admits to a plan (eg, overdosing) yet is withholding much of his intent because of a strong desire to die. The clinician explores the ideation related to overdosing and then prematurely (before carefully eliciting other suicidal ideation and planning that may better reflect the patient’s true intent and method of choice) begins crisis transformation. Being a skilled clinician, the crisis is effectively resolved. The client reports feeling much better. The clinician makes a recommendation for follow-up such as, “Sometime in the near future, I urge you to seek out a therapist.”
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