Because the clinician did not do a thorough assessment of reflected intent before beginning crisis transformation (he or she prematurely assumed that the method first supplied by the client—overdosing—was the method of choice), the clinician is unaware that the client has been thinking about shooting himself for weeks; has gotten the gun out on several occasions (loaded it once); and was in need of much more careful follow-up, including the fact that the patient’s mother could have removed the gun. Unfortunately, three days after the “successful” crisis intervention, the patient’s girlfriend leaves him, he begins drinking, and his suicidal intent returns with a vengeance and the sound of a gunshot.
Lost data for the receiving clinician. A clinician who helps a patient to open up about his suicidal ideation and who uses effective interviewing techniques (described in Part 2 of this article online) may have an unusually good opportunity to obtain an accurate picture of both stated and reflected intents during the initial crisis intervention. The patient may be affectively charged at the time and such emotional turmoil may make the client’s unconscious and conscious defenses less active so that it is easier for the truth to emerge.
It is of great value for a triage clinician, such as a school counselor, primary care physician, or crisis line counselor to gather as much information as possible at this time because during the trip to the ED a surprising number of patients undergo a “miraculous cure” during transport. In short, they clam up. It is important for professional gatekeepers to gather as much information as possible regarding reflected intent because the receiving mental health professional, whether in an ED later that night or in a community mental health center 2 days later, may be dependent on this relayed information when making a formulation of risk.
The power of a thorough elicitation of suicidal ideation, behavior, and intent to save a life
The issue of credibility. Especially in situations in which the patient is not known to the interviewer, such as may occur in EDs and during consultation and liaison assessments following a suicide attempt, a determination of the credibility of the patient’s self-report is of vital importance. In such situations, one can compare the validity of what is being reported with what has been documented in the past. Although previous charts are not always available (electronic records may diminish this problem), when they are, information documented on reflected intent may be invaluable in assessing the reliability of the patient’s current self-reporting.
A marked discrepancy between what the patient reports about past suicidal ideation and what is actually documented may be the best indicator of whether the patient is telling the truth. Such a contradiction may guide the clinician to seek collaborative sources of information and/or to discuss the discrepancies with the patient. It also emphasizes the need to reevaluate the patient’s immediate safety.
Reaching for life. Regarding future safety, the act of eliciting a thorough database on suicidal ideation and actions may be of value not only in the content of the database obtained but in the therapeutic fashion in which this information is garnered. Clinicians who have been trained to use an engaging strategy for eliciting suicidal ideation, such as the Chronological Assessment of Suicide Events–CASE Approach (see online article),1,18-20 may often create a positive interpersonal experience during the initial assessment. Such a patient may remember the sense of safety and comfort he felt talking with this clinician who neither overreacted nor underreacted to the patient’s description of his suicidal thought. If, in the future, that patient becomes dangerously suicidal—and is debating whether to call for help or proceed with the attempt—the patient may decide to reach for the phone, not for a gun.
In Part 2 of this series on suicide assessment, we will look at a flexible approach for uncovering suicidal ideation and intent that addresses the concerns described above. The CASE Approach is an interviewing strategy designed to increase the likelihood that the patient’s stated intent is accurate, that the reflected intent is comprehensive and valid, and that the amount of withheld intent is minimized or absent.
But before we leave the topic of the importance of eliciting a thorough history of suicidal ideation and action, it cannot be overemphasized that collaborative sources, such as family members, therapists, and police, may play a defining role in gathering the pieces of the risk assessment puzzle. One study of completed suicides showed that 60% of the patients had communicated suicidal thoughts to a spouse and 50% to a relative.21 Fortunately, the interviewing strategy described in the online article may prove to be equally useful in obtaining valid information from collaborative sources, who may have their own hesitation about sharing the patient’s suicidal ideation.