A sound suicide assessment approach or protocol is made up of 3 components:
• Gathering information related to risk factors, protective factors, and warning signs of suicide.
• Collecting information related to the patient’s suicidal ideation, planning, behaviors, desire, and intent.
• Making a clinical formulation of risk based on these 2 databases.
Practical approaches to integrating these 3 aspects of a suicide assessment have been well delineated for adults and adolescents.1-8 Innovative systematic approaches, such as the Collaborative Assessment and Management of Suicidality (CAMS) approach created by David Jobes,9 have also been developed for integrating all 3 tasks while providing collaborative intervention, which may help lay the foundation for a more evidence-based protocol for suicide assessment. Recently, Joiner and colleagues10 have delineated a promising approach based on the interpersonal theory of suicide, which gracefully integrates all 3 components necessary for a suicide assessment.
In the clinical and research literature, much attention has been given to the first and third tasks (gathering risk/protective factors/warning signs and clinical formulation). Significantly less attention has been given to the second task—the detailed set of interviewing skills needed to effectively elicit suicidal ideation, behaviors, and intent. But in many respects, it is the validity of the information from the second component that may yield the greatest hint of imminent suicide. Moreover, as any clinical supervisor will testify, there is little doubt that 2 clinicians, after eliciting suicidal ideation from the same patient, can walk away with surprisingly different information.
The importance of uncovering suicidal ideation
Some patients who are seriously suicidal may actually share their real intent, secondary to their own ambivalence and/or the effective interviewing skills of the clinician. Such information subsequently serves to sculpt safe triage, whether offered in an emergency department (ED), outpatient clinic, or on the telephone with a crisis counselor.
This information may also be useful in a prospective sense if accurately documented; a thorough record of suicidal ideation and action provides subsequent clinicians with a baseline of the patient’s suicidal activity at a specific point. This reference point can be used by future clinicians—such as crisis intervention clinicians or inpatient staff contemplating a pass for a patient—to determine whether the patient’s current suicidal ideation is increasing or decreasing.
Not all dangerous patients relay suicidal ideation to clinicians.11 One could argue that many dangerous patients—those who truly want to die and see no hope for relief from their suffering—would have little incentive to do so. Even if their ambivalence about attempting suicide leads them to voluntarily call a crisis line or go to an ED, they may be quite cautious about revealing the full truth, for a large part of them still wants to die. Such patients may be predisposed to share only some of their suicidal ideation or action taken on a particular plan, while hiding their real intent or even their method of choice (such as a gun tucked away at home).
Many reasons exist why patients, even with various ranges of intent, may be hesitant to openly share, including the following:
• The impulsive patient may lack extensive suicidal ideation before his or her attempt. (This is one reason it may be necessary to hospitalize a patient who denies suicidal ideation.)
• The patient has had marked suicidal ideation and is serious about completing the act but is purposely not relaying suicidal ideation or is withholding the method of choice because he does not want the attempt to be thwarted (another reason to hospitalize a patient who may be denying or minimizing suicidal ideation).
• The patient feels that suicide is a sign of weakness and is ashamed to acknowledge it.
• The patient feels that suicide is immoral or a sin.
• The patient feels that discussion of suicide is, literally, taboo.
• The patient is worried that the clinician will perceive him as crazy.
• The patient fears that he will be locked up if suicidal ideation is shared or, if during a crisis call, that the police will appear at his door.
• The patient fears that others will find out about his suicidal thoughts through a break in confidentiality.
• The patient does not believe that anyone can help.
• The patient has alexithymia and has trouble describing emotional pain or material.12
It is sometimes easy to believe that if we ask directly about suicide, the patient will answer directly—and truthfully. From the above considerations, it is apparent that this is not necessarily the case. The real suicidal intent of a patient can be more accurately conceptualized by the following “Equation of Suicidal Intent”:
Real Suicidal Intent = Stated Intent + Reflected Intent + Withheld Intent
Thus, a patient’s actual intent may equal his stated intent, reflected intent, and withheld intent; any one of these 3; or any combination of the 3. The more intensely a patient wants to proceed with suicide, the more likely he is to withhold his true intent. In addition, the more taboo a topic is (eg, incest and suicide) the more one would expect a patient to withhold information. In such instances, both conscious and unconscious processes may underlie the withholding of vital information.