The strategy for exploring the suicidal history of the past 2 months is easy to learn and simple to remember. It also flows imperceptibly for the patient, frequently increasing engagement as the patient is pleasantly surprised at how easy it is to talk to the clinician about issues that had frequently been shouldered as a topic of shame. It also becomes apparent from the questioning that the interviewer is quite comfortable talking about suicide and has clearly discussed it with many others. This represents yet another shame-reducing metacommunication.
With each bit of information, the clinician is invited deeper and deeper into the patient’s unique world. A clearer and clearer picture emerges of how serious the patient’s suicidal planning has become; this may better reflect the real intent than the patient’s stated intent. Moreover, a sound database has been collected for future clinicians that can alert them to the types of methods the patient frequently contemplates and it can also serve as a method of assessing the patient’s current credibility as a historian as discussed in Part 1 of this series.
There is no better way to illustrate the power of this strategy than to see it directly at work with Mr Thompson. The skilled interviewing has already uncovered information that suggests that Mr Thompson’s real intent may be higher than his stated intent would suggest. Moreover, his list of risk factors is high and his support system other than his nearest son have been markedly weakened by the loss of his wife. The fact that he is wrestling with the notion that it is “wrong” to kill oneself may be creating both ambivalence (good) and a skewed self-admission as to the depth of his suicidal desire and intent (bad), because unconscious defense mechanisms could be protecting him from viewing himself as a bad person by minimizing the severity of his real intent.
Notice that the clinician is quite explicit with the time frame, stating the exact duration as opposed to using a vague term such as “recently.” This specificity is important because it helps the patient remain focused on the desired time frame while decreasing time-wasting sidetracks.
Patient: Nope. I just thought I needed a rest of some sort, and I wanted to talk it all over with Nick.
Clinician: Good. How about over the past couple of months, have you had any other thoughts of overdosing? (behavioral incident, the clinician is gracefully moving into the region of recent suicide events with a classic bridging question)
Patient: A few times but I never got no pills out or something.
Clinician: What other ways have you thought about killing yourself? (gentle assumption)
Patient: Oh not much. . . . I suppose I thought about hangin’ myself, but that is not a good way to die. You know, it doesn’t always work, at least that’s what I been told.
Clinician: Have you ever gotten a rope out or something else to use to hang yourself? (behavioral incident)
Patient: No sir, I haven’t.
Clinician: What other ways have you thought about killing yourself? (gentle assumption)
Patient: Well, I have gone out to the barn to see if we still had some of that pesticide I used a couple of years ago.
Clinician: And? (variant of a sequencing behavioral incident)
Patient: Oh we did. And . . . and I was thinking about taking some and then burning the barn down with me inside it.
Patient: Yea (pause) sort of Hollywoodish (smiles) but it’s no good, way too apt to not work out right.
Clinician: How often did you go out to the barn thinking about that? (behavioral incident)
Patient: Maybe 4 or 5 times, I don’t really remember exactly.
Clinician: What other ways have you thought of killing yourself? (behavioral incident)
Patient: That’s about it. Nothing else really.
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