Speaker: Shawn Christopher Shea, M.D.
The Delicate Art of
Eliciting Suicidal Ideation
About the Speaker
Shawn Christopher Sliea, MD
Director, Training Institute for Suicide Assessment
and Clinical Interviewing (TISA)
www.suicideassessment.com
Commercial Associations: None
I SUICIDE ASSESSMENT PROTOCOL I
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Rrotective Factors
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Suicidal Ideation
and Intent
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Clinical Fwmulation
of Risk
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Equation of Suicidal Intent
Real
Intent
=
=
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Reflected 9 Withheld
9
Intent
Intent
Intent
Chronological Assessment
of Suicide Events
I Past i,¢:J Recent
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Intent
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Intent
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Chronological Assessment
of Suicide Events
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(2 Months)
Puzzle Piecies Needed for the Region of Presenting
Events: Overdose as an Example
1 ) What kind of .pills
2) How many pills
3) How many pills left in the bottle (Phantom Number)
4) Immediate trigger
5) Where were they taken
6) Likelihood of rescue
7) Lethality (Real and perceived lethality)
Puzzle Pieces Needed for the Region of Presenting
Events: Overdose as an Example (cont.)
8) Impulsive versus planned
9) Drugs and/or alcohol involved
i 0) How did the person feel about the attempt failing
11 ) Whet stopped the person
12) What happened afterwords (the denouement)
3
l SUICIDE ASSESSMENT PROTOCOL I
Risk and
Protectivli Factors
Suicidal Ideation
I
and Intent
Clinical Formulation
of Risk
Puzzle Pieces Needed for the Region of Presenting
Events: Overdose as an Example (cont.)
8) Impulsive versus planned
9) Drugs and/or alcohol involved
10) How did the person feel about the attempt failing
11 ) What stopped the person
12) What happened afterwords (the denouement)
Chronological Assessment
of Suicide Events
t
[?� y -��:�;,:_ y r�;��;�"9. l���:�� �:I
(2 Months)
4
Equation of Suicidal Intent
Real
- Stated
Intent =
Intent
9
Reflected 9 Withheld
Intent
Intent
Validity Techniques for Exploring
Sensitive Topics Once Raised
1) Behavioral Incident
2) Gentle Assumption
3) Denial of the Specific
4) Catch-All Question
5) Symptom Amplification
Exploring the Region of Recent Events
S-1
GA
S-2 --l> B! ___,. B! - Bl
GA E
S-3 --l> Bl - Bl --+ Bl
GA E
i
8>
Continued
5
Validity Techniques for Exploring
Sensitive Topics Once Raised
1) Behavioral Incident
2) Gentle Assumption
3) Denial of the Specific
4) Catch-All Question
5) Symptom Amplification
Exploring the Region of Recent Events
OS
!
·-----�-
S-4--+ Bl - Bl --+ Bl
OS c-
OS
CaQ
Equation of Suicidal Intent
Real = Stated
Reflected 9 Withheld
9
Intent
Intent = Intent
Intent
6
Workshop Outline: "The Chronological Assessment of Suicide Events: A New
Interviewing Strategy for Eliciting Suicidal Ideation (CASE Approach)"
Workshop Leader : Shawn Christopher Shea M.D.
I) Introduction: "The Art of Suicide Assessment"
A. Prevalence of Suicide
1. One completed suicide in America every 15 minutes
2. In 2010, there were 38,364 completed suicides for the year
3. Tenth leading cause of death across all ages
4. Third most common cause of death in 15-24 year olds (follows
accidents and homicide)
5. Second leading cause of death in 25-34 year olds.
6. From 1952-1992 the rate of suicide tripled in the age group of 15-24
year olds. In 2010, there were 4600 deaths in this age group.
7. In 2010, 267 children from the ages of 10-14 killed themselves
8. Estimated that close to one-half million adolescents and young
adults perform suicide gestures or attempts per year
B. Key clinical skill for both mental health professionals and primary care
clinicians.
1. Roughly 50% of people who go on to kill themselves have seen a
physician within 1-2 months, usually a non-psychiatrist
C. Suicide assessment is composed of three discrete processes
1. The elicitation of suicidal ideation and intent
2. The elicitation of statistical risk factors
3. Clinical decision making based upon factors such as the severity of
the suicidal ideation and the presence of suicide risk factors
D. Complementary interplay between the CASE Approach and the
Columbia-Suicide Severity Rating Scale
II) "CASE Approach" (Chronological Assessment of Suicide Events)
(Please Refer to Illustration 1)
A. Presenting Events (gesture or attempt)
1. phenomenology of attempt
a. trigger "event" if present
b. plan (including such factors as lethality of suicide agent,
likelihood of being discovered, letters to family and will,
and familiarization with practical employment of plan)
c. actions taken on plan (what pills? how many? etc.)
2
d. presence of alcohol/drugs and degree of impulsivity
e. degree of hopelessness
f. what stopped the patient if anything
g. how were they found
h. attitudes and behaviors after being found
2. use of behavioral incidents to create a "verbal videotape"
B. Recent Events (last 6-8 weeks)
1. Flexibly utilizing gentle assumption, denial of the specific,
and behavioral incidents
2. Specific Interview Strategies
Strategy I: (Refer to Illustration 2) Sequentially uncover a method
using gentle assumption or denial of the specific. After each
method is uncovered immediately delineate the actions taken
on the method using a series of behavioral incidents. After all
methods are uncovered and explored, assess the combined
frequency, duration, and urgency.
Strategy II: Uncover all methods using gentle assumption and denial
of the specific. Return to each individual method and assess the
actions taken using a series of behavioral incidents. After all
methods are uncovered and explored, assess the combined
frequency, duration, and urgency.
3. Flexibly adapt the system to the unique needs of the patient
C. Past Events
1. most serious attempt (review method, degree of lethality and
similarity to current presentation with regard to stressors and
situational factors)
2. most recent attempt
3. number of attempts
D. Immediate Events
1. Now and Next
2. immediate intention
3. assessment of hopelessness
4. role of "safety contracts"
a. limitations
b. use as assessment tools more than as deterrents
E. Video demonstration
s,
I
GA
I
CAQ
I
I
SA
FIGURE 2-2. Prototypic exploration of the
region of recent suicide events.
Should be flexibly adapted in response to client's answers and clinical presentation.
BI=behavioral incident; CAQ=catch-all question; DS=denial of the specific; GA=gentle
assumption; S=suicide method; SA=symptom
amplification. Solid outlined bar indicates client denial of suicidal ideation.
Suggested Readings: The Delicate Art of Suicide Assessment
Shawn Christopher Shea, M.D.
1. Berman, A.L., Jobes, D.A., and Silverman, M.M.: Adolescent Suicide: Assessment
and Intervention. Washington, DC, American Psychological Association,
2005.
2. Bongar, B., Berman, A.L., Maris, R.W., Silverman, M.M., Harris, E.A., and
Packman, W.L.: Risk Management with Suicidal Patients. New York, The
Guilford Press,1998.
3. Busch, K.A., Clark, D.C., Fawcett, J., and Kravitz, H.M.: Clinical features of
inpatient suicide. Psychiatric Annals 23: 256-262, 1993.
4. Chiles, J.A., Strosahl, K.D.: The Suicidal Patient: Principles of Assessment,
Treatment, and Case Management. Washington, DC, American Psychiatric
Press, 1995.
5. Clark, D.C.: Suicidal behavior in childhood and adolescence: Recent studies
and clinical implications. Psychiatric Annals 23: 271-283, 1993.
6. Ellis, T.E., Newman, C.F.: Choosing to Live: How to Defeat Suicide Through
Cognitive Therapy. Oakland, CA, New Harbinger Publications, Inc., 1996.
7. Fawcett, J., Clark, D.C., and Busch, K.A.: Assessing and treating the patient
at risk for suicide. Psychiatric Annals 23:245-255, 1993.
8. Fremouw, W.J., de Perczel, M., Ellis, T.E.: Suicide Risk: Assessment and
Response Guidelines. New York, Pergamon Press, 1990.
9. Jacobs, D.G.: The Harvard Medical School Guide to Suicide Assessment and
Intervention. San Francisco, Jossey-Bass Publishers, 1999.
10. Jamison, K. R.: Night Falls Fast. New York, Alfred A. Knopf, 1999.
11. Jobes, D. A.: Managing Suicidal Risk: A Collaborative Approach, New York, The
Guilford Press, Inc., 2006.
12. Joiner, T.: Why People Die by Suicide, Cambridge, Harvard University Press,
2005.
2
13. Maltsberger, J. T.: Suicide Risk: The Formulation of Clinical Judgment. New York,
New York, University Press, 1986.
14. Maris, R.W., Berman, A.L., and Silverman, M.M.: Comprehensive Textbook of
Suicidology. New York, New York, The Guilford Press, 2000.
15. Patterson, W. M., Dohn, H. H., Bird, J., and Patterson, G.: Evaluation of
suicidal patients: The SAD PERSONS scale. Psychosomatics 24:343-349,
1983.
16. Posner K., Brown, G., et al: The columbia-suicide severity rating scale:
initial validity and internal consistency findings from three multisite
studies with adolescents and adults. Am J Psychiatry 168(12):1266-1277,
2011.
17. Shea, S.C.: "Exploring Suicidal and Homicidal Ideation" In The Psychiatric
Interview: The Art of Understanding, 2nd edition. Philadelphia. The
Saunders Company, 1998.
18. Shea, S.C.: The Practical Art of Suicide Assessment, (expanded paperback edition)
Stoddard, NH. Mental Health Presses, 2011.
19. Shea, S.C.: The chronological assessment of suicide events: A practical
interviewing strategy for the elicitation of suicidal ideation. Journal of
Clinical Psychiatry (supplement 20) 59: 58-72, 1998.
20. Shea, S.C.: The delicate art of eliciting suicidal ideation. Psychiatric Annals 34:
385-400, 2004.
21. Shea, S.C., Barney, C.: Macrotraining: A "how-to" primer for using serial
role-playing to train complex clinical interviewing tasks such as suicide
assessment. Psychiatric Clinics of North America, June, e1-e29 on web at
www.psych.theclinics.com , 2008.
22. Shea, S.C.: Suicide Assessment: Part 1: Uncovering Suicidal Intent—A
Sophisticated Art. Psychiatric Times, December, 2009 on web at:
www.psychiatrictimes.com/display/article/10168/1491291
.
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23. Shea, S.C.: Suicide Assessment: Part 1: Uncovering Suicidal Intent— Using
the Chronological Assessment of Suicide Events (CASE Approach).
Psychiatric Times, December, 2009 on web at:
www.psychiatrictimes.com/display/article/10168/1501845
24. Reed, M. & Shea, S.C. Suicide Assessment in College Students: Innovations in
Uncovering Suicidal Ideation and Intent: Understanding and Preventing College
Student Suicide, Lamis, D. and Lester, D. (eds.), Charles Thomas Publishers, 2011.
25. Shea, S.C. The Interpersonal Art of Suicide Assessment: Interviewing
Techniques for Uncovering Suicidal Intent, Behaviors, and Ideation. Simon, R.
and Hales, R. (eds.) : Textbook of Suicide Risk and Assessment, Second Edition,
American Psychiatric Publishing, Inc., 2012.