Another Subtle Gauge for Suicidal Intent

Mar 07, 2017

“Science without conscience spells ruin for the soul. But conscience without science means ruin too.”

Louis Pauwels and Jacques Bergier from The Morning of the Magicians

Another Subtle Gauge for Suicidal Intent

TISA Description of the Problem: Uncovering suicidal intent remains one of the most critical and daunting of clinical interviewing tasks. Sometimes clients provide accurate reports of their suicidal intent when asked. On the other hand, sometimes they don’t. Fears of what will happen to them (Will I be forced into hospitalization?), stigmatization (“People will think I am a bad person, if I am having thoughts of suicide), and unconscious defense mechanisms (if a client strongly views suicide as a sign of weakness, defense mechanisms such as intellectualization, repression and denial may unconsciously minimize the intensity of the client’s intent – in which case the client himself or herself may not be consciously aware of the severity of their own intent). In such instances, of which there are many, the clinician may need to rely on reflections of the client’s suicidal intent. The following clinical interviewing tip was provided by a participant in one of my workshops, who, unfortunately, I cannot locate their name. It is an outstanding tip, which I now teach regularly in my workshops on suicide assessment. If you are the person who provided the tip, please let me know, for I would love to give you credit. In any case, here it is.

Tip: If a client presents with a suicide attempt such as an overdose, the number of pills taken in the suicide attempt may not be the only number that indicates intent. The number of pills left in the bottle may be an even more powerful indicator of intent. Consequently when working with people who have overdosed, I ask the following question:

“I’m wondering how many pills were left in the bottle?”

TISA Follow-up: Here is a nice example of how, when it comes to the art of clinical interviewing and teaching clinical interviewing, sometimes the simplest ideas are the most powerful. I love the above question, and now call it “the shadow question” for it is easy to remember to ask it, for it naturally shadows a question on how many pills were taken during an overdose.

Learning how to uncover reflected intent is one of the most striking skills seen in experienced clinicians. It is one of the reasons that it is important to elicit all of the different methods the client has been contemplating in the past several months, even after you have uncovered a clearly dangerous method in which some action was taken, for the other methods may yield insight into the overall intent of the client to proceed with suicide. And, occasionally, especially with clients with high intent to commit suicide, the client will not yield his or her method of choice at first. Instead the client, when asked directly about suicide chooses to first talk about a secondary or tertiary method, either because of stigmatization or because the client does not want to share the true method of choice for fear the method will be removed (e.g.: the client is hesitant to talk about his thoughts about shooting himself, for the client is afraid his gun will be removed). Only after sensitive yet persistent questioning about the presence of other methods is the method of choice revealed.

To learn more about how to effectively uncover suicidal intent, the interested reader is referred to the interview strategy called the Chronological Assessment of Suicide Events (the CASE Approach), which is described in detail in an article on this website easily reached on our home page (see CASE Approach button) or described in my book The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors.

Tip provided by:

Workshop participant at the workshop: “The Chronological
Assessment of Suicide Events: The Delicate Art of Uncovering Suicidal Ideation”