Author's Preface

    Currently, the major bottleneck in suicide prevention is not remediation, for there are fairly well-known and effective treatment procedures for many types of suicidal states; rather it is in diagnosis and identification."

      Edwin Shneidman
      Father of modern suicidology

This is a book designed specifically for front-line clinicians. Few clinical challenges are as daunting nor as critical as the art of suicide assessment. This book is intended to be a fast-paced and practical guide to this art. Much has been written about suicide, but the field lacks a single concise introduction for busy everyday clinicians in the fields of mental health, substance abuse, and school counseling. This book attempts to fill this gap.

In particular surprisingly little has been written about the actual elicitation of suicidal ideation, yet there can be little doubt that clients can provide strikingly different databases to different clinicians depending on how the clinicians phrase their questions and establish a sense of safety. This book focuses directly on this art of eliciting suicidal ideation. It introduces an innovative interview strategy, the Chronological Assessment of Suicide Events (the CASE Approach), that was initially developed in the "clinical trenches" of a busy urban emergency room at Western Psychiatric Institute and Clinic in Pittsburgh, Pennsylvania, and subsequently refined doing community mental health work in the rural settings of southern New Hampshire.

In addition an attempt is made to help the reader gain a clearer understanding of the complex inner worlds of both the client contemplating suicide and the clinician trying to prevent it. These two worlds invariably interact and change one another. Whether the client and the clinician choose to acknowledge it, both are changed by the act of sharing such intimate material. Towards this end the fascinating world of suicidal etiology and phenomenology is explored in detail. A heavy emphasis is placed on illustrating potentially confusing clinical presentations ranging from suicide assessments in ongoing therapy to emergency room settings.

Part One, The Experience of Suicide: Etiology, Phenomenology, and Risk Factors, is composed of three chapters. In Chapter 1 an effort is made to highlight the impact of suicide and to demonstrate some of our current limitations at its prediction while pointing out that there is hope that our predictive abilities can be improved. In the second chapter we will embark upon a detailed examination of the etiology of suicide and the phenomenology of people who are contemplating it. An understanding of the diversity of the etiologic roots of suicide can help the clinician to recognize its many faces. By exploring the phenomenology of the inner world of the acutely suicidal client, I believe a clinician can increase his or her "intuitive ear" perhaps hearing a danger that others, less trained, would miss. In the third chapter we will look at two illustrative clinical presentations which bring suicidal risk factors into sharper focus.

In Part Two, Uncovering Suicidal Ideation: Principles, Techniques, and Strategies, we will address the interview itself, getting down to the nitty gritty of everyday assessment. In Chapter 4 we will explore the resistances and biases of both the client and the clinician that can disrupt the uncovering of suicidal intent. In Chapter 5 six validity techniques will be illustrated that the reader can use immediately, and which will serve as the foundation stones for the CASE Approach. In Chapter 6 the CASE Approach itself is carefully delineated. Chapters 5 and 6 rely heavily upon the direct demonstration of the techniques described in the book via carefully designed sample interviews and numerous examples of specific questions. In addition, in Chapter 6 we will look at an actual transcript of an assessment using the CASE Approach from front to back, illustrating and discussing the nuances of the techniques as they unfold.

Part Three, Practical Assessment of Risk: Flexible Strategies and Sound Formulations, consists solely of Chapter 7. In this chapter we will explore the complicated variables that can make arriving at a sound clinical judgment of risk so daunting. This chapter explores critical issues such as contradictory data, client deceit, the role of corroborative sources of information, and the always vexing issues of forensic liability. All of these complicating "real-life" difficulties in suicide assessment are looked at via seven clinical case presentations from a variety of settings.

Please note that the names of all clients have been changed, and at times distinguishing characteristics or facts have been altered to further protect their identity.

In closing I should emphasize that this book is not an attempt to review the vast body of literature on suicide. It is my hope that it will stir readers to explore this fascinating reading for themselves. The focus in this book is on a no nonsense approach to suicide assessment for the busy clinician of today. Edward Shneidman, in the opening epigram, pointedly referred to a bottleneck in suicide prevention. It is my sincere hope that the principles delineated in the following pages will serve as one step toward the dismantling of this bottleneck and ultimately help us to save lives.

    Dartmouth School of Medicine
    Hanover, New Hampshire


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