Excerpts from Must Read Books & Articles on Mental Health Topics
Books, Part XXI

The Practical Art of Suicide Assessment
Shawn Christopher Shea, M.D. (2002)

Chapter Three- Risk Factors: Harbingers of Death (pp. 69-106)

Cases of suicide occur at all ages of life, even among mere children. We have already seen that it is frequently hereditary, and that it may alternate with other forms of insanity in different generations. It is about three times more frequent among males than females. The most recent and reliable statistics would seem to indicate that it is increasing in frequency at a most astounding and, so to speak, progressive rate. W. Griesinger, M.D., University of Berlin, 1882 (1)

INTRODUCTION
It is important to understand the distinction between "risk factors" and "risk predictors." A risk factor is a characteristic of a large sample of people who have committed suicide, that appears to be statistically more common than would be expected. In contrast, a risk predictor is a characteristic of a specific living person that indicates the likelihood of imminent suicide for that individual. Risk factors often include demographics (such as age or sex), living circumstances (such as the presence of a severe stressor or the lack of a significant other), historical associations (a family member has committed suicide or the client has a previous history of attempting suicide), and clinical condition (such as the presence of acute alcohol intoxication or psychosis).
     It has always been hoped that risk factors, if studied collectively in a specific client, would also serve as reliable risk predictors alerting the clinician to an immediate danger of suicide. Such is not the case. Not a single piece of research has shown that the presence of any collection of risk factors can accurately predict the imminent dangerousness of a client.
     An example can help to illustrate this dilemma. Let us rate a client's dangerousness using the SAD PERSONS Scale, (2) a ten-point risk-factor scale that we will make use of later in this chapter. It consists of ten risk factors. The presence of each factor is allotted a point value of 1. The closer one approaches to ten points, the more dangerous the person is supposed to be. But is this true? Let us look at a middle-aged woman who has the following characteristics: she is not particularly depressed, has never attempted suicide, does not drink alcohol or use drugs, has a loving nuclear family (including two healthy parents and three loving brothers living nearby), has a wonderful spouse, has no organized suicide plan, and has no chronic illnesses. She lacks nine of the ten risk factors on the SAD PERSONS Scale. The very highest she could score is one point out of ten (if she has the last risk factor). Using this scale, the clinician would rate the client's immediate risk as quite low.
     The last risk factor rated on the scale is the presence of psychotic process. Our hypothetical client is unfortunately in the throes of a postpartum psychosis. She is convinced that demons have entered her daughter and are torturing her relentlessly. The voice of the main demon, who, she believes, is Satan himself, is hounding her minute by minute. He harangues, "You must pay for your sins. Kill yourself now or we will torture your daughter forever." The woman turns to the clinician and begs frantically, "Do something. You've got to stop them. I can't let them do this to her. You've got to stop them." Rather dramatically, our scale has failed us as a predictive instrument. The client, despite a very low risk rating on the SAD PERSONS Scale, is potentially at very high risk. She is perhaps best served by acute hospitalization.
     If risk factors are not necessarily good risk predictors, one might wonder why we study them at all. The answer lies in the utility of risk factors to alert the clinician not to the fact that the client is at higher risk but that there is good reason to suspect that the client may be at higher risk. Such situations often require particular tenacity in the clinician's approach. It may even signal one of the most dangerous of situations, a client who has truly decided to kill himself or herself and is intent on hiding this information. The presence of a large number of risk factors may also suggest that corroborative sources should be interviewed. They may provide a picture of the client's suicidal intent that is markedly different from the patient's self-report. In short, the elicitation of numerous risk factors may trigger both analytic and intuitive suspicions that all is not as it appears to be.
     The search for risk factors provides other benefits as well; sometimes, it suggests specific lines of questioning. Psychotic process may indicate the need for quite specific lines of questioning, such as inquiries about the presence of command hallucinations, which proved to be so telling with the hypothetical middle-aged woman described above. Consistent elicitation and formulation of risk factors serve yet one more practical function: conditioning the clinician to consider suicide risk with every client. Such a clinical habit can only prove to be beneficial over time. It will prompt careful suicidal formulation even when the clinician is feeling pressured, weary, or harried, or is simply having an "off day."
     Two clinical case studies will launch our inquiry into risk factor analysis. With these studies, we will attempt to accomplish the following goals:
1. Introduce the commonly cited risk factors associated with suicide.
2. Demonstrate specific questions for effectively eliciting these factors.
3. Illustrate the use of specialized interview strategies indicated by the presence of specific risk factors (such as questions to ask psychotic patients).
4. Briefly introduce the formulation of acute versus chronic risk, based on the presence or absence of specific risk factors.

CASE PRESENTATION ONE:
MR. FREDERICKS
Mr. Fredericks, a 21-year-old male, presents to the emergency room on a Sunday afternoon at around 3:00 P.M. He prefers being called "Jimmy" and quickly hastens to say, "I'm not here for an emergency. I can come back at another time if you're busy. I just need some help with my stress. I'm really stressed out." Jimmy is a junior at a prestigious university where he sports a rather remarkable 3.8 grade-point average. He is well on his way to a career in dental school, much to his parents' pride.
     Jimmy is spending the summer at school. He is working in a nearby dental lab in an effort to bolster his already bulging list of extracurricular accomplishments. His light red T-shirt and Bermuda shorts hang on a thin frame-a frame that has been toughened by a demanding jogging schedule. His hair, dark and trimmed short, complements a lightly tanned and freshly shaven face. His face is somewhat curious, less for what it shows than for what it doesn't show. Jimmy has a restricted affect although he manages to push out a sheepish but somehow winning smile, especially in moments when he feels self-conscious. Such moments are not uncommon in the interview. Despite all of his academic accomplishments, Jimmy is refreshingly unassuming. He is also quite troubled.
     His main complaint is: "I'm just really stressed out, I can't stop being anxious. I just can never relax." He ascribes this situation to his intensely competitive nature, "It's like there's a man in my head, always pushing me. I always feel I'm not good enough. A 92% on a final is not enough, I need to get a 100%." This last statement tails off into one of his embarrassed smiles. "I know I shouldn't talk like this. It sounds like I'm complimenting myself. But this is what I'm feeling." Jimmy pauses and then repeats, "I know I shouldn't talk like this."
     He denies feeling depressed, and he reports few neurovegetative symptoms of depression except for a sleep disturbance. The discussion of his sleep problems draws another sheepish smile. He comments that he has been taking some "pep" pills to key him up for some upcoming tests. "I know that's not right. And I'm not going to do it anymore." Jimmy's need to please the interviewer is painfully tangible. The interviewer almost feels as if he is hearing a confession. Further inquiry reveals only a handful of occasions of pill popping. Adolescents are notorious for minimizing drug use, but one gets the feeling that Jimmy is telling the truth. Jimmy denies the use of alcohol, LSD, crack, marijuana, or any other street drugs.
     When asked about whether he wants to kill himself, Jimmy comments, "Not really. But sometimes I feel pressure to do that. But I know it's wrong." Asked to elaborate, Jimmy's smile returns, and he quickly changes the topic. "I'm not going to kill myself. That's why I'm here. I think I need therapy. Something is not right. Life can't be this stressful. You know, at midnight on a Saturday I still feel like I should be in the library studying. Now that's not right."
     By the end of the interview, Jimmy is well engaged and very comfortable with the idea of outpatient counseling. The interviewer is not equally comfortable. Perhaps an examination of some of Jimmy's risk factors may help explain the clinician's unsettled feelings.
     Jimmy's sex and age are consistent with an increased suicide risk. With regard to sex, males more frequently successfully commit suicide at a three-to-one ratio when compared to females. On the other hand, females attempt suicide three times more frequently than males. (3) Perhaps this increased "suicide efficiency" in males relates to the choice of the means of suicide. Males more frequently choose guns and other violent methods that provide a surer means of death.
     With regard to age, in general, suicide risk is greater for both sexes with increasing age. In women, the suicide rate increases until midlife, after which it tends to plateau. In men, the suicide rate increases precipitously with advancing age; the highest rate is in white males 70 years and older. But the suicide curve for all males is complicated by a bimodal tendency. A second peak occurs in late adolescence (4) a point of special significance with regard to Jimmy.
     Unfortunately, in recent years, there has been a marked rise in the frequency of adolescents' attempting suicide; suicide now represents the third highest cause of death among teenagers. Although white males traditionally are at highest risk, there has been a disturbing increase in adolescent suicides in both African American and Native Americans. (5) Between 1952 and 1992, the rate of suicide tripled in the age group of 15 to 24 years. (6) It has been estimated that a staggering half-million adolescents and young adults perform suicide gestures or attempts each year. (7) Moreover, a clinician should always keep in mind that even though young children are much less likely to commit suicide, they still do. As mentioned in Chapter 1, this fact is driven home by the knowledge that 330 children, ages 10 to 14, killed themselves in 1995. (8)
     Jimmy's age points toward another important risk factor: use of alcohol and/or street drugs. His admission that he used "uppers" was at first disturbing and suggested a possible reason for both his anxiety and his sleep problem. But if he is telling the truth, his small dose of amphetamine is unlikely to be a causative agent for this amount of distress.
     Chronic alcohol abuse or other drug abuse is a significant risk factor because these agents may decrease impulse control or precipitate psychotic process. But, beyond poor impulse control, alcohol also appears to cause long-term problems with suicidal ideation. It has been shown that people who have a chronic depression directly caused by alcohol abuse are at a significantly higher risk of making a serious suicide attempt. (9)
     An acutely intoxicated patient presents a particular problem because, in two ways, the intoxication predisposes the patient toward a suicide attempt. First, the person's impulse control may be significantly lowered. Second, because of cognitive impairment, the patient may inadvertently commit suicide-for example, by forgetting that a large number of pills were taken earlier in an evening and subsequently proceeding to ingest "just a few more." Such miscalculations can result in a fatal overdose. Because of these dangers even chronic emergency-room abusers who present with serious suicidal ideation while acutely intoxicated should be observed until they sober up. Frequently, as the alcohol wears off, the suicidal ideation disappears and may not even be remembered.
     There was more to worry about with Jimmy than the implications of his sex and age. The interviewer left the encounter feeling there was something slightly "odd" about Jimmy's presentation. His affect was restricted, he appeared unusually intense, and he displayed a powerful need to please the interviewer. More puzzling were his references to "the man in my head," which he described as being only a metaphor but almost sounded drawn from experience. The clinician doubted Jimmy was psychotic, but he was upset that he had not explored psychotic process in more detail.

EXPLORING DANGEROUS PSYCHOTIC PROCESS
Psychosis should be considered a potentially major suicide risk factor because rational thought often acts as the final obstacle to selfdestruction. In particular, three disturbing processes that could possibly push a patient toward violence to self (or to others, for that matter) should be carefully evaluated when the clinician is suspicious of psychotic process: (1) command hallucinations, (2) feelings of alien control, and (3) religious preoccupation.
     Command hallucinations are auditory commands to perform specific acts. Such commands may be egging on patients to harm themselves or others. Their presence, in some instances, should strongly lean the evaluator toward the patient's immediate hospitalization. Because they are often not volunteered by the psychotic patient, they require active inquiry by the clinician.
     During an inquiry into command hallucinations, several phenomenological considerations merit the attention of the clinician. Command hallucinations are not black-or-white phenomena in the sense that the patient either has them or does not. Command hallucinations can vary in numerous ways. Among their defining characteristics are: emotional impact on the patient, loudness, frequency, duration, content, degree of hostility, and degree to which the patient feels driven to follow them.
     Command hallucinations can vary from relatively innocuous phenomena that are infrequent and have little impact on the patient to dangerous phenomena in which the voices incessantly hammer at the patient in an effort to provoke violence. Some people suffering with chronic schizophrenia have adapted to their voices and pay them little heed. This level of command hallucination is probably of minimal concern. At the other end of the continuum, command hallucinations can become acutely harassing, loud, and insistent. In such cases, the clinician should always ask to what degree the patient feels in control. Some patients may feel unable to resist soft yet persistent voices. These types of acutely dystonic command hallucinations generally indicate the need for acute hospitalization. To determine the dangerousness of the command hallucinations, the clinician must take the time to explore these phenomenologic variables.
     Over the years, a variety of papers have purported that there is little or no statistical correlation between command hallucinations and suicide or violence. (10-14) But, from a close look at these papers, it becomes evident that none of the research carefully categorized the hallucinations along the critical phenomenological variables listed above. The research is generally based on hospital charts, which are notorious for poor reporting of the nuances of patient phenomenology. In this research, it is unclear whether the voices were at one end or the other end of the continuum of dangerousness. Consequently, the statistical analyses are difficult to interpret.
     A paper by Junginger, published in 1990, utilized direct interviews of patients who had recently experienced command hallucinations. (15) Although this study was not prospective in nature, the results are worth noting. Of the twenty patients who had experienced dangerous command hallucinations, eight had acted on them. These results are more consistent with the observations of experienced clinicians, and the paper represents a first step toward a more rigorous study of the phenomena of command hallucinations.
     Nevertheless, to date, I have not seen a prospective study that carefully operationalized the phenomenological data in such a way that the data are appropriate for statistical analysis. Until such a study exists, clinicians must remember that some patients do act violently in response to command hallucinations.
     In a similar sense, alien control, as evidenced by the feeling that one is being controlled by an outside agent, is a second dangerous psychotic process if this "other agent" becomes suicidally or homicidally oriented. It is not uncommon for a patient to battle off such potentially lethal urges on a minute-by-minute basis. The most common reputed agents of alien control are devils, but one can also feel that an evil persecutory figure has taken control of one's mind. In our high-tech society, it has also become more common for patients to feel that they are being controlled by radio waves, satellites, television celebrities, and computers.
     A third significant concern arises when a patient exhibits a specific type of excessive religious preoccupation. This type of rumination centers on ideas that God wants the patient to perform certain acts to prove his or her love for God or to carry out an act of atonement. These acts may include suicide, homicide, or self-mutilation. Such concerns can be associated with command hallucinations, as described above, except that the commands originate from figures as ultimately persuasive as God. Patients may feel that their faith is being tested. They may compare themselves with Abraham, who was commanded by God to sacrifice his only son, Isaac. This "Abraham Syndrome" can prove fatal. Some patients may feel that Satan is pushing them toward violence.
At this juncture, a direct transcript from an interview I performed with another adolescent male may bring to life the peculiar hyperreligiosity that sometimes can be a true harbinger of imminent dangerousness. It also highlights a specific aspect of this hyperreligiosity, about which the clinician should directly inquire if the client appears to be psychotic. The patient, who unfortunately suffers from schizophrenia, was being assessed in our emergency room after a recent suicide attempt.

CLINICIAN: You had mentioned a little bit earlier, Dan, that you had felt guilty and that you needed to get back at yourself for doing something. What were you referring to?
PATIENT: I was [pause] I called it chastising myself back then. Like my right hand [patient rubs his right wrist with his left hand], I'd cut off circulation to my right hand.
CLINICIAN: [pointing to patient's right hand] Is that what that scar is? It looks like an older scar.
PATIENT: Yeah. I took a steak knife and cut it. I was feeling angry with myself at the time. [pause] I was also into the Bible. You know, where it says, "If thy right hand offends thee, cast it off." I took that too literally.
CLINICIAN: And what did you think that meant?
PATIENT: I thought it meant to actually cut your right hand off.
CLINICIAN: So what did you do?
PATIENT: I cut it. I almost cut into the main ligament or the main blood
vessel, whatever. For some reason I didn't get that far.
CLINICIAN: Thankfully.
PATIENT: [patient nods in agreement] Yeah.
CLINICIAN: So that is what that scar is from? [points toward wrist]
PATIENT: Yeah.
CLINICIAN: So when you were cutting at your wrist, when was that, Dan?
PATIENT: That was back in 1994. I think I was only 15 at the time.
CLINICIAN: Now how long had you been thinking about that Bible
verse, when you did that back then?
PATIENT: When I got to that Bible verse is when I cut my hand. There
wasn't no long period to it.
CLINICIAN: From the time you read it in the Bible till you cut yourself,
how long had elapsed?
P-ATIENT: Well, about a month, I think.
CLINICIAN: From the time you read about it, it took a month before you actually cut?
PATIENT: No. [pause] I cut my right hand when I was reading the Bible. I had the Bible up in my foster Dad's station wagon. And I was reading a verse, and I had the steak knife, and I was going at it as I read the verse that day.
CLINICIAN: So you were aware of that verse before, but you came upon it again?
PATIENT: Yeah.
CLINICIAN: In the days right before you cut yourself, had you been thinking about that Bible verse?
PATIENT: No. I was thinking about what my right hand was doing,
though. And I wanted to stop what it was doing.
CLINICIAN: And your right hand at that time was doing what?
PATIENT: [pause] Masturbation.

     This excerpt highlights the fact that some patients may be preoccupied with specific verses from the Bible that suggest violent action. In this case, the biblical injunction that prompted the patient's attempt at self-mutilation is from Matthew 5:29, where lustful wanderings of the eye are handled in a rather absolute fashion:

So if thy right eye is an occasion of sin to thee, pluck it out and cast it from thee; for it is better for thee that one of thy members should perish than that thy whole body should be thrown into hell. And if thy right hand is an occasion of sin to thee, cut it off and cast it from thee; for it is better for thee that one of thy members should be lost than that thy whole body should go into hell. (16)

     Bizarre methods of self-mutilation, such as autocastration and removal of the tongue, may result when verses such as this one are twisted by psychotic thought. (17) If religious preoccupation is found, simple questions can help to uncover dangerousness: "Are there parts of the Bible that seem particularly important to you?" or "Are there parts of the Bible that you feel are directing you to do something?"
     Although we have been focusing on some of the common ways in which psychotic process can lead to self-harm, it is important to remember that the most dangerous times for most people with longterm psychotic disorders are not during phases of acute psychotic process. Patients with diseases such as schizophrenia and schizoaffective disorder more frequently attempt suicide, not in relation to active psychotic processes, but in relation to the devastating demoralization-resulting from years of pain, frustration, and lowself esteem-caused by the disease process itself. (18-20)
     Schizophrenia rapes the soul of the patient, robbing an individual of the chance to pursue the dreams that motivate all of us. The core pains of losing a sense of internal control, and, subsequently, a loss of meaning in life can prove unbearable even for the most courageous of people. As people suffering from schizophrenia perceive themselves to be hopelessly damaged, their reasons for living are gradually extinguished. It has been postulated that patients with the following characteristics may be most at risk: young age, chronic relapses, good educational background, high performance expectations, painful awareness of the illness, fear of further mental deterioration, suicidal ideation or threat, and hopelessness (21)
     A psychotic process not yet described, delirium, is one of the most commonly encountered psychotic states. Delirial states, whether caused by street drugs, medications, or metabolic imbalances, can precipitate serious impairments in sensorium and/or confusional states. During these periods of confusion and psychotic process, patients may be at increased risk for self-harm. Any fluctuation in the level of consciousness or the presence of impaired concentration warrants careful attention during the interview, a more formal cognitive mental status and a close exploration for the presence of hallucinations and delusions.

CASE PRESENTATION ONE:
NEW INFORMATION
Returning now to our case study, the clinician was considering reinterviewing Jimmy in an effort to uncover any evidence of psychotic dangerousness. He then noticed that someone displaying a mildly annoyed air was talking with Jimmy in the waiting room in an animated fashion. The visitor would prove to be Jimmy's roommate at college. Here was a chance for some fresh information.
     With Jimmy's readily granted approval, the roommate was interviewed. When the interviewer began, "Well, it's very nice of one of Jimmy's friends to come down with him," the roommate was quick to answer, "I'm not exactly a friend, more of a roommate. I don't think Jimmy has too many friends. He's a bit of a geek [smiles], but an okay geek, don't get me wrong. [pause] To tell you the truth, I'm a little worried about him. I think he's taking this school thing a little too seriously, if you know what I mean."
     Jimmy's roommate proceeded to validate Jimmy's self-report of a proclivity for late nights at the library. He added that Jimmy had not seemed himself for almost two months. About two months before, he had received a B-minus on a political science exam, his lowest score since entering college. He really seemed "bent out of shape" about this grade and hadn't seemed the same since. The interview, as reconstructed, proceeded as follows:

CLINICIAN: When you say he hasn't been the same since, how do you mean?
ROOMMATE: I don't know. Sort of ... I don't know. He's just sort of spooking me.
CLINICIAN: In what sense?
ROOMMATE: He gets up a lot at night. Not every night; about a couple times a week maybe. And he's really uptight. He sometimes seems sort of angry. He's always pacing around. It's driving me nuts!
CLINICIAN: What else have you noticed?
ROOMMATE: Nothing really. He's just got to "cool down," that's all.
CLINICIAN: When you say he was sort of spooking you, has he done
anything that you feel is sort of strange?
ROOMMATE: Not really.
CLINICIAN: Anything?
ROOMMATE: I don't want to get him into trouble or anything, and I don't want you to think he's wacko or something, 'cause he's not, but [pauses]....
CLINICIAN: But?
ROOMMATE: I think he's talking to himself a lot. It's sort of weird. But I catch him sort of mumbling to himself, like he's angry with himself. He doesn't do it a lot, but sometimes at night he does it and that's what spooks me the most. [pause] Oh yeah, I remember something else sort of weird. About a week ago, while we were eating dinner, he asked me if I believed in demons. After the look I gave him, he changed the subject and laughed, saying that he didn't either. But that was sort of weird.
CLINICIAN: Is Jimmy pretty religious?
ROOMMATE: [shaking his head negatively] Not that I know of.
CLINICIAN: You know, sometimes when people are stressed out, they have thoughts of killing themselves. Has Jimmy ever said anything about that?
ROOMMATE: Nope. If he has, he didn't say it to me.
CLINICIAN: You'd mentioned that he was angry a lot. Has he said anything about a specific person or talked about hurting anybody?
ROOMMATE: Jimmy? [looking skeptical] No way.
CLINICIAN: Did you ever see Jimmy harm himself or anything like that?
ROOMMATE: No way. [long pause] Hmm.
CLINICIAN: You look like you're remembering something.
ROOMMATE: Well, you know, there is something.
CLINICIAN: And what's that?
ROOMMATE: I saw a pack of razors in our bathroom a couple of weeks ago.
CLINICIAN: Is that strange?
ROOMMATE: It is, if both of us use electric razors.

     The evidence was building rapidly that some type of psychotic process was brewing. Delusional thoughts and fears are often viewed as very intimate material by patients. Perhaps Jimmy just didn't feel comfortable enough to share these experiences in detail during his first meeting with the clinician. Who knows, perhaps Jimmy's open willingness to have his roommate interviewed was an unconscious wish that some of this material would somehow surface. Regardless of how the information was gained, it was definitely time for a second interview with Jimmy. But before we study the transcript, it will be informative to look at some of the implications of our new information with regard to risk factors.
     One cause for concern regarding the newly gleaned information was the presence of intense anxiety in Jimmy. Recent research has suggested that increased anxiety, especially if acute and intense, may play a role in impulsive suicide attempts. On inpatient units, there is evidence that patients with high levels of anxiety and agitation are more prone to kill themselves. (22) Jimmy's anxiety could be related to a variety of factors. At first glance, it sounded like the prototypic anxiety of a "pre-dent" college kid on superego overdrive. But the input from his roommate suggested that a more worrisome process might be at work, and its etiology could be caused by, among other things: intense generalized anxiety; the anxiety seen with panic disorder or obsessive compulsive disorder; the anxiety seen with substance abuse/withdrawal; or, more ominously, the anxiety seen with emerging psychotic process. Jimmy's roommate, upon further questioning, denied that Jimmy used drugs other than "a rare tab of speed the night before a test. He hardly ever uses drugs. He's squeaky clean, trust me."
     The above data, culled from a corroborative source, illustrate the important principle of interviewing appropriate friends or family members when assessing suicide potential. In an emergency room situation, it is often critical to talk with significant others before making a decision on safety. If there are serious concerns about safety, they outweigh confidentiality. At times, it is necessary to contact relatives against a person's will. These contacts should be made after consulting with a supervisor or colleague, and clearly stated on the patient's chart should be the reason for choosing to break confidentiality and the role of the consultation.
     In general, corroborative sources should be asked whether they have seen anything that suggests possible suicide intent. After such a general inquiry, specific questions such as the following may be useful:

Has he made any comments about being "better off dead?" Has he joked about killing himself?
Have there been any statements about "things being better soon?"
Does he have any potential weapons available, such as guns or knives?
Has he ever tried to hurt himself before, even in small ways like taking a few pills too many?
Has he appeared depressed or tearful?
Is he spending more time alone than usual?

     In this type of questioning, besides determining lethality, the clinician is searching for information that would fulfill involuntary commitment criteria. Specifically, using New Hampshire criteria (criteria differ from state to state), one checks to see whether the patient has participated in behavior that is a clear danger to self or others. The criteria are also met if the patient has expressed a desire to harm self or others while taking some steps (such as purchasing a weapon) to fulfill this desire. Jimmy's roommate knew of no such behavior but was wary of the purchase of the razor blades. We do not know for a fact that the razor blades were bought for the purpose of self-harm (thus, committable grounds are not yet present), but knowledge of the purchase of the razor blades allows a much more powerful window for inquiry when Jimmy is reinterviewed. With adolescents, the most common method of suicide is shooting, distantly followed by hanging. (23)
     A corroborative interview also provides a chance to determine stressors and social supports. With regard to stress, the clinician should search for situations such as unemployment, family disruption, rejection by a significant other, abrupt changes in career responsibilities, or a recent catastrophic stress. Although there is no typical catastrophic stress in Jimmy's recent life, one wonders whether the impact of the "low" test score was psychologically catastrophic to this relatively frail college student. A lack of friends, family, or societal supports such as church organizations has often been reported as a risk factor. In particular, the clinician should be looking for evidence of recent losses.
     In their practical primer on the assessment and treatment of suicidal patients, Fremouw, de Perczel, and Ellis (24) point out that one of the more striking statistical correlations with suicide is the increased risk associated with the absence of a spouse. The highest risk is among couples who are separated. Divorced people have the next highest risk, and those who have lost their spouse to death follow. People who have never been married are next in order of risk, and happily married couples are at least risk.
     Regarding the risk factor of social isolation, Jimmy is a cause for concern. His roommate paints a picture of an isolated individual more at home with the silence of a library than the confidences of a friend. During the social history, Jimmy related that he had never dated. He was an only child but had distanced himself from loving but overbearing parents. It was no coincidence that Jimmy was attending college on the East Coast and his parents lived in California.
     Determining the quality of immediately available supports is of particular importance if an emergency room clinician has decided to release a somewhat tentative patient who has agreed to come for reassessment the next day. If friends or family members can stay with the patient until the scheduled appointment, then such a plan may be more feasible.
     In such cases, it is critical that the family members thoroughly understand that the patient is not to be alone. I generally find it useful to have a discussion with the patient and the family together, talking openly about suicidal concerns and the design of the safety plan. Such a procedure helps to teach the patient and his or her family members that it is both safe and appropriate to discuss suicidal ideation frankly. Suicidal ideation not talked about may prove deadly.
     Although not immediately obvious, one other support system should always be considered in a suicide assessment: the quality of the mental health system itself. Considerations include: outpatient "waiting list" time, availability of twenty-four-hour crisis support, presence of crisis support groups, and a frank analysis of the quality of the clinicians available. Not all clinicians are comfortable with helping clients who have significant suicidal ideation. Such a lack of outpatient expertise can suggest the wisdom of briefly admitting a somewhat tenuous patient who otherwise might have been referred for outpatient services. Jimmy's catchment center had an excellent crisis team as well as an ongoing crisis group staffed by talented clinicians.
     At this point, despite some growing concerns that Jimmy had some psychotic process and that other significant risk factors were identifiable, it remained unclear how lethal a risk Jimmy presented. It must be remembered that he denied suicidal intent, albeit in a somewhat quizzical fashion, and grounds for commitment were lacking.
     As noted earlier, it is sometimes expedient to reinterview a patient, especially in emergency room settings. Coupled with knowledge garnered from corroborative sources as well as the improved engagement secured from the first interview (in essence, the client is no longer talking with a stranger), the reinterview results are sometimes rather startling.
     In the second encounter with Jimmy, the interviewer will make an even more concerted effort to bring psychotic ideation to the surface while persistently listening for adequate grounds for commitment. After carefully bridging the topic of school stress, the clinician has decided to once again visit Jimmy's comments that it sometimes feels "like there is a man in my head," for these feelings may be the outward manifestation of his psychotic process. As we will see in the following direct transcript, this time around, Jimmy will prove to be more forthcoming:

CLINICIAN: Now you had mentioned something about the guy inside you. Tell me a little bit more about that. What's that like?
PATIENT: Well, he doesn't like me at all. No. What he wants is complete control of my body. And that's the way he'd get it.
CLINICIAN: And in what sort of way would he get complete control?
PATIENT: Because once I die [pause] once I die, once I die I wouldn't have any strength to fight him anymore.
CLINICIAN: And then what would probably happen?
PATIENT: Then he'd take completely over.
CLINICIAN: Would he be able to live in your body then?
PATIENT: Yeah. No. Well, I think he'd just look for someone else. He'd go on, that was his goal. Unless he has me, he won't like me anymore. You know, he won't be satisfied. He likes the challenge.
CLINICIAN: The challenge to sort of take over, to win out over someone?
PATIENT: Yeah.
CLINICIAN: Now when you talk about the guy, do you have a name for him?
PATIENT: No, I don't have a name for him. [pause] I don't call him by name or any thing. It's just a feeling. That's all it is, it's just a feeling.
CLINICIAN: How long has he been around?
PATIENT: As soon as I came to college. Well, I feel he's been a little bit around in high school. But since I came to college, he saw me as a good target.
CLINICIAN: You said in high school you thought there was a little bit of him. When did you first even get suspicious that there may be this guy?
PATIENT: Maybe once I realized I was gonna go to college. Well, I knew I was going to go to college. Maybe, I guess it happened in my senior year of high school, when I was filling out all those big long applications.
CLINICIAN: And what happened?
PATIENT: That could have been when it started, it's hard to remember, it's hard to remember the exact time. It's not like I have it or I don't have it. But I feel that that is when it could have started to happen.

     We are entering a strange world indeed. Perhaps what is most striking is the markedly increased openness of Jimmy during the second interview. The "guy" in his head is discussed much more as an entity, not a metaphor. It appears from the new interview material that, at times, Jimmy is intermittently psychotic. As we now recall the words of his roommate ("But I catch him sort of mumbling to himself, like he's angry with himself"), we realize that it is not himself he had been engaging in conversation. It was the man inside himself.
     Through some deft interviewing, which occurred only because of the clinician's wise decision to perform a corroborative interview and to subsequently reinterview Jimmy, a much more accurate picture of Jimmy's state of mind is unfolding. Having pinpointed the presence of psychotic process, the interviewer will now probe for the specific areas of psychotic dangerousness discussed earlier: alien control, command hallucinations, and hyperreligiosity. Note the way in which the interviewer explored this material with a nonjudgmental and matter-of-fact approach. It would prove to be one of the keys to his success in interviewing Jimmy.

CLINICIAN: Do you ever feel like, literally, that you have an alien force in you?
PATIENT: Well, I do feel that this thing, that this thing, we'll call it a thing, we'll call it a guy, that this guy, he's not human. So I feel, I do feel like, he came from, well, I'm religious, and I do feel like he came from Hell. [said softly]
CLINICIAN: In the sense of a demon?
PATIENT: Yeah.
CLINICIAN: Do you know which demon in your mind?
PATIENT: Not an exact demon, no, but a demon, yeah.
[The interviewer briefly explores Jimmy's views of the demon and then proceeds as follows, in an effort to further pin down Jimmy's acute dangerousness.]
CLINICIAN: To me it sounds like a very frightening type of experience to feel like there is this thing inside you.
PATIENT: Yeah, it is. [pause] I feel sorry for other people having him too.
CLINICIAN: Do you ever hear his voice?
PATIENT: I don't actually hear it, well, I don't actually hear it in my ears, but somehow I hear it.
CLINICIAN: When you are having that experience, does it sound exactly like your normal thoughts, or are you quite aware that there is something different happening, and you are hearing his voice.
PATIENT: It's a feeling. It sounds like my thoughts, but they are a little bit different, the way that I can hear them.
CLINICIAN: And how do you hear them?
PATIENT: They just seem to come to me. [pause, then speaking very softly, almost in a whisper] They just seem to come to me.
CLINICIAN: Does the voice ever tell you to hurt yourself?
PATIENT: Yeah. That's what he's telling me.
CLINICIAN: What exactly will it say?
PATIENT: He'll say. He'll find another way to do it. Like, he'll say, "Don't study, do bad on the test." And that's his way of saying to hurt myself. And once I do bad on the test, then it will be easy for him to talk to me. [pause] It will be hard not to listen to him.
CLINICIAN: It changes if you feel you failed on some level?
PATIENT: I can hear him louder.
CLINICIAN: Does he ever tell you to cut yourself or to take pills, anything like that?
PATIENT: He tells me a little bit, and he makes me feel that way also. He'll hint sort of. He'll tell me. [pause] He'll tell me.
CLINICIAN: What will he say?
PATIENT: He'll say, "Just do it." He'll say, "Do it." [pause] It's scary.
CLINICIAN: I'm sure it is. [patient smiles and nods agreement]

     The clinician's graceful structuring of Jimmy into the regions of psychosis that are associated with suicide risk is paying off. The roommate's reflections on the razor blade now appear more ominous. A simple question such as, "Jimmy, I'm wondering, if in response to the voices, you ever got a razor blade or knife out with thoughts of cutting yourself?" could quickly uncover grounds for involuntary commitment. Further interviewing will help clarify the imminent dangerousness of Jimmy, but hospitalization may be indicated.
     Notice the clinician's adept interplay between the use of open-ended and closed-ended inquiries. Whenever a potentially psychotic patient is vague, it is often useful for the interviewer to try to enter the patient's world through an open-ended inquiry, especially if the patient has shown intense affect around a topic. For instance, when Jimmy began to describe his voices as, "It's a feeling. It sounds like my thoughts, but they are a little bit different, the way that I can hear them," the interviewer queried, "And how do you hear them?" Jimmy replied with a peculiar affect that further betrayed the presence of his underlying psychosis: "They just seem to come to me. [pause, then speaking very softly, almost in a whisper] They just seem to come to me." This exchange created a "spooked" sensation in the clinician, similar to the response Jimmy had created in his roommate back in the dormitory.
     On the other hand, the clinician directly utilized many closedended questions, as he attempted to address the specific areas of dangerousness associated with Jimmy's psychotic process. No room for miscommunication here. A series of closed-ended questions followed, phrased in a nonjudgmental way and with a genuine sense of curiosity: "Does the voice ever tell you to hurt yourself?" "What exactly will he say?" and "Does he ever tell you to cut yourself or to take pills, anything like that?"
     As we end our discussion of our first case illustration, a review of some basic principles highlighted by Jimmy's presentation may be of value:

1. A relatively small but significant number of people who attempt suicide are actively psychotic.
2. Any evidence of psychosis warrants a thorough evaluation of lethality.
3. Command hallucinations, feelings of alien control, and hyperreligiosity are particularly dangerous areas of psychotic process. These areas should be actively probed by the interviewer if not elicited spontaneously.
4. Recent evidence suggests that many suicides in schizophrenia occur in response to depressive episodes and/or episodes of intense demoralization while the patient is relatively nonpsychotic.
5. Demographic material such as age, sex, and marital status may indicate risk factors for suicide.
6. Recent losses and poor social support systems are prominent risk factors for suicide.
7. Alcohol, drugs, or any physiologic insult to the central nervous system, as seen with delirium, may increase the likelihood of suicide or homicide.
8. When evaluating systems of immediate outpatient support, clinicians should carefully consider whether the mental health system itself is prepared to offer adequate support.
9. Interviews with corroborative informants may yield valuable information.
10. Clinicians should not be hesitant about reinterviewing a client.

CASE PRESENTATION TWO:
MRS. KELLY FLANNIGAN
Mrs. Kelly Flannigan is a 40-year-old mother of two, and owner of a local coffeehouse called The Morning Stop. A one-time graphics artist, she turned entrepreneur roughly seven years ago, after leaving New York City to gain a slower pace of life in the hills of New Hampshire. She presents today for an initial assessment at a busy community mental health center. She was discharged two weeks ago from a psychiatric unit, secondary to an overdose of fifteen Tylenol pills.
     When the hospital referred her, the chief social worker had commented, "Kelly is a class act--a little zany, mind you--but a class act. We all liked her. She's just beat-up. I don't mean by anyone. I mean beat-up by life and by her disease. Her husband is not exactly a charmer either, I can tell you that."
     "Kell," as she likes to be called, is blessed with a winning smile. Her cat-green eyes peer from beneath a disobedient mane of red hair. She has the delightful ability to make people feel special, a trait that has drawn customers to the steps of The Morning Stop every hour of the day and night. The cafe has been a big success. Her multiple sclerosis struck about four years ago, with devastating fury. Her husband began having affairs about two years ago, with disturbing frequency. The panic attacks began a year ago. The drinking is still going on.
     She arrived five minutes late for the appointment and had Jennie and Julie, her 8- and 12-year-old daughters, in tow. "I'm sorry I brought the kids but my baby sitter panned out on me." She managed a bit of a coy smile, "Sorry. Is this okay?"
     Although feeling much better than before her hospitalization, she still acknowledges being quite depressed. She complains of many of the neurovegetative symptoms of depression. She manages to smile intermittently, but she moves with a halting quality and sometimes slurs her speech, not from the effects of alcohol, but from the remnants of her most recent exacerbation of multiple sclerosis.
Just as the chief social worker had suggested, there is something immediately engaging about Kell that's hard to put into words. This day, she looks weary, her speech punctuated with depressive sighs. When discussing the impending necessity of selling The Morning Stop, because she simply can't keep up the pace required of an effective owner, she begins to cry. Unlike Jimmy, she has no evidence of psychotic process. Her intellectual and cognitive functioning is fine.
     When asked about suicide, she openly discusses her recent suicide attempt emphasizing, "I didn't really want to kill myself, you know, I stopped myself. Nobody else stopped me." She denies any specific suicidal ideation or plans since her discharge, other than, "Sometimes I wish I was dead, but I've got to go on."
     Kell raises concerns different from those encountered with Jimmy. First, she presents with a depressed affect and reports numerous depressive symptoms consistent with the DSM-IV criteria for a major depression. In addition, she presents with multiple psychiatric diagnoses. In addition to her depression, she has a panic disorder and was also felt to meet the criteria for alcohol abuse. As one would expect, the presence of depression represents a significant risk factor for suicide. In addition to the classical presentation of depression, which Kell illustrates, the clinician must also keep in mind the possibility of atypical depressions.
     A presenting depression may also represent a secondary response to an even more problematic primary diagnosis, whose symptoms the patient is hesitant to talk about for fear of embarrassment. It is very common for patients with disorders such as Obsessive Compulsive Disorder (OCD) and Posttraumatic Stress Disorder (PTSD) to hide their underlying symptoms or problems while presenting with depressive complaints. One study demonstrated that the average number of years before a patient with OCD seeks help is 16. (25) This is particularly disturbing when one realizes that it has been estimated that people suffering from OCD represent nearly 2% of all suicides in the United States annually. (26) Somatoform disorders, such as psychogenic pain syndrome and hypochondriasis (which probably represents a variation of OCD), may also present with comorbid depressions. It is critical to search for such comorbid disorders. If untreated, they can greatly increase the risk of suicide.
     The presence of a severe psychiatric disorder such as a major depression is probably the single most robust statistical correlate with suicide risk. In response to the question, "What is one of your best tips for predicting long-term suicide potential?" I often reply, "Begin with a good diagnostic assessment." Reviews of completed suicides have shown that as high as 95% of all suicides, including both adolescents and adults, occur in people suffering with a psychiatric disturbance. (27) Major depression leads the pack. It is followed by alcoholism, schizophrenia, bipolar disorder, and people coping with a severe borderline personality disorder. (28)
     The intensity of Kell's anxiety was disturbing, for there is increasing evidence that people experiencing frequent panic attacks are at a higher risk for suicide. If the panic attacks occur in conjunction with a severe depression, as with Kell, then a "red flag" should go up. In a study of nearly 1,000 patients with a mood disorder, Fawcett found that depressed patients who also experienced panic attacks demonstrated three times the suicide rate of other patients and accounted for nearly two-thirds of the suicides in the first year of the study. (29, 30) Other research has supported the idea that patients with panic attacks show an increase in suicidal ideation, but whether this translates into a definitely higher rate of suicide attempts is unclear. (31)
     In Chapter 2 and in the discussion of Jimmy's case, we described the importance of stressors and loss as risk factors for suicide. Unlike Jimmy, Kell has had several devastating stressors: the loss of her health, the deterioration of her marriage, the loss of her ability to function effectively at work (she finds the slurring of her speech to be particularly disturbing and feels it "makes me look like I'm drunk"). In the near future, she faces the impending loss of her cafe. This formidable list of stressors substantially increases her chronic suicide risk.
     The presence of a severe and debilitating illness, such as Kell's multiple sclerosis, is one of the highest factors associated with completed suicide. Particular attention should be given to illnesses that result in decreased mobility, disfigurement, chronic pain, or loss of functionality, exactly the types of losses we saw in Chapter 2 that prompted Bruno Bettelheim to commit suicide. Kell's multiple sclerosis markedly changed her life and resulted in fluctuating periods of paresis, slurred speech, urinary incontinence, and severe vision problems. An interviewer should note the impact of any illnesses in which the patient anticipates an unavoidable loss of function or projects a horrifying demise. Such illnesses as Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease), Huntington's chorea, Alzheimer's disease, severe diabetes, severe chronic obstructive pulmonary disease, and paralysis may present more suffering than some individuals can face or would choose to accept.
The interaction of the patient's medical illnesses with the patient's underlying personality structure also warrants attention. Some people, when locked into damaging structures such as narcissistic, histrionic, or borderline personalities, may have an inordinate amount of difficulty dealing with disease processes that others can handle better because they are lucky enough to have more mature coping skills.
     Along these lines, Leonard has described three personality types that may be predisposed to suicide when severely stressed." The first type is a controlling personality. These patients tend to constantly manipulate their environment. They are often hard-driven and feel a need to be "on top of things." They frequently pilot their way into roles of power and authority. When such people are suddenly struck by the loss of control caused by a crippling illness, they may attempt escape through death.
     A second personality type at risk is characterized by a dependent/ dissatisfied approach to life-a common trait of people suffering with borderline personality disorders, narcissistic personality disorders, and passive-aggressive structures. Such people often leave a long line of exasperated care providers in their wake. When the last source of interpersonal support finally closes the door, these people are suddenly without any means of emotional support. Suicide may loom as the only viable option.
     A third predisposing characterological type is found in people who have evolved a truly symbiotic relationship with a significant other. These people are at high risk if their sustaining support dies or abandons them.
     All of these examples reemphasize one of the most important hallmarks of suicide described in Chapter 2. Suicide is often an interpersonal phenomenon. As we saw with Jimmy, an evaluation of suicide risk involves not only consideration of the identified client but also assessment of the people surrounding the identified client. At times, as we saw with Jimmy, this evaluation proceeds through the use of corroborative interviews. When corroborative sources are not available, the interviewer must depend solely on information provided by the patient. In either case, a careful consideration of interpersonal factors is warranted. A brief look at some of Kell's reconstructed dialogue may provide some insight into the importance of these interpersonal considerations.

CLINICIAN: You had mentioned that you felt you wouldn't kill yourself because you felt you had to go on. I'm wondering what it is that compels you to go on.
KELL: [points toward the door] Them.
CLINICIAN: Your children?
KELL: Absolutely. I couldn't do that to them. Julie in particular would never recover. Just not fair. [pause] I'll tell you. If they were not in the picture, I'd be gone by now. That simple.
CLINICIAN: What about your husband? Do you feel he needs you?
KELL: [raises her eyebrows and smiles] Let me put it to you this way, Doc. About a month ago, I turned to Kevin and told him he might be more sorry than he thinks if I killed myself. You know what he said?
CLINICIAN: What?
KELL: Nothing. [pause] Absolutely nothing. He rolled his eyes, shook his head, and walked right out of the room. [pause] Oh yeah, he did say something as he strutted out.
CLINICIAN: What was that?
KELL: "You're fucking crazy."
CLINICIAN: You tried to kill yourself shortly after that, didn't you? Do you think that exchange was the trigger?
KELL: I don't know. [shakes her head from side to side] What do you think?
CLINICIAN: I don't know either. You just sort of look like you're feeling angry and demoralized about things right now, understandably so.
KELL: Yeah. I am. I really am. Both of those things. [pause] You think it's okay to feel both those things?
CLINICIAN: Sure do.
KELL: [nods head up and down ever so slightly] Hmmm.
CLINICIAN: Do you see any hope for the future?
KELL: If you mean do I see hope that I'll get through all this and help my kids to grow up with a reasonably okay childhood? Yea. I'll do that. I have to, if the MS doesn't kill me first. But if you mean do I feel hope that I'll ever be happy again, [pause, then leans forward in chair] no way. You know and I know this disease will get worse. You know and I know I'll probably end up wheelchair bound or worse. I don't think that picture fills one with hope, do you?

      This pointed dialogue illustrates the importance of determining whether the patient is returning to a supportive or a hostile environment. If the patient's family and/or friends provide a caring milieu, this fact bodes well for the patient, but a paradoxical problem can still arise if the patient begins to feel guilty about "being a burden to everyone." There was little doubt that Kell faced a hostile environment. Her husband's affairs and acerbic comments suggest that he has already "moved out" in a psychological sense, leaving Kell alone with her growing fears and disabilities. One can sometimes tap the interpersonal tensions surrounding the client and his or her thoughts of suicide with questions such as the following:

1. If you were to kill yourself, how do you think that would affect your family?
2. How do you think your spouse would feel if you killed yourself?
3. What are your thoughts about your responsibilities to your family and children if you kill yourself? (33)

     Such questioning may uncover evidence of an interpersonal maelstrom or of reasons for life, such as Kell's need to care for her children. On the darker side, the interviewer seeks clues indicating that a supposed support system actually wishes that the patient were dead. The death wish may be unconscious or conscious, innocuous or sinister. The clinician's recognition of such a death wish is not a moral judgment passed upon a potential support system but rather an attempt to see the potentially lethal ramifications stemming from such a situation. Premature dismissal of such factors may represent a dangerous naivete on the part of the interviewer. In Kell's case, one wonders to what degree the marital alliance has been irrevocably destroyed. At some level, does Kevin Flannigan "want out"?
     An unconscious death wish may show itself in a family's lax attitude toward appropriate precautions against suicide. The clinician may discover that the safety suggestions of previous mental health professionals, such as removing a firearm from the home, have not been followed by the family. On another plane, there may be resistance to hospitalizing a seriously lethal patient. Considering the perspective of psychological defense mechanisms, family members may see a falsely rosy picture because of denial or repression.
     At a more disturbing level, clinicians will undoubtedly encounter a death wish laced with true malice. Perhaps a spouse has long been denied a divorce, or a battered significant other has been unable to retaliate. These family members, rightly or wrongly, may consciously wish the patient dead. It is not known how many people have waited a few hours before contacting help when they have happened upon a "sleeping" family member surrounded by empty pill bottles.
     I remember one patient I hospitalized from the emergency room. During our interview her spouse literally yelled at her, "Why don't you just take the damn pills? In fact, I'll stuff them down your throat and, trust me, I won't call a soul." Such vicious interaction should serve as a warning to the clinician. It may mean hospitalizing a patient who otherwise might have been perfectly safe if discharge to a more supportive environment were possible.
     In another aspect of hostile environments, the client may be equally angry with family members. With revenge in mind, clients may kill themselves hoping "to show them, they'll be sorry when I'm gone." Responses to questions such as "What have you pictured your funeral being like?" may provide revealing insights into the client's motive for suicide. Some clients answer with variations of "They'll be devastated once they realize what they've done to me." In a similar vein, some authors have viewed suicide as the result of a murderous impulse turned inward--symbolic murder with an ironic satisfaction. (34)
     Another aspect of anger, for which experienced assessment clinicians should be watchful, may surface in the denouement of a suicidal act. Suicide engenders anger in those left behind. In some instances, it is a justified anger for they were meant to be hurt.
     Returning for a moment to Kurt Cobain's suicide note (see Chapter 2), we see some of this process. In a subtle way, Cobain's letter seems to demonstrate the passive-aggressive flavor that is not uncommon in a suicidal matrix. This undercurrent of passive aggression shows itself in the very first line of the letter, paradoxically, through Cobain's heavy-handed use of his own self-denigrations. When one rereads them--"Speaking from the tongue of an experienced simpleton who obviously would rather be an emasculated, infantile complainee."--it is apparent that the self-denigrations of his letter are dramatic or even, arguably, overly dramatic. They leave no room for significant others to express their anger toward him, for he has already belittled himself to the ultimate degree. In fact, his self-denigrating exhortations place a subtle pressure on significant others to refute their truth--in essence, to pull him back up. If a person is angry with someone who has just been deliberately hurtful, this pressure to say something soothing is frankly annoying, even posthumously.
     A further complication is the disturbing psychological bind that the act of suicide places on those left behind, the bind of having to continue the struggle of life alone. An almost galling quality is perceived by some survivors when a suicide note is filled with new demands on the living. Cobain's dying command to his wife, "Please keep going Courtney, for Frances," is a double-edged sword. The remaining parent, greatly traumatized by the role of single parenthood and by intense grief, must now go on alone with life's many struggles while the person committing suicide has "ducked out." The topper to this phenomenon is that survivors, after having recognized this anger, often feel guilt for having it. A clinician can use this understanding to greatly help survivors in the emotional aftermath of a completed suicide.
     Of more importance to our goals is the fact that an understanding of these dynamics can be of immediate value in risk assessment itself. The same feelings of resentment and betrayal often occur in friends and family members, albeit to a lesser degree, after a failed suicide attempt. Indeed, repetitious attempts can engender an insidiously growing anger toward the patient in the very people who may be of vital importance to the clinician in safe discharge planning. This process is already well underway between Kell and her husband, as evidenced by his response to her veiled threat that he may be more sorry than he thinks if she kills herself: "You're fucking nuts."
     In sharp contrast to the suicidal dynamic engendered by hatred is the equally powerful suicidal dynamic engendered by compassion. Some people kill themselves to help others. As discussed in Chapter 2, the more apparent relief the suicide will bring to those left behind, the more concerned the interviewer should become. It is particularly ominous when the patient perceives suicide as "the only way I can really help my family. My schizophrenia is ruining us. We can't pay for these hospitalizations. And I can't let my kids see me this way. They need a better dad."
     Returning to the specific world of Kell, several indicators appear to suggest lowered suicide risk. First, Kell denies immediate hopelessness, albeit in a somewhat unconvincing fashion. In Chapter 2, I noted that Aaron Beck's work has suggested that the presence of hopelessness may be an ominous sign. In fact, hopelessness may even be a more reliable indicator of lethality than the severity of depressive mood over time. (35) Viewed from a logical perspective, suicide usually represents a last option taken when no other alternatives are apparent to the patient. Moreover, a sense of helplessness is often coupled to this state of despair. Patients generally kill themselves for one major reason-to escape from unbearable pain that appears inescapable.
     Further inquiry revealed that Kell was a devout Catholic. Believing suicide to be a mortal sin, she felt its end-result would be eternal damnation. At this intensity, religion is probably acting as a major framework for meaning that precludes the suicide option. But our interview excerpt provides a window into an even more powerful framework for meaning for Kell, a framework that, in my opinion, represents her strongest tie to the world of the living: the welfare of her children. Other patients may have different frameworks for meaning, such as caring for elderly parents, community projects, religious/spiritual beliefs, patriotism, or ties with specific subcultures such as the biking culture, sports, or AA. The clinician should seek out evidence of such powerful deterrents as part of every suicide assessment.
     Although they often represent a powerful set of deterrents to suicide, ties to one's children can take a paradoxically dangerous turn if the client begins to feel that the child would be better off with the parent dead. Kurt Cobain stated this plainly in his suicide note. A revealing question can be: "What do you foresee for your children in the future, if, indeed, you were dead?"
     A peculiar and unsettling twist can enter the picture with regards to children in this light. A suicidal parent may decide that his or her children would be even worse off after the parent's suicide. For instance, the spouse who would survive may have alcoholism and/or an active history of physically and sexually abusing the children. The suicidal parent may then contemplate taking the lives of the children before killing himself or herself. Although rare, one only needs to read the newspaper in order to learn about such tragedies. If such an outcome is suspected, the clinician should ask directly whether such thoughts are harbored. There are many ways of sensitively broaching such a potentially charged topic. If considerable anger is present, this anger can be used as a gateway into an exploration of violent impulses, which, in turn, can gracefully tie into thoughts of taking the lives of one's children. Here is a possible sequence for these sensitive topics:

CLIENT: I am a total failure, at least that's what my husband says. And he says it every minute of every day.
CLINICIAN: It sounds like a lot of anger has built up over the years between the two of you.
CLIENT: You better believe it. I can safely say I hate the abusing son of a bitch. But he'll be sorry when I'm dead.
CLINICIAN: You mean after you kill yourself?
CLIENT: Yeah. That's what I mean. [pause] Maybe I won't kill myself. I don't know. I just don't know anymore.
CLINICIAN: With all your anger toward him, have you had any thoughts of killing him?
CLIENT: No. I'd just end up in jail. And then what's going to happen to my kids? Who is going to take care of them?
CLINICIAN: In that line of thinking, you had mentioned the negative impact on your husband if you kill yourself. What do you think the impact would be on your children?
CLIENT: [long pause] Horrible. [pause] I can't imagine what it would be like. I can't picture leaving them with him. That wouldn't be right. He's a monster, he really is.
CLINICIAN: As difficult as the thought might be, do you ever have the thought, even fleeting, of killing your children first before taking your own life?
CLIENT: [long pause, client begins to sob] I've thought of it. But it's a horrible thought. I just don't know what to do anymore. I just want it to all end. That's all. To end.
CLINICIAN: I'm sure that's a terribly painful thought to have for you. I know you adore your children. I'm sure those thoughts come from your pain. Tell me, if you can, exactly what you've thought about doing.
CLIENT: [client sighs] It's hard for me to say this, but I thought about overdosing them. Just briefly. A couple of weeks ago. [sighs again] But that's not an answer. I know that now.

     At other times, the following type of approach is useful. The clinician broaches the topic by inquiring directly about the patient's prediction of the children's future after his or her suicide:

CLIENT: My husband will never change. He likes to hurt us. We have no future and I now realize that suicide is my only option.
CLINICIAN: You mentioned "we." What do you think is going to happen to your children after you kill yourself?
CLIENT: [long pause] I don't really know. Nothing good.
CLINICIAN: Sometimes, parents consider taking the lives of their children. Has that thought ever crossed your mind?
CLIENT: Yes, it has ... it's a terrible thought, but it has.
CLINICIAN: What exactly have you thought of doing?

     Returning to Kell, there is another positive note in her presentation: the lack of an abrupt change in her clinical condition in either direction. A sudden onset of severe sleeplessness, agitation, or marked dysphoria may indicate that patients are rapidly approaching a pain level they cannot tolerate. On the other hand, one sometimes hears the often quoted clinical observation, noted at the beginning of Chapter 2, that an unexpected improvement in clinical condition may be masking a sinister outcome. The patient's peace may be secondary to the patient's decision to commit suicide. Suddenly, the patient senses a perceivable end to the suffering. The most momentous decision of the patient's life has been made.
     Another curious problem is the propensity of some seriously depressed patients to attempt suicide as they begin to improve. Suicide is less common while they are in the troughs of their depression. This finding is probably related to the fact that, as they initially improve, they regain initiative and energy while still suffering from an intensely dysphoric mood. The clinician should keep this fact in mind when encountering a patient recently started on an antidepressant.
     Further interviewing revealed that Kell had no immediate models for suicide. No friends or family members had ever attempted suicide. A legacy of suicide in a family tree should arouse concern. A particular threat arises when clients see themselves as being similar to someone dear who has committed suicide, as in this response: "Yeah. My Aunt Jackie killed herself when she turned thirty. She was my favorite aunt. My mom has always chided me for being just like her. [pause] Maybe I am." As mentioned in Chapter 2, especially with adolescents, one should be on the lookout for suicide compacts or copycat suicides following the suicide of a fellow student or a celebrity. Adolescents should be routinely asked, "Has anybody in your school or have any of your friends attempted suicide?" If the news media are focusing on a student or celebrity suicide, the clinician should explore an adolescent patient's thoughts on the specific suicide in question.

This summary of issues raised in our discussion of Kell may reinforce some key principles:

1. The presence of medical illnesses such as severe diabetes, rheumatoid arthritis, and multiple sclerosis may increase suicide risk, especially if it leads to immobility, disfigurement, loss of functioning/livelihood, or chronic pain.
2. The interviewer should routinely search for evidence of hopelessness by directly asking about it if it is not spontaneously described by the client.
3. A hostile interpersonal environment may substantially increase suicide risk, and some members of the patient's family and/or friends may consciously or unconsciously undercut plans for safety.
4. A strong framework for meaning, such as deeply held religious convictions or commitments to one's children, may decrease risk. The clinician should ask direct questions that will uncover such convictions.
5. Abrupt and unexpected positive or negative changes in clinical condition, including a sudden and unexpected increase or drop in anxiety, may indicate an increased risk.
6. Rational excuses based on a sense of helping others or lessening the burden on others--"They'd be better off with me dead. Honestly, they would"--should be carefully evaluated.
7. The presence of a positive family history of suicide, as well as copycat suicides among adolescents, should be actively looked into by the clinician.
8. Suicide assessment should always include a search for major psychiatric disorders such as major depression, alcohol/street drug abuse, schizophrenia, schizoaffective disorder, bipolar disorder, obsessive-compulsive disorder, posttraumatic stress disorder, panic disorder, and severe character disorders such as borderline personality disorder.

STATISTICAL AND CLINICAL RISK FACTORS: A QUICK SUMMARY
When pressured by time constraints, clinical demands, and the other everyday pressures of being a mental health professional, substance abuse counselor, or school counselor, it is sometimes difficult to remember all of the risk factors discussed above. Two acronyms can facilitate their recall. The SAD PERSONS Scale, developed by Patterson, Dohn, Bird, and Patterson, (36) serves as a useful checklist of pertinent risk factors. The NO HOPE Scale, developed by the author, (37) adds further depth to the evaluation of suicide potential by emphasizing the need to inquire about feelings of hopelessness and other important risk factors.

     If clinicians routinely explore the ramifications of these risk factors and the others described in this chapter, they can be assured they are utilizing a sound knowledge base. Moreover, the presence of a large number of these factors should increase clinicians' suspicions of suicide potential.
     As we looked at the risk factors present with Jimmy and Kell, we discussed some of their implications for suggesting a chronic risk for suicide. But the question remains for a clinician who must decide what to do with other Jimmys or Kells: How immediately dangerous are they? Do they require hospitalization?

CHRONIC VERSUS IMMEDIATE RISK OF SUICIDE:
THE TRIAD OF LETHALITY
Let us begin with Kell. Perhaps the most important indicator that Kell is probably not imminently suicidal is the fact that she denies current suicidal intent and has no organized plan to harm herself. She also spontaneously expresses an extremely strong rationale for living-the need to be there for her children Jennie and Julie. Still, Kell represents a long-term risk for suicide. This point illustrates the usefulness of distinguishing between chronic suicide potential and immediate suicide potential. If a patient presents with numerous risk factors over a long period of time, that patient may be at chronic risk for suicide, and the clinician will need to periodically check that patient for the appearance of suicidal ideation. Such is the case with Kell, who presents with the following risk factors: presence of a major psychiatric disorder (major depression, panic disorder, and alcohol abuse), numerous major life stresses, loss of functioning, debilitating illness (multiple sclerosis), a tendency toward hopelessness/demoralization, a history of a suicide attempt, recent discharge from a hospital, and a strained marital alliance that may actually represent a hostile environment.
     But the presence of numerous risk factors does not necessarily indicate an immediate risk of suicide. By way of example, Kell could probably be safely treated as an outpatient, despite her long list of risk factors. Thus, the pressing question facing the assessment clinician is: What factors would have suggested that Kell was in more immediate danger of committing suicide?
     In my opinion, the three most useful indicators--a lethal triad of sorts--are:

1. The patient presents immediately after attempting a serious suicidal act.
2. The patient presents with a dangerous display of the psychotic processes suggestive of lethality.
3. The patient shares suicidal planning or intent in the interview, suggesting that he or she is seriously planning imminent suicide (or corroborative sources supply information suggestive of such planning).

     The presence of any element of this triad should alert the clinician that suicide may be imminent. In such instances, with respect to triage, the clinician should strongly consider hospitalization even if opposed by the patient. In my opinion, the last element of the triad, which is primarily dependent on the clinician's interviewing skills, is the single most important indicator of suicide potential. So important is this interviewing process that Part Two of this book is entirely devoted to exploring its subtleties.
     In the meantime, as we look at the first element of the triad of lethality-the patient presents immediately after attempting a serious suicidal act-certain points are of practical clinical relevance. First, the clinician wants to determine the potential dangerousness of the method used. Impulsively downing a few extra aspirin is a great deal less disconcerting than shooting oneself or ingesting lye. A threat of an overdose made by a physician who understands the lethal nature of specific medications and has the wherewithal to procure them is more worrisome than the same threat made by a nonphysician.
     Second, the clinician wants to determine whether the patient appeared to really want to die. In other words, did the patient leave much room for rescue? The interviewer should search for these and similar factors: Did the patient choose a "death spot" where he or she could easily be discovered? Did the patient choose a spot where help was nearby? Did the patient leave any hints of suicidal intention that could have brought help, such as an easily accessible suicide note? Did the patient contact someone after the suicide attempt? (38) Answers to these questions may provide pivotal evidence as to imminent dangerousness. The significance of these questions will be explored in more detail in Chapter 6.
     Note that Kell lacks all three elements of the triad of lethality. Although she presents with a relatively recent suicide attempt, it was not a serious one. She ingested a low number of pills, stopped herself, and feels regret at the attempt. Concerning the second and third elements of the triad, Kell shows no evidence of psychosis, and she denies current ideation or intent. Her immediate safety is further bolstered by the strong framework for meaning provided by her children and her religious beliefs. Despite her numerous risk factors, Kell is probably not in immediate danger, although she will certainly require close follow-up.
     Jimmy is considerably trickier. He falls closer to the other end of the continuum--away from chronic risk and toward more acute risk. His risk factors include his adolescent age, his sex, and the fact that, from a psychological perspective, the "low" grade on his test may actually represent a catastrophic stressor to him. Yet, curiously, compared to Kell, he seems to have far fewer risk factors. And he certainly has far less intense stressors, by any objective measure of absolute stress. Unlike Kell, he has not had a recent suicide attempt nor has he recently been hospitalized. Yet he feels more dangerous.
     It is the presence in Jimmy of the second element in the triad of lethality, his psychotic process, that is most disturbing. And it is the artful fashion in which the clinician is asking about Jimmy's specific suicidal thoughts and plans, the third element in the triad of lethality, that is bringing dangerous material to the surface. More detailed interviewing about his suicidal planning and his ability to refrain from acting on it will be necessary to determine his immediate dangerousness. For instance, it may be uncovered that the razor blades were bought for the purpose of self-harm. Perhaps a suicide gesture has actually already occurred. Further interviewing may show that Jimmy is less distanced from recent suicidal planning than he intimated thus far in the interview. Hospitalization, even involuntary in nature, may prove to be necessary to ensure safety.
     In this sense, Jimmy represents an example of the fact that the number of risk factors present does not necessarily provide an adequate picture of dangerousness. It is necessary to enter the part of the client's interior world where the most intimate details of suicidal thought and intent lay buried. It is here, in the patient's concrete world of suicidal planning that the true harbingers of death can be heard. The practical art of eliciting this suicidal ideation is the topic of Part Two.

NOTES
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