The Suicidal Patient: Principles of Assessment, Treatment, and Case Management

In the opening lines of Moby Dick, Ishmael states, “Whenever it is a damp, drizzly November in my soul; whenever I find myself involuntarily pausing before coffin warehouses, and bringing up the rear of every funeral I meet…I count it high time to go to sea as soon as I can. This is my substitution for pistol and ball.” Ishmael’s suicidal rumination reflects Camus’s contention: “There is but one truly serious philosophical problem and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy” (1). To assist frontline clinicians “with a sense of what to do with the suicidal patient” as they deal with patients’ suicidal behavior, Drs. Chiles and Strosahl have authored a very valuable and practical guide in The Suicidal Patient.

With their recognizing that suicidal behaviors—rumination, attempt, and completion—may not represent a continuum (most of those who ruminate about suicide do not attempt suicide and most of those who attempt do not die), the authors devote most of their book to expanding their underlying and fundamental observations. They “treat suicidal behavior as a method of solving problems and…focus on nonfatal forms of the behavior.”

The book is divided into three sections. Section 1 includes four chapters on understanding suicidality. In chapter 2, for example, I found an excellent discussion of the affective, ethical, and legal issues confronting the clinician who is treating a suicidal patient. Most clinicians fear that no matter what was done, they will somehow be both blamed and sued if there is a suicide. The authors’ advocacy of reducing the volume of potential litigation regarding alleged negligence in treatment by “moving suicide into the realm of nonculpability…[and thereby] more accurately represent[ing] the nature of the act itself and specifically honor[ing] the fact that the mental health profession does not currently possess the technology for accurate prediction or prevention of the act” is both timely and reassuring in the litigious climate that overshadows current clinical practice.

Key to an understanding of the suicidal crisis is to accept the authors’ conviction that suicidal behavior is a learned method of problem solving. Thus, in chapter 4, Drs. Chiles and Strosahl define the “three Is”: anyone can become suicidal if a situation produces emotional pain and is believed to be inescapable, interminable, and intolerable. Consequently, if a patient sees that all other reasonable, problem-solving options have become ineffective or have been tried and failed, then the option of suicide becomes increasingly more desirable. Rather than convince the patient that the suicidal act is wrong, it is preferable to intervene by getting the patient to acknowledge his or her ambivalence and to discover overlooked, alternative problem-solving options.

In section 2, which also includes four chapters, the authors provide the reader with the basic message and details of their learned behavior treatment model. Drs. Chiles and Strosahl use clinical vignettes to proffer goals and strategies in making interventions with inpatients and outpatients manifesting suicidal behavior and demonstrate both crisis and case management expertise as they address the more clinically challenging patients who evidence recurrent suicidal behavior. With the latter, the authors provide five central principles for successful intervention: 1) Suicidal behavior is designed to solve specific problems that are enmeshed in the “three Is.” 2) Approach the suicidal crisis in a candid, easygoing, nonapprehensive manner. 3) Remember that most suicidal crises are nonlethal, and that no form of intervention can prevent a determined suicide. 4) Actual suicide crises are self-limiting, of short duration, and can usually last no more than 48 hours. 5) The goal of intervention is to help patients solve their existential problems in nonlethal ways.

The third and final section devotes its three chapters to special clinical problems. Included in this group are chapters on the repetitiously suicidal patient; the suicidal patient in general health care; and special populations, settings, and techniques. This last chapter examines such diverse but at- risk populations as the patient who is taking psychoactive medication, the substance-abusing patient, the psychotically ill patient, and the high-risk groups of adolescents and the elderly.

In sum, I find this book both well written and clinically relevant for all practitioners who may see a suicidal patient in their practice. Although the twin crisis intervention skills of validating emotional pain and forming an effective problem-solving plan with the patient are still germane, one population underrepresented in this work is the jail inmate. Here the core issue of the “suicide bind” is amplified in the mental health practitioner who provides services to this population, which is growing with the underfunding of community mental health services and the redirection of the mentally ill into the less clinically sophisticated criminal justice system. The authors define the “suicide bind” as “the inescapable fact that the power to commit suicide or engage in suicidal behavior is finally and completely in the hands of your patient. No amount of coercion, restraint, persuasion, or pleading is going to change the fact that your patient in the long run controls destiny. The suicidal bind can leave you feeling powerless and simultaneously feeling responsible for doing something miraculous.” I hope the authors will add the jail inmate to their chapter on special populations or settings in future editions.

Finally, as Dr. Stelzner writes,