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Book Forum: Suicide   |    
The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors
JOHN J. SCHWAB, M.D.
Am J Psychiatry 2000;157:1535-1536. doi:10.1176/appi.ajp.157.9.1535
View Author and Article Information
Louisville, Ky.

By Shawn Christopher Shea. New York, John Wiley & Sons, 1999, 235 pp., $47.50.

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This outstanding book is informative, interesting, and clinically useful. Shea emphasizes that suicide is a major public health concern. It is the ninth leading cause of death in adults and the third leading cause in the 15–25-year-old age group; from 1952 to 1992, the adolescent and young adult rate tripled. Prevention of suicide depends on the timely assessment of suicide risk. Shea says that timely assessment depends on clinicians’ overcoming their own fixed ideas and basing their assessment on three pillars: analyzing the risk factors and predictors, uncovering and understanding suicidal ideation, and developing prevention strategies.

Although the well-known sociodemographic and family history risk factors are "harbingers of death," they are characteristics of groups of people who have committed suicide and, alone, are not reliable predictors of dangerousness for an individual. In contrast, a risk predictor is a characteristic of an individual such as mental illness, especially psychosis, that indicates the likelihood of imminent suicide. Shea’s case histories point out a lethal triad: the patient is seen immediately after making a serious suicidal attempt, manifests psychotic processes suggestive of lethality, and shares suicidal intent or planning.

The second pillar, uncovering suicidal ideation, is the essence of the assessment. Too often, however, suicidal ideation is incompletely evaluated because of myths about it, taboos, and such countertransference issues as the psychiatrist’s biases, fear of provoking an attempt, and anxiety about the patient. Shea views the uncovering of suicidal ideation as opening a window on the patient’s intent and plans and cites Thomas Kuhn’s famous statement: "The answers you get depend upon the questions you ask."

The fundamentals of the assessment of suicidal ideation are six validity techniques: 1) behavioral incidents, 2) shame attenuation, 3) gentle assumption, 4) symptom amplification, 5) denial of the specific, and 6) normalization. Clinical vignettes point out the importance of asking about specific behavioral incidents and such concrete behavioral facts or trains of thought as, "Exactly how many pills did you take?" or "When you placed the gun in your mouth, did you take the safety off?" and "In the past 2 weeks, have you had even a single thought of killing yourself, even for a fleeting moment?" Unfortunately, many interviewers focus on the patient’s feelings at the expense of information about behavior intrinsic to suicide. Also, symptom amplification questions, such as asking whether the patient ever drank a fifth or more of liquor or spends as much as 80% or 90% of the day thinking about suicide reveal the clinical facts about what has been happening.

The interview strategy is built on Shea’s chronological assessment of suicide events, an approach that he developed in a busy urban emergency department. The focus is on the patient’s presentation, the recent (preceding 8 weeks) and the past suicidal ideation and behaviors, and the immediate and future plans for its implementation. The 2 months preceding an attempt is the critical time period. Asking about a series of behavioral incidents and maintaining good eye contact can bring to light specific data about suicidal ideation and attempts that, coupled with knowledge about the risk factors and predictors, are the two databases for strategic clinical decision making. Shea emphasizes, "People who can talk about it tend not to do it. It’s when you don’t talk about it that it becomes more dangerous."

The third pillar is the "putting it all together," the case formulation and critical decision making that complete the assessment. The chronological assessment of suicide events approach uses cognitive therapy principles to transform dangerous suicidal ideation into reconstructive intervention.

Shea confronts the many difficulties of suicide assessment. Case histories deal with such practical situations as assessing an unknown patient in the emergency room, working with patients who have borderline personality disorder, and the need for ongoing suicide assessment of our own patients in therapy.

Shea’s well-written, interesting book, with its excellent case vignettes and specific clinical pointers, includes a short historical case study of Elizabeth Siddal, Dante Gabriel Rossetti’s first wife, who killed herself after she delivered a dead baby and then was unable to obtain a wanted adoption. Shea’s quotations of Edgar Allen Poe’s "Descent Into the Maelstrom," and Anne Sexton’s lines—"But suicides have a special language. Like carpenters they want to know which tools. They never ask why build" (p. 143)—enliven the book and its deadly topic. I recommend it highly. It is a reasonably short, direct clinical guide that is a testimony to the author’s extensive clinical and teaching experience and his ability to take us into the mind of the suicidal patient. It will be meaningful and helpful to experienced practitioners, residents, other mental health clinicians, and students.

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