Reminder from the headlines: Suicide not just about depression

28 08 2007

The Washington Post reported yesterday that the Virginia Tech shooter had an anxiety disorder as a child.   I don’t want to say much more about that, and I don’t know enough about Seung Hui Cho to know whether this did or did not play a role in his actions in April.

But such news can provide a useful reminder to review the prototypes and heuristics clinicians have in our heads about suicide.  Specifically, we need to resist the temptation to only think or ask about suicide in cases of depression.  Although depression is present in a large proportion of  people who die by suicide, suicide is by no means synonymous with depression.   Anxiety disorders, personality disorders, and psychotic disorders are all associated with risk for suicide.  This begins to make sense when you think about suicide often being a response to hopelessness, despair, agitation, and a feeling of being trapped (often with an overlay of substance abuse disinhibiting the person’s symptoms and behavior).   When put that way, it’s not hard to see how chronic intense anxiety could lead to suicidal thinking (or action).

I think this is something many clinicians know, but old prototypes can be stubborn and often get in the way of us accessing what we know.   When we refresh our thinking, we  can more effectively remember to to ask about suicidal ideation in every case, not just when depression is prominent.

Related posts:
Murder-Suicide, Domestic Violence…Common threads in violence against self and others
Suicide turned outward: Times of London Article by Dewey Cornell
Erratum on previous post: Cornell not author, just interviewed


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Categories : clinical interview, current events, risk assessment, suicide

Where’s the Family?

28 03 2007

I was just looking at the post counts on my categories and seeing few posts I have (only 2) family therapy category.   I think that reflects the state of the field right now, as well as my own internal conceptual development which is not yet entirely integrated.  Two things for sure:

1.  Almost everything I’ve read in the clinical suicide assessment literature assumes a one-on-one context.   Family therapy is usually not mentioned.  Families are sometimes mentioned, usually as potential sources of information when things get really risky, but without much attention to how to do that.

2. Family therapists tend to get pretty individualistic when they teach or write about suicide prevention.   This tendency was unmistakable in a recent Family Therapy Magazine, a publication of AAMFT that is distributed free to all members.   The July/Aug 2006 issues was titled “Suicide in the Family.”   Yet if you look at the articles there is almost no content related to family therapy.  In fact, if you removed the cover and took out a couple of intro paragraphs, the articles would be indistinguishable as a family therapy publication.   Remarkable.

I think this state of affairs reflects that fact that it’s not easy to bring the two together in practice.   How, when and of whom do you ask about suicidality in a room full of family members of different ages?  How do you bring up a topic that is hard enough to bring up with one person in front of you?   How much history about self-harm do you gather in front of children?  I don’t think anyone has really spelled out how to translate the relatively linear risk assessment principles to skillful systems work. If there is work in this area, I’d be interested to learn more about it.That said, I think it’s hard and we don’t have good models, but it is not impossible.  I see our trainees doing it exceptionally well.   It is demanding, but do it well because they are talented and devoted–and because we emphasize it, in part, because of my developing expertise in the area.  But I don’t think any of us yet has a clearly-enough articulated model to present as the standard of care.

I feel obligated to add here, that there are some equally hard questions that a family therapist could ask an individual therapist too.  Like…how can you possibly get a complete risk assessment picture without talking with family members, seeing the patient interact with them, understanding the family pathology and strengths?  How do you monitor warning signs without inside players?   I’ve lately been reading extensive case reports of people who died by suicide.  In each of the cases I read, it would have been impossible to understand the risk picture without extensive information from family members.  Many of those truly at risk of killing themselves just do not disclose enough and the right kind of information.

This is an area in much need of development.


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Categories : Needs development, clinical interview, family, health care delivery, risk assessment, suicide

“How bad has it gotten?”

9 01 2007

When I teach about clinical interviewing, I often recommend this phrase (or some variation) as an entry point to questions about suicidal ideation. This accomplishes a couple of things:

1. Frames the discussion about suicidal ideation as one that is exploring the person’s subjective experience and suffering, avoiding the impression of ticking through the required elements of a clinical interview.

2. It begins a sequential approach where it then feels logical to ask about the extremes of desperation.

3. Signals to the person that you want to hear the full extent of the pain.

The exact words don’t matter, of course, but it is probably helpful for each clinician to develop a few standard ways he or she enters in to the conversation. This could be one of them.


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Categories : clinical interview, risk assessment, therapeutic alliance