Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors / Edition 1

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The Practical Art of Suicide Assessment covers all the critical elements of suicide assessment-from risk factor analysis to evaluating clients with borderline personality disorders or psychotic process. This highly acclaimed text provides mental health professionals with the tools they need to assess a client's suicide risk and assign appropriate levels of care using the highly acclaimed interview strategy for eliciting suicidal ideation-the Chronological Assessment of Suicide Events (the CASE Approach). Now available in paperback, the leading book on suicide assessment also contains three important new appendices: How to Document a Suicide Assessment Safety Contracting Revisited: Pros, Cons, and Documentation A Quick Guide to Suicide Prevention Web Sites

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Editorial Reviews

From the Publisher
"Shea's approach to suicide risk assessment is at once elegant in its simplicity and comprehensive in its scope and depth." (Preventing Suicide, 3/1/2004)

"This book is, to date, one of the most helpful and well-written works about the in-depth evaluation of suicidal patients." (The Journal of Nervous and Mental Disease, Volume 191, Number 10, October 2003)

Journal of Clinical Psychiatry
A concise, carefully conceptualized, well-written book . . . highly recommended for all psychiatric residents and all other mental health students.
American Journal of Psychiatry
This outstanding book is informative, interesting, and clinically useful.
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Product Details

  • ISBN-13: 9780471237617
  • Publisher: Wiley
  • Publication date: 8/8/2002
  • Edition description: New Edition
  • Edition number: 1
  • Pages: 336
  • Product dimensions: 6.00 (w) x 9.09 (h) x 0.60 (d)

Meet the Author

SHAWN CHRISTOPHER SHEA, MD, is a nationally acclaimed workshop leader and innovator in the field of diagnostic interviewing and author of the bestselling text, Psychiatric Interviewing: The Art of Understanding, Second Edition. He is also Director of the Training Institute for Suicide Assessment and Clinical Interviewing ( and Adjunct Assistant Professor at the Dartmouth Medical School in Hanover, New Hampshire.

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Read an Excerpt

The Practical Art of Suicide Assessment

A Guide for Mental Health Professionals and Substance Abuse Counselors
By Shawn Christopher Shea

John Wiley & Sons

ISBN: 0-471-23761-2

Chapter One

Suicide: The Ultimate Paradox

In this life it is not difficult to die. It is more difficult to live.

Vladimir Mayakovsky, Russian revolutionary (Died by suicide, 1931)


This exploration of suicide began on a Sunday in a most unlikely place: a drafty old bookshop on the outskirts of a small town in southern New Hampshire. As I entered the shop, the welcoming heat of the woodstove provided a sharp counterpoint to the crisp autumn air. I am a lover of books, and on that particular Sunday I spent the better part of the morning browsing the shelves and chatting with Henry, the always amiable shop owner.

I wandered about the aisles, hoping to stumble upon some secret treasure that others had unwittingly passed by. When I reached the section on psychology, I spotted what looked like a promising find. I pulled the book down and flicked it open to the title page. I stopped. For a moment, not a muscle in my body moved. My eyes held the name in sharp focus. I blinked and looked again at the name.

It was not the name of the author that caught my attention. It was the name of the previous owner, scrawled across the upper tip of the title page. Jackie, as I shall call her, had been a colleague in our small community ofmental health professionals. Jackie had killed herself some months before.

I placed the book back on the pine shelf. Perhaps a morbid sense of curiosity propelled me to pull out the volume sitting beside it. Different tip of a different page in a different book; same name. Next book, same name. Next book, same name. I realized then that either Jackie, in desperation, had sold off her book collection as her alcoholism swallowed her dreams, or else the books had been bought cheap from her estate. I quietly left the bookshop and drove home.


I begin with this incident because I believe that the chill that it created in me, and still creates in me as I write about it now, serves a useful purpose. It highlights the power of suicide to engender intense emotional reaction in all of us. For mental health professionals, an understanding of this reaction is one of the cornerstones of effective assessment and management of a suicidal patient. Many emotional currents dart beneath this chill: fear, grief, anger, puzzlement, and even condemnation. When unrecognized, these feelings can drag an unwary clinician into a sea of countertransferential responses and unproductive interventions. The potentially dangerous undertow, beneath this sea, can pull us away from the very people who most need our help: acutely suicidal patients.

When a clinician begins to understand his or her own attitudes, biases, and responses to suicide, he or she can become more psychologically and emotionally available to a suicidal client. Clients seem to be able to sense when a clinician is comfortable with the topic of suicide. At that point, and with such a clinician, clients may feel safe enough to share the immediacy of their pull toward death.

One of the goals of this book is to help readers become more comfortable with their own emotional responses to the topic of suicide. Hopefully, the reading of the book will also spur clinicians to discuss the topic of suicide in more depth with fellow therapists, supervisors, and trainees, for it is often only through such intimate conversations that we can more clearly see the undertows beneath our own personal seas. And here we meet one of the first paradoxes of suicide. As a topic for discussion, it is often avoided by clinicians; yet, discussion of it offers us one of the greatest gateways into personal, spiritual, and professional growth.

The opening vignette about Jackie is a reminder of the ubiquitous nature of suicide. No group of humans has a monopoly on suicidal behavior. It is seen in the rich and the poor, the famous and the unknown, male and female, older adult and child. Mental health professionals are far from immune to its draw; many of us have been touched by suicides among our friends, family members, and colleagues. Contemplation of suicide may even be part of our own past or future history.

It is important to realize that suicide "works" at some level; it provides a solution to intense personal pain. As life ends, the pain ends. Acceptance of the effectiveness of suicide is an important first step in a clinician's understanding of why suicide is relatively common. We humans are a solution-oriented species.

This does not mean that the clinician must agree with or accept the solution. We are all entitled to our own moral beliefs. But, without conveying judgment, the clinician can recognize why suicide presents as a natural solution for many people. When clients sense that they are not being "put down" for their choice of a solution, but rather, the clinician is seeking a more effective and life-enhancing solution, they may be more willing to explore other alternatives. The clinician's ability to convey a nonjudgmental understanding of the client's right to view suicide as a rational solution may introduce the rapport that is needed to help the client choose another solution. This irony is just one of the many contradictory elements of suicide.


The implementation of suicide is often one of the most private of all human actions, yet its impact on the people left behind could not be more profound. Self-destruction frequently crosses the minds of vast numbers of humans, but it remains among the most taboo of topics. Mental health professionals encourage the public to feel comfortable discussing suicidal thoughts, yet many of these same professionals are hesitant to ask family members or colleagues whether they are having such thoughts. Death is sometimes chosen as the only alternative by people who feel deeply alone or shamed, yet are profoundly loved and respected. The manner of suicide adds to the paradox. If a businessman takes his life in an effort to avoid scandal and the pain of admitting his wrongdoing to his family, he may be labeled as a coward; yet a soldier who jumps on a land mine to save fellow troops will undoubtedly be called a hero.

The paradoxical nature of suicide has not been lost on philosophers. Arthur Schopenhauer cogently captured the essence of the most ironic paradox of the suicidal act:

Suicide may also be regarded as an experiment-a question which man puts to Nature, trying to force her to answer. The question is this: What change will death produce in a man's existence and in his insight into the nature of things? It is a clumsy experiment to make, for it involves the destruction of the very consciousness which puts the question and awaits the answer.

Its paradoxical nature is one of the reasons that exploration and discussion of suicide, within the clinical interview, raise such powerful emotions in both patients and clinicians. Some of its greatest paradoxes still await us. They will surface as we begin to more carefully explore the nature of suicide by looking, first, at its epidemiology and then at some of the practical problems inherent in its prediction.


Suicide is one of our most pressing public health concerns. In the United States, suicide is the ninth leading cause of death in adults, with 30,903 suicides in 1996. It has been estimated that a suicide occurs every twenty minutes. In the age group of 15 to 25 years, suicide is the third leading cause of death in America (accidents and homicides are first and second, respectively). Between 1952 and 1992, the rate of suicide among adolescents and young adults tripled. And even though young children are much less likely to commit suicide, they still do. In the United States in 1995, 330 children, ages 10 to 14, killed themselves and seven children, ages 5 to 9, committed suicide.

The development of improved ways of spotting and providing relief to acutely suicidal patients could dramatically decrease one of the leading causes of death in both the United States and the world at large. As a society, we must openly address suicide as a public health problem and, as was done with smoking, aggressively address methods of decreasing its prevalence.

Is such a goal possible? Several studies have shown that roughly 50 percent of people who commit suicide have been seen by a primary care physician within the month prior to their death. This staggering statistic provides hope. If effective screening mechanisms can be developed and are subsequently embraced and effectively utilized by primary care physicians, a marked drop in suicide could result. This is not a pipe dream. It can happen.

But the task is formidable. Current research shows that clinicians have little ability to predict imminent suicide. For a moment, let us look at this problem of prediction more carefully. What are some of the factors that might help us to predict that a person is not acutely suicidal? In essence, what are the risk factors and what does the absence of these risk factors mean? (We shall examine these risk factors in much greater detail in Chapter 3, but a glance at them now will prove to be quite useful.)

Reproduced below are two pieces of writing, a letter and a poem. They contrast the types of reassuring circumstances versus risk factors that suggest whether suicide is or is not imminent. The author of the letter, which was addressed to her mother, had been suffering from depression for years. She had recently moved to England from the United States, a move that seemed to ease her ongoing battle, although she acknowledged that the transition was tough. In the letter, she displayed a sense of hope, an intense interest in the parenting of her children, and a deeply held conviction that she needed to be there for them. As you read the letter, note the strong framework for meaning (parental responsibilities, in this case) and the sense of hopefulness that suggest suicide is not near.

February 4, 1963

Dear Mother,

Thanks so much for your letters. I got a sweet letter from Dotty and a lovely hood and mittens for Nick from Warren and Margaret. I just haven't written anybody because I have been feeling a bit grim-the upheaval over, I am seeing the finality of it all, and being catapulted from the cowlike happiness of maternity into loneliness and grim problems is not fun. I got a sweet letter from the Nortons and an absolutely wonderful, understanding one from Betty Aldrich. Marty Plumer is coming over at the end of March, which should be cheering.

I have absolutely no desire ever to return to America. Not now, anyway. I have my beautiful country house, the car, and London is the one city of the world I'd like to live in with its fine doctors, nice neighbors, parks, theatres and the BBC. There is nothing like the BBC in America-over there they do not publish my stuff as they do here, my poems and novel. I have done a commissioned article for Punch on my schooldays and have a chance for three weeks in May to be on the BBC Critics program at about $150 a week, a fantastic break I hope I can make good on. Each critic sees the same play, art show, book, radio broadcast each week and discusses it. I am hoping it will finish furnishing this place, and I can go to [Devon] right after. Ask Marty for a copy of the details of the two places and the rent, and maybe you could circulate them among your professor friends, too.

I appreciate your desire to see Frieda, but if you can imagine the emotional upset she has been through in losing her father and moving, you will see what an incredible idea it is to take her away by jet to America. I am her one security and to uproot her would be thoughtless and cruel, however sweetly you treated her at the other end. I could never afford to live in America-I get the best of doctors' care here perfectly free, and with children this is a great blessing. Also, Ted sees the children once a week and this makes him more responsible about our allowance ... I shall simply have to fight it out on my own over here. Maybe someday I can manage holidays in Europe with the children.... The children need me most right now, and so I shall try to go on for the next few years writing mornings, being with them afternoons and seeing friends or studying and reading evenings.

My German "au pair" is food-fussy and boy-gaga, but I am doing my best to discipline her. She does give me some peace mornings and a few free evenings, but I'll have to think up something new for the country as these girls don't want to be so far away from London.

I am going to start seeing a woman doctor, free on the National Health, to whom I've been referred by my very good local doctor, which should help me weather this difficult time. Give my love to all.


Although this letter is a bit lengthy, I have chosen to include the entire piece, for it provides important clues to the types of risk factors that may be of value in suicide assessment. In this case, the absence of these risk factors is striking. It clearly points toward the patient's strengths and increases one's prediction of her safety in the near future.

Still, we must acknowledge that some of the risk factors that are described could suggest lethality. The author is in pain; she openly acknowledges it with her allusion to "feeling a bit grim." She also appears to be suffering from a significant psychiatric disorder, as reflected by her referral to a psychiatrist. Apparently, another risk factor-a recent loss, which sounds like a divorce-is also present.

On the other hand, the letter is filled with reassuring signs of renewed strength. With genuine enthusiasm, the author talks about the many aspects of Britain and London that she loves. She is very excited about her career possibilities, and feels appreciated by both her British peers and the British public. On an interpersonal level, she sounds supported and is grateful for the support: "I got a sweet letter from the Nortons and an absolutely wonderful, understanding one from Betty Aldrich." All of these are good signs suggesting a lowered risk for suicide.

The appearance of hopelessness would serve as a potentially ominous sign. But as we weigh the risk factors reflected in this letter, the absence of this frame of mind is conspicuous. The author sounds hopeful about her medical care and clearly plans to be around for quite a while: "...


Excerpted from The Practical Art of Suicide Assessment by Shawn Christopher Shea Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Foreword by David A. Jobes, PhD.

Preface to the Paperback Edition.


Acknowledgments to Paperback Edition.



1. Suicide: The Ultimate Paradox.

2. Descent into the Maelstrom: Etiology and Phenomenology of Suicide.

3. Risk Factors: Harbingers of Death.


4. Before the Interview Begins: Overcoming the Taboo against Talking about Suicide.

5. Validity Techniques: Simple Tools for Uncovering Complex Secrets.

6. Eliciting Suicidal Ideation: Practical Techniques and Effective Strategies.


7. Putting It All Together: Safe and Effective Decision Making.

Appendix A: How to Document a Suicide Assessment.

Appendix B: Safety Contracting Revisited: Pros, Cons, and Documentation.

Appendix C: A Quick Guide to Suicide Prevention Web Sites.


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