Week 3 Discussion: Client Case, Summary & Reflection Chapter 4,5&6

Sequence of Questions that may be Helpful for Inquiring about Specific Aspects of Suicidal Thoughts, Plans, and Behaviors

Begin with questions that address the patient’s feelings about living

Have you ever felt that life was not worth living? Did you ever wish that you could go to sleep and just not wake up?

Follow up with specific questions that ask about thoughts of death, self-harm, or suicide Is death something you’ve thought about recently? Have things ever reached the point that you’ve thought about harming yourself?

For individuals who have thoughts of self-harm or suicide When did you first notice such thoughts? What led up to the thoughts (e.g., interpersonal and psychosocial precipitants, including real or imagined losses; specific symptoms such as mood changes, anhedonia, hopelessness, anxiety, agitations, psychosis)? How often have these thoughts occurred (including frequency, obsessional quality, and controllability)? How close have you come to acting on those thoughts? How likely do you think it is that you will act on them in the future? Have you ever started to harm (or kill) yourself but stopped before doing something (e.g., holding knife or gun to your body but stopping before acting, going to the edge of a bridge but not jumping)? What do you envision happening if you actually killed yourself (e.g., escape, reunion with significant other, rebirth, reaction of others)? Have you made a specific plan to harm or kill yourself (If so, what does the plan include)? Do you have guns or other weapons available to you? Have you made any particular preparations (e.g., purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid discovery, rehearsing the plan)? Have you spoken to anyone about your plans? How does the future look to you? What things would lead you to feel more (or less) hopeful about the future (e.g., treatment, reconciliation of relationship, resolution of stressors)? What things in your life would lead you to want to escape from life or be dead? What things in your life make you want to go on living? If you began to have thoughts of harming or killing yourself again, what would you do?

For individuals who have attempted suicide or engaged in self-damaging action(s), parallel questions to those in the previous section can address the prior attempt(s). Additional questions can be asked in general terms or can refer to the specific method used and may include:

Can you describe what happened (e.g., circumstances, precipitants, view of future, use of alcohol or other substances, method, intent, seriousness of injury)? What thoughts were you having beforehand that led up to the attempt? What did you think would happen (e.g., going to sleep versus injury versus dying, getting a reaction out of a particular person)? Were other people present at the time? Did you seek help afterward yourself, or did someone get help for you? Had you planned to be discovered, or were you found accidentally? How did you feel afterward (e.g., relief versus regret at being alive)? Did you receive treatment afterward (e.g., medical versus psychiatric, emergency department versus inpatient versus outpatient)? Has your view of things changed, or is anything different for you since the attempt? Are there other times in the past when you’ve tried to harm (or kill) yourself?

For individuals with repeated suicidal thoughts or attempts About how often have you tried to harm (or kill) yourself? When was the most recent time? Can you describe your thoughts at the time that you were thinking most seriously about suicide?

When was your most serious attempt at harming or killing yourself? What led up to it, and what happened afterward?

For individuals with psychosis, ask specifically about hallucinations and delusions Can you describe the voices (e.g., single versus multiple, male versus female, internal versus external, recognizable versus nonrecognizable)? What do the voices say (e.g., positive remarks versus negative remarks versus threats)? (If the remarks are commands, determine if they are for harmless versus harmful acts; ask for examples) How do you cope with (or respond to) the voices? Have you ever done what the voices ask you to do? (What led you to obey the voices? If you tried to resist them, what made it difficult)? Have there been times when the voices told you to hurt or kill yourself? (How often? What happened?) Are you worried about having a serious illness or that your body is rotting? Are you concerned about your financial situation even when others tell you there’s nothing to worry about? Are there things that you’ve been feeling guilty about or blaming yourself for?

Consider assessing the patient’s potential to harm others in addition to him- or herself Are there others who you think may be responsible for what you’re experiencing (e.g., persecutory ideas, passivity experiences)? Are you having any thoughts of harming them? Are there other people you would want to die with you? Are there others who you think would be unable to go on without you?

Source: American Psychiatric Association. (2003). Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors. http://www.psych.org/psych_pract/treatg/pg/pg_suicidalbehaviors.pdf