Suicide Assessment and Prevention

NOTE: At Jack Hirose's request, I am sharing with you an excerpt from my unpublished psychotherapy book which has the working title, Tools, Not Schools, of Therapy. I hope to publish the book. Therefore, please be advised that this is for your eyes only, and is not to be quoted or distributed in any way. If you have positive or negative feedback about this chapter, I would be pleased to hear from you: david@feelinggood.com. Thanks!

Chapter 8

By David D. Burns, M.D. (with Signe Burns)
©2001–2007

A colleague described a harrowing phone call from a depressed 24-year old woman suffering from Borderline Personality Disorder. She explained that she was lying on her dining room table and had just inserted a hypodermic needle into an artery in her right arm. She said, “Right now, I'm watching the blood spurt out and splatter on the wall with each heartbeat. It's entertaining. But don't worry. I'll take the needle out just before I bleed to death. In case I miscalculate and do die, I just wanted to thank you for all the help you've given me. You're the best! By the way, in case you try to call me or contact the authorities, I want you to know that I've just moved to a new apartment and I have an unlisted number, so there's no way you won't be able to track me down. That way, you won't have to feel guilty or upset if I do die. I know I'm not important to you, anyway.” Then she hung up on him.

The therapist spent the next three days struggling with intense feelings of anxiety, guilt, inadequacy, frustration, and anger. His desperate attempts to locate his patient were unsuccessful. Fortunately, she showed up at his office later in the week for her regularly scheduled therapy session. You might argue that her actions actually represented a “suicide gesture” or “plea for help,” and not a real suicide attempt. This line of thinking may be comforting but can be very misleading, because many of these patients eventually commit suicide.

In fact, the experts tell us that as many as 10% or more of chronically depressed patients commit suicide, even if they're receiving treatment. If patients have comorbid problems, such as alcohol or drug abuse, or serious personality disorders, the percentages are even higher. These are sobering statistics. I'm convinced that the vast majority of suicide attempts can be prevented – but it may require a significant shift in how you approach the problem.

You'll notice that the Brief Mood Survey [at end of story] includes two suicide-screening items along with a five-item depression scale as well as several other assessment instruments. If you require all your patients to complete the Brief Mood Survey at the beginning and end of every therapy session, you can see exactly how they feel and whether they've improved during the session. You'll also find out how they feel about you, and whether they felt the session was helpful. And most pertinent to this chapter, you'll also know the moment that they develop any suicidal urges. Then you can evaluate these feelings and take any steps that may be necessary to prevent a suicide attempt, such as hospitalization.

My colleagues and I ask our patients to come to their sessions five minutes early so they can fill out the Brief Mood Survey in the waiting room before the session starts. Patients can complete the "Before Session" section of the form (see page 14) indicating how they are feeling at that exact moment. It only takes patients about 60 seconds to complete that portion of the Brief Mood Survey. Then, when the session starts, you can record the patient's scores on the brief Depression, Suicide, Anxiety, Anger, and Relationship Satisfaction scales in the chart. This requires less than 30 seconds, and shows you exactly how the patient is feeling, and whether there have been any changes from the previous week. If the patient is feeling despondent or suicidal, you'll have plenty of time to evaluate these feelings during the session and take any steps necessary to prevent a suicide attempt.

All of the scales on the Brief Mood Survey will be relevant when you're evaluation the patient's suicidal potential. We all know that depression is strongly associated with feelings of hopelessness and suicidal urges. However, some experts believe that intense anxiety can also increase the likelihood of suicide. My own research indicates that feelings of anger and bitterness may be even more strongly associated with suicidal urges than feelings of depression and hopelessness. And the lack of support on the Relationship Satisfaction scale should tip you off that the patient may not feel loved or have a meaningful support network.

We record the patient's scores on the Brief Mood Survey on a one-page flow sheet that we keep at the front of the chart. This takes about 15 seconds at the start of the session. The flow sheet shows how the patient's feelings have change in several dimensions from the start of the therapy, so you can see exactly how much progress the patient is making. You can also see exactly how much the patient improves, or fails to improve, during sessions and between sessions.

If you look at the example on page 14 you'll see that the patient was feeling extremely depressed and struggling with suicidal thoughts and urges. In addition, he was anxious and angry, and indicated extremely poor satisfaction in his relationship with his wife. These symptoms need to be explored as the top priority in the session because the patient may be on the verge of a suicide attempt.

Following the session, you can hand the form back to your patients and ask them to fill it out in the waiting room once again and leave it for you. They can leave it with the receptionist, slip it under your door or put it in your mailbox before they go home. This time, they can fill out the "After Session" portion of the depression, suicidal urges, anxiety, anger, and relationship scales, along with the Evaluation of Therapy Session on page 15. This assessment instrument is photocopied on the back of the Brief Mood Survey. You can look at the form when the session is still fresh in mind and see immediately how the patient experienced the session.

Notice that the patient who filled out the Brief Mood Survey and Evaluation of Therapy Session did not improve during the session, but actually felt worse. Of particular concern is his sharp increase in suicidal urges. In addition, he did not experience much warmth or empathy from his therapist, and indicated that his therapist did not understand how he was feeling inside. He also indicated that the session was not helpful. This is a dangerous situation for a variety of reasons, but if you know what's going on, it will nearly always possible to intervene effectively.

Even if the patient wasn't suicidal at the start of the session, there could be an upsurge in suicidal feelings during the session because you touched on a sensitive topic. However, the patient may not have verbalized those feelings during the session. When you review the patient's response on the Brief Mood Survey following the session, you'll immediately spot any increase in suicidal feelings. If necessary, you can get on the phone and attempt to contact the patient immediately. This is rarely necessary but on occasion, it could save a patient's life.

The therapist in the example above called the patient and expressed concern. The patient seemed relieved and agreed to come back for an additional session the same day. When he returned, he confessed that he was feeling hopeless about his depression and angry with his wife, because he suspected she was having an affair. He was planning to shoot himself in front of her with a pistol he'd just purchased at a gun shop. The patient agreed to be hospitalized and eventually recovered.

Of course, no therapist can be 100% effective, and some patients will commit suicide no matter what. Their deaths represent needless and horrible tragedies for themselves, their families and friends, and their therapists.

An attorney told me that he had to defend a psychiatrist in a malpractice suit. Apparently, the patient committed suicide several hours after his therapy session, so the family sued. When the attorney was reviewing the chart, he discovered that the patient had filled out the 15-item version of the Burns Depression Checklist the day that he committed suicide, and indicated that he had no suicidal fantasies or urges at that time. The attorney showed the test to the judge, who ruled that one of two things must have happened: either the patient intentionally deceived the psychiatrist, or something upsetting had happened immediately after the session that triggered the suicide attempt. The judge ruled that patients have the right to fool their psychiatrists, but when they do, psychiatrists cannot be held responsible for the patient's death. The judge threw the case out of court.

Luckily, most patients are honest when they fill out the Brief Mood Survey, and so these instruments can prevent many needless tragedies. Even if the tests fail to protect the patient, because of willful deception, they may still protect you. Make sure you record the patient's scores on these tests in the chart, and document your thinking in case there's an emergency. When in doubt, obtain a consultation from a colleague and document the consultation in the chart.

You can see the Suicide Assessment Interview I've developed at the end of the story. The interview takes about 15 minutes and is well worth the time. If you have any doubts about the patient's feelings about suicide, the interview could be life saving.

I keep photocopies the Suicide Assessment Interview available in my office so I can grab one and fill it out while I'm asking the questions. The interview helps me clinically, because it reminds me of the most important questions to ask. I put the completed form in the patient's chart, where it serves as documentation of the fact that I did a thorough job of assessing the patient's suicidal feelings.

Remember that the questions on the interview are just general guidelines. Ultimately, you'll have to rely on your own clinical judgment whenever you assess a suicidal or homicidal patient. Any structured interview is only intended to guide you through some of the most relevant topics you'll need to explore.

Pay careful attention to items #19 – 21. Patients must persuade me that they will not make a suicide attempt, no matter what, if they want to work with me as outpatients. I don't feel that it's my job to persuade them not to make a suicide attempt. It's the other way around. They have to persuade me to work with them. If they can't convince me that they're completely safe, then outpatient treatment is not indicated because it's simply too risky. In this case, I would pursue other treatment options with the patient, such as voluntary or involuntary hospitalization. It is best to negotiate this at the initial evaluation, before you've accepted the patient for treatment, but this type of negotiation can occur at any point during the therapy.

Of course, trust and openness are crucial to successful treatment, and patients have to feel free to discuss any suicidal or homicidal fantasies. There are many CBT techniques that can help patients overcome feelings of hopelessness, worthless, desperation, or anger. However, I can only do this kind of work if I'm convinced that the patient and I are both safe, and that we're not playing Russian roulette. I want to go home at night with peace of mind, without having to worry that the patient may do something self-destructive or violent in the middle of the night. That's why all my patients have to convince me that they will not, under any circumstances, make a suicide attempt if they want to work with me.

In my experience, this approach is radically different from the way 99% of my colleagues approach the problem of therapy with the suicidal patient. First, they almost never assess the patient's feelings of depression, anger, anxiety, and relationship satisfaction, as well as suicidal urges, at every session, much less at the start and end of every session. Second, they almost never make suicidal urges a topic of negotiation with the patient. Rather, they feel it is their job to persuade the patient not to make a suicide attempt. This stance, unfortunately, gives the patient tremendous power to manipulate the therapist. This type of manipulative behavior can be especially problematic if the patient is suffering from Borderline Personality Disorder.

When you've completed the Suicide Assessment Interview, you can summarize your recommendations. When in doubt, check with a colleague who has expertise in treatment of depression and in the evaluation of patients with suicidal urges, and document your consultation in the chart. This is another form of malpractice insurance.

It's my understanding that you can't be successfully sued for coming to the wrong conclusion about a patient. You can only be sued for failing to do sound, competent work. Although there's a great deal you can do to drastically reduce the probability of a suicide, you can never provide any absolute guarantees. That's why the documentation of your assessment is vitally important. It will help you clinically and legally. You'll be head and shoulders above the majority of your colleagues who do not approach this problem nearly so systematically.

Although violent fantasies are probably not as common as suicidal urges, they do occur. Remember that your perceptions of how patients feel won't usually be accurate. That's why assessment instruments on the Brief Mood Survey can be so vitally important. If the patient has an elevated score on the anger scale on the Brief Mood Survey, you can ask who they're mad at and determine whether they have any violent fantasies or urges to do something violent. Violent fantasies are common, and they're not usually dangerous. However, if the patient is struggling with the urge to hurt someone, then you'll have to do a thorough violence assessment and document your impressions in the chart. If the patient threatens to hurt someone, you may have to contact the authorities and warn the victim as well. If in doubt, get a consultation immediately from a colleague with expertise in the assessment of violence, and document the consultation in the chart.

Questions You May Have

1. Why would I have to use the Brief Mood Survey and Evaluation of Therapy Session? Aren't my clinical impressions good enough?
Our research and clinical experience indicate that clinicians' impressions of how their patients feel, and how their patients feel about them, are not at all accurate. The correlations between how patients feel, and how their therapists think their patients feel, are shockingly low. The consistent use of the Brief Mood Survey with all your patients at every session can make an enormous impact on your understanding of your patients and your clinical effectiveness as well.

2. What if patients aren't honest when they fill out the forms? Won't they just tell me what I want to hear?
In my experience, patients are surprisingly honest. Take the five-item Therapeutic Empathy subscale on page 15 for example. Scores of 19 or below on this test indicate significant failures in the therapeutic alliance that need to be addressed. When clinicians use the Brief Mood Survey for the first time, they discover that they have made significant empathy failures in 50% to 100% of their sessions. This type of information can be a shock to the system, but if you address the patient's perceptions tactfully and non-defensively, the dialogue can be extremely helpful. So the real problem is that patients will tell you what you don't want to hear! If you have courage and humility, the consistent use of the Brief Mood Survey and Evaluation of Therapy session can greatly boost your therapeutic effectiveness and transform your treatment skills.

Notice the "Difficulties with the Questions" subscale on page 15 (items 18 – 20). Some patients will indicate that they did have trouble answering some of the items honestly. If so, you can ask them which items they had the most trouble with. If you do this in a warm and respectful tone of voice, they will nearly always open up and tell you right away.

Ultimately, you cannot rely on any test to do your thinking for you. You will have to evaluate the findings, just as a medical doctor has to interpret blood tests and x-rays. If you have reason to suspect that the patient isn't being entirely honest, use your interviewing skills to probe more deeply. There are situations where patients may, in fact, try to make themselves look worse than they really are. For example, let's say that the patient is applying for disability or is involved in a lawsuit. There are also situations where patients may try to make themselves look better than they really are. An example would be an involuntarily hospitalized patient who is desperately trying to get out of the hospital.

These tests will provide you with an abundance of invaluable data you would not otherwise have access to. The interpretation of the tests, and the way you dialogue with your patients, will reflect your skills, sophistication, and compassion.

3. Won't these forms make me more liable in case a patient commits suicide and I'm sued?
I'm not an expert in legal issues. As a clinician, I want the information. If a patient is suicidal, I want to know about it so I can try to prevent the suicide attempt. In my opinion, not knowing how a patient feels is a fool's insurance. I doubt it would make for a good defense in court. But if you do collect this type of data, you will want to use the information in a responsible way and document your thinking and clinical decisions in the chart.

4. Where do the patients get blank copies of the Brief Mood Survey to fill out before the session starts?
We ask patients to photocopy their own supply and bring a blank Brief Mood Survey to each session.

5. What if the patient doesn't want to fill out these forms?
This is not negotiable. At the initial evaluation, I let patients know that this is a necessary part of the treatment. If they feel strongly that they do not want to fill out the forms for any reason, I let them know that I cannot accept them for treatment but can refer them to another therapist. I have never had a patient refuse treatment for this reason. However, you do have to be firm about it.

5. When do you talk to patients about their responses on the Evaluation of Therapy Session?
You will not get the patient’s completed Evaluation of Therapy Session until he or she has left the office, so you can discuss their positive and negative perceptions of the session at the start of the next session.

6. I notice the forms are copyrighted. How can I get access to them?
I'm not pushing for you to use these particular forms, as there are a variety of assessment tests available in the marketplace. If you like these instruments, you can purchase a copy of my Therapist's Toolkit. There are hundreds of pages of assessment and treatment tools. The Brief Mood Survey is just one of a large number of instruments I have developed. When you purchase a Toolkit, you’ll receive a license to photocopy all of these assessment and treatment tools in unlimited quantities for the rest of your career – so you will no longer have to pay royalties each time you administer a test. The Toolkit also contains information about the reliabilities and validities of the instruments, which are outstanding. Feel free to email me (david@feelinggood.com) for more information.

DOWNLOAD LINK REMOVED - The assessment forms are available as part of the Therapist's Toolkit, for sale through Dr. David Burns. www.feelinggood.com for more information.