you know that there is hope. While it may not be evident now, things can get better and there are solutions to these problems other than dying.” ● Honesty and openness : Perhaps most importantly, do not be afraid to use the word suicide. When clinicians express an openness to talk about suicide or about killing oneself, adolescents may feel more comfortable sharing their experiences by using the word suicide as well. Finally, Shea (2002) describes six additional techniques that can assist in generating accurate data during the assessment: ● Behavioral incident : Cognitive distortions often present when clinicians ask about opinions instead of behavior. Behavioral incident is the technique of asking about specific behavioral events or concrete trains of thought, not opinions. ● Shame attenuation : This involves meeting patients where they are emotionally, to help reduce shame in reporting. An adolescent who feels that his or her parents are overly critical might be approached by saying, “Have you ever found that your parents are always on your case and chewing you out for no reason?” If the adolescent responds positively, it may be followed with “I wonder, then, if there are some things that you just avoid talking about with them.” This may lead to a discussion about such issues as risky behaviors or failing to do schoolwork which may produce a sense of shame, but with this approach, may be discussed more openly. ● Gentle assumption : This technique is designed to elicit sensitive material by gently making assumptions about the presence of some behaviors or thoughts. For example, instead of asking an adolescent, “Do you drink alcohol?” the clinician might begin with, “Tell me about your alcohol use.” This suggests to the adolescent that the clinician is aware that alcohol use is a possible behavior and it is acceptable to discuss it. ● Symptom amplification : This technique is based on the assumption that patients often downplay the frequency or amount of their disturbing behavior. Following up on the alcohol example above, the clinician might say, “So how much beer do you drink in one evening – a whole case?” While it may be unlikely that most teens will drink 24 beers Case study 7: Youth suicide risk assessment Hannah is a 17-year-old white female who presents at a youth crisis center after she reported in school that “life sucks. I just don’t want to be here anymore.” The school counselor was concerned about possible suicidal ideation, and school district policy requires a psychiatric evaluation when any level of suicidal concern is present. Upon initial interview, Hannah discloses that she once saw a therapist for depression, but “that was a long time ago and those problems have gone away.” When asked about her statement in school, she reports, “Sometimes people just bother me, and I just want to get away.” When directly asked about suicidal thoughts, Hannah admits that she occasionally thinks about it. Utilizing a decision tree model (Joiner et al., 2009), the interview continues: Clinician : Do you think about wanting to be dead? Hannah : Of course. That would just make things go away. It would be nice to go to sleep until everything was better. Clinician : Do you feel connected to other people? Hannah : I have a few friends at school. Clinician : Do you spend time with them outside of school? Hannah : Not really. Clinician : What about having someone to talk to when feeling sad? Hannah : I used to be able to talk to a few kids at school, but they are doing their own thing these days, so we don’t talk much.
in an evening, if the clinician amplifies the response, then the youth may more accurately report that he or she drinks 10 to 12 beers in an evening. Had the question originally been stated, “So how much beer do you drink in one evening – three or four?” that same youth who drinks 10 to 12 beers may simply respond “yes,” and the severity of the drinking behavior may not be accurately reported. Clinicians should not be surprised, however, if an adolescent actually responds, “yes” to drinking a full case in one evening. This is a data point that most clinicians would never get accurately without symptom amplification. ● Denial of the specific : Even when a youth denies a generic question such as, “Do you use any other street drugs to get high?” it may be surprising how many positive responses may come from asking specifically about a number of street drugs separately. It is important not to combine more than one example into each question, or the clinician may find it necessary to then determine which example was being affirmed. ● Normalization : Normalizing experiences, particularly for youth, may help generate an atmosphere in which the individual’s experience is not viewed as unique or the individual is not seen as the only one affected by something. Normalization allows the experience to be discussed. For example, instead of asking youth directly about withholding information from their parents, particularly about self-injury and other risky behaviors, it may be more helpful to suggest, “Teenagers often have difficulty talking with their parents about personal matters because they are afraid of how their parents might react. Are there times when this happens to you?” If the adolescent responds positively, then follow up: “What about more serious matters or things that your parents might find scary or confusing?” Although these elements to a successful assessment may appear overwhelming, they are merely strategies and techniques that can assist in the assessment process. Taking time to develop a therapeutic relationship with youth will make each of these strategies easier to employ. Clinician : I’m sorry to hear that. You know, somewtimes people feel that others would be better off without them. Do you ever feel that way? Hannah : I don’t know. I guess I sometimes think my parents would be happier if I wasn’t such a big problem. Clinician : When you think about suicide, how often do those thoughts last? Hannah : I try to just distract myself when that happens, so it’s usually only for a few minutes. Occasionally, I think about it for a while. Clinician : Like how long, when you think about it for a while? Hannah : Sometimes a few hours, but usually not. Clinician : On a scale of 1 to 10 with 10 being the strongest, how strong is your intent to kill yourself? Hannah : Oh, I don’t know. Maybe a 3 to 4. I’m not sure that I really want to die. Clinician : Have you ever tried to kill yourself? Hannah : No. Never. Clinician : Well, when you think about suicide now, what do you imagine you would do? Hannah : I don’t know. Probably something that wouldn’t hurt, but I don’t know where to find a gun, and I would probably screw up with pills or hanging and not die. That would just hurt. Clinician : Do you have access to pills or something to hang yourself with? Hannah : My mom takes something for her blood pressure, so I would probably take that. I don’t know if it would kill me, but I
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