Tuesday, September 11, 2012

The Chronological Assessment of Suicide Events (CASE) Approach: Interview and Role Play with Shawn Christopher Shea, M.D.

[Episode 74] Today’s Social Work Podcast is an interview with Shawn Christopher Shea, M.D., developer of an approach to uncovering suicidal ideation and intent called the Chronological Assessment of Suicide Events (CASE) approach. In today’s episode, Shawn takes us through the CASE approach. He explains the value of assessing for suicidal content at different time points and emphasizes that eliciting suicidal ideation and intent is a difficult and sensitive topic. He talks about how moving through the CASE approach to help establish a therapeutic alliance and rapport with suicidal clients. He emphasizes the art of the interview, using validity techniques, and how we use words as central to uncovering suicidal ideation and intent. He talks about how the CASE approach is useful for any mental health provider. Shawn makes the argument that the CASE approach is an ideal approach to for assessing for suicidal risk that doesn’t sound like a pat suicide assessment. He emphasizes that the CASE approach is one-third of a thorough suicide assessment, the other two parts being identifying risk and protective factors, and the final part being developing a clinical formulation.
This figure represents the three components of a thorough suicide assessment. The CASE approach  provides a framework for assessing the information in the red square (ideation, plan, behaviors, desire, and intent).
Shawn has written that a thorough suicide assessment has three parts: 1) Gathering information related to risk factors, protective factors, and warning signs of suicide; 2) Collecting information related to the patient’s suicidal ideation, planning, behaviors, desire, and intent; and 3) Making a clinical formulation of risk based on these 2 databases. He writes that in the “clinical and research literature, much attention has been given to the first and third tasks (gathering risk/protective factors/warning signs and clinical formulation). Significantly less attention has been given to the second task—the detailed set of interviewing skills needed to effectively elicit suicidal ideation, behaviors, and intent. But in many respects, it is the validity of the information from the second component that may yield the greatest hint of imminent suicide.” (Shea, 2009, p. 1).

My interview with Shawn is a single episode in two continuous parts. In Part I Shawn and I talk about the CASE approach, including some of the validity techniques he has developed or uses to elicit suicidal ideation and intent. In the second part Shawn and I do a role play where he uses the CASE approach. 

Download MP3 [1:05:09]

Bio (from his website):
Shawn Christopher Shea, M.D. is an internationally acclaimed workshop leader and innovator in the fields of suicide prevention, building resiliency, clinical interviewing, and improving medication adherence having given over 850 presentations worldwide. He is the creator of the highly acclaimed interviewing strategy for uncovering suicidal ideation and intent - the Chronological Assessment of Suicide Events (the CASE Approach). His other clinical interviewing innovations, including facilic supervision, macrotraining, and the Medication Interest Model (MIM) have been adopted around the world with his writings being translated into a variety of languages as diverse as French, Greek, Japanese, and Chinese.


Jonathan Singer: Today’s Social Work Podcast explores the issue of, “how do we know if our client wants to die by suicide?” Uncovering suicidal ideation and intent is one of the most challenging things that clinicians are expected to do. And if you can’t do that, then you can’t really do a thorough suicide assessment. And, as we all know, doing a thorough suicide assessment is one of the basic expectations of clinical social work. So, even though one of my first episodes of the Social Work Podcast addresses suicide assessment, I wanted to provide more in-depth information on the topic. So, I was very glad to be able to talk with one of the leading experts in the world, Shawn Christopher Shea.

I’ve known Shawn for a number of years. He and I served on a committee together through the American Association of Suicidology, developing a workshop on Recognizing and Responding to Suicide Risk. Shawn developed an approach to uncovering suicidal ideation and intent called the Chronological Assessment of Suicide Events, or CASE, approach. He developed this over years, doing the work. This wasn’t developed in a research lab conceptually. I’m a big fan of this approach. I love Shawn’s book, “The Practical Art of Suicide Assessment” and I took his half-day workshop on the CASE approach a couple of years ago. I find his techniques and this approach to be ideal for clinicians.

Today’s episode is a little bit different from most episodes that I publish, for a couple of reasons. One, this is the longest episode I’ve ever published. It clocks in at over an hour. And, I’m not going to do a big long intro because I want to get right to the heart of the interview. There are really two parts to the interview. The first part is a conversation with Shawn where we talk about the CASE Approach, the importance of using specific techniques to uncover ideation and intent, as well as the importance of asking about ideation and intent both at the present moment but also at points in the past. And the CASE approach sets out a nice easy way of remembering and figuring out how to do that.

What happens next in this interview is that, I ask Shawn if he could do a role play. I was sitting there and I was thinking “this stuff is really, really valuable. And it is great to talk about it conceptually. But, wouldn’t it be so much better if we could do a demonstration?” And, Shawn was fantastic. He said, “sure, let’s go for it.”

So the second part of the interview, we do a role play where I’m a suicidal teenager and he’s a school counselor using the CASE Approach. Now, a quick word about the role play. It is an intense role play. We talk about suicide. We talk about ways that a teenager might kill himself. We talk about bullying, about feelings of isolation, sadness, and hopelessness. We talk like I’m actually at risk for killing myself. I am not an actor, so I doubt if anyone is going to forget that it is a role play. But, in the spirit of full disclosure, and recognition that this is one of those topics that can bring up a variety of reactions - some that you might not want to have while running on the treadmill or sitting in your university’s computer lab, this is an intense episode. The good news is that Shawn models genuineness, empathy and unconditional positive regard, as well as a deep understanding of how to figure out if someone is suicidal.

And so, without further ado, on to Episode 74 of the Social Work Podcast: The Chronological Assessment of Suicide Events (CASE Approach): Interview and Role Play with Shawn Christopher Shea, M.D.

Jonathan Singer: Shawn, thank you so much for being here today and talking with us about assessing suicidal ideation, working with folks who are suicidal. I really appreciate you're taking the time.

Shawn Christopher Shea: It's a delight and an honor to be here Jonathan. I'm excited.

Jonathan Singer: Could you talk about the CASE Approach?

Shawn Christopher Shea: Yeah. The CASE Approach is an interviewing strategy for helping all of us in the frontlines to help our clients to feel more comfortable literally sharing their suicidal ideation, their behavior, their planning and especially their intent. And it's literally built with a series of interviewing techniques that are flexible. Nobody, certainly not I, am saying this is the right way to uncover suicidal thought or a standard of care or anything like that, but I think it's a reasonable way to uncover suicidal thought and ideation and intent. And the CASE Approach ultimately - and stands by the way, for the Chronological Assessment of Suicide Events (that’s what the acronym is) - but it's a framework that can allow all of us to find our way for uncovering suicidal ideation and attempt. Because I'm absolutely convinced the way you and I and all of your listeners elicit suicidal ideation - the actual words we use - changes the database. And the CASE Approach allows us to say “well, how do I do it compared to this and do I like this about it?” And by the way, I invite anybody who’s interested in the CASE Approach, the things you like about it, hopefully you'll adapt. Things you don’t like, you should throw out and not do. No one should do anything in an interview they're uncomfortable with. And also hopefully we'll generate an excitement about the power of interviewing and principles of how you can study what you're already doing and find those things and make them even better.

Jonathan Singer: So, the chronological aspect–

Shawn Christopher Shea: Yeah.

Jonathan Singer: Does that mean that you start with sort of what's oldest and then come to what's newest or what does it mean for the chronological assessment?

Shawn Christopher Shea: Right. Once again, to emphasize one aspect of it, it's not about risk and protective factors which are very important and you're going to garner those in a different part of your interview. This is really looking at just one specific set - pieces of information - which is the actual suicidal behavior and intent of the person. So, it focuses on what types of behaviors and thoughts have they demonstrated that might reflect that they really do intend to kill themselves. And so we do that by going chronologically to make sure we're not missing something.

So, it starts with you would hopefully sensitively raise the topic using, for instance, a technique called Shame Attenuation, which focuses on the pain of the person. You might say, you know, “Jonathan with all of your pain, have you been having any thoughts of killing yourself?” And so that brings that up to the recent, the suicidal ideation a person has and you explore that sensitively, but comprehensively so you really understand the angst and the amount of planning and the intent behind it.

Then you shift - it's why it's called chronological is we didn’t go over what we call recent suicidal thoughts and behaviors, so that’s the previous two months before the interview. And that’s a gold mine of information of the person’s actual pain, but also the degree with which they're actually thinking about killing themselves, planning it out, practicing it.

And then you shift to past suicide attempts.

And then the final timeframe, which is one that’s often I don’t think emphasized enough, is that we actually then shift the whole way back to the present moment and explore what the person has been thinking about suicide while we're actually speaking. So, a person you know by the way, in an emergency room for instance could be sitting there while you're interviewing them going “I just wish this guy would shut up and I'm going home and shoot myself.” Or they can be in an inpatient unit and the person who might have died by suicide say two days after discharge, last couple of people they might have seen they might have been sitting there just saying to themselves say what he wants, get home, get the gun. Say what wants – so, those are people having suicidal thoughts while they're being interviewed and we really think that’s important to tap.

Jonathan Singer: So, you start out with what's going on in the moment, go back two months, go back–

Shawn Christopher Shea: Yes.

Jonathan Singer: – a lifetime, the past and then you come right back–

Shawn Christopher Shea: To right now.

Jonathan Singer: – to right now.

Shawn Christopher Shea: And one of the things the reason we do it in that order is that it is really hard for people to talk about suicide. I mean, perhaps somebody who’s coping with borderline process might talk about it a fair amount to get some relief and a sense that people care. The typical person really doesn’t want to talk much about their suicidal thought. Many people who die by suicide might leak it to a family member. You know they might say something like don’t worry about me or you won't have to worry about me in six months or in the summer, but it is the rare person who would sit down and say, “Oh and by the way, I'm thinking of shooting myself and you know last night I had a gun out and I had it loaded and I had it in my mouth and my mouth is in the…” They don’t say stop right there.

Jonathan Singer: Right. They're not going to do your assessment for you.

Shawn Christopher Shea: No. No, they don’t.

Jonathan Singer: Yeah.

Shawn Christopher Shea: And they don’t say that to the family members is what I'm saying. So, they have to shoulder the shame and the guilt and the stigma. So, if the interviewer is actually very matter of fact and open and sensitive, but comprehensively about asking them about their suicidal planning and they realized that “this guy is neither, you know, overreacting to jump and put me in a straightjacket or underreacting like he’s afraid of this. He doesn’t want to talk about it, but geez this guy is just talking to me about my suicidal thought. It's a safe place to talk.”

And what we find is that very often as people go through these chronological aspects of the CASE Approach, the therapeutic alliance often strengthens, because you're probably the first person in their life that they’ve ever been able to share this type of stuff with. And so then as it gets better and better the therapeutic alliance, we wait until the last part of the CASE Approach to ask about right now, do we need to be worried about what you're – because we want the therapeutic alliance as powerful as possible before you ask about something that critical.

Jonathan Singer: So, you're doing all of this work so that they can believe in you.

Shawn Christopher Shea: Sure, yeah.

Jonathan Singer: Yeah. But you also said that there's a lot of shame and stigma associated with suicide. So what are some of the ways that you address that respectfully or do it in such a way that you're not shaming and stigmatizing them?

Shawn Christopher Shea: Right. Well, one thing is is first of all, the timing of this which is you know, the CASE Approach, this interview strategy which is very flexible. I mean, you pick and choose and match it to the uniqueness of the human being. You know, the first thing is when you're going to do it. And obviously you don’t do it right off the bat with somebody. You wait until you’ve already done the good stuff we all do which is engage well, communicate empathy, good eye contact, so it's usually done deeper into the interview if it's a 60-minute interview or an intake of 15, you know, it's usually done in 20 minutes or 30 minutes, so you’ve already engaged the person -hopefully very well.

And then the techniques themselves are even themselves engaging. I'm a huge proponent that there's not an antagonism between sound data gathering and the communication of empathy when they are both done well. And so the CASE – people who like to tell their story. And so what it does is it helps people to walk through what they're actually experiencing. It borrows from several well-known interviewers, validity techniques and some of the validity techniques that I myself have developed, and it weaves them together sensitively.

For instance, I demonstrated the one technique, shame attenuation, which is a nice way to raise the topic. You cue off of their pain to attenuate their shame. So, as I said, “you know, with all your pain, have you been having any thoughts of killing yourself?” Another way of getting at it to raise the topic is a technique that I developed called Normalization. Normalization, I help you to feel safe to communicate something that is awkward like suicidal ideation by letting you know I've heard this from other people. So, I might say, “Jonathan sometimes people who have been dealing with so much pain as you have been talking about in the past, you know, 15 minutes, they find themselves having thoughts of killing themselves and I'm wondering if those thoughts have your mind.”

And boom, you're right in there. But I want to emphasize one thing that’s, you know, I think this is both hopefully very useful to people, but it's also very intellectually exciting because we're learning how to use language well, is that all of the validity techniques, these specific techniques like normalization, shame attenuation, there's a whole bunch of them, gentle assumption, they weren't developed for uncovering suicidal ideation. They were developed by clinical interviewing experts to uncover any sensitive material. Incest, substance abuse, domestic violence, obviously something like suicide, so for people who learn how to do the CASE Approach, they're actually learning validity techniques that they can use with absolutely every client that you see every time you're seeing them because you're uncovering sensitive material and so that’s what we do.

Jonathan Singer: So, how many validity techniques are there? I mean, do people have to learn like 50 or–

Shawn Christopher Shea: Oh, no, no. There's about six or seven validity techniques that are used in the chronological assessment of suicide events. In the literature though, you know, I've just written in one my one textbook, on just clinical interviewing, I now have a whole chapter just on validity techniques and there's many more of them, you know, seven. There are all sorts of validity techniques that are used on all sorts of different circumstances. The ones in the CASE Approach that are very popular or the two ways of raising a sense of topic, shame attenuation, normalization which I've already talked about then once you’ve raised the topic, it's how do you explore it in a sensitive way.

So, there's an interviewing technique called The Behavioral Incident by Gerald Pascal. There's an interviewing technique called The Gentle Assumption which was developed, I believe it's by Pomeroy. Then there's an interviewing technique called Denial of the Specific which we developed. There's one called Symptom Amplification which we developed and all of these are utilized to explore the suicidal ideation in more sensitive yet thorough way.

Jonathan Singer: And these are the things that you talk about in your book on the CASE Approach.

Shawn Christopher Shea: Oh, absolutely.

Jonathan Singer: So, if people want to know more about how to learn how to do these, they can get the–

Shawn Christopher Shea: Oh, they certainly can. I mean, you know, one thing just so people knows. You can learn all about the CASE Approach without even buying the book. If you go to our website which we can talk about I suppose later, there's a free PDF, a nice little monograph, a published monograph, on the CASE Approach which is a free download. Now, the book itself The Practical Art of Suicide Assessment, that covers the CASE Approach, but that’s all about all sorts of aspects of suicide assessment, so that also talks about risk and protective factors and warning signs. It talks about the etiology. An entire chapter on formulation and how you put it altogether whether you're working with a person with borderline process or psychotic process even have a document effect, so the book covers much much more than the CASE Approach.

Jonathan Singer: And so with the CASE Approach, this is something that a clinician could use that doesn’t work in an emergency department or doesn’t see folks who are suicidal like as their job. But you know maybe work in a domestic violence shelter or something like that and they start to think well, maybe this person might be suicidal. Is that how it starts for people who don’t know that they're going to be working with folks who are suicidal?

Shawn Christopher Shea: Yeah, I mean, you can – I mean, the chronological assessment of suicide events, the CASE Approach is, you know, literally a flexible interview and strategy, so it can be used by all mental health professionals in all disciplines in any situation, so whether it's your initial meeting with someone or whether you're seeing them on an inpatient unit, whether you're in private practice and you're doing psychotherapy and counseling, it's quite popular with substance abuse counselors. In fact, there was a lead article on it in Counselor magazine. So yeah, anybody – by the way, anybody that I think you're meeting for an initial assessment, you should always do a suicide assessment, you know, no matter what they're presenting with because you have no – it's such a taboo topic. You have no idea.

And how do you weave it into that conversation? And one of the things that we really emphasize and that I think anyone of listeners who learn about the CASE Approach and flex we learn how to utilize it is it's really designed to feel extraordinarily conversational, you know, to the client. You have absolutely no idea that you're actually using specific interviewing techniques to help them to share these materials. So, it's just simply feels, when it's done well, like I'm really just with somebody who’s a great listener, who cares. And of course, hopefully they are. But that great listener who cares is also a skilled clinician and they are actually using techniques that a best friend could not use. And that’s why people come to us because we have an expertise that even an emphatic listener who’s a friend does not have. So, hopefully, we’re as emphatic as a best friend, but we also – there are interviewing techniques that have, you know, good evidence-based that they help people to share difficult material and that’s what it's all about. We are very guardedly optimistic that the CASE Approach can really save a lot of lives. I've been doing a lot of work with our military and a lot of work in high schools, colleges and we think that it can help in a lot of different places.

Jonathan Singer: So, at the end of doing a suicide assessment using the CASE Approach, what is it that a clinician should be able to do or should know?

Shawn Christopher Shea: It raises an interesting point that’s not I think talked enough about in the literature, that a suicide assessment is actually not a single thing. It's an ongoing process and it actually is composed of three different processes or tasks. There are two data gathering tasks. 1) You uncover risk and protective factors and warning signs. And then there's another whole set of data that you need to gather which is 2) the unique suicidal ideation, behavior planning and intent. That’s the phonological, that’s the human part of it. So, it's like you're putting a jigsaw puzzle together. Those are the two bags of puzzle pieces that you have to uncover.

Jonathan Singer: And so when say like gathering the risk factors and warning signs, so you're talking about like risk factors might be you're like a 65-year-old white male who is living alone, owns a gun–

Shawn Christopher Shea: Right, right.

Jonathan Singer: Right. Sort of the things that are statistically–

Shawn Christopher Shea: Yeah, the classic risk factors of family, history, a sense of loss or ongoing pain, medical illnesses, presence of a specific diagnosis and so those are the two data areas: 1) is the classic risk factors and protective factors and then 2) the unique suicidal ideation, behavior planning. So, those are two components of a suicide assessment. The third component has nothing to do with the interviewing or data gathering. It's after you gather those things, how do you formulate it and that’s a pure, cognitive and intuitive process. And sometimes we don’t emphasize intuition and intuition really does play a role in how we put this all together, but what's important to realize is a true suicide assessment has all three of those components.

The CASE Approach just to be, you know, really clear because it actually has a very modest goal to it. It isn't a suicide assessment protocol. It doesn’t cover all three of those things. It is actually simply an interviewing strategy to uncover one of the bags of the puzzle pieces - the suicidal ideation, behavior, planning and intent. It says nothing about how to gather risk and protective factors and warning signs. You have to do that in a different part of the interview either before you do the CASE Approach or after you did the CASE Approach. and it says absolutely nothing about how you put it all together, you know, the clinical formulation.

What it does is it just makes sure that that one bag of puzzle pieces, which by the way, I think is extraordinarily difficult to garner the truth on, the actual intent of the patient, that that bag of puzzles pieces, the interviewer has the best possible pieces that they can get so they can plug that into their own formulation of risk. So, it has a very modest task. What I would argue is arguably one of the most important if not the important task of a suicide assessment or at least it's a foundation. I always use the analogy it's like a computer: garbage in, garbage out. You could be the best clinical formulator in the world if the client has not shared with you their real intent, you can't possibly come up with a good suicide assessment.

Jonathan Singer: Right. It could be – sound beautiful when you're stuffing it, you know, with your supervisor, the psychiatrist or whomever and you're actually telling them crap–

Shawn Christopher Shea: Right.

Jonathan Singer: – because you’ve gotten above.

Shawn Christopher Shea: Because you don’t have the truth.

Jonathan Singer: Yeah, because you don’t have the truth.

Shawn Christopher Shea: You don’t have the truth, and as you know, this is just one area of what I'm interested in clinical interviewing and so I've been studying clinical interviewing for almost three decades and I'm very convinced that we can train ourselves and train our staffs and the people that we ourselves are supervising to really do surprisingly sophisticated interviewing and it is an art, but it's not just an art. It's also a craft and it's a skill set. And one of the things is it really needs to be practiced and crafted and you know, I think especially for instance in schools of social work and counseling, it has been emphasized that you have to learn interviewing skills by people actually, you know, coaching you.

I'm a huge fan by the way of the counselor Allen Ivey and his concepts of microtraining. One of the things that I think is sort of the next level is recognizing that beyond just emphatic statements and maybe open-ended questions, there are whole literally probably hundreds of interviewing techniques that are very sophisticated and those can be practiced and taught and we are very involved in developing the educational technology and I don’t mean electronic. I mean, just the idea of how do you teach.

There are styles of role playing and training that can allow us for instance quite literally I can take 28 graduate students in social work and then one day of training will use an ultra-sophisticated style of role playing that I can tell you a little bit about if you want, but in one day training, we can train them and do most of the CASE Approach with surprising sophistication and with the idea that it will stick. They will do it then with a client later that night or six months from then. And it's really exciting to see and once you learn the CASE Approach, you'll see it's a sophisticated interview strategy.

It has many many sequences of these techniques, but you can train somebody to do it and it gives them a sense of competence, an excitement about the interviewing process and people recognize that we really are professionals, you know, that people they're banking on us to have a skill set that their best friend doesn’t have and that skill set is what we bring to the unique dynamic we create with the person in pain.

Jonathan Singer: So, I am interested in how you do that, but I also was wondering – could I put you on the spot?

Shawn Christopher Shea: [laughing] You have many times earlier before we have this mike on, yeah.

Jonathan Singer: Okay. So, I was wondering, could we do a quickie role play?

Shawn Christopher Shea: We can, sure. [laughing] Who are we going to do it with? Oh, you mean with me. Oh, yes, yes.

Jonathan Singer: Yeah. So, I would like to be let's say a teenager–

Shawn Christopher Shea: Okay.

Jonathan Singer: – who is coming to you and I just want you to demonstrate a little bit of what you're talking about.

Shawn Christopher Shea: Okay.

Jonathan Singer: Okay. So, let's just say that we've been talking for 15, 20, 25 minutes, right and you know that I've been having some problems in school, you know–

Shawn Christopher Shea: Right.

Jonathan Singer: – some bullying maybe–

Shawn Christopher Shea: Right.

Jonathan Singer: – problems with friends, you know. I don’t get along well with my parents–

Shawn Christopher Shea: Right.

Jonathan Singer: – and you know, I've had a history of suicide attempts in the past and I've been referred by my teacher to you, the school counselor–

Shawn Christopher Shea: Yeah, yeah.

Jonathan Singer: – because I just have been basically lethargic in class all day.

Shawn Christopher Shea: Yeah. Now, it's really important to make this really – to keep in mind, I've been interviewing you for 20 minutes, so all the material you just described we're going to assume I have already sensitively uncovered, okay.

Jonathan Singer: Exactly.

Shawn Christopher Shea: So, we're now deep into the – to make this really useful though, I want you if you can, I want you to picture what your method of choice is to kill yourself.

Jonathan Singer: Okay.

Shawn Christopher Shea: I want you to have – well, because I want this to be realistic, I want you to have at least several other ways that you thought of and we're also going to set the scene and a very important point that many people miss which is how people respond to these questions and how open they're going to be are going to vary on how much they want to die and that is often missed in the field.

So, I want you to pick somebody who really really wants to die - that if I don’t uncover this in the next three days, this would unfortunately be a teenager who died by suicide. And that they are in tremendous angst and they're also quite worried that if they share their method of choice, I'll stop them and not that they won't, but I have to ask the right question to get at it and that when we first ask a typical person like that, if they really really want to die, they very frequently, when asked about suicide, will share not the method of choice first.

They’ll share something else that they thought about and maybe they’ve even had some actions on it and they’ll share those actions, but they're keeping this close to their hip, the method of choice and what we're trying to train people is it's not enough to just ask. It's not enough to just start to explore a method even if there's actual action taken on it. It's if you're in the room with that person who really wants to die. Can you use techniques that will help them to ultimately share the method of choice with you? And that’s really where we save people’s lives.

And the other thing that’s important for people to realize is that that’s a relatively a rarity for us to be with such an individual. Most of the people we're doing suicide assessments with are not imminently dangerous and so it's important to realize that we want to practice the techniques that we're going to use with the person who is imminently – with everybody that we're working with in a sense that we've become comfortable, it's graceful, it's second nature because that one in a hundred person or that one in a thousand person who actually is at imminent risk with you, you got it. You’ve got the techniques. You're used to them. You're comfortable with them and you'll hopefully save their lives and I always like to think that, you know, that’s what they're coming to us for, that person who’s really close to killing themselves, that they are in the room with somebody who has the skill set to save their life and it's not just asking them about suicide. It's much more complicated.

I always like to emphasize to people that remember suicide, we all know this, that suicide is highly stigmatized, you know. Not perhaps as stigmatized as say incest, but it's close. You would never think that if you met a family where there was some incest for an initial intake and you’ve got a hint of incest, you could just turn to this family and go, “tell me all about your incest” and they're going to tell you all about it. No. That’s laughable because we know that people are going to be hesitant to share about stigmatizing. Yet clinicians will sometimes think “well, if I ask someone about suicide directly, they're going to tell me.” Well, not necessarily true at all. And if it's just as stigmatizing as or close as incest, it could be very hesitant. And not only that, if they really REALLY want to kill themselves and they are worried you're going to stop them, well then they might be very hesitant to share a method of choice, so yeah.

Jonathan Singer: Okay.

Shawn Christopher Shea: So, let's pick that up and–

Jonathan Singer: Okay.

Shawn Christopher Shea: So, we assume we've been talking. You want to be called Jonathan?

Jonathan Singer: Yeah, sure, sure, you call me Jonathan, yeah.

Shawn Christopher Shea: And why don’t you give me – tell me just a little bit – let's pretend that you described all of the stresses that you had just described and we've talked hopefully in depth about the violence that some of the other students are showing you and the verbal abuse. And maybe you’ve even shared with me a lot of your depressive symptoms.

Jonathan Singer: Mm-hmm.

Shawn Christopher Shea: So, let's assume that as a clinician I feel I've got good engagement. I got a reasonable picture of the stresses. I even understand that in a differential diagnosis, you look like you have a major depression. So, I'm sitting here in my clinician’s chair – “wow, I wonder if Jonathan is suicidal?” So that’s where we're at. Why don’t you say some stuff about, you know, some of your depressive feeling wrap up on say you can't sleep or whatever, so then I'll raise the topic and we'll see what happened.

-- 29:17: Beginning of Role Play --

Jonathan Singer: Well, I mean, I guess I just haven’t been sleeping well. I don’t like to – I mean, I don’t like to go to bed at I guess what most people would consider like normal bedtime.

Shawn Christopher Shea: Yeah.

Jonathan Singer: Like, you know, I would much rather go to bed at 4:00 in the morning–

Shawn Christopher Shea: Yeah.

Jonathan Singer: – and then sleep until, I don’t know, 4:00 in the after- I think if I did that, maybe I'll get some sleep, but I don’t know I wake up and I'm still tired and… um…

Shawn Christopher Shea: Yeah. Well, you know, Jonathan you’ve been describing a lot of depression, a lot of pain from you know, not being able to sleep and I know you’ve been crying a lot and the world looks very bleak to you. I'm wondering with all of your pain, have you been having any thoughts of killing yourself?

Jonathan Singer: No… um… I mean, not – like a while ago, a little bit.

Shawn Christopher Shea: Well, it looks like it's hard to talk about it. It's tough to talk about suicide. What kinds of ways have you thought of, even if they're fleeting?

Jonathan Singer: Well, I've thought about there's this bar in my room and I've got some rope–

Shawn Christopher Shea: Okay.

Jonathan Singer: – and–

Shawn Christopher Shea: Have you ever gotten a rope out while you're actually having thoughts of killing yourself?

Jonathan Singer: Yeah, yeah. Uh-huh. Yeah.

Shawn Christopher Shea: When was that?

Jonathan Singer: So, today is – so Tuesday.

Shawn Christopher Shea: Okay.

Jonathan Singer: Tuesday.

Shawn Christopher Shea: That’s pretty recent. And where were you? You say you're in your room when you have thought with the rope out, or…?

Jonathan Singer: Yeah, yeah. My mom doesn’t know that it's there.

Shawn Christopher Shea: Oh, yeah, yeah.

Jonathan Singer: But yeah, it was in the garage and I moved it into my bedroom because she found me actually a couple of years ago. I just tied it around my neck.

Shawn Christopher Shea: Wow, that was a couple of years ago.

Jonathan Singer: A couple of years ago.

Shawn Christopher Shea: So now I want to go back to what happened just recently though–

Jonathan Singer: Yeah.

Shawn Christopher Shea: – because that’s where your pain is.

Jonathan Singer: Yeah.

Shawn Christopher Shea: When you got that rope out, did you actually make it into a noose?

Jonathan Singer: Yeah.

Shawn Christopher Shea: Mm-hmm.

Jonathan Singer: Yeah.

Shawn Christopher Shea: And did you actually tie it around that bar and…

Jonathan Singer: A couple of days ago?

Shawn Christopher Shea: Yeah.

Jonathan Singer: Yeah.

Shawn Christopher Shea: Okay.

Jonathan Singer: Yeah.

Shawn Christopher Shea: So, you know, you're really at some level thinking about it in a fairly serious way. Did you actually put the noose around your neck while you were thinking about it?

Jonathan Singer: Yeah.

Shawn Christopher Shea: Wow, okay.

Jonathan Singer: Yeah.

Shawn Christopher Shea: And when you over – what were you standing on when you did that?

Jonathan Singer: So, there's a chair that I have for my desk–

Shawn Christopher Shea: Oh, okay.

Jonathan Singer: I just moved it over there.

Shawn Christopher Shea: Okay.

Jonathan Singer: But–

Shawn Christopher Shea: So, when you were standing on the chair and you had the rope around your neck like that and what kinds of thoughts were going through your mind?

Jonathan Singer: That everybody would be better off if I was dead.

Shawn Christopher Shea: Okay. And as you were thinking that, you're obviously weighing the pros and the cons and that’s a very difficult thought and what other thoughts did you have?

Jonathan Singer: That my – I was really feeling guilty that my mom was going to have to explain this to my younger sister and that I didn’t want anybody to think that this was their fault.

Shawn Christopher Shea: Okay. And what ultimately do you think stopped you?

Jonathan Singer: So, I started to step off the chair–

Shawn Christopher Shea: Mm-hmm.

Jonathan Singer: – and I, I don’t know, I just – I just didn’t – I couldn’t do it.

Shawn Christopher Shea: Okay.

Jonathan Singer: I don’t know why.

Shawn Christopher Shea: Oh, you said part of it though is that you didn’t want your mom to find you and didn’t want her have to explain that your sister, so I mean–

Jonathan Singer: Yeah.

Shawn Christopher Shea: – these were powerful things and also showing that even amidst of all your pain, which obviously is very severe, you know, what's striking to me is you're still thinking about other people, which is a wonderful thing. You know, you struck me as somebody who’s very caring and I'm sure you do a lot of good things for a lot of people and that’s, you know, one of the reasons I suppose that it stopped you.

Jonathan Singer: I hope so.

Shawn Christopher Shea: Yeah. Well, you know, just to get a better idea of what was going on with you during that night, how long were you actually up on that chair with the noose around your neck and…

Jonathan Singer: I mean I think it was probably like 15 minutes maybe.

Shawn Christopher Shea: Oh yeah.

Jonathan Singer: Just kind of thinking about it.

Shawn Christopher Shea: Yeah. What did you do with the noose?

Jonathan Singer: I just put it back under my bed.

Shawn Christopher Shea: Is it still there?

Jonathan Singer: Mm-hmm. Yeah.

Shawn Christopher Shea: Is it still made as a noose?

Jonathan Singer: Mm-hmm.

Shawn Christopher Shea: Well, that will be something it’ll kill you, so you’ve got to get that out of there and we'll talk more about that at the end of the talk. One of the things I'm wondering is is that over say roughly the past two months, what other ways have you thought perhaps of killing yourself.

Jonathan Singer: I mean just, you know, just the rope really, just the rope.

Shawn Christopher Shea: Is there another time that you actually got the rope out over the past two months?

Jonathan Singer: Yeah, but just like a couple of times–

Shawn Christopher Shea: Okay.

Jonathan Singer: – I think.

Shawn Christopher Shea: And so you said that a couple of times you’ve gotten the rope out. Now, I'm wondering there's lots of different thoughts that can go through somebody’s mind and at this point in time, if you can think sort of back over it, had you thought of any other ways that you might actually kill yourself such as you know, a common way that cross people’s minds today as they think of overdosing unless that’s something might have crossed your mind.

Jonathan Singer: Yeah, yeah.

Shawn Christopher Shea: Okay.

Jonathan Singer: Yeah, yeah, yeah.

Shawn Christopher Shea: And in what ways did you think of overdosing? What types of pills or?

Jonathan Singer: So, I'm on some medication like – I forget what it's like, Prozac or something and I was–

Shawn Christopher Shea: Oh, for depression or–

Jonathan Singer: Yeah.

Shawn Christopher Shea: Oh.

Jonathan Singer: And, you know, I haven’t been taking it really regularly, so I have a bunch of them, so I was thinking maybe that.

Shawn Christopher Shea: Yeah, sure. Do you know the names of those pills are?

Jonathan Singer: Oh, what it's called? Serata.

Shawn Christopher Shea: Sertraline?

Jonathan Singer: Sertraline, yeah. That’s it. That’s it. Yeah, yeah, yeah, yeah, yeah.

Shawn Christopher Shea: Now, did you ever get the Sertraline out while you're having thoughts of killing yourself?

Jonathan Singer: Yeah, yeah.

Shawn Christopher Shea: Okay. Now, when was that?

Jonathan Singer: That was about – see today’s Thursday, so okay, I guess it was about maybe a couple of Thursdays, a couple – it was on a Friday.

Shawn Christopher Shea: Okay.

Jonathan Singer: I didn’t go to school that day, so a couple – yeah.

Shawn Christopher Shea: And where were you when did that?

Jonathan Singer: In my room.

Shawn Christopher Shea: Oh, so the same room where you get the rope out.

Jonathan Singer: Yeah, yeah, yeah. I spend a lot of time in my room.

Shawn Christopher Shea: Not bad, you know.

Jonathan Singer: Because I got – I have my TV and computer and my new–

Shawn Christopher Shea: That’s also a sort of a safe refuge from what you said earlier in the interview. It's a place where you're safe. You don’t have to interact with your family and–

Jonathan Singer: Yeah, yeah.

Shawn Christopher Shea: So, I want to go back though because it looks like you have these pills, you're thinking about them.

Jonathan Singer: Uh-huh.

Shawn Christopher Shea: Now, did you actually have the pills out while you were thinking of overdosing, right?

Jonathan Singer: Yeah, I did. I just kind of poured them out on the table.

Shawn Christopher Shea: Did you take any?

Jonathan Singer: I took just a couple because I didn’t have any water–

Shawn Christopher Shea: Mm-hmm.

Jonathan Singer: – in my room and I didn’t want to have to–

Shawn Christopher Shea: It's so hard to swallow.

Jonathan Singer: Yeah. I didn’t want to go out because my mom sometimes she’s worried about me and so she’ll actually ask me what's going on.

Shawn Christopher Shea: So, how many pills do you think you actually took?

Jonathan Singer: Probably like I don’t know, a couple maybe.

Shawn Christopher Shea: 5, 10, 15?

Jonathan Singer: Probably like eight I think.

Shawn Christopher Shea: Okay. Did you any take any other pills besides Sertraline?

Jonathan Singer: No. Well, I had just – there were a couple of Advil–

Shawn Christopher Shea: Okay.

Jonathan Singer: – that I took.

Shawn Christopher Shea: Now, what stopped you from taking more of that? Now, one thing you couldn’t drink you said, but was there also something else that actually stopped you that you said this, I don’t want to do this. Why? And here's why I don’t want to do this.

Jonathan Singer: I heard that somebody once said that you couldn’t actually kill yourself with those things.

Shawn Christopher Shea: Okay.

Jonathan Singer: And so I thought well, so if I don’t have – like if I'm out and my mom asks where did they go,–

Shawn Christopher Shea: Yeah.

Jonathan Singer: – like I would have to explain it to her and so I was like this is not going to work anyway maybe–

Shawn Christopher Shea: Yeah.

Jonathan Singer: – and so I just, it didn’t seem like it was going to work.

Shawn Christopher Shea: Yeah.

Jonathan Singer: So, I just didn’t want to do that.

Shawn Christopher Shea: You know when you're – any amount of pain you’ve been in which is obviously extreme pain and you thought about the hanging and actually had some pretty serious thoughts about that and had a small, relatively small overdose of the pills it's were like common for people to be thinking about other ways of thinking themselves. I mean, I find that’s a very common thing for people and they sort different ways, so I'm interested there might have been even some other way that you’ve been thinking about like another common way in our culture will be to shoot oneself and I'm wondering if you’ve thought of using a gun or anything like that.

Jonathan Singer: Yeah. No, I actually – I don’t believe in guns actually.

Shawn Christopher Shea: Okay, good.

Jonathan Singer: I think that there are – yeah. I don’t think people should be allowed to have guns.

Shawn Christopher Shea: Okay.

Jonathan Singer: It's too dangerous.

Shawn Christopher Shea: Okay. What about things – another thing that’s sometimes fairly common is people will either say drive their car very rapidly off into a three or off the road. Any thoughts like that?

Jonathan Singer: No. I mean, I have a learner’s permit, but I can't – no. But I did think – so I thought about jumping.

Shawn Christopher Shea: Yeah. I was just going to ask you about that–

Jonathan Singer: Yeah.

Shawn Christopher Shea: – because that is another common way, yeah.

Jonathan Singer: But I don’t know where I would do it so…

Shawn Christopher Shea: Did you ever go anywhere hunting for a bridge or…

Jonathan Singer: Well, there's – I mean there is bridge, but it's I don’t know, the idea of getting in that water just is awful. I don’t think I can do that.

Shawn Christopher Shea: Okay.

Jonathan Singer: I mean, I – yeah, I mean, I've thought about it, but I don’t really think I can do that.

Shawn Christopher Shea: Yeah.

Jonathan Singer: Like…

Shawn Christopher Shea: Yeah.

Jonathan Singer: Yeah.

Shawn Christopher Shea: And we talked about the car and you're not really driving that much at this point in time–

Jonathan Singer: Right.

Shawn Christopher Shea: – and another thing that sometimes people think about is carbon monoxide poisoning like at other parents’ garage or something like that with a car, have thought of that?

Jonathan Singer: Yeah. Actually, we – our car doesn’t fit in our garage.

Shawn Christopher Shea: Okay.

Jonathan Singer: Now somebody online said that if you run a lawnmower–

Shawn Christopher Shea: Okay.

Jonathan Singer: – you fill it up with gas, but we have an electric lawnmower so–

Shawn Christopher Shea: Yeah.

Jonathan Singer: – that, so no, not really that either.

Shawn Christopher Shea: Yeah. Sounds like you puzzled through some stuff. I'm curious roughly how much time have you spend online, on the web trying to find different ways because you know, before doing that now–

Jonathan Singer: Yeah, yeah.

Shawn Christopher Shea: – a fair amount actually.

Jonathan Singer: You know not – I mean, not much I guess.

Shawn Christopher Shea: Okay. Well, are we talking an hour a day, once a week…

Jonathan Singer: I mean, probably an hour, maybe a couple of hours a day.

Shawn Christopher Shea: Searching on the web for something about suicide...

Jonathan Singer: I mean not just like how to do it, but I mean, you know, just you know the web is good because there are a lot of other people that are upset and–

Shawn Christopher Shea: Yeah.

Jonathan Singer: – you know it's – I find that I can talk to people there.

Shawn Christopher Shea: Oh sure.

Jonathan Singer: Yeah.

Shawn Christopher Shea: They can be really good supports and by the way–

Jonathan Singer: Yeah.

Shawn Christopher Shea: – often can help prevent a suicide by finding other people who can provide some support and–

Jonathan Singer: Yeah. People have been like don’t do it man.

Shawn Christopher Shea: Oh good. That’s good.

Jonathan Singer: You know, yeah so…

Shawn Christopher Shea: That’s what we're hoping will happen on the web.

Jonathan Singer: Yeah.

Shawn Christopher Shea: Well, you know, you and I have talked about an awful lot of different ways you’ve been thinking about and I'm curious, is there any way that you’ve thought about that we haven’t talked about?

Jonathan Singer: I don’t think so. No, those are the – I mean, that’s really the – those are it.

Shawn Christopher Shea: On your very worst days Jonathan, you know, when you're thinking the most about killing yourself, you know, roughly how much time do you spend thinking about killing yourself? 70% of your waking hours, you know 80%, 90% of your waking hours, just roughly how much?

Jonathan Singer: Probably like half the time.

Shawn Christopher Shea: Half the time that you're awake.

Jonathan Singer: Yeah.

Shawn Christopher Shea: That’s a lot of pain.

Jonathan Singer: Yeah.

Shawn Christopher Shea: You know, I have in talking with you and you know your pain is very very real and we’d like to be able to help you with that and – but I'm really struck with the significance of the pain and its intensity and I think we're going to be able to help, but I want to learn a little bit more about suicidal thought for you, so we make sure that you're safe and we can help you to cope with those thoughts and find other reasons to live because I think you have lots of great reasons to live that we've been talking about, but what about in the past. Have you actually ever tried to kill yourself in the past?

Jonathan Singer: Yeah. There were a couple of months where I tried probably every couple of weeks–

Shawn Christopher Shea: Okay.

Jonathan Singer: – or like two months.

Shawn Christopher Shea: And when was that roughly?

Jonathan Singer: About two years ago.

Shawn Christopher Shea: Okay. And what ways did you actually attempt suicide like that?

Jonathan Singer: Hanging. Yeah. There were a couple of times where I was just hanging.

Shawn Christopher Shea: Wow.

Jonathan Singer: Like just for like three or four seconds and then I like kind of got my feet back on the chair and…

Shawn Christopher Shea: Okay.

Jonathan Singer: Yeah.

Shawn Christopher Shea: And other ways that you actually attempted suicide in the past?

Jonathan Singer: I mean I was doing some cutting, but not to really to die.

Shawn Christopher Shea: Yeah.

Jonathan Singer: Because you know that’s not – I mean, I just don’t – I think it hurts, but I don’t think I can do that so.

Shawn Christopher Shea: Yeah, okay.

Jonathan Singer: This is mostly is the hanging.

Shawn Christopher Shea: Yeah, you know, the reason I'm asking is is that you know I want to get a good feel for what's going on in the past with you with suicide, so we can help to make sure, you know, that doesn’t happen for you or something you feel the need to do now and with the hanging, that sounds, you know, fairly serious to me. Actually, if you said that a couple of seconds of maybe just hanging there. That’s a scary thing.

Jonathan Singer: Yeah.

Shawn Christopher Shea: What was going on back then that was – so was the stress the same? Were you being bullied back then or were they similar stresses to what was happening now? What was going on?

Jonathan Singer: Yeah. There were some kids at school that were, that I thought were my friends and it turns out that they were being really mean online and then I would come to school and like this – I play keyboards–

Shawn Christopher Shea: Yeah, okay.

Jonathan Singer: – and these kids that I've known for a long time they invited me over to play–

Shawn Christopher Shea: Yeah.

Jonathan Singer: – some music with them and I got over there and they just spent the whole time like mocking me–

Shawn Christopher Shea: Bragging on you.

Jonathan Singer: Yeah, bragging so like “Oh, I thought you said you could play and you suck” and you know–

Shawn Christopher Shea: Yeah.

Jonathan Singer: – like you know, like you know, “Why don’t you play chopsticks again,” and like it was–

Shawn Christopher Shea: Yeah, yeah.

Jonathan Singer: It was just humiliating and I–

Shawn Christopher Shea: And it was, yeah.

Jonathan Singer: Yeah, and these were like my friends or I thought and then I, I mentioned it to somebody and they were like “They talk about you all the time man.”

Shawn Christopher Shea: What a sense of betrayal.

Jonathan Singer: It was awful.

Shawn Christopher Shea: Yeah.

Jonathan Singer: And so–

Shawn Christopher Shea: So, it's a little bit similar to what we were talking about earlier in the interview when we – about some of the things that kids had been saying and–

Jonathan Singer: Yeah.

Shawn Christopher Shea: – recently a friend really seemed to betray you and–

Jonathan Singer: Yeah, yeah, yeah. Yeah, it's big.

Shawn Christopher Shea: And any other attempts, serious attempts?

Jonathan Singer: Just – well, I mean, like about – I guess about six months ago also by hanging, but that’s when my mom came in–

Shawn Christopher Shea: Okay.

Jonathan Singer: – and she totally freaked out.

Shawn Christopher Shea: Oh yeah. Well, who wouldn’t?

Jonathan Singer: Yeah.

Shawn Christopher Shea: Yeah.

Jonathan Singer: And so – but that was it.

Shawn Christopher Shea: Okay.

Jonathan Singer: Yeah.

Shawn Christopher Shea: Now, getting back, you know, to the present moment right now where we're talking, as we've been talking, have you been having any thoughts of killing yourself?

Jonathan Singer: Not really.

Shawn Christopher Shea: Well, you look at some level just because of your hesitancy and because you might have some thoughts or…

Jonathan Singer: I guess I'm just like, you know, like what is the point of all this, you know?

Shawn Christopher Shea: Sure.

Jonathan Singer: Like yeah, so yeah I guess.

Shawn Christopher Shea: Okay.

Jonathan Singer: Yeah.

Shawn Christopher Shea: And, you know, as you were thinking, while we're here talking, you know, this is surprising (indiscernible 0:42:06.1) because you know a lot of pain. Were you actually thinking of a specific method?

Jonathan Singer: I was thinking about the rope.

Shawn Christopher Shea: Oh okay. It's still back there, right you told me, under the bed?

Jonathan Singer: Yeah, under the bed, yeah.

Shawn Christopher Shea: So, we definitely have to get that rope out of there, okay?

Jonathan Singer: Yeah.

Shawn Christopher Shea: That’s one thing that’s for sure.

Jonathan Singer: Yeah.

Shawn Christopher Shea: Well, you know, and certainly that you're wondering to whether it's worth going on and if we had looked at the amount of pain you're feeling from the betrayal and what's going on with the bullying and that type of thing, if zero was your feelings and say geez, you know, I'm in a lot of pain from this, but I think I can cope with it and a 10 was, you know, the pain is so great that I don’t know if I can actually continue and I really think that I might have to kill myself soon.

Jonathan Singer: Mm-hmm.

Shawn Christopher Shea: Where would you put yourself on that scale from a 0 to 10?

Jonathan Singer: Right now?

Shawn Christopher Shea: Right now.

Jonathan Singer: Probably about 8.

Shawn Christopher Shea: Wow, that’s a lot. Are you feeling hopeless?

Jonathan Singer: Yeah. I mean, it's – when I first came in I think I was probably more like a 10.

Shawn Christopher Shea: Okay.

Jonathan Singer: But, yeah, again, I mean I just, you know, this place sucks like my parents don’t take – I mean, they're nice and everything.

Shawn Christopher Shea: Yeah.

Jonathan Singer: But like, I don’t know, it's just been going on so long.

Shawn Christopher Shea: Yeah.

Jonathan Singer: Like, you know, we got those stupid videos online like it gets better and it's like really?

Shawn Christopher Shea: Yeah.

Jonathan Singer: When?

Shawn Christopher Shea: Yeah.

Jonathan Singer: When does it get better, you know?

Shawn Christopher Shea: Yeah. You sort of see stuff that’s like the rose-colored glasses, you know, if you just think positive and you know frankly it's tougher than that, but the one thing I really am glad that you came in because I do think that there's clearly some things that we can do that I'd like to spend a little time now talking more about, but first of all, I think it is great that you actually came in. You know that something prompted that. I don’t what it is. You know, I would think perhaps it's a part of you that really wants to live and a part of you that wants to help your siblings and friends and your parents or whatever. But we do know one thing something prompted you to come in. That we know for a fact and so whatever that ambivalence was, that’s a good thing. That’s why you're here.

Jonathan Singer: Yeah. Well, I mean, it was you know, it was Mrs. Stevens who was like you need to go.

Shawn Christopher Shea: Yeah, yeah.

Jonathan Singer: And–

Shawn Christopher Shea: Thanks for Mrs. Stevens–

Jonathan Singer: Yeah, and–

Shawn Christopher Shea: But you know what, you’ve certainly seemed to open up about this stuff, so given the chance to talk about it unless I'm misreading you. Okay. You’ve shared a lot of about it, so there's a part of you that wants to share or you wouldn’t be sharing.

Jonathan Singer: That’s true. I mean, I – you know, I like people.

Shawn Christopher Shea: Yeah. (crosstalk 0:45:10.6).

Jonathan Singer: I just don’t know why don’t like me.

Shawn Christopher Shea: Yeah, yeah. Well, that’s for some of the stuff that we're going to take a look at is what is going on and what is happening with relationships and also, you know, you certainly bring a lot of good things too. And you’ve described some interactions earlier in our interview where, you know, there certainly were people who are enjoying you. You were talking about that one night for instance with the music and how much the crowd was into that. You're smiling even as we were talking about that and I want to learn more about, those aspects of your life that are positive and, but I have no doubts about the pain and so that’s something that hopefully we're going to be able to help you with today.

So, you know, I'd like to go back and talk a little bit about something you said earlier in the interview. You had commented that you were actually drinking a little bit more than you normally would like to be drinking and that you're a little bit concerned about your drinking. So, just tell me just a little bit more about what the drinking has been like for you and what your concerns are about it. [fade out]

-- 50:40: End of Role Play --

Shawn Christopher Shea: Anyway, how is that? How is that? I thought it was going to be a little bit, you know, so. [lauging]

Jonathan Singer: Okay.

Shawn Christopher Shea: What was that like for you?

Jonathan Singer: First of all, it was very warm and connecting–

Shawn Christopher Shea: Oh good.

Jonathan Singer: – and emphatic and it was gentle and you were picking up on all sorts of things that I wasn’t going to talk about.

Shawn Christopher Shea: Yeah.

Jonathan Singer: But that I wanted to talk about.

Shawn Christopher Shea: Yeah.

Jonathan Singer: So, that was amazing.

Shawn Christopher Shea: Yeah. Oh good. Well, you know, you were a tough cookie there. I mean, you obviously were in a lot of pain and you were clearly playing a role when you talk about playing a role where someone who is in a lot of pain and really wanted to die and you know, one of the things that for your listeners to point out, that I'd like to point out – actually something is a little bit atypical there which is is that I think someone with that amount of pain when first asked about suicidal thought, wouldn’t share the hanging.

The first thing he probably would have shared was say the overdose or thinking about that because I find that many people who are in intense pain and want to kill themselves – so, we’d like to give a number or percentage that the first percentage is how much a person wants to die. The second percentage is how much we think they want to live. So, a 10/90 or 10% who wants to die, 90% of them wants to live and, you know, 40/60 or 40% who wants to die, 60% – you know, in those range are some stuff when we asked the questions.

I don’t think it's at all unusual for a person to tell us a fair amount about the truth and they will often share, you know, maybe even if they’ve had a method of choice. They often don’t have a method, but they have when they share that. But where we're really concerned are the 95/5-ers or the 90/10 or someone who 95% of them wants to die, just a small 5% prompted them to call us on a crisis line or to go to the school counseling center or whatever. Those people who really want that, those are the ones who probably be (cagier) and so I think generally, you know, I would predict that the student are most likely would have first shared the thoughts of overdosing because they're more comfortable doing that plus also they don’t want you taking a role.

And then they're going to watch how clinician responds to talking about the overdose and if the clinician looks ill-at-ease, which is meta-communicating that “I don’t want to hear this or I'm uncomfortable with this or you're a bad person for having this,” they may further clam up. Whereas if they feel hopefully like you were, well this guy can listen to me and this is not unfamiliar turf for this clinician. He sees just flat out asking me in a sensitive matter of fact way. And then they're more likely to share as you probe further and you can see, you know, with that particular student that we just interviewed that you played.

You know at first you wouldn’t have thought that he had such extensive thoughts of hanging himself or that there were serious attempts in the past. You noticed that I was checking to see what I uncovered where that sounded like a fairly significant behavior in the past where it's actually suspended. I mean, that’s as close as you can get and often by the way, for many people you know if you’ve kicked away the chair then that’s why the people die even if they change their minds because it's very hard to stop a suffocation with a rope, a hanging.

So, fortunately, you must have not move far off of the chair, had it available, but even with that situation, you know, you really saw that by probing a little bit better you could find out, you want to find out if that serious past attempt, the triggers are similar to what is going on now and is the method the same. You know, Thomas Joiner has really helped us to understand that people may practice suicide methods and that practice might indicate their closer and so if you find a past suicide attempt, that serious one and you realized and you then ask specifically – I recommend asking what were the triggers and what is the method because if the triggers and the method are now identical – so, if I'm interviewing a 27-year-old man who’s contemplating, you know, taking a big overdose of aspirin because he’s going through a divorce, if when I uncover the past suicidal ideation he tells me he had a serious attempt in college, I would then ask what did you do and if he told me an overdose, I'd say what kinds of pills to see if they were aspirin again.

And then once again, just as I did here I'd ask him what was the situation and if he said, “Well, my girlfriend had broken up with me.” These are red lights. Does this person, you know, practice this in the past? This is a stress that we know resulted in a major overdose in the past and that’s how we start to gather information that gives us better predictive abilities with this person.

Jonathan Singer: This is so incredibly powerful, everything that you’ve been talking about.

Shawn Christopher Shea: Oh good.

Jonathan Singer: Yeah, absolutely. The techniques that you were using–

Shawn Christopher Shea: Yeah.

Jonathan Singer: I mean, obviously you know, the case that sort of–

Shawn Christopher Shea: Yeah.

Jonathan Singer: – what's going on and then two months and then the past and then right now, how are you feeling. A couple of times it seemed like you were asking me about how often I was thinking of things or–

Shawn Christopher Shea: Right. We used actually, what hopefully, you know, could come across to listeners and sometimes it's harder to do when you can't see the interview you get, you know, you’d lack those non-verbals, but actually if you read the articles or you study the book on The Practical Art of Suicide Assessment, you'll see that actually that interview, I was flexibly structuring and determining how I want to do it, but I was actually intentionally asking and using very specific techniques. You actually – you saw me use a technique called Gentle Assumption where instead of saying have you thought of other ways.

A sex researcher Pomeroy and Company found that it's more powerful to say what other ways have you thought of killing yourself and of course, you know, when they learned by doing, take sex histories, that you know, if you asked a person, you know, do you masturbate? A lot of people say “no.” If you say what do you experience when you masturbate? People often will tell you.

Jonathan Singer: Which answers the first question, too. Yeah.

Shawn Christopher Shea: Yeah. They call that a Gentle Assumption.

Jonathan Singer: Okay.

Shawn Christopher Shea: And so we used gentle assumption instead of saying have you thought of other ways after they’ve described, you know, a way. We’d say “Oh, what are the ways have you thought of Jonathan.” And then you saw the creation of what we call Verbal Videotape. In a traditional sense, that’s called like a chain analysis in Cognitive Behavioral Therapy or DBT [Dialectical Behavior Therapy], but we’d like to call it the Verbal Videotape which is you use a technique called the Behavioral Incident that was developed by Gerald Pascal, a psychologist, and you're asked fact finding questions or sequencing questions, you know, “what happened next, what did you do next” and you literally walk the person through the event, sort of step by step so they make up - In your mind you're using this behavioral incidents, so the client can create a verbal videotape where you can see it unfolding. And if you get a gap, you just read what we call those Nixon gaps. If there's a Nixon gap that take–

Jonathan Singer: There's like 18 minutes that -

Shawn Christopher Shea: [Laughs] Yeah, yeah.

Jonathan Singer: – that nobody can–

Shawn Christopher Shea: There are 18 minutes. That’s really scary.

Jonathan Singer: Even 18 seconds is scary, yeah.

Shawn Christopher Shea: I hope your listeners know what we’re referring to here. But anyway, if you have one of these nix and gaps, you just rewind the tape and restart it. That'll show you how powerful that is. You're exploring with a verbal videotape using Pascal’s behavioral instance and you find out the person overdosed. You find out what the pills where they overdosed. Also, by the way, often you're able to find out how many pills were left in the bottle. That gives you an idea of the reflection of the intent. And then I say with this–

Jonathan Singer: And by that, do you mean like if they say oh, there were 35 left in the bottle then–

Shawn Christopher Shea: Yeah. If someone – if two different individuals, each took 20 aspirin and one of them I said, “You know I'm just curious, how many pills were left?” And the first guy says, “Oh my God, there are you know other pills all over the place. You know I know where you're going with this and my wife is a junkie. Trust me, there's drugs – I'm going to be dead, I'd be dead.” Okay. That gives me one level of intent. Now, if somebody took the exact same number of aspirin, 20 aspirins and at the same point I say, “You know I'm curious, how many pills were left?” And he turns to me and goes to me “You know what, there weren't any damn pills left in that bottle and I’d ransacked the damn house until goddamn it I passed out.” Okay. That is an entirely different intent level, but they both, what’s curious is that they both took the same pills and the same number of pills, but it was by asking how many pills were left, you got a reflection of the intent. It was, you know, certainly different.

Jonathan Singer: And the intention is so central.

Shawn Christopher Shea: Oh, that’s where we're about is people kill themselves not because statistics say they should, they kill themselves because they intend to kill themselves. You know with rare exceptions for somebody by accident ends up killing or taking more than they thought, but you know, it's a choice. You’ve decided you want to kill yourself which is a tough place to be, but I want to go back that, so if I then turn to that person, and I said, “What happened after you took the pills?” They said, “I ended up in the emergency room.” Well, there's your Nixon gap, you know, it's – I could see them in my head taking the pills and I can see them being you know snaked with a tube in the emergency room, but I have absolutely no idea how they got from the bathroom to the emergency room and so what in the CASE Approach, the principle is if you're making a verbal videotape, walk through what happened. If you can't see it, rewind the tape and restart with the behavior and – so I'd go back and I'd say, “Well, right after you took the pills Jim, what happened next?” And he goes, “Well, I called my brother.” I said, “You know, what did you say to your brother?” “I just told him I did something silly I shouldn’t do. I took some pills I shouldn’t. Would you mind taking me to the emergency room?”

What a huge puzzle piece was just uncovered by that interviewer. And I like to point out that, you know, that’s a puzzle piece that when you do start to do your clinical formulation which is not the case first. That’s what you do with the material, but when you do the clinical formulation, that’s a puzzle piece that might prevent an unnecessary hospitalization. Because that one does not reflect much intent at all. That reflects, actually, a powerful sense of I still want to be alive. That puzzle piece, unless you use something like the CASE Approach just comprehensively walking through this material, you might not have when you're doing your clinical formulation. If you didn’t do that, the next thing you know this guy’s in a hospital and he doesn’t need to be in a hospital.

So, it's all built to get the puzzle pieces about suicidal ideation, behavior, planning and intent. And so that we can then make, we plug those then into our clinical formulation and now we know we've got the best possible data we have and then we can do a good clinical formulation.

Jonathan Singer: So, are there any other things about that that you wanted to highlight for our listeners?

Shawn Christopher Shea: Just only in a sense that, you know, I truly believe that we can save lives by using things and learning to use something like the CASE Approach and it would be wonderful. Imagine if every graduate student of social work and/or social work student, every medical student, every nursing student, every psychiatry residency, if actually we train them in this and tested them out. You know, one of the things that we're doing is we really have learned a way that we use in our center to actually role play people so they really do know how to do this.

I mean you can think you know how to do it even, you know, from just hearing this podcast, but the truth of the matter is, it's actually practicing it and having a coach there, but imagine if every single social worker or every single medical student would have to do this and do it to a reasonable fidelity with one of their faculty before they could graduate, first of all, the sense of confidence that all of these students would have and then their skill levels would have skyrocketed compared to what is typically being done now and I just – let's leave social workers and psychiatrists out of the picture for a minute, psychologists and instead focus on primary care physicians, nurses and PAs.

Fifty percent of all people who die via suicide have seen one of the primary care people within a month find that very hope-producing. You know, the tenth leading cause of death in America, 50% of the time they're in a room with a professional who could help to turn this around. If we had each of those professionals as students spend just one day practicing the CASE Approach the way we're describing it from our center and then test out on it, the likelihood that those students when they become residents in family practice or endocrinology or nursing or whatever, that they will ask I think has skyrocketed because people like to do what they feel competent in and boy, if you do a day of training of this you're not really – and then have practiced it and not only that, they not only know how to raise the topic, they're going to know how to explore it and they're going to know how to hunt for the method of choice and they're going to know that just because you asked directly, you don’t get a direct answer at first.

I truly believe it is one of the best chances we have in the country to drop the suicide rate. If we know for a fact, our evidence base is 50% of all suicides that occur the person has seen one of these professionals and primary care in one month then if we can teach them how to do this, I truly believe it's one of our greatest chances to drop the suicide rate.

Jonathan Singer: Well, I hope that we're able to figure that out one day, how to make that happen.

Shawn Christopher Shea: Oh, that will be wonderful.

Jonathan Singer: Yeah. I think it will be great. Shawn, I want to thank you so much for taking your time and for sharing all these insights that you have gleaned over your 30+ years of–

Shawn Christopher Shea: Oh thanks.

Jonathan Singer: – of doing this work.

Shawn Christopher Shea: Thirty plus, it means I'm really old, really.

Jonathan Singer: I'm sorry. The last four years of – sorry.

Shawn Christopher Shea: I'm only 27. You know this, I dye my hair white.

Jonathan Singer: [laughing] Yeah, it's an amazing look.

Shawn Christopher Shea: Yeah. These are fake chins. That’s a fake triple belly.

Jonathan Singer: But no, but seriously thank you for taking the time to talking with us today–

Shawn Christopher Shea: Oh, it's my pleasure. It's an honor.

Jonathan Singer: – you know, about suicide assessment, the CASE Approach–

Shawn Christopher Shea: Yeah.

Jonathan Singer: – and for doing the role play and put you on the hot spot and you–

Shawn Christopher Shea: Oh yeah.

Jonathan Singer: – you exceeded all expectations.

Shawn Christopher Shea: Oh good. Thanks a lot Jonathan.

-- END --

References and Resources

Reed, M. H. & Shea, S. C. (2011). Suicide Assessment in College Students: Innovations in Uncovering Suicidal Ideation and Intent. In Understanding and Preventing College Student Suicide, Dorian A. Lamis and David Lester (Eds). Springfield, Illinois: Charles C. Thomas, Publisher.

Shea, S. C. (2012) The interpersonal art of suicide assessment: interviewing techniques for uncovering suicidal intent, ideation, and actions. In The American Psychiatric Publishing Textbook of Suicide Assessment and Management, Robert I. Simon and Robert E. Hales (Eds). Washington DC: American Psychiatric Publishing.

Shea, S. C. (2011). The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors. Stoddard, N.H.: Mental Health Presses.

Some of Shawn's books on sale at the 2012 American Association of Suicidology conference

Shawn and I talking at the book table at the 2012 American Association of Suicidology Conference
Training Institute for Suicide Assessment and Clinical Interviewing (TISA)

  • This website has great resources for graduate students (and professors) and more experienced clinicians including the Interviewing Tip of the Month, an up-to-date article on the CASE Approach, several other free articles on interviewing and teaching interviewing, as well as information on didactic workshops on suicide prevention and on clinical interviewing. It also includes information on group experiential certification in the CASE Approach

APA (6th ed) citation for this podcast:

Singer, J. B. (Producer). (2012, September 11). #74 - The Chronological Assessment of Suicide Events (CASE) Approach: Interview and role play with Shawn Christopher Shea, M.D. [Audio podcast]. Social Work Podcast. Retrieved from http://www.socialworkpodcast.com/2012/09/the-chronological-assessment-of-suicide.html

1 comment:

Unknown said...

This was an incredibly well done podcast and a most and engaging information session Even among the many stellar interviews in the SWP this one stands out.

However one area has left me hanging (please pardon the pun). Audio problems ended the interview prematurely and I don't know how Dr. Shea would have ended it. Given the powerful role play by Jonathan, how would Dr. Shea have gotten the rope out of Jonathan's room, who else would he have informed and how would he have done so without scaring Jonathan from ever coming back into treatment?

If it's not too much to ask, could you perhaps bring him back and finish this part of the interview, or direct us to where we could get closure on this final and very critical part of the interview? Dr. Shea's gentle probing style was a much, perhaps more a part of his effectiveness as was the model. I would love to hear his voice wrapping the session up