Real-Life Suicide Assessments: Who, What, When, How Don't make the same mistakes Hollywood does in portraying

suicidality Gosling's character informs McGregor's that he's going to kill himself. In the 2005 film Stay, a suicidal client played by Ryan Gosling informs Ewan McG regor s psychiatrist character, Sam, that he intends to kill himself in 3 days. McGregor s character proceeds to freak out (which doesn t make sense; most therapist s deal with suicidality on a regular basis), lunging for the phone (which could violate confidentiality, since a therapist needs to be sure there s truly a life-o r-death emergency before telling anyone) and then, after Gosling leaves, seeking out a friend who works in a hospital psych ward to check the protocol on involun tary committal. (Any therapist who doesn t know the protocol on involuntary commitm ent needs to stop practicing and get some supervision immediately!) The movie then portrays the hospital as a horrifying place where the doctors are jaded and screaming patients are regularly tackled and forcibly injected with m edications. Even the doctor McGregor consults says it s a horrible place for patie nts to be. (Frankly, most hospitals aren't that bad of a place to be if you need the help. But portrayals like this certainly keep people from wanting to go if they need to!) (Note: "The 'twist' of the film makes all of the characters' behaviors work, eve n the inaccuracies, but in real life many of Sam's and Henry's behaviors would b e seen as inappropriate, and the way psychology is practiced in the movie is not adhering to ethical or sometimes even practical standards.) What is a Suicide Assessment? Suicide assessments are informal evaluation processes psychological professional s go through to decide 1. Whether a client might be suicidal and 2. How immediate any danger is When is a Suicide Assessment Done? Typically as part of the initial intake interview, and any other time that a cli ent indicates possible suicidal ideation (thoughts about suicide) through speech or behavior. Who Does the Assessment? Sometimes the client is in the office when he indicates that he has suicidal ide ation, but sometimes a concerned friend, family member, or even coworker will ca ll. If the therapist already sees the person in question, it's her job to assess the client's present state of mind. If the person in question isn't the therapi st's client, she'll advise the caller to go to the nearest emergency room or cri sis center. Immediate Danger If the client is clearly in immediate danger of harming himself, the therapist w ill ask the client or caller to go directly to the closest hospital's emergency room. All emergency rooms have a social worker available to decide whether the p erson should be admitted. If the client is going to be admitted, the therapist will often meet her at the emergency room. Thanks to the red tape of insurance, it's not uncommon for the a dmittance process to take 3 to 5 hours, which means a lot of sitting around the waiting room. Less Immediate Danger If the caller or client isn't in immediate danger but is still feeling unsafe, t he therapist will ask him to come in for an emergency appointment. She'll probab ly encourage him to have someone drive him, not only because it's safer for him (and probably the other folks on the road), but also so the client has a ride an d emotional support if he does need to go to the hospital. How is the Suicide Assessment Done? A therapist never talks to anyone outside the office about a client unless she h as the client's written permission (for example, because she's consulting with a nother of the client's doctors) or the client is in immediate danger. That means that when suicidality is involved, she must assess whether the situation is ser ious enough to involve other people. Every suicide assessment contains three par

ts: plan, means, and time. The therapist asks: 1. If the person knows how he would harm himself (plan). 2. If he has the means to do it (means). 3. If he has a time planned (time). People who are serious often do, or the y may just say, "I can't stand it anymore," which pretty much means "now." If so meone doesn't have a clear and immediate answer to this question, the therapist may ask, "Can you be safe?" or "Can you stay safe if you go home?" Someone who i s really in trouble will generally say, "No." Therapists can usually tell pretty quickly how urgent the situation is, mostly b ecause people have little problem telling them! Obviously, if someone is in so m uch emotional pain that he'd rather die than finish the day, the hospital is the next stop. Involuntary Hospitalizations Psychiatric hospitalization is like any other hospitalization. The doctors work hard to provide symptom relief as fast as possible, and keep the person in an en vironment where if there's an emergency, someone is there right away to help. An d the hospital may be the only place the problem can be properly treated the bone will be set, the person with pneumonia is given antibiotics to help the body's n atural immune systems fight off infection, and the person who's suicidal will us ually be given medication and therapy that will quickly help stabilize brain che micals. Involuntary hospitalizations are actually rarer than the average person thinks: most people who feel this bad really just want to feel better, and if that means going to the hospital, they're ready to go! You also have to remember that peop le who really want to die don't typically tell anyone. They just do it. If someo ne realizes your character is suicidal, it's because he's struggling to keep him self going. People who do commit suicide do so because they've reached the point where they see no other solution. In the rare situation that a client really doesn't want to go to the hospital an d is really in danger of killing himself, the therapist can explain that she's l egally and ethically obligated to do everything she can to keep him safe, up to and including involuntary hospitalization. Then she explains (and this works bet ter if the therapist can say this kindly) that the police are the ones responsib le for taking him to the hospital, which means he's likely to end up in the back of a squad car. In the end, most people agree that it's a lot easier to just go voluntarily. Safety Plans If the client believes he can stay safe for a given period of time (say, a week as king a client to stay safe for one week at a time is reasonable) and can promise to tell someone or go to the hospital if that changes, he and the therapist may create a Safety Plan. In a safety plan, the client promises (often in writing) that he will not harm himself, and if he feels he can't hold to that, he has a s eries of things to do, in the order he should do them. Usually safety plans incl ude things like calling a trusted friend, asking someone to come over and stay, calling the therapist, and going to the emergency room. Though all of these steps are taken for both clinical and legal purposes, having done all of these things correctly doesn t necessarily protect the therapist from a lawsuit if the individual kills himself. Using the Information in Your Story Though it can feel stilted to include the assessment in your story if you're not quite sure how one would go in real life, the assessment is usually where the m ost important (and interesting) information is revealed. Knowing that your chara cter not only plans to shoot himself but also has a gun in the car and intends t o drive out to a field after the session and do it, for example, forces the ther apist to take immediate action. Men are more likely to use violent means like guns, while women are more likely to do things they can "change their minds" on, like taking pills or slitting the ir wrists. Women attempt suicide more often, but men complete suicide more often . The Aftermath of Suicide and Suicide Attempts

Some people time their attempt so someone can "accidentally" find them, and peop le who change their minds often call 911 or ask someone else in the building for help. Those who slit their wrists usually have "hesitation" or "practice" marks , which are shallower cuts they make while they're working their way up to somet hing that's actually deadly. Many people who actually die during a suicide attem pt probably didn't mean to. Also think beyond the drama of an actual suicide. One of the most horrible thing s anyone can face is finding the body of someone who killed himself, because the re are always self-recriminations. People who commit suicide have often thought about how it will affect those left behind: they have been known to lay out plas tic to make sure blood is easy to clean up, to kill themselves away from home (l ike in a hotel room), or to use methods they believe will be "cleaner" than othe rs, like closing themselves in a garage with a car engine running. (Note: there is no clean method carbon monoxide poisoning suffocates every cell in the body, an d that doesn't make for a pretty corpse). People also screw up suicide attempts, making their problems worse. A bullet to the head isn't always deadly, and people have taken full shotgun blasts in the f ace and survived. In 2005, a man who intended to kill himself by driving his SUV onto commuter train tracks panicked at the last minute and ran from the SUV; un fortunately, the people on the train didn't have that option, and 11 were killed and nearly 200 were injured. Juan Manuel lvarez was subsequently arrested and fo und guilty of 11 counts of first degree murder and one count of arson; in 2008 h e was sentenced to 11 consecutive life sentences. For more information on using accurate psychology in your writing, check out The Writer's Guide to Psychology: How to Write Accurately About Psychological Disor ders, Clinical Treatment and Human Behavior. More information is available on th e book's website.