Suicide Risk Assessment Technique

[Zephyrill]

Hey everyone. I'm a psych intern and have lately had a couple suicide risk assessments where the patients would become visibly frustrated that I was called and ask for the interview to be cut short. Fortunately I was able to reach out to collateral in both cases to gather psychiatric, family, social, substance use history, etc., but the patients themselves both shut down after I had obtained an HPI. Both patients had expressed some vague passive SI, one after recently being involved in a MVC (question of whether the collision was intentional) and another after having to come back to the hospital following a complication related to quadriplegia.

Anyway, I was wondering if you guys have a particular style or way of introducing yourselves to patients when doing these risk assessments to facilitate information gathering and rapport building. In both cases, I introduced myself as the resident psychiatrist and explained the reason for consultation and was essentially asked to leave on the spot. I was a little taken aback since this has worked well for me in the past. Any tips from some seasoned vets?

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[splik]

When you get a consult you should always ask if the pt has been informed that psychiatry has been consulted. If not, then tell them to call back once the patient has been informed of the consult request. You can imagine that patients might be unhappy to see a psychiatrist if they haven't been informed you would be coming. There are some exceptions to this (for example some patients will freak out when told that psychiatry will come to see them especially if they have a history of severe mental illness or have been traumatized/abused by psychiatrists in the past). In these cases I don't tell them I am a psychiatrist and just say I'm a doctor. In fact, when consulting in the general hospital I will rarely say I am a psychiatrist, but might tell pts that I am one of the doctors specializing in psychological medicine etc.

Because patients can shut down or terminate prematurely in these cases it is a good idea to go in and do a focused interview asking all the most important questions up front. I.e. dont ask a lot of fluff, go straight in with a focused risk assessment. It is also a good idea to tell patients what you already know, how long you anticipate being with them, to pull up a chair and sit down, so you show you are interested in them, and what the purpose of the visit is.

Also, if they refuse to talk to you, you then have to assume they are high risk and if you inform them of this and they aren't personality disordered, they may well relent and begrudgingly talk to you.

 

[Armadillos]

It seems around here the standard of care is that if an ER is concerned enough to call psych and then someone won't participate to our satisfaction in evalauation and safety planning, they are going to get admitted involuntarily. Which is unfortunate from a moral standpoint, but does take some of the pressure off the psychiatrist if the patient isn't cooperating.

 

[clausewitz2]

When you get a consult you should always ask if the pt has been informed that psychiatry has been consulted. If not, then tell them to call back once the patient has been informed of the consult request. You can imagine that patients might be unhappy to see a psychiatrist if they haven't been informed you would be coming. There are some exceptions to this (for example some patients will freak out when told that psychiatry will come to see them especially if they have a history of severe mental illness or have been traumatized/abused by psychiatrists in the past). In these cases I don't tell them I am a psychiatrist and just say I'm a doctor. In fact, when consulting in the general hospital I will rarely say I am a psychiatrist, but might tell pts that I am one of the doctors specializing in psychological medicine etc.

Because patients can shut down or terminate prematurely in these cases it is a good idea to go in and do a focused interview asking all the most important questions up front. I.e. dont ask a lot of fluff, go straight in with a focused risk assessment. It is also a good idea to tell patients what you already know, how long you anticipate being with them, to pull up a chair and sit down, so you show you are interested in them, and what the purpose of the visit is.

Also, if they refuse to talk to you, you then have to assume they are high risk and if you inform them of this and they aren't personality disordered, they may well relent and begrudgingly talk to you.

Most frustrating admission of my life was a guy in our psych ED who was brought by police who said something foolish because he was angry with his mother but stuck very doggedly to the theoretical point that it was impossible for human beings to predict the future and so refused to comment on whether or not he felt safe outside of the hospital. He really didn't want to be admitted, but there was a distinct personality component that would not allow him to grant that his philosophical argument about the intrinsic ineffability of the future might be defeasible in the face of not undergoing an involuntary commitment.

 

[Zephyrill]

When you get a consult you should always ask if the pt has been informed that psychiatry has been consulted. If not, then tell them to call back once the patient has been informed of the consult request. You can imagine that patients might be unhappy to see a psychiatrist if they haven't been informed you would be coming. There are some exceptions to this (for example some patients will freak out when told that psychiatry will come to see them especially if they have a history of severe mental illness or have been traumatized/abused by psychiatrists in the past). In these cases I don't tell them I am a psychiatrist and just say I'm a doctor. In fact, when consulting in the general hospital I will rarely say I am a psychiatrist, but might tell pts that I am one of the doctors specializing in psychological medicine etc.

Because patients can shut down or terminate prematurely in these cases it is a good idea to go in and do a focused interview asking all the most important questions up front. I.e. dont ask a lot of fluff, go straight in with a focused risk assessment. It is also a good idea to tell patients what you already know, how long you anticipate being with them, to pull up a chair and sit down, so you show you are interested in them, and what the purpose of the visit is.

Also, if they refuse to talk to you, you then have to assume they are high risk and if you inform them of this and they aren't personality disordered, they may well relent and begrudgingly talk to you.

Thanks splik, this is exactly what I was looking for.

 

[nitemagi]

Always align with the patient, even in risk assessments. Which can be a balancing act. Acknowledge your role, but align with being there to help with their safety. Acknowledge the information you have and how that has to be taken seriously, but that it may be incomplete and you want their side of the story.

 

[Salpingo]

Generally, I'll try to respect the patients autonomy. They're in the hospital, often having the worst day of their life, with no ability to control who goes in or out, multiple orifices being examined by total strangers they didn't choose to be their doctor.

But the easiest thing to do is normalize: "that sounds awful. Many times when people are in your situation, their mind can wander and they begin to think life isn't worth living. Has that occurred to you? What keeps you going?" There's also the play dumb but professional technique. Basically, starting with the premise that you didn't come seeking them out, but you were called in to do your job, ask certain questions. What can you do? You're both stuck in this situation, but maybe there's something you can understand to help. Regardless, whether you agree on the principles of mental health or not, you can both agree that you have an obligation to do your job. That helps with the more paranoid personalities.

The trap people fall in is making it a game, where you have to pry or trick information out. Many patients are apprehensive of psychiatrists to begin with as manipulative mind readers, and don't like feeling deceived or bullied (whether that's your intent or not).

 

[FreudianAutocorrect]

Generally, I'll try to respect the patients autonomy. They're in the hospital, often having the worst day of their life, with no ability to control who goes in or out, multiple orifices being examined by total strangers they didn't choose to be their doctor.

But the easiest thing to do is normalize: "that sounds awful. Many times when people are in your situation, their mind can wander and they begin to think life isn't worth living. Has that occurred to you? What keeps you going?" There's also the play dumb but professional technique. Basically, starting with the premise that you didn't come seeking them out, but you were called in to do your job, ask certain questions. What can you do? You're both stuck in this situation, but maybe there's something you can understand to help. Regardless, whether you agree on the principles of mental health or not, you can both agree that you have an obligation to do your job. That helps with the more paranoid personalities.

The trap people fall in is making it a game, where you have to pry or trick information out. Many patients are apprehensive of psychiatrists to begin with as manipulative mind readers, and don't like feeling deceived or bullied (whether that's your intent or not).

I agree. It really depends on the person in front of you as well. After a while you can guess the approach to take before you even enter the room. E.g the mid-30s male blue collar worker that's a bit dismissive of psych is probably going to respond better to the sympathetic but "I'm doing my job" approach. If it's clear that in situations with other people similar to this, certain procedures have to be followed, it's nothing personal. Other people are going to find that approach much too invalidating and cold of course.
Sometimes I even appeal to their sympathy, saying that if I'd be on the hook if I didn't do my job properly. I'm not sure if that's a good approach or not, I suppose it could backfire badly with some personalities.

 

[smalltownpsych]

Along the lines of the, "just doing my job" with some patients, especially when patient has substance abuse history, I'll align with their frustration with the system. It's not much of a stretch for me to empathize with that sentiment.

 

[Shikima]

"Unable to contract for safety"

 

[WingedOx]

It seems around here the standard of care is that if an ER is concerned enough to call psych and then someone won't participate to our satisfaction in evalauation and safety planning, they are going to get admitted involuntarily. Which is unfortunate from a moral standpoint, but does take some of the pressure off the psychiatrist if the patient isn't cooperating.

unfortunate for an ethical standpoint too...