43 The clinical interview as a method in suicide risk assessment

In this chapter we describe the role of the clinical interview in the assessment of suicide risk. In the course of the interview the clinician must endeavour to understand the patient's crisis from both the ‘objective/descriptive’ and the ‘experiential’ perspectives, each of which we describe in detail. A focus on both of these perspectives is critical in the clinician's coming to the best possible understanding of the patient. In addition to the role of the clinical interview in assessing risk, this critical clinical interaction is also the beginning of the treatment relationship and crisis intervention; thus it has a role in reducing risk as well. Finally, we comment briefly on the clinician's conscious as well as unconscious responses to the patient, or ‘countertransference’, that can arise in the interview of potentially suicidal patients and influence the clinical assessment.

The clinical interview remains the fundamental instrument in the assessment of suicide risk. In considering this aspect of clinical assessment we discuss the interview as a single encounter, though it may in fact encompass a series of interviews and clinical interactions depending on the clinical situation and venue. We conceptually divide the functions of the interview into what we call the ‘objective/descriptive’ and the ‘experiential’ perspectives. The objective/descriptive perspective, commonly given greatest emphasis, is that from which the clinician performs a medically oriented psychiatric evaluation. Equally important, however, is that the clinician also hold the experiential perspective; that is, in addition to observation and gathering objective data, the clinician must endeavor to understand the subjective inner experience of the patient. Thus, the clinician who is attempting to come to the best possible understanding of the patient's risk for suicide has the challenging task of holding and moving back and forth between these perspectives in the course of the clinical evaluation.

This perspective encompasses the use of the clinical interview to gather objective data about the patient that can aid in assessing the degree of suicide risk. In addition to taking a clinical psychiatric history, this includes recognizing the overt manifestations of a suicidal crisis, identifying risk factors for suicide, and assessing high-risk clinical symptoms. We will discuss each of these in turn.

It is of paramount importance that the clinician recognize those observable signs that signal that the patient is in a crisis that could lead to suicide. Most obvious, of course, is the patient's direct expression of suicidal thoughts. The clinician's task is to recognize the intensity of these thoughts and whether the patient has associated intent, or suicidal urges even in the absence of conscious intent. Other questions include whether the patient has had a specific plan for suicide, the potential lethality of the plan, and whether the patient has access to lethal means. Also important is whether the patient has been rehearsing for suicide—either overtly or cognitively—and whether they have been behaving in such a way that appears to reflect preparation for suicide.

Of note, a patient's denial of suicidal thoughts is not necessarily reassuring in the context of other signs pointing to a suicidal crisis. While patients often give some indication of suicidal thoughts or intent, this communication is not always direct, and is often to others in his life but not to the clinician (Robins 1981; Wolk-Wasserman 1987b; Fawcett et al. 1990, 1993; Pallaskorpi et al. 2005). In a chart review of 76 inpatient suicides, 78 per cent had documented denial of suicidal thoughts just prior to the event (Busch et al. 2003). Thus, the clinician must not only attend to the patient's words, but also ask: is there anything about the patient's clinical situation and mental status that makes me question whether he might still be at risk? In this context collateral information from family, friends, and other clinicians—regarding both the patient's recent statements as well as behaviour—can be critical to the assessment. For example, has the patient who currently appears calm and denies suicidal thoughts been making what appear to be preparations for suicide, such as giving away possessions, getting affairs in order, or planning a funeral?

Why might a suicidal patient deny suicidal thoughts when interviewed by the clinician? One possibility is that the patient is lying about, or at least minimizing, the extent of his suicidal thoughts and intent. The patient may, for example, have an explicit suicide plan and want to avoid discovery. Another possibility, however, is that the patient might believe that the prospect of suicide is anxiety-provoking to the clinician and might put the relationship at risk; thus, concealment might be in the service of preserving the relationship. Still another possibility is that the patient is not lying or consciously minimizing at all. Perhaps he has experienced transient relief in the context of being in the therapist's office or emergency department, and genuinely does not recognize the degree to which they are likely to feel overwhelmed and suicidal shortly after leaving (Wolk-Wasserman 1987a). Perhaps the patient is so disconnected from his inner experience (as sometimes occurs in psychotic illnesses) that the denial of suicidal thoughts is genuine, even as the patient might the next moment be seized by an overwhelming suicidal urge.

A full review of suicide risk factors is beyond the scope of this chapter, and precipitating events to suicide are discussed by Hendin in the next chapter. One area of potential confusion, however, is to what degree the identification of risk factors can aid the clinician in the clinical assessment. Risk factors are helpful in identifying patients who fall into high-risk groups, which can help to heighten the vigilance of the clinician in the assessment of these patients. Unfortunately, however, the number of risk factors does not inform the clinician about the risk of suicide in an individual patient (Pokorny 1983; Goldstein et al. 1991; Powell et al. 2000). Conversely, the absence of identified risk factors is not at all protective in the face of other clinical variables. For example, a history of previous suicide attempts is well known as a strong risk factor for completed suicide (Owens et al. 2002). In the context of other reasons for concern, however, the absence of such a history is not reassuring in that approximately two-thirds of completed suicides occur on the first attempt (Mann et al. 1999).

There is another way in which the significance of a history of previous self-harm as a risk factor is at times misunderstood by clinicians. Patients with repetitive low-lethality, low-intent self-harm are often seen as having interpersonal manipulative motives; the fact that they have not made higher lethality attempts is taken as an indication that they are at low risk of ever actually completing suicide, as implied by the commonly used term ‘suicide gesture’. This can be a dangerous over-simplification. First, it is important for the clinician to be aware of a variety of possible motivations for self-harm, including the possibility that it may serve to relieve intolerable tension. Secondly, the assessment of suicide risk in these patients is often not a simple matter. While it is true that patients who make high lethality attempts are statistically at greatest risk (Rosen 1976; Douglas et al. 2004), low-lethality self-harm—even in the absence of suicidal intent—still increases the risk of eventual suicide (Gunderson and Ridolfi 2001; Oldham 2006). In particular, the clinician should be vigilant to changes in affective state or psychosocial situation that might put the patient at increased risk, and not be lulled into a false sense of security.

It is widely known that patients with affective disorders are at highest risk for eventual suicide, and that psychotic features and concomitant substance abuse (particularly alcohol) increase the risk (Robins 1981; Roose et al. 1983; Fawcett et al. 1990; Chirpitel et al. 2004; Pallaskorpi et al. 2005). We will focus here on three other high-risk clinical symptoms that are less widely known to clinicians: hopelessness, anxiety, and sleep disturbance.

Prospective studies of psychiatric patients after hospital discharge have found that the extent of a patient's hopelessness is more highly correlated with suicidal thoughts, intensity of suicidal intent, and eventual suicide than is depression (Bedrozian and Beck 1979; Wetzel et al. 1980; Beck et al. 1985, 1993). Outpatients with severe hopelessness are have also been found to be at significantly increased risk of eventual suicide (Brown et al. 2000). The association between hopelessness and suicide makes clinical sense, in that the hopeless patient is less likely to see alternatives to suicide in times of crisis.

Hopelessness is a subjective experience, often without outward manifestations, and thus can easily be missed if the interviewer does not understand the need for specific assessment. It is particularly easy to underestimate the degree to which a patient may continue to feel hopeless even after apparent clinical improvement and the remission of other affective symptoms. Attunement to this continued ‘trait’ hopelessness is important in the assessment of suicide risk, as it has been associated with an increased risk of suicide attempts (Young et al. 1996).

The clinician should try to answer a number of questions in the interview. To what extent if any was the patient able to generate alternatives at the moment of crisis? What about now? Does the patient continue to feel hopeless at the time of evaluation? Is there any experience of relief and hope for help? In the ambivalent internal struggle around suicide, the extent to which a patient experiences a continued wish to die—as opposed to a competing increase in hopefulness and wish to live—increases the risk of eventual suicide (Brown et al. 2005; Henriques et al. 2005).

The clinical assessment of the patient who is persistently hopeless can be very challenging. The patient's life situation is often so difficult, and his hopelessness about the possibility of any change so genuine and persuasive, that the clinician can easily begin to feel that the patient is right: nothing will ever actually help. It is important that the clinician recognize such an internal response, particularly since the patient is likely extremely sensitive to even subtle signs of hopelessness in the clinician. A recent study on a trial of cognitive therapy is helpful in this regard, in that patients who had attempted suicide showed improvement in both hopelessness and depression—and a 50 per cent lower risk of repeat attempts—at 18 months (Brown et al. 2005).

Also often under-appreciated is that the assessment of the patient's level of anxiety is a critical aspect of the clinical evaluation of suicide risk. In prospective studies of patients with affective disorders both panic attacks and ‘psychic’ anxiety were strongly associated with increased short-term risk of suicide, within weeks to one year (Fawcett et al. 1990; Maser et al. 2002). It may often be anxiety that makes the experience of depression and hopelessness intolerable, adding a potentially lethal urgency to act (Fawcett et al. 1993). It is essential that the clinician explicitly assess the extent of the patient's anxiety, particularly since it may readily be treatable both pharmacologically (i.e., benzodiazepines, atypical antipsychotics) and psychotherapeutically (i.e., cognitive skills, coping strategies).

The extent of a patient's anxiety can easily be missed in the clinical interview, particularly if it is a quiet form of anxiety. A good example was a 46-year-old female inpatient who had been admitted for suicidal ideation and was seen by one of the authors (M.S.) several days after admission. The patient had spent most of the first few days of her hospitalization sitting in her room, appearing quietly depressed. She did not seem outwardly anxious, and had not received any doses of the benzodiazapine that had been ordered on an ‘as needed’ basis by the admitting physician. When the author interviewed her he explicitly asked about anxiety, despite the lack of outward manifestations. The patient described feeling severely anxious, as though she ‘could not take it any more’, she felt she would ‘do anything’ to put a stop to the experience. She was treated with a standing order for a benzodiazepine, the clinical focus shifted to specifically helping with her anxiety, and she subsequently experienced rapid improvement.

Sleep disturbance is another potentially treatable clinical symptom that may be associated with increased risk of suicidality in depression. Like anxiety, global insomnia has been identified as one of the factors associated with increased short-term risk of suicide, within weeks to one year (Fawcett et al. 1990). Depressed patients who report suicidal ideation have been found to have greater subjective sleep disturbance that those who do not (Ağargün et al. 1997), and both insomnia and frequent nightmares have been associated with increased suicidal ideation in depressed patients (Bernert et al. 2005). In a prospective study of elderly patients a correlation was found between subjective sleep disturbance and a higher risk of eventual completed suicide (Turvey et al. 2002). Like anxiety, sleep disturbance is a symptom that may be readily treatable but is not always spontaneously reported by the patient. Thus, it is essential that the clinician specifically assess sleep in the evaluation of depressed and potentially suicidal patients.

As Birtchnell (1983) has pointed out, the ‘medicalization'of the clinical interview—by which he means a focus on medically oriented symptoms without sufficient emphasis on understanding the patient's subjective experience—carries the risk of unintentionally curtailing the exchange for both clinician and patient:

The therapist conveys to the patient that the suicidal urge is a manifestation of the illness, that it has nothing to do with the patient himself. If the patient can allow the doctor to eliminate the illness he will find that his suicidal urge has gone away… The psychiatrist asks the patient whether he feels that life is worth living; whether he feels like putting an end to it all. Once the patient has answered yes, the symptom has been elicited, and the psychiatrist wishes to know no more.

Birtchnell (1983, p. 27)

Thus it is essential that the clinician also try to understand the patient's subjective inner experience of the suicidal crisis. What was/is the patient actually feeling, beyond a delineation of clinical symptoms? In what way(s) are the patient's suicidal thoughts or actions understandable given that experience? (Linehan 1993, 1997). The clinician who focuses exclusively on the elicitation of symptoms runs the risk of not meeting the patient's basic need to be seen, understood, and accepted; this can paradoxically can leave the patient feeling more alone, even in the context of seeking help. As we will discuss, the clinician's effort to understand the patient's subjective experience includes eliciting the patient's personal narrative, understanding his affective experience, assessing sustaining resources, and identifying underlying beliefs, motivations, and fantasies. We will also discuss the clinician's capacity for empathy as an important tool in this aspect of the clinical interview.

In eliciting the patient's personal narrative the clinician's goal is to understand what led to the suicidal crisis from the patient's perspective. The hope is to engage the patient—to the extent possible—in arriving at a shared understanding of his distress, and how it was that he came to see suicide as the solution. While this may sound obvious, it is a goal that is frequently far from attained in clinical practice. In fact, there is often discontinuity between a patient's understanding of the reasons for his suicidal behaviour and those attributed by the clinician. Patients most often describe a wish for relief from unbearable mental anguish as the reason for a suicide attempt; clinicians commonly identify interpersonal communication and manipulation as primary motives (Bancroft et al. 1979; Michel et al. 1994). It is therefore essential that the clinician be alert to any preconceived notions, biases, feelings, and past experiences that may lead to premature inferences and conclusions about the patient's experience.

Our emphasis on understanding suicidality from the patient's perspective can readily be misunderstood. It does not mean that the clinician must take the patient's perspective on his suicidal crisis at face value, eschewing critical thinking, clinical inference, and independent judgement. It is in fact essential that the clinician understand that patients often have many levels of motivation for their behaviour, some less readily identified and disclosed than others, and some truly outside of awareness. However, if the patient's own experience is not the starting place for exploration a major opportunity is lost, and the chances of arriving at the best possible understanding damaged. The patient is likely not to feel heard and understood, and is subsequently less likely to feel able and willing to be open and forthcoming.

Shneidman describes suicide as ‘a combined movement toward cessation and away from intolerable, unendurable, unacceptable anguish’ (1992, p. 6). There is widespread agreement that this effort to escape psychological pain and an intolerable affective state is a primary driver of suicidal behaviour (Buie and Maltsberger 1983; Maltsberger 1988; Shneidman 1992; Linehan 1993; Hendin et al. 2004). Hendin et al. (2004) found that therapists reported a higher number of intense affective states in their patients who completed suicide in the course of treatment than in a non-suicidal comparison group with severe depression. The most frequently cited affect was desperation, defined as a state of anguish accompanied by an urgent need for relief. Under the pressure of such unbearable affective intensity cognition narrows, the experience can feel interminable, and the capacity for such functions as self-soothing and problem-solving can transiently be lost. Patients often report breakdowns in self-control; they will say that they are losing their grip, and of this they are often very ashamed. They may know better than to do or to say certain things, but unable to restrain themselves under the pressure of intense feeling, they act or speak out anyway. The dread accompanying the self's breaking up, sometimes called annihilation anxiety, is a profound experience of helpless horror. When the patient sees no alternative, no end point or escape from unbearable suffering, the risk of suicidal behaviour is increased.

It is essential to be aware that under certain circumstances, such as in the holding environment of a hospital or a therapist's office, even overwhelming affect and unbearable psychological pain can transiently be relieved. The clinician must therefore be attuned not only to the patient's affective experience at the time of the interview, but also to their experience in the moment of crisis. The challenge is to understand to what degree the relief experienced by the patient is transient and unstable, and to help the patient to understand this as well. Ideally clinician and patient can use the opportunity of temporary calm to problem-solve, work on coping strategies, and develop a crisis plan so that the patient will be better prepared to deal with the next affective storm.

Clinicians often undervalue the role of intolerable affect, and mistakenly see suicidal thoughts and behaviour as arising only as symptoms of clinical depression. Thus, a patient who describes feeling suicidal in the absence of current clinical signs and symptoms of depression is likely to be seen as motivated by secondary gain, and perhaps to be malingering. While this is at times undoubtedly true, the clinician should be aware of other possibilities as well. For example, a patient who is calm and apparently euthymic after admission to the hospital may inaccurately be using the term ‘depression’ to describe an intolerable experience of anguish and desperation that has now transiently been relieved by hospitalization. The danger here is that the clinician will mistake this either for manipulation or for improvement in the patient's ‘depression’. In either case, both physician and patient may misunderstand the patient's current euthymia to mean a decrease in suicide risk, when in fact he is just as vulnerable to being overwhelmed by intolerable affect when once again outside the office or hospital.

All of us rely on outside resources such as spouses, friends, school, or job to support our sense of self; for some, however, this is a critical need, the loss of which leads to an experience of aloneness, overwhelming affect, and unbearable psychological pain. The experience of aloneness is an unbearable psychological state; it differs from loneliness in that it leaves the individual unable to feel the presence of comforting and sustaining supports, even if they are genuinely available. From a psychoanalytic perspective (Adler and Buie 1979; Buie and Maltsberger 1983; Maltsberger 1988) this vulnerability is seen as a developmental deficit: the patient has not had the opportunity to internalize and thus later to be able to evoke soothing introjects (i.e., images of others, inner voices), which leads to an over reliance on others (i.e., self-objects) to modulate negative affect and sustain the sense of self. In this context the loss—real or perceived—of a critical sustaining resource such as a relationship or a job can lead to a suicidal crisis.

This inability to make use of available sustaining resources can also be a ‘state’ experience in the absence of clear developmental deficit. The severely depressed and/or psychotic patient can transiently lose the capacity to evoke soothing introjects, and thus be unable to feel even the genuine presence and support of others; this can evoke an overwhelming experience of aloneness and increase the risk of suicidal behaviour.

In assessing suicide risk, then, the clinician should keep the following questions in mind. Who/what does the patient have to live for? Who/what does the patient rely on to sustain his sense of self? Has there been a change, particularly a real or perceived loss of any of these critical supports? Is patient able to make use of available sustaining resources given his current mental status? What about once the patient is outside the interview room or hospital, at a moment of crisis?

A frequently neglected aspect of the suicide risk assessment is the importance of the patient's beliefs about suicide. The clinician's goal here is to find out what the patient actually thinks will happen if he attempts suicide; to assess the strength and rigidity of these beliefs; and to see if the patient can entertain other alternatives. For example, does the patient believe that he will complete the attempt and end up dead? What consequences does the patient believe this would have on others, such as spouse, children, family, friends? To what degree has the patient been able and willing to genuinely explore these consequences, and can he do so now? If the patient views suicide as an effective solution, the risk of future suicide attempts is increased (Chiles et al. 1985).

Also important are the patient's overall beliefs and attitudes about suicide. In general, patients who endorse ‘reasons for living’—such as positive beliefs about capacity to cope, concerns for family/children, fear of social disapproval and moral/religious objections to suicide—have been found to have less suicidal ideation, to make fewer suicide attempts, and to have less suicidal intent than those who do not (Linehan et al. 1983; Strosahl et al. 1992; Malone et al. 2000). In addition, strong moral/religious objections to suicide have been correlated with lower lethality suicide attempts (Malone et al. 2000). The caveat here is that the clinician must be careful not to allow generalizations based on clinical research to preclude a genuine inquiry into the meaning of an individual patient's beliefs and attitudes. For example, the clinician might assume that a mother's concern for the well-being of her children is a mitigating factor against suicide. But what if her concerns have turned to a belief that she has been an utter failure as a parent, and that her children would ultimately be better off without her? In this case, what might have been seen as a ‘protective’ factor may be such a source of shame that it actually worsens the patient's despair and increases her risk of suicide.

The clinician should also be aware that the idea of suicide can have very different meanings and be motivated by different sets of fantasies. Some fantasies and motivations are fully or partially conscious, and some may be outside of awareness. For example, the patient may feel he deserves punishment, may long for a fantasized reunion with a lost other, may wish for retaliation (and paradoxically have a fantasy that they will experience the pleasure of retaliation even in the context of suicide), or wish to destroy a hated aspect of self such as an identification with an abuser (Maltsberger and Buie 1980; Maltsberger 2004).

Essential to this aspect of the clinical assessment is the clinician's willingness not only to ask about but also to offer respectful alternatives to the patient's stated beliefs. Is the mother who believes that her child would be better off without her able/willing to consider that she may be misreading the situation because of her depression, and that her child would likely be irrevocably damaged by her suicide? Is the man who has felt utterly alone since his father's death, and longs for a reunion through suicide, able/willing to consider the possibility that suicide might not mean blissful reunion? Is the woman who has strong religious objections to suicide but has decided that God sure would forgive her about this, or is she open to the possibility that she might be wrong? The clinician's willingness to enter into this kind of dialogue with the patient allows for an assessment of the strength and rigidity of beliefs that may predispose the patient to suicidal behaviour. It also helps in starting to build a treatment alliance, demonstrating the clinician's interest in a genuine and full understanding of the patient's experience. Finally, this level of inquiry is the beginning of crisis intervention and treatment, offering a challenge to the cognitive constriction—the no alternative/no option thinking—that characterizes the patient's suicidal crisis.

The clinician's capacity for empathy— that is, to understand and to feel intuitively the perspective and experience of another—is critical to the clinical interview. In addition to listening to the patient's words, the clinician picks up something else from patient—a non-verbal affective communication—that stimulates an empathic resonance, a sense of understanding what the other is feeling. As part of this process clinicians makes reference to their own past experiences that inform this intuitive sense of affective understanding. The process of empathy is often preconscious or even completely out of the clinician's awareness, yet it is a critical source of clinical data (Wolk-Wasserman 1987a).

Often the clinician's empathic experience is consonant with the patient's conscious and stated declaration of his emotional state, adding a resonance and a deepening of connection. At times, however, there may be a discordance between what the patient says and what the clinician picks up empathically, a time when the ‘words and the music’ don't seem to match. A patient may, for example, deny suicidal thoughts while the clinician is picking up empathic cues of distress that raise a question about safety. Alternatively, a patient may express suicidal thoughts while the clinician's empathic experience is that the patient is overstating the degree of distress, raising a question about the possibility of secondary gain. In either case the clinician's empathic experience is an important tool, but the clinician must be aware that as a sole source of data it is prone to error. Thus, the clinician must ask: ‘Why doesn't this fit? Where is my concern coming from?’ This leads the clinician to integrate his empathic experience with the other sources of clinical data about the patient.

In addition to its essential role in suicide risk assessment, the clinical interview is also the starting point of the treatment relationship and crisis intervention. This beginning is often complicated by the feelings that the patient brings to the encounter, such as shame, self-blame, hopelessness, aloneness, anger, distrust (Leenaars 1994). At this moment the patient is quite likely to believe that help is not possible, and that full engagement is not even worthwhile. Thus, an additional major goal of the interview is to enhance motivation, to join with the patient in initial problem-solving, and to increase the likelihood that the patient will follow through with recommended treatment.

Perhaps the most important tool available to the clinician in this regard is an attitude of non-judgmental acceptance and validation of the patient's experience (Linehan 1993, 1997; Schechter 2007). It is essential that the patient feel heard by the clinician to the extent possible, and that the clinician demonstrate an understanding of the way or ways in which suicidal thoughts and/or behaviour are at least understandable given his situation and internal experience. This serves a number of functions: it helps to relieve to some degree acute distress and aloneness, minimizes the patient's propensity for self-blame, models a hopeful attitude about problem-solving and treatment, and offers at least the possibility that the patient can be understood and ultimately helped. Ideally, this increases the likelihood that the patient can become a full and active participant in the evaluation and treatment planning process, and enhances motivation for treatment adherence

A full review of the countertransference issues involved in the evaluation of suicidal patients is beyond the scope of this chapter, and will be covered elsewhere. There are, however, a few issues that we will highlight in the context of our discussion of the clinical interview.

Hendin et al. (2006) aptly describe the universal difficulty involved in assessing and treating potentially suicidal patients:

The added gravity common problems assume when suicide is a risk … invariably involves unique anxieties related to the possibility that despite the therapist's best efforts, the patient may kill himself and the therapist may be blamed. Therapists' fear that a patient may commit suicide frequently impedes their ability to deal effectively with the danger.

(2006, p. 70)

While the goal of the clinical interview is an objective assessment of suicide risk, the assessment cannot help but be affected by the feelings, biases, and pre-existing inclinations that the clinician brings to a clinical encounter in which the stakes truly are life and death. Each of us bears anxiety, ambiguity, and risk in characteristic ways. Some, for example, are more likely to take control and thus to minimize uncertainty; others have a greater tolerance for anxiety and are willing to bear greater risk in the hope of promoting to the extent possible a patient's autonomy. What is essential is that clinicians have as much self-knowledge as possible about where they fall on this continuum, and that real-time consultation is sought as needed.

One clinical scenario that has major potential for counter-transference difficulties is that in which the clinician encounters an angry, hostile, and/or devaluing patient. This presents an inherently problematic situation: no matter how disrespectfully the patient behaves, the clinician still must come away from the interview with an objective assessment of suicide risk. It is not uncommon for the clinician to experience anger toward such a patient. This emotional response may conflict with the clinician's ideals, which increases the likelihood that it will defensively be kept from his full awareness. In addition, the clinician may unconsciously accept the patient's devaluing projections, leading to feelings of incompetence, guilt, and increased anxiety. The clinician's capacity to be aware of the feelings engendered is of utmost importance, so that the countertransference pressures experienced do not lead to a distortion of the risk assessment. Of greatest concern are unrecognized feelings of aversion toward the patient (Maltsberger and Buie 1974; Wolk-Wasserman 1987a, c), which can lead to unconscious withdrawal and increase the possibility that the clinician will not fully appreciate the extent of the patient's suicidal crisis and immediate needs.

In this chapter we have reviewed the functions of the clinical interview, which depending on setting and clinical need may in fact encompass a series of interviews and clinical interactions over time. We have divided these functions conceptually into the ‘objective/descriptive’ and the ‘experiential’ perspectives. The clinician must be able to move comfortably between these perspectives in order to come to the best possible understanding of the patient's suicide risk. In addition to its role in risk assessment, the clinical interview is also the beginning of the treatment relationship and crisis intervention. Finally, it is important that the clinician be aware of countertransference issues that commonly arise in the evaluation of suicidal patients, which if unrecognized can have an inadvertent influence on the clinical assessment.