Vignette Discussion Example

Vignette Example 1

Twenty-six year old white female phoned her counselor, stated that she might take pills, and then hung up and kept the phone off the hook. The counselor called the police and the patient was brought to the crisis intervention center on a transportation hold. Patient was angry, denied suicidal attempt, and refused evaluation; described as selectively mute, which means she wouldn’t answer any of the questions she didn’t like.
Facilitator: How high a risk is this person for committing suicide? Low, moderate or high?

Student Answer 1: Maybe moderate because the person is warning somebody, basically a plea for help.

Facilitator: Okay, so we have suicidal talk. That’s one of our red flags. What else?

She said she might take pills, so we didn’t know if she does have the pills. So she has a plan. The plan would be to take pills, but we don’t know if we have means.

Student Answer 2: High. She’s also angry. I don’t know if she’s angry often.

Facilitator: A person in this situation who is really thinking about killing themselves tends not to deny it. They tend not to deny it. There are exceptions to everything, but most of the time, for some reason, this is one of the things where people tend to mostly tell you the truth. If you ask people, they tend to tell you the truth. It’s a very funny thing about suicide that way. That’s certainly not true about most things. If you ask people how much they drink…But, “Are you thinking about killing yourself?” “Well, yes.” If you ask a question, you tend to get a more or less accurate, straight answer.

Student question: Is that because it doesn’t matter anymore? If they’re going to die anyway, who’s going to care about what anybody thinks or what happens?

Facilitator: My hypothesis would be, when someone is at that point, they’re talking about real, true things. They’re not into play. This is where they are. If they’re really looking at it, then they’re just at that place. What’s to hide at that point? You don’t have anything to lose. It’s a state of mind. And then if you’re not in that place—it’s like, how close are you to the edge of that cliff? “I’m not there. I know where that is, and I’m not there.” “If you get there, will you tell me?” “Yeah, I’m not there.” So, people have a sense—if they’ve gotten that close, they know where that line is, and they know about where they stand in regard to it, because it’s a very hard-edged, true thing.

Vignette 2

Twenty-three year old white male, self-referred. Patient bought a gun two months ago to kill himself and claims to have the gun and four shells in his car. Police found the gun but no shells. Patient reports having planned time and place for suicide several times in the past. States that he cannot live anymore with his emotional pain since his wife left him three years ago. This pain has increased during the last week, but the patient cannot pinpoint any precipitant. Patient has a history of chemical dependency but has been sober for 20 months and currently goes to AA.

Facilitator: How high a risk is this person for committing suicide? Low, moderate or high? On a scale from 0 to 7 (7 being very high).

Student Answer 1: High.

On a scale of 0 to 7?

Student Answer: Six.

Student Answer 2: I would say three. I think it would be lower because if he’s already bought the gun two months ago and he’s self-referring himself to get help, he wants to live. He has not made peace with whatever, and he’s more likely not give away his things, and he’s going to AA meetings. I think it’s lower than really an extreme…I would say a three or four.

Student Answer 3: I would say a four or five, moderate.

Student Answer 4: About a five..several times and hasn’t followed through, tells me he doesn’t really want to follow through with it.

Facilitator: And there are no shells, right? So we can see some of the red flags are there, but some of them aren’t. He’s still sober…

Student: He has a support group.

Student: He’s not using, though he bought a gun—so that’s a concern. There is a lot there.

Student: He may not have the shells so he doesn’t have the opportunity to.

So does that make him more…?

Student 2: Think I’ll change mine to a five.

Facilitator: So the mean was 4.68, so 5 was the mode. If we’re saying this is a moderate risk, what things would we look for that would make this a high risk?

Student: Take away AA.

Student: If he falls off the wagon, he goes right to the top.

Student: And if he finds the shells.

Facilitator: Because it probably is not that hard to find shells. All these stores around here, you can get shells quicker than you can get a gun, so he’s only a five-minute purchase away from having lethal—in contrast to not having the gun.

Student: Could there be a difference in the time? Let’s say his wife left him just four to six months ago rather than three years. Would that be something that would be more serious?

Facilitator: Yes, or if his wife just left him. So, say his wife left him a month ago that would bump it up. So that’s unresolved. That’s taking a person that was worried and that’s pushing him higher.

Student: It also raises the homicide rate.

Facilitator: Yes, because these tend to be murder-suicides. How often have we seen that? Murder-suicide is a big deal. If she won’t be with me, she won’t be with anybody.