Book Review: Trials and Tribulations

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Book Description

Medical malpractice has become a hot issue in our litigious society. The trial lawyers are locked in battle with the doctors, while the politicians and the patients look on. This is about one skirmish in that battle, told by one of the casualties.

Donald Austin, M.D., was a well-respected neurosurgeon, operating at the cutting edge of medical technology. He was justly regarded as an expert in the field, and as such gave testimony for the defense in many malpractice lawsuits. However, he was shocked by some instances of malpractice, and when he decided to testify for plaintiffs as well, he did not bargain for what ensued. As his testifying became known, both his professional colleagues and the medical societies carried out a smear campaign that ended his professional career.

About the Author

Donald Austin, M.D., is a third-generation doctor. A native of Indiana, he now lives in Michigan. He was chief of the neurosurgery section of the Hutzel Hospital in Detroit for many years and associate professor of neurosurgery at Wayne State University. He is married, with four grown children, and is now, reluctantly, retired.

There is no such thing as a small fire. Fire knows no boundaries and adheres to no restrictions. It is limited only by its supply of oxygen and the availability of a fuel source. Someone can set a small and insignificant fire, but fires only start small. They can fizzle out and die, but all too often they grow, vast and terrible. They destroy property. They take lives.

Sadly, the most persistent and dangerous incendiary fire-setters are the weakest and least responsible of us all: children. According to the New Jersey Division of Fire Safety, juveniles in the United States annually set 41,900 fires that result in 165 deaths, 1,900 injuries, and $272 million in property damage. Fifty-five percent of all arson arrests in the United States are children under the age of 18, nearly half of whom are under the age of 15, and 6.8% of whom are younger than 10 years old. Who are these children, and why do they set fires?

A 3-year-old innocently playing with a cigarette lighter left out by a careless parent might cause a conflagration in which his entire family dies. A 10-year-old might ignite his mattress in a desperate attempt to draw attention to an intolerable home situation. A high school student might throw a match into a wastebasket so that an alarm will go off and disrupt a dreaded test. One teenager might set fire to a car. Another might set fire to a rival’s home. Some have even been known to toss flammable liquids on derelicts because it amused them to watch the wretched souls flailing frantically at flames and screaming in pain. A successful actress I once knew told me that as a child, she had set fires for emotional relief. Children set fires out of boredom, anger, and rage. The motivations of youthful fire-setters run the gamut from curiosity to pathology, from innocence to evil.

Recently, I received a letter from a special education teacher, whom I will call Sarah Nelson, who works for the New York City school system. Her letter began:

Dear Shelly,

Gerald, who is repeating third grade, did so well that I was wondering WHY he had been placed in my class until, following a real fire evacuation at about 11 o’clock that morning (after someone had set the paper towel dispenser in the boys’ bathroom ablaze), I was called into the principal’s office.

There sat Gerald, two other boys, and his teacher.

“Mrs. Nelson,” asked the principal. “Was Gerald with you between 10:45 and 11:00 a.m. today?”

“Yes. He was taking the assessment test.”

“Did Gerald leave you at any time to use the bathroom?”

In the 47 seconds or so that Gerald had taken “to relieve himself,” he had pulled out a purloined lighter from his pocket and lit up the paper towels.

And this was not his first fire of the day!

A few hours before, Gerald, in the presence of the other two boys sitting in the principal’s office, had used matches to light up a toilet paper roll!

In the case of the paper towels, one of the male teachers had happened by, saw flames coming from the dispenser, rushed to the science room where there were two buckets filled with water, and attacked the fire. It was then that smoke had come pouring out of the bathroom and the alarm had been sounded.

Dismayed as I was to hear about these fires, it was not until I had read the next paragraph that I changed my mind about how I was going to approach this subject:

Of course, we did not DARE disturb the fire department to check our suppression efforts and/or “light” into the student body about fire safety. And our principal refuses to let us cover the incident in our student newspaper. It is for this reason I thought of you and wondered if you could give me some tips about juvenile fire-setters.

Needless to say, the small, unreported fires in Sarah’s school did not loom in my mind as small. I saw them as the deadly conflagrations that they might so easily have become. To alert my friend to the seriousness of her situation, I related some frightening statistics accumulated in the spring of 2004 by the Massachusetts Coalition for Kids in Danger. The Coalition’s purpose was to track media coverage of children who set fires or set off bombs.

In the first 201 days of the project, children burned over 57 vehicles, set fires that destroyed over 48,594 acres of forest, set 218 houses on fire, and destroyed 228 apartments, 30 businesses, and 13 churches. Additionally, they killed 80 people (26 of whom were children who perished in fires that they, themselves, had set) and injured 346 people, including 63 firefighters, police officers, and bomb technicians. Relative to institutions of learning, in its first 7 months of information gathering, the study found that 301 or 31% of the 901 fires set by children had targeted schools. These statistics, however, reflect only fires that were reported in the media. If we could add in fires like those described to me by Sarah Nelson—ones left unreported because principals do not want their schools to look bad—the statistics would become ominous indeed.

My involvement with juvenile fire-setters began when a polygraph expert contacted my late husband and me. He had been hired by a drug rehabilitation facility that I will call Kid City (my version of Boys Town) to determine which of the young people on the premises was responsible for setting a series of fires. Because there were hundreds of suspects and the polygraphist could not possibly test them all, he suggested that Kid City hire us. Our company, Charles G. King Associates, investigates the origin and cause of fires (origin: where a fire started; cause: what or who initiated the blaze).

At that time, most of the high school-aged children in Kid City had either been remanded there by the courts or had been placed there by family members or guardians for drug rehabilitation. The greatest percentage of those in the facility were criminals, and some were hardened criminals. All were underage. Their ages were relevant because Kid City was mandated by law to maintain the absolute confidentiality of their juvenile population. This meant that, although the local fire department could be called in to fight a fire, after extinguishment, they were required to leave. Nor would a city, county, or state fire marshal be permitted to enter the building to analyze the fire scene, search for hidden stashes of matches, or interview the residents.

This left Kid City in a terrible bind because at least one of their residents had set a series of fires, but, unlike the public school system situation related to me by Sarah Nelson, Kid City was completely committed to the continued safety of the young people in its charge. This is why they brought us in to investigate the fires. First, Charlie and I were asked to sign documents protecting the confidentiality of the residents (all of the names and places in this article have been changed); then we were briefed.

Kid City was located about 2 hours north of a big eastern city. The four-story structure was slightly larger than a county hospital, and it was surrounded by acres of beautiful farmland where residents were encouraged to grow crops and take nature walks. Other than some pleasant administrative offices on the ground floor and an elegant wood-paneled religious sanctuary, the building itself was institutional and utilitarian: cinderblock classrooms, cinderblock dormitory, communal dining rooms, and so on.

During our briefing by the director of Kid City, we were told that over the past seven months, three fires had occurred:

1. February 28 –Someone had taken a bunch of papers, piled them in a bin in the basement of Kid City, and ignited them. The fire was set at 8:20 a.m.
2. July 13 –Someone had shoved a wad of toilet paper between the arm and cushion of a sofa and set it on fire. This fire had not occurred at Kid City proper, but at its induction facility over 50 miles south. The fire had been discovered a little after midnight.
3. August 14 – This fire was set between two mattresses stored in the cinderblock closet of an empty room on the fourth floor of Kid City where the kids used to “coop,” or hang out. The fire occurred at 6:57 p.m.

We were called in after the third fire. Initially, the task of discovering who had set these fires was daunting, in no small part because our pool of suspects was upward of 150 residents. We then had to multiply this pool by three (once for each fire). In order to cut the list down to a manageable size, we asked the administrators to go through their files and give us only the names of those residents who had been at Kid City for at least the last two and optimally for all three of the fires. This reduced our pool to a little over one hundred suspects. To whittle the list down further, we drafted an affidavit and had copies distributed to the 100 plus residents on the list, as well as to all of the counselors, teachers, and administrators in Kid City.

The affidavit asked the individual to write his or her name and to answer four questions about each of the three fires. The questions were carefully worded to make the respondents feel that they were only reporting their observations, and not being tattletales or informants. It was not their job to identify the fire setter, it was ours. The four questions were

1. Where were you at the time of the fire?
2. What were you doing?
3. Who did you see?
4. Who saw you?

After the forms had been filled out, they were returned to us. Once we had a chance to look them over, we realized, somewhat to our surprise, that not only had the residents been willing to answer our questions, they had done so eagerly. We also noticed that fear of injury or death superseded peer group loyalty. The teenagers in the facility had a firm grasp of how dangerous a fire could be. Most of the students had been in residence only for the fires that had occurred in Kid City and made no mention of the fire at the induction facility. Many gave detailed observations that specified locations, recalled times, and named names. What follows is a sampling of typical responses:

Richard C.

During the first fire I was with my clan leader Evelyn V. talking about my problems. Then I went to seminar at 1:00 o’clock.

During the second fire I was in the rec room relating with Margaret C. Rene D., Dave H., Todd M., Marty E., and Jerome L.

Ken B.

First Fire – I was eating lunch until approx. 12:45. Then I went down to the auditorium for seminar. I do not remember who I was with at the time. Evelyn V. was going to give the seminar. I was reading until the fire began. At approx. 1:05 the alarm went off and I went outside.

Second Fire – I was in the recreation room, listening to music with Donald A., Joe Z., Joe B., and one other person. At approx. 9:30 I went upstairs to my room, and was still there when the alarm went off. When I was leaving the floor during the alarm, Bill D., saw me on the floor.

From these responses, we extrapolated where people were, when they were there, what they were doing, whom they saw, and who saw them. Then we tediously cross-referenced times, places, and residents. If Donna wrote that she had seen Thomas, Iris, and Edwin in the basement, we wanted to know if Thomas, Iris, and Edwin had also seen Donna. Our ultimate goal was to identify who had been in the area of the various fire scenes at the times of the fire and who had not.

The work was time-consuming and required meticulous attention to detail, but it produced results. Once we had completed and studied our charts, we were able to eliminate all but four suspects: Chris Ramirez, Fred Pozniak, Tyrell Washington, and Randy Scarp.

Chris Ramiriz

• Chris Ramirez had been seen on the fourth floor immediately before the fire.
• When the alarm went off, he was overheard saying that there were mattresses in room 411 that would be easy to set on fire.
• He was seen smoking a cigarette on the fourth floor immediately prior to the fire.
• He had set two fires before he was 6 years old. One in his grandfather’s garbage and one in his father’s grocery store. Coincidentally, the pizza store next door to his father’s grocery store had also burned down.

Fred Pozniak

• Fred Pozniak was seen on the fourth floor shortly before the fire.
• He was moody, quiet, and used to hang out on the mattresses in the “fire room.”
• He was a bed wetter and claimed to have been an abused child.
• He was a loner and was picked on and teased for being unattractive.
• He was very grim and depressed on the day of the fire.

Tyrell Washington

• Tyrell Washington had told two other boys at Kid City that he had a prior arrest for arson that was not in his records.
• He was present for all three fires.
• He had a hostile attitude and was overheard threatening to blow up the building.

Randy Scarp

• Randy Scarp wanted to leave Kid City and hated the place.
• He was reported to have a sadistic streak and laughed when other people were in pain.
• He seemed to have no control over his emotions.
• He was heard stating that “people are going to start dropping” at Kid City.
• Many of the other residents thought that he was not really a drug addict, but that he was crazy.

Once our list had become manageable, we moved to the next phase of our investigation. This was to interview each suspect individually and ask him what he had seen, when and where he had seen it, and who he thought had set the fires. Our interview strategy was low-key. Each youngster would be brought into a private room, asked questions, and invited to respond at length. None of the interviews were tape-recorded. Nobody from the staff was present. Charlie and I took turns asking questions, and I took all the notes.

After we had finished our interviews, we created four final charts, one for each suspect. Each consisted of three columns. The first column was headed “Witness” and listed the names of the residents who had seen one of the four main suspects at the time of a fire. The Second column was headed “What clears him” and delineated what the witness had seen that seemed to exculpate the suspect. The third column, headed “What makes him look suspicious,” did the same for what made him look guilty.

The following might be a typical entry for Tyrell Washington:

• Witness—Bill Hix
• What clears him— Bill saw Tyrell in the courtyard after dinner.
• What makes him look suspicious—Tyrell was present for all three fires and is known to have a hostile attitude. He told Bill and at least two other kids that he had been arrested for arson prior to coming to Kid City. Bill also overheard Tyrell threatening to blow up a building.

Our analysis of the entries on these four charts made it evident that only Randy Scarp had been sighted by multiple witnesses in the areas of all three fires. The “conclusion” column on his chart read:

Randy Scarp is the only suspect who was confirmed to be on the fourth floor at the time of the fire and who admits to being there. He denies setting the fire, but cannot explain why he did not see who did, because he was in the hall at the time the fire was set. There is also a problem with his disposal of a cigarette he was smoking at the time, as he said that he tossed it out a window, but that window is covered with a screen.

At the interview, he presented himself as compassionate and good-natured. He said he did not resent being accused of setting the fire, that he was not angry, and that he had not been out to get anybody lately.

The most suspicious thing about Randy, other than his proximity to both fires, is the benign way in which he presented himself. This benevolence is in complete contrast to the way others describe him. Also, unlike the others who were interviewed, at the end of his interview, we felt that Randy gave an audible sigh of relief that it was over.

After we had finished our interviews, our charts, and our analyses, we told the Kid City director that we had eliminated three of our four prime suspects and that we believed Randy Scarp, alone, had set all three fires. He responded that they were going to polygraph all four boys.

Subsequently, the polygraphist told us that Randy Scarp was, and I quote from my notes, “heavy duty guilty.”

Nevertheless, all four boys were kicked out. Charlie and I may have cleared Chris Ramirez, Fred Pozniak, and Tyrell Washington of involvement in those specific incendiary incidents, but Kid City was not going to take any chances. Fire is too dangerous, and too many lives were at stake. They knew, as we do, that children who set fires are a fact of reality, an unfortunate fact brought home to me when my friend, Sarah Nelson, contacted me again—this time on a cell phone from her classroom. After a minute or two, I had calmed her down enough to learn that two more fires had been set that morning in her school. As before, school officials had themselves extinguished the fires and had not contacted the fire department. Unlike the administrators at Kid City, they had not learned the most important lesson about fire, one I believe should be engraved in giant letters for all to see:

THERE IS NO SUCH THING AS A SMALL FIRE. THERE ARE ONLY FIRES THAT HAVE NOT GOTTEN BIG—YET.

Shelly Reuben King is the author of Tabula Rasa, Origin & Cause, Spent Matches, the Edgar-nominated Julian Solo, and Weeping. She is a licensed private detective and a certified fire investigator who has been investigating fires and arson for more than 20 years. King is a Diplomate of the American Board of Forensic Examiners and has been a member of the American College of Forensic Examiners since 1996.

Antidepressant Withdrawal Syndrome and DUI Evaluation

Antidepressant Withdrawal Syndrome and DUI Evaluation

By Henry Spiller, MS, DABAT, FACFEI, DABFE, and Tama S. Sawyer, PharmD, CSPI

Key Words: withdrawal syndrome, DUI, selective serotonin reuptake inhibitor

Abstract

Millions of Americans annually receive selective serotonin reuptake inhibitor antidepressants and dual-action antidepressants for their symptoms of depression. These patients are at risk for a well-documented withdrawal syndrome if they abruptly stop their medication. This withdrawal syndrome may produce significant effects that may impair a person’s ability to drive, putting at risk both the driver and others on the road. In a situation of the antidepressant withdrawal syndrome, the impairment is due to the absence of drugs in the patient, producing the paradox of a potentially impaired driver because of an absence of the influence of a drug. This article reviews the antidepressant withdrawal syndrome and describes the effects on cognition, memory, vision, and motor performance and reviews how these clinical effects might be misinterpreted using standardized field sobriety tests suggesting the patient is intoxicated in the absence of other drugs or alcohol.

THE FORENSIC EXAMINER Fall 2007

This article is approved by the following for continuing education credit:

(ACFEI) The American College of Forensic Examiners International provides this continuing education credit for Diplomates.

(CFC) The American College of Forensic Examiners International provides this continuing education credit for Certified Forensic Consultants.

The American College of Forensic Examiners International is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). The American College of Forensic Examiners International designates this educational activity for a maximum of 1 hour AMA PRA Category 1 Credits™.. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Introduction

Worldwide use of antidepressants has increased dramatically in the past decade (Berndt, Bhattacharjya, Mishol, Arcelus, & Lasky, 2002; Ciuna et al., 2004; Helgason, Tomasson, & Zoega, 2004; Hemels, Koren, & Einarson, 2002). Use of antidepressants may range from 26 to 72 defined daily doses per 1000 people, depending on the country (Ciuna et al.; Helgason et al.; Hemels et al.). The estimated range of Americans using antidepressants is from 7 to 18 million patients annually. Of the various classes of antidepressants available, the Selective Serotonin Reuptake Inhibitors (SSRI) and Dual Action Antidepressants (DAA), involving serotonin and norepinephrine reuptake inhibition, make up more than 75% of the prescriptions filled for antidepressants (Berndt et al.; Hemels et al.). Additionally, use of SSRIs and DAAs has increased more than 600% in the last 10 years (Ciuna et al.). While the drugs in these two classes have proven to be generally safe and effective, studies have documented a problem with the effects of withdrawal (Stahl et al., 1997).

Though symptoms from withdrawal are diverse, all include effects on cognition (impaired concentration and/or confusion) and motor performance (impaired coordination, loss of balance). (See Table 2 for a complete list of the clinical effects reported with withdrawal syndrome associated with the SSRI and DAA drugs.) These withdrawal effects may put patients at risk of impaired driving in the absence of other drugs or alcohol. While this is a potentially serious problem for both the patient/driver and others on the road, it has not been previously explored in the literature. This article describes the withdrawal syndrome associated with the SSRI and DAA drugs including clinical effects, with a focus on the potential effects these drugs may have on driving. Additionally, this article includes a discussion on the impact antidepressant withdrawal syndrome might have on field evaluation of a driver with tests such as the standard field sobriety test.
Antidepressant Withdrawal syndrome

Several groups of antidepressants, including the tricyclic antidepressants, the tetracyclic antidepressants, the SSRIs, the DAAs, and newer antidepressants such as mirtazapine (Remeron), may produce a withdrawal syndrome (Benazzi, 1998a; Coupland, Bell, & Potokar, 1996; Dilsaver, Kronfol, Sackellares, & Greden, 1983; Hindmarch, Kimber, & Cockle, 2000; Rosenbaum, Fava, Hoog, Ascroft, & Krebs, 1998). However, the withdrawal syndrome produced by the SSRIs and the DAAs is clinically different from that produced by the classic tricyclic antidepressants (Lejoyeux, Ades, Mourad, Solomon, & Dilsaver, 1996; Stahl et al., 1997). The withdrawal syndrome from the tricyclic and tetracyclic antidepressants is primarily a cholinergic syndrome with symptoms such as nausea, vomiting, anorexia, diarrhea, rhinorrhea (runny nose), diaphoresis (excessive sweating), myalgias (muscle pain), increased anxiety, agitation, and sleep disturbances (Dilsaver, 1994; Dilsaver et al.). In contrast, the withdrawal syndrome from the SSRIs and DAAs is primarily a serotonergic syndrome, with symptoms such as dizziness, lethargy, impaired concentration, electric-like shock sensations, impaired coordination, blurred vision, and sleep disturbances (see Table 2). This article discusses the impact of the serotonin-related antidepressants. The SSRI and DAA drugs that may produce a withdrawal syndrome are listed in Table 1. The syndrome may be seen in a substantial minority of patients taking these drugs—up to 25% (Coupland et al.; Michelson et al., 2000; Rosenbaum et al., 1998).

A brief understanding of the mechanism(s) of action of these drugs will improve the understanding of the withdrawal syndrome. The selective serotonin reuptake inhibitor class includes 6 drugs that are widely available. (See Table 1 for a list of drugs in this class with associated pharmacokinetic information.) These drugs inhibit the human serotonin transporter, inhibiting re-uptake of serotonin into presynaptic neurons (Schmidt, Fuller, & Wond, 1988). This allows for persistence of serotonin in the neuronal synapse and increased serotonergic neuron transmission. In effect, it increases activity on the pathways of the brain that use serotonin as the neurotransmitter. Chronic use has been shown to cause reduced serotonin transporter density, maintenance of normal cell-firing rates, and increased activation of post-synaptic firing.

The SSRIs produce little or no clinically significant activity on dopamine, norepinephrine, histamine, or acetylcholine receptors, or re-uptake transporters. The DAAs inhibit both the human serotonin transporter and the human norepinephrine transporter, inhibiting re-uptake of both serotonin and norepinephrine. The end result of the actions of both these classes of drugs is increased nerve transmission in select areas of the brain because of prolonged duration of neurotransmitters in the synapse. The sudden withdrawal of these drugs produces a sudden decrease in serotonin transmission due to reduced persistence of the neurotransmitter in the synaptic cleft (Zajecka, Tracey, & Mitchell, 1997). In effect, it produces a reduction of activity in some areas of the brain controlled by serotonin in the case of SSRIs and by serotonin and norepinephrine in the case of the DAAs.

It is this sudden decrease in activity that is responsible for the effects seen in these patients. If the decrease is of sufficient magnitude, an antidepressant withdrawal syndrome will occur. The dosage range of these drugs varies, with as much as a five-fold difference in some of the drugs between the lower and upper range of the therapeutic dose. (See table 1.) Any decrease that significantly effects serotonin transmission may produce a withdrawal syndrome. The withdrawal syndrome is transitory but may persist for days to weeks as the brain adjusts to new levels of activity on these neuronal pathways. Additionally, the syndrome may be reversed by restarting the antidepressant therapy. The true incidence of the withdrawal syndrome is unclear, with reports suggesting that 3%–30% of patients experience some form of the syndrome (Coupland et al., 1996; Oehrberg et al., 1995; Stahl et al., 1997).

The most frequently reported symptoms from the serotonin antidepressant withdrawal syndrome are dizziness, altered balance, lethargy, parathesias (numbness, tingling feeling, electric shock-like sensations), nausea, behavioral changes, and sleep disturbances. The clinical effects that can occur with the antidepressant withdrawal syndrome are diverse, and a broader list is provided in Table 2. It should be noted that the syndrome is varied from patient to patient—from mild to severe—and not all symptoms will be seen in every patient.

Criteria for diagnosis of antidepressant withdrawal syndrome vary, but generally include sudden discontinuance or reduction of dosage of an SSRI or DAA after a period of at least 1 month of use, two or more symptoms from Table 2, and symptoms not triggered by a general medical condition or other recognized cause (Black, Shea, Dursun, & Kutcher, 2000; Ditto, 2003). The onset of symptoms may be interpreted as a return of psychiatric symptoms (Benazzi, 1998b). Additionally, it may be interpreted by the patient as the onset of a flu-like syndrome (nausea, fatigue/lethargy, dizziness) along with return of depression (behavioral changes and sleep disturbances). The symptoms may be sufficiently severe to interrupt activities of daily living, such as going to work or driving a car, and patients should be warned about the dangers of operating a motor vehicle if they begin experiencing moderate to severe withdrawal symptoms. In some cases, the symptoms may be severe enough for the patients to recognize they should not drive (Campagne, 2005). However, in other cases, the patients may not recognize the degree of impairment and attempt to continue with their daily lives including commitments to work, school, or other outside commitments.

Patients may have an interruption in their medication for a number of reasons. They might miss one or several days of therapy due to non-compliance (“drug holiday”) (Hylan, Dunn, Tepner, & Meurgey, 1998) or there may be an interruption in the patients’ medication supply due to travel, lack of access to a pharmacy, or inability to pay (Campagne, 2005). In some cases, the patient will suddenly stop taking the medication due to perceived problems with the side effects of the medication itself (Leiter, Nierenberg, Sanders, & Stern, 1995).

Symptoms of the SSRI and DDA withdrawal syndrome may occur from as early as 12 hours after a missed dose and up to 3 weeks after discontinuance, although the average time of onset of symptoms is 1 to 3 days (Campagne, 2005; Zajecka et al., 1997). One factor impacting the onset of symptoms is the half-life of the drug involved, which can vary significantly depending on the drug involved (Michelson et al., 2000) (See Table 1).

Withdrawal Syndrome and Driving

Generally speaking, impaired driving (driving while intoxicated) is considered secondary to the effects of drugs or alcohol while these substances are in the patient and producing a direct effect on cognition, attention, motor control, and reaction time. However, in the situation of the antidepressant withdrawal syndrome, the impairment is due to the absence of drugs in the patient. This produces the paradox of a potentially impaired driver that is not under the influence of any drugs or alcohol. While there may be significant impairment, the term driving under the influence may be an inappropriate term for these cases.

There are a number of symptoms of the withdrawal syndrome that could potentially cause a patient to operate a motor vehicle in a manner that might be interpreted as operating under the influence of alcohol or drugs. These symptoms include visual disturbances, dizziness/vertigo, impaired coordination, tremors, confusion, impaired concentration, and jerking eye movements that cause difficulty with tracking and memory impairment. These clinical effects might produce an altered driving pattern, including weaving, erratic speed and erratic lane changes, which might be interpreted as driving while intoxicated. Additionally, if the vehicle were stopped for possible impaired driving and the patient evaluated, there are a number of symptoms that might be interpreted as the patient being under the influence of drugs or alcohol. These symptoms include confusion, agitated behavior, distracted affect if the patient is experiencing repeated sensations of electric shocks, an unsteady gait, and inattention to questions because of inability to hear on account of tinnitus.

Withdrawal Syndrome and the Standard Field Sobriety Test

When a police officer stops a driver for suspicion of impaired driving, the most common procedure is to have the driver perform a field sobriety test. The National Highway Traffic and Safety Administration (NHTSA) has validated three tests that have become generally recognized as the Standardized Field Sobriety Test (Tharp, Burns, & Moskowitz, 1981). These three tests are the Walk and Turn (WAT), Horizontal Gaze Nystagmus (HGN), and One Leg Stand (OLS). However, other tests may be performed at the discretion of the police officer or local jurisdiction such as asking the driver to count backwards from a certain number and to stop at a certain number (e.g. count down from 55 to 18) or to recite the alphabet beginning at a particular letter and ending at a particular letter (e.g., beginning at F and ending at R). These latter tests have not been validated by NHTSA.

In the course of administering the WAT, the subject is given oral instructions to take nine steps heel-to-toe along a straight line. After taking nine steps the subject must execute a one-foot turn and return in the same manner in the opposite direction. There are 7 indicators of impairment for which the police officer is instructed to watch to indicate successful completion or failure of the test: 1) subject cannot maintain balance while listening to instructions, 2) subject begins test before instructions are complete, 3) subject stops to regain balance while walking, 4) subject does not touch heel-to-toe, 5) subject uses arms to maintain balance, 6) subject loses balance during turn, and 7) subject takes incorrect number of steps. In a patient experiencing antidepressant withdrawal syndrome, there are a number of symptoms that would cause them to fail the WAT test, even in the absence of intoxicants. The most important of these are gait instability, dizziness/vertigo, lack of coordination, and loss of balance. Additionally, such symptoms as confusion, impaired concentration, and short-term memory impairment might cause the patient to fail by beginning too soon, failing to take the correct number of steps, or failing to walk heel-to-toe on the return walk.

In the course of administering the HGN, the subject is instructed to focus on an object 12 to 15 inches in front of his or her face as the object is moved horizontally to the left and right. The police officer is instructed to watch for smooth pursuit, nystagmus before onset of 45 degrees, distinct nystagmus at maximal deviation, and head movements and/or jerks. A patient experiencing antidepressant withdrawal syndrome might fail the HGN because of misinterpretation of already existing jerking eye movements and blurred vision.

In the course of administering the OLS, the subject is instructed to stand with one foot held approximately 6 inches off the ground and to count by thousands (e.g. one thousand one, one thousand two, etc.) until told to put the foot down. The subject is timed for 30 seconds. There are 4 indicators of impairment that the police officer is instructed to watch for to indicate successful completion or failure of the test: 1) swaying while balancing; 2) using arms to balance; 3) hopping to maintain balance; and 4) putting the raised foot down. There are numerous symptoms that could cause a patient experiencing antidepressant withdrawal syndrome to fail the OLS test, even in the absence of intoxicants. The most important of these are dizziness/vertigo, lack of coordination, and loss of balance.

Finally, the patient may be agitated and experiencing significant anxiety. The patient’s behavior may initially be interpreted by the police officer as a refusal to obey commands during the initial evaluation or during one of the SFSTs. In either case, refusal may be interpreted as reason to suspect intoxication.

It should be noted that the primary role of field sobriety tests is to give the police officer a reasonably accurate tool to determine if intoxication might be suspected and if further verifiable documentation such as an alcohol breathalyzer test or blood alcohol test should be administered. The tests themselves should not be sufficient evidence of intoxication without clinical evidence such as a breathalyzer test or blood alcohol test. In the case of drug intoxication, field sobriety tests again are not sufficient evidence of intoxication without supporting evidence of a blood concentration of the suspected drug. Because of situations such as the antidepressant withdrawal syndrome, the field sobriety tests may provide misleading indications of intoxication when no intoxication has occurred.

Conclusion

Millions of Americans annually receive SSRIs and DAAs for their symptoms of depression. These patients are at risk for a well-documented withdrawal syndrome if they abruptly stop their medication. The antidepressant withdrawal syndrome may produce significant effects on cognition and motor performance. Further, these effects might be misinterpreted in the use of standardized field sobriety tests to suggest the patient is intoxicated in the absence of other drugs or alcohol.

References

Benazzi, F. (1998a). Mirtazapine withdrawal symptoms. Canadian Journal of Psychiatry, 43(5), 525.

Benazzi, F. (1998b). Sertraline discontinuation syndrome presenting with severe depression and compulsions. Biological Psychiatry, 43(12), 929–930.

Berndt, E. R., Bhattacharjya, A., Mishol, D. N., Arcelus, A., & Lasky, T. (2002). An analysis of the diffusion of new antidepressants: Variety, quality, and marketing efforts. Journal of Mental Health Policy and Economics, 5(1), 3–19.

Black, K., Shea, C., Dursun, S., & Kutcher, S. (2000). Selective serotonin reuptake inhibitor discontinuation syndrome: proposed diagnostic criteria. Journal of Psychiatry and Neuroscience, 25(3), 255–261.

Campagne, D. M. (2005). Venlafaxine and serious withdrawal symptoms: Warning to drivers. Medscape General Medicine, 7(3), 22.

Ciuna, A., Andretta, M., Corbari, L., Levi, D., Mirandola, M., Sorio, A., et al. (2004). Are we going to increase the use of antidepressants up to that of benzodiazepines? European Journal of Clinical Pharmacology, 60(9), 629–634.

Coupland, N. J., Bell, C. J., & Potokar, J. P. (1996). Serotonin reuptake inhibitor withdrawal. Journal of Clinical Psychopharmacology, 16(5), 356–62.

Dilsaver, S. C. (1994). Withdrawal phenomena associated with antidepressant and antipsychotic agents. Drug Safety, 10(2), 103–114.

Dilsaver, S. C., Kronfol, Z., Sackellares, J. C., & Greden, J. F. (1983). Antidepressant withdrawal syndromes: Evidence supporting the cholinergic overdrive hypothesis. Journal of Clinical Psychopharmacology, 3(3), 157–164.

Ditto, K .E. (2003). SSRI discontinuance syndrome: Awareness as an approach to prevention. Postgrad Medicine, 114(2), 79–84.

Helgason, T., Tomasson, H., & Zoega, T. (2004). Antidepressants and public health in Iceland. Time series analysis of national data. British Journal of Psychiatry, 184(2), 157–162.

Hemels, M. E., Koren, G., & Einarson, T. R. (2002). Increased use of antidepressants in Canada 1991–2000. Annals of Pharmacotherapy, 36(9), 1375–1379.

Hindmarch, I., Kimber, S., & Cockle, S. M. (2000). Abrupt and brief discontinuation of antidepressant treatment: Effects on cognitive function and psychomotor performance. International Clinical Psychopharmacology, 15(6), 305–318.

Hylan, T. R., Dunn, R. L., Tepner, R. G., & Meurgey, F. (1998). Gaps in antidepressant prescribing in primary care in the United Kingdom. International Clinical Psychopharmacology, 13(6), 235–243.

Leiter, F. L., Nierenberg, A. A., Sanders, K. M., & Stern, T. A. (1995). Discontinuation reactions following sertraline. Biological Psychiatry, 38(10), 694–695.

Lejoyeux, M., Ades, J., Mourad, I., Solomon, J., & Dilsaver, S. (1996). Antidepressant withdrawal syndrome. Recognition, prevention and management. CNS Drugs, 5(4), 278–292.

Michelson, D., Fava, M., Amsterdam, J., Apter, J., Londborg, P., Tamura, R., et al. (2000). Interruption of selective serotonin reuptake inhibitor treatment: Double-blind placebo-controlled trial. British Journal of Psychiatry, 176(4), 363–368.

Oehrberg, S., Christiansen, P. E., Behnke, K., Borup, A. L., Severin, B., Soegaard, J., et al. (1995). Paroxetine in the treatment of panic disorder. British Journal of Psychiatry, 167(3), 374–397.

Rosenbaum, J. F., Fava, M., Hoog, S. L., Ascroft, R. C., & Krebs, W. B. (1998). Selective serotonin reuptake inhibitor discontinuation syndrome: A randomized clinical trial. Biological Psychiatry, 44(2), 77–87.

Schmidt, M. J., Fuller, R. W., & Wond, D. T. (1988). Fluoxetine, a highly selective serotonin reuptake inhibitor: A review of preclinical studies. British Journal of Psychiatry, 153(3), 40–46.

Stahl, M. M. S., Lindquist, M., Pettersson, M., Edwards, I. R., Sanderson, J. H., Taylor, N. F. A., et al. (1997). Withdrawal reactions with selective serotonin re-uptake inhibitors as reported to the WHO system. European Journal of Clinical Pharmacology, 53(3–4), 163–169.

Tharp, V., Burns, M., & Moskowitz, H. (1981). Development and field test of psychophysical tests for DWI arrest. (DOT HS 805–864). Washington, DC: U.S. Department of Transportation, NHTSA.

Young, A., & Haddad, P. (2000). Discontinuation symptoms and psychotropic drugs. Lancet, 355(9210), 1184.

Zajecka, J., Tracey, K. A., & Mitchell, S. (1997). Discontinuation symptoms after treatment with serotonin reuptake inhibitors: a literature review. Journal of Clinical Psychiatry, 58(7), 291–297.

Henry A. Spiller, MS, DABAT, DABFE, FACFEI, is board certified in Toxicology and the Director of a certified regional poison center, with more than 20 years clinical experience. He has authored more than 180 toxicology related publications, including peer-reviewed medical/scientific journals, comprehensive toxicology textbooks, and scientific abstracts. He has more than a decade of experience in training toxicologists and specialists in poison information and has directed, as principal investigator, more than 35 multi-center national studies in toxicology. He has made toxicology-related presentations at scientific meetings in North America, South America, and Europe and has presented evidence as an expert in numerous state and federal courts on toxicology related subjects.

Tama Sawyer, PharmD, is a Certified Specialist in Poison Information with more than 20 years clinical experience at a regional poison center.

Fall 2007 THE FORENSIC EXAMINER

THE FORENSIC EXAMINER Fall 2007

Table 1: SSRI and DAA Medications

Generic Drug Name Brand Name Drug Class Elimination Half-life Starting Dose Dosing Range

Escitalopram

Citalopram

Fluoxetine

Fluvoxamine

Paroxetine

Sertraline

Duloxetine

Venalfaxine

Lexapro

Celexa

Prozac

Luvox

Paxil

Zoloft

Cymbalta

Effexor

SSRI

SSRI

SSRI

SSRI

SSRI

SSRI

DAA

DAA

22–32 hours

33–37 hours

70 hours

17–23 hours

15–22 hours

24–27 hours

11–16 hours

5 hours

10mg

20mg

20mg

50mg

10mg

50mg

20mg

75mg

10–20mg

20–60mg

20–60mg

50–300mg

10–50mg

50–200mg

20–60mg

75–375mg

Cognitive Impairment Effects

• Agitation
• Anxiety
• Confusion
• Depersonalization/detachment
• Electric shock-like sensations
• Impaired concentration
• Irritability
• Short-term memory impairment

(Table complied from references: Black, Shea, Durson, & Kutcher, 2000; Campagne, 2005; Coupland, Bell, & Potokar, 1996; Leiter, Nierenberg, Sanders, & Stern, 1995; Michelson et al., 2000; Rosenbaum, Fava, Hoog, Ascroft, & Krebs, 1998; Stahl et al., 1997; Young & Haddad, 2000; Zajecka, Tracey, & Mitchell, 1997)

Table 2: Clinical Effects Reported with Antidepressant Withdrawal Syndrome

Motor Impairment Effects

• Blurred vision
• Dizziness/lightheaded/vertigo
• Gait instability
• Incoordination or impaired coordination
• Jerking eye movements
• Loss of balance
• Tremor
• Visual disturbances

Other Effects

• Diarrhea
• Chills
• Headache
• Insomnia
• Myalgia
• Nausea/vomiting
• Parathesias
• Sleep disturbances
• Suicide thoughts or behavior
• Sweating
• Tinnitus (ringing in the ears)
• Vivid dreams or nightmares

Fall 2007 THE FORENSIC EXAMINER

THE FORENSIC EXAMINER Fall 2007 - published by Dr. Robert OBlock

Forensic Engineering Evaluation of Premises Maintenance

Forensic Engineering Evaluation of Premises Maintenance

Abstract

A premises (building and its site) consists of components to form a safe, usable facility. The components must be maintained in order to keep them functioning. Forensic engineers are often asked to render their opinions concerning a component’s performance and the maintenance it has received. Because the results are to be used in a forensic forum, the engineer must have a well-documented methodology and a firm basis for his or her opinions. One method of making such an evaluation is to employ a systems approach.

When a component and its maintenance are treated as a system, the engineer considers its various aspects and the interaction between those aspects. Furthermore, the examiner can test “what if” hypotheses using the same method. This article discusses a method to achieve that end while giving the forensic engineer a strong foundation for his or her opinion.

THE FORENSIC EXAMINER Fall 2007

Fall 2007 THE FORENSIC EXAMINER

This article is approved by the following for continuing education credit:

(ACFEI) The American College of Forensic Examiners International provides this continuing education credit for Diplomates.

By John A. D’Onofrio, MS, CE, PE, DABFE, DABFET, DNAFE

Key Words: buildings, premises, maintenance, systems evaluation

Introduction

A premises (buildings and its site) consists of a group of systems working together to form a facility. The components of these systems must be maintained in order to keep them functioning. Following an accident or system failure, a forensic engineer is often asked to make an examination and render an opinion concerning a component’s performance and the maintenance it received. Such requests are most common in civil litigation, but may be required in a criminal case as well. Because of the complexity of a premises (both the building and its site), such services may be requested from engineers in many disciplines and some examinations may require an interdisciplinary team. Because the result is to be used in a forensic forum, the engineer must have a well-documented methodology and a firm basis for his or her opinions.

One method to make such an evaluation is to employ a systems approach. System analysis, as defined in this article, is the critical examination of the technical and managerial skills used to maintain the premises. This approach recognizes that continued, acceptable operation of a component is dependent upon a system consisting of the component itself and the maintenance it receives. Systems, whether including human activity or not, are subject to limitations whose effects can best be understood through system analysis. Furthermore, the examiner can test “what if” hypotheses by assuming changes in the system and analyzing the results. The result of an analysis is a simple statement of opinion; however, time, work, and data are needed to posit an opinion with a strong foundation.

The remainder of this article discusses a method to achieve that end. Many of the principles discussed have their origin in health and safety engineering. Often, premises maintenance evaluations are required when an accident or injury has occurred. Therefore, the method described here is closely related to safety engineering practice.

The Flow Chart (Figure 1)

By applying the evaulation flow chart, the examiner covers a wide range of pertinent topics. Not only does this provide a guideline to the examination, but it also provides an excellent foundation for the engineer’s opinions. The flow chart has two flow paths, Component and Maintenance. Each path consists of decision points where the engineer finds the aspect under consideration either acceptable (yes) or unacceptable (no). A “no” evaluation leads to an Inadequate System rating. A series of “yes” evaluations leads to the And gate toward the bottom of the flow chart. Both paths of the flowchart must be evaluated and lead to the And gate in order for the system to receive a Good rating. If the first path leads to the And gate, then the second path must be evaluated to complete the process.

Once an Inadequate System rating is reached, theoretically, there is no need for further evaluation. However, an Inadequate System rating is often the beginning of the next phase of the investigation, an explanation of cause. Because a system may be inadequate for numerous causes, the engineer alone must decide whether he or she should continue the evaluation further.

An Example

The following example follows Figure 1 and includes a discussion of the evaluation process. The example is a request to evaluate the floor of a small mercantile establishment where a patron slipped and fell on a rainy day. There is an allegation that water was present on the floor at the time of this fall. The component to be evaluated is the flooring. The maintenance program is that which the proprietor uses for safety during inclement weather.

Operating Conditions

The first step in the evaluation process is to determine the operating conditions. These are the conditions under which the system is expected to operate and give the engineer insight to the system when working the evaluation paths.

The operating conditions are best determined by site inspection, document review, and testimony of various parties. A document review may include but is not limited to:

• Plans and specifications prepared by the building architect or design engineer
• Lease documents that may specify permitted activities within the building
• Building and maintenance codes
• Zoning ordinances and other regulatory documents
• Indoor environmental standards common to the industry

In this example, the site inspection revealed that the space was being used as a haberdashery. Flooring was a commercial grade vinyl tile. The slip location was approximately 7 feet from the entry. The document review has determined that, at the time of the fall, the building was approximately 25 years old. The architect’s plans indicate the space to be used for retail use. The use of the space for mercantile purposes is consistent with the permitted uses in the zoning ordinance. The lease between the owner and tenant indicates that the space is to be used for the legal, retail sale of goods, not to include food or personal services. Based on the site inspection and document review the engineer can reasonably conclude that the use of the space is “anticipated.”

Note from Figure 1 that the evaluation process does not depend upon the operating conditions; however, if unanticipated conditions are involved, the examiner must decide and note if the evaluation is made for the actual conditions encountered, the anticipated conditions, or both. The examiner must also recognize that a component may be exposed to an unanticipated condition and continue to function well.

Component

Component evaluation follows the right side of Figure 1. Here, the specific component under examination is scrutinized under the chosen operating conditions.

Component Specifications. The next step in component evaluation is to determine if it meets specification. This step implies that the engineer has determined the component’s specification and an appropriate test for compliance. The component specification may be either specific (specified by size, make, and model) or performance (i.e. 100 cfm fan, 230VA) oriented. Oftentimes, component specifications are not specific and must be derived from document review. These include, but are not limited to:

• Plans and specifications prepared by the building architect or design engineer
• Manufacturer’s specifications
• Building codes
• Typical architectural and engineering details (graphic standards)
• Engineering organization standards
• Authoritative consensus standards

In the example, the architectural plans were silent on the flooring material. According to testimony, the vinyl tile was selected by the owner and was in place when the tenant moved in. The manufacturer is unknown at this time. The tenant space was inspected by the construction official before opening to the public and received a certificate of occupancy. The local building code requires that all walking surfaces be slip-resistant.

A literature search revealed an ASTM standard that relates slip resistance to the floor’s static coefficient of friction with a shoe-leather test surface and a threshold level. On-site testing of the floor material was conducted and determined it to be slip-resistant.

Based on the site inspection, document review, and testing, the engineer can reasonably conclude that the material used to construct the floor surface meets specification.

Component Installation. The next step in Figure 1 is to examine the component installation. Poor workmanship should be noted and described. The manufacturer’s installation guide for the component should be consulted, if possible, whenever installation is drawn into question. In the example, the vinyl tile was examined and found to be tight, stable, and planar. Based on the site inspection, the engineer was able to reasonably conclude that the installation was not an issue and probably followed the manufacturer’s specification.

Maintenance

The maintenance flow path follows the left side of Figure 1. Here, the maintenance program under examination is scrutinized under the chosen operating conditions. This flow path incorporates work on safety done in the United States and the United Kingdom. The U.S. recommendations were developed and promulgated for workplace safety. The U.S. Department of Labor, through the Occupational Safety and Health Administration (OSHA), publishes a document entitled Keeping Your Workplace Safe (1999). This document describes four elements that every effective program should have:

• Management, leadership, and employee involvement
• Workplace analysis
• Hazard prevention and control
• Training and education

Similarly, the Health and Safety Executive of the United Kingdom publishes a document entitled Managing Health and Safety – Five Steps to Success (1998). The document states: “This leaflet contains notes on good practice which are not compulsory, but which you may find helpful in considering what you need to do.” The five steps are

• set up your policy;
• organize your staff;
• plan and set standards;
• measure your performance;
• learn from experience.

Figure 1 incorporates these into the four aspects of the maintenance procedure flow path.

Maintenance Procedure

Maintenance procedures may be written and formalized. This is commonly found at locations that have a maintenance department or are part of a nationally operated or franchised establishment. Managers responsible for large buildings or multiple premises may have routine and preventative maintenance scheduled and noted by computer. On the other side of the spectrum, other business or industrial locations may not have a written plan, and the examiner must determine the maintenance procedure through investigation, interview, or testimony.

The second aspect of the maintenance procedure is to determine if it conforms to or follows a standard. The examiner must keep an open mind and not judge the book by its cover. Policies and procedures that are extensive, written, and neatly bound are not necessarily more compliant with standards than those that are less organized. A lack of organization and record-keeping may be a regulatory violation, but is insufficient by itself to consider the system inadequate. However, policies and procedures that are unclear may be considered outside the standards because of ambiguity. Further, loosely stated maintenance procedures can have an effect on other aspects of the maintenance program.

The engineer must determine the appropriate standard by which to measure the subject procedure. The manufacturer’s specification on how to maintain the component should be investigated and may specify a performance standard for maintenance. For example, certain filters may need to be checked at a maximum time interval and cleaned following a specified process. Property maintenance regulation may specify the maximum time that snow or ice may be allowed to remain untreated or the length of time that rainwater may accumulate before it is considered stagnant.

In cases where the standard is not straightforward, the engineer must be prepared to ascertain industry standards for maintenance based on authoritative and circulated industry publications. Standards organizations such as the American Society of Testing and Materials (ASTM) and the American National Standards Institute (ANSI) publish a wealth of information. The insurance industry has a long history of underwriting standards for buildings and sites. They pioneered sprinkler system standards for fire control, and many insurance companies sponsor safety research to this day. Over time, these findings become industry standards and find their way into loss-control and underwriting literature. The National Safety Council (NSC) and the American Society of Safety Engineers (ASEE) are another source of information. The U.S. Army Corps of Engineers and the Air Force have extensive procedures for maintaining buildings and sites with a wealth of information available on their websites (Secretary, 2004; U.S. Army, 2003).

When deciding on an appropriate standard, the examiner must be sure that the standard is widely circulated and does not conflict with jurisdictional building codes, maintenance regulations, or site improvement standards. The challenge is to determine reasonable industry standards for a given situation, especially in view of critics that are always present around any issue. Cutting-edge academic and scientific papers should be used with caution. They may be useful to explain or substantiate a principle, but most are not widely circulated amongst maintenance practitioners, and the author’s view may not be widely accepted or adopted as a standard.

When researching standards, remember that a maintenance procedure in practice must include a method of discovering conditions that need to be maintained. Discovery of a condition that has developed relative to a component is an essential part of maintenance. The time required to correct such conditions (correction time) includes both the amount of time the condition exists before it is discovered (discovery time) and the amount of time required to do the work using reasonable dispatch (work time). Hence, there will always be a time interval between the instant a component develops a condition requiring work and when the work is completed. Often a condition that develops will not be obvious and the maintenance procedure must be proactive to minimize the discovery time. For example, mechanical equipment should be checked on a periodic basis to assure it is either functioning properly or exhibiting telltale signs of impending failure.

Published standards must also be read with this principle in mind. They will often indicate that certain actions must be taken “immediately.” This should be interpreted as acting “without delay upon discovery” because instantaneous discovery (zero discovery time) and correction (zero work time) is, in most cases, impossible.

The procedure and standard examination may require some iteration. The examiner should have the standard in mind when examining the procedure and the procedure in mind when examining the standard. After interviewing the various parties or reviewing their deposition testimony, review both the procedure and the standard for modifications afterward. This will help assure that nothing out of the ordinary is missed.

In the example, the engineer researched Best’s Loss Control Manual (2000), a loss-control engineering guide and authoritative publication for insurance underwriting. After selecting the appropriate use, he reviewed the various items of concern and selected those that were appropriate to floor maintenance and the conditions at hand. This subset of conditions became the performance standard for the evaluation. Also, it was determined that local building and maintenance codes provided no performance standard for floor maintenance. Further review of a NSC publication concerning falls on floors revealed similar recommendations therein. The engineer felt confident that the items selected represented good practice and industry standard.

The maintenance procedures for floor maintenance were written and posted on the bulletin board in the employee area of the store along with emergency phone numbers. While not detailed, they covered the items in the standard and were straightforward and easy to understand. They included employee assignments and response measures to inclement weather conditions. The engineer determined that the maintenance procedure did follow standard.

Education

Education refers to the training that maintenance personnel receive. Depending upon the maintenance tasks, the education may require specialized training or schooling. Most commonly, however, maintenance personnel receive on-the-job training, especially if the maintenance tasks are more janitorial than repair in nature. Management must be involved to assure that education is not a one-time experience. New equipment or changes in business operations may require re-training of maintenance personnel. Further, it must also be determined that the specific personnel responsible for the maintenance had received the training and understood their duty. Maintenance personnel must be taught and encouraged to trust their judgment and report their opinions concerning the component or the maintenance procedure to management without fear of reprisal.

In the example, it was determined that all employees are instructed as to the safety procedures for inclement weather. The maintenance was basically a janitorial function. Safety posters were on the employee bulletin board, and the owner discussed safety at all employee meetings, instructing them to place mats on the floors and warning cones at the entrance when it starts to rain. Employees were instructed how to properly clean water and spills from the floor and to watch for such conditions as they move about the store. The specific employee at the store when the incident occurred had 3 years of experience with the company and was thoroughly familiar with the procedures. The engineer concluded that the personnel were sufficiently trained to properly maintain the floor.

Management

Management works hand-in-hand with education and is a critical component in resources. Management must consider maintenance a priority aspect of their business and be committed to keeping the system working. The attitude of management influences the personnel; if the boss does not care, neither will the staff. Management should

• have a system of reporting and tracking maintenance functions. This data can point to problems and the need for improvement in the system;
• check to assure that adequate resources in the form of manpower and equipment are available to keep the system running;
• reinforce education amongst the workers;
• create a climate where maintenance is a priority.

Sometimes an evaluation of management can be simple and straightforward. In other situations, it can be complex and difficult. A proprietor of a space that ships and receives merchandise from one or two loading docks may have no problem both scheduling and managing his truck traffic. The traffic manager for an industrial or warehouse operation may have traffic engineering and safety problems to be solved while, at the same time, keeping the system running. It is important that the examiner keep his own house in order and recognize when a consultant or team approach is required.

The proprietor of the establishment in the example had two locations to manage. He visited both of them more than five times a week and had constant cell-phone contact whenever the stores were open for business. He met with employees and conversed with each one every 2 weeks. Premises maintenance was always discussed. Furthermore, he rotated and replaced the signs, posters, and instructions posted in the employee areas. Based on this testimony, the engineer concluded that the management of the system is adequate.

Resources

Resources are the manpower, equipment, and material required to keep the maintenance program working. It is tied to management because management allocates the funds, hires the people, and sets the work schedules. Management also determines how and when the resources are allocated. Personnel view resources as a management statement, equating adequate allocation of resources to a top management priority. Conversely, management that is perceived as “doing-it-on-the-cheap” is considered to have maintenance as a low priority.

Although budgets are an important factor in any business, resources are best measured by what takes place at the premises. It is one thing to budget for an adequate number of filters and another thing to have them in the supply room when they are needed. It is one thing to budget for a snow removal contractor and another thing to have sufficient manpower to do the job properly. Therefore, resources are a topic of investigation with both management and the personnel at the site.

At many small premises, maintenance responsibilities are shared amongst the general staff. Workers in a machine shop may also do regular maintenance on the machines and pitch in for janitorial work. At large premises, there will be a maintenance department. Each can be satisfactory, and each presents challenges to the examiner. Staffing levels will vary from place to place, and the examiner will often rely on management testimony concerning overall staffing levels. However, the examiner needs to assure him or herself that there is adequate manpower to maintain the component under consideration. In any examination, testimony from the personnel specifically assigned to the component’s maintenance will be valuable. This is another area where the examiner may need input from a consultant.

Communication is another resource. At small premises, a few employees can respond quickly when a condition arises based on verbal communications. Larger premises may require radio or telephone communication systems to report a condition when it is discovered and to dispatch personnel to do the work.

The engineer must keep in mind that a maintenance evaluation of a particular building component is not an examination of the entire building. If the examiner fails to properly limit his investigation, he runs the risk of following many irrelevant paths at a cost of much time and effort. He also exposes himself to irrelevant information that clouds his judgment. This leaves the engineer open to charges of bias or “witch-hunting.”

In the example, the proprietor scheduled a minimum of two employees on each shift, one for general operations and one at the cash register. The retail space is not large and the operations employee were easily able to make half-hour inspection rounds. Furthermore, he observed the store while moving about and assisting customers and responded to instructions from the cash register station by a hand-held radio. Floor mats, warning signs, mops, and buckets were kept in the maintenance closet. Floor mats were serviced by an outside contractor every 2 months. Three mops and buckets were available—one for each employee and a spare.

Based on the site inspection and testimony from the various parties, the engineer concluded that the system was supported by sufficient resources to properly maintain the floor during wet weather. This results in a “yes” for resources.

However, during his examination the engineer discovered that one employee was sick the day of the incident, leaving only one person to man both the cash register station and cover general operations. There was no one else available to cover the shift. When the rain started he placed the mats and warning signs at the entrance. However, he was unable to make regular rounds of the store looking for water and spills on the floor. The water on the floor was brought to his attention when the patron fell.

Opinions and Conclusions

According to the flow chart, when there are two “yes” results at the And gate, the engineer can feel confident that the component is adequate and the maintenance system can keep it functioning properly under the expected operating conditions. Therefore, a Good System rating is in order.

The fact that a component has failed does not affect this rating; it is the system being evaluated and not a single event. Components and maintenance can fail, even in a good system, because all systems have limitations; they are subject to randomly occurring and unpredictable events.

In the floor accident example, the system recieved a Good rating. However, insight into the event under consideration was gained by analyzing the conditions at the time of the failure. A re-analysis using the staffing conditions on the day of the component failure resulted in a “no” (not adequate) classification for resources because staffing fell below management’s recommended levels, and proper inspections were not taking place because of the short-staffing condition. Under these conditions, the flow chart leads to an Inadequate System rating for that particular circumstance. The forensic engineer must clearly make the distinction between the system’s rating overall and its rating as operating at a particular time. This distinction can be important in a forensic forum.

The use of systems analysis, as presented here, offers the forensic engineer a methodology of evaluation that is both comprehensive and flexible. The example presented shows that the method has application to simple as well as complex systems. The engineer must remember that the analysis is only as good as the input data, the end result is the opinion of an engineer who may have to defend it, and this analysis and opinion are seldom the end of the questions to be answered.

References

A. M. Best Company, Inc. (2000). Best’s loss control manual (version 2006). Oldwick, NJ: Author.

Brauer, R. L. (1990). Safety and health for engineers. New York: VanNostrand Reinhold.

Health and Safety Executive Books. (1998). Managing health and safety—Five steps to success. United Kingdom: Author.

Secretary of the Air Force. (2004). Safety and health standards. Washington DC: U.S. Government Printing Office.

U.S. Army Corps of Engineers. (2003). Safety and health requirements manual. Washington DC: U.S. Government Printing Office.

U.S. Department of Labor. (1999). Keeping your workplace safe. Washington, DC: U.S. Government Printing Office.

Wausau Insurance Company. (1990). Hazard survey guide. Wausea, MN: Author.

About the Author

John A. D’Onofrio, MS, CE, PE, is a professional engineer in private practice with more than 30 years experience in the engineering design and forensic evaluation of buildings and premises. He holds a bachelor’s degree and a master’s degree in civil engineering from the New Jersey Institute of Technology. D’Onofrio is a licensed professional engineer in New York, New Jersey, and the Commonwealth of Pennsylvania and has been recognized as an expert in federal court and in the courts of all three states. He has taught at Rutgers University in New Brunswick, New Jersey, and at the Community College of Morris in Randolph, New Jersey. He has been a guest lecturer before the New Jersey Municipal Engineer’s Foundation and the New Jersey Society of Professional Land Surveyors.

This article published by Dr. O’Block

Strategies for Understanding and Assessing Suicide Risk in Psychotherapy

This 1-credit continuing education opportunity is co-sponsored by the American College of Forensic Examiners International (ACFEI) and the American Psychotherapy Association. ACFEI maintains responsibility for all continuing education accreditations. This article is approved by the following for 1 continuing education credit:

APA provides this continuing education credit for Diplomates.

The American College of Forensic Examiners International is an NBCC Approved Continuing Education Provider (ACEP) and may offer NBCC approved clock hours for events that meet NBCC requirements. The ACEP solely is responsible for all aspects of the program. Provider #5812.

The American College of Forensic Examiners International is approved by the American Psychological Association to sponsor continuing education for psychologists. ACFEI maintains responsibility for this program and its content.

The American College of Forensic Examiners International is an approved provider of the California Board of Behavioral Sciences, approval PCE 1896. Course meets the qualifications for 1 hour of continuing education credit for MFTs and/or LCSWs as required by the California Board of Behavioral Sciences.

This organization, American College of Forensic Examiners International Approval Number 1052, is approved as a provider for continuing education by the Association of Social Work Boards 400 South Ridge Parkway, Suite B, Culpeper, VA 22701. www.aswb.org. ASWB Approval Period: 9/13/2004 to 9/13/2007. Social workers should contact their regulatory board to determine course approval. Social workers will receive 1 continuing education clock hours in participating in this course.

Suicide is one of the few topics that almost uniformly triggers anxiety and apprehension in clinicians, both novice students and seasoned practitioners (Rudd, 2006). Moreover, the actual assessment and subsequent treatment plans for suicidal clients are perhaps the most challenging clinical endeavors mental health practitioners may face during their careers. Literature shows that this is often the case because one concrete outcome of negligence in this area is a client fatality and resultant liability for the clinician (Jobes, 2006; Jobes & Drozd, 2004; Packman, Marlitt, Bongar, & O’Connor-Pennuto, 2004; Peruzzi & Bongar, 1994). Perhaps this explains one reason why psychotherapists seem to focus on collecting data surrounding lethality and risk factors instead of exploring the narrative story of the suicidal client (Rogers & Soyka, 2004). As Schwartz and Rogers (2004) explain, psychotherapists should realize that although they will be unable to successfully prevent all instances of suicide due to the unpredictability of human nature, clinicians can lessen the number of completed suicides by being able to better identify at-risk populations and common themes of suicidality. However, clinicians should also remember not to omit a thorough exploration of the individual meanings of suicidality for a particular client.

Approximately 71% of psychotherapists report managing at least one client who has attempted suicide, with 28% reporting having had at least one client die by suicide (Rogers, Gueulette, Abbey-Hines, Carney, & Werth, 2001). For psychotherapists, the psychological impact of losing a client by suicide is similar to the stress and trauma that would be experienced in the death of a loved one (Chemtob, Hamada, Bauer, Torigoe, & Kinney, 1988). Therefore, updated information surrounding suicide risk factors, myths, assessment strategies, treatment options, and additional resources are crucial when working with this particularly challenging population.

Information on Suicide Risk Factors

Suicide takes the lives of over 30,000 Americans every year according to the Centers for Disease Control and Prevention’s (CDC) Fatal Injury Report, making it the eighth leading cause of death for males and the 19th leading cause of death for females (Centers for Disease Control [CDC], 2006). Overall, in the United States, suicides outnumber homicides 3:2 and take the lives of twice as many persons as HIV/AIDS (CDC, 2006). Over the last century, researchers have tried to produce a set of “risk factors,” which, when identified, would label a client as someone who might take his or her own life (Maris, Berman, & Silverman, 2000). The underlying premise is that if there were a way to predict suicidal behavior, lives would be saved (Maris et al., 2000). Unfortunately, research has not yielded a specific flow chart that all clinicians can follow when working with a suicidal individual. In fact, according to research by Plutchik (1995), 41 factors correlate with the risk of completed suicide. Although no one person could either remember or assess all potential risk factors, below are some of the most common ones discussed in the literature.

First, suicide among young people between the ages of 15 and 24 ranks as the third leading cause of death (National Center for Health Statistics, 2002). This represents 7.9 deaths per 100,000 persons, with a male-to-female ratio of 3:1. Between the ages of 20–24, suicide claims the lives of 12 persons per 100,000, with a male-to-female ratio of 7:1 (National Institute of Mental Health, 2001). Within the last few decades, teen suicides have steadily been on the rise. In fact, in a study conducted of high school age students, as many as 15% have made at least one suicide attempt (King, 1997), with teen girls being particularly vulnerable (Lewinsohn, Rohde, Seeley, & Baldwin, 2001). Teens who suffer from depression and substance abuse are at a higher risk, and both of these factors are on the rise (Gould & Kramer, 2001). Perhaps teens are more at risk due to their lack of financial and social resources, lack of emotional self-control, poorer problem-solving capacity, and lack of mobility (Reynolds & Mazza, 1994).

Currently, the age group considered most at risk contains white males who are over the age of 65 (CDC, 2006). Suicide among the elderly represents 14.6 deaths per 100,000 persons, a highly at-risk age group that is often under-assessed by mental health professionals. Particularly distressing is that 75% of the elderly use a gun of some sort, leaving a significantly reduced margin for failed attempts (Frierson & Melikian, 2002). It has been speculated that at this age, the elderly are struggling with physical and mental depreciation, as well as with the loss of friends and family members, leading to a mild or moderate depression that they may never have experienced before. Therefore, their coping strategies may be inadequate (CDC, 2006; Maris et al., 2000).

Although age is considered one important risk factor to evaluate, gender also provides information regarding the plausibility of a client attempting and/or completing suicide. As stated above, suicide is the eighth leading cause of death for males and the 19th leading cause of death for females (CDC, 2006). Subsequently, there are four male-completed suicides for every one female-completed suicide, but there are three female-attempted suicides for every one male attempt (CDC, 2006). Simply stated, more men complete suicide, while more women attempt it.

In addition to age and gender, people suffering from a mental illness (e.g., DSM diagnosis) are another at-risk group, accounting for an estimated 95% of all completed suicides (Shea, 2002). One of the most reliable predictors of suicidality is current, severe, depressive symptoms. In fact, the risk of suicide in clients with Major Depressive Disorder is approximately 20 times that of the general population (American Association of Suicidality [AAS], 2005). Research shows that seven out of every 100 men and one out of every 100 women who have had clinical depression at some point in their lifetime will go on to complete suicide (AAS, 2005). Although depression is a primary risk factor, a diagnosis of schizophrenia, bipolar disorder, and severe borderline personality disorder are also considered to put an individual at risk for completing suicide (Maris et al., 2000; Schwartz & Rogers, 2004; Shea, 2002).

It is important to monitor clients with mental illness under a psychiatrist’s care, as well as those currently in psychotherapy. Between 50% to 67% of individuals completing suicide had seen a doctor less than one month prior, between 10%–40% saw a doctor in the week preceding death, and in over half of suicides via overdose, the prescription had been either written, or refilled a week prior to the overdose (U.S. Preventive Services Task Force, 1996). Therefore, clients taking psychotropic medications should be monitored closely. Also, clients who are actively engaging in substance use and abuse are more likely to complete suicide due to the exacerbation of other environmental problems, as well as lowered inhibition when making a suicide attempt (Maris et al., 2000; Westefeld et al., 2000). Moreover, clients who are dependent on substances often have a number of supplementary risk factors for suicide (i.e., depression, engagement in high risk/self-injurious behaviors, or financial problems), which should be assessed by psychotherapists (Jobes, 2006; Shea, 2002).

Clients who are coping with chronic illness or chronic pain may be unable to imagine the possibility of change or progress in their struggle and may look to suicide as a way of absolving themselves of being “stuck” (Reeves, Bowl, Wheeler, & Guthrie, 2004). Moreover, these clients may be psychologically overwhelmed to the point that they can no longer cope with their current suffering, nor find a means of relief from it (Jobes, 2006; Shneidman, 1993; Schwartz & Rogers, 2004). Finally, the three most critical at-risk factors for suicide assessment are the number and severity of previous attempts, a family history of suicide, and current suicidal ideation (Jobes, 2006; Maris et al., 2000; Peruzzi & Bongar, 1994; Rogers & Soyka, 2004). Consequently, research by Packman, Marlitt, Bongar, and O’Connor-Pennuto (2004) found that multiple attempters possessed a greater overall baseline risk, indicating that suicide attempts increase the overall vulnerability for future suicide completion. Moreover, a familial pattern of suicidal behavior is considered an amplifier of risk through genetic and temperament influences and possible behavioral modeling (Packman et al., 2004).

Myths About Suicide and the Psychotherapy Relationship

There are several myths surrounding suicide that may inadvertently influence a clinician’s ability to accurately assess a client’s lethality. Most importantly, individuals in general (and some clinicians, as well) often believe that discussing suicide may directly lead to increased suicide risk. As Schwartz and Singer (2005) point out, clients kill themselves because they decide to, not because it was discussed in a psychotherapy session. In fact, there are data suggesting that psychotherapists rarely explore with their clients past experiences with suicidal thoughts or attempts (Rogers & Soyka, 2004). This clinical pattern may serve the purpose of helping clinicians to “feel better” while unwittingly contaminating the suicide assessment process (Schwartz & Singer, 2005).

Other common misperceptions about suicide are that suicide is an “irrational” act, or that suicidal behaviors are always “impulsive” acts, that children and elderly may be at risk but do not actually complete suicide, and that people who commit suicide usually do not actively seek help beforehand (Peruzzi & Bongar, 1994; Schwartz & Rogers, 2004; Schwartz & Singer, 2005; Wingate, Joiner, Walker, Rudd, & Jobes, 2004). However, a review of 71 completed suicides showed that more than half of the victims communicated their suicidal ideation within 3 months before the fatal attempt (Isometas et al., 1994). A final myth that should be noted is that people whose suicide attempts have failed really were not seriously contemplating suicide. That is, these clients were only looking for sympathy or attention (Segal, 2000). Unfortunately, research has shown that 40% of all suicide victims (i.e., those who completed suicide) made previous attempts or threats, and as the number of attempts increases, so does the likelihood that a future attempt will be fatal (Goldstein, Black, Nasrallah, & Winokur, 1991). In fact, all of the myths described above have been disputed both by clinical reports, as well as empirical research findings. Even though these suicide-related myths abound in American popular culture, it is crucial that clinicians do not succumb to their damaging influence. For various reasons—discomfort with the suicide assessment process, fears of client vulnerability and suicidality, clinician countertransference (perhaps one’s friend or relative attempted or completed suicide)—psychotherapists are at risk of not hearing clients’ calls for help. Clinicians should be aware of the myths outlined above because by increasing their understanding of what is, and is not, linked to suicidality, psychotherapists can remain open and objective during the assessment process (Schwartz & Rogers, 2004).

It is vital that psychotherapists listen intently to what clients mean behind what they say, objectively and empathically, in order to fully engage clients in a thorough suicide assessment (Schwartz & Singer, 2005). Jobes (2006, p. 7) observes that given what we currently know about people who commit suicide, there are “three essential truisms” for clinicians to note:

1) Most suicidal people do not want to end to their biological existence; rather, they want an end to their psychological pain and suffering.

2) Most suicidal people tell others (including mental health professionals) that they are thinking about suicide as a compelling option for coping with their pain.

3) Most suicidal people have psychological problems, social problems, and poor methods for coping with pain—all things that mental health professionals are usually well trained to tackle.

Strategies for Suicide Assessment

Despite the fact that several useful surveys and questionnaires are available to help clinicians evaluate suicide risk, a face-to-face clinician/client interview is thought to be both preferential and necessary to the assessment process (Reeves, Bowl, Wheeler, & Guthrie, 2004). Whether this interview is done from a crisis intervention framework, a cognitive framework, an existential-constructionist framework, or a collaborative framework, a face-to-face thorough assessment remains the only valid method for determining risk (O’Connor, Warby, Raphael, and Vassallo, 2004). The psychotherapy relationship therefore becomes the pivotal pathway for clinicians to access clients’ lethality. In order to accomplish this task, it is the responsibility of the psychotherapist to maintain an awareness of current information on suicide risk assessment practices (Westfeld et al., 2000). In this regard, the crisis interview method utilizing Shea’s validity techniques (2002), the Collaborative Assessment and Management of Suicidality (CAMS) model (Jobes, 2006), and the Aeschi Group’s Guidelines for Clinicians will be examined below.

One of the first things a clinician must be willing to participate in is a self-inventory for the identification of biases regarding suicide as an act. This self-reflection can determine whether an intervention will be a success or a failure (Shea, 2002). Self-exploration is not a static awareness, but on ongoing process (Shea, 2002). Attitudes can range vastly from “suicide is wrong” to “suicide has intrinsic positive worth” (Shea, 2002). Suicide is a difficult topic for discussion, even for the experienced therapist. It is for this reason that the therapist should be aware and keep track of his or her values and ongoing emotional experiences. Counter-transference is one phenomenon the psychotherapist should be continually checking in with, as this can create a power struggle between client and therapist. For example, Maris, Berman, and Silverman posit that suicidal clients can actually be “help-rejecting” as well as engaging in a wide variety of “interpersonally alienating behaviors” (p. 513), which may create negative counter-transference.

There are many schools of thought on how to assess a suicidal individual. One such assessment is the crisis interview wherein the psychotherapist directly asks questions regarding suicidality (e.g., ideation, intent, plan, means of completion). During this process, a helpful hint is to use very specific and concrete wording such as “kill yourself” or “commit suicide” versus general “softer” words such as “stop the pain” (Shea, 2002). The client needs to know that the psychotherapist can handle their thoughts surrounding taking their own life, as many clients do not have anyone else with whom to discuss these confusing thoughts.

Shea (2002) offers several other points to keep in mind when assessing a client’s lethality. First, the slightest hesitancy in a client’s response may suggest that he or she has thought about suicidal ideation (even if they deny it). Next, answers such as “no, not really” when clients are questioned about suicidal ideation usually means there have been at least some suicidal thinking. Clinicians should also try to be as present with the client as possible to pick up on any non-verbal cues he or she may be sending. For this reason, it may be beneficial for clinicians not to take notes (or to do so sparingly) during the suicide assessment, so they may be 100% available to the client during the process. Clinicians should routinely check themselves during the interview, asking “What am I feeling right now?” and “Is there any part of me that doesn’t want to hear the truth right now?” These simple preparations can help guide the techniques the clinician will use when eliciting suicidal intent.

In The Practical Art of Suicide Assessment, Shea (2002) discusses six validity techniques that clinicians can utilize to explore sensitive material with a client. These can be used with a variety of sensitive topics, such as domestic violence, substance abuse, antisocial behavior, sexual abuse, and suicide. The first validity technique, the behavioral incident, is when the clinician asks about concrete behavioral facts. Questions like, “Exactly how many pills did you take?” provide the facts of the incident. The next technique is shame attenuation, which relates to the therapists’ ability to inquire about information without making the client feel shame or guilt. Instead of asking the client, “Do you have a bad temper and tend to pick fights?” the clinician could ask, “Do you find people tend to pick fights with you when you are out trying to have a good time?” Or, “Some people have told me that when they get angry they tend to pick fights, has that happened with you?”

The next technique is designed to help increase the chances the client will be open with sensitive information. Gentle assumption is a technique that proposes that the behavior is already happening. Instead of asking, “Do you drink?” The therapist can ask, “How much do you drink?” In the case of potential suicidality, if the client is severely depressed the clinician may ask, “During the past two weeks how difficult has it been to not think about taking your own life?” This technique helps clients bypass the psychological hurdle of admitting to problem behaviors in the first place.

The technique symptom amplification uses the client’s natural tendency to minimize or downplay quantitative information about problem behaviors. By setting the upper limits of the quantity higher than average during questioning, the client has “room to move” while being more truthful about the actual number. For example, rather than asking, “Have you had thoughts of suicide during the past week?” the therapist could ask, “How many times has the thought of suicide entered your mind during the past week, fifteen or twenty?” This allows the client to ease his or her natural defense mechanisms and avoid confrontation. The question may be particularly effective after a gentle assumption (see above) has already exposed suicidality.

The technique denial of the specific involves asking the client specific questions versus generic or global questions. The rationale is that it is easier to deny a generic question than a specific one. If trying to assess the use of drugs a clinician might ask, “Have you ever tried cocaine?” or, “Have you ever smoked crack?” or, “Have you ever used crystal meth?” or, “Have you ever dropped acid?” rather than, “Do you use illegal drugs?” Regarding suicidality, when assessing a plan after suicidal ideation and/or intent has been revealed, the clinician may ask, “Have you thought about overdosing on your medication?” and, “Have you thought about taking your life by hanging?” and, “Have you considered using a gun to take your life?”

The last validity technique Shea (2002) offers is normalization. By normalizing their problem behavior, the client may not feel as embarrassed or anxious when discussing it. For example, regarding depressive symptoms, the therapist may ask, “Sometimes when people are depressed they will have a decrease in their sex drive . . . has this happened to you?” When assessing suicidality, a therapist might ask, “Many times when people are sad and ‘in the dumps’ as you have described yourself, they say the thought of wanting to die comes into their minds . . . has this thought surfaced for you?” Letting people know they aren’t the only ones to experience the behavior allows them to feel less anxious about it and free to share it with the interviewer.

When completing an assessment of a potentially suicidal client, the clinician must be aware of the most important information needed from the client: mainly, the client’s current level of suicidal ideation, suicidal intentions, whether a plan for action has been considered, and what access the client has for the means of completion (O’Connor et al., 2004; Packman et al., 2004; Schwartz & Rogers, 2004; Shea, 2002; Wingate et al., 2004). As the amount of information from these four areas increases, so does the probability that the client may be truly at risk. For example, if suicidal ideation is present, the clinician should evaluate how often these thoughts are occurring, how long the thoughts have been present, whether or not the thoughts have become more intense over time, and how difficult is it for the client to keep from acting upon these thoughts (Schwartz & Rogers, 2004). Another clinically important area would be to determine whether or not the client has a specific plan to harm him or herself. If a plan exists, the clinician would need to determine how well developed the plan is and whether the client has the means accessible to complete the plan. Not only will this exploration of ideation help to determine the lethality of the client, but it will also provide direct suggestions for setting up a safety plan.

Lethality is a function not only of risk factors, but also of whether or not protective factors are present (Maris et al., 2000). Below are some general guidelines provided by Schwartz and Rogers (2004) that may be helpful in determining the lethality of a client who acknowledges suicidal ideation:

* Low lethality—suicidal ideation is present but intent is denied, client does not have a concrete plan, and has never attempted suicide in the past.
* Moderate lethality—more than one general risk factor for suicide is present, suicidal ideation and intent are present but a clear plan is denied, and the client is motivated to improve his/her psychological state if possible.
* High lethality—several general risk factors for suicide are present, client has verbalized suicidal ideation and intent, has a coherent plan to harm him or herself, and reports access to resources needed to complete the plan.
* Very high lethality—client verbalizes suicidal ideation and intent, he or she has communicated a well thought out plan with immediate access to resources needed to complete the plan, demonstrates cognitive rigidity and hopelessness for the future, denies any available social support, and has made previous suicide attempts in the past.

Although suicide involves a complex range of behaviors, thoughts, and affective states, the evaluation of concrete suicide markers (i.e., ideation, intent, planning, and means) may increase a clinician’s success in predicting a client’s overall lethality (Schwartz & Rogers, 2004; Shea, 2002). However, as O’Connor et al. (2004) state, it is important to realize that “every clinician lives with the knowledge that even with our best efforts and exemplary care, there will still be some suicide deaths” (p. 359).

Another assessment approach that has been gaining popularity is an inclusive or “team-building” approach called the Collaborative Assessment and Management of Suicidality (CAMS), created from the research of David Jobes and associates. The main focus and uniqueness of this assessment model is that it targets the client’s subjective suicidality as the central clinical problem, independent of objective diagnosis (Jobes, 2006). In addition, by utilizing the Suicide Status Form (SSF), both the clinician and client develop a shared understanding of the client’s suicidality by rating the client’s current psychological pain, press (stress), perturbation (agitation), hopelessness, and poor self-regard (self-hate) (Jobes, 2006; Jobes & Drozd, 2004). With the CAMS model, even the traditional face-to-face seating is changed once suicide is mentioned. The clinician asks for permission to sit side-by-side the client while filling out the SSF in order to facilitate a more collaborative feeling (Jobes, 2006; Jobes & Drozd, 2004).

In addition to ranking risk-related characteristics, the CAMS model also helps the client to identify reasons for living as well as reasons for dying. In doing this, the clinician receives a glimpse at some of the protective factors that have kept the client from taking his or her life up to this point. As Jobes & Drozd (2004) profess, it is our job as clinicians to help suicidal individuals find alternative ways of coping with the unbearable pain and stress in their lives in order to alleviate suicide as a viable option. Finding a common ground and being able to agree on mutual goals increases collaboration immensely (Ellis, 2004).

The CAMS model incorporates its own documentation throughout each of the stages. In this model, the SSF has 4 sections:

Section A: This initial section is completed collaboratively in order to extract a true understanding of the meaning the world has for the client currently.

Section B: This section is completed by the clinician who asks specific questions regarding plan, preparation, rehearsal, history of suicidality, and so on.

Section C: This section is completed collaboratively and explicitly states what the outpatient treatment plan will be.

Section D: This section is completed by the clinician post-session and includes a mental status exam, preliminary diagnosis, and the client’s overall suicide risk level. Also, this section provides a place for the clinicians to jot down any additional information not otherwise covered in sections A-D.

There is a place at the bottom of each section for the client and clinician’s signature and date. This aspect of the model also reinforces collaboration during the assessment process, because the information collected is reviewed and agreed to by both clinician and client. This same process would be completed each session until there were three consecutive sessions without suicidal ideations (Jobes, 2006). As Jobes (2006) states, “I truly believe that through collaboration all things are possible, not the least of which is coaxing a life to be meaningfully lived back from the jaws of suicidal death” (p. 137)

By Michelle E. Toth, MA; Robert C. Schwartz, PhD; and Sandy T. Kurka, MA