2023 14th Annual NUBE Conference

Intentionality can be defined as “the act of being deliberate or purposive.” Although a crucial element reflective of a patient’s current mental health state and the degree of desire to end their life, it can be challenging for clinicians working in an emergency setting with people who may be at risk of harming themselves to determine the level of intentionality behind self-harm and suicide gestures/attempts, varying from impulsive to pre-meditated. How can we best get to the Who, What, Where, When, How, and Why? How can we determine what the patient thought might happen? What has potentially changed in the patient’s life since this behavior took place?Once assessed/determined, what are the implications for clinical practice in an emergency room setting?Through an overview of operational criteria, three brief case examples (breaking down the behaviors, potential motives, and potential for disposition) and thoughtful discussion, this presentation seeks to widen the optic by exploring patient behavior in the context of the environment, coping skills, level of maturation, degree of impulsivity, presence of Axis 1 psychiatric and substance use disorders, potential lethality of actions, intentionality, and wished outcome of events by the patient. We can take a quick look into a few examples of screening tools that can be used to help assess suicidal intentionality, including:-Patient Health Questionnaire-9 (PHQ-9) – a nine-item questionnaire used in primary care and other clinical settings to screen for depression.1-Ask-Suicide Screening Questions (ASQ) tool – four questions that can be used in any setting to screen for suicidal ideation and behavior over the previous month.2-Columbia-Suicide Severity Rating Scale (C-SSRS) – comprehensive instrument consisting of six subscales to assess the full spectrum of suicidal ideation and behavior.3-Scale for Suicide Ideation (SSI) – a 19-item scale, covering three domains, used to measure the current intensity of a person’s specific attitudes, behaviors, and plans to commit suicide.4Beyond these tools, how can we continue to advance our understanding and clinical judgment in assessing self-harm in an emergency setting? Suicidal ideation and behavior can change over time and across situations, so how can we best account for these factors in an emergency room where action may be needed quickly and without the ability to have assessed a patient’s patterns over an ongoing period of time?Additionally, patients may have more than one intention for their behavior(s) and thoroughly assessing intentionality can help differentiate NSSI from suicidal behavior, because while they share numerous clinical characteristics, the best treatment course between them can vary and the co-existence of both behaviors can be a useful indicator for additional diagnoses such as borderline personality disorder and other impulsive personality disorders.5 Measuring suicidal intentionality can help to identify the level of risk, the need for intervention, overall patient care plans, and the potential outcomes of suicidal behavior. It is key to continually broaden our line of questioning around self-harming behaviors to assist us in providing safer and higher-quality patient care, resulting in increased positive patient outcomes.

Learning Objectives:

1. To broaden our line of questioning around self-harming behaviors.
2. To put a spotlight on intent in an emergency room setting when assessing lethality and safety.
3. To advance our understanding of the multitude of issues at play when assessing self-harm in the Emergency setting.