SCL1201 - Assessment for Suicidality: A Primer for Mental Health Clinicians
by Charles D. Safford, LCSW
Charlie Safford is the president and owner of yourceus.com. Mr. Safford has over twenty years of post-masters experience as a clinical therapist. In addition to his work as a therapist, he has been a trainer and training developer for over twenty years.
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This training is designed to provide a comprehensive overview of how to assess for suicidality. Upon completing this course, the trainee should understand:
- the risk factors related to suicide
- how to assess for suicidality
- the implications of this assessment for responding to suicidal clients.
This training course can help to prepare mental health clinicians for this difficult aspect of their professional work.
This course is designed for beginning level clinical professionals or for more experienced professionals who wish to review this subject area.
3 contact hours: Core clinical
References and Test
Section One: Overview – Questions and Answers about Suicidality
We will take a close look at some of the questions that are most frequently asked about suicidal clients and suicidality. This information is designed to be helpful and directive with regard to some of the most difficult aspects of assessing and responding to clients who are at risk for harming or killing themselves. It is not designed to be used as a replacement for good clinical judgment, but rather in conjunction with good judgment and the use of other important clinical skills.
What is suicidality?
Suicidality is the intent to end one's own life, including the intent to bring harm to oneself in ways that may intentionally or unintentionally lead to the loss of one's own life. Suicide may be accomplished by active attempts, through the self-application of lethal force or means. Suicide may also be accomplished by putting oneself in a position where others - particularly law officers - will be forced to apply lethal force. Suicide may also be accomplished by placing oneself in risky or dangerous situations in which there is a high probability of a lethal outcome, such as engaging in reckless driving or other dangerous activities. In situations where the person is killed in the pursuit of their dangerous activities, it is often difficult to prove the death was by suicide.
Why does a person commit suicide?
There are many reasons why a person may commit suicide. Sometimes suicide is an expression of anger, a way to "get back at someone" by holding them responsible for one's choice to commit suicide. Likewise, suicide can be an extreme expression of the need to exercise control, to demonstrate that others will not be able to control one's actions. Suicide may also be used as an expression of social protest, intentionally taking one's own life to highlight some social injustice in one's society. Suicide may also be an attempt to remove oneself from some difficult problem or situation for which there is felt to be no immediate solution. In such cases, the act of suicide may be impulsive or poorly thought out, without a clear understanding of the finality of such an approach.
At other times, suicide may be thought through very carefully. The choice to end one's life may arise from a conscious wish or hope to be reborn, or reunited with another person, or from the conclusion that the pain of continuing to live is greater than the fear or pain of dying. In some cultures, these choices command great respect and are sanctioned by the dominant cultural values. In other cultures, suicide is always viewed as a wrong choice, and may be classified as a sin, or a crime, or at least an event that must be prevented at all costs. In many cases, there will be multiple reasons why a person considers suicide. These social and individual meanings and motives are very important to consider, and will inform and direct the clinician's attempts to provide therapeutic assistance to the person contemplating suicide, as we will see in later sections of this training.
When is a person likely to commit suicide?
While it is impossible for even the most skilled mental health clinicians to predict with absolute certainty when a person is going to commit suicide, there are several situations in which the risk of a client committing suicide is believed to be increased:
1. When a client has a history of chronic mental disorders that include a high degree of hopelessness and despair.
2. When a client is in a period of significant and acute turmoil with extremely high levels of anxiety and depression combined with somatic disturbances such as insomnia, confusion, and loss of pleasure.
3. When a client has had a profound life loss, such as the death of a child, or the death of a long-time spouse or partner.
4. When a client has a history of chronic or acute substance abuse that has led to major life disruptions and/or losses.
5. When a client is elderly and has had a major life loss and/or a serious decline in physical and/or emotional health.
6. When a client is under twenty-five, has few or poor family and social attachments, and has a history of depression and/or substance abuse.
7. When a client has a history of impulsive and/or risky behaviors, and recent or impending losses, life disruptions, depression and/or substance abuse.
8. When a client has a medical disorder, such as chronic pain or a terminal illness that carries a high degree of discomfort and/or a poor prognosis.
9. When a client is exhibiting open aggression, anxiety or agitation in conjunction with significant depression.
10. When a client has a recent or impending significant restriction of freedom, either through incarceration or hospitalization.
12. When a client has a loss that is devastating to an overall sense of identity, such as the sudden loss of a longtime career, or catastrophic financial setbacks.
13. When a client has experienced or been witness to catastrophic trauma, such as torture, repeated sexual assault, genocide, or other overwhelming disasters.
What other factors are considered important in determining a client's risk?
A client is considered more at risk to commit suicide if he or she has access to the means to commit suicide. Since the most common means to commit suicide is the use of firearms, the presence of a firearm in a client's home must be considered as a factor that increases risk. The presence of potentially lethal medications can also increase the risk for a client by offering the means to commit suicide.
A client is also considered to have increased risk if he or she has a prior history of suicide attempts, or if he or she has had exposure, or been witness to suicides or suicide attempts. If, for instance, a student at a school commits suicide, it increases the level of risk for other students at that school.
This aspect of increased risk, colloquially called "copy cat behavior", expresses the psychological principle of contagion. When one individual engages in a behavior, even if the behavior is unwise, unsafe, or unsanctioned, it creates a reduction in resistance to the behavior for others in the person's sphere of influence. The risk is increased to some degree when the persons committing or attempting suicide are peers or fellow members of the community. The risk is increased even more when the person committing suicide is an admired celebrity. This risk factor is further heightened if the act of suicide receives significant and repeated exposure through the news media, which in a sense lends celebrity status to the person's death.
Who should be assessed for suicidality?
Any client who meets the risk criteria noted in the previous sections should be given a thorough and probing assessment for suicidality. Even in the absence of more dramatic indications of suicidal risk, all clients with a diagnosable substance abuse problem, or a diagnosable mental illness should be given at least a preliminary assessment for suicidality. All clients with a significant history of depression, anxiety or impulse control problems should be given at least a preliminary assessment for suicidal ideation or planning, as should any client who, in the course of treatment, expresses thoughts of harming oneself or others.
When should a suicidal client be considered for hospitalization?
You must consider hospitalization for a client if the client cannot be safely maintained outside of the hospital setting. There are several factors that must be considered in making this determination:
-Is there imminent risk, as evidenced by overt and explicit declarations of an intent to kill oneself, with a clear and concrete plan, and the means to carry out that plan?
-Does the client require the medical resources of the hospital setting to prevent or contain imminent risk or to provide services that are not available anywhere else?
-Is the client not competent to make good safety decisions - due to substance abuse, mental illness, impulse control disorders - in ways that create an unacceptable level of risk in the context of his/her current situation?
The standard for committing a client to a hospital on an involuntary basis is set very high. Imminent risk, or incompetence (a demonstrated lack of ability to take care of oneself) must usually be evident, otherwise the client's right to autonomy is considered a higher right than the concerns for safety.
Voluntary hospitalizations will be based upon the same general set of standards. A client requesting hospitalization for safety concerns will usually be accorded it, since his/her perception of a need for increased safety will usually be sufficient to demonstrate imminent risk.
What steps should be taken if a client presents with suicidality?
A client who presents with suicidal thoughts or ideation should always receive a thorough assessment for suicidality. The components of that assessment will be discussed in the course of this training program.
From a thorough assessment, the clinician will gather information about the degree of risk, the driving forces behind the suicidal intentions, factors that may decrease the risk of suicide, and other important variables at play in the client's state of mind as he/she sits before the clinician. The clinician must line up the information gathered with what is known about risk factors to make a determination of what steps must be taken - in what time frames - in order to preserve the client's safety.
For clients who present with minimal risk factors, the clinician's job will be to make note of the suicidal ideation in the client's record, and to ensure that the risk is regularly re-evaluated in the course of treatment.
For clients who present with moderate risk factors, a more active targeting of the suicidality may be indicated. This means the clinician may need to raise suicidality as a topic for discussion, helping the client to clarify the implications and meaning of suicide in a real sense. The clinician will then go on to target those factors - such as stress, depression, losses - that may have contributed to the development of suicidality.
If a client presents with a very high degree of suicidality, the clinician's job is much more involved. The assessment must include an evaluation of the imminent risk for the client, this is to say whether the client may be at risk to commit suicide right now or in the immediate, foreseeable future. If imminent risk is discovered, the clinician has obligations to keep the client safe. Hospitalization may need to be considered.
If a client at imminent risk declines to accept voluntary hospitalization, the clinician may need to take steps to have the client admitted on an involuntary basis. Each state will have defined steps for how an involuntary hospitalization is to be performed, and the clinician must follow those steps in a very precise manner.
If a client has a high degree of suicide risk, but does not meet the criteria for imminent risk, the clinician must proceed with normal treatment planning for that client, but be prepared to conduct ongoing and continuous evaluation for imminent risk until the risk has been contained.
Suicidality can increase and decrease very rapidly in some clients, so the clinician must be very clear about his/her capacity to provide the level of support required to perform this ongoing evaluation process. If the clinician is unable to provide that level of contact with the client, a referral must be made to a more appropriate treatment resource.
Because these cases may often be very complex and emotionally taxing, it is usually wise to seek out consultation and support from a trusted colleague as an extra step in the decision making process. In addition to helping the clinician to make the best decision possible, it also offers some liability protection should events turn out badly.
All interactions with the client, and all treatment decisions should be carefully documented. If a colleague has offered consultation, it may be advisable to have that colleague sign off on the client's documentation.
What kind of documentation should be performed to record the assessment for suicidality?
Documentation should include: the date and time of the assessment for suicidal ideation and intent, specific questions and responses (recording as closely as possible the actual words used), objective information concerning non-verbal communication and non-verbal cues from the client that may express state of mind or mood, findings from other assessment tools, such as mental status examinations or formal suicide assessment tools, the clinician's findings or assessment of the information taken, specific interventions planned to address the risk factors that are found to be present, and the clinician's name, licensure and job title. When there is a risk of suicide, it may also be useful to have a supervisor or professional provide peer review for the assessment and record the supervision, as has been previously noted.
Is there anything else a person needs to know about assessment for suicidality?
It is important to visualize the assessment process of having two interrelated parts. The first part is the elicitation of suicidal ideation and thoughts, indicating the presence in the client of the state of mind that creates an increased risk of suicide. The second part, however, is concerned with whether the thoughts are likely to be translated into suicidal plans and actions. While most people, at some point in the course of their lifetimes, have at least fleeting thoughts of harming or killing themselves, only a small percentage of people will actually engage in activities that are self-harmful or self-threatening to the point of risking death. A smaller percentage still will be successful in their suicide attempts. The second goal of the assessment must be aimed at trying to determine which group is which.
The willingness of the client to follow through with a serious suicide attempt is extremely difficult to assess. Unfortunately, the clients who are most serious about killing themselves may be the least likely to reveal this information in an assessment, since this may lead to interventions that prevent them from following through with their wish to die. In such cases, the clinician has little other recourse than to make his or her best assessment based on the current facts and the historical record, and err on the side of safety.
It is always advisable for the clinician to be aware of sudden changes in mood or behavior for a client whose record contains numerous risk factors for suicide. The act of preparing oneself to die often follows predictable stages, ending in a stage of acceptance of the willingness to die. Clients who have reached such a point may exhibit great calm or peaceful elation, in contrast to earlier states of agitation or depression. This change in mood, in the absence of an overall understanding of the process of suicide, may be misinterpreted as an improvement in the client's well being, and may mistakenly be taken as a signal to remove physical restrictions to a person's opportunities to harm him or herself. If this state of calm occurs with preparations for death, such as the writing of a will, or giving away possessions, risk is considered high.
With this in mind, let us move to an examination of the assessment that should be performed on a client to elicit information about their potential to harm or kill him/herself.
In 2013, suicide was the 10th leading cause of death in the United States, and the third leading cause for people 15-24.
Source: Center for Disease Control
The most common method of committing suicide for both men and women is by use of firearms.
Source: Center for Disease Control