To this point, we have been providing the trainee with the raw materials needed to conduct a thorough assessment of a suicidal client.

It is now time to give an overview of how these pieces all fit together into a comprehensive process that creates the highest degree of safety for the client.

The first element is concerned with what the clinician must know even before he/she begins the assessment process with the client, several parts of which have been covered in the course of this training. Before the clinician begins the assessment process, he/she must know the following:

-Demographic, psychosocial and other factors that correlate with an increased risk of suicide
-What information must be sought to determine risk
-How to conduct a suicide assessment interview
-How to direct a client to safety should the level of risk indicate the need for a more secure environment
-How to document each step of the assessment process

For a review of the demographic, psychosocial and other factors that correlate with increased risk, the trainee is encouraged to return to the first section of this training, where this is covered in some detail. Briefly, however, there are four important areas to look for. They are:

-Socio-demographic factors, such as the increased risk seen in elderly men, military veterans of war and impulsive teenagers
-The presence of psychiatric illness
-The presence of substance abuse
-The presence of acute stressors

The information that must be sought concerning risk will be gathered from several sources - information gathered from the client, from family and other parties who have important relationships with the client, and from case records and direct communication from other medical or mental health personnel who may have treated the client.

Whenever possible, the clinician should attempt to gather information from as many sources as are available to get the clearest picture of the client that can be reached in the assessment process.

This is where the information should come from. The other aspect of this is what information is needed.

First, and most obvious, is whether there is evidence of suicidal ideation and intent at the present time. Second, there is information on whether any of the factors that correlate with increased suicidal risk have been part of the client's historical record. The third element is whether any present or imminent factors that correlate with increased risk are currently influencing the client's actions and decisions.

Finally, in order to give a more complete picture of the client's risk, and to prepare the ground for later interventions to decrease the risk of suicide, the clinician must be ready to look at the client's motives or reasons for considering suicide, the means available to the client to commit suicide, what factors help create resistance to suicide, and - most importantly – ongoing information about the client's motivation to commit suicide.

These factors are from the formula for risk described earlier in the training.

Next on our list of things to know is how to conduct an assessment interview with the client, since this will provide both the most ready and the most immediate source of information about the client's risk factors. The assessment interview, of course, has been described in some detail in terms of the questions to be posed to the client (as well as to the family and other parties connected to the client).

There are two components in this interview process that will be important in terms of assessment of suicide risk. The first will be information gathered from what the client reports in response to the interview questions.

It must not be assumed, however, that clients who are distressed enough to be at risk for suicide will always provide accurate verbal information. For this reason, information gathered from the client should also involve a close and detailed assessment of behaviors and non-verbal cues given by the client. Clinicians should always be concerned when the client’s verbal information and non-verbal information do not correlate in this area. This may be indicative of some serious problems with personal organization or internal cohesion and/or serious problems in accepting intervention from supportive therapeutic relationships.

One item that not has been covered, but which is part of what the clinician must know prior to assessing the client, concerns the procedures to follow should the client need to be directed, voluntarily or involuntarily, to more supportive and/or restrictive levels of care.

This will vary from state to state for mental health clinicians. There are different rules in different states about which professionals are permitted to hospitalize clients involuntarily. While it is beyond the scope of this training to cover each state, it is important that each clinician know the specific rules, and procedures to follow, in his/her own state.

Finally, it is important to know what and how to create a documentation record when performing an assessment of suicide risk. Documentation is not just concerned with protecting the clinician from liabilities; it is also concerned with creating a record that will help with continuity of care. For this reason, the record should be as complete and thorough as possible.

Only when the clinician has the knowledge required in each of these areas is he/she ready to engage in an assessment process. A visual representation of how these pieces work together is presented on the next pages.

What the Clinician Needs to Know

Risk factors:

Psychiatric illness
Substance abuse
Acute stressors

What information must be sought to determine risk

Presence of suicidality

Gather this information from 3 sources: from the client, from the client's family, friends and other parties, and from prior case records

How to document

Date, time, questions, answers, non-verbal cues, mental status exams, findings, interventions planned, name, title, signature

How to conduct a suicide assessment interview

25 Questions to ask
How to ask them

How to direct a client to safety

Know the rules for involuntary hospitalization for your state

The second element is concerned with the performance of the assessment and evaluation process. This will be followed by the third element, which is the beginning of the therapeutic process.

In some sense, these two elements must be considered together, because the therapeutic process cannot be neatly disconnected from the assessment process. The manner in which the clinician approaches the client during the assessment has implications for the success of later therapeutic work, not to mention that the client may require intervention before the assessment has been fully completed.

The focus of this training is concerned with the assessment and evaluation process. Intervention with suicidal clients is complex, and requires its own full training program. Therefore, we will not go into great detail about the therapeutic process.

The assessment and evaluation process puts into action all of the elements that were discussed in terms of what the clinician must know in preparation for conducting a suicide assessment. This component is what must be included: information from the client, family/other contacts, case record, risk factors, motive, means, motivation, resistance, etc.

The other important item involved in this aspect of the assessment process is how this process is to be done. This is to say, the clinician must give some thought to the way in which he/she wishes to present him/herself to the client in the course of the interview - how calm should the clinician be, how confident, how optimistic, how warm and concerned, how firm, and many other factors involved in creating a therapeutic relationship.

It is not always possible for the clinician to know how to present him/herself prior to meeting the client. The client's needs will determine to a great degree the clinician's approach.

This is to reinforce a point that is important to all therapeutic intervention: the clinician's efforts will be more effective if he/she uses approaches that are defined by what the client needs, not by what the clinician is good at or comfortable in doing. This principle is universal to good therapy, but is more crucial when a client is suicidal.

We will not belabor this point, since it is an understanding that is routinely covered in many other circumstances. Being ready to put one's ego aside in order to respond to the client's needs is simply part of the preparation process for this kind of assessment.

The level of flexibility required to respond effectively to the client's needs in this area can be considerable. Particularly when clients are in significant distress, the levels of contagion and countertransference present in the interview process can be very high, presenting a formidable challenge to the skills, resources, and emotional security and stability of the clinician.

It is tremendously important, in this arena, for the clinician to stay very focused on the assessment and intervention tasks at hand, to follow a well-prepared, though flexible, assessment and intervention process, and to have available adequate back-up resources.

It may also be helpful here to reiterate a point that was made much earlier in this training. The clinician must enter into this process with a very clear sense of the responsibilities - and the limitations - of the role assigned to the person making this assessment.

If the clinician enters into a highly charged suicide assessment process afraid of the responsibilities, or unclear of his/her own limitations, there may be negative effects upon the assessment and intervention process. In presenting him/herself in this process, the clinician must have the proper respect - and humility - for what is occurring: a task with potential life and death outcomes.

It is important to approach each suicide assessment, even those that are seemingly routine and perfunctory, with this same degree of respect and humility. No assessment tool, no degree of experience, no level of skill offers complete protection from the unpredictability of human behavior.

One other aspect of how to approach this assessment process bears mention here. This is to follow up on a point made earlier. An enormous degree of flexibility is required to gather information in a thorough suicide assessment.

This flexibility includes the area that has already been discussed: the willingness to respond to the client's needs. The level of flexibility required extends beyond just this one principle, however.

It is important to be flexible, as well, in the pursuit of information that may allow the clinician to understand the client: his/her line of reasoning, values, motives, yearnings, disappointments. Where all of these aspects of a client's make-up are different from those of the clinician, it will pose a challenge to the clinician to think creatively and flexibly in search of the right questions to know how to keep a client safe.

The final step of pulling all the pieces together is concerned with stabilizing the suicidal client, and beginning the process of therapy. As previously mentioned, this will, at times, need to occur simultaneously with the assessment process, but will also be informed by information that is derived from the assessment process.

While a comprehensive investigation of this area is beyond the scope of this training, it is important to provide some information about what is involved. We will organize this into several different areas related to the material that has already been presented.

From the assessment process, the clinician should become aware of specific points of impact relevant to the client's suicidality. The points of impact will be related to the theoretical formula we proposed earlier in this training: motive, means, motivation and resistance.

In situations of extreme or high risk, the means to commit suicide is usually addressed first, either by removing the means for suicide from the client, or by removing the client from the means for suicide. In the most extreme situations, this may means placing the client in a restrictive environment, where no means are available.

This may also be viewed as increasing resistance to suicide by putting in physical barriers to suicide. In less extreme situations, it may involve removing guns and other lethal weapons from the client's home.

The clinician would next want to reduce the client's motivation for suicide, and increase resistance. Interventions in this area might include attempts to reduce psychic pain, provide optimism and hope, support and reinforce important relationships and social connections, and make active and present any reasons that the client may have to remain connected to life.

Where any distortions or misperceptions exist in the client's understanding of the world and him/herself, the clinician may also begin the gradual process of correcting the distortions, using principles from cognitive-behavioral approaches to therapy.

Where motivation for suicide is based upon the presence of real life stresses, the clinician's job is much less cerebral and much more practical: to help the client problem solve and find workable solutions to the life stresses.

Where the client's resistance to suicide is threatened by impulsiveness - either because of a problem with drugs or alcohol, or because of impulse control disorders - the clinician must create support for the client through the use of external structure and limits, and other ego supportive measures.

It may be useful to note here that one of the most commonly used approaches to create increased resistance to suicide - a contract - is not viewed as a guarantee of safety for many clients. Contracts may give clinicians a false sense of security if this is not understood.

Contracts are most effective with clients who have a therapeutic relationship firmly established with a clinician. Contracts are much less protective with a client whom the clinician is assessing for the first time. Clients who are extremely impulsive, actively delusional, or who have prominent Axis II disorders are likely to be poor candidates for this type of contracting.

Contracts must therefore be viewed as a part of an overall safety plan, but not as a substitute for an overall safety plan. The clinician must be clear about the uses, and limitations, of a contract prior to using it as a suicide prevention tool.

Finally, the clinician must come back to an examination of the client's motives for considering suicide. This aspect of the process may have both long-term and short-term components that must be understood.

We have already addressed some of the short-term considerations with regard to addressing the client's immediate motivation for suicide. Psychic pain, life stresses, lost optimism all can be part of the reason why the client is willing to consider suicide as a solution to his/her problems.

The clinician must simultaneously begin the therapeutic work of helping the client to become aware of and find solutions to these burdens, and helping the client re-examine the decision to view suicide as a viable option for taking care of these burdens.

Those aspects of the client's reason for considering suicide that are based upon real stresses and burdens may respond fairly readily to short-term therapeutic approaches. Those aspects that may be based upon delusions or misperceptions will likely require much more long-term therapeutic approaches.

Axis II disorders, for instance, that leave the client vulnerable to wide fluctuations in mood based upon very faulty or poorly developed ways of viewing the world and him/herself, may require enormous efforts on the part of numerous caregivers to create helpful shifts in thinking and feeling.

Likewise, neurochemical disorders, such as bi-polar disorder or schizophrenia, may require interventions of many kinds to reduce the threat of suicidality, including the proper use of psychotropic medications. The clinician must be prepared to direct the client to the proper resources for interventions of this sort when conducting treatment planning at the end of the assessment process.

It must be reiterated that a comprehensive examination of all the treatment implications of an assessment for suicidality is beyond the scope of this training. What we will present to you - as a final component of this brief overview of treatment considerations - is a summary of areas to consider when stabilizing, then treating the suicidal client.

This summary is presented on the pages that follow.

Stabilizing and Treating the Suicidal Client

Remove access to the means to commit suicide, especially guns, other lethal weapons and lethal medications.

Create physical barriers to suicide: structure, limits setting, regular interpersonal contact with care providers.

Encourage the use of social connections and social resources that increase emotional resistance to suicide.

Address the misuse of substances that may contribute to poor judgment and poor impulse control.

Help the client to re-examine and reframe motives for suicide.

Help the client to find solutions for reducing pain, discomfort, and stress.

Model and champion optimism and hope.

Target suicidality as an issue to be examined and discussed: clear up distortions and magical thinking around suicide.

Help client begin treatment for underlying disorders that may be contributing to suicidality.

Accentuate and build on client's existing intra-personal resources, while targeting additional skills and resources to build.

Teach and develop better stress management.

Coordinate treatment with other caregivers to address all areas uncovered in the assessment process, including referral for appropriate psychotropic medication.

This concludes our review and summary section. The next part of this training program will present the trainee with an opportunity to practice the information that has been gathered so far. A scenario will be presented, and the trainee will be asked to develop an outline for an assessment of the client's suicidality.

Because an assessment interview is an interactive event, this approach will not allow the trainee to fully experience this kind of assessment. It will, however, direct the trainee to engage in the kind of preparation needed to lay the groundwork for a successful assessment interview.

Following the presentation of the scenario, the trainee will be asked to answer some questions. These questions are designed to direct the trainee towards the preparation work leading up to an assessment for suicidality.

The last section of this training program will then provide some analysis of the questions and the scenario.