SCL1201 - SECTION 4: ADDITIONAL INFORMATION TO GATHER IN A SUICIDE ASSESSMENT
In addition to the information elicited by the interview of the suicidal client, there are a number of other areas that must be investigated in any thorough evaluation of a person's risk for suicide. First, it is often helpful to ask for a family member, friend or other important party in the client's life to provide feedback and a different perspective on the client's interview responses.
It is not unusual for a suicidal client to give erroneous historical information - for instance concerning prior history of suicide attempts or a history of substance misuse - that can be corrected by another party.
It is important to remember, in this regard, that family members, or other significant others, may themselves not always be reliable sources of accurate information. This other perspective, however, is often useful in providing information about both cognitive distortions on the part of the client, and problematic relationships that may contribute to the client's stress.
There are advantages in seeking information in these important assessment areas from a number of different parties connected to the client. This may allow the clinician to keep a clear sense of where distortions exist.
One of these other areas that must also be assessed is concerned with the capacity of the client to utilize his or her relationships, including the therapeutic relationship, for support and to help stabilize his or her situation. This question is important for the immediate effects it holds on keeping the client safe, and for the implications for the treatment to follow.
Elicitation of this information may be sought in the interview with the client, but may also require input from family members or friends, reviewing client notes from other therapeutic interventions, or viewing the client's interactions in counseling sessions over time.
In particular, the clinician will be concerned with answers to the following questions:
1. Is the client able/competent to participate in treatment?
2. Is the client able to form a therapeutic alliance?
3. Is the client receptive to offers of support, comfort, love and affection?
4. Is the client receptive to directive and supportive interventions, such as the setting of limits, or the redirecting of behaviors?
5. Does the client have sufficient "people skills" (such as assertiveness, empathy, communication abilities) to participate effectively in complex social relationships?
The ability of the client to have and maintain meaningful social connections offers some degree of insulation from the despair and hopelessness that can be a precipitant for suicide. It is important, however, to evaluate the meaning and degree of this social connection from the client's perspective, not from the perspective of the clinician.
What the average person, or the average clinician, would interpret as good and meaningful social connection, may not be what the client views as good and meaningful social connection.
Likewise, an assessment must be performed around the client's overall coping mechanisms and coping potential. This consists of two interconnected parts: the client's optimal coping mechanisms and potential, and the client's useable coping mechanisms and potential.
This is to say that clients may have latent coping mechanisms and potential that they are not able to use under certain circumstances or states of being. For example, very depressed clients may not have the capacity to use coping skills that are available to them when the level of depression lifts somewhat.
The available coping skills and potential must be assessed in order to add to the understandings about current risk, and the latent coping skills and potential must be assessed to inform the therapeutic interventions and direct the treatment planning to lessen the risk.
Assessment of coping skills and potential is performed both through direct questioning of the client, and through peripheral information gathered from the historical record of the client and interviews with family members and other concerned parties.
It needs hardly be mentioned that the gathering of information of this sort can itself serve as a therapeutic intervention for clients. The goals of returning clients to a state of better functioning include both improving coping skills and potential, and helping them to develop a greater degree of confidence in and awareness of their own coping abilities.
Many suicidal clients - for neurochemical reasons, or for emotional reasons - are poorly aware, or outright delusional about their current condition, and the strengths and abilities they possess to confront their condition
This tenuous hold on reality - with delusional content - is often an ongoing feature of bi-polar disorders, but is also evident to some degree in anyone who is sufficiently depressed to consider suicide.
The client may not only misinterpret his or her coping skills, but may also misinterpret the degree to which he or she is responsible for the conditions which may have caused him or her to get depressed. Rational Emotive Therapy (RET) or Cognitive Behavioral Therapy (CBT), or other treatment approaches derived from these approaches, can often be useful tools in addressing this aspect of suicidal risk.
The coping skills of the client, both available and potential, must always be evaluated in concert with another important area that must be assessed. The client's current level of stress, as well as anticipated level of stress, must be known.
The level of stress takes place in a complex interplay of factors: the number and intensity of stressors, how the stressors are perceived and experienced by the client, how well the client handles the stressors with his/her coping skills, and how the stressors and coping skills interact with other factors at play in the client's life.
Because of the complexity of this factor, it is advisable for the clinician to do very detailed work in soliciting information about the client's important stressors, and to keep comprehensive records that allow the clinician to follow the sometimes rapid turns and shifts in the level of stress.
Particularly when the motive for considering suicide is related to pain and discomfort, the overt level of stress that the client experiences at any point in time can be the most compelling factor in the client's motivation to commit suicide. It must be tracked very carefully
This brings us towards - but not to - the close of the information gathering elements in the suicide assessment process. There are other pieces of information that may be required for the clinician to create a comprehensive understanding of any specific client's suicidal potential.
What additional information may be required, however, will be derived from the interactive nature of the therapeutic process. The clinician will be pointed in the direction of what other factors are relevant by the information provided by the individual client.
As was stated earlier, this training is designed to present a framework for suicide assessment, not a step by step set of instructions applicable to all clients. The clinician must also use his/her judgment to pursue other lines of questioning that will yield other important clues to the client's motives, motivation and resistances.
In the next section, we will attempt to pull together and summarize the most important elements of what has been presented so far in preparation for the final section, which will briefly cover implications of the assessment process for treatment of suicidal clients.
There is one death by suicide in the US every 12.3 minutes.
12.7 in 100,000 young adults ages 20-24 die by suicide each year.
Source: National Institute for Mental Health