SCL1201 - SECTION 7: CONDUCTING A SUICIDE ASSESSMENT: SCENARIO ANALYSIS
Scenario Question One
What risk factors can you identify for the client in our scenario, based upon the information given?
There are a number of risk factors that can be readily identified from the information given in this scenario. Let's look at each. First, the client is almost certainly in a period of acute turmoil from the multiple areas of stress. It may be a wise idea to see if there are somatic disturbances - such as sleep or appetite problems - present in the client. This would create an additional source of stress, and decrease resistance to suicide.
Second, the client has had a significant life loss, with the separation from his wife and the loss of contact with his children. The degree to which this is perceived to be upsetting to the client must be determined in the course of the assessment, but it is certainly an area that must be examined.
Next, there are indications that the client may be abusing alcohol. This must be evaluated further to see how severe a problem it may represent. It must also be determined whether it has contributed to the marital problems, and to problems with judgment and impulse control, as may be evident by the need for the client's wife to secure a restraining order. The client, of course, may have problems with impulse control and judgment apart from alcohol abuse, a factor that must also be evaluated.
The client's current career problems must also be evaluated. If the client's identity is deeply tied to his career, his demotion, and the unraveling of his career track may be a serious blow to his identity and self-esteem.
It may also be fruitful to evaluate whether this client has had repeated exposure to violent and disturbing events. If this is an officer who has been involved in traumatic work situations, it may have an effect on his willingness to consider suicide. It may decrease his resistance, due to his becoming desensitized to the idea of violence, or it may increase his resistance, due to exposure to the effects of the events upon the survivors. In either event, this is important assessment information.
It may also be a good idea to evaluate this client's current support system in some detail. Two areas where support might be expected - at his work and in his marital relationship - are experiencing problems. If there are limited sources of support in other areas, this may create an increased level of risk.
Finally, this is an individual who is familiar with the use of weapons, and has ready access to those weapons. This represents one of the most important risk factors in this scenario. Police officers are among the groups of people who have elevated rates of suicide. One of the contributing features is the ready availability of weapons.
This concludes our analysis of question one. How well did you do in identifying he areas of risk for this client?
Let's move on to examining question two.
Scenario Question Two
What third parties, if any, do you think may be useful to contact as part of this assessment process?
There are several third parties that may be helpful to contact in this case. It may be helpful to gather information from the client's workplace concerning the exact nature of the job problems. It may be helpful to talk to the client's estranged wife to gather more information about their relationship woes, as well as another perspective on client's ability to utilize relationships for support. Client's parents may also have information about this client's current mood and functioning, as well as his current level of alcohol use.
This is not to say that this client would be willing to sign a release of information to allow a clinician to talk to any of these third parties. He may not wish for anyone at his workplace to be aware of his counseling. He may fear that his estranged wife may use information about his seeking help in their various legal struggles.
It may be more likely that this client would be willing to allow the clinician to talk to his parents. He may have confided in them about his workplace problems, and they may know his wife and children, and be able to give some perspective on the client's problems in these areas. It may also be helpful to ask the client if he has ever seen a mental health clinician prior to this meeting. The client may have been referred to a clinician through his work, and prior information may be available about his ability to utilize treatment.
It is important that the evaluating clinician use good sense when deciding how hard to push the client to allow third party contact. The client will be making important decisions about whether to trust the evaluating clinician, which will in turn have a direct impact on the quality of the information gathered in the assessment.
It is also important to be aware of other potential third party contacts that may be identified by the client in the course of the assessment session. The client's most trusted confidante may be a fishing partner, an old friend from high school, a great-uncle - someone the clinician might not readily think of including in the assessment process.
This ends our analysis of question two. Let's move on to our next question.
Scenario Question Three
What concerns do you have, if any, about how to approach the topic of suicidality with this client?
While it is unfair to stereotype any groups of people to the detriment of viewing each person as a unique individual, there are certain factors that must be taken into consideration when deciding how to approach this client about a topic as sensitive as suicidality. This client has self-selected into a profession that is paramilitary in structure, authoritarian in nature, and historically oriented towards "machismo" attitudes.
While it is completely possible that this client is entirely different from any stereotype of a police officer, it is probably wise for the clinician to enter into a discussion of emotional material more cautiously than with a client from a less "machismo" culture. The client's capacity for tackling the affective components contained in the assessment must be evaluated with care as the clinician proceeds.
Based upon the evidence, it might also be wise for the clinician to be prepared to respond to some issues related to control as the topic of suicide is raised. The client exhibits several areas where he seems to be struggling with control problems. It may require a delicate combination of gentleness and firmness to direct the client through such a potentially painful assessment process. The clinician is likely to know quite early in the assessment process whether either of these areas will be problematic.
This completes our analysis of question three. Let's move to the last of our questions.
Scenario Question Four
If suicidality is present, what steps might need to be considered first in stabilizing this client and keeping him safe?
When a client is suicidal, and he/she works in a profession in which weapons are used, the first consideration will almost always be concerned with what to do with those weapons, particularly during any period of time when the client may be more actively suicidal. Depending upon the level of imminent risk, it may be necessary for the clinician to push the client to arrange a shift in his/her work structure so that weapons are not immediately available.
This sets up some difficult dilemmas in treatment planning. Our client in this scenario has already experienced a loss in his career track. A recommendation to move to a desk job where weapons aren't needed may create additional stress and resistance. This topic would need to be addressed very carefully.
The other question that would need to be addressed immediately would be the matter of the client's alcohol use. A depressed client, with major life losses, the ready availability of a weapon, and good judgment and reasoning clouded by alcohol is a dangerous combination. The client would need to be directed to a position of remaining sober until stability can be achieved.
Along a similar vein, the clinician will need to see if the client's depression is sufficient to cloud his reasoning and judgment even without the alcohol. If so, another early step might be to refer the client for an evaluation for antidepressant medication.
If the level of suicidality is serious enough, of course, the clinician has the obligation to put aside all other considerations and direct the client - voluntarily or involuntarily - to a safe and secure environment. Without further information, the need for hospitalization cannot be determined in this scenario, but the clinician must always be prepared to consider it when information points in that direction.
There are many other steps that might need to be considered here - always based upon the information that is gathered in the course of the assessment process. Again, this training is designed to present an overall framework for this process. The clinician will need to use his/her professional skills to fill out that framework to work with individual clients.
Action Alliance for Suicide Prevention, http://actionallianceforsuicideprevention.org/
American Association of Suicidology, http://www.suicidology.org/resources/facts-statistics
CDC, Suicide Facts at a Glance, https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf
ENR, Clinical Practice Guideline: Suicide Risk Assessment, https://www.ena.org/practice-research/research/CPG/Documents/SuicideRiskAssessmentCPG.pdf
Mental Health America, http://www.mentalhealthamerica.net/suicide
Suicide Awareness Voices of Education, http://www.save.org/about-suicide/
World Health Organization, Suicide Data,
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