SCL1201 - SECTION 2: SUICIDE ASSESSMENT: A THEORETICAL MODEL
To this point, we have been presenting background information about suicidality, including factors that create increased suicide risk for a client. While this is a useful starting point, it is now time to move on to something more concrete and useful for the clinician. We are going to look at how one proceeds in conducting a thorough assessment of a client's risk for suicide. This process will involve gathering a sizeable amount of information.
Before we begin to look at which information to gather, it may be helpful to examine why we want to gather that information. Towards this end, we will propose a theoretical formula for what creates suicidal risk. This formula is not designed to be an actual mathematical representation, but rather a way to visualize the interactions between several important elements in way that will inform our understanding of why certain questions must be brought into the assessment process. The formula is presented below, with detailed analysis to follow.
When suicidality is present...
(Motive + Means) X Motivation – Resistance = Risk
Let's take a look at the elements involved in this understanding of suicide risk. The first element is the motive, or the reason, why the person is considering suicide. This element has been examined briefly in the previous section, but it may be helpful to review for the purposes of looking more deeply at risk assessment.
A person may have a single reason, or multiple reasons, for wanting to commit suicide. It is important for the clinician to know these reasons from the client's point of view or perspective.
At times, the motive(s) for the suicide may make sense to the clinician. At other times, the motive(s) will be so peculiar to the client's way of looking at the world that it will be difficult for the clinician to understand how it influences the actions of the client. It is such a key element, however, that the clinician should go to great lengths to reach an understanding of it.
This process of reaching an understanding of the client's motives for considering suicide may involve helping the client to look for clarification of his or her own motives. Suicide attempts often happen when clients are very confused, when their motives for action are unclear.
In such instances, the client may be unable to tell the clinician his or her motives. This means that the assessment process might require that the clinician direct the process by taking educated guesses about what reasons the client might have for considering suicide, in a manner akin to helping young children understand and clarify their feelings by naming the feelings for them.
In addition to moving forward the assessment process, this may also begin the therapeutic process by decreasing the client's confusion, thereby relieving one potential component of the client's stress.
In looking for the motive or reason for the client considering suicide, it is important to remain supportive and non-judgmental. While it may be difficult for the clinician to understand or relate to the client's rationale for considering suicide, the motives are experienced by the client as making sense from his/her perspective, and must therefore be respected. In order to help the client re-evaluate and redefine his/her motives, the clinician must help the client feel comfortable about sharing and discovering what those motives are.
On the pages that follow, there is a list of the most frequent reasons why a client would consider suicide.
Common Reasons Clients Consider Suicide
The physical, emotional or psychic pain and discomfort in the client's life is experienced as too great a burden to bear.
The client wishes to communicate anger, or a need for control, to significant others in his/her life.
The client wishes to be reunited with a loved one who has already died.
The client wishes to make an expression of social protest against a government or other social institution.
The client wishes to escape from problems for which no other workable solution can be envisioned.
The client wishes to exit his/her life with dignity in accordance with deeply held personal or social values.
The client envisions loved ones providing to the client in death the attention, affection or affirmations not received in life.
The client is faced with sudden overwhelming shame or other psychological burdens that leave him/her feeling trapped or backed into a corner.
The second part of our formula is concerned with the availability of the means to commit suicide. Without ready means, it is surprisingly difficult to kill oneself. Furthermore, many methods of killing oneself involve the possibility of a sizeable amount of physical pain before the moment of death is reached. This is a considerable deterrent to most people, and decreases the risk that a person will attempt suicide.
On the other hand, the availability of a largely pain free method of death removes one of the practical impediments to suicide. Unfortunately, we live in a time where there are a number of easy ways to kill oneself.
As previously noted, the most frequently utilized method of committing suicide in the United States is a gun. It offers the user a generally fast, efficient and relatively painless way to die. If a person at risk to commit suicide has a firearm readily available, it raises the risk of a suicide occurring considerably.
The increased risk may not be confined just to the availability of an easy way to kill oneself. The risk may also be increased by a psychological principle known as "object attraction." If a weapon is present, its very features suggest its use, and create a psychological tendency to want to use it.
This phenomenon is similar to the way in which food creates hunger to someone trying to stay on a diet, or how the presence of alcohol creates cravings to an alcoholic trying to stay in recovery. In practical terms, it means that it is very important to determine whether a suicidal person has easy access to a firearm.
There are also other easy and relatively painless ways for a suicidal person to kill him/herself. There are numerous medications relatively easy to obtain that may be lethal in the right doses, and yet may also produce a death that is largely or completely pain-free.
Since some of these medications may be prescribed for exactly the kinds of symptoms exhibited by suicidal clients, it is very important to be aware of what medications are immediately available to the client. Again, the presence of lethal means creates increased risk due to object attraction.
Apart from the use of a firearm, the use of lethal medications is the preferred approach to committing suicide in this country, particularly for women.
The next area that must be evaluated in a thorough assessment for suicidality is the question of how motivated the client is to commit suicide. This factor is, in many ways, the single most important determinant of whether the client will ultimately commit suicide, and the most complex and difficult aspect to assess in a concrete and meaningful way.
Unlike many of the other risk factors, motivation is not fixed by demographics or history. It is fluid, changing rapidly for reasons that often exist only in the mind and emotions - or neurochemistry - of the client.
While all the other risk factors for suicidality represent the accumulated explosive potential of the client, motivation represents the fuse. A client with great explosive potential may be safely transported for many years through rocky emotional terrain, but when the fuse is lit and set off, imminent risk is created. For this reason, in our formula, motivation is viewed as a multiplying factor, not a factor of addition.
And how does a conscientious clinician evaluate motivation to commit suicide? Consciously, carefully, and, when working with clients at high risk, continuously.
The most frightening aspect of suicide prevention for mental health clinicians lies in the impossibility of completely keeping up with the vagaries of the client's motivation to commit suicide. At the moment that the mental health clinician does his/her most thorough and comprehensive assessment for suicide, a client may exhibit limited motivation to commit suicide.
Hours, or even minutes, later, a subtle shift in one or two critical elements can light the motivational fuse for the client, for reasons that - if the client successfully commits suicide - are never to be known.
This is not to discourage the mental health clinician from engaging in the process of assessing risk; it is rather an invitation to enter into this process with the proper degree of humility and respect for that which we do not know. This is more protective of the clinician, and, ultimately, the client, as well.
It is often the case that motivation to commit suicide must be inferred, as well as searched for through active and ongoing communication with the client. Many - although not all - clients will exhibit behavioral indices of their motivation to move towards the ultimate act of harming themselves.
The final element of our equation is the one element that works to decrease risk. This is the resistance the client has to killing him/herself or engaging in the act of committing suicide.
There are many potential elements to this factor in the formula. First, there is the fear of death, and the finality of death. This clear and instinctive fear is a very strong part of our biological imperative, and offers the first line of resistance to suicide.
On top of this primary biological fear, there are usually differing layers of moral and social injunctions, involving a person's sense of connection to society at large and other important people in particular. Where there are positive sentiments for these relationships, resistance is increased, since a person often does not wish to bring sadness or emotional pain to those whom he/she loves.
There are other resistances, as well. One's sense of pride or courage in facing adversity, one's connections to life's joys and pleasures, one's adherence to particular religious beliefs, all of these create certain degrees of resistance.
As in other areas, it is important for the clinician to assess this factor in relation to the client's perception of these resistances. The client's understanding of what constitutes a reason not to commit suicide may be quite different from the clinician's idea. A client who is very confused, or outwardly psychotic, may have strange or unusual perceptions in this area.
It is also important to evaluate whether the client is attuned to his/her own resistances. Very impulsive clients may move towards suicidal acts without even considering the consequences of their actions. In such cases, the resistance is not useful.
Each of the factors addressed by this formula offers not only information that must be gathered in a thorough suicide assessment, but also labels points of impact for the process of stabilizing clients who are suicidal. Later in this training, we will briefly look at how to utilize these points of impact in a therapeutic manner.
With our formula as a visual representation of why certain information must be gathered, it is now time to turn to examination of what questions must be asked in order to gather the right information. This is the subject of our next section.
Every day in the United States, approximately 105 people die from suicide
Source: Centers for Disease Control.
Among elderly adults, there is one suicide for each four attempts.
Source: Centers for Disease Control