Assessing the risk of suicide
By Douglas Flemons
Q: I feel unprepared to make a proper suicide assessment with my clients. I’m nervous that I’ll neglect to ask, or the client won’t tell me, something vital to making the right clinical decision. Can you recommend an objective measure for reliably determining suicidality?
A: Suicide assessment is a high-stakes process infused with uncertainty, so your desire to find an assessment instrument to help with your decision-making is understandable. However, even the best scales can be unreliable when they’re completed in the midst of an emotional crisis. Thus, rather than outsourcing your decision-making to an instrument, I recommend that you learn how to conduct a conversational evaluation that builds on your therapeutic skills. While most clinicians already know to ask whether a client has an intent to die, a suicide plan, or access to a means for carrying it out, it’s important to go beyond simply posing these questions to get a fuller picture of the client’s risk of suicide.
Effective suicide assessments are built on a foundation of empathic connection. When clients feel heard, understood, and respected, they’re likelier to let down their guard and explore sensitive topics. In broaching such topics, the best way to protect them from feeling grilled is to intersperse your questions with empathic statements, such as “Sometimes your obligations feel impossible to meet,” or “It sounds exhausting to have to fend off intrusive thoughts of taking your life all the time.”
To help guide your assessment dialogue, my colleague, psychiatrist Len Gralnik, and I have identified four broad categories of inquiry:
Disruptions and demands—such as the loss of a relationship or social and financial status, overwhelming expectations and obligations, legal entanglements, and instances of abuse, bullying, or other traumas.
Suffering—from emotional problems (depression, mania, anxiety, anger, obsessive thinking), psychiatric problems (hallucinations and delusions), social pain (conflicted identity, shame), sleep problems, and physical problems (pain and illness).
Troubling behaviors—those that increase the danger of a client’s situation, such as withdrawing from activities and other people, engaging in substance abuse or disordered eating, acting impulsively or compulsively, and harming oneself or others.
Desperation—which encompasses many of the most urgent indicators for concern, such as hopelessness, an intense desire for relief, an intent to die, a plan for making a suicide attempt, a history of making one or more attempts, or making preparations for a future attempt.
To get a deeper sense of whether clients are in imminent danger of making a suicide attempt, you must obtain a clear view not only of the likelihood that they’ll act on their desperation, but also of their resources for making it through the crisis. To this end, you’ll want to explore intra- and interpersonal sources of resilience, protective beliefs, exceptions to problems, past successes, current skills, and effective strategies for dealing with stressors. For example, I once saw a former college football player whose game-hardened ability to keep moving forward, regardless of injuries and pain, served as a source of resilience when he felt like succumbing to suicidal thoughts. Also, some of my deeply religious clients have been protected by their faith’s prohibitions against suicide. I can almost always find some degree of variation in my clients’ desperation. If there are times when they feel more overwhelmed and depressed, that means there are times when they feel less so.
However, when you make note of your clients’ resources, take care not to appear overly impressed by their resilience or the support that’s available to them. To them, life is hopeless, so straightforward optimism on your part will likely be slapped away as irritating naivety. Instead, it’s helpful to adopt a casual manner when making resource-based inquiries and noting any positive discoveries. For example, you could say to my client who’d played football, “So when you were playing college ball, you didn’t let the pain slow you down? Have you always had that kind of strength and determination, or was it something you learned? How’s that coming into play these days?”
Some clinicians routinely use boilerplate no-harm or no-suicide contracts, hoping to secure a troubled client’s commitment to live and lessen their own legal exposure if the client were to end up completing suicide. Research has shown, however, that signing such contracts doesn’t afford the client any added protection; and when sued, clinicians who use contracts don’t fare any better in the courtroom.
Instead of no-harm or no-suicide contracts, I prefer working with clients to construct a uniquely relevant safety plan, a resource-based to-do list that identifies protective steps the client and his or her significant others are willing and able to undertake.
In developing the safety plan together, first decide how the client and significant others can restrict access to all possible means for attempting suicide. You can also explore reasonable alternatives to troubling behaviors for coping with distress and identify safe havens the client could access for a limited time if necessary. Write down the contact information for anyone who could offer a safe haven or other forms of support.
I once consulted on a case involving a young suicidal woman, Michelle, who had persistent thoughts of jumping off the balcony of her 11th-story apartment. Although her parents weren’t available to help, Michelle said she had a good friend, Vanessa, who lived on the ground floor of the same building. I arranged for Vanessa to come into our session, and the three of us worked out details of a safety plan. We decided that whenever the thoughts of jumping ramped up, Michelle would first go to her walk-in closet, which she considered a safe haven. Once there, she’d meditate and, if necessary, call the numbers of family, friends, and professional resources that we wrote down. If these measures didn’t feel safe enough, she’d take the elevator down to Vanessa’s, and—with the key that Vanessa said she’d give her once they got home—let herself in. Michelle didn’t consider or worry about any other methods of dying, so the measures necessary for keeping her relatively safe were fairly straightforward.
A safety plan is designed as a temporary measure to get suicidal clients through distressing times, so you need to make sure the plan is reasonable and doable. A plan that’s too elaborate or demanding isn’t safe. In addition to significant others, you and the client should consider enlisting his or her work supervisors or school administrators to alter the client’s schedule, reduce his or her workload, or grant a leave of absence. Also, determine whether the client would consider initiating, resuming, or continuing relevant therapy or treatment. In addition to generating a list of personal and professional contacts the client could call if necessary, identify emergency contacts such as crisis lines and nearby hospitals. Once the safety plan is complete, make a copy for your file and give the original to the client.
If the client appears to be at imminent risk of making a suicide attempt and a safety plan doesn’t seem feasible or sufficient to keep him or her safe, then you’ll need to arrange transportation to a psychiatric receiving facility for evaluation and possible involuntary admission. But never make this choice simply to be on the safe side. Sending someone to the hospital who’s depressed but not suicidal, for example, may alleviate your immediate anxiety, but it may cause the client to avoid seeking out mental health treatment in the future.
Arrive at your safety decision by piecing together all the information you gather throughout the assessment: what the client tells you, what you empathically glean, and what you know from the professional literature about risks and resources. Whenever possible, consult with a colleague or supervisor, so you can compare your perspectives.
Once you make a decision, give yourself the opportunity to take a second look at it, along with the data informing it. If, upon considering everything a second time, you come to the same conclusion, then you can proceed with added confidence. If you end up with second thoughts, listen to your doubts and use them to prompt further information gathering.
It isn’t unusual for me during an assessment to change my mind several times about whether a safety plan can be a viable option for keeping a client alive. Much of what Michelle told me—about her depression, thoughts about jumping, absence of family—pointed to hospitalization as the best choice for keeping her safe. But glimmers of hope kept appearing, so I kept asking questions, and together we finally determined that she had the necessary resources to stay safe—and we were right. She told me much later, when the crisis had passed, that she’d pinned up her safety plan inside her walk-in closet and would go in there and read it as a source of reassurance and inspiration.
Ultimately, suicide assessments are inherently anxiety-provoking and emotionally taxing, even when they go well and the client can safely negotiate harrowing desires, thoughts, and circumstances. Following an assessment, it helps to secure time with colleagues to talk through how the client presented, what you were able to discover, what you decided, how the client responded to the process as a whole, and what you were experiencing throughout the process. Taking care of yourself in this way will help you feel better prepared the next time.
Douglas Flemons, PhD, is Professor of Family Therapy and Clinical Professor of Family Medicine at Nova Southeastern University. He’s coauthor of Relational Suicide Assessment, author of Of One Mind, and coeditor of Quickies: The Handbook of Brief Sex Therapy. He offers workshops on suicide assessment, hypnosis, and brief therapy. Contact: email@example.com.
Tell us what you think about this article by email at firstname.lastname@example.org.