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?Answer:
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.You'll find this full article in the September/October 2013 issue of Psychotherapy Networker magazine; subscribe here.