7.2 SUICIDE RISK

SUICIDE RISK

SUICIDE RISK nine steps

• risk factors

• suicidal ideation

• how concrete & specific

• hopelessness & plans for the future

• ideas & feelings of guilt

• real & perceived social support

• values, beliefs & protective factors

• questionnaires & standardised scales

• assessment of the level of risk & decision making

Risk factors increase concern, but

• they do not predict what a person will do

• they tell you where to look

if suicidal ideation present

• ask directly

• the C-SSRS provides a simple structure

• asking directly does not put the idea into someones head → it makes suicidal thinking easier to identify

How concrete & specific is it?

• If suicidal ideation is present assess method, plan, intent & preparation

• thoughts alone, thoughts with intent & a specific plan with access & preparation represent very different levels of concerns

Hopelessness & plans for the future → what to do

• explore whether the person sees any possibility of change

• hopelessness can increase risk, but do not reinforce it by agreeing that the situation is hopeless.

Ideas & feelings of guilt → what to explore

• explore guilt & perceived burdensomeness

• listen for the meaning behind the guilt, rather than trying to reassure the person immediately

Real & perceived social support → what to do

• assess both who is available & whether the person feels able to use that support

• a support network is protective only if the person can actually access it when they need it

Values, beliefs & protective factors → what to explore

• explore what keeps the person connected to life

• protective factors are not

Questionnaires & standardised scales → what to do

• Standardised measures complement the interview; they do not replace it

• a score does not determine risk → it tells you where to explore further

Suicidal ideation & behaviour → scales

• C-SSRS → suicidal ideation & suicidal behaviour

• Suicidal Intent Scale (SIS) → suicidal intent

Associated factors → scales

• Beck Hopelessness Scale (BHS) → hopelessness

• Beck Depression Inventory (BDI) → depressive symptoms

• Reasons for Living Inventory → protective beliefs & reasons for living

Assess the level of risk & decide what to do → consider

• acute risk

• vulnerability

• protective factors

acute risk

• Current suicidal ideation

• Intent

• Specific plan

• Access to means

• Preparation

• Recent suicidal behaviour

• Increasing intensity or frequency

Vulnerability

• Previous attempts

• Mental or physical illness

• Substance use

• Trauma or significant losses

• Isolation

Protective factors

• Relationships & support

• Reasons for living

• Future goals

• Values & responsibilities

• Willingness to accept help

How imminent is the risk?

• What needs to happen now to keep this person safe?

  • if risk is acute

  • if risk is not acute

• risk assessment is not about predicting the future with certainty → it is about identifying what is happening now & deciding what needs to happen next

If risk is acute

• do not leave the person alone

• follow the service's emergency protocol

• involve appropriate support

• reduce access to lethal means

• document the assessment & decision-making.

If risk is not acute

• agree on the next steps

• strengthen protective factors & support,

• consider developing a safety plan with the person

you own emotions → What are you going to feel

1. Fear of making it worse

2. Fear of being responsible

3. The urge to fix it

4. Wanting it to end

5. And afterwards: rumination

Fear of making it worse

• Of asking about suicide & planting the idea.

• Of naming violence & precipitating something.

Fear of being responsible

•  For a decision that is not yours to make, & for an outcome you cannot control.

The urge to fix it.

• To tell her to leave

• To make him promise.

• To fill the silence after bad news with a plan.

Wanting it to end

• The relief when the hour is up, & the guilt that follows the relief

And afterwards: rumination

•  Going over what you said, at night, for days.

all five are

• ordinary & information

• none of them is evidence that you have chosen the wrong profession

What to do with these emotions

• Self-knowledge

• Self-regulation, in the session.

 Self-knowledge connected with the

• four horsemen:

  • anxiety

  • urgency

  • pessimism

  • excess of responsibility

Self-regulation, in the session

• A pause before you respond.

• "Give me a moment to think about what you've told me."

• Your own breathing.

• Calmness is contagious and so is urgency

afterwards

• Talk to someone the same day. Not to be reassured → to be heard.

• Supervision, & a team

• Know your limits & say it before you reach out

Vital experience

• Your own history is in the room with you.

→ If something here is yours, that is not a reason to leave the profession —it is a reason to know it, & to have somewhere to take it.

A therapist who is frightened

• A therapist who is frightened & knows it is safe

• A therapist who is frightened & does not know it will either avoid the question or rush the answer