Suicide Risk Assessment Notes
Overview
Authors: John Sommers-Flanagan (University of Montana), Sidney L. Shaw (Walden University)
Context: The United States has experienced alarming increases in suicide rates, prompting a critical need for enhanced suicide risk screening and assessment protocols across healthcare settings. This trend highlights deficiencies in traditional approaches and underscores the urgency for more effective, evidence-based methods.
Objective: This work aims to critically discuss the inherent limitations of the traditional medical model in suicide assessment and to thoroughly review modern methodological, theoretical, and clinical advancements. The goal is to inform practitioners about a more comprehensive, patient-centered approach to identifying and managing suicide risk.
Current Issues in Suicide Rates
Data Trends:
Rates of suicide have increased significantly between 2000-2014 indicating a concerning public health crisis. (CDC, 2016)
In 2000: per individuals.
In 2014: per individuals.
This is a 27.6% increase over 15 years
Affects various demographics highlighting a systemic challenge in mental healthcare and public health.
Policy and Professional Response:
Legislative Response
Washington state law mandated continuing education for all healthcare providers involved in patient care
Surgeon General Update
The Surgeon General updated National Strategy for Suicide Prevention
Emphasizes all healthcare providers role in prevention by enforcing improved screenings, intervention, and postvention strategies
Importance of Suicide Assessment for Psychologists
Suicide assessment is extremely prevalent across various domains
Clinics and Private Practices: Where individuals seek mental health support.
Hospitals and Emergency Departments: For immediate crisis intervention and risk stratification.
Residential Treatment Centers: Providing intensive, structured care for at-risk populations.
Correctional Facilities: Addressing mental health needs within the justice system.
Schools and Universities: Supporting young populations.
Training in suicide risk assessment and management can be inconsistent across graduate training programs in psychology
Varied levels of competency among professional practitioners.
Inconsistency in training can result in missed opportunities for intervention and potentially inadequate care.
Key Shifts in Suicide Risk Assessment
Shifts redefining the Suicide Risk Assessment & Intervention Approach
1. Suicide Risk Factors
Historical Focus/Aim
We used to recognize diagnosis & history of attempts as primary risk factors
These are proven to be poor predictors of individual suicide outcomes
Current Aim to Focus On
A. Dynamic, modifiable factors
B. More nuanced understanding of an individual's current state
C. Protective factors
2. Model Transition
Historical Focus/Aim
Used to purely use medical models to assess risk
These models often pathologize suicidal ideation
Current Aim to Focus On:
Use collaborative, patient-centered social constructionist approaches.
This new model views suicidal ideation as a complex distress signal rather than solely a symptom of mental illness.
3. Theoretical Advances
Historical Significant improvements in theoretical understanding of suicidal behavior and individuals, moving beyond simplistic views to comprehensive frameworks that integrate psychological, social, and biological factors (e.g., Joiner's Interpersonal Theory of Suicide, Shneidman's Mentalistic Theory).
Clinical Encounters: Enhanced emphasis on the quality and nature of therapeutic relationships through comprehensive suicide assessment interviews. This involves fostering trust, empathy, and open dialogue to create a safe space for disclosure.
Advanced Questioning Techniques: Development of improved and more sensitive methods for clinicians to inquire about suicidal ideation, plans, and intent. These techniques are designed to normalize the conversation and reduce patient reluctance to disclose.
Long-Term Monitoring: Development and implementation of enhanced strategies for ongoing monitoring and follow-up of suicide ideation and risk over time, recognizing that risk can fluctuate and requires continuous assessment and support.
Limitations of Traditional Suicide Risk Factors
Overreliance on static status or demographic variables (e.g., specific psychiatric diagnoses, previous suicide attempts, gender, age) is largely ineffective for predicting individual suicide events. These factors yield very low probabilities of actual suicides, making them unreliable for clinical decision-making within individual cases. The challenge lies in their poor positive predictive value.
Example: While patients with Major Depressive Disorder (MDD) have a statistically higher risk of suicide compared to the general population, this increased risk translates minimally when considering individual predictions. For instance, the general population suicide rate of per might increase to approximately per for individuals with MDD. Although this is a significant relative increase, the absolute risk for any given individual with MDD remains very low (, or less than half of one percent) meaning the vast majority will not die by suicide.
Empirical Conclusion: Broad high and low-risk categorizations based on traditional factors are not clinically useful nor adequately informative for guiding tailored treatment or intervention strategies at the individual patient level. They do not effectively differentiate who will or will not make an attempt.
Moving Away from the Medical Model
Historical Perspective: Historically, suicide ideation was often viewed primarily as a profound psychological deviance or symptom of severe mental illness. This led to a medicalized approach often characterized by coercive and paternalistic medical evaluations and interventions, focusing on diagnosis and containment rather than understanding.
Psychological Reactance: Patients may actively resist treatment approaches viewed as judgmental, dismissive of their pain, or overtly coercive. This can lead to psychological reactance, defined as an increased motivation to restore perceived freedom when it is threatened. In the context of suicide assessment, this might manifest as non-disclosure of ideation, refusal to engage in safety planning, or disengagement from therapy.
New Approaches: Modern, collaborative models prioritize the patient's lived experience and subjective distress over a rigid, diagnose-driven mechanical evaluation. These approaches foster a supportive and empowering dynamic, underpinned by open, non-judgmental communication about suicidal ideation as a complex signal of profound distress, rather than merely a pathological symptom.
Progress in Theoretical Understanding
Shneidman’s Mentalistic Theory (Principally, The Psychache Theory): This foundational theory posits that the primary cause of suicide is psychache, defined as unbearable psychological pain or anguish originating from frustrated psychological needs. Key concepts include:
Psychological Pain (Psychache): The core emotional suffering that drives suicidal behavior, often seen as an overwhelming sense of distress, hopelessness, and helplessness.
Perturbation: The state of feeling disturbed, agitated, or emotionally upset. High perturbation often correlates with an increased likelihood of suicidal acts.
Press: The internal and external life events or circumstances that exert pressure on an individual, contributing to their distress and psychache.
Egression: The act of escaping or leaving a situation, which in the context of suicide, refers to the perception that suicide is the only viable option to escape unbearable pain.
Shneidman emphasized that suicide is less about a wish to die and more about a desire to escape intolerable internal pain.
Other Theoretical Advances: Subsequent theories have expanded upon this, such as Thomas Joiner's Interpersonal Theory of Suicide, which proposes that suicide results from the simultaneous presence of thwarted belongingness, perceived burdensomeness, and the acquired capability for suicide.