Suicide Risk Assessment: What Psychologists Should Know
Introduction to Suicide Risk Assessment
Context:
Rise in suicide rates in the U.S. created more need to improve suicide risk assessments
Psychologists must engage in advanced education and training for effective suicide assessment.
The Need for New Approaches
Traditional medical models have limitations in assessing suicide risk.
Modern methods advocate for collaborative and social constructionist approaches.
Six key shifts in suicide assessment practices:
Acknowledgment that suicide risk factors are minimally helpful for practitioners.
Shift from a medical model to collaborative strategies.
Advancement in understanding suicidal behavior theories.
Importance of clinician-patient engagement in assessments.
Innovative methods of querying patients about suicidal thoughts.
Techniques for evaluating suicidal ideation over time.
Trends in U.S. Suicide Rates
Suicide statistics have risen from 10.4 per 100,000 in 2000 to 13.4 per 100,000 in 2014.
This increase, a 27.6% rise over 15 years, has triggered national action for improved mental health responses.
Legislative actions mandate continuing education for healthcare providers in suicide assessment.
Historical Perspective on Suicide Assessment
Psychologists often encounter suicidal patients across various settings: hospitals, residential centers, clinics, and more.
Despite strong training in suicide risk assessment, practitioners may not consistently apply these competencies.
Key Shifts in Mental Health Perspectives
Limitations of Traditional Risk Factors:
Heavy reliance on demographic and diagnostic factors does not effectively predict suicide risk.
Example:
Diagnosis of major depressive disorder (MDD) raises risk to 402 per 100,000, corresponding to approximately 0.00402%.
Descriptive quote from Robert Litman reflecting unpredictability in suicide outcomes.
Males demonstrate higher rates yet it does not necessitate differential treatment from females in crises.
Clinical Approach Recommendations:
Avoid risk categorization and focus on observable needs and preferences.
Establishing a collaborative relationship is crucial.
Open discussions about treatment choices with patients are recommended.
Moving Away from the Medical Model
The medical framework has often pathologized suicidal ideation, treating it as deviance.
This perspective leads to coercive interventions which can provoke psychological reactance.
Psychological Reactance:
A documented response where perceived loss of freedom increases the desire to assert autonomy (Brehm & Brehm, 1981).
If patient feels that they are being judged as deviant, they will exibit less openness and cooperation
Empirical research: Reactance (alternative to resistance)
Patient’s with high reactance appear to benefit more from treatments that are less directive
This finding suggests that psychologists should use less directive strategies with patients who are suicidal and reactive
if they do not, they may contribute to the patient’s “non-compliance”
A Collaborative, Social Constructionist Approach:
Historically, patient-provider model emphasized providers who emphasized diagnostic-based decisions about treatment
Today, the more modern model favors the social-constructivist model. This model believes:
a. suicidal ideation is a naturally developing symptom of distress
b. de-emphasis on diagnosis
collaborative interactions where suicidal thoughts are treated as communications of distress rather than pathologies.
This model allows for more natural authentic conversation to develop between the patient-provider where suicidal ideation is regarded as valuable communication
This can allow patients to feel safe to disclose these thoughts freely so that provider then has opportunitity to collaboratively problem solve
Additional to stimulation of reactance:
patient may become less open if feeling sense that they are being judged as deviant
Nietzsche claimed for some, contemplating suicide is comforting as an alternative to a life of continuing painful misery
Patient’s with Borderline Personality (BPD)
Provider Countertransference:
Mental health professionals' anxieties can lead to less effective treatment when reacting to patients' suicidal ideation (Geltner, 2006).
Establishing an open, less directed relationship encourages genuine communication.
Important take aways
Sometimes when patient feels they are being judged or stigmatized as deviant, they are more likely to become less open with their providers about suicidal ideation or impulses
Therefore psychologists need to cultivate a welcoming, compassionate, less diagnostic, nonjudgemental space
Some patients with Borderline Personality Disorder (BPD) experience distress when their healthcare provider (psychologist) try to get them to stop thinking about suicide
This may happen because patients with BPD use suicide ideation as a Nietzscheian coping strategy that relieves their distress
a Nietzscheian coping strategy is: embracing suffering as a means to foster personal growth and resilience, allowing individuals to find meaning in their struggles rather than defaulting to suicidal thoughts.
Theoretical Progress in Understanding Suicide
Shneidman's Mentalistic Theory:
Introduces concepts of psychache, constriction, and perturbability that contribute to suicidal behavior.
Empirical support exists for the relevance of psychological distress to suicidality.
Joiner's Interpersonal Theory of Suicide:
Identifies thwarted belongingness and perceived burdensomeness as key predictors of severe suicidal behavior.
Acquired Capability:
Individuals must overcome inherent fear of death and develop pain tolerance to commit suicide.
Klonsky and May’s Three-Step Theory (3ST):
Distinguishes three steps from ideation to action including emotional pain, social connectedness, and practical means.
Effective intervention must address these factors to take a holistic view of the individual.
Comprehensive Approach to Suicide Assessments
Clinical Interviewing:
Essential starting point for psychotherapy with a focus on comprehensive suicide risk assessment.
Interview processes must be empowering and patient-focused.
Components of a Comprehensive Interview:
Explore psychological pain, social connections, and hope/hopelessness.
Use clinical tools to ask about suicidal ideation.
Assess the nature of patients' previous suicide plans and attempts.
Examine self-control and agitation characteristics.
Create collaborative safety plans as required.
Effective Questioning Strategies
**Direct Inquiry Techniques:
Lead with a normalizing framework to reduce stigma around suicidal thoughts.
Gentle assumptions can facilitate more open discussions.
Mood Ratings with a Suicide Floor:
Utilize rating scales to help patients articulate their current emotional states while addressing suicidal thoughts directly.
Self-Report Instruments:
Instruments like Beck's Scale for Suicide Ideation and the Columbia Suicide Severity Rating Scale can be used to assist and initiate dialogues about suicidality.
Monitoring Suicide Risk Over Time
Suicide risk assessment is ongoing and may evolve as treatment progresses.
Clinicians must be prepared to modify their interventions based on changing risk levels.
Periodic evaluations should be woven into standard practices for persistent or emerging risks.
Concluding Remarks
Assessing suicide risk can be challenging and evoke stress among psychologists.
Emphasizing collaborative approaches can alleviate some of this stress.
Ongoing education and skill development are critical for achieving competency in suicide assessment.
References
Extensive list of references contributing to the methodologies, theories, and findings related to suicide assessment.