Anybody wondering what’s new in suicide assessment and treatment?
If so, come listen to any or all of a very nice suicide prevention/intervention line-up on November 7 and 8 on the campus of Montana State University in Billings. Here’s a news link with detailed info: https://billingsgazette.com/news/local/let-s-talk-montana-suicide-prevention-workshops-coming-to-msub/article_9a6f04ff-376f-56b8-a6a8-9a0160ba1cbb.html
For my part, I’m presenting the latest iteration of the suicide assessment and treatment model Rita and I have been working on for the past couple years. To help make suicide assessment and treatment planning easier, we’ve started using six common sense life domains to organize, understand, and apply specific assessment and intervention tools.
Another unique component of our model is an emphasis on client strengths and wellness. Obviously, in the context of suicide, it’s impossible (and wrong) to ignore clients’ emotional pain and suffering. However, we also think it’s possible (and right) to intermittently recognize, nurture, and focus on clients’ strengths, well-being, and goals.
What follows is a sneak peek at what I’ll be covering on Friday, November 8.
Suicide Interventions and Treatment Planning: Foundational Principles
Two essential principles that cut across all modern evidence-based protocols and evidence-based interventions form the foundation of all contemporary suicide assessment and treatment models:
- Collaboration – Working in partnership with clients
- Compassion – Emotional attunement without judgment
Collaborative practitioners work with clients, not on clients. Clients experiencing suicidal thoughts and impulses typically know their struggles from the inside out. Their self-knowledge makes them an invaluable resource. Carl Rogers (1961) put it this way,
It is the client who knows what hurts, what directions to go, what problems are crucial, what experiences have been deeply buried. It began to occur to me that unless I had a need to demonstrate my own cleverness and learning, I would do better to rely upon the client for the direction of movement in the process. (p. 11)
Compassionate practitioners resonate with client emotions and engage in respectful and gentle emotional exploration. Although compassion involves an empathic emotional response, it also includes tuning into and respecting client cognitions, beliefs, and experiences. For example, some clients who are suicidal feel spiritually or culturally bereft or disconnected. Regardless of their own beliefs and cultural values, compassionate counselors show empathy for their clients’ particular spiritual or cultural distress.
Clients who are or who become suicidal are often observant, sensitive, and intelligent. If they feel you’re judging them, they’re likely to experience a relationship rupture (Safran, Muran, & Eubanks-Carter, 2011). When ruptures occur, clients typically become less open, less engaged, and less honest about their suicidal thoughts and impulses. They also may become angry, aggressive, and critical of your efforts to be of help. In both cases, relational ruptures signal a need to work on mending the therapeutic relationship.
[For a helpful meta-analysis with recommendations on repairing ruptures, check out this article from the Safran lab: http://www.safranlab.net/uploads/7/6/4/6/7646935/repairing_alliance_ruptures._psychotherapy_2011.pdf%5D
The Six Life Domains
Working with clients who are suicidal can be overwhelming. To help organize and streamline the assessment and treatment planning process, it’s helpful to consider six distinct, but overlapping life domains. These domains provide a holistic description of human functioning. When clients experience suicidal thoughts and impulses, you can be sure the suicidal state will manifest through one or more of these six domains (i.e., emotions, cognitions, interpersonal, physical, spiritual/cultural, and behavioral; see below for a brief description of the six domains). All case examples and content in the workshop use these six domains to focus and organize client problems, goals/strengths, and interventions.
Suicidality as Manifest through Six Life Domains
| The Emotional Domain. A driving force in the suicidal state is excruciating emotional distress. Shneidman called this “psychache” and toward the end of his career concluded: “Suicide is caused by psychache” (1993, p. 53). Extreme distress is experienced subjectively. This is one reason there are so many different suicide risk factors. When a specific experience triggers excruciating distress for a given individual (e.g., unemployment, insomnia, etc.), it may increase suicide risk. Reducing emotional distress and facilitating positive emotional experiences is usually goal #1 in your treatment plan. Treatment plans often target general distress as well as specific and problematic emotions like (a) sadness, (b) shame, (c) fear/anxiety, and (d) guilt/regret. |
| The Cognitive Domain. Suicidal distress interferes with cognitive functioning. The resulting constricted thinking impairs problem-solving and creativity. The emotional distress and depressed mood associated with suicidality decreases the ability to think of or value alternatives to suicide. Several other cognitive variables are also linked to suicidality, including hopelessness and self-hatred. Most treatment plans will include collaborative problem-solving, and gentle challenging of maladaptive thoughts. Specific interventions may be employed to support client problem-solving, increase client hopefulness, and decrease client self-hatred. |
| The Interpersonal Domain. Hundreds of studies link social problems to suicidality, suicide attempts, and suicide deaths. Joiner (2005) identified two interpersonal problems that are deeply linked to suicide: thwarted belongingness and perceived burdensomeness. Many risk factors (e.g., recent romantic break-up, family rejection of sexuality, health conditions that cause people to feel like a burden) can exacerbate thwarted belongingness and cause people to perceive themselves as a social burden. Improving interpersonal relationships is often a key part of treatment planning. |
| The Physical/Biogenetic Domain. Physiological factors can contribute to suicide risk. In particular, researchers have recently focused on agitation or physiological arousal; these physical states tend to push individuals toward suicidal action. Additionally, chronic illness or pain, insomnia, and other disturbing health situations (including addictions) contribute to suicide, especially when accompanied by hopelessness. When present, physical conditions and biogenetic predispositions should be integrated into suicide prevention, treatment planning, and risk management. |
| The Spiritual/Cultural Domain. Meaningful life experiences can be a protective influence against suicide. No doubt, a wide range of cultural or religious pressures, spiritual/religious exile, or other factors can decrease an individual’s sense of meaning and can contribute to suicidal thoughts and behaviors. Including spiritual or meaning-focused components in a treatment plan can improve outcomes, especially among clients who hold deep spiritual and cultural values. |
| The Behavioral Domain. All of the preceding life domains can contribute to suicide, but suicide doesn’t occur unless individuals act on suicidal thoughts and impulses. The behavioral domain focuses on suicide intentions and active suicide planning. When clients actively plan or rehearse suicide, they may be doing so to overcome natural fears and aversions to physical pain and death; natural fears and aversions stop many people from suicide. Joiner (2005) and Klonsky and May (2015) have written about how desensitization to physical pain and to ideas of death move people toward suicidal action. Several factors increase risk in this domain and may be relevant to treatment planning, (a) availability of lethal means (especially firearms), (b) using substances for emotional/physical numbing, and (c) repeated suicide rehearsal (e.g., increased cutting behaviors). |
*Note: These domains will always overlap, but they can prove helpful as you collaboratively identify problem areas and goals with your client.
If you’re interested in learning more about this suicide assessment and treatment planning model, I hope to see you in Billings on November 8!
John Sommers-Flanagan 