Differential Activation Theory
Differential activation theory suggests that when previously depressed and suicidal individuals experience a negative mood, they are likely to have their negative information processing biases reactivated. The original theory:
. . . stated that during a person’s learning history—and particularly during episodes of depression—low mood becomes associated with patterns of negative information processing (biases in memory, interpretations, and attitudes). Any return of the mood reactivates the pattern, and if the content of what is reactivated is global, negative, and self-referent (e.g., “I am a failure; worthless and unlovable.”), then relapse and recurrence of depression is highly likely. (Lau, Segal, & Williams, 2004, p. 422)
This theory and supporting empirical research indicates that during the course of a clinical interview, certain questioning procedures may move a previously depressed client toward a more negative mood state with an accompanying increase in negative information processing and suicide ideation. In fact, there are many studies indicating that both depressed and non-depressed clients and non-clients can be quickly and powerfully affected by mood inductions (Lau et al., 2004; Mosak, 2000; Teasdale & Dent, 1987).
For example, in a recent study, participants were divided into three groups: (a) those previously depressed with suicide ideation; (b) those previously depressed without suicide ideation; and (c) those with no history of previous depression (Lau et al., 2004). Following a mood challenge in which participants spent eight minutes listening to a depressive Russian opera at ½ speed while reading 40 negative statements such as, “There are things about me that I do not like,” participants generally experienced a worsening of mood and performed more poorly on a cognitive problem-solving test than prior to the mood challenge. Additionally, the participant group with a history of depression and suicide ideation exhibited significantly greater impairment in problem solving than the comparison groups. The authors concluded: “. . . when mood has returned to normal, cognitive variables may return to normal, but those who have been depressed and suicidal in the past are vulnerable to react differentially to changes in mood—with greater deterioration in problem-solving ability” (p. 428). This deterioration in problem solving is consistent with Edwin Shneidman’s concept of mental constriction, which we address later in this chapter.
Overall, the research clearly indicates that all individuals, depressed or not and suicidal or not, can have their mood quickly and adversely affected through rather simple experimental means. Additionally, it appears that previously depressed individuals may experience differential activation and therefore also have increases in negative cognitive biases about the self, others, and the future. Further, it appears that previously suicidal individuals may be particularly vulnerable to having their problem-solving abilities adversely affected when they experience a negative mood state.
Depressogenic Social, Cultural, and Interview Factors
In addition to the preceding research findings, there are a number of contemporary social and cultural factors that may predispose or orient individuals toward depressive and suicidal states. More than ever the United States media is involved in defining depressive states and promoting medical explanations for depression and suicidality. There are many books, magazine articles, and Internet sites encouraging individuals to examine themselves to determine if they might be suffering from depression, bipolar disorder, an anxiety disorder, AD/HD or other mental disorders. In particular, pharmaceutical advertisings encourage individuals to consult with their doctor to determine whether they might benefit from a medication designed to treat their emotional and behavioral symptoms. Unfortunately, as most of us know from personal experience and common sense, it is very easy to move into a negative mood in response to suggestions of personal defectiveness (which, over time, certainly may be as potent as eight minutes of a slow Russian opera). Consequently, it would not be surprising to find that continually rising depression rates and accompanying pharmaceutical treatments are, in part, related to increased awareness of depressive conditions.
Even more relevant to the suicide assessment interviewing process, it may be that interviewers who focus predominantly or exclusively on the presence or absence of negative mood states inadvertently increase such states. This possibility is consistent with constructive theory in that whatever we consciously focus on, be it relaxation or anxiety or depression or happiness, tends to grow. It is also consistent with anecdotal data from our students who report feeling surprisingly down and depressed after conducting and role-playing suicide assessment interviews.
Our concern is that traditional medically oriented depression and suicide assessment interviewing may sometimes inadvertently contribute to, rather than alleviate, underlying depressive cognitive and emotional processes. Consequently, in the following sections on suicide assessment interviewing, we guide you toward balancing negatively oriented depression and suicidality questions with an equal or greater number of questions and prompts designed to increase the focus on more positive client experiences and emotional states. This serves two functions. First, including positive questions and prompts may help clients focus on positive experiences and therefore improve their current mood state and problem-solving skills. Second, if clients are unable to focus on positive personal experiences or display positive affect, it may indicate a more chronic or severe depressive and suicidal condition. Overall, our primary message is that we should always pay close attention to the manner in which we use words, questions, and language when conducting depression and suicide assessment interviews.
Adopting a New Client and Suicide-Friendly Interviewer Attitude
Consistent with the CAMS approach as well as other more recent treatment perspectives (Action and Commitment Therapy (ACT); and Dialectal Behavior Therapy (DBT); we want to encourage you to adopt a fresh new attitude toward clients who may present with depressive and suicidal symptoms. Specifically, consider these attitudinal statements:
Depression and suicidality are natural conditions that arise, in part, from normal human suffering. Consequently, just because a client arrives in your office with depressive symptoms and suicidal features, this does not necessarily indicate deviance—or even a mental disorder.
Given that depressive and suicidal symptoms are natural and normal, it is acceptable for you, as an interviewer, to validate and normalize these feelings if they arise. This is especially important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they are a burden to others (Joiner, 2005). There is no danger in accepting and validating client emotions—even self-destructive emotions.
In the spirit of the CAMS approach, we encourage you to listen to your clients’ suicidal thoughts and impulses nonjudgmentally; these thoughts and impulses represent your clients’ unique efforts to cope with their interpersonal and life problems.
Rather than continually drilling down into your clients’ depressive and suicidal symptoms, be sure to balance your clinical interview with questions that focus on the positive and your clients’ unique reasons for living. Forgetting to ask your client about positive experiences is like forgetting to go outside and breathe fresh air.
Fortunately, most people who experience depression recover, with or without treatment. Additionally, most people at least briefly consider suicide as an alternative to life, and of those who seriously contemplate—or even attempt—suicide, most end up choosing life instead of suicide.
A note of caution is in order. People often hesitate to ask directly about suicidal ideation out of a fear that they will somehow cause a sad person to suddenly think of suicide as an option. Asking about suicidal thoughts or impulses is not the same as dwelling on negative and depressing thoughts and feelings. Balancing the focus between negative and more positive, solution-focused material can be both wise and helpful. Failing to ask about suicide is neither.
Suicide Interviewing Assessment Documentation
The following materials are brief adaptations from: J. Sommers-Flanagan & Sommers-Flanagan (2009), Clinical Interviewing (John Wiley & Sons), Chapter 9: Suicide Assessment. Full citations for the references listed below are available in the text.
Professional interviewers should always document contact with clients (Shea, 2004; Wiger, 2005). It is especially important when working with suicidal clients to document the rationale underlying your clinical decisions. For example, if you are working with a severely or extremely suicidal client and decide against hospitalization, you should outline in writing exactly why you made that decision. You might be justified choosing not to hospitalize your client if a suicide-prevention or safety agreement has been established and your client has good social support resources (e.g., family or employment).
When you work with suicidal clients, keep documentation to show you:
1. Conducted a thorough suicide risk assessment.
2. Obtained adequate historical information.
3. Obtained records regarding previous treatment.
4. Asked directly about suicidal thoughts and impulses.
5. Consulted with one or more professionals.
6. Discussed limits of confidentiality.
7. Implemented suicide interventions.
8. Developed a collaborative treatment plan.
9. Gave safety resources (e.g., telephone numbers) to the client.
Remember, the legal bottom line with regard to documentation is that if an event was not documented, it did not happen (see also, Putting It in Practice 9.2, from the Clinical Interviewing text).
Using a Comprehensive Suicide Risk Factor Checklist for a Thorough Suicide Assessment
For graduate students and practicing clinicians, having knowledge of suicide risk factors is very important, but a bit of a paradox. This is because suicide is such a low base-rate phenomenon that it’s impossible to predict suicide attempts or completions—even if you were to have perfect knowledge of every potential risk factor. Similarly, if you know someone is in a very low risk population (e.g., adult African American women), that doesn’t mean you shouldn’t or wouldn’t conduct a suicide assessment interview.
Although suicide risk factors (as well as protective factors) are no guarantee of anything, they do provide clinicians with useful information. However, rather than relying on risk factors alone to try to predict suicide (which is always a losing proposition), the effective clinical interviewer establishes rapport, works collaboratively with clients, and uses risk factors in combination with a thorough suicide risk interview. Additionally, during this interview the clinician should be sure to move beyond the medical model, also evaluating for strengths and protective factors. Finally, although establishing a suicide prevention agreement can help reassure us that the client is committed to life, these agreements or contracts have little empirical evidence supporting their effectiveness and if completed in a cursory manner, can even cause clients to feel more negative about the treatment alliance than they would otherwise. When agreements are used they should be done so in a way that communicates compassion and collaboration so clients feel clinicians are working with them to address their distress and isolation.
All that being said, here’s a list of adult suicide risk factors. I’ve got 25 factors and a few sub-factors on this list. I don’t want to claim that it’s a perfectly complete list, but it includes some pretty good information.
General Suicide Assessment Risk Factor Checklist
- The client is in a vulnerable group because of age/sex characteristics.
- The client has made a previous suicide attempt.
- The client is using alcohol/drugs excessively or abusively.
- The client meets DSM-IV or ICD-10 diagnostic criteria for a specific mental disorder (clinical depression, bipolar disorder, schizophrenia, substance abuse or dependence, substance – induced disorders, borderline personality disorder, antisocial personality disorder, anorexia).
- The client is unemployed.
- The client is unmarried, alone, or isolated.
- The client is experiencing physical health problems.
- The client recently experienced a significant personal loss (of ability, objects, or persons; e.g., a romantic break-up).
- The client is a youth and is struggling with sexuality issues.
- The client was a victim of childhood sexual abuse or is a current physical or sexual abuse victim.
- If depressed, the client also is experiencing one or more of the following symptoms:
- Panic attacks
- General psychic anxiety
- Lack of interest or pleasure in usually pleasurable activities
- Alcohol abuse increase during depressive episodes
- Diminished concentration
- Global insomnia
- The client reports significant hopelessness, helplessness, or excessive guilt.
- The client reports presence of suicidal thoughts. Note in your evaluation:
- Frequency of thoughts (How often do these thoughts occur?)
- Duration of thoughts (Once they begin, how long do the thoughts persist?)
- Intensity of thoughts (On a scale of 0 to 10, how compelling are the thoughts?)
- The client reports a specific plan.
- The client reports a lethal or highly lethal plan.
- The client reports availability of the means to carry out the suicide plan.
- The client does not have social support nearby.
- The client reports little self-control.
- The client has a history of impulsive behavior.
- The client reports suicide ideation and a plan and has a history of overcontrolled behavior or presents as emotionally constricted or displays psychomotor agitation.
- The client reports a moderate to high intent to kill self (or has made a previous lethal attempt).
- The client was recently discharged from a psychiatric facility after apparent improvement.
- The client was recently prescribed an SSRI and has associated disinhibition or agitation.
- The client has access to firearms.