Tomorrow, I’ll be online again with PacificSource, doing Part 2 of a three-part webinar series titled, “Caring for People Who are Suicidal.” Last week we focused on how to talk with people in general about this challenging topic. This week, the focus is on: “Blending Traditional and Strengths-Based Approaches to Suicide Assessment“
I’ll be talking for about an hour, which means we’ll really only quickly graze the topic. Below, for webinar viewers and other interested readers, I’ve posted the ppts, and excerpted the section in our Clinical Interviewing text that focuses on assessing suicide plans, patient impulsivity, suicidal intent, and a bit of information on talking with patients about previous attempts.
The ppts:
The excerpt follows . . .
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Assessing Suicide Plans
Once rapport is established and the client has talked about suicidal ideation, it’s appropriate to explore suicide plans. You can begin with a paraphrase and a question:
You said sometimes you think it would be better for everyone if you were dead. Some people who have similar thoughts also have a suicide plan. Do you have a plan for how you would kill yourself if you decided to follow through on your thoughts?”
Many clients respond to questions about suicide plans with reassurance that they’re not really thinking about acting on their suicidal thoughts; they may cite religion, fear, children, or other reasons for staying alive. Typically, clients say something like “Oh, yeah, I think about suicide sometimes, but I’d never do it. I don’t have a plan.” Of course, sometimes clients will deny having a plan even when they do. However, if clients admit to a plan, further exploration is crucial.
When exploring and evaluating a client’s suicide plan, assess four areas (M. Miller, 1985): (a) specificity of the plan; (b) lethality of the method; (c) availability of the proposed method; and (d) proximity of social or helping resources. These four areas of inquiry are easily recalled with the acronym SLAP.
Specificity
Specificity refers to the details. Has the person thought through details necessary to die by suicide? Some clients describe a clear suicide method, others avoid the question, and still others say something like “Oh, I think it would be easier if I were dead, but I don’t have a plan.”
If your client denies a suicide plan, you have two choices. First, if you believe your client is being honest, you can drop the topic. Alternatively, if you suspect your client has a plan but is reluctant to speak about it, you can use the normalizing frame discussed previously.
You know, most people who have thought about suicide have at least had passing thoughts about how they might do it. What kinds of thoughts have you had about how you would [die by suicide] if you decided to do so? (Wollersheim, 1974, p. 223)
Lethality
Lethality refers to how quickly a suicide plan could result in death. Greater lethality confers greater risk. If you believe your client is a very high suicide risk, you might inquire not simply about your client’s general method (e.g., firearms, toxic overdose, or razor blade), but also about the way the method will be employed. Does your client plan to use aspirin or cyanide? Is the plan to slash their wrists or throat with a razor blade? In both of these examples, the latter alternative is more lethal.
Availability
Availability refers to availability of the means. If clients plan to overdose with a particular medication, check on whether that medication is available. (Keep in mind this sobering thought: Most people keep enough substances in their home medicine cabinets to die by suicide.) To overstate the obvious, if the client is considering suicide by driving a car off a cliff and has neither car nor cliff available, the immediate risk is lower than if the person plans to use a firearm and keeps a loaded gun in an unlocked location.
Proximity
Proximity refers to proximity of social support. How nearby are helping resources? Are other individuals available to intervene and provide rescue if an attempt is made? Does the client live with family or roommates? Is the client’s day spent alone or around people? The further a client is from helping resources, the greater the suicide risk.
If you have an ongoing therapy relationship with clients, you should check in periodically regarding plans. One recommendation is for collaborative reassessment at every session until suicide thoughts, plans, and behaviors are absent in three consecutive sessions (Jobes, 2016).
Assessing Client Self-Control
Asking directly about self-control and observing for agitation, arousal, and impulsivity are the main methods for evaluating client self-control.
Asking Directly
If you want to focus on the positive while asking directly about self-control, you can ask something like this:
What helps you stay in control? Or, What stops you from killing yourself?
If you want to explore the less positive side, you could ask:
Do you ever feel worried that you might lose control and make a suicide attempt?
Exploring both sides of self-control (what helps maintaining self-control and what triggers a loss of self-control) can be therapeutic. This is done together with clients to understand their perception of self-control. Rudd (2014) recommended having clients rate their subjective sense of self control using a 1-10 scale (although we prefer 0-10). When clients are feeling or acting “out of control” hospitalization should be considered. Hospitalization can provide external controls and safety until clients feel more internal control.
Here’s an example of a discussion that shows (a) an interviewer focusing on the client’s fear of losing control and (b) an indirect question leading the client to talk about suicide prevention.
Client: I’m afraid of losing control late at night.
Therapist: Sounds like night is the roughest time.
Client: I hate when I’m awake and alone into the night.
Therapist: So, late at night, you’re sometimes afraid you’ll lose control and kill yourself. What has helped keep you from doing it.
Client: I think of how my kids would feel when they couldn’t get me to wake up. I can’t even think of that.
A brief verbal exchange, such as this, isn’t a final determination of safety or risk. However, this client’s children are a mitigating factor that may help with self-control.
Observing for Arousal/Agitation
Arousal and agitation are contemporary terms used to describe what Shneidman originally referred to as perturbation. Perturbation is the inner push that drives individuals toward suicidal acts. Arousal and agitation are underlying components of several other risk factors, such as akathisia associated with SSRI medications, psychomotor agitation in bipolar disorder, and command hallucinations in schizophrenia.
Arousal or agitation adversely affect self-control. Unfortunately, systematic methods for evaluating arousal are lacking. This leaves clinicians to rely on five approaches to assessing arousal, agitation, and impulsivity:
- Subjective observation of client increased psychomotor activity (as in an MSE)
- Client self-disclosure of feeling unsettled, unusually overactive, or impulse ridden (often accompanied by statements like, “I need to do something”)
- Questionnaire responses or scale scores indicating agitation
- A history of agitation-related suicide gestures or attempts
- Clients report impulsivity around aggression and/or substance use
Assessing Suicide Intent
Suicide intent is defined as how much an individual wants to die by suicide. Suicide intent can be evaluated via clinical interview (Lindh et al., 2020), standardized questionnaire (e.g., the Beck Suicide Intent Scale, Beck et al., 1974), or after completed suicides. When evaluated after suicide deaths, higher suicide intent is linked to lethality of means, more extensive planning, and a negative reaction to surviving the act.
Assessing suicide intent prior to potential attempts is challenging. In an interview, the question can be placed on a scale and asked directly:
On a scale from 0 to 10, with 0 being you’re absolutely certain you want to die and 10 that you’re absolutely certain you want to live, how would you rate yourself right now?
Suicide intent is also related to suicide planning; that means when you’re evaluating suicide plans, you’re also evaluating suicide intent. More specificity and lethality in planning is linked to intent. Overall, standardized questionnaires and clinical interviews are equivalent in their predictive accuracy (Lindh et al., 2020).
Obtaining detailed information about previous attempts is important from a medical-diagnostic-predictive perspective, but less important from a constructive perspective, where the focus is on the present and future. Whether to explore past attempts or to stay focused on the positive is a dialectical problem in suicide assessment protocols. On the one hand, suicide scheduling, rehearsal, experimental action, and preoccupation indicate greater risk and, therefore, are valuable information (Rudd, 2014). On the other hand, to some extent, detailed questioning about intent, plans, and past attempts reinforces client preoccupation with suicide and suicide planning.
Balance and collaboration are recommended. As you inquire about intent, continue to integrate positively oriented questions into your protocol:
- How do you distract yourself from your thoughts about suicide?
- As you think about suicide, what other thoughts spontaneously come into your mind that make you want to live?
- Now that we’ve talked about your plan for suicide, can we talk about a plan for life?
- What strengths or inner resources do you tap into to fight back those suicidal thoughts?
Eventually you may reach the point where directly asking about and exploring previous attempts is needed.
Exploring Previous Attempts
Previous attempts are considered the strongest of all suicide predictors (Franklin et al., , 2017). Information about previous attempts is usually obtained through the client’s medical-psychological records or an intake form, or while discussing depressive symptoms during a clinical interview (see Case Example 10.2). It’s also possible that you won’t have information about previous attempts, but you decide to ask directly:
Have there been any times when you were so down and hopeless that you tried to kill yourself?
Once you have or obtain information about a previous attempt or attempts, you have a responsibility to acknowledge and explore it, even if only via a solution-focused question.
You’ve tried suicide before, but you’re here with me now . . . What has helped?
If you’re working with a client who’s severely depressed, it’s not unusual for your solution-focused question to elicit a response like this:
Nothing helped. Nothing ever helps.
One error clinicians often make at this point is to venture into a yes-no questioning process about what might help or what might have helped in the past. If you’re working with someone who is extremely depressed and experiencing the problem-solving deficit of mental constriction, your client will respond in the negative and insist that nothing ever has helped and that nothing ever will help. Encountering a negative response set requires a different assessment approach. Even severely depressed clients can, if given the opportunity, acknowledge that every attempt to address depression and suicidality isn’t equally bad. Using a continuum where severely depressed and mentally constricted clients can rank intervention strategies (instead of a series of yes-no questions) is a better approach:
Therapist: It sounds like you’ve tried many different things to help you through your depressed feelings and suicidal thoughts. Of all the things you’ve tried and all the ideas that professionals like me have recommended, which one has been the worst?
Client: The meds were the worst. They made me feel like I was already dead inside.
Therapist: Okay. Let’s put meds down as the worst option you’ve experienced so far. So, which one was a little less bad than the meds?
Instead of asking the client “What worked best?” and getting a bleak depressive response, the therapist asked which therapeutic recommendation had been “the worst?” Focusing on what’s worst resonates with the negative emotional state of depressed clients. Identifying the most worthless of all therapeutic strategies is more likely to produce a response and you can build from there to strategies that are “a little less bad.” Later in the interview process, you can add new ideas that you suggest or that the client suggests and put them in their appropriate place on the continuum. When this strategy works, it produces a list of ideas (some new and some old) for potential homework and experimentation (see also Sommers-Flanagan & Sommers-Flanagan, 2021).
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As I read through the preceding excerpt, I realize there’s so much more that could be covered. For more info, we also have our strengths-based suicide assessment book, which you can find online through different booksellers. Just search for our name and strengths-based suicide assessment to find a plethora of resources, many of which are free.
John Sommers-Flanagan 