Tag Archives: suicide risk factors

Individualizing Suicide Risk Factors in the Context of a Clinical Interview

Spring 2020

In response to my recent post on “The Myth of Suicide Risk and Protective Factors” Mark, a clinical supervisor from Edmonton, wrote me and asked about how to make individualizing suicide risk factors with clients more concrete/practical and less abstract. I thought, “What a great question” and will try to answer it here.

Let’s start with two foundational prerequisites. First, clinical providers need to be able to ask about suicide in ways that don’t pathologize the patient/client. Specifically, if clients fear that disclosing suicide ideation will result in them being judged as “crazy” or in involuntary hospitalization, then they’re more likely to keep their suicidal thoughts to themselves. This fear dynamic is one reason why we emphasize using a normalizing frame when asking about suicide.

Second, both before and after suicide ideation disclosures, providers need to explicitly emphasize collaboration. Essentially, the message is: “All we’re doing is working together to better understand and address the distress or pain that underlies your suicidal thoughts.” In other words, the focus isn’t on getting rid of suicidal thoughts; the focus is on reduction of psychological pain or distress.

With these two foundational principles in place, then the provider can collaboratively explore the primary and secondary sources of the client’s psychological pain. In our seven-dimensional model, we recommend exploring emotional, cognitive, interpersonal, physical, cultural-spiritual, behavioral, and contextual sources of pain. Collaborative exploration is fundamental to individualizing risk factors. The general statistics showing that previous attempts, social isolation, physical illness, being male, and other factors predict suicide are mostly useless at that point. Instead, your job as a mental health provider is to pursue the distress. By pursuing the distress, you discover individualized risk factors. The following excerpt from our upcoming book illustrates how asking about “What’s bad” and “What feels worst?” results in individualized risk factors.


     The opening exchange with Sophia is important because it shows how clinicians—even when operating from a strength-based foundation—address emotional distress. In the beginning the counselor drills down into the negative (e.g., “What’s making you feel bad?”), even though the plan is to develop client strengths and resilience. By drilling down into the client’s distress and emotional pain, and then later identifying what helps the client cope, the counselor is individualizing risk and protective factor assessment, rather than using a ubiquitous checklist.

Counselor: Sophia, thanks for meeting. I know you’re not super-excited to be here. I also know your parents said you’ve been talking about suicide off and on for a while, so they wanted me to talk with you. But I don’t know exactly what’s happening in your life. I don’t know how you’re feeling. And I would like to be of help. And so if you’re willing to talk to me, the first thing I’d love to hear would be what’s going on in your life, and what’s making you feel bad or sad or miserable or whatever it is you’re feeling?

The counselor began with an acknowledgement and quick summary of what he knew. This is a basic strategy for working with teens (Sommers-Flanagan & Sommers-Flanagan, 2007), but also can be true when working with adults. If counselors withhold what they know about clients, rapport and relationship development suffers.

The opening phrase “I don’t know. . .” acknowledges the limits of the counselor’s knowledge and offers an invitation for collaboration. Effective clinicians initially and intermittently offer invitations for collaboration to build the working alliance (Parrow, Sommers-Flanagan, Sky Cova, & Lungu, 2019). The underlying message is, “I want to help, but I can’t be helpful all on my own. I need your input so we can work together to address the distress you’re feeling.”

The opening question for Sophia is negative (i.e., What’s making you feel bad or sad or miserable or whatever it is you’re feeling?). This opening shows empathy for the emotional distress that triggers her suicidality and clarifies the link between her emotional distress and the triggering situations. By tuning into negative emotions, the counselor hones in on the presumptive primary treatment goal for all clients who are suicidal—to reduce the perceived intolerable or excruciating emotional distress (Shneidman, 1993).


Collaborative exploration is the method through which risk and protective factors are individualized. If Sophia had a previous attempt, the reason to explore the previous attempt would be to discover what created the emotional distress that provoked the attempt, and how counseling or psychotherapy might address that particular factor. For example, if bullying and lack of social connection triggered Sophia’s attempt, then we would view bullying and social disconnection as Sophia’s particular individualized risk factors. We would then build treatments—in collaboration with Sophia and her family—that directly address the unique factors contributing to her pain, and provide her with palpable therapeutic support.

I hope this post has clarified how to individualize suicide risk factors and use them in treatment. Thanks for the question Mark!

Suicide Risk Factors, Part III

It’s been awhile since I started my holiday and post-holiday look at suicide risk factors. In previous posts I focused on Demographic and Ethnic Factors related to death by suicide and then on the broad category of Mental Disorders and Psychiatric Treatment. This post focuses on Personal and Social Factors that are linked to suicide.

Not to worry, soon I’ll be moving beyond this tragic but important topic.

The following is mostly an excerpt from our Clinical Interviewing text.

Social and Personal Factors

There are a number of social and personal factors linked to increased suicide risk. Many of these factors have been reviewed and integrated into Thomas Joiner’s interpersonal theory of suicide (Joiner & Silva, 2012; Van Orden et al., 2010).

Social Isolation/Loneliness
In a review of the literature, 34 research studies were identified that include support for social isolation as a suicide risk factor (Van Orden et al., 2010). These findings provide support for Joiner’s (Joiner & Silva, 2012) attachment-informed interpersonal theory of suicide. Van Orden et al (2008) described the two primary dimensions of Joiner’s interpersonal theory:

The theory proposes that the needs to belong and to contribute to the welfare of close others are so fundamental that the thwarting of these needs (i.e., thwarted belongingness and perceived burdensomeness) is a proximal cause of suicidal desire. (Van Orden et al., 2008, p. 72)

Interpersonal theory explains why a number of social factors, such as unemployment, social isolation, reduced productivity, and physical incapacitation are associated with increased suicide risk. Specifically, research indicates that divorced, widowed, and separated people are in a higher suicide-risk category and that single, never-married individuals have a suicide rate nearly double the rate of married individuals (Van Orden et al., 2010). Based on interpersonal theory, an underlying reason that these factors are linked to suicidality is because they involve thwarted belongingness and a self-perception of being a burden to family and friends, rather than contributing in a positive way to the lives of others.

In a fairly recent study, the suicide notes of 98 active duty U.S. Air Force (USAF) members were analyzed. Using Joiner’s interpersonal theory, results indicated strong themes of hopelessness, perceived burdensomeness, and thwarted belongingness. Overall, interpersonal risk factors were communicated more often than intrapsychic risk factors. (Cox et al., 2011).

Physical Illness

Many decades of research have established the link between physical illness and suicide. Specific illnesses that confer suicide risk include brain cancer, chronic pain, stroke, rheumatoid arthritis, hemodialysis, and HIV-AIDS (e.g., (Lin, Wu, & Lee, 2009; Martiny, de Oliveira e Silva, Neto, & Nardi, 2011). Overall, although physical illness is a major predictor, several social factors appear to mediate the relationship between illness and death by suicide. In particular, Joiner’s concept of becoming a social burden seems a likely contributor to suicidal behavior, regardless of specific diagnosis (Van Orden et al., 2010). Similar to previously hospitalized psychiatric patients, medical patients also exhibit higher suicidal behavior shortly after hospital discharge (McKenzie & Wurr, 2001).

Previous Attempts

Over 27 separate studies have indicated that suicide risk is higher for people who have previously attempted (Beghi & Rosenbaum, 2010). Van Orden et al. (2010) refer to previous attempts as “. . . one of the most reliable and potent predictors of future suicidal ideation, attempts, and death by suicide across the lifespan” (p. 577).

As one example, in a 15-year prospective British study of deliberate self-harm, repeated self-harm was a strong predictor of eventual suicide, especially in young women (Zahl & Hawton, 2004). By the study’s end, 4.7% of women who had repeatedly engaged in deliberate self-harm committed suicide as compared to 1.9% in the single episode group. In this study, deliberate self-harm was defined as intentionally poisoning or self-injuring that resulted in a hospital visit. The study concluded that repeated deliberate self-harm increases suicide risk in males and females, but is a particularly salient predictor in young females. This is the case despite the fact that some clients use cutting, burning, or other forms of self-harm to aid in emotional regulation. Overall the research suggests that self-harm that rises to the level of hospitalization is likely beyond that which enhances self-regulation and instead constitutes practicing or successive approximation toward suicide.


Individuals who have suffered any form of recent, significant personal loss should be considered higher suicide risk (Hall, Platt, & Hall, 1999). However, in particular, unemployment is a life situation that repeatedly has been linked to suicide attempts and death by suicide. Joiner’s (2005) interpersonal theory of suicide posits that unemployment confers suicide risk at least partly because of individuals experiencing an increased sense of themselves as a burden on others. Other losses that can increase risk include (a) status loss, (b) loss of a loved one, (c) loss of physical health or mobility, (d) loss of a pet loss, and (e) loss of face through recent shameful events (Beghi & Rosenbaum, 2010; Packman, Marlitt, Bongar, & Pennuto, 2004).

Sexual Orientation

Over the years the data have been mixed regarding whether gay, lesbian, bisexual, or transgender individuals constitute a high suicide risk group. More recently, a 2011 publication in the Journal of Homosexuality reported there is no clear and convincing evidence that GLBT individuals die by suicide at a rate greater than the general population (Haas et al., 2011).
Although this is good news, the data also show that GLB populations have significantly higher suicide attempt rates. Haas et al (2011) wrote:

Since the early 1990s, population-based surveys of U.S. adolescents that have included questions about sexual orientation have consistently found rates of reported suicide attempts to be two to seven times higher in high school students who identify as LGB, compared to those who describe themselves as heterosexual. (p. 17)

Overall, it’s likely that transgender people and youth questioning their sexuality may be at increased risk for suicide attempts or death by suicide. Additionally, GLBT youth who have experienced homosexual-related verbal abuse and parental rejection for their behaviors related to gender and sexuality are more likely to engage in suicidal behaviors (D’augelli et al., 2005).

In conclusion, as you can probably see from this and the two previous posts, there are many complex and potentially interacting factors associated with increased suicide risk, but no great predictors. This is unfortunate for those of us who would like to use prediction methods to prevent and reduce suicide rates. But, at the same time, the fact that many people who experience great suffering in their lives still choose life, is a testament to human strength and resiliency.

And, speaking of resiliency, maybe I’ll be focusing on an exciting and upbeat topic like that next time. Until then, I wish you all the best in your efforts to help your clients through difficult times in their lives. Your work may be more important than you think.

Suicide Risk Factors: Part II

There are many ways to think about suicide risk factors. In my last post, I focused on demographic and ethnic factors related to death by suicide. In this post, the focus is on the broad category of Mental Disorders and Psychiatric Treatment. The next post will focus on Personal and Social Factors that are linked to suicide.

As you’ll see below, the relationship between mental disorders, psychiatric treatment, and suicide is complex. The following material is adapted from our textbook, Clinical Interviewing and so you can find more information there: http://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1118270045/ref=asap_B0030LK6NM?ie=UTF8

Mental Disorders and Psychiatric Treatment

In general, psychiatric diagnosis is considered a risk factor for suicide. However, some diagnostic conditions (e.g., bipolar disorder and schizophrenia) have higher suicide rates than others (e.g., specific phobias and oppositional-defiant disorder). Several diagnostic conditions associated with heightened suicide risk are discussed in this section.


Schizophrenia is a good example of a mental disorder that has a complex association with increased suicide risk. As you may realize, many individuals diagnosed with schizophrenia are unlikely to attempt suicide or die by suicide. Some individuals with a schizophrenia diagnosis are at higher suicide risk than others.

In 2010, Hor and Taylor conducted a research review of risk factors associated with suicide among individuals with a diagnosis of schizophrenia. They initially identified 1,281 studies, eventually narrowing their focus to 51 with relevant schizophrenia-suicide data. Overall, they reported a lifetime suicide risk of about 5% (Hor & Taylor, 2010). Given that the annual risk in the general population is about 12 in 100,000 and assuming a life expectancy of 70 years the general lifetime risk is likely about 840 in 100,000 or 0.84%. This suggests that suicide risk among individuals diagnosed with schizophrenia is about 6 times greater than suicide risk within the general population.

However, there are unique predictive factors within the general population of individuals diagnosed with schizophrenia that further refine and increase suicide prediction. Hor and Taylor (2010) reported the following more specific suicide risk factors within the general population of individuals with a schizophrenia diagnosis:

  • Age (being younger)
  • Sex (being male)
  • Higher education level
  • Number of prior suicide attempts
  • Depressive symptoms
  • Active hallucinations and delusions
  • Presence of insight into one’s problems
  • Family history of suicide
  • Comorbid substance misuse (p. 81)

If you’re working with a client diagnosed with schizophrenia, the lifetime suicide prevalence for that client is predicted to be higher than in the general population. Presence of any of the preceding factors further increases that risk. This leaves a “highest risk prototype” among clients with schizophrenia as:

A young, male, with higher educational achievement, insight into his problems/diagnosis, a family history of suicide, previous attempts, active hallucinations and delusions, along with depressive symptoms and substance misuse.

Given what’s known about suicide unpredictability, it’s also important to remember that someone who fits the highest risk prototype may not be suicidal, whereas a client with no additional risk factors may be actively suicidal.


The relationship between depression and suicidal behavior is very well established (Bolton, Pagura, Enns, Grant, & Sareen, 2010; Holikatti & Grover, 2010; Schneider, 2012). Some experts believe depression is always associated with suicide (Westefeld and Furr, 1987). This close association has led to the labeling of depression as a lethal disease (Coppen, 1994).

It’s also clear that not all people with depressive symptoms are suicidal. In fact, it appears that depression by itself is much less of a suicide predictor than depression combined with another disturbing condition or conditions. For example, when depression is comorbid (occurring simultaneously) with anxiety, substance use, post-traumatic stress disorder, and borderline or dependent personality disorder, risk substantially increases. (Bolton et al., 2010). Earlier research also supports this pattern, with suicidality increasing along with additional distressing symptoms or experiences, including:

  • Severe anxiety
  • Panic attacks
  • Severe anhedonia
  • Alcohol abuse
  • Substantially decreased ability to concentrate
  • Global insomnia
  • Repeated deliberate self-harm
  • History of physical/sexual abuse
  • Employment problems
  • Relationship loss
  • Hopelessness (Fawcett, Clark, & Busch, 1993; Marangell et al., 2006; Oquendo et al., 2007)

Given this pattern it seems reasonable to conclude that when clients are experiencing greater depression severity and/or additional distressing symptoms, suicide risk increases. Van Orden and colleagues offered a similar conclusion:

. . . data indicate that depression is likely associated with the development of desire for suicide, whereas other disorders, marked by agitation or impulse control deficits, are associated with increased likelihood of acting on suicidal thoughts. (Van Orden et al., 2010, p. 577)

Bipolar Disorder

Research has repeatedly shown that individuals diagnosed with bipolar disorder at increased risk of suicide. Similar to schizophrenia and depression, there are many specific risk factors that predict increased suicidality among clients with bipolar disorder.

In a large-scale French study, eight risk factors were linked to lifetime suicide attempts (Azorin et al., 2009). These included:

1. Multiple hospitalizations
2. Depressive or mixed polarity of first episode
3. Presence of stressful life events before illness onset
4. Younger age at onset
5. No symptom-free intervals between episodes
6. Female sex
7. Greater number of previous episodes
8. Cyclothymic temperament (p. 115)

These findings are consistent with the research on unipolar depression; it appears that severity of bipolar disorder and accumulation of additional distressing experiences increase suicide risk. Another study identified (a) White race, (b) family suicide history, (c) history of cocaine abuse, and (d) history of benzodiazepine abuse were associated with increased suicide attempts (Cassidy, 2011)

Post-Traumatic Stress

In 2006, renowned psychologist Donald Meichenbaum reflected on his 35-plus years of working with suicidal clients. He wrote:

In reviewing my clinical notes from these several suicidal patients and the consultations that I have conducted over the course of my years of clinical work, the one thing that they all had in common was a history of victimization, including combat exposure (my first clinical case), sexual abuse, and surviving the Holocaust. (Meichenbaum, 2006, p. 334)

Clinical research supports Meichenbaum’s reflections. For example, in a file review of 200 outpatients, child sexual abuse was a better predictor of suicidality than depression (Read, Agar, Barker-Collo, Davies, & Moskowitz, 2001). Similarly, data from the National Comorbidity Survey (N = 5,877) showed that women who were sexually abused as children were 2 to 4 times more likely to attempt suicide, and men sexually abused as children were 4 to 11 times more likely to attempt suicide (Molnar, Berkman, & Buka, 2001). Overall, research over the past two decades points to several stress-related experiences as linked to suicide attempts and death by suicide (Wilcox & Fawcett, 2012). These include general trauma, stressful life events, and childhood abuse and neglect. Characteristics of these experiences that are most predictive of suicide are:

  • Assaultive abuse or trauma.
  • Chronicity of stress or trauma.
  • Severity of stress or trauma.
  • Earlier developmental stress or trauma. (Wilcox & Fawcett, 2012)

These particular life experiences appear related to suicidal behavior across a variety of populations—including military personnel, street youth, and female victims of sexual assault (Black, Gallaway, Bell, & Ritchie, 2011; Cox et al., 2011; Hadland et al., 2012; Snarr et al., 2010; Spokas, Wenzel, Stirman, Brown, & Beck, 2009).

Substance Abuse

Research is unequivocal in linking alcohol and drug use to increased suicide risk (Sher, 2006). Suicide risk increases even more substantially when substance abuse is associated with depression, social isolation, and other suicide risk factors.

One way that alcohol and drug use increases suicide risk is by decreasing inhibition. People act more impulsively when in chemically altered states and suicide is usually considered an impulsive act. No matter how much planning has preceded a suicide act, at the moment the pills are taken, the trigger is pulled, or the wrist is slit, some theorists believe that some form of disinhibition or dissociation has probably occurred (Shneidman, 1996). Mixing alcohol and prescription medications can further elevate suicide risk.

Several other specific mental disorders have clear links to death by suicide. These include:

  • Anorexia nervosa
  • Borderline personality disorder
  • Conduct disorder (see Van Orden et al., 2010)

Post-Hospital Discharge

For individuals admitted to hospitals because of a mental disorder, the period immediately following discharge carries increased suicide risk. This is particularly true of individuals who have additional risk factors such as previous suicide attempts, lack of social support, and chronic psychiatric disorders. Overall, suicide ideation and attempts are predictably high. In one study 3.3% completed suicide within 6 months of discharge, whereas 39.4% had self-harm behaviors or suicide attempts (Links et al., 2012). Another study reported “3% of patients categorized as being at high risk can be expected to commit suicide in the year after discharge” (Large, Sharma, Cannon, Ryan, & Nielssen, 2011, p. 619).

Selective Serotonin Reuptake Inhibitors (SSRIs)

Over the past two decades, empirical data linking SSRI medications to suicidal impulses has accumulated to the point that recent administration of SSRI medications should be considered a possible suicide risk factor (Breggin, 2010; Valenstein et al., 2012). This is true despite the fact that some research also shows that SSRI antidepressants reduce suicide rates (Kuba et al., 2011; Leon et al., 2011). Overall, it appears that in a minority of clients (2–5%) SSRI antidepressants may increase agitation in a way that contributes to increased risk for suicidal behaviors (J. Sommers-Flanagan & Campbell, 2009).

In September 2004, an expert panel of the U.S. Food and Drug Administration (FDA) voted 25–0 in support of an SSRI-suicide link. Later, the panel voted 15–8 in favor of a “black box warning” on SSRI medication labels. The warning states:

Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of Major Depressive Disorder (MDD) and other psychiatric disorders. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber.

In 2006, the FDA extended its SSRI suicidality warning to adult patients aged 18–24 years (United States Food and Drug Administration, 2007).

There’s no doubt that debate about whether SSRI medications increase suicide risk will continue. In the meantime, prudent practice dictates that mental health providers be alert to the possibility of increased suicide risk among clients who have recently been prescribed antidepressant medications (Sommers-Flanagan & Campbell, 2009).

In the next post in this series I’ll be focusing on Personal and Social factors associated with suicide.