Tag Archives: suicide

Clinical Interviewing, Personal Reflections, Suicide Assessment and Intervention

My (Virtual) Visit to South Korea

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Last Friday night (or Saturday morning in South Korea), I had the honor and privilege of spending three hours online with 45 South Korean therapists. We were talking, of course, about strengths-based suicide assessment and treatment. Given my limited Korean language skills (is it accurate to say my language skills are limited if I can’t say or comprehend ANYTHING in Korean?), I had a translator. Although I couldn’t tell anything about the translation accuracy, my distinct impression was that she was absolutely amazing.

I had a friend ask how I happened to get invited to present to Korean therapists. My main response is that I believe the time is right (aka Zeitgeist) for greater integration of the strengths-based approach into traditional suicide assessment and treatment. The person who recruited me was Dr. Julia Park, another absolutely amazing, kind, and competent South Korean person, who also happens to hold an Adlerian theoretical orientation. Thanks Julia!

Just for fun, I wish I had my Korean translated ppts to share here. They’re unavailable, and so instead I’m sharing an excerpt from Chapter 10 (Suicide Assessment Interviewing) of our Clinical Interviewing (2024) textbook. The section I’m featuring is the part where we review issues and procedures around suicide risk categorization and decision-making.

You may already know that some of the latest thinking on suicide risk assessment is that we should not use instruments like the Columbia to categorize risk. You also may know that not only am I a believer in this latest thinking, I can be wildly critical of efforts to categorize suicide risk. . . so much so that I often end up using profanity in my professional presentations. Of course, because the context is a professional presentation, I only use the highly professional versions of profanity.  

Here’s a LinkedIn comment about that issue from Craig Bryan. Dr. Bryan is a suicide researcher, professor at The Ohio State University, and author of “Rethinking Suicide.” In support of him and his research and thinking, I’d like to professionally say that although I lean away from reductionistic categorization of things, all signs point to the likelihood that Dr. Bryan has a very large brain.   

The good news is that I feel validated by Dr. Bryan’s strong comments against categorizing suicide risk. But the bad news is that we all live in the real world and in the real world sometimes professionals have to do more than just swear about risk categorization—we have to actually make recommendations for or against hospitalization, consult with other professionals who want our opinion, and quoting me as saying that risk factor categorization is pure bullshit may not be the best and most professional option.

So . . . what are we to do? First, we parse Dr. Bryan’s comments. He’s not saying NEVER categorize risk or make risk estimates. He’s saying don’t categorize “negative screens as low risk” which is slightly different than don’t try to estimate risk. His message is that we have too many false negatives—where someone screens negative and then dies by suicide. In other words, we should not be confident and say negative screens are “low risk.” That’s different from throwing the baby out with the bathwater.  

It might be easy to think that Dr. Bryan’s comments are discouraging. But I view him as just saying we should be careful professionals. To help with that, below is the excerpt on Suicide risk categorization and decision-making, from our textbook. If you’re in a situation where you have to make a professional recommendation about suicide risk, this information may be helpful. BTW, the reason I was inspired to post this excerpt is because the Korean participants were wonderful and asked lots of hard questions, including questions related to this topic.

Suicide Risk Categorization and Decision-Making

Throughout this chapter, we have acknowledged the limits of categorizing clients on the basis of risk. The current state of the science indicates that efforts to predict client suicides (i.e., categorize risk) are likely to fail. Nevertheless, when necessary—because of institutional requirements or client inability to collaborate on safety or treatment planning—all clinicians should be able to use their judgment to estimate risk and make disposition decisions for the welfare of the client. As a consequence, we review a suicide risk categorization and decision-making model next.

Consultation

Consultation with peers and supervisors serves a dual purpose. First, it provides professional support; dealing with suicidal clients is difficult and stressful; input from other professionals is helpful. For your health and sanity, you shouldn’t do work with suicidal clients in isolation.

Second, consultation provides feedback about appropriate practice standards. Should you need to defend your actions and choices following a suicide death, you’ll be able to show you were meeting professional standards. Consultation is one way to monitor, evaluate, and upgrade your professional competency.

Suicide Risk Assessment: An Overview

We reviewed an overwhelming number of suicide risk and protective factors earlier in this chapter. Generally, more risk factors equate to more risk. However, some risk factors are particularly salient. These include:

Previous attempts

A previous attempt is sometimes viewed as suicide rehearsal. Two previous attempts are especially predictive of suicide because they represent repeated intent. Also, when previous attempts were severe and the client was disappointed not to die, risk is high.

Command hallucinations

When clients are experiencing a psychotic state accompanied by command hallucinations (e.g., a voice that says, “You must die’), risk is at an emergency level.

Severe depression with extreme agitation

The combination of depression and agitation can be especially lethal. Agitation can take the form of extreme anxiety or extreme anger.

Protective factors

A single protective factor may outweigh many risk factors. But, it’s impossible to know the power of any individual protective factors without an in-depth discussion with your client. Engagement in therapy and collaboration on a safety plan (and the hope these behaviors signal) can substantially reduce risk.

Nature of Suicidal ideation

As discussed earlier, suicidal ideation is evaluated based on frequency, triggers, intensity, duration, and termination. Some clients live chronically with high suicidal ideation frequency, intensity, and duration—and are low risk. However, if ideation is frequent and intense and accompanied by intent and planning, risk is high.

Suicide Intent

Suicide intent is the factor most likely to move clients toward lethal attempts. Intent can be based on objective or subjective signs. Objective signs of intent include one (or more) previous lethal attempt(s). Subjective signs of intent can include a client rating of intent or client report of a highly lethal plan.

Clinical Presentation

How clients present themselves during sessions is revealing. Clients can be palpably hopeless, talk desperately about feelings of being trapped, and express painful and unremitting self-hatred or shame. But if clients have adapted to these experiences, they may not have accompanying intent and active planning. Observations of how clients talk about their psychological distress will contribute to your final decisions.

Final Decisions

Using a traditional assessment approach, you can estimate your client’s suicide risk as fitting into one of three categories:

  • Minimal to Mild: Client reports no suicidal thoughts or impulses. Client distress is minimal. Plan: Monitor client distress. If distress rises, or depressive symptoms emerge, re-assess for suicidality.
  • Moderate to High: Client reports suicidal ideation. As client distress, planning, risk factors, and intent increase, risk increases. Plan: Manage the situation with a collaborative safety plan. Depending on client preference, engaging family or friends as support may be advisable. Make sure firearms and lethal means are safely stored.
  • High to Extreme: Client reports suicidal ideation, plans, multiple risk factors (likely including a previous attempt), intent, and has access to lethal means. Engagement in treatment is minimal to non-existent. Plan: Treatment may include hospitalization and/or intensive outpatient therapy with a safety plan implemented in collaboration with family/friends. Make sure firearms and lethal means are safely stored.

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As always, please share your thoughts in the comments on this blog.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, culture, diversity, Happiness, Multicultural, Personal Reflections, Research, Suicide Assessment and Intervention

Ten Things Everyone Should Know about Mental Health, Suicide, and Happiness

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I’ve spent the better part of the past two weeks doing presentations in various locations and venues. I did five presentations in Nebraska, and found myself surprisingly fond of Lincoln and Kearney Nebraska. On Thursday I was at a Wellness “Reason to Live” conference with CSKT Tribal Services at Kwataqnuk in Polson. Just now I finished an online talk with the Tex-Chip program. One common topic among these talks was the title of this blog post. I have found myself interestingly passionate about the content of this particular. . . so much so that I actually feel energized–rather than depleted–after talking for two hours.

Not surprisingly, I’ve had amazingly positive experiences throughout these talks. All the participants have been engaged, interesting, and working hard to be the best people they can be. Beginning with the Mourning Hope’s annual breakfast fundraiser, extending into my time with Union Bank employees, and then being with the wonderful indigenous people in Polson, and finally the past two hours Zooming with counseling students in Texas . . . I have felt hope and inspiration for the good things people are doing despite the challenges they face in the current socio-political environment.

If you were at one of these talks (or are reading this post), thanks for being you, and thanks for contributing your unique gifts to the world.

For your viewing pleasure, the ppts for this talk are linked here.

Ten Things Tex Chip April 2025Download

Clinical Interviewing, Happiness, Suicide Assessment and Intervention

Strengths-Based Suicide Assessment and Treatment for the Western Oregon Mental Health Association

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For fans of Strengths-Based suicide workshops, this Friday I’m doing a three hour online workshop for the Western Oregon Mental Health Assocation.

The workshop is happening this Friday from 9-noon (PDT).  It’s a pretty reasonable deal: $60 for licensed WOMHA members, $75 for licensed non-members, $35 for pre-licensed people, and $5 for students.

Sorry for the late notice, but here’s the link to register:

https://bookwhen.com/womha#focus=ev-s8as-20250411090000

And here’s a copy of the ppts:

Traditional and SB for WOMHA 2025Download

I’m looking forward to my virtual trip back to Oregon this Friday!

Clinical Interviewing, Happiness, Personal Reflections, Research, Suicide Assessment and Intervention

Why I’m Mostly Against Universal Suicide Screenings in Schools

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I’ve been in repeated conversations with numerous concerned people about the risks and benefits of suicide screenings for youth in schools. Several years ago, I was in a one-on-one coffee shop discussion of suicide prevention with a local suicide prevention coordinator. She said, more as a statement than a question, “Who could be against school-based depression and suicide screenings?”

I slowly raised my hand, forced a smile, and confessed my position.

The question of how and why I’m not in favor of school-based mental health and suicide screenings is a complex one. On occasion, screenings will work, students at high-risk will be identified, and tragedy is averted. That’s obviously a great outcome. But I believe the mental health casualties from broad, school-based screenings tend to outweigh the benefits. Here’s why.

  1. Early identification of depression and suicide in youth will result in early labeling in school systems; even worse, young people will begin labeling themselves as being “ill” or “defective.” Those labels are sticky and won’t support positive outcomes.
  2. Most youth who experience depressive symptoms and suicide ideation are NOT likely to die by suicide. Odds are that students who don’t report suicidal ideation are just as likely to die by suicide. As the scientists put it, suicidal ideation is not a good predictor of suicide. Also, depression symptoms generally come and go among teenagers. Most teens will recover from depressive symptoms without intensive interventions.
  3. After a year or two of school-based screenings, the students will know the drill. They will realize that if they endorse depression symptoms and suicidal items that they’ll have to experience a pretty horrible assessment and referral process. When I talk to school personnel, they tell me that, (a) they already know the students who are struggling, and (b) in year 2 of screenings, the rates of depression and suicidality plummet—because students are smart and they want to avoid the consequences of being open about their emotional state.
  4. About 10-15% of people who complete suicide screenings feel worse afterward. We don’t really want that outcome.
  5. There’s no evidence that school-based screenings are linked to reductions in suicide rates.   

For more info on this, you can check out a brief commentary I published in the American Psychologist with my University of Montana colleague, Maegan Rides At The Door. The commentary focuses on suicide assessment with youth of color, but our points work for all youth. And, citations supporting our perspective are included.

Here are a few excerpts from the commentary:

 Standardized questionnaires, although well-intended and sometimes helpful, can be emotionally activating and their use is not without risk (Bryan, 2022; de Beurs et al., 2016).

In their most recent recommendations, the United States Preventive Services Task Force (2022) concluded that the evidence supporting screening for suicide risk among children and adolescents was “insufficient” (p. 1534). Even screening proponents acknowledge, “There is currently little to no data to show that screening decreases suicide attempt or death rates” (Cwik et al., 2020, p. 255). . . . Across settings, little to no empirical evidence indicates that screening assessments provide accurate, predictive, or useful information for categorizing risk (Bryan, 2022).

And here’s the link to the commentary:

Empathy and Compassion in AP with MRATD 2024Download
Happiness, Personal Reflections, Suicide Assessment and Intervention

Two Talks from this Week — Resources

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This week I had a chance to do a couple presentations for a couple awesome groups.

On Monday, along with Victor Yapuncich, I presented a talk at Fairmont titled “Why We Should Be in Pursuit of Eudaimonia (Not just “Happiness”)” to the Rural Medical Training Collaborative of the Family Medicine Residency of Western Montana. The group was amazing, and we even got Evelyn and Shilo to sing with us at the end. Here are the ppts for the Fairmont talk:

Eudaimonia Family Medical Residency March 2025Download

Today, I had the honor to deliver the closing talk for Tamarack Grief Resource Center’s annual Grief Institute. Thanks Tina . . . for the amazing opportunity. It was fabulous to be with such an incredibly dedicated and compassionate group of professionals who are using their gifts to help people through the journey of grief. Here are the ppts for the Grief Institute:

Ten Things Grief Institute 2025Download
Clinical Interviewing, Suicide Assessment and Intervention

The Handout for this Friday’s Strengths-Based Suicide Workshop

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Sorry for all the posts, but apparently there’s lots happening in early 2025.

The big NEWS post won’t be until tomorrow.

As you know, on this Friday, January 10, I’ll be doing an online, two-hour workshop on Strategies for Integrating Traditional and Strengths-Based Approaches to Suicide for the Cognitive Behavior Institute.

I’m posting the workshop handouts here, in advance, for anyone interested.

Traditional and SB Assessment for CBI 2025Download

You may recall that this workshop is ALMOST FREE. Only $25. There’s still time to register here:

https://cbicenterforeducation.com/courses/strategies-for-integrating-traditional-and-strengths-based-approaches-to-suicide-january-2025

I hope to see you there!

Clinical Interviewing, Suicide Assessment and Intervention

Coming this Friday: Online Workshop — “Strategies for Integrating Traditional and Strengths-Based Approaches to Suicide”

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Happy Sunday Evening,

Last week I shared my 2025 predictions with you. This week, I’ve got another prediction . On Friday, January 10, I’ll be doing an online, two-hour workshop (title listed above) for the Cognitive Behavior Institute. I predict that if you sign up, you’ll be happy you did.

The other good news about this workshop is that it’s ALMOST FREE. Only $25. Here’s the link to register:

https://cbicenterforeducation.com/courses/strategies-for-integrating-traditional-and-strengths-based-approaches-to-suicide-january-2025

I hope to see you there!

If you’re interested in this topic and can’t make it (or even if you can make it), here’s a pdf of an article I wrote about suicide assessment for a Psych journal in 2018:

2018 Conversations About SuicideDownload

And here’s a link to the first journal article that Rita and I wrote on suicide assessment way back in the 20th century (in 1995!):

Suicide Interviewing 1995Download

Clinical Interviewing, culture, diversity, Happiness, Suicide Assessment and Intervention, Uncategorized

Tomorrow Morning in Ronan, MT: A Presentation and Conversation about Strengths-Based Suicide Assessment and Treatment

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Tomorrow morning, three counseling interns and I will hit the road for Ronan, where we’ll spend the day with the staff of CSKT Tribal Health. We are honored and humbled to engage in a conversation about how to make the usual medical model approach to suicide be more culturally sensitive and explicitly collaborative.

Here are the ppts for the day:

Clinical Interviewing, diversity, Happiness, Suicide Assessment and Intervention

Strengths-Based Suicide Assessment with Diverse Populations — The PPTs

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Tomorrow morning (Wednesday, October 2) I have the honor and privilege of being the keynote speaker for Maryland’s 36th Annual Suicide Prevention Conference. So far, everyone I’ve met associated with this conference is amazing. I suspect tomorrow will be filled with excellent presentations and fabulous people who are in the business of mental health and saving lives.

I hope I can do justice to my role in this very cool conference.

Here’s a link to tomorrow’s ppts:

SB Assessment for Diverse People Maryland REVDownload
Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, culture, diversity, Happiness, Suicide Assessment and Intervention

Coming Soon: Maryland’s 36th Annual Suicide Prevention Conference

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Why Do We Need a Strengths-Based Approach to Suicide Assessment and Treatment?

Imagine this: You’re living in a world that seems like it would just as soon forget you exist. Maybe your skin color is different than the dominant people who hold power. Maybe you have a disability. Whatever the case, the message you hear from the culture is that you’re not important and not worthy. You feel oppressed, marginalized, unsupported, and as if much of society would just as soon have you become invisible or go away.

In response, you intermittently feel depressed and suicidal. Then, when you enter the office of a health or mental health professional, the professional asks you about depression and suicide. Even if the professional is well-intended, judgment leaks through. If you admit to feeling depressed and having suicidal thoughts, you’ll get a diagnosis that implies you’re to blame for having depressing and suicidal thoughts.  

The medical model overfocuses on trying to determine: “Are you suicidal?” The medical model is also based on the assumption that the presence of suicidality indicates there’s something seriously wrong with you. But if we’re working with someone who has been or is currently being marginalized, a rational response from the patient might be:

“As it turns out, I’ve internalized systemic and intergenerational racism, sexism, ableism, and other dehumanizing messages from society. I’ve been devalued for so long and so often that now, I’ve internalized societal messages: I devalue myself and wonder if life is worth living. And now, you’re blaming me with a label that implies I’m the problem!”

No wonder most people who are feeling suicidal don’t bother telling their health professionals.

When I think of this preceding scenario, I want to add profanity into my response, so I can adequately convey that it’s completely unjust to BLAME patients for absorbing repeated negative messages about people who look like or sound like or act like them. WTH else do you think should happen?

This is why we need to integrate strengths-based principles into traditional suicide assessment and prevention models. Of course, we shouldn’t use strengths-based ideas in ways that are toxically positive. We ALWAYS need to start by coming alongside and feeling with our patients and clients. As it turns out, if we do a good job of coming alongside patients/clients who are in emotional pain, natural opportunities for focus on strengths and resources, including cultural, racial, sexual, and other identities that give the person meaning.

I’m reminded of an interview I did with an Alaskan Native person from the Yupik tribe. She talked at length about her depression, about feeling like a zombie, and past and current suicidal thoughts. Eventually, I inquired: “What’s happening when you’re not having thoughts about suicide?” She seemed surprised. Then she said, “I’d be singing or writing poetry.” I instantly had a sense that expressing herself held meaning for her. In particular, her singing Native songs and contemporary pop songs became important in our collaborative efforts to build her a safety plan.

This coming Wednesday morning I have the honor of presenting as the keynote speaker for the Maryland Department of Health 36th Annual Suicide Prevention Conference. During this keynote, I’ll share more ideas about why a strengths-based model is a good fit when working with diverse clients who are experiencing suicidal thoughts and impulses.

With all that said, here’s the title and abstract of my upcoming presentation.

Strengths-Based Assessment, Treatment, and Prevention with Diverse Populations

Traditional suicide assessment tends to be a top-down information-gathering process wherein healthcare or prevention professionals use questionnaires and clinical interviews to determine patient or client suicide risk. This approach may not be the best fit for people from populations with historical trauma, or for people who continue to experience oppression or marginalization. In this presentation, John Sommers-Flanagan will review principles of a strengths-based approach to suicide prevention, assessment, and treatment. He will also discuss how to be more sensitive, empowering, collaborative, and how to leverage cultural strengths when working with people who are potentially suicidal. You will learn at least three practical strengths-based strategies for initiating conversations about suicide, conducting culturally-sensitive assessments, and implementing suicide interventions—that you can immediately use in your prevention work.