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This is an intermediate-level course. After completing this course, mental health professionals will be able to:
These course materials are based on contemporary theory, research, and practice pertaining to suicide assessment and treatment. However, because the scientific literature on suicide is voluminous and ever-changing, additional information will always be available to clinicians who want to keep learning. You should be aware that reading about suicide can be triggering. Additionally, although the knowledge and skills in this course may improve your abilities to conduct suicide assessments, because suicide is inherently difficult to predict and prevent, using the information herein does not guarantee positive outcomes.
In 1974, Wollersheim published an article in Psychotherapy: Theory, Research & Practice titled, “The assessment of suicide potential via interview methods.” In the early 1980s, while a doctoral student in clinical psychology at the University of Montana, I had the privilege of learning suicide assessment and treatment planning principles directly from Dr. Wollersheim. Following several of Dr. Wollersheim’s key principles, including normalization of suicidal ideation, my wife Rita and I began writing about and publishing book chapters and articles on suicide assessment and treatment beginning in the early 1990s (Sommers-Flanagan & Sommers-Flanagan, 1993; Sommers-Flanagan & Sommers-Flanagan, 1995). Being immersed in the suicide literature, while simultaneously working with clients and teaching and supervising counselors and psychologists-in-training, naturally stimulated our ideas about how to teach suicide assessment and treatment planning, resulting in this two-course series: this first course, and the second course, Suicide Interventions and Treatment Planning for Clinicians: A Strengths-Based Model.
Suicide assessment, management, and treatment planning is the most stressful and challenging of all counseling and psychotherapy situations (Binkley & Liebert, 2015; Maris, 2019; Michaud, et al., 2020). On the surface, talking about suicide and working with clients who are suicidal is stressful for obvious reasons; when clients are suicidal, thoughts of emergency phone calls, decisions about hospitalization, and the possibility of losing clients to death by suicide are quickly triggered.
At deeper levels, suicide is about life and death. As the great existentialist Irvin Yalom (2008) has articulated, most people have visceral and emotional responses to the idea of death. Even further, many professionals have their own previous traumatic experiences around suicide, whether it involves family members, friends, clients, or their own suicidal thoughts or crises (Cureton & Clemens, 2015). All this leads to a natural outcome – professionals need support to develop self-awareness and a balanced attitude toward suicide, while at the same time gathering knowledge and developing skills for coping with and effectively managing suicide-related clinical situations (Bryan & Rudd, 2018; Sommers-Flanagan & Sommers-Flanagan, 2021).
In a word, the focus of this suicide assessment course is competence. After years of working with clients who are suicidal, training clinicians, and supervising professional counselors and psychotherapists, I’ve come to the conclusion that the best remedy for the stress, angst, and emotional ramifications of suicidal crises is for clinicians to work on developing suicide-specific competencies.
It’s helpful to think of suicide competencies as encompassing four general parts of a big symphony that includes many different notes, movements, and melodies. Consistent with the American Association of Suicidology (AAS) Core Competencies and other competency models (Cramer, et al., 2013), these three parts include:
At the beginning and throughout this suicide assessment and treatment planning symphony, a steady drumbeat of ethical and legal standards is in the background. This drumbeat will sometimes distract you and provoke anxiety; to deal with it, you’ll need knowledge about ethical decision-making models, including the professional consultation and support that helps mental health professionals continue to face and cope with the next suicidal crisis.
Working with clients who are suicidal is one of the most stressful tasks mental health professionals face (Michaud, et al., 2020). It takes little imagination to conjure up the stress. Consider this:
Your new client tells you he’s thinking of suicide … you try to connect with him, assess his risk, and develop a collaborative safety plan … he assures you he’ll be fine and thanks you for your concern … but you’re not entirely confident he’s safe, and then, during the subsequent week, he ends his life.
Scenarios like this make it easy to understand why working with clients who are suicidal is so stressful.
The law is clear about working with clients who are suicidal: You have a professional duty to protect. Jobes and O’Connor (2009) wrote:
All states … have explicit expectations of a duty to protect that requires clinical recognition of the severity of clients’ emotional and behavioral problems when these struggles pose an imminent danger to self. (p. 165)
The duty to protect is an ethical and legal mandate (Tarasoff v. Board of Regents of California, 1974; Tarasoff v. Regents of the University of California, 1976). If you judge that your client is actively suicidal, you have legal responsibility to initiate safety planning and, if needed, break confidentiality (Jobes, 2016). This guide is designed to help you face suicide situations and have ethical and competent professional responses.
Edwin Shneidman, often referred to as the father of suicidology, developed a “mentalistic theory of suicide.” Shneidman briefly and vividly summarized his theory of the inner world of individuals with suicidal impulses:
Suicide always involves an individual’s tortured and tunneled logic in a state of inner-felt, intolerable emotion. In addition, this mixture of constricted thinking and unbearable anguish is infused with that individual’s conscious and unconscious psychodynamics (of hate, dependency, hope, etc.), playing themselves out within a social and cultural context, which itself imposes various degrees of restraint on, or facilitations of, the suicidal act. (Leenaars, 2010, p. 8; bold added)
Shneidman’s description of the suicidal mind is provocative. Reading his ideas and these suicide course materials, as well as working with clients who are suicidal, can and will evoke emotional responses. Your emotional responses may be bigger or smaller depending on whether you’ve had someone close to you attempt or complete suicide, or if you, like many people, have contemplated suicide at some point in your life. As needed, while reading this curriculum, you should engage in positive self-care.
We live in a button-pushing culture. You can push a button to upload a photo and click on a hotlink to read a newspaper article. We all know how buttons work. Push a button, you get results.
When it comes to suicide, we all have our own unique emotional buttons. Your buttons might be related to deep religious beliefs. Maybe you were taught that thinking about suicide or acting on suicidal impulses is sinful. Or, your suicide buttons might be related to personal experience. Maybe you had a friend die by suicide; having had that experience can make it easy for waves of painful emotions to come back whenever suicide is mentioned. Or, you may struggle with suicidal thoughts yourself. Whatever the case, conversations about suicide will trigger your own unique emotional response. As a mental health professional, gaining experience can mute or muffle your emotional responses to suicide scenarios, or it might magnify them. Either way, having a plan for coping with your emotional responses makes for better professional practice.
I began facilitating workshops, lectures, and trainings on suicide assessment, prevention, and intervention early in my career. One presentation stands out. About 80 professionals were in attendance. I asked the group, “How many of you have worked with suicidal clients?” Nearly every hand raised. I followed up, “How many of you have worked with a client who died by suicide?” About 15 hands went up. After sharing some of my experiences, we transitioned to talking about coping strategies for professionals when clients complete suicide.
While talking, I noticed a bit of activity in the back of the room; Rob, a colleague I knew well, stood up and slipped out of the room. Rob was a licensed mental health professional, an unflappable guy, complete with a rough New York accent and a reputation for working with the toughest teens in town. I didn’t make much of his exit. But later, a mutual friend said, “Rob couldn’t handle it. When you started talking about client suicides, he had to get out. I’ve never seen him so emotional.”
Eventually, I spoke with Rob directly. He said, “I’ve had six teenage clients complete suicide. When you did that survey, memories came flooding back. I had to stop listening and get out. I had to take care of myself.”
Rob stepped out of the suicide workshop for two reasons. First, he recognized that his emotional bucket was full and decided – at least for the moment – to stop listening. Second, as he stepped away, he also recognized that he needed to take care of himself. As you read this content and work with clients who are suicidal, I recommend that you consider similar strategies.
Stop Reading. During suicide workshops and college classes, I tell participants and students that if they start feeling triggered or don’t want to get triggered, they can do what my teenage clients do: Just stop listening. I tell them this because it’s easy to get suicide information overload. One method for dealing with information overload is to do what Rob did: Stop the information input.
To stop reading sounds easy, but if you’re an avid reader, you can get swept into information about death and suicide and later discover you’re overdue for a break. Proactively planning breaks from this course and other suicide-related content might be a good idea. You can read for 20 or 30 minutes, or limit yourself in one way or another. No matter where you place your limit, consider inserting a fun, creative, social, or reflective activity into your life after reading for your designated time period.
Taking breaks is one coping technique, but it’s not the only one. Having a variety of strategies for self-care is recommended. Based on numerous research studies, Norcross and Vandenbos (2018) identified common and effective strategies psychotherapists use to effectively manage their daily stress in healthy ways. What follows is my version of Norcross and Vandenbos’ (2018) recommendations.
Recognize the Hazards. Talking and reading about suicide is a life hazard. Humans aren’t built to continually focus on suicide and death without paying an emotional toll. If you consider this topic stressful, join the club. You’re not being weak. Recognizing and accepting that suicide is a hazardous topic is a healthy start.
Intentionally Focus on Positive and Rewarding Life Experiences. Many people believe life should naturally bring positive rewards. Research and common sense indicate that professionals who cope effectively with powerful life stresses are people who don’t wait for positive experiences to come to them, but instead, regularly schedule positive activities in their lives. To do this, you’ll need to be aware of what brings you joy, what brings you laughter, and what brings you gratification. Then, you’ll need to make a commitment to regularly weaving those things into your everyday life.
Use a Variety of Self-Care Strategies. A single self-care strategy can’t work as the best solution for everyone; we all have our own preferred coping techniques. What’s less obvious is that the best way to cope with stress and stay healthy is to develop a smorgasbord of stress management and self-care strategies (Norcross & Vandenbos, 2018). If you love exercise, that’s great, but you need other activities in your stress management tool box. Try meditation, support groups, recreational pursuits, your own psychotherapy, gourmet food, excellent movies or concerts, spiritual or religious study groups, or whatever alternatives appeal to you. Your self-care mantra should be to use what works for you – and then keep expanding your repertoire.
Pay Attention to Yourself and Make Conscious and Intentional Choices to Engage in Healthy Behaviors. What most people find especially health-enhancing is to flex their personal choice-making muscles. Exactly what you do hardly matters. What matters is that you exert your power of choosing and self-agency on your life. This can include intentional choices to benefit not just yourself, but your family, colleagues, and community.
Manage Your Environment. Achieving total control of your environment is impossible. But there’s solid research on what behaviorists call, “stimulus control.” What this means in normal language is that you should control at least a few key components of your living and working environments. Stimulus control is about making sure your environment prompts positive behaviors; it might mean a pair of running shoes by the door, healthy snacks in your desk, or your best friend saved in Favorites on your phone for one-click dialing. Since you know yourself best, strive not only to create an environment that’s comfortable, but also one that will help you easily move toward engaging in your personal menu of healthy behaviors.
Engage in and Practice Self-Soothing Behaviors. If you find yourself feeling distress, one solid response is to find a safe time and place to honor and explore the emotion. Beyond that, one of the best questions to ask yourself is: “When I’m upset, what usually helps me calm down?” The answer might include going for a walk, engaging in deep breathing, coloring, or holding hands with a friend or romantic partner. As you probably know, several forms of psychotherapy require that clients find their “safe space” before facing difficult or traumatic memories. That said, now is a good time for you to reflect on and identify your “go-to” strategies for self-soothing and relaxation. As you read this material and work with clients who are suicidal, you should have clarity on what you can do to soothe and calm yourself when the content gets intense. One caveat here: You need to scratch the use of substances for self-soothing off your list. Although using substances for recreational purposes can be a reasonable personal preference, relying on substances for self-comfort is a bad idea.
Set Reasonable Goals and then Cut Yourself Some Slack. As a mental health professional, you’re probably familiar with “SMART goals.” You can find definitions of SMART goals all over the internet. SMART goals are commonly attributed to Peter Drucker – a renowned management consultant, Austrian immigrant, and author of 39 books. Drucker is commonly considered one of the most important thought leaders in business management. Using Drucker’s principles, back in 1981, George T. Doran published a paper in Management Review titled, “There’s a S.M.A.R.T. way to write management’s goals and objectives.” Although variations exist, SMART goals are typically defined as:
S - Specific
M - Measurable
A - Achievable or Assignable
R - Relevant or Realistic
T - Time-bound
Drucker and Doran were writing from a business management perspective, but SMART goals are also intrinsic to psychotherapy and personal growth. William Glasser (2000) and Robert Wubbolding (2011), have described important variations of SMART goals in psychotherapy. The philosophy of Glasser and Wubbolding is simply common sense: “A goal should be within your control.” Put differently, if you identify goals that depend on other people’s behaviors, then frustration and other problems will inevitably ensue.
For now, keep in mind that goal-setting – although a highly effective personal growth strategy – can be fraught with frustration. Imagine the athlete or musician who focuses exclusively on perfect performances. Although perfect performances are something to aspire toward, when reality sets in and the performance is less than perfect – as it always will be – frustration and disappointment follow. Realistic and SMART goal-setting, along with self-compassion for your failures, is a healthier road to success.
Your job is to be aware of your attitudes about suicide and to not let them interfere with the professional care you provide clients. Let’s say your religious beliefs lead you to conclude that death by suicide is a sinful behavior. Having that belief might make you feel an extreme commitment to pushing clients to embrace life. Although, as professionals, we’re mandated to help prevent suicide, suicide researchers and contemporary suicide competencies consistently note that professionally competent suicide assessment and interventions begin with an acceptance of clients’ suicidal impulses (Sommers-Flanagan & Sommers-Flanagan, 2021). Put another way, if you embrace your inner beliefs about suicide as sinful and subsequently advocate too hard and too soon against suicide, you may activate client resistance and instead of saving a life, you may end up contributing to a suicide death.
The other extreme occurs when professionals believe deeply in the right to death by suicide. Although this is a reasonable philosophical position, it’s possible for practitioners to communicate that philosophy in a manner that’s too strong and potentially destructive. For example, if your client leaves the session thinking, “Hmm, my therapist seems to advocate suicide,” then you’ve done your client a disservice and probably behaved in ways that, upon review, would be considered unethical.
This brings us to the bottom line about cultivating your suicide awareness and being cognizant of your attitudes and beliefs about suicide: Although it’s perfectly fine for you to hold personal, religious, and philosophical beliefs about suicide, if those beliefs interfere with your competence in providing assessment services, developing a therapeutic relationship, establishing a collaborative treatment plan, or providing ongoing management of suicidal behaviors and research-supported interventions – then you’re engaging in unprofessional and unethical practice.
Information about suicide and specific suicide assessment methods is voluminous and overwhelming. In the following pages, I’ve distilled essential information into chunks (sections and subsections). One strategy for managing and using all the suicide-related information available is to read, pause, reflect, and then consider how each chunk of information can apply to your clinical practice.
Every year, the Centers for Disease Control and Prevention (CDC) provide national statistics on death by suicide. Updated data are available through the CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS).
Suicide rates are commonly reported by number of deaths per 100,000 individuals. Using this metric, suicide rates in the U.S. are generally stable from year to year. However, over the past 20 years, death by suicide in the U.S. has edged upward, increasing 40% (from 10.0 per 100,000 individuals in 1999 to 13.5 deaths per 100,000 individuals in 2020). In 2020 (the most recent data available), suicide rates decreased by about 3% from 2019 rates (from 13.9 to 13.5 per 100,000; Curtin, et al., 2021).
Suicide is a major national health concern. The numbers are tragic, but statistically speaking, death by suicide occurs at a very low base rate (i.e., 13.5/100,000). This low base rate poses a prediction problem. Robert Litman, a renowned suicidologist wrote:
At present it is impossible to predict accurately any person’s suicide. Sophisticated statistical models … and experienced clinical judgments are equally unsuccessful. When I am asked why one depressed and suicidal patient commits suicide while nine other equally depressed and equally suicidal patients do not, I answer, “I don’t know.” (Litman, 1995, p. 135)
For clinicians, Litman’s prediction problem translates into a prevention problem. Predicting which 13.5 individuals of every 100,000 will die by suicide is virtually impossible. The good news is that since Litman’s 1995 statement, research that might aid in the prediction and prevention of death by suicide has accumulated. However, there’s also bad news; based on the CDC’s suicide data over the past 18 years, and despite implementation of the National Strategy for Suicide Prevention (2001, 2012), there’s little evidence that our ability to predict and prevent suicide has improved. This has led to calls for new approaches to understanding and preventing suicide (Bryan, 2022; Sommers-Flanagan, 2018).
The word “myth” has two primary meanings.
A myth is a traditional or popular story or legend used to explain current cultural beliefs and practices. This definition emphasizes the positive guidance that myths sometimes provide. For example, the Greek myth of Narcissus warns that excessive preoccupation with one’s own beauty can become dangerous. Whether or not someone named Narcissus ever existed is irrelevant; the story tells us that too much self-love may lead to our own downfall.
The word myth is also used to describe an unfounded idea, or false notion. Typically, the false notion gets spread around and, over time, becomes a generally accepted, but inaccurate, popular belief. One contemporary example is the statement, “Lightning never strikes the same place twice.” In fact, lightning can and does strike the same place twice (or more). During an electrical storm, standing on a spot where lightning has already struck, doesn’t make for a good safety strategy.
The statement “We only use 10% of our brains” is another common myth. Although it’s likely that most of us can and should more fully engage our brains, scientific researchers (along with the Mythbusters television show) have shown that much more than 10% of our brains are active most of the time – and probably even when we’re sleeping.
False myths can stick around for much longer than they should; sometimes they stick around despite truckloads of contradictory evidence. As humans, we tend to like easy explanations, especially if we find them personally meaningful or affirming. Never mind if they’re accurate or true.
Historically, myths were passed from individuals to groups and other individuals via word of mouth. Later, print media was used to more efficiently communicate ideas, both factual and mythical. Today we have the internet and instant mythical messaging.
Suicide myths weren’t and aren’t designed to intentionally mislead; mostly (although there are some exceptions) they’re not about pushing a political agenda or selling specific products. Instead, suicide myths are the product of dedicated, well-intended people whose passion for suicide prevention sometimes outpaces their knowledge of suicide-related facts (Bryan, 2022).
Depending on your perspective, your experiences, and your knowledgebase, it’s possible that my upcoming list of suicide myths will push your emotional buttons. Maybe you were taught that “suicide is 100% preventable.” Or, maybe you believe that suicidal thoughts or impulses are inherently signs of deviance or a mental disturbance. If so, as I argue against these myths, you might find yourself resisting my perspective. That’s perfectly fine. The ideas that I’m labeling as unhelpful myths have been floating around in the suicide prevention world for a long time; there’s likely emotional and motivational reasons for that. Also, I don’t expect you to immediately agree with everything in this document. However, I hope you’ll give me a chance to make the case against these myths, mostly because I believe that hanging onto them is unhelpful to suicide assessment and prevention efforts.
Myth #1: Suicidal thoughts are about death and dying.
Most people assume that suicidal thoughts are about death and dying. Someone has thoughts about death, therefore, the thoughts must literally be about death. But the truth isn’t always how it appears from the surface. The human brain is complex. Thoughts about death may not be about death itself.
Let’s look at a parallel example. Couples who come to counseling often have conflicts about money. One partner likes to spend, while the other is serious about saving. From the surface, you might mistakenly assume that when couples have conflicts about money, the conflicts are about money – dollars, cents, spending, and saving. However, romantic relationships are complex, which is why money conflicts are usually about other issues, like love, power, and control. Nearly always, there are underlying dynamics bubbling around that fuel couples’ conflicts over money.
Truth #1: Among suicidologists and psychotherapists, the consensus is clear: suicidal thoughts and impulses are less about death and more about a natural human response to intense emotional and psychological distress (aka psychache or excruciating distress). The take-home message from busting this myth should help you feel relief when clients mention suicide. You can feel relief because when clients trust you enough to share their suicidal thoughts and excruciating distress, it gives you a chance to help and support them. In contrast, when clients don’t tell you about their suicidal thoughts, you’re not able to provide them with the services they deserve. Your holding an attitude that welcomes client openness and their sharing of distress and suicidal thoughts is foundational to effective treatment.
Myth #2: Suicide and suicidal thinking are signs of mental illness.
Philosophers and research scientists agree: nearly everyone on the planet thinks about suicide at one time or another – even if briefly. The philosopher Friedrich Nietzsche referred to suicidal thoughts as a coping strategy, writing, “The thought of suicide is a great consolation: by means of it one gets through many a dark night.” Additionally, the rates of suicidal thinking among high school and college students is so high (estimates of 20%-40% annual incidence) that it’s more appropriate to label suicidal thoughts as common, rather than a sign of deviance or illness.
Edwin Shneidman – the American “Father” of suicidology – denied a relationship between suicide and so-called mental illness in the 1973 Encyclopedia Britannica, stating succinctly:
Suicide is not a disease (although there are those who think so); it is not, in the view of the most detached observers, an immorality (although … it has often been so treated in Western and other cultures).
A report from the U.S. Centers for Disease Control (CDC) supports Shneidman’s perspective. The CDC noted that 54% of individuals who died by suicide did not have a documented mental disorder (Stone, et al., 2018). Keep in mind that the CDC wasn’t focusing on people who only think about or attempt suicide; their study focused on individuals who completed suicide. If most individuals who die by suicide don’t have a mental disorder, it’s even more unlikely that people who think about suicide (but don’t act on their thoughts), suffer from a mental disorder. As Wollersheim (1974) used to say, “Having the thought of suicide is not dangerous and is not the problem (p. 223).”
Truth #2: Suicidal thoughts are not – in and of themselves – a sign of illness. Instead, suicidal thoughts arise naturally, especially during times of excruciating distress. The take-home message here is that clinicians should avoid judgment. I know that’s a tough message, because most of us are trained in diagnosing mental disorders and as we begin hearing of signs of depression, emotional lability, or other symptoms, it’s difficult not to begin thinking in terms of psychopathology. However, especially during initial encounters with clients who have suicidal ideation, it’s deeply important for us to avoid labeling – because if clients sense clinicians judging them, it can increase client shame and decrease the chances of them sharing openly.
Myth #3: Scientific knowledge about suicide risk factors and warning signs support accurate prediction and prevention of suicide.
Most suicidologists agree: Suicide is extremely difficult to predict (Franklin, et al., 2017).
To get perspective on the magnitude of the problem, imagine you’re at the Neyland football stadium at the University of Tennessee. The stadium is filled with 100,000 fans. Your job is to figure out which 13.5 of the 100,000 fans will die by suicide over the next 365 days.
A good first step would be to ask everyone in the stadium the question that many suicide prevention specialists ask, “Have you been thinking about suicide?” Assuming the usual base rates and assuming that all 100,000 fans answer you honestly, you might rule out 85,000 people (because they say they haven’t been thinking about suicide). Then you ask them to leave the stadium. Now you’re down to identifying which 13.5 of 15,000 will die by suicide.
For your next step you decide to do a quick screen for the diagnosis of clinical depression. Let’s say you’re highly efficient, taking only 20 minutes to screen and diagnose each of the 15,000 remaining fans. Never mind that it would take 5,000 hours. The result: Only 50% of the 15,000 fans meet the diagnostic criteria for clinical depression.
At this point, you’ve reduced your population to 7,500 University of Tennessee fans, all of whom are depressed and thinking about suicide. How will you accurately identify the 13 or 14 fans who will die by suicide? Mostly, based on mathematics and statistics, you won’t. Every effort to do this in the past has failed. Your best bet might be to provide aggressive pharmacological or psychological treatment for the remaining 7,500 people. If you choose antidepressant medications, you might inadvertently make about 200-250 of your “patients” even more suicidal. If you use psychotherapy, the time you need for effective treatment will be substantial. Either way, many of the fans will refuse treatment, including some of those who will later die by suicide. Further, as the year goes by, you’ll discover that several of the 85,000 fans who denied having suicidal thoughts, and whom you immediately ruled out as low risk, will confound your efforts at prediction and die by suicide.
To gain a broader perspective, imagine there are 3,270 stadiums across the U.S., each with 100,000 people, and each with 13 or 14 individuals who will die by suicide over the next year. All this points to the enormity of the problem. Most professionals who try to predict and prevent suicide realize that, at best, they will help some of the people, some of the time.
Truth #3: Although there’s always the chance that future research will enable us to predict suicide, decades of scientific research don’t support suicide as a predictable event. Even if you know all the salient suicide predictors and warning signs, in the vast majority of cases you won’t efficiently predict or prevent suicide attempts or suicide deaths. The take-home message from busting this myth is this: Lower your expectations about accurately categorizing client risk. Most of the research suggests you’ll be wrong (Bryan, 2022; Large & Ryan, 2014). Instead, as you explore risk factors with clients, use your understanding of risk factors as a method for deepening your understanding of the individual client with whom you’re working.
Myth #4: Suicide prevention and intervention should focus on eliminating suicidal thoughts.
Logical analysis implies that if psychotherapists or prevention specialists can get people to stop thinking about suicide, then suicide should be prevented. Why then, do the most knowledgeable psychotherapists in the U.S. advise against directly targeting suicidal thoughts in psychotherapy (Linehan, 1993; Sommers-Flanagan & Shaw, 2017)? The first reason is because most people who think about suicide never make a suicide attempt; that means you’re treating a symptom that isn’t necessarily predictive of the problem. But that’s only the tip of the iceberg.
After his son died by suicide, Rick Warren, a famous pastor and author, created a YouTube video titled, “Rick Warren’s Message for Those Considering Suicide.” The video summary reads,
If you have ever struggled with depression or suicide, Pastor Rick has a message for you. The pain you are experiencing will not last forever. There is hope!
Although more than 1,000 viewers clicked on the “thumbs up” sign for the video, there were 535 comments; nearly all of these comments pushed back on Pastor Warren’s well-intended video message. Examples included:
Pastor Rick isn’t alone in not getting it. Most of us don’t really get the excruciating distress, deep self-hatred, and chronic shame linked to suicidal thoughts and impulses. And because we don’t get it, sometimes we try to rationally persuade individuals with suicidal thoughts to regain hope and embrace life. Unfortunately, a nearly universal phenomenon called “psychological reactance” helps explain why rational persuasion – even when well-intended – rarely makes for an effective intervention (Brehm & Brehm, 1981).
While working with chronically suicidal patients for over two decades, Marsha Linehan of the University of Washington made an important discovery: When psychotherapists try to get patients to stop thinking about suicide, the opposite usually happens – patients become more suicidal.
Linehan’s discovery has played out in my clinical practice. Nearly every time I’ve actively pushed clients to stop thinking about suicide – using various psychological ploys and techniques – my efforts have backfired.
Truth #4: Most individuals who struggle with thoughts of suicide resist outside efforts to make them stop thinking about suicide. Using direct persuasion to convince people they should cheer up, have hope, and embrace life is rarely effective. The take-home message associated with busting this myth is that the best approaches to working with clients who are suicidal are collaborative. Instead of taking the role of an esteemed authority who knows what’s best for clients, effective counselors and psychotherapists take a step back and activate their client’s expertise as collaborators on the suicidal problem.
Individuals who are suicidal are complex, unique, and in deep distress. Judging them as ill is unhelpful. Believing that we can successfully predict and prevent suicide borders on delusional. Direct persuasion usually backfires (Sommers-Flanagan & Shaw, 2017).
Letting go of the four common suicide myths might make you feel nervous. At least they provided guidance for action. But clinging to unhelpful myths won’t, in the end, help us be more effective. How do we start over? Where do we go from here?
All solutions – or at least most of them – begin with a clear understanding of the problem. As someone who has worked directly with suicidal individuals for decades, there’s no better person to start us on the journey toward a deeper understanding of suicide than Marsha Linehan.
Linehan is the developer of dialectical behavior therapy (DBT; 1993). DBT is widely hailed as the most effective evidence-based approach for working with chronically suicidal patients (Linehan, et al., 2015). To help her students at the University of Washington better understand the dynamics of suicide, Linehan begins with this story:
The suicidal person [is] trapped in a small, dark room with no windows and high walls (in my mind always with stark white walls reaching very, very high). The room is excruciatingly painful. The person searches for a door out to a life worth living but, alas, cannot find it. Scratching and clawing on the walls does no good. Screaming and banging brings no help. Falling to the floor and trying to shut down and feel nothing gives no relief. Praying to God and all the saints one knows brings no salvation. The only door out the individual can find is the door to death. The task of the therapist in this situation, as I always tell my clients also, is to somehow find a way to get into the room with the person, to see the person’s world from his or her point of view; to get inside the person, so to speak, and then together search again for that door to life that the therapist knows must be there. (Linehan, 2011, p. iv)
Efforts to understand someone else’s reality are destined to fall short. You can’t always get it right, but that’s okay, because, as you know, empathy is more about being with and feeling with others, than it is about understanding them perfectly. Trying to understand the inner world of others is an act of courage and compassion. Thus, our next step is to begin our descent into that small, dark room with no windows.
The primary thought disorder in suicide is … a pathological narrowing of the mind’s focus, called constriction, which takes the form of seeing only two choices; either something painfully unsatisfactory or cessation.
(Edwin Shneidman, 1984, pp. 320-32; American Journal of Psychotherapy)
Over the past 20-plus years, hundreds of risk factors and dozens of warning signs have been identified in the research literature (Franklin, et al., 2017; Nie, et al., 2021). Individual studies consistently uncover new links to suicidal behavior and give hope to improved suicide prediction and prevention (Garcia de la Garza, et al., 2021).
Unfortunately, suicide risk factors, protective factors, and warning signs are not especially helpful to clinicians (Bryan, 2022; Franklin, et al., 2017; Sommers-Flanagan & Sommers-Flanagan, 2021). There are many reasons for this, including, but not limited to: (a) the overwhelming number of risk/protective factors and warning signs available; (b) the extremely low base rate of death by suicide (and the proliferation of false positive predictions); and (c) the fact that even the best risk factors and warning signs don’t effectively distinguish between suicidal and non-suicidal individuals (Franklin, et al., 2017).
Although risk factors and warning signs are covered next, this coverage is brief. We then move to information that will provide you with a more nuanced awareness of the multidimensional and multi-determined nature of suicide. As you read this section, remember that although knowing suicide risk factors and warning signs is useful, developing a positive working alliance with potentially suicidal clients is far more important. Also note this essential fact: An absence of risk factors and warning signs in individual clients is no guarantee of safety.
A suicide risk factor is a measurable demographic, trait, behavior, or situation that has a positive correlation with suicide attempts and/or death by suicide. In the past, researchers and clinicians have developed strategies for remembering and assessing the presence or absence of suicide risk factors within individual clients. Most contemporary suicidologists, researchers, and practitioners agree: For clinicians, too much focus on suicide risk factor checklists doesn’t help with predicting suicide or categorizing risk, and becoming preoccupied with checklists draws the clinician’s attention away from developing a therapeutic relationship (Sommers-Flanagan & Sommers-Flanagan, 2021).
Prominent researchers and practitioners have questioned the utility of suicide risk factors for categorizing client risk (Corke, et al., 2021; McHugh & Large, 2020). Why then am I now turning to a review (albeit brief) of suicide risk factors, protective factors, and warning signs?
Although suicide risk factors are empirically linked to suicide attempts and death by suicide, relying on risk factors for prediction and risk categorization results in an unacceptable number of false positive (prediction of suicide when it doesn’t occur) and false negative (prediction of no suicide, and it does occur) predictions (Nielssen, et al., 2017). There are many reasons why risk factors don’t accurately predict suicide, but one of the most important reasons is because some risk factors can also function as protective factors. For example, cutting is generally considered a risk factor for suicide. However, in some individuals, cutting is used as an emotional regulation tool, and consequently functions as a protective factor against suicide. In the latter situation, if cutting is prohibited, then suicidality may increase. Similarly, a new antidepressant medication prescription (i.e., for a serotonin-specific reuptake inhibitor) is generally considered a protective factor. However, in individual cases, approximately 2%-5% of new prescriptions can increase agitation and violent thoughts, and can also increase suicidality (Sommers-Flanagan & Campbell, 2009).
Because some traditional risk factors can increase risk or increase protection, traditional risk factors are primarily, if not exclusively, useful only in an individualized context. Specifically, clinicians should be knowledgeable about traditional risk factors (although no one can remember them all) and then, as appropriate with individual clients, collaboratively explore how risk and protective factors affect an individual’s suicidality. When clinicians mutually explore and discover what’s helpful and what increases risk for individual clients, clinical tasks linked to both suicide assessment and suicide treatment are accomplished.
Suicide prevention websites and resources often emphasize that 90%-plus of individuals who die by suicide have a diagnosable mental disorder. Although the 90% number sounds impressive, nearly 100% of clients you’ll see in clinical settings will have diagnosable mental disorders and so this statistic is basically meaningless. In a systematic research-based analysis of the 90% mental illness estimate, Bryan (2022) emphasized that the results don’t “come anywhere close to this value” (p. 37). Further, the CDC reported that only 46% of completed suicides between 1999 and 2016 were associated with a mental disorder (Stone, et al., 2018). As Maris (2019) noted,
Certainly, most suicides are not “crazy.” For the most part, they know what they are doing, are basically rational, and, rightly or wrongly, see suicide as problem-solving. (pp. 175-176)
Although, as Maris (2019) described, most suicides are personal efforts at problem-solving, it is also true that some specific mental disorders, symptom clusters, and psychiatric treatments do confer greater risk. However, like Bryan (2022), I want to emphasize that each of the following mental disorders, although important, only confer slightly elevated suicide risk.
Depression. The relationship between depression and suicidal behavior is well established. Clients with clinical depression and one or more of the following symptoms are at significant risk (Fawcett, et al., 1993; Marangell, et al., 2006):
One key point: because rates of depression are so high, clinical depression, in and of itself, is not a particularly good predictor of suicide risk (Picard & Rosenfeld, 2021). However, depression “plus” another disturbing symptom (as listed above) significantly increases risk.
We will return to the issue of depression assessment with suicidal clients later.
Post-Traumatic Stress Disorder. In a file review of 200 outpatients, child sexual abuse was a better predictor of suicidality than depression (Read, et al., 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, et al., 2001). Overall, trauma appears more predictive of suicide when it occurs earlier in life and is assaultive, chronic, and severe (Angelakis, et al., 2020; Wilcox & Fawcett, 2012).
Conversely, it’s important to note that trauma is also associated with strength. In such cases, the strength associated with trauma is popularly referred to as post-traumatic growth (Jayawickreme & Infurna, 2020). Assessment with clients who are suicidal can help reveal whether individual clients are weakened or strengthened by their traumatic experiences.
Bipolar Disorder. Researchers have identified many specific risk factors among clients with bipolar disorder that predict increased suicidality (Maina & Bramante, 2019):
Substance Abuse or Dependence. Research unequivocally links alcohol and drug use to suicide (Sher, 2006). Suicide risk increases even more substantially when substance abuse is linked to other risk factors, such as depression and social isolation (Madrigal de Leon, et al., 2019). Because alcohol and substances reduce inhibition, they increase immediate suicide risk.
Schizophrenia. A diagnosis of schizophrenia generally increases suicide risk, but among individuals diagnosed with schizophrenia, the specific factors increasing risk include:
Anorexia Nervosa. Anorexia is linked to higher suicide rates, but also has the unpleasant distinction of being a mental disorder that can directly cause death. This has led some to contend that anorectic symptoms represent low-grade, chronic, suicidality. Researchers report that purging and depressive features increase suicidality in some clients, while anxiety along with restricting symptoms increases suicide risk in others (Forcano, et al., 2011).
Borderline Personality Disorder. Clients with a borderline personality diagnosis are well-known for experiencing affect dysregulation and engaging in repeated self-harm or parasuicidal behavior (Rogers & Joiner, 2016). They’re also at higher risk for death by suicide, particularly if they’re also suffering from insomnia (DeShong & Tucker, 2019). Training in Dialectical Behavior Therapy (DBT) and in using a DBT suicide risk assessment and management protocol is vital to working effectively with chronically suicidal patients with borderline personality disorder (Linehan, et al., 2015).
Conduct disorder. Youth diagnosed with conduct disorder are at higher suicide risk (Wei, et al., 2016). This is especially true if depression and/or substance abuse/dependence are also present. It may be that the impulsiveness, poor family relations, and other factors linked to misconduct contribute to heightened suicide risk (Vander Stoep, et al., 2011).
Insomnia. Insomnia in the context of other mental disorders has long been known to increase suicide risk. However, more recently, data have accumulated indicating that insomnia is an independent risk factor, particularly among individuals who report sleeping less than seven hours per night (Hedstrom, et al., 2021). In one study of young adults in the military, self-reported insomnia was more significant than several traditional suicide risk factors (e.g., hopelessness, PTSD diagnosis, depression severity, alcohol and drug abuse; Ribeiro, et al., 2012).
Post-Hospital Discharge. Psychiatric patients are at increased risk for suicide immediately following hospital discharge. This is particularly true of individuals with additional risk factors such as previous suicide attempts, lack of social support, and chronic mental disorders (Links, et al., 2012). There is some debate over whether specific adverse events that occur during hospitalization or some other factors are the biggest contributors to post-hospitalization suicides (Chung, et al., 2016; Large & Kapur, 2018). Individuals discharged from non-psychiatric facilities who have accompanying suicidal thoughts or behaviors are also at greater risk (Wang, et al., 2019).
Serotonin Specific Reuptake Inhibitors (SSRIs). All SSRI medication labels in the U.S. include a black box warning (United States Food and Drug Administration, 2007). 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.
Recent administration of SSRIs (after 30 minutes and until 30 days) is the period during which agitation and violent thoughts are most likely to be stimulated (Healy, 2009; David Healy, personal communication, February 17, 2004). As the renowned suicidologist Ronald Maris (2007) wrote, “I would stress that suicide is an inevitable risk of antidepressant treatment of depressive disorders” (p. 600). The main point here is that although administration of an SSRI antidepressant functions as a protective factor against depression and suicidality for many clients, SSRIs can also stimulate suicidality in an estimated 2%-5% of clients (Sommers-Flanagan & Campbell, 2009).
Many social, personal, and contextual factors are linked to increased suicide risk. A list and brief description of these factors follows.
Social Isolation/Loneliness. Divorced, widowed, and separated people are in a higher suicide-risk category. Single, never-married individuals have a suicide rate nearly double that of married individuals (Van Orden, et al., 2010). Researchers have reported that factors traditionally linked to loneliness (e.g., social scapegoating, unemployment, physical incapacitation), probably contribute most strongly to suicide when combined with hopelessness (Hagan, et al., 2015). Joiner (2005) identified two primary social or interpersonal suicide risks: Thwarted belongingness and perceived burdensomeness.
Previous Attempts. Suicide risk is higher for people with previous suicide attempts (Franklin, et al., 2017). 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). Although previous attempts are important, and asking about and exploring previous attempts is part of a comprehensive suicide assessment interview, in some cases, previous attempts can function as a protective factor.
Non-Suicidal Self-Injury (NSSI). NSSI or self-mutilation is generally considered a means of emotional regulation and not indicative of increased suicide risk. However, repeated self-harm also predicts eventual suicide, especially in young women (Zahl & Hawton, 2004). Specifically, when self-harm progressively rises to single or repeated hospitalization, it may constitute an experimental or practicing behavior that leads to death by suicide. The complicated relationship between NSSI and suicide attempts is one reason why the DSM-5-TR emphasizes client intent when coding for NSSI.
Physical Illness. Many decades of research have established the link between physical illness and suicide (Beghi, et al., 2021). Specific illnesses that confer increased suicide risk include brain cancer, chronic pain, stroke, rheumatoid arthritis, hemodialysis, dementia, and others (Jia, et al., 2014).
Unemployment or Personal Loss. Individuals who suffer personal loss are at higher suicide risk. Unemployment is a particular loss-related life situation linked to suicide attempts and death by suicide. The increased risk may arise, in part, because individuals experience a sense of being a burden on others (Joiner, 2005). Other losses that increase risk include: (a) status loss; (b) loss of a loved one; (c) loss of physical health or mobility; (d) loss of a pet; and (e) loss of face through shameful events (Mandal & Zalewska, 2012; Maris, 2019).
Military Personnel and Veteran Status. Data on military personnel and veteran status are difficult to interpret. However, veteran status in general, and being a young veteran in particular, appears to confer substantially higher suicide risk. The reasons for this may include: (a) post-traumatic stress; (b) access to firearms; (c) difficulties adjusting to civilian life; and (d) reluctance to acknowledge emotional problems or to seek help (Bongar, et al., 2017; Bryan, 2022).
Sexual Orientation and Sexuality. Reports are mixed as to whether Lesbian, Gay, Bisexual, Transgender, or Queer (LGBTQ+) individuals are a high suicide risk group. A 2011 publication in the Journal of Homosexuality reported no clear evidence that Gay, Lesbian, or Bisexual individuals die by suicide at a rate greater than the general population (Haas, et al., 2011). However, LGBTQ+ populations have significantly higher suicide attempt rates, and unique risk factors may be associated with different sexual minority groups (Chang, et al., 2021). In particular, sexuality-related verbal abuse, parental rejection, depression, hopelessness, shame, and previous suicide attempts appear to substantially increase suicide risk for this population (Kaniuka, et al., 2019).
Firearms Availability. Firearms constitute a highly lethal suicide method. This may be why over 50% of deaths by suicide in the U.S. involve firearms. Access to firearms is a suicide risk factor within the U.S. and in other countries (Anestis & Houtsma, 2018; Runyan, et al., 2015). Firearms safety and restriction are associated with reduced suicide rates, especially among males (Houtsma, et al., 2018).
Suicide Contagion. Suicide contagion is defined as indirect or direct passing on of suicidal behavior from one person to another. Researchers report that suicide contagion operates in conjunction with other pre-existing suicide risk factors (Lake & Gould, 2014). Whether it’s a local suicide, a suicide within a high-risk occupation, or highly publicized suicide (e.g., Robin Williams), individuals with a history of depression and suicide attempts have the highest risk (Cheng, et al., 2007; Too & Spittal, 2020).
Abuse and Bullying. Social trauma and bullying can be distinct contextual factors linked to suicidal ideation, attempts, and death by suicide. Bullying and abuse can occur online (cyberbullying), in school, or outside school. Some researchers describe a phenomenon referred to as “spontaneous, unplanned adolescent suicides” that appear unrelated to depression and other traditional risk factors (Reed, et al., 2015, p. 128).
Demographics: Sex, Age, and Race. Age, sex, and race are not strong predictors of suicide, but some clinicians find having knowledge about higher and lower risk groups is helpful. The most common demographic findings include the following:
Protective factors against suicide are personal or contextual factors associated with decreased suicide risk or aid in resisting suicide impulses. Researchers have identified two types of protective factors: (a) factors empirically linked to reduced suicide risk in the U.S. population; (b) factors that protect against suicide for individuals within specific populations (e.g., military, transgender individuals, Native American youth, etc.).
General suicide protective factors include, but are not limited to, the following (Rudd, 2014):
Specific protective factors include:
Similar to risk factors, suicide protective factors offer clinicians negligible statistical or predictive advantage (Franklin, et al., 2017). However, knowing and understanding protective factors can deepen your understanding of what might help protect clients from suicide. Additionally, if you understand protective factors, you’re better prepared to work collaboratively with individual clients to expand on the unique protective factors they find most personally meaningful and relevant.
In 2003, the American Association of Suicidology (AAS) brought together a group of expert suicidologists to develop an “evidence-based” list of suicide warning signs. The purpose was to provide an alternative to risk factor assessment. The hope was to use suicide warning signs in a manner similar to how warning signs are used for heart attacks; signals of immediate suicide risk could guide medical interventions.
The AAS workgroup reviewed hundreds of warning signs in the research literature and on public internet sites. They distilled these to their 10 top suicide-specific warning signs. The acronym IS PATH WARM was used to facilitate recall of the warning signs:
I - Ideation
S - Substance Use
P - Purposelessness
A - Anxiety
T - Trapped
H - Hopelessness
W - Withdrawal
A - Anger
R - Recklessness
M - Mood Change
IS PATH WARM is referred to as evidence-based because the AAS workgroup based their decision-making on empirical research. Unfortunately, subsequent research hasn’t supported IS PATH WARM. In one study, the only warning sign that distinguished between individuals who made a suicide attempt and those who had suicidal ideation – but didn’t make an attempt – was anger/aggression (Gunn, et al., 2011). Another study showed that IS PATH WARM failed to discriminate between genuine and simulated suicide notes (Lester, et al.,2011). These studies illustrate the frustration of trying to predict or anticipate suicidal behavior. There is no robust, empirically supported assessment approach that utilizes suicide warning signs or risk factors (Franklin, 2017). As Bryan (2022) wrote: “any given warning sign for suicide will be wrong far more often than it will be right” (p. 54).
Although suicide rates vary across cultural groupings (e.g., Native Americans) and minority status (e.g., LGBTQ+), most suicide assessment instruments and protocols operate with an assumption of cultural universality. This leaves clinicians with little guidance regarding how to sensitize existing instruments or interview protocols to detect suicide risk and protective factors unique to cultural minority groups (Chu, et al., 2017).
Joyce Chu and colleagues are addressing this gap in the research literature. She refers to her approach as the cultural theory and model of suicide. She’s in the process of evaluating the psychometrics of an instrument, i.e., the Cultural Assessment of Risk for Suicide; CARS, that includes four culturally distinct suicide-relevant categories and eight factors that appear relevant and meaningful for Asian, Latino/a, African American, and sexual minority clients (Chu, et al., 2013). Chu’s categories and sample items representing factors from her questionnaire follow:
Social Discord. This category focuses on “alienation, conflict, or lack of integration with one’s family, community, or friends” (p. 426). For example, family conflict within Asian families is linked to higher suicide risk.
Family Conflict Item: “There is conflict between myself and members of my family.” (p. 429)
Social Support Item: “I have access to many resources in my community.” (p. 429)
Minority Stress. This category includes stresses unique to individuals who identify as being a minority (e.g., this can include mistreatment or harassment associated with cultural or sexual identity and many intersecting identities).
Sexual Minority Stress Item: “The decision to hide or reveal my sexual or gender orientation to others causes me significant distress.” (p. 429)
Acculturative Stress Item: “Adjusting to America has been difficult for me.” (p. 429)
Nonspecific Minority Stress Item: “People treat me unfairly because of my ethnic, sexual, or gender identity.” (p. 429)
Idioms of Distress. This category includes cultural variations in how suicidality is expressed and potential suicide methods (e.g., Latinos are viewed as expressing suicidality via high risk behaviors).Idioms of Distress Item (Emotional/Somatic): “When I get angry at something or someone, it takes me a long time to get over it.” (p.429)
Idioms of Distress Item (Suicidal Actions): “I have thought of my household possessions as things that could be used to commit suicide.” (p. 429)
Cultural Sanctions. This category focuses on cultural values or practices about the acceptability of suicide and the shame or acceptance cultural minority clients might feel about specific life events that could increase suicide risk.
Cultural Sanctions Item: “Suicide would bring shame to my family.” (p. 429)
Suicide risk can be unique within specific cultural groups. Chu, et al., (2019) reported that using the CARS added substantial variance to accuracy in suicide prediction, beyond that which was obtained using the Beck Depression Inventory, the Beck Hopelessness Scale, and the Reasons for Living Inventory. When working with cultural minorities, it may be helpful to use Chu’s instrument or to integrate content from her questionnaire into your suicide assessment interview.
In addition to knowledge from suicide risk factors, protective factors, and warning signs, several suicide theories are helpful for understanding suicide on a deeper level. The following theoretical models are broadly evidence-based and can inform a practical, client-friendly strategy for your work with suicidal clients.
Shneidman posited three factors that directly contribute to suicidality:
Shneidman used Psychache to describe the intense personal pain, anguish, shame, and other negative emotions associated with suicidal crises. He believed that as psychache increases and becomes intolerable, suicide emerges as a potential solution. Not only is the intensity of psychache important, but the degree to which psychache is experienced as unrelenting and permanent also drives suicidal behavior. Psychache plus hopelessness creates higher suicide risk.
Mental constriction is a problem-solving deficit that occurs when suicidal individuals cannot see beyond two alternatives: (a) continued psychache and misery OR (b) cessation of life to eliminate psychache. Researchers have reported that as depression and suicidal ideation increase, problem-solving ability becomes impaired (Ghahramanlou-Holloway, et al., 2012). Suicide interventions should include active and collaborative problem-solving (Quinones, et al., 2015; Sommers-Flanagan & Sommers-Flanagan, 2021).
Perturbability is a state of agitation or heightened arousal; it’s characterized by an inner drive to act or “do something.” When psychache is present, perturbability drives clients toward stopping their pain and misery. Researchers also refer to this as agitation, arousal, or overarousal, noting that sleep disturbance and agitation are linked to suicidal behavior (Ribeiro, et al., 2014).
Shneidman’s three factors should inform all suicide assessment interviewing and intervention models (Sommers-Flanagan & Shaw, 2017). As mental health professionals, we should be thinking about how to assist clients in reducing their pain, improving problem-solving skills, and coping with agitation/arousal.
Many risk and protective factors fall under the broad umbrella of Joiner’s interpersonal theory of suicide (Joiner & Silva, 2012). Joiner (2005) theorized that two interpersonal factors can be proximal causes of suicidal intent.
Well over 50 empirical studies indicate that social isolation contributes to suicide risk and, conversely, that social support is a protective factor (Chu, et al., 2017). Your primary goals should include establishing an empathic interpersonal connection with clients and strengthening your clients’ social networks.
Klonsky and May’s (2015) 3ST is rooted in an “ideation-to-action” framework. They describe the development of ideation and “progression from ideation to suicide attempts” as “distinct processes with distinct explanations” (2015, p. 114). Their theory includes three steps:
Step 1 focuses on the development of suicidal ideation. Similar to Shneidman’s formulation, psychological or emotional pain drives individuals toward suicidal ideation (Klonsky & May, 2015). However, Klonsky and May add that pain alone does not lead to suicidal ideation, but when pain is combined with hopelessness, then ideation is likely.
Step 2 involves social connectedness factors. Klonsky and May (2015) posit that social connectedness is protective and buffer individuals from pain and hopelessness. They define social connectedness broadly; it might include connection to important people, a job, a project, or a role. Higher connectedness protects patients from pain and hopelessness and consequently can prevent progression to step 3.
Step 3 focuses on the progression from suicidal ideation to suicide attempts. Factors that move individuals to suicide attempts can be dispositional, acquired, and practical. Dispositional factors are largely biogenetic (e.g., pain (in)sensitivity; Klonsky & May, 2015). Acquired factors are similar to Joiner’s model; they involve individual life experiences that, over time, have resulted in habituation to pain, fear, and/or death. Practical factors refer to concrete environmental variables, such as whether or not an individual has access to lethal means and the knowledge and ability to utilize those means.
Based on an integration of Shneidman’s, Joiner’s, and Klonsky’s work, the crucial factors that should guide you in your empathic efforts and evaluation include: (a) substantial psychological or emotional pain, (b) social disconnectedness, thwarted belongingness, and/or a sense of being burdensome, (c) hopelessness about the psychological, emotional, or interpersonal angst ever resolving, (d) problem-solving deficits, (e) agitation or arousal, (f) diminished fear of suicide or increased pain tolerance that push individuals toward (g) an accessible lethal means. Also, given that social connection protects against suicide, you should make efforts to establish an empathic and supportive interpersonal connection with patients who report suicide-related thoughts and behaviors (Konrad & Jobes, 2011; Sommers-Flanagan & Sommers-Flanagan, 2021).
Scientific knowledge about suicide and suicide prevention naturally changes over time. Well-meaning practitioners sometimes operate on old, outdated information. Knowing the latest research and practice information for working with suicidal clients is essential.
The medical model refers to the diagnosis and treatment of illness. To focus on illness, identify or name it, and then apply treatments to make it go away, is a good fit for many health conditions. However, emphasizing illness isn’t a good fit for suicide assessment and treatment.
Contemporary practitioners began integrating a constructive (narrative and solution-focused) perspective into suicide prevention work in the 1990s. This perspective holds that, at least to some extent, individuals construct their own personal meaning and reality (Sommers-Flanagan & Sommers-Flanagan, 2018).
Based on constructive theory, whatever we consciously focus on – be it relaxation or anxiety or depression or happiness – shapes individual reality (Gergen, 2009). What this means for suicide assessment and treatment going forward is that clinicians should move away from illness-based weaknesses, deficits, and limitations and instead, adopt a stronger emphasis on clients’ strengths, resources, and potentials.
Holding the belief that suicidal ideation is pathological creates distance between clinicians and clients. If clients sense negative judgments, they’ll be less honest about their suicidal thoughts. In one study, 78% of patients who died by suicide in hospitals denied suicidal thoughts during their last professional contact (Busch, Fawcett, & Jacobs, 2003). Viewing suicidal ideation as a natural means of communicating distress allows clinicians and clients to work more effectively on the problems leading to the suicidal impulses.
The medical model’s focus on what’s wrong or diseased is a compelling perspective. Pursuing a mental disorder diagnosis can be hard to resist, but doing so will over-emphasize risk-factor assessment during clinical interviews:
Similarly, when performing a diagnostic assessment for clinical depression, there can be an excessive emphasis on the negative:
Many studies have illustrated how easy it is to get humans to experience low and depressive moods (Lau, et al., 2012; Teasdale & Dent, 1987). Focusing exclusively on risk factors and diagnostic criteria during a clinical interview can activate or exacerbate your client’s depressive mood state and potentially impair problem-solving. This is an example of how an illness-oriented perspective can inadvertently facilitate an iatrogenic process (Horwitz & Wakefield, 2007).
Rather than continually drilling down into your clients’ depressive and suicidal symptoms, balancing risk factor and diagnostic assessments with questions focusing on wellness is recommended. Forgetting to ask your client about positive experiences is like forgetting to go outside and breathe fresh air. To help facilitate a greater focus on the positive, Cureton and Fink (2019) developed SHORES, an acronym to guide clinicians to consistently ask about protective factors:
S - Ask about Skills and Strategies
H - Ask about Hope
O - Ask about Objections to suicide
R - Ask about Reasons to live and Restricted suicide means
E - Ask about Engagement in care
S - Ask about Supportive relationships and environments
The idea that healthcare professionals must take an authoritarian role when evaluating and treating suicidal clients has proven problematic (Konrad & Jobes, 2011). Authoritarian clinicians can activate oppositional or resistant behaviors (Miller & Rollnick, 2013). If you try arguing clients out of suicidal thoughts and impulses, they may shut down and become less open.
For decades, no-suicide contracts were a standard practice for suicide prevention and intervention (Drye, et al., 1973). These contracts consisted of signed statements such as: “I promise not to commit suicide between my medical appointments.” In a fascinating turn of events, during the 1990s, no-suicide contracts came under fire as (a) coercive and (b) as focusing more on practitioner liability than client well-being (Edwards & Sachmann, 2010; Rudd, et al., 2006). Suicide experts no longer advocate using no-suicide contracts.
Instead, collaborative approaches to working with suicidal clients are strongly recommended. One such approach is the Collaborative Assessment and Management of Suicide (CAMS; Jobes, 2016). CAMS emphasizes suicide assessment and intervention as a humane encounter honoring clients as experts regarding their suicidal thoughts, feelings, and situation. Jobes and colleagues (2007) wrote:
CAMS emphasizes an intentional move away from the directive “counselor as expert” approach that can lead to adversarial power struggles about hospitalization and the routine and unfortunate use of coercive “safety contracts.” (p. 285)
Along with Shneidman, Jobes (2016) recommended viewing clients’ suicidal thoughts and behaviors as efforts to cope with and manage personal pain and suffering (see also Freedenthal, 2018; Maris, 2019). Using the CAMS model, therapist and client collaborate, monitor suicidal ideation, and develop an individualized treatment plan (Jobes, et al., 2004). From first contact, treating clients with suicide potential now emphasizes a collaborative therapy alliance (see Clinical Interviewing, 2017, Chapter 7).
Table 1: Summary of Old Suicide Myths and New Narratives |
|
| Old Myth or Method | New Narrative and Approach |
We interpret suicidal ideation as pertaining to death. |
We interpret suicidal ideation as pertaining to emotional/psychological pain. |
| We look for pathology. | We look for strengths. |
| We view suicidal ideation as deviance. | We normalize suicidal ideation and view it as a communication of distress or psychache. |
| We emphasize risk-factor assessment and diagnostic interviewing. | We balance risk-factor assessment with protective-factor assessment and recognize diagnosis is nearly irrelevant. |
| We implement treatments on clients and establish no-suicide contracts. | We engage clients empathically in a collaborative process of assessment, treatment, and safety planning. |
All of the preceding information about personal reactions to suicide, suicide statistics, risk factors, protective factors, warning signs, suicide theory, and suicide myths was designed to build a foundation for your primary suicide assessment and intervention assignment: To perform a state-of-the-art (and science) collaborative suicide assessment interview.
A comprehensive and collaborative suicide assessment interview is the professional gold standard for assessing suicide risk (Sommers-Flanagan, 2018). Suicide assessment scales and instruments can be a valuable supplement – but not a substitute – for suicide assessment interviewing.
To help you recall essential components of a comprehensive suicide assessment interview, I’m using an acronym. Although I recognize this acronym is imperfect (and, as my wife says, “weird”), it helps me systematically remember areas to cover during an interview. You should feel free to ignore this acronym, create your own, or have a reminder card to help you cover the following components:
In addition to the RIP-SCIP (pronounced Rip Skip) assessment model, you should also consult with one or more professionals and keep detailed documentation of your assessment and decision-making process.
Suicidal ideation is directly linked to potential suicide behavior. It’s difficult to imagine anyone dying by suicide without having first experienced suicide ideation.
You may decide to systematically ask every client about suicide ideation during every initial clinical interview. This approach guarantees you won’t face a situation where you should have asked about suicide, but didn’t. Alternatively, you may decide to weave questions about suicide ideation into clinical interviews as appropriate.
At least initially, for developing professionals, we recommend using the systematic approach. However, we recognize that this can seem rote. From our perspective, you will learn to ask artfully by systematically asking over and over. Later, you may decide to vary your timing of asking about suicide. In one study, researchers reported that the timing of asking about suicide (i.e., beginning of the session compared to mid-session) had no effects on client disclosure of suicidality (Chu, et al., 2017).
The nonverbal nature of communication has direct implications for how and when you ask about suicidal ideation, depressive symptoms, previous attempts, and other emotionally laden issues. For example, it’s possible to ask: “Have you ever thought about suicide?” while nonverbally communicating to the client: “Please, please say no!” Therefore, before you decide how you’ll ask about suicidal ideation, you need to adopt the right attitude about asking the question.
Individuals with suicidal thoughts can be extremely sensitive to social judgment. They may have avoided sharing suicidal thoughts out of fear of being judged as “insane” or some other stigma. They’re likely monitoring you closely and gauging whether you’re someone to trust with this deeply intimate information. To pass this unspoken test of trust, it’s important to embrace and directly or indirectly communicate the following beliefs:
If you don’t embrace these beliefs, clients experiencing suicidal ideation may choose to be less open.
Asking about suicidal ideation may feel awkward. Learning to ask difficult questions in a deliberate, compassionate, professional, and calm manner requires practice. It also may help to know that, in a study by Hahn and Marks (1996), 97% of previously suicidal clients were either receptive or neutral about discussing suicide with their therapists during intake sessions. It also may help to know that you’re about to learn the three most effective approaches to asking about suicide that exist on this planet.
Use a normalizing frame. Most modern prevention and intervention programs recommend directly asking clients something like, “Have you been thinking about suicide recently?” This is an adequate approach if you’re in a situation with someone you know well and from whom you can expect an honest response. However, based on a meta-analysis of 70 studies, Matthew Large and his research team reported that about 60% of people who died by suicide denied suicidal ideation when asked by a general practitioner or psychiatrist(McHugh, et al., 2019). This finding implies that there are psychological and interpersonal barriers to disclosing suicidal thoughts.
To improve your chances at getting an honest self-disclosure, using a nuanced approach to asking about suicide may help. Using a normalizing or universalizing statement about suicidal ideation is recommended. Here’s the classic example:
Well, I asked this question since almost all people at one time or another during their lives have thought about suicide. There is nothing abnormal about the thought. In fact, it is very normal when one feels so down in the dumps. The thought itself is not harmful. (Wollersheim, 1974, p. 223)
Three more examples of using a normalizing frame follow:
A common fear is that asking about suicide will put suicidal ideas in clients’ heads. There’s no evidence to support this (Jobes, 2016). More likely, your invitation to share suicidal thoughts will reassure clients that you’re comfortable with the topic, in control of the situation, and capable of dealing with the problem.
Use gentle assumption. Based on over two decades of clinical experience with suicide assessment, Shea (2011) recommended using a framing strategy referred to as gentle assumption. To use gentle assumption, the interviewer presumes that certain illegal or embarrassing behaviors are already occurring in the client’s life, and gently structures questions accordingly. Instead of asking “Have you been thinking about suicide?” you would ask:
When was the last time when you had thoughts about suicide?
Gentle assumption can make it easier for clients to disclose suicidal ideation. Shea recommended it for emergency room situations, in particular.
Use mood ratings with a suicidal floor. It can be helpful to ask about suicide in the context of a mood assessment (as in a mental status examination). Scaling questions can be used to empathically assess mood levels (see also, below).
The preceding protocol assumes clients are minimally cooperative. More advanced interviewing procedures can be added when clients are resistant (see Clinical Interviewing, 2017, Chapter 12). By exploring mood states and situational triggers, you may uncover a deeper understanding of life events linked to negative moods and suicidal ideation. This can lead to formal counseling or psychotherapy, as well as safety planning.
Let’s say you broach the question and your client openly discloses the presence of suicidal ideation. What next?
First, remember that hearing about your client’s suicidal ideation is good news. It reflects trust. Also remember that depressive and suicidal symptoms are part of a normal response to distress. Validate and normalize:
Given the stress you’re experiencing, it’s not unusual for you to think about suicide. It sounds like things have been really hard lately.
This validation is important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they’re a social burden (Joiner, 2005). Your empathic reflection may be more or less specific, depending on how much detailed information your client has given you.
As you continue the assessment, collaboratively explore the frequency, triggers, duration, and intensity of your client’s suicidal thoughts.
As you explore the suicidal ideation, strive to show calmness and curiosity, rather than judgment. Instead of thinking, “We need to get rid of these thoughts,” engage in collaborative and empathic exploration.
Some clients will deny suicidal thoughts. If this happens, and it feels genuine, acknowledge and accept the denial, while noting that you were just using your standard practice.
Okay. Thanks. Asking about suicidal thoughts is just something I think is important to do with everyone.
On the other hand, if the denial seems forced, or is combined with depressive symptoms or other risk factors, you’ll still want to use acknowledgment and acceptance, but then find a way to return to the topic later in the session.
You may be in a clinical situation where it’s your role to conduct a formal diagnostic assessment for depression. If so, you should use a diagnostic assessment procedure or protocol (see Clinical Interviewing, 2017, Chapter 11). However, when possible, using a balance of positive- and negative-oriented questions is recommended. Sample questions that focus on different dimensions of depression follow.
Mood-Related Symptoms. Open-ended questions are useful:
In response, clients may or may not use diagnostically clear words such as “sadness” or “irritability.” Instead, you might hear, “I’ve just been feeling really shitty lately.” If that’s the case, paraphrase with language similar to your client (see Case Example 1, below).
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To maintain balance, it’s useful to use mood questions with a positive focus:
Positive mood questions can pull clients toward more positive moods. If the client brightens, then you’re seeing positive mood reactivity. If the client doesn’t brighten, the depressive condition may be deeper and more difficult to change.
Anhedonia. Major depressive disorder can involve a loss of interest or pleasure in usually enjoyable activities. This symptom is known as anhedonia (without pleasure).
Positive questions about anhedonia include:
Physical or Neurovegetative Symptoms. Clients with depression frequently experience physical symptoms related to eating and sleeping. Psychiatrists refer to these symptoms as neurovegetative signs and consider them cardinal features of biological depression.
Neurovegetative questions include:
Cognitive Symptoms. Negative cognitions are a hallmark of depression and often center around Beck’s (1976) cognitive triad: negative thoughts about the (a) self, (b) others/world, and (c) the future.
One especially important cognitive symptom linked to suicidality is hopelessness (Van Orden, et al., 2010; Wenzel, Brown, & Beck, 2009). Depending on your affinity for numbers and your client’s tolerance of rating tasks, you could repeat the mood rating task but focus on hopelessness:
On that same scale from 0 to 10 that we talked about before, this time with 0 meaning you have no hope at all that your life will improve and 10 being you’re full of hope that things will improve and you’ll start feeling better, what rating would you give?
Hopelessness may be expressed in different ways, such as “I don’t see how things will ever be different” or “I’ve felt like this for as long as I can remember.” Client ability to make constructive or pleasurable future plans is an important gauge of hopefulness.
Future-oriented questions include:
Questions that require clients to reflect on past successes or third-person situations can be useful for evaluating whether hopefulness can be stimulated:
Social/Interpersonal Symptoms.Clients with depressive symptoms may not be fully aware of their isolation. If you believe you don’t have the full picture, you may need a release of information to speak with family or friends. It’s helpful to listen for statements indicating that the client has changed and become more distant, hard-to-reach, despondent, or exceptionally touchy or irritable.
Even though you’re trying to be helpful, potentially suicidal clients will sometimes treat you with hostility. The basic principles for dealing with this are: (a) take nothing personally, (b) only go as deep as needed, (c) respond to everything with compassion and empathy, and (d) maintain your helpful demeanor.
Client hostility is usually related to irritability, a common symptom of depression. This next section is adapted from Sommers-Flanagan (2018).Dealing with Client Irritability. When clients are extremely irritable it may be difficult to develop rapport. Client irritability also can provoke negative emotional reactions in you. Consequently, if you have a client who is insulting you (e.g., “Everything you say is such bullshit. I’ll kill myself if I want to.”), using a three-part response is recommended: (a) reflective listening, (b) gentle interpretation, and (c) a statement of commitment to keep working with and through the irritability.
Client irritability can also signal a relationship rupture. You may have said something that your client didn’t like and, in response, your client may show irritability and anger, or withdraw. If you think your client’s irritability is about a relational rupture (instead of irritability associated with depression), several options can be useful (Safran, et al., 2011; Sommers-Flanagan & Sommers-Flanagan, 2017). These options include:
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 with similar thoughts also have a plan for dying by suicide. 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. If clients do admit to a plan, further exploration is crucial.
When exploring and evaluating suicide plans, Miller (1985) recommended assessing four areas: (1) specificity of the plan; (2) lethality of the method; (3) availability of the proposed method; and (4) proximity of social or helping resources. These four areas of inquiry are easily recalled with the acronym SLAP: Specificity, Lethality, Availability, Proximity.
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 still 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 refers to how quickly a suicide plan could result in death. Greater lethality is associated with 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, razor blade), but also about the way the method will be employed. For example, 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 refers to availability of the means. If the client plans 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 complete a 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 the bedroom.
Proximity refers to proximity of social support. How nearby are helping resources? Are other individuals available to intervene and rescue the client if an attempt is made? Does the client live with family or roommates? Is the client’s day spent alone or around people? Generally, 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).
Asking directly about self-control and observing for agitation, arousal, or impulsivity are the main methods for evaluating client self-control.
If you want to focus on the positive while asking directly about self-control, you can ask something like:
What helps you stay in control and 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 try to kill yourself?
Exploring both sides of self-control (what helps with maintaining self-control and what triggers a loss of self-control) can be therapeutic. This is done together with your client in an effort to understand the client’s perception of self-control. Rudd (2014) recommended having clients rate their subjective sense of self control using a 1-10 scale. When clients express doubts about self-control that cannot be addressed therapeutically, hospitalization is a reasonable consideration. Hospitalization can provide external controls and safety until the client feels more internal control.
Here’s an example of a discussion that includes: (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 often fear losing control late at night.
Therapist: Sounds like night is the roughest time.
Client: I hate when I’m awake and alone after midnight.
Therapist: So, late at night, especially around midnight, you’re sometimes afraid you’ll lose control and kill yourself. What has helped keep you from doing it.
Client: I think of the way my kids would feel when they couldn’t get me to wake up in the morning. I just start bawling my head off at the thought. It always keeps me from really doing it.
A brief verbal exchange such as this isn’t a final determination of safety or risk. However, this client’s love for her children is a mitigating factor that may work against a loss of self-control.
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 effects self-control. Unfortunately, systematic methods for evaluating arousal are lacking. This leaves clinicians to rely on five approaches to assessing arousal, agitation, and impulsivity:
Suicide intent is defined as how much an individual wants to die by suicide. Suicide intent is usually evaluated following a suicide attempt (Hasley, et al., 2008). Higher suicide intent is linked to more lethal means, more extensive planning, a negative reaction to surviving the act, and other variables. In a small, longitudinal research study, suicide intent, as measured by the Beck Suicide Intent Scale (BSIS), was a moderate predictor of death by suicide (Stefansson, et al., 2012).
Assessing suicide intent prior to a potential attempt is more challenging and less well researched. 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 is you’re absolutely certain you want to live, how would you rate yourself right now?
It’s also possible to infer intent based on the SLAP assessment of client suicide plans. This has some evidence base because suicide-planning items on the BSIS are the strongest predictors of death by suicide (Stefansson, et al., 2012).
Obtaining detailed information about previous attempts is important from a medical-diagnostic-predictive perspective, but unimportant from a constructive perspective where the focus is on the present and future. Whether to explore past attempts or 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, is valuable information (Clark, 1998; Rudd, 2014). On the other hand, to some extent, detailed questioning about intent, plans, and past attempts involves a deepening preoccupation with 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.
Previous attempts are considered the strongest of all suicide predictors (Bryan, 2022). Information about previous attempts is usually obtained through the client’s med-psych records, an intake form, or while discussing depressive symptoms (see Case Example 2, below). It’s also possible that you won’t have information about previous attempts, but you decide to ask directly. Again, using a normalizing frame is advisable:
It’s not unusual for people who are feeling very down to have made a suicide attempt. And so I’m wondering if there have 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 that, 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 is 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 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 interventions 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. I’m guessing they all haven’t been equally bad. I’m sure that some of them are worse than others. For example, you’ve tried physical exercise, you’ve tried talking to your brother and sister and one friend, and you’ve tried different medications. Let’s list these out and see which of these has been worse and which has been less bad.
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 worse than the meds?
You’ll notice the therapist emphasized that some efforts at dealing with depression/suicide were worse than others. This language resonates with the negative emotional state of depressed clients. It will be easier to begin by identifying the most worthless of all their strategies and build from there to strategies that are “a little less bad.” Building a personal and unique continuum of helpfulness for your client is the goal. Then, you can add new ideas that you suggest or that the client suggests, and put them on the continuum. If this approach works well, you’ll have several ideas (some new and some old) that are worth experimenting with in the future (see also Sommers-Flanagan & Sommers-Flanagan, 2021).
In the text revision of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR; American Psychiatric Association, 2022), clinicians can code for the presence of suicidal behaviors. The central features of this symptom code include potentially self-injurious behavior plus an intent to die by suicide. Your client’s intent to die by suicide may be inferred (through observation and history) or explicit (via self-report).
The DSM-5-TR also includes a new symptom code for non-suicidal self-injury. This code is used when intentional self-injury has occurred, but intent to die by suicide is absent. These two symptom codes (i.e., suicidal behavior and non-suicidal self-injury) are important because previous suicide attempts confer greater suicide risk, while repeated non-suicidal self-injury may function, for some clients, as a protective factor (Bjureberg, et al., 2021; Turner, et al., 2022). Of course, discerning client intent, as discussed elsewhere, is challenging.
Outside of formal suicide assessment interviews, three main sources of information can be used to initiate a discussion with clients about suicide risk and protective factors:
If available, your client’s previous medical or mental health (med-psych) records are an efficient source for client risk and protective factor information. Many risk factors listed in this curriculum won’t be in your client’s records, but you should look for factors such as: (a) previous suicidal ideation and attempts; (b) a history of a depression diagnosis; and (c) familial suicide. After your standard intake interview opening and rapport building, you can use the records to broach these issues.
I saw in your records that you attempted suicide back in 2012. What was going on in your life back then to trigger that attempt?
When exploring previous suicide attempts, it’s important to do so in a constructive manner that can contribute to treatment (see Case Example 2, below). Using psychoeducation to explain to clients why you’re asking about the past helps frame and facilitate the process.
The reason I’m asking about your previous suicide attempt is because the latest research indicates that the more we know about the specific stresses that triggered a past attempt, the better we can work together to help you cope with that stress now and in the future.
Don’t forget to balance your questioning about previous suicide attempts with a focus on the positive.
Often, after a suicide attempt, people say they discovered some new strengths or resources or specific people who were especially helpful. How about for you? Did you have anything positive you discovered in the time after your suicide attempt?
It may be difficult to identify protective factors in your client’s med-psych records. However, if you find evidence of protective factors or personal strengths, you should bring them up in the appropriate context during a suicide assessment interview. For example, when interviewing a client who’s talking about despair associated with a current depressive episode, you might say something like:
I noticed in your records that you had a similar time a couple years ago when you were feeling very down and discouraged. And, according to your therapist back then, you worked very hard and managed to climb back up out of that depressing place. What worked back then?
Strive to use information from your clients’ records collaboratively. As illustrated, you can use the information to broach delicate issues (both positive and negative).
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Suicide assessment instruments are a means for collecting information regarding many different suicide risk and protective factors (Hughes, 2011). Some clients find it easier to be open about their suicidal thoughts and past when filling out a questionnaire. Suicide questionnaires have the advantage of providing substantial suicide-related information quickly, in a standardized format.
The disadvantages of assessment instruments lie primarily in their impersonal-ness and standardization. They don’t flex, pause, or give clients an empathic look or word of encouragement. They don’t directly contribute to your therapeutic alliance. Also, although you have information at your fingertips, that information is only useful if clients respond honestly, and only if you review the instrument before or during the session.
Assessment instruments can alert you to potential suicide risk. If a client endorses a questionnaire item indicating suicidality, you should discuss it openly, in a way that models transparency and collaboration:
The reason I had you fill out those questionnaires was to help focus our time together. When I reviewed your responses, I noticed several things to discuss. First, you indicated you have high stress in your life right now. Second, you mentioned you’ve had thoughts about suicide. Third, the way you filled out the questionnaire suggests you’re feeling pretty angry. I’ve listed these three issues for us to talk about. What else should we discuss?
Suicidal thoughts and impulses don’t constitute an emergency. When clients endorse suicide-related questionnaire items, there’s no need to over-react. The recommended approach is to acknowledge and accept suicidal thoughts and impulses as one of many important discussion topics.
To whet your appetite regarding the multitude of potentially useful measures, several are listed and described below.
The Columbia-Suicide Severity Rating Scale (C-SSRS; Posner, et al., 2011)
The C-SSRS is considered the gold standard for suicide screening. The C-SSRS is used by several largescale organizations, including the Centers for Disease Control and the National Institute of Mental Health. Many U.S. school districts also use the C-SSRS.
The C-SSRS has two opening questions; one assesses for passive suicide ideation and the other assesses for active suicide ideation. If respondents answer “Yes” to the active suicide ideation question, four follow-up questions are administered. The final question is a preparation question: “Have you ever done anything, started to do anything, or prepared to do anything to end your life?” Responses to the C-SSRS are color-coded to indicate low, moderate, or high risk. Despite its widespread use, the C-SSRS is not a particularly good predictor of suicide. For example, in a recent study of 1,376 adult patients in an emergency room setting, the C-SSRS had weak psychometrics and did not perform well in predicting future suicide attempts. The researchers concluded, “The utility of the C-SSRS in an [emergency department] setting is inadequate in terms of predictive power, though may be useful for classification of suicidal thoughts and behavior” (Brown, et al., 2020, p. 7).
The Patient Health Questionnaire-9 (PHQ-9, Kroenke & Spitzer, 2002). The PHQ-9 may be the most commonly used suicide screener, especially within medical settings. Subsidized by Pfizer, the PHQ-9 consists of the nine diagnostic criteria for major depression, set to a 4-point Likert scale, where 0 indicates no symptoms and 3 indicates symptoms are present “Nearly every day.” As in the DSM-5-TR criteria, item 9 is the suicide item and reads: “Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?”
As administered, the PHQ-9 relies on a single item for assessing suicidality. If you read the item closely, you can discern several issues associated with it:
I’ve deconstructed item 9 of the PHQ-9 to illustrate how and why an instrument cannot replace a clinical interview. Specifically, if a patient rates item 9 as a 1, 2, or 3 on the Likert scale, a clinician is needed to further evaluate whether the ideation is passive or active, whether the ideation involves self-harm, as well as the many other dimensions of suicidal ideation and action described in the RIP-SCIP interview protocol.
The PHQ-9 has high validity for the diagnosis of major depression (Kroenke & Spitzer, 2002). This makes logical sense because patient self-report on the same exact items clinicians are using for establishing a diagnosis should show high consistency. The PHQ-9 is also viewed as having high utility in medical settings.
The Reasons for Living Inventory (RFL; Linehan, Goodstein, Nielsen, & Chiles, 1983). Most suicide screening instruments focus exclusively on the presence or absence of risk factors. In contrast, the 48-item RFL focuses exclusively on protective factors (i.e., reasons for living). It includes six main factors: (a) Survival and Coping; (b) Responsibility to Family; (c) Child-Related Concerns; (d) Fear of Suicide; (e) Fear of Social Disapproval; and (f) Moral Objections (Linehan, et al., 1983, p. 283). A briefer version is also available (Ivanoff, et al., 1994). Using the RFL may help balance the traditional risk factor and symptom-oriented questionnaires.
The Beck Hopelessness Scale (BHS; Beck & Steer, 1988). This 20-item true/false self-report questionnaire focuses on hopelessness. The item content includes negative and positive beliefs about the future. It has high reliability (.87 to .93) and has been shown to predict suicide attempts and death by suicide (Brown, et al., 2000).
The Cultural Assessment of Risk for Suicide (CARS; Chu, et al., 2013). This 39-item scale is newer. Initial data indicate it may be especially useful for Asian, Latino/a, African American, and LGBTQ+ individuals (Chu, et al., 2013). Reading through the items on this culturally-oriented scale can help enhance your sensitivity to culturally-unique suicide risk factors.
Using Multiple Questionnaires and Practical Issues. Many agencies and clinicians use two or more questionnaires for suicide screening, followed by clinical interviews. In a workshop sponsored by the American Psychological Association, the presenters were clear that questionnaires add only modest value to a suicide assessment interview. However, they also emphasized that using a standardized questionnaire is especially important to limit liability in cases of completed suicides. You may want to select a brief screening tool to use in conjunction with your clinical interview.
Collateral informants represent an often untapped source of information about client risk and protective factors. In addition, collateral informants represent a potential source of social support.
Informants can provide information before, during, or after your initial clinical interview. Due to legal/ethical issues, you must have a consent for release of information to share anything about clients. However, even without a release of information, you can listen to what collateral informants say. Consider the following telephone scenario.Therapist: Hello. This is Rita Sommers-Flanagan.
Informant: Hi Rita. My name is Megan McClure. I’m calling about a friend of mine, Kristin Eggers. She’s coming to see you today and I have something you should know.
Therapist: Okay. Thanks for telling me that. I can’t tell you if I know anyone by that name without a release of information.
Informant: Right. Well, I’m her good friend and I know she’s seeing you today, because she told me.
Therapist: Although I can’t tell you anything, I can listen. Then, if it turns out I see someone with the name you mentioned and it seems like the right thing, I could get a release of information signed so we can talk again.
Informant: I don’t care about all that. I just want to tell you that she’s been talking about suicide and I’m very concerned about her. I’m just not sure how open she’ll be and so I wanted you to know.
Therapist: Thanks for that information. Whether or not I ever see someone of that name, I just want to say that you’re a dedicated and concerned friend … which is very nice.
This therapist chose to listen to and receive information about the client. You may not always make this choice, but if you do, it includes a subsequent cascade effect of ethical decision-making. In this case the caller (Megan) has no professional relationship with the therapist and therefore there’s no confidentiality obligation. It may be appropriate, when Kristin arrives for counseling, to tell her early in the session that Megan called and what Megan said. Alternatively, the therapist could have immediately told Megan,
Before you share anything, I should tell you that my policy is to discuss phone calls like this one with clients directly.
If the therapist shares about Megan’s telephone call, Kristin may feel either supported or betrayed. If she feels supported, there may be ways to weave Megan into the counseling to provide support if risk escalates. However, if she feels betrayed, it may cause an alliance rupture between the therapist and Megan (which can be dealt with using the rupture and repair guidelines in Clinical Interviewing, Chapter 7).
Throughout your clinical interview or psychotherapy session, you will face stressful decision-making. In some cases, you’ll need to decide whether to initiate a safety planning protocol (Stanley & Brown, 2012). In other cases, you may decide that the suicidal thoughts are minimal, and agree with your client to do a regular suicide check-in from session to session. In still other cases, you may prompt your client to voluntarily be hospitalized, or you may decide that your client is so extremely suicidal that involuntary hospitalization is necessary.
There are two overlapping approaches to final decision-making with clients who are suicidal. The first and more traditional medical approach involves you taking on the role of medical or psychological expert and making authoritative treatment recommendations based on the factors reviewed in this course. As the medical authority, you may decide your client requires hospitalization. You may pursue hospitalization even if the client objects. Although the probability of you having to involuntarily hospitalize a client is low, every clinician should be able to take on this role of medical authority. Hopefully you won’t have to exercise that ultimate authority, but sometimes during suicidal crises, mental health professionals need to hospitalize clients against their will.
The second and less traditional approach emphasizes clinician-client collaboration. From this perspective, as a collaborator, you do everything you can to avoid usurping your client’s decision-making power. Even in cases of extreme suicidality, collaboratively oriented clinicians will seek ways to establish a plan “with” their clients. For example, you might recommend hospitalization, but if the client objects, you might work out a less extreme and more palatable situation where, along with an intensive safety plan, the client is monitored and supported by immediate family and friends.
The second course in this two-course series focuses on treatment planning and suicide interventions, including collaborative safety planning. For this course (Part 1), despite my previously having questioned suicide risk categorization, I will now review a more traditional approach, focusing on suicide risk factors, protective factors, warning signs, and other variables. When necessary, all clinicians should be capable of using their independent judgment to estimate risk, even though in most cases you will want to work using a collaborative approach. Unfortunately, the reality is that sometimes clients will be so impaired that they’re not able to offer much assistance in the decision-making process.
Most suicide risk categorization models include consultation. Whenever possible, you should reach out to trusted colleagues to help you make suicide-related client decisions. In addition, most suicide risk categorization models include an assessment of the following factors.
Suicide Risk Factors: Suicide risk factors were reviewed earlier in this chapter. Specific suicide risk factor checklists are available online and at many agencies. Generally, more risk factors equate to more risk. However, some risk factors are particularly clinically salient. These include:
Protective Factors: Any single protective factor may outweigh many risk factors. But, as mentioned previously, it’s impossible to know the depth or meaning of any individual protective factors without discussing the factors with your client.
Warning Signs: As noted previously, IS PATH WARM is a reasonably good set of warning signs. However, Bryan (2022, p. 51) summarized a slightly different list, including:
Nature of Suicidal Ideation: As discussed earlier, suicidal ideation can be evaluated in terms of frequency, triggers, intensity, and duration. Increases in any one or more of these dimensions increases risk, but it’s sometimes true that the more disturbed clients are by their own suicidal thoughts, the higher the risk.
Suicide Intent: In most cases, suicide intent is the factor most likely to move clients toward a lethal attempt. Suicide intent can be based on more 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: Sometimes, 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. These signs during an interview will contribute to your final evaluation.
Using a traditional assessment approach, you should estimate your client’s suicide risk as fitting into one of these three categories:
Mild: Minimal risk. The situation may be managed with weekly monitoring and an emergency plan. Although depression and suicide ideation are not good predictors of suicide, if either is present you should make sure firearms and lethal means are safely stored.
Moderate. The situation should be managed with an active 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: Treatment may include hospitalization and/or an intensive safety plan implemented with family/friends. Make sure firearms and lethal means are safely stored.
Following the guidance in this course will help you provide state-of-the-science comprehensive suicide assessments. But I would be remiss if I didn’t also share the truth with you: Conducting a perfect suicide assessment is impossible. I know that’s not what you wanted to hear at the end of this course. You might do a nearly perfect assessment and seemingly make all the right decisions, and still have clients who attempt or complete suicide. If that happens, please engage in the best self-care you can.
As one of my former patients once said, “The mind is a terrible place to go … alone.” I pass on his advice to you. When you work with patient clients who are suicidal, it can take you to dark places. Don’t go there alone. Find a professional support group, a friend, or your own psychotherapist; take someone with you to those dark places. Maintaining your own mental health, optimism, and wellness will enable you to continue to meet the challenge of suicide assessment and management (Sommers-Flanagan, 2018).
No doubt, as we come to the end of this course, you may still feel anxious. You may be thinking, “I need to know more” or “Isn’t there a perfect formula that will help me make the correct decisions.” Sadly, we all need to know more and there is no perfect formula. That said, if you absorb the content of this course you’ll have a better chance of making reasonable clinical decisions, and you’ll be able to meet or exceed the usual standards of care.
This course focuses on clinician awareness, attitude, and knowledge, and touches on some components of clinical skills. Although the content in this course stands on its own, it is the first course in a two-course series. The second course, Suicide Interventions and Treatment Planning for Clinicians: A Strengths-Based Model, includes more content on skill development, case examples, and guidance for treatment planning and implementing specific suicide interventions, as well as decision-making around hospitalization. If this course leaves you wanting more, the good news is that there’s also a second course.
For more information on the strengths-based approach, you can read our book, Suicide Assessment and Treatment: A Strengths-Based Approach (2021) and/or watch our 7.5-hour video series at psychotherapy.net, Assessment and Intervention with Suicidal Clients (2019).
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