Suicide Assessment:  Assessing through the Grays by Balancing Risk and Protective Factors

Courtesy: Joe Houghton. Flickr. License: Creative Commons.
Courtesy: Joe Houghton. Flickr. License: Creative Commons.

Our clients most often come to us at their most vulnerable state when we first meet them. One of the toughest calls for social workers is determining when and how to make a suicide assessment.

What is the short answer for the exam and practice? Always.  Assessment is an ongoing process during engagement, treatment, and before termination.

It’s an especially sensitive issue because it depends on a highly developed sense of clinical judgment: we have to be careful not to under-assess and ignore significant material that comes up in session (such as a client voicing that they see “no purpose” to living), but we also don’t want to extrapolate conclusions and immediately hospitalize a client for having passive thoughts which lack a plan or intent.  I have often had clients who have been scared away from engaging in mental health because of previous negative experiences of being hospitalized, perhaps out of another clinician’s justified anxiety, and have been apprehensive about re-engaging in mental health.

All thoughts are to be taken seriously, but a highly developed sense of clinical judgment obtained through experience and supervision will help social workers in making the call between an immediate risk and passive ideation, the latter being when the client possess the insight and motivation for treatment.

Suicide assessment can be thought of not as a single event or question, but as a balancing probing between a client’s high risk factors and protective factors, or things that mitigate the risk (CDC, 2015). For example, a client may have had recent loss, but also lives with a supportive family system and is financially stable, which highly mitigates the risk. Someone who lives alone and is financially vulnerable, given the same immediate stressor, may be more at risk.

Examples of Risk Factors

  • Substance abuse
  • Family history of suicide
  • Gender (male)
  • Access to firearms
  • Recent loss (relational, financial)
  • History of previous attempts
  • Psychotic symptoms (e.g., command hallucinations telling the client to harm themselves). This is considered an immediate call for hospitalization, especially if there is low insight.
Examples of Protective Factors

  • Supportive family system
  • Financial stability
  • Personal/cultural beliefs supporting life preservation
  • Living accompanied
  • Good rapport with therapist and/or psychiatrist (engagement)

Source: CDC, 2015.


Clinical Pointers

  • Talking about suicide does not encourage it. This has been a long-held myth that talking about suicide encourages it. Instead, talking about it normalizes our client’s feelings, and can create a sense of hope through exploring themselves as individuals holding a shared experience as others before them, rather than a unique despair.  It also helps the clinician explore and reality-test some of the source of hopelessness.  See The Samaritan’s helpful guide on other myths.
  • Empathy versus sympathy. While our first instinct as a clinician may to immediately mitigate a client’s feelings, empathy (reflecting, validating, and sincerely approaching an empathic mirroring of the client’s feelings) will often go a longer way than sympathy (simply offering platitudes or pat responses about things improving). Sometimes, a presence that will “stay” with the client’s feelings versus immediately suppressing it down may go further in helping the client feel understood and “normal.”
  • Never go it alone. This one cannot be stressed enough. No matter how many years you have been in the field, you are not meant to assess it or go it alone.  If even in the slightest doubt, always be sure that you can call a supervisor into your session, or seek advice of a psychiatrist who will help you make a fully informed hospitalization decision. In the interest of self-care, and fully competent practice, you should never feel the weight of a major decision solely on you.
  • Protective factors. After the immediate crisis is over, the client’s protective factors can be an invaluable source to build resilience. The protective factors are the most powerful starting points to work with clients from a strengths-based perspective.

Disclaimer: This is just a starting point for what can be a complicated and serious clinical situation to accurately assess. This post is not meant to be a replacement for supervision or psychological/psychiatric advice, and only aims to serve the purpose of offering knowledge points that can apply to the licensing exam.

Suicide Prevention Resources
National Suicide Prevention Hotline 1-800-273-8255
Samaritans 24-Hour Crisis Hotline 212-673-3000
Trevor Project 212- 695-8650

References

Myths About Suicide – The Samaritans. (n.d.). Retrieved September 29, 2015. http://samaritansnyc.org/myths-about-suicide/.

Suicide: Risk and Protective Factors. (2015, August 28). Retrieved September 29, 2015, from http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html

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