Assessing Suicide Risk

It is almost World Suicide Prevention Day again (see last year’s post here and look for a new one shortly). This is a big and important topic for any mental health professional. As it is for anyone whose life has been impacted by suicide.

I have written previously about suicide and trauma survivors as well as how anti-gay bullying can increase suicide risk for LGBT youth. How to best identify suicide risk is (and what to do about it) is an ongoing conversation in the mental health field. I learned recently about new research in this area: psychologists at Harvard University have developed two new tests that provide a different means of assessing suicide risk. These measures look at current thoughts about suicide and the likelihood of an individual attempting suicide in the future. Unlike current methods of assessing risk that rely on self-report and a clinical interview, these tests are objective. You can read more about the specifics here.

Harvard Professor of Psychology Matthew K. Nock describes the problems with current approaches to assessing suicide risk as follows:

The current approach, based on self-reporting, leads to predictions that are scarcely better than chance, since suicidal patients are often motivated to conceal or misrepresent their mental state. We sought to develop more sophisticated, objective measures of how psychiatric patients are thinking about suicide. Our work provides two important new tools clinicians can use in deciding how to treat potentially suicidal patients

It is true that in therapy clients may not always be completely forthcoming, about suicidal thoughts or many other issues for that matter. This happens for many reasons, some particular to the individual’s dynamics and others that are related to the therapeutic relationship. It of course takes time to develop the trust required to share one’s innermost feelings and struggles with another person. Getting to this point is the stuff of forming a therapeutic alliance. What impact would it have on the individual and the therapeutic relationship, I wondered as I read about these tests, to gain information that the client was not volunteering willingly?

Elana Premack Sandler, L.C.S.W., M.P.H. poses some questions about the ramifications of these tests at her blog Promoting Hope, Preventing Suicide:

1) Should there be, a “magic bullet” for suicide prevention?

A “suicide test” challenges conventional wisdom around suicide prevention in clinical settings. Traditionally, practitioners have struggled with how to ask about suicide and how to gauge what answers really indicate acute risk. A test that objectively predicted suicide risk would be quite a relief. But, that raises another question:

2) How might these tests take away the human dimension of a clinical assessment?

Even as I wrote out that question, I thought, “Well, the point of a clinical assessment is that there is some objectivity, and as humans we’re rarely objective.” So maybe the point is to take away the subjectivity, to make it clear – this person is suicidal, and this person is not. But, people aren’t really that simple, are we?

3) Wouldn’t it be equally useful to, in my colleague’s words, research the helpful dialogues that get patients to tell practitioners that they have suicidal thoughts?

Yes, please. My colleague is a natural skeptic, so she really wants to put these tests to the test. Being the nerd I am, I’m excited to think that there could be a scientifically proven way to help more people that might be easier than asking really hard questions. At the same time, I wouldn’t want to de-emphasize the value of the relationship between a clinician and a patient. Ideally, suicide assessment would involve a combination of an objective measure and a relationship-based conversation.

This last point, about assessing for suicide in the context of a relationship between the client and therapist resonated for me. It has me thinking about what I understand about suicide and what gets someone to the point of seeing it as an option, or their only option. Of course given the focus of my practice I see suicidal thoughts and feelings often resulting from unaddressed trauma (big T and little t). The combination of tremendous psychological pain and the (faulty) belief that this current state is permanent may lead the trauma survivor to see death as the only escape. Often this is coupled with actual or felt isolation and disconnection from others. I have written before about how meaningful connection with others is a key part of what makes life living. What then if you believe you lack that?

That brings me back to the therapeutic relationship. Sometimes this is the only or first place a trauma survivor is able to feel a connection. I also see it as my role to help those struggling with suicidal thoughts realistically assess their importance to others. Most often, you matter more to others than you believe you do! And your life impacts many in ways you may never fully grasp. Having been a witness to the devastating and life-altering impact of suicide on the survivors, even decades later, I can attest to this fact: every single one of our lives matter.

Of course I see a place for the quick and definitive identification of suicide risk. In the short term it is crucial to intervene in any way to prevent someone from acting irrevocably from this place of pain and faulty belief. I say faulty because help IS available. Trauma and depression can be treated and the pain lessened. Even when you cannot see it, there is hope for your healing. Suicide is never, every your only option.

I can imagine these tests being of great value in crisis assessment, emergency rooms and as a screening tool prior to admission and discharge from psychiatric hospitals. However, in the ongoing work of therapy I think about what comes after suicide assessment; giving hope to the hopeless, finding meaning in a life that seems meaningless, these are tasks that must occur in the context of relationship and connection.

Kathleen Young, Psy.D.

Connection Heals

I have written in previous articles about how crucial connection is and how we can learn to create positive relationships after trauma (including even creating families of choice).

I have also been thinking a lot about a unique type of connection: the therapy relationship. I have heard and firmly believe that a huge piece of what works about therapy IS the relationship.  Sharing your inner self (selves) and what makes you feel vulnerable in the context of a healthy relationship can be transformative.

That this is challenging for those who have already been betrayed and traumatized in the context of relationships is a huge understatement. Sometimes it may seem to trauma survivors that in order to heal they must do the very thing they fear most: trust someone else.

I am still gathering my thoughts about healing in the context of the relationship and therapy, so stay tuned for more on that!  In the meantime, a friend shared the following story and images with me. To me, it speaks to the drive for connection, how we can find it at times in unlikely places and that the capacity for love and trust can remain even after abuse and neglect.

The Story of Suryia and Roscoe

The orangutan was in a rescue and not doing well. This old hound wandered in absolutely emaciated and the orangutan snapped to like his buddy had arrived. He stayed with the hound night and day until he was well and in the whole scenario, found a reason to live. They are now inseparable.

Connection Heals

Connection Heals

Connection Heals
Kathleen Young, Psy.D.

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3 Responses to Assessing Suicide Risk

  1. Kent Brooks says:

    Insightful post, I really enjoyed it. As soon as the word objective comes out I have to perk up… is there any such thing as an objective test, really?

    Risk assessment isn’t about predicting violence, it’s about preventing it. The article seems to suggest that they have a silver bullet to prevent malpractice suits… i.e. we give the test, see low risk, and we as clinicians are subsequently exonerated if that individual subsequently does something violent.

    I’m curious if it works?

  2. Lothlorien says:

    You are right that it is difficult for clients to be forthcoming about suicidal thoughts. Inherently I knew my thoughts thoughts and feelings were “wrong”. I was ashamed that I felt this way. Then there was a time I feared being completely honest because I was afraid of hospitalization. I actually feared that more than dying!! I guess because I wasn’t sure how I was going to keep my thoughts and feelings private if that were to happen. Wouldn’t my family find out? What would my friends think? What about my job? I have always struggled with Major Depressive Disorder. After I was finally put on medication for it in the early ’90′s things really improved. However, the medication began losing its effectiveness and down I went again after 12 years of peace. In my desperation I went back into therapy and was VERY forthcoming with my thoughts and feelings only to be labeled Borderline!!! I was not manipulating; I was not “begging for attention”, I had no motives—-I just wanted out of the dark hole of depression. I wanted help. It is sad that when someone is forthcoming that they can be perceived as being Borderline because “most” people aren’t so open about their feelings of suicide. These feelings scared me. I also have DID and feared I would “watch” myself —–. I have since changed therapists. It was the best thing I have ever done. Once I asked my new therapist if she thought I was Borderline because if I really am, I want to know, and she looked at me as if I had suggested the most ridiculous thing. “Absolutely not,” was her reply. I hope that other therapists read this.

  3. Pingback: Not All Wounds Are Physical: National Depression Screening Day | Dr. Kathleen Young: Treating Trauma in Chicago

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