Abstract
Information about specific risk and protective factors for assessments are presented in Chapter 4. In this chapter, we present selected clinical considerations for integrating and synthesizing information gathered about well-known risk factors so that it can be used to improve our understanding of the individual person and drive plans and responses.
A Introduction
Information about specific risk and protective factors for assessments is presented in Chapter 4. In this chapter, we present selected clinical considerations for integrating and synthesizing information gathered about well-known risk factors so that it can be used to improve our understanding of the individual person and to drive plans and responses.
Depending upon your role, you may have responsibility for different parts of an assessment process. Can you identify your role? Are you gathering information and passing it on to others? Are you responsible for synthesizing and acting on risk assessment? Even if you are only responsible for a small part of the overall process, it will be useful to understand the whole framework so that you can contribute effectively to a team.
The first part of this chapter will provide a repeatable structure for gathering and communicating key information about the person’s life and experiences that provide a context for understanding suicidal thoughts and behavior.
The second part focuses on detection and assessment of suicidal ideation, behavior, and risk. This includes structured screening and assessment, interviewing techniques, and emerging methods that do not rely on self-report.
The third part of this chapter covers prevention-oriented risk formulation – a framework for synthesizing and communicating about risk in a way that is anchored and actionable in a particular setting and in a particular individual’s life.
Figure 6.1 Prevention-oriented risk formulation
The left side of the figure provides a repeatable structure for gathering and communicating data that informs assessment. The right side of the figure provides a framework for synthesizing and communicating about risk in a way that is anchored and actionable in a particular setting and in a particular individual’s life.
B Principles
Assessment of suicide risk must go beyond just questions about suicidal thoughts and plans. The goal of an assessment is to understand suicide risk in the context of the whole person and their situation.
Routine use of structured screening tools helps ensure consistent assessment and decreases the chances that key questions will be missed.
Protocols and techniques for responding to a positive screen are just as important as the instrument you choose.
Structured screening alone will miss many people at risk, often including those with the highest intent. The validity techniques covered in this chapter enhance the accuracy of answers to screening questions.
When assessing data for a risk assessment, it is important to consider the level of engagement of the person and the reliability of their answers.
Prevention-oriented risk formulation helps healthcare professionals develop a personalized and context-specific understanding of the dynamics of a person’s situation, and helps communicate this complex and changing situation to others.
Risk formulations start from understanding the enduring and dynamic factors underlying suicide risk: strengths and protective factors; long-term risk factors; impulsivity and self-control; stressors and precipitants; symptoms, suffering, and recent changes.
The purpose is not prediction, but planning. The goal of risk formulation is to promote communication, collaboration, and action among professionals, patients, and families in order to reduce risk.
While stratification into high, medium, or low risk can be useful, more nuanced formulations will consider the person’s risk relative to broader populations (risk status) and their risk relative to themselves at other times (risk state).
More important than the level of risk is identifying what could exacerbate risk and what resources are available to help in crisis and treatment.
C Understanding the Context for Suicide Risk
The first part of this chapter will introduce a structure for understanding and communicating contextual information about suicide risk. Having a structure for person-specific information helps organize the elements of a person’s story so that it can be used to drive responses and provide a common “language” for communicating with colleagues inside and outside one’s organization, in team meetings and hand-offs, and in health record documentation.
Enduring versus Dynamic Factors
Information relevant to suicide risk can be organized loosely into factors that are more enduring and factors that are more dynamic. When first working with someone, it is critical to understand their history and background. Enduring factors emerge from listening to a person’s history. Over time, tracking changes in dynamic factors is critical for identifying specific periods of vulnerability.
Enduring Factors
Strengths and Protective Factors
Chapter 4 listed some statistically important protective factors. In addition to these, it is helpful to identify things that make a person feel unique or good about themselves, whether or not these are documented epidemiological protective factors. Does the person have talents or hobbies? Do their friends say they have a great sense of humor? Do they have a strong family support system or a connection to a religious community?
Patient Perspective
“Sometimes you’ll encounter a person who can’t seem to say anything positive about themselves. That was me when I was thinking about suicide. I thought the world would be better off without me, and I didn’t see anything good about myself. If you are working with someone like that, you could ask what positive things other people might say about them.”
Gathering information about what is strong, special, and unique about a person and about what is important to them helps all involved to see the at-risk person as more than just a diagnosis or a list of problems. Eliciting strengths helps forge a connection between clinician and patient and provides insights into how the patient sees themselves or their contribution to the world. Understanding how a person sees their core strengths provides insights into what future changes or losses might lead to increased risk and provides a starting place for protective plans.
Jessica is a 14-year-old girl.
Traditional case presentations start with the problem: “This is a 14-year-old girl with a long history of depression, multiple foster-care placements, presents with agitation.”
But with only a little extra effort, we can set the scene with strengths: “Jessica is a 14-year-old girl who loves to sing and draws cartoons that all the other kids love.”
Beginning with the person’s strengths and uniqueness evokes a different picture to those who hear the presentation. The presentation is about a person, not a list of problems. We must include and address the information about depression, foster care, and agitation, but leading with strengths respects the person as an individual human.
On a more directly practical front, if Jessica loves to draw, then we might see it as a warning sign if she were suddenly to stop drawing, or if she threw out her collection of sketchbooks.
Long-Term Risk Factors
Specific risk factors for suicide are discussed elsewhere in this book (see Chapter 4). The goal of the present section is to reflect on how knowledge about risk factors can inform clinical understanding and action.
The concept “risk factors” is taken from epidemiology and can be challenging to apply in clinical circumstances. The key is to remember that the “factors” are more than just statistical variables that predict risk; they are part of the “setting” to a person’s story. Seen this way, they provide insights into what a person has been through, the challenges they have survived, and what kinds of burdens they might need help carrying.
Clinical Tip: Who Can You Tell Anything To?
When assessing strengths and protective factors, inquire about social support and connectedness. One particularly rich question to ask is: “Who can you tell anything to?” The answer can tell you (a) whether or not the person has one or more people they can trust and turn to, and (b) whether the person is willing and able to tell people about their inner life, and even about things that make them feel bad or ashamed about themselves.
Clinical considerations for eliciting information about enduring risk factors include:
Mental health history: It is not only about depression. Depression is often the first condition that comes to mind when clinicians think about suicide risk. However, other disorders, including anxiety, bipolar disorder, schizophrenia, and certain personality disorders, are also implicated. Many of these conditions can come with strong feelings of anxiety, urgency, and agitation – a feeling of being trapped and wanting to get out of one’s own skin. This feeling can be particularly potent among youth. Understanding this dimension of a person’s mental health condition can help in formulating an assessment that takes account of the felt experience of the individual.
Family history of suicide: If you don’t ask, they might not tell. Having a family member who died by suicide means that a person has been exposed to suicide as an “option.” They may see suicide as a viable response to pain and, consequently, may turn to it more readily. It is important to keep in mind that many families will not mention this history unless directly asked.
History of child maltreatment: Trauma-informed care is critical to suicide prevention. Research has shown associations between suicide attempts and all types of childhood abuse and neglect, with sexual and emotional abuse appearing to be particularly important in explaining suicidal behavior. Assessing and addressing these factors requires a trauma-informed approach.1 Learning about a background of abuse can play a critical role in helping the clinician identify possible stressors that can be mitigated, as well as in safety planning that makes appropriate use of family resources.
Demographics: Avoid stereotypes; understand the experience. Risk factors can vary according to demographics, with different age groups, cultures, and sexual preferences, for example, all being associated with statistically different rates of suicide. Useful as this information might be, the primary reason for exploring and synthesizing demographic data is that this context is important for understanding where an individual person is coming from and for grasping how they, as a unique individual, might have been impacted by belonging to any of these groups.
Clinician Perspective
I worked in a pediatric primary care center for six years. Even though I was pretty detailed in putting together family histories, it wasn’t until I started learning more about suicide risk that I began to directly and routinely ask about family history of suicide. When I did, I was shocked to find that so many of the children or parents I knew well had very close relatives who had died by suicide. Now, whenever I gather information, I’ll ask something like, “In a family this large, has there been anybody who’s died by suicide? How about any close friends?” That’s one way to ask that might feel less stigmatizing.
Impulsivity and Self-Control, and Alcohol and Substance Misuse
Impulsivity is the tendency for a person to act without thinking, particularly in contexts in which their actions may put themselves or others in danger. People who have difficulty with impulse control can act quickly when they are frustrated or provoked. They are less likely to stop and think about how to moderate or restrain their reactions, and more likely to respond to situations without planning or considering the consequences of their actions. While there is not yet any consensus on how impulsivity works as a risk factor for suicide death, there is a correlation between impulsivity and suicide attempts.
Clinical Tip: Listen for the Experience Behind the Epidemiology
Information about the epidemiology of suicide is most useful in a clinical context if you ask about the individual experiences that might lie behind the numbers. For example, LGBTQ youth statistically have greater risk for suicidal ideation and behavior (see Chapter 16). But what do you do with these numbers when you are working with an individual? Rather than focus on statistical risk, let this knowledge prompt you to ask about the kind of experiences that might account for the epidemiology. For example, knowing that LGBTQ youth are at higher risk relative to the general population can lead us to ask about experiences that may play a role in that statistical risk, but which are specific to the individual, such as strains in family relationships, bullying, and sexual violence. Our goal in asking about long-term risk factors is not to categorize the person as a member of a group, but to use what we know about these groups to shed light on the individual case.
Alcohol and drug misuse clouds judgment and disinhibits risky behavior. Further, alcohol and drugs can restrict a person’s ability to see that they have options available to them other than suicide to find a way out of their pain. When exploring a person’s history of substance abuse, it is important to ask whether they were using drugs or alcohol when thinking about or attempting suicide in the past.
Drug and Alcohol Recovery: A Sensitive Period
While substance abuse can be an important factor for formulating a risk assessment, it is also important to remember that suicide risk can increase during recovery from dependence. Even if a person is being treated for a chemical dependency and has a good relapse prevention plan, it is still necessary to consider the risks that can come if a relapse does happen.
For both impulsivity and substance use, the most important clinical consideration is how these factors will affect the person’s ability to follow through with crisis and safety plans. The efficacy of such plans will likely be diminished. This does not mean safety planning should not be used with persons who are highly impulsive or likely to use substances, but it does indicate a greater need to take other prevention measures, such as involvement of other support persons in plans and closer, more frequent follow-up and observation. These measures are covered in greater detail in Chapter 7.
Dynamic Factors
Stressors and Precipitants: Listen for the Meaning
Most stressors that have been empirically linked to suicide (relationship disruptions, financial trouble, health concerns, etc.) are extremely common. The question then arises as to what makes an otherwise ordinary stressor become something that could trigger suicide. Leading theories of suicide2–4 provide useful clues concerning what clinicians should ask about and listen for when hearing about a stressful life event.
The key is to listen for the subjective meaning or consequence of the stressor. In particular, clinicians should listen for stressors that make the person feel:
All alone, isolated
Like a burden, having nothing to offer
Socially defeated, humiliated
Trapped
If you work with families in the child welfare system, you will want to keep the welfare of parents in mind as well. In a 2017 study with over 10,000 mothers, mothers of children who had been removed from the home and taken into care had higher rates of suicide attempts and deaths than mothers who received services but did not have children taken into care.
Symptoms, Suffering, and Recent Changes
This key domain includes symptoms that are often found on diagnostic checklists. However, “symptoms” are generalized concepts rather than individual experiences, so the word “suffering” is also included in the framework here to reflect the more specific lived context of the individual person. Thinking about both symptoms and suffering can help remind the clinician that the assessment process is not just a box-ticking exercise but has a real human being at its center.
Hopelessness, feeling out of control, being more withdrawn, and feeling that there is no hope for improvement are the kinds of symptoms and suffering clinicians need to be particularly alert for. Knowing what might change for the worse for a specific person will also be central to suicide prevention planning.
It is important to note recent changes because they can help tell the clinician where a person is right now and can also provide some indication of where that person might be heading in the near future. In order to understand the dynamics of suicide risk, it is important to pay attention to whether symptoms and suffering are increasing or decreasing. Risk can only be assessed in a way that can usefully be applied if the assessment assists in understanding the trajectory of the individual’s experiences.
Stressors and precipitants can also manifest as current symptoms and causes of suffering. Increases in anger, isolation, depression, and/or hopelessness can all translate into a sense of being demoralized about the future and into feelings of hopelessness about things ever getting better. Similarly, impulsivity and a person’s sense that they lack self-control can lead to feelings of regret and to the suffering such feelings can bring.
Engagement and Reliability: Explicitly and Honestly Assess the Person’s Ability to Engage with Services and Reliably Report their Distress
When assessing the gathered data, it is important to consider the level of engagement between the clinician and the person being assessed. The individual’s degree of openness, their relationship with the clinician, and the extent to which they engage with the process all impact the kind of support plans that can be developed. It is important to be honest in assessing engagement, as the likelihood that important information may not have been volunteered will contribute to future planning. Concluding that the person has not engaged openly is not a negative judgment on them. Often, systems are not set up in a way that optimizes engagement for those with suicide risk (systems may be unfriendly, hard to access, inconvenient, or expensive, for instance).
A related issue is the question of the degree to which a person’s report has been honest, reliable, and credible. Tools for improving the fidelity of data gathered are discussed in this chapter under the heading “Interview Strategies and Techniques.” However, even when using such tools, a clinician may still in some cases suspect that the information they have collected is incomplete or inaccurate. If there are reasons to believe that a person is downplaying or exaggerating any aspect of their thinking, their behavior, or the things that have happened or might happen to them in their lives, then this needs to be accounted for in the assessment. The person might, for instance, suffer from psychosis, or have cognitive challenges, or even just change their story a lot. They may be wary about communicating honestly if they believe this will have negative consequences for their relationships with family members. Including these factors in an assessment, and in the communication of this assessment to colleagues, provides an important aid in calibrating how to deal with the other information that has been gathered. Determining that a person’s account is not reliable does not mean making a moral judgment about their character. It is simply a case of determining how to help them as effectively as possible.
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