Having a suicidal patient is every therapist's nightmare. Although there is little data on the number of mental health professionals who experience the death of a client, it is estimated that one in every five will lose a patient to self-inflicted death. The anxiety provoked by such a prospect is daunting for many reasons, including legal liability, emotional distress, feeling unprepared to handle suicidality, and insufficient local resources for treatment. As overwhelming as it may be, knowing how to manage a patient in crisis is crucial for keeping them safe and for providing the highest standards of care.
Checking for suicide risk should be part of any initial assessment procedure, even if the patient doesn't report it as an existing concern. One of the ways to do this is to include direct questions on the paperwork they fill up when they first come to the office. Having this option may help bridge the natural resistance and allow the client to mention suicide in a more subtle way. A trusting relationship needs to be built before these individuals share existing ideation to their therapist.
When creating such questions, it is important to know that suicide follows a continuum that begins with less severe forms of thoughts to serious expressions of intent (attempts and completed suicide). Every step should be assessed. These are: random thoughts and ideation - which are more prevalent - to planning, attempts and completed suicides. It is by knowing where the patient stands that the mental health professional will be able to put together a safety plan with effective interventions.
Particular attention should be given to those who have a history of ideation in adolescence but it is relevant to note that having thoughts doesn't necessarily lead to an attempt. The relationship between these two points of the spectrum is twofold: only a fraction of people who experience ideation will proceed to the next stages. On the other hand, the majority of attempters and individuals who die by suicide have transitioned from ideation to planning. This is not enough for reaching reliable predictions, though. The therapist must consider other contributing factors, particularly the patient's history of mental disorder, risk and protective factors, as well as genetic and environmental influences.
Because no validated predictive tools exist, clinical judgment guides the decision-making process.
Research shows that non-fatal suicidal behavior is the strongest known clinical predictor of eventual suicide.
Although there is insufficient evidence to support routine screening, evidence shows that asking high-risk patients about suicidal intent leads to better outcomes and does not increase the risk of suicide. Important elements of the history that permit evaluation of the seriousness of suicidal ideation include the intent, plan, and means; the availability of social support; previous suicide attempts; and the presence of comorbid psychiatric illness or substance abuse. After intent has been established, inpatient and outpatient management should include ensuring patient safety and medical stabilization; activating support networks; and initiating therapy for psychiatric diseases. Care plans for patients with chronic suicidal ideation include these same steps, as well as referral for specialty care. In the event of a completed suicide, physicians should provide support for family members who may be experiencing grief complicated by guilt, while also activating their own support networks and risk management systems.
Evidence shows that inquiring about suicide does not increase suicidal ideation or attempts.
Direct inquiry concerning suicidal ideation in patients with risk factors is associated with more effective treatment and management7,8 because it allows the physician to gain necessary information while potentially alleviating patient anxiety.
Direct inquiry concerning suicidal ideation in patients with risk factors is associated with more effective treatment and management.
Screening for depression, anxiety, and alcohol use helps to determine symptom severity in a patient with possible suicidal ideation.
Use of suicide prevention contracts should generally be avoided.
Treatment of suicidal ideation should include medications and psychological interventions.
In a simple, straightforward manner, these are the main aspects that should be taken into consideration when assessing suicidality:
1. Risk Factors: suicidal behavior (be direct), psychiatric disorder (family history), current stressors, access to methods.
2. Protective Factors:
a. Personal - religion, coping mechanisms, personality, tolerance to frustration, anger management.
b. External - support system, pets, therapy, relationships, children.
3. Suicidality: ideation frequency, plan (how far), prior attempts, access to weapons.
4. Choose intervention (according to risk):
a. High: admission, hospitalization
b. Moderate: maybe admission, crisis plan + resources
c. Low: outpatient referral, symptom reduction, work on triggers, emergency/crisis resources
Risk assessment - RF and WS
Despite the widespread use of no-suicide contracts, there exists no empirical support for their use. They appear to be more useful as a tool to measure the strength of the therapeutic alliance than in any other application: clients who share a strong relationship with their therapist are likely to see them as a demonstration of genuine caring; those with suspicions may see them as a means to relieve the therapist’s own anxiety about suicide and its ramifications.
An alternative to the no-suicide contract is the commitment to treatment statement (CTS). The CTS is an agreement that the client will commit to therapy and outlines what this will look like, such as identifying the roles of client and therapist, communicating openly and honestly, and accessing emergency services during crises that threaten a client’s ability to honor the agreement. The latter is facilitated by the creation of a crisis response plan (CRP) that details steps the client can take in a crisis situation to ensure their safety, from self-soothing techniques to calling a crisis line or emergency services. Both documents are formulated collaboratively with the client in handwriting during the session and should be revisited and revised as therapy progresses.
need to err on the side of client safety.
improve their clinical practices
detection, prediction and management
these challenges include providing sufficient informed consent, performing competent assessments of suicidal risk, using empirically supported treatments/interventions, and using suitable risk management techniques. In summary, there are many complicated clinical issues related to suicide
, provided that the professional feels
n inaccurate belief may persist that hospitalization is the optimal clinical response to a distressed patient. This is a problem, given the absence of evidence supporting the enduring efficacy of acute hospitalization, particularly compared to randomized controlled behavioral treatment trials reporting reduction of risk using psychosocial outpatient interventions for suicidal behaviors
Ethical Considerations in the Assessment and Management of Suicide Risk (APA)
Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (SAMHSA)
Developing Clinical Skills in Suicide Assessment, Prevention, and Treatment
Impact of Patient Suicide on Psychiatrists and Psychiatric Trainees
Graduates in practice and trainees of the residency program of the University of Toronto from 1980–1995 (N = 495) were surveyed, retrospectively, with 239/495responding (48%). Demographic and educational information, exposure to suicide, impact of the suicide(s), use of support systems, acute stress disorder and posttraumatic stress disorder symptoms, and impact of events and social relationship scores were collected. Results: One-half of the respondents (120/239) experienced at least one suicide of a patient, 62% of them (74/120) during postgraduate training.
a study 376 professional counselors participated, found that approximately 24 percent of counselors had lost clients to suicide. Among the counselors who had gone through that experience, approximately one-fifth were student counselors.
American Psychiatric Association - Helping Residents Cope With a Patient Suicide
Working with Suicidal Clients: 6 Things You Should Know
Article on client suicide: McAdams, C. R. III, & Foster, V. A. (2000). Client suicide: Its frequency and impact on counselors. Journal of Mental Health Counseling, 22(2), 107-121.
Article: Sveticic, J., & De Leo, D. (2012). The hypothesis of a continuum in suicidality: a discussion on its validity and practical implications. Mental illness, 4(2), e15. doi:10.4081/mi.2012.e15.
Article: Norris, D., & Clark, M. (2012). Evaluation and Treatment of the Suicidal Patient. American Family Physician, 15;85(6), 602-605.
Support Group material
American Foundation for Suicide Prevention's Training - CLICK HERE
American Association of Suicidology's guiding principles of suicide bereavement groups - CLICK HERE
How to start a survivor's group by the World Health Organization, WHO - CLICK HERE
APA's Distribution of Licensed Psychologists and Suicide Rates - https://www.apa.org/workforce/publications/suicide-mortality.pdf
APA's story on ways to prevent suicide - https://www.apa.org/monitor/2019/07-08/cover-prevent-suicide?utm_source=facebook&utm_medium=social&utm_campaign=apa-monitor&utm_content=impact-suicide