Suicide Risk Assessments as it Pertains to Rehabilitation Counseling Yoshekia Wilson Dr. Patrick Oigbokie Jackson State UniversitySpring 2014 Suicide and suicidal behavior is among the most common and the most dreaded mental healthcare issue Rehabilitation Counselors and other mental health professionals will face. A national survey found that about half of psychiatrists and one of every four psychologists who provide patient care reported having had a patient commit suicide (McNiel, Fordwood, Weaver, Chamberlain, Hall, & Binder, 2008). Identifying individuals who are at increased risk of suicide is a major clinical challenge. Approximately 9% of people report having serious thoughts of suicide at some point in their lives and 3% actually make a suicide attempt (Borges, Nock, Abad, Hwang, Sampson, Alonso, Andrade, Angermeyer, Beautrais, Bromet, Bruffaerts, de Girolamo, Florescu, Gureje, Hu, Karam, Kovess-Masfety, Lee, Levinson, Medina-Mora, Ormel, Posada-Villa, Sagar, Tomov, Uda, Williams, & Kessler, 2010).
Each year, approximately 1 million people die by their own hand. Given the estimates that there are 50 suicide attempts for each suicide death, the morbidity and mortality due to suicidal behavior are staggering (Flemons & Gralnik, 2014). But research has assisted us in determining some of the risk factors of suicidal behavior. Mood disorders, aggression, impulsivity, hopelessness, and past suicidal behavior are all important predictors of suicidal behavior as well as socio-demographics, childhood, marital status, employment, parental psychopathology, and education. The DSM-V lists suicidal behavior disorder under Conditions for further study, which is also a subcategory of the model for personality disorders. Suicide is defined as the act of killing oneself intentionally or to intentionally kill oneself. For awhile, suicidal behavior was listed under mood disorders, but clinicians have seen this disorder in many other diagnosis, such as substance abuse, personality, anxiety, and schizophrenia, just to name a few. Some even consider suicidal behavior a symptom of major depressive episode or borderline personality disorder, which is consistent with the current DSM-V. To understand suicide, you must first understand what may cause someone to make them want to perform such an act.
The most common psychiatric symptoms associated with suicidal behaviors include, agitation, anxiety, insomnia, substance abuse, depression, and psychosis. Although these symptoms can be prevented with the use of medication, medications do not reach the therapeutic levels immediately. Medication is typically used as an immediate intervention but you have to be careful of the side effects of the medicines as well. Your clients’ levels of toxicity should also be monitored because of adverse effects and the possibility of overdosing. Suicidal ideations, plans, and attempts are complex behaviors and are associated with a variety of psychological, biological, sociocultural, and environmental risk factors (Torchalla, Strehlau, Li, Schuetz, & Krausz, 2012). Studies of risk factors predicting suicide consistently suggest that suicidal ideation and a history of suicide attempts are among the most salient risk factors for suicide. A structured assessment of suicidal ideation and behavior significantly improves identification of high-risk patients relative to a routine clinical interview (Posner, Brown, Stanley, Brent, Yershova, Oquendo, Currier, Melvin, Greenhill, Shen, & Mann, 2011). There are a number of fabrications surrounding suicide risk assessment.
One is that certain risk factors can predict the likelihood of suicide in individual patients, another is that people in high risk groups are likely to die by suicide, focusing resources on these high risk groups reduces the number of suicides, and addressing and treating risk factors will result in a lower suicide rate. These myths have led t the assumption that suicide could be reduced if increased risk assessments were more rigorously applied and appropriate treatment initiated (Mulder, 2011). Suicide risk assessment must take into account unique and distinctive patient risk and protective factors for which no evidence base exits. Protective factors may include a cherished animal, rewarding employment, important relationships, a compelling interest or avocation, and other factors that only a thorough knowledge of the patient will reveal (Simon, 2006). As a Rehabilitation Counselor, it is our duty to perform thorough screening and examine our clients’ background as it pertains to their medical history, in detail, to determine if our clients’ are indeed suicidal. Counseling in rehabilitation generally refers to the therapeutic context in which the service planning and delivery process takes place. Rehabilitation counselors are trained to be coordinators of the service delivery sequence and also to function as therapeutic facilitators of client improvement. A history of a suicide attempt is the strongest predictor of future suicide attempts, as well as death by suicide.
Asking those hard questions about suicidal ideation, intent, plan, and attempts is not an easy discussion to have. More often times than not, our clients will not openly discuss or ask about suicide and because of the stigma that is so closely related to suicide; they will deny and disregard any mentions of the word. The key to setting the stage for openly discussing suicide is to inform the patient that screening is a natural part of the overall assessment of their current problem (American Psychiatric Association, 2004). It is really up to the rehabilitation counselor to decide when a situation may warrant suicide screening questions to be asked and it also depends upon how comfortable a counselor is with the topic and asking those important questions. The best time to address he incident is immediately following the report of suicide or if the client is in distress. Leading questions open the way to ensuring an informative and easy dialogue and reassures the client that we are prepared for and interested in the answers. It is important to ask about the history of attempts because majority of attempters are repeaters and will use more lethal means on preceding attempts. The history of a prior attempt is the best known predictor for future suicidal behaviors, including death by suicide. Asking about hopelessness, present and future, have been found to be a very strong predictor of suicidal thoughts and self-destructive behaviors. Feelings of helplessness, worthlessness, and despair are all associated with hopelessness and are key words to look for when a client is discussing how they are feeling. It is also important to discuss these feelings with the client to better assess where these thoughts and expressions of suicidal behavior are coming from.
Along with expressions of hopelessness, some clients may convey that they have in fact had suicidal ideations which are associated with a desire or wish to die. Sometimes clients’ will initially deny the presence of suicidal ideation for a variety of reasons including, the stigmas associated with mental disorders, fear of being scorned or mocked, or being judged negatively by others. The loss of independence and control over life situations and the fright of being hospitalized involuntarily are also reasons why a client will deny suicidal ideation. As a counselor, it is our duty to assess our clients’ well being as a whole. Therefore, any mention of suicidal ideation, intent, or a plan requires that a mental health assessment be performed. This is where the suicide risk assessment comes into play. A suicide risk assessment is a legal construct in a clinical guise, which can be used to justify the rationing of emergency psychiatric resources or intrusion into patients’ civil liberties. Which means that if a client is deemed suicidal, he or she could be subjected to screening and possibly monitored for at risk behavior? The purpose of suicide risk assessment is to identify treatable and changeable risks and protective factors that inform the client’s treatment team of possible at risk behaviors. It is designed to differentiate whether a person is in fact suicidal, contemplating killing oneself, or if a he or she is suffering from some other type of disorder or mental illness. Either as part of an intake assessment or based on information you have gathered indicating that a suicide assessment is in order, the starting point is ask directly if the client ahs thoughts of suicide. Example, “have you thought of committing suicide?” If the answer is anything but no, then the assessment should proceed. Even in cases when a client answers by saying, “No,” continued exploration and discussion of what the client has said or presented that may be related to suicidal ideation is warranted.
“Have there been previous attempts? When? How often? What happened? What was going on in your life at the time?” If attempts were made, then exploration of method and rescuer should be explored. If the client does not answer questions about suicide, the answers are vague, or client conveys that he or she has entertained thoughts of suicide then, ask “are the thoughts pervasive or intermittent? What can you do on your own if you become suicidal again, to help yourself not to act on your thoughts or urges? What activities could you do to help take your mind off your problems even if it is for a brief period of time (Stanley & Brown, 2008)?” Various instruments have also been used to assess for suicide risk. These include assessments such as the Hopelessness Scale, the Beck Depression Inventory, Suicide Behaviors Questionnaire, Reasons for Living Inventory, Suicidal Ideation Questionnaire, and Suicidal Ideation Scale were designed specifically to measure suicide ideation. With all of the assessments, tools, and research that have been formulated on suicide and suicidal behavior, there are a few flaws. Very few psychiatric interventions have been shown to reduce the incidence of suicide (Simon, 2009). The current preoccupation with risk assessment is that it has the potential to harm clients, counselors, and the organizations in which they work. This occurs when a counselor uses only the assessment model and not his or her clinical experiences when dealing with client’s that may be suicidal. Most studies have identified risk factors for suicidal thoughts or attempts, but not what factors predict which suicide thinkers will make a suicide attempt. With any assessment there is going to be some type of down fall or issue with how it may or may not benefit your client. In this case, an issue with suicide risk assessments is that not all clients will be truthful when answering questions. Another issue is that this assessment may be given to someone who is under duress and not thinking clearly, therefore the responses to the assessment are flawed.
Using good judgment and clinical experiences are typically the best tools to use when thinking of administering a suicide risk assessment. This is an important concern for counselors who often must predict not who in the general population will make a suicide attempt, but which of their clients with suicidal thoughts will make a suicide attempt in the coming days, weeks, or months (Borge et al, 2010). Although clinical expertise is only one way of assessing suicidal risk, it can be more beneficial to the counselor and his or her client’s if knowledge is included with a standardized tool. Sometimes counselors get too caught up in the ideals of assessment tools and forget to trust their gut. No two clients are the same and therefore each individual should be treated as such. There is no textbook way of treating clients and the textbook should be used as a resource or reference. To decrease a client’s suicide risk, the treatment should attempt to mitigate or strengthen those risk and protective factors that can be modified (American Psychiatric Association, 2004). A study conducted on Veterans from Oregon found little evidence to suggest that inquiring about suicide will successfully identify the veterans most at risk of suicide. Three quarters of those who were asked about thoughts of suicide in the year before death denied such thoughts (Denneson, Basham, Dickinson, Crutchfield, Millet, Shen & Dobscha, 2010). But because of the lack of reporting among the veterans, the study could not effectively determine whether preventative assessments accurately depicted suicide outcomes. This is especially important to counselors because they have to go in depth with clients’ in order to get to the truth. In conclusion, Rehabilitation counselors play a vital role in the lives of their client’s on a day to day basis. In depth intakes and evaluations are key informational gathering tools during initial points of contact.
Getting to know your client as time will permit, allows each participant to feel comfortable with asking the hard questions and it also permits them to receive information from genuine place. Doing your job isn’t enough these days and therefore sometimes we have to go above and beyond to reach a satisfactory compromise with your client. A psychological disorder such as suicidal behavior warrants a lot of attention from counselors, family, friends, and colleagues of the individual in question. It takes a team to assist in crisis like this. Taking ones life is not the answer to everyday life stressors. There are some situations where confidentiality cannot be maintained and in these circumstances, counselors are obligated to fully inform clients of potential situations in which they may need to break confidentiality. But the right to confidentiality must be balanced against the right to protect society and particularly for individuals who are most vulnerable. All in all, it is our duty to protect our client’s from doing harm to themselves and others. If used properly, a suicide risk assessment could possibly save a life. References American Psychiatric Association. (2004). Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors In: Practice Guidelines for the Treatment of Psychiatric Disorders Compendium (2nd ed.). Arlington, VA: American Psychiatric Publishing. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
If used properly, a suicide risk assessment could possibly save a life. References American Psychiatric Association. (2004). Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors In: Practice Guidelines for the Treatment of Psychiatric Disorders Compendium (2nd ed.).