Suicidality: Assessment and Treatment Strategies 1

Suicidality: Assessment and Treatment Strategies

Shawn A. Wygant

Michigan School of Professional Psychology

PSYC 550: Professional and Scientific Ethics

October 25, 2016

 Suicidality: Assessment and Treatment Strategies 2

Suicidality: Assessment and Treatment Strategies

Abstract

Assessing and treating suicidal clients requires clinicians to be familiar with the
literature on suicide and have a working knowledge of the DSM-5. These materials
provide insight and tools for clinicians to inform their clinical judgment and
decision making. This becomes critical when a decision has to be made concerning
a suicidal client as to what form of treatment they require to keep them safe. The
following article addresses standard assessment and treatment strategies for
suicidality and provides a wealth of references to enhance a clinicians diagnostic
and clinical acumen.

Keywords: self-harm, risk factors, precipitants, suicidal ideation

1. Assessment

Suicide is a very serious problem in our culture especially among teenagers (King,
Foster, & Rogalski, 2013). The CDC has listed suicide as the second leading cause of death
among adolescents and young adults ages 13-24 (CDC, 2016) and is the tenth leading cause of
death for both genders and all races (AFSP, 2016). Researchers have found that men commit
suicide at a much higher rate than women (4:1), although women are much more likely (2-3x) to
attempt suicide (Dexter-Mazza & Korslund, 2007). Every year more than forty thousand people
in our country commit suicide and roughly ten times that number are hospitalized for non-
accidental self-harm (Jobes & Linehan, 2016). Some researchers believe that suicide is
preventable since roughly 90% of all its victims suffered from a diagnosable Axis I mental
disorder (Conwell et al., 1996). Luoma, Martin, and Pearson (2002) discovered that many of
these individuals contacted a professional in the mental health field sometime within the last year
of their life.

This means that mental health professionals need to be competent in handling clients who
present with suicidal behaviors (Woo & Keatinge, 2008). Professionals must have good
interviewing skills and always conduct a comprehensive suicidal risk assessment whenever a
client indicates a desire to harm themselves (Dexter-Mazza & Korslund, 2007). A
comprehensive suicidal risk assessment involves; interviewing the client with direct questions
about dangerousness to self while taking a detailed psycho-social history (inclusive of obtaining
medical, legal, social, personal, psychiatric, and familial information) followed by a thorough
evaluation and categorization of all risk and protective factors, stressors, and precipitants
(Bongar & Sullivan, 2013; Marttunen, Aro, & Lnnqvist, 1993).

a. Interviewing

For those clinicians who do not have a lot of experience with interviewing clients who
express past or current self-harming behaviors, there are a number of structured interviews which
can be effective (J. Sommers-Flanagan & R. Sommers-Flanagan, 2015). Two of these are worth
mentioning: the CASE (Shea, 1998) and the SASII (Linehan et al., 2006). Marsha Linehan and
her colleagues (2006) helped develop and test the Suicide Attempt Self-Injury Interview (SASII)
which has proven successful with clinicians in assessing suicidal intent and suicidality
 Suicidality: Assessment and Treatment Strategies 3

independent of the consequences or form of any suicidal behaviors (p. 309). It also provides
ratings for lethality which are individualized to the client (Linehan et al., 2006). The
Chronological Assessment of Suicidal Events (CASE) is another good structured interview,
developed in the 1990s by Dr. Shawn Christopher Shea (1998), which provides questions that
will help elicit from the client any presenting suicidal behavior, recent (within the last 2-3
months) suicidal behavior, past suicidal behavior (any history of suicidality), and immediate
plans to commit suicide in the future.

Regardless of whether or not a clinician uses a structured interview (Shea, 1998) or

unstructured interview (Jones, 2010), three tasks must be accomplished: the clinician has to
gather the necessary information related to the clients specific risk factors, obtain any and all
information related to the clients plans or ideas about committing suicide, and from these two
sources of information make an appropriate assessment of the clients risk factors as it relates to
intervention, prevention, and treatment strategies (Jacobs et al., 2010). To facilitate this process,
it is recommended that clinicians establish an open ended discussion about self-harm taking care
to avoid being passive and always expressing a caring attitude that communicates a willingness
to help (Woo & Keatinge, 2008). Within this environment, the interview needs to contain direct
and specific questions about suicidal ideation and behaviors that will establish whether or not the
clients self-harming thoughts are chronic or acute (Beautrais, Joyce, & Mulder, 1997). Chronic
(distal) risk factors are ongoing characteristics shown to be associated with a higher risk of
suicide over some period of time (Chehil & Kutcher, 2012).

An example is a female client with borderline personality disorder stating that she has
attempted to kill herself several times over the past 5 years by taking pills and cutting her wrists
(Oumaya et al., 2008). Her previous suicide attempts and wrist cutting behavior are chronic risk
factors and show a documented history of suicidal tendencies most likely related to impulsive
expressions of self-directed hatred (Kernberg, 2004, p. 38). In contrast with chronic factors,
acute (proximal) risk factors are most often associated with recent or current events which can
create an imminent risk or warning sign of suicide (Jobes & Linehan, 2016, p. 34). An
example is a man, Mr. Q., in his early 60s who has suffered from severe depression over the past
10 years and after finding out he has stage 4 lung cancer and that his wife of 25 years has left
him, he starts putting rope around his neck and choking himself unconscious telling friends he
wants to kill himself (Snowden, 2001). This latter example demonstrates how important it is for
an interviewer to obtain enough information to find out what, if any, chronic factors exist (i.e.,
depressed for years), and what, if any, acute factors exist (i.e., wife leaving, physical illness)
(King, Foster, & Rogalski, 2013). This helps establish a foundation for making appropriate
decisions regarding the level of care required to keep the client safe (Jacobs et al., 2010). Any
client like Mr. Q. who indicates during an interview that they have been rehearsing to kill
themselves with a rope, demonstrates that they have a specific plan, their plan is highly lethal,
and the instrument of their demise is readily available (Simon & Hales, 2006).

b. Assessing & Evaluating Risk Factors

Suicide planners like Mr. Q. need to be evaluated immediately for the specificity of their
plan, its lethality, the availability of their chosen means, and their proximity to any helping
resources (Woo & Keatinge, 2008). This is known as the S.L.A.P. method of suicide plan
assessment (J. Sommers-Flanagan & R. Flanagan, 2014). Generally, the more specific the plan
 Suicidality: Assessment and Treatment Strategies 4

the higher the risk. Likewise, when lethal means are readily available (such as a loaded gun on
the kitchen table) and the planner is far away from help risk is high and there is a greater need for
intervention which could require involuntary commitment to an inpatient psychiatric facility
(Dexter-Mazza, 2007). Even in the absence of a specific lethal plan to commit suicide, clinicians
need to be very familiar with the literature on suicide and have a good working knowledge of the
DSM-5 (Bongar & Sullivan, 2013).

The literature provides vital information about what to look for when questioning a client
about suicide. For example, the literature informs mental health professionals that when a person
is hopeless, has attempted suicide in the past, suffered a significant loss (death of a spouse), is
physically ill, has an addiction to alcohol or drugs, has a family history of suicide completion,
owns a firearm, is looking for ways to commit suicide, talks about death or dying, or is socially
isolated they are at a heightened risk for suicidal ideation, planning, or completion (Bongar &
Sullivan, 2013). The DSM-5 mentions suicidal ideation 43 times (American Psychiatric
Association, 2013). Many mental disorders in the DSM-5 are associated with suicidal thoughts
such as depressive disorders, bipolar and related disorders, schizophrenia and other psychotic
disorders, severe cluster B personality disorders, and post-traumatic stress disorder (American
Psychiatric Association, 2013). According to the DSM-5, approximately 20% of schizophrenics
attempt suicide and over 5% are successful in their attempts (American Psychiatric Association,
2013, p. 104).

c. HIDE the Bullet CLIPS

In addition to knowledge and familiarity with the DSM-5 and the literature on suicide,
Woo and Keatinge (2008) recommend integrating the identification and assessment of risk
factors into the interview process with the following mnemonic device: HIDE the Bullet
CLIPS (p. 68). HIDE the Bullet CLIPS stands for assessing the clients history, ideation and
intention, diagnoses, emotional state, behavior, any communications concerning a desire to die,
lack of support, inflexibility of cognitions, precipitants, and statistics (Woo & Keatinge, 2008, p.
68) as follows:

History: Any family history that involves instability, parental loss, high conflict, or
using suicide as a problem-solving strategy or coping mechanism is a significant risk
factor and needs to be documented (Ronquillo, Minassian, Vilke, & Wilson, 2012).

Ideation & Intention: Clinicians must explore the clients thoughts about suicide and
make specific inquiries as to what goes through the clients mind when the client
thinks about suicide (noting the frequency, intensity, and duration). Clients who are
preoccupied with a desire to die are at a greater risk of suicide compared with those
who only think about it occasionally (Luoma, Martin, & Pearson, 2002). When it
comes to evaluating intention, this can be assessed by listening to whether the clients
thoughts are passive or active and whether or not the client has a plan in place. Active
thoughts of suicide involve a higher degree of intentionality such as the statement: I
want to shoot myself and end it all right now. Passive suicidal ideation has less
intentionality such as the following: I wish someday I would just get hit by a bus to
put me out of my misery.
 Suicidality: Assessment and Treatment Strategies 5

Diagnoses: As stated above, the presence of one or more major psychiatric disorders
raises the risk level of suicide. There are a plethora of studies showing that
individuals who suffer from major depression are thirty times more likely to kill
themselves than the general population (Sanchez & Le, 2001; Bradvik & Berglund,
2000; AAS, 2014; Joiner et al., 2005). Therefore, it is vitally important that the
clinician find out if the client has any current or past mental diagnoses.

Emotional State: Likewise, part of any comprehensive suicidal assessment involves

ascertaining the clients current and recent emotional state because any extreme
emotional states that accompany expressions of despair, hopelessness, guilt, shame,
anxiety, self-hatred, depression, anguish, exhaustion, or agitation are strong
predictors of suicide (Neufeld & ORourke, 2009, p. 686).

Behavior: Clinicians need to inquire about and look for certain behaviors associated
with suicide such as suddenly selling possessions, making out a will, fantasizing
about what others would do if the client kills themselves, rehearsing suicidal plans, or
any sudden feelings of happiness after feeling depressed for a long time (Woo &
Keatinge, 2008).

Communication: Communication is a big factor in risk assessment for self-harm

because more than 75% of people who have committed suicide told someone of their
intention to die (Harrison et al., 2014). Clinicians should make inquiries with the
clients friends and family to find out if the client has communicated a wish to kill
themselves.

Lack of Support: Loneliness and lack of support are significant risk factors which the
clinician must screen for during the assessment process (Cooper et al., 2006). Woo
and Keatinge (2008) suggest that clinicians need to identify the quality and number of
the clients interpersonal and social relationships because suicide is more likely when
a person is isolated and lonely.

Inflexibility of Cognitions or an Inability to See Alternatives: Suicidal clients often

express a lack of insight into alternatives to killing themselves. This may come across
during the interview as a rigid mind-set that is extremely constricted and narrowly
focused on death without consideration of any consequences (Jobes, Lento, &
Brazaitis, 2012). This predisposes the client to perceive suicide as the only rational
or viable solution (Woo & Keatinge, 2008, p. 74). This cognitive inflexibility more
often than not produces feelings of hopelessness and despair which is why Kral and
Sakinofsky (1994) suggest that the most important questions to ask when determining
suicidal risk are: Is suicide an option? and Is it the only option? (p. 321).

Precipitants: Interpersonal and significant losses, such as a being fired from a job,
death of a close family member, or the end of a marital relationship, are stressful life
events that can precipitate suicidal ideation (Osman et al., 1999). For example, just
this past week Travis Andrews (2016) reported in the Washington Post that a
Missouri father, Christopher Cadenbach, killed himself and his two sons after his wife
announced she was divorcing him and filing a police report for domestic violence. In
 Suicidality: Assessment and Treatment Strategies 6

addition to loss of employment, death, or divorce, being admitted into a psychiatric

facility for mental illness or substance abuse can precipitate suicide as in the case of
Clifton Washington who hung himself after being involuntarily committed to the
Metropolitan State Hospital in Norwalk (Hymon, 2004).

Statistics and Suicide Scales: Clinicians need to have a firm grasp of the statistics
and scales used to assess suicidality (Woo & Keatinge, 2008). The CDC, the
American Association of Suicidology, and the American Foundation for Suicide
Prevention all publish statistical information concerning suicide (CDC, 2016; AAS,
2014; AFSP, 2016). These are helpful resources to inform the clinician about the risks
of suicide associated with the clients age, gender, and ethnicity (Woo & Keatinge,
2008). Standardized scales are another important resource used during assessment of
suicidality. There are several reliable scales that have utility for use with suicidal
clients such as: The Scale for Suicide Ideation, the Beck Hopelessness Scale, the
Adult Suicidal Ideation Questionnaire (ASIQ), the Suicidal Behavior Questionnaire,
the Reasons for Living Inventory, the Acquired Capability for Suicide Scale, the
Columbia Suicide Severity Rating Scale, and the Child-Adolescent Suicidal Potential
Index (CASPI) (Woo & Keatinge, 2008; Pinto, Whisman, & McCoy, 1997; Posner et
al., 2011; Ribeiro et al., 2014; Pfeffer, Jiang, & Kakuma, 2000).

2. Intervention, Prevention, Management, and Treatment

Once a risk of self-harm has been identified and evaluated, there are several management
and therapeutic strategies available to the clinician (Sakinofsky, 2007). Before a treatment plan
can be formulated or implemented, the clinician needs to quantify the level of risk by identifying
whether it is mild, moderate, or severe (Woo & Keatinge, 2008). A mild level of risk would be a
client who presents with some protective factors and a few risk factors accompanied by
infrequent suicidal ideation absent a specific plan. Moderate suicidal risk would be found with
clients who have more frequent suicidal thoughts that tend to be limited in their duration and
intensity accompanied by some risk factors and specific or general plans without lethality.
Severe risk clients are those who have intense and enduring thoughts of killing themselves
accompanied by specific lethal plans, many risk factors, little or no protective factors, and few if
any helping resources within close proximity (Woo & Keatinge, 2008, p. 78).

Once a client is determined to be suicidal and there is an accurate assessment of their

degree of risk, a decision needs to be made whether the clients needs are best served and
managed through outpatient or inpatient services (Bongar & Sullivan, 2013). In severe cases,
with clients who are presenting as extremely suicidal and lacking in self-control, inpatient
treatment is usually the safest course of intervention and treatment strategy (Bongar & Sullivan,
2013). For those who are moderately or mildly suicidal, outpatient services can be ordered
although it is recommended that these clients be seen on a more frequent basis than clients who
are not suicidal (Woo & Keatinge, 2008). Suicidal clients who are suffering from intense feelings
of depression, anxiety, or other major psychic disturbances should be evaluated for medication
through a referral to a medical doctor or psychiatrist (Woo & Keatinge, 2008). It is important
when implementing any outpatient therapeutic intervention strategies with suicidal clients to
formulate a plan for safety such as the Safety Planning Intervention (SPI) (J. Sommers-Flanagan
& R. Sommers-Flanagan, 2015). The SPI involves the following six components: reducing
 Suicidality: Assessment and Treatment Strategies 7

access to lethal means, contacting mental health agencies or professionals, contacting family
members and friends who are available and willing to help, utilizing social contacts as a way of
distracting the client from suicidal ideas, employ coping strategies, and recognizing the warnings
signs of an impending suicidal crisis (Stanley & Brown, 2012, p. 257).

a. Identification of Suicide Alternatives and Developing a Suicide Prevention Contract

Part of safety planning and intervention involves identification of alternatives to suicide

(J. Sommers-Flanagan & R. Sommers-Flanagan, 2015) and developing a suicide prevention
contract (Kernberg, 2004). The key intervention strategy behind helping a suicidal client identify
suicide alternatives is to re-direct their cognitive resources away from suicidal ideation and onto
personal reasons for living that are more desirable than death by suicide (J. Sommers-Flanagan
& R. Sommers-Flanagan, 2015, p. 319). This logic assumes that suicidal clients are more willing
to consider alternatives to suicide when they are offered alternatives as opposed to being told that
suicide is bad option (J. Sommers-Flanagan & R. Sommers-Flanagan, 2015).

Whenever clinicians focus on the suicidal thoughts of the client in a way that
communicates a desire on the part of the clinician to take away the clients power to choose
suicide, this can produce disastrous results because for many suicidal clients the power to choose
death by ones own hand may be their only sense of control over circumstances or events in their
life which they perceive are not under their control (Bongar & Sullivan, 2013). In addition to
having the client identify suicide alternatives, clinicians should develop a suicide prevention
contract which Kernberg (2004) says encourages the expression of any underlying self-hatred to
be channeled through the transference rather than through somatization or acting out (p. 43).
Suicide prevention contracts are most effective when a therapeutic relationship is flexible yet
firm and allows the client to experience support, hope, acceptance, relief from despair, and a
lifesaving connection (Woo & Keatinge, 2008, p. 79).

b. Evidence Based Treatments for Suicidality

Over the past 30 years, many psychotherapeutic interventions with suicidal clients have
been shown to produce positive effects for preventing suicide attempts or self-directed
violence (Brown & Jager-Hyman, 2014, p. S186). Among these reported by Brown and Jager-
Hyman (2014) are: mentalization-based treatment (MBT), problem-solving therapy (PST),
dialectical behavior therapy (DBT), cognitive-behavioral therapy (CBT), and cognitive therapy
for suicide prevention (CT-SP).

Cognitive therapy for suicide prevention has been shown to produce a 50% reduction in
suicide reattempts by previous attempters compared with treatment as usual (Brown & Jager-
Hyman, 2014). CBT also was found to significantly reduce self-harming behaviors compared
with TAU. Problem-solving therapy focuses the client on learning how to use alternate means to
solve problems through divergent thinking exercises which have been shown to reduce suicidal
ideation while raising self-esteem and assertiveness (Bongar & Sullivan, 2013). Dialectical
behavior therapy involves an intensive therapy regimen including group and individual DBT
skills training on a weekly and sometimes daily basis which is effective in reducing suicide
attempts and ideation through helping clients be mindful, tolerate and resolve dialectical
dilemmas and distress, and regulate self-harming emotional states (Jacobs et al., 2010).
 Suicidality: Assessment and Treatment Strategies 8

Mentalization based therapy of suicide is effective in teaching suicidal clients to be

understand how other people think and to be able to accurately assess their own thinking in
relation to others (Rossouw & Fonagy, 2012). These researchers found that suicidal adolescents
who underwent MBT treatment show a significant decrease in self-reported depression
(Rossouw & Fonagy, 2012). Another evidence based intervention shown to be effective as an
adjunct to those therapies listed above is the development of protective factors (Surgenor, 2015).
Surgenors (2015) study found that through the development of a suicidal clients protective
factors both depressive and suicidal thoughts decreased.

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