Suicide Assessment

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Your client is elderly, has recently lost his spouse, and sees no reason to go on living. During a visit to the client in his new assisted living facility, the client revealed to you that he has experienced tremendous grief following the loss of his wife and does not want to live. In your assessment of this client, you are concerned that he has the motivation to kill himself, has decided on the means with which to do so, and has no supports to constrain him from taking such action.

Prepare a suicide assessment of this client along with a plan for his treatment. In your assessment, address each of the following questions in addition to any other items you feel are requisite.

  1. How would you assess this client; what would you require to better evaluate his suicidal state?
  2. Do you have enough information to take action?
  3. What action options would you consider taking given his suicidal ideation?

Discuss and cite two textbook readings for Module 6 and at least one additional credible or scholarly source to support your analysis and positions. Your paper should be two or three pages in length with document and citation formatting per APA Requirements.



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See discussions, stats, and author profiles for this publication at: Suicide Risk Assessment in Clinical Practice: Pragmatic Guidelines for Imperfect Assessments Article in Psychotherapy Theory Research Practice Training · March 2012 DOI: 10.1037/a0026148 · Source: PubMed CITATIONS READS 97 3,004 1 author: James Christopher Fowler Baylor College of Medicine 118 PUBLICATIONS 1,708 CITATIONS SEE PROFILE Some of the authors of this publication are also working on these related projects: Is extended inpatient treatment contraindicated for borderline personality disorder? View project All content following this page was uploaded by James Christopher Fowler on 02 January 2014. The user has requested enhancement of the downloaded file. Psychotherapy 2012, Vol. 49, No. 1, 81–90 © 2012 American Psychological Association 0033-3204/12/$12.00 DOI: 10.1037/a0026148 PRACTICE REVIEW Suicide Risk Assessment in Clinical Practice: Pragmatic Guidelines for Imperfect Assessments James Christopher Fowler Baylor College of Medicine This practice review focuses on the challenges of conducting sensitive and accurate assessments of the relative risk for suicide attempts and completed suicides. Suicide and suicide attempts are a frequently encountered clinical crisis, and the assessment, management, and treatment of suicidal patients is one of the most stressful tasks for clinicians. An array of risk factors, warning signs, and protective factors associated with suicide risk are reviewed; however, we are not yet in possession of evidence-based diagnostic tests that can accurately predict suicide risk on an individual level without also creating an inordinate number of false-positive predictions. Given the current limitations of assessment strategies, clinicians are advised to keep in mind that patients contemplating suicide are under enormous psychological distress, requiring sensitive and thoughtful engagement during the assessment process. An overarching goal of these assessments should be conducted within the therapeutic frame, in which efforts are made to enhance the therapeutic alliance by negotiating a collaborative approach to assessing risk and understanding why thoughts of suicide are so compelling. Within this treatment heuristic, the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) is recommended as a pragmatic multidimensional assessment protocol incorporating the best known risk and protective factors. Keywords: suicide assessment, risk factors, alliance associated with treating suicidal patients can, at times, lead clinicians to lose sight of the primary objective of psychotherapy (namely the relief of suffering through greater self-understanding and improvement in social functioning). Powerful emotional reactions to a suicidal patient can fuel a pattern of defensive behavioral management that runs the risk of eclipsing the patients suffering, leading to subtle and overt power struggles. In some cases, a pattern of chronic crisis management can emerge in which the clinician adopts a role of a constant savior (Hendin, 1991). Although it is first and foremost necessary to protect the life of the patient, clinicians must guard against the treatment devolving into chronic crisis management in which the mutually agreed upon purpose of the treatment is inadvertently jettisoned. Therefore, the overarching goal of any assessment of suicide risk should be conducted within a therapeutic frame in which collaboration and negotiation of role responsibilities are clearly articulated (Plakun, 1994). At the same time clinicians must work to enhance the therapeutic alliance by negotiating a collaborative approach to understanding why thoughts of suicide are so compelling (Jobes, Louma, Jacoby & Mann, 1998; Jobes, 2011). The scope, breadth, and volume of suicide research precludes an exhaustive review of the literature, and any attempt to do so here would certainly do injustice to the field of suicidology, and subvert the purpose of this article—those interested in a deeper examination may find the reference list and a list of hyperlinks (Table 1) useful. This practice review will focus on three elements: (1) Challenges facing clinicians assessing risk for adult patients, (2) An overview of the best predictors of suicide risk, and (3) Pragmatic recommendations for ongoing risk assessment that places a Psychotherapists have much to worry about: Turf battles over medication prescription privileges, third party reimbursement, and the ongoing quest for mental health parity. Closer to the consulting room, we worry about patient’s psychological well-being, improvement, and safety— of greatest concern is their short and long-term risk for suicidal behavior and death. Clinicians have reason for concern: As death rates decline for many medical conditions, suicide rates have risen approximately 60% over the last 45 years, with yearly estimates of 1 million suicides worldwide (World Health Organization, 2005). In the United States more than 32,000 suicides occurred annually—Suicide is the second leading cause of death among 25 to 34 year olds, and the third leading cause of death for people between the ages of 15 and 24 (Centers for Disease Control, 2007). Suicide attempts are 10 to 40 times greater than completed suicides, with US estimates nearing 650,000 per year (Goldsmith, Pellmar, Kleinman, & Bunney, 2002). Suicide and suicide attempts are a frequently encountered clinical crisis, and the assessment, management, and treatment of suicidal patients is one of the most stressful tasks for clinicians (Jobes, 1995). According to survey data, 28% of psychologists and 62% of psychiatrists reported experienced the loss of a patient to suicide, most frequently in outpatient settings (Chemtob, Bauer, Hamada, Pelowski, & Muraoka, 1989). The stress and anxiety Correspondence concerning this article should be addressed to J. Christopher Fowler, PhD, Menninger Department of Psychiatry and Behavioral Sciences Baylor College of Medicine, 2801 Gessner Drive, Houston, TX 77080. E-mail: 81 FOWLER 82 Table 1 Selected Resources for Suicide Assessment and Suicide Facts American Association of Suicidology American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors American Foundation for Suicide Prevention (AFSP) International Association for Suicide Prevention: IASP Guidelines for suicide prevention National Suicide Prevention Resource Center Risk Management Foundation Harvard Medical Institutions Substance Abuse and Mental Health Services Administration (SAMHSA) Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) Suicide Awareness Voices of Education Suicide Prevention International Suicide Prevention Resource Center WHO Suicide Prevention premium on maintaining a collaborative therapeutic frame, attending to the therapeutic alliance as well as alliance ruptures, and maintaining an active curiosity regarding the triggers for the suicidal crisis. Challenges to Suicide Assessment Effectively assessing suicide risk is dependent on the availability of sensitive and specific measures of long-term risk factors, short-term warning signs, and an appreciation for the complexity and variability of suicide risk over time. Unlike many diagnostic procedures assessing relatively stable phenomena, we do not yet possess a single test, or panel of tests that accurately identifies the emergence of a suicide crisis. Among the many reason is that suicide risk is fluid, highly state-dependent, and variable over time (Rudd, 2006). It should not be a terrible shock, then, to realize that most of our research efforts to diagnose risk for suicide and suicide attempts fall short. Historically, research demonstrates statistical associations among various risk factors aggregated across large groups of individuals; however, translating elevated risk to the single individual falters because specific predictors are found among many individuals who are not suicidal (resulting in high false-positive prediction). Thus, despite decades of research, accurate prediction of suicide and suicide attempts remains elusive. The American Psychiatric Association (APA) Guidelines on Suicidal Behavior (APA, 2003) concluded that predicting suicide appears impossible in large part due to the rarity of suicide, even among high-risk individuals such as psychiatric inpatients. Beyond statistical challenges posed by low base rates, longitudinal prediction using relatively distal variables such as psychiatric diagnoses, demographics, and selfreported psychological states consistently yield high false-positive prediction rates, limiting their predictive value (Goldsmith et al., 2002; Rudd et al., 2006; Oquendo, Halberstam, & Mann, 2003). Complicating the assessment strategy is the fact that most studies assess single risk factors, leaving clinicians and expert panels to estimate how risk factors interact to influence outcomes. While prediction appears unlikely at this stage, clinicians are nonetheless responsible for assessing suicide risk, and for providing treatment to decrease risk (APA, 2003). Modifiable risk factors include the short-term safety of patients, and treating psychiatric SuicidalBehavior_Inactivated_04–16–09.pdf–4432 symptoms/disorders using evidence-based treatments. Among the hundreds of interventions for suicidality, the following treatments appear particularly effective in randomized clinical control trials: lithium prophylaxis for mood disorders (Baldessarini et al., 2006), clozapine for psychotic disorders (Glick et al., 2004; Meltzer et al., 2003), psychosocial treatments for suicidal patients with borderline personality disorder (Bateman & Fonagy, 2008; Clarkin, Levy, Lenzenweger, & Kernberg, 2007; Doering et al., 2010; Levy et al., 2006; Linehan et al., 2006), and outreach via communicating caring and concern remotely (Motto & Bostrom, 2001; Fleishmann, Bertolote, Wasserman et al., 2008) or in-home psychodynamic consultations (Guthrie et al., 2001). The aforementioned psychosocial interventions demonstrate the efficacy of developing and maintaining a caring interpersonal contact (even if by letter or phone) in reducing suicide risk. As will be discussed in a later section, the quality of social relationships can either serve as a protective or risk factor, and it stands to reason that the quality of a collaborative therapeutic relationship, the clinician’s ongoing care and interest in the patient, and efforts to repair ruptures in the alliance may exert a powerful influence on the patient’s degree of hope for the future, and the degree to which suicidal related behaviors decrease. Recent open trials of a suicide prevention strategy based on collaboration, therapeutic alliance, and enhancing social contacts reduced rates of suicidality (Ellis, Green, Allen, Jobes, & Nadorff, in press; Jobes, Wong, Conrad, Drozd, & Neal-Walden, 2005; Jobes, Kahn-Greene, Greene, & Goeke-Morey, 2009). It is therefore recommended that clinicians work to enhance the therapeutic alliance, consider recent ruptures that may contribute to suicidal ideation, and work to develop a collaborative approach to understanding the underlying causes for suicidal ideation (Jobes, 2011). With this practice heuristic in mind, the brief review of suicide research will touch on the evidence for those risk and protective factors with the strongest evidence base, then turn to a pragmatic and clinically sensitive approach to discussing suicide risk with patients. Static Risk Factors for Suicide and Suicide Attempts Suicide research began, and for the most part continues to focus on single, static risk factors such as demographic factors, psychiatric diagnoses, past high-risk behaviors, and more recently, ge- PRAGMATIC GUIDELINES FOR SUICIDE RISK ASSESSMENT 83 Table 2 Selected Static Risk Factors Associated With Individual Risk for Suicide and Suicide Attempts Variable Past suicide attempts Co-morbid psychiatric diagnoses Single diagnoses Severity of mental illness Algorithms of multiple domains Psychological vulnerabilities Genetic markers Demographic (gender, age, race, economic status) Relative predictive strength False-positive risk Strongest consistent predictor for both suicide attempts and completed suicide across many studies Risk increases with greater co-morbidity, especially for substance, mood and personality disorders Eating disorders, and substance abuse disorders carry the highest risk, mood, and personality disorders carry moderately high risk, anxiety disorders carry lower risk Limited studies suggest severity of impairment may be a risk factor beyond the specific diagnosis Diagnoses, symptoms, demographic and past history of hospitalization result in moderate true positive prediction but high false positive Impulsivity/aggression, depressive symptoms, anxiety, hopelessness, and self-consciousness/social disengagement increase risk, yet some studies are inconclusive 5-HTT serotonin gene most studied with moderate association: other candidate genes vary by study Males complete more suicides, females attempt more, nonmarried marital status, elderly, adolescent and young adult age groups, and Caucasian race are all associated with increase risk Moderate-high netic markers. Researchers contribute an impressive list of factors demonstrating the presence of specific signs or markers that increase the odds of suicide and suicide attempt—Table 2 includes a sample of static risk factors associated with increase risk. A good example of the epidemiological research is the cross-national survey of 84,850 adults assessing sociodemographic and psychiatric risk factors for suicidal behaviors. Results indicated that being younger than 25 years of age, female, less educated, unmarried, and having a mental disorder (mood disorders in high income countries, and impulse disorders in middle and low income countries) each imparted a degree of risk for suicide-related behaviors, with risk increasing with greater psychiatric comorbidity (Nock, Borges, Bromet et al., 2008). From epidemiologic and social policy perspectives, this information may be useful in developing targeted programs for intervention and prevention; yet, distal data alone are marginally helpful to clinicians—the odds of any of these factors predicting suicide-related behaviors is relatively low, with excessively high false-positive rates for each risk factor. Retrospective and psychological autopsy studies indicate that a diagnosable mental illness is present in at least 90% of all completed suicides (Isometsa et al., 1995; Rich, Young, & Fowler, 1986; Conwell et al., 1996). Clinicians and researchers have long presumed that some psychiatric disorders convey greater risk for suicide than others. Harris and Barraclough (1998) found increased suicide risk for all psychiatric disorders except mental retardation. Suicide mortality rates were highest for individuals diagnosed with substance abuse and eating disorders, moderately high rates for mood and personality disorders, and relatively low rates for anxiety disorders (Harris & Barraclough, 1998). The difficulty with such evidence is the fact that the majority of individuals suffering from psychiatric disorders never make a suicide attempt. Furthermore, over 70% of individuals with a psychiatric disorder have co-occurring disorders (Kessler et al., 2003), making prediction based on single diagnoses somewhat spurious. Efforts to assess comorbidity and severity of psychiatric disorders demonstrate some promising trends. Recent evidence from a 10-year prospective study of suicidal ideation, suicide plans and attempts revealed that the total number of co-occurring psychiatric High High High High High Unknown Extremely high disorders was consistently more predictive of subsequent suiciderelated behaviors than types of disorders (Borges, Angst, Nock, Ruscio, & Kessler, 2008). A 3-year prospective study revealed that individuals with comorbid substance abuse disorders and BPD were more likely to make future suicide attempts (Yen et al., 2003). Soloff and Fabio (2008) found that comorbid major depression and BPD, in combination with poor social adjustment was predictive of suicide attempts at 12-month follow-up. Severity of personality pathology (defined as meeting criteria for two or more personality disorders) was correlated with recurrent suicide attempts, but this effect held true only for younger females with severe personality disorders (Blasco-Fontecilla et al., 2009). Efforts to predict suicide using finer grain psychiatric variables such as previous hospitalization, depression, hopelessness, bipolar disorder, psychotic spectrum disorders, impulsivity, and plans or thoughts of dying fail to provide sensitive and specific metrics to function as diagnostic tests (even when combined in risk factor algorithms). For example, the 5-year prospective study predicting suicide risk among 4800 psychiatric inpatients found the following: During the follow-up period the best algorithm correctly identify 35 of 63 future suicides; yet, 1206 false positive predictions resulted in a positive prediction value of less than 3%, thus diminishing the prospect of utilizing the algorithm for diagnostic purposes (Pokorny, 1983). Focusing on 743 subjects identified as a high-risk cohort, the results were only slightly improved: the algorithm correctly identify 21 out of 28 future suicides; yet, 164 false positive predictions resulted in a positive prediction value of approximately 11 percent. Assessment of psychological vulnerabilities (an even finer grained analysis) seemed a logical approach, yet a review of empirical literature yielded mixed results for the most consistently studied psychological constructs of impulsivity/aggression, depression, anxiety, hopelessness, and self-consciousness/social disengagement (Conner, Duberstien, Conwell, Seidlitz & Caine, 2001). While impulsivity/aggression has a substantial genetic loading, and shows strong family affinity in those whose family members have made suicide attempts, there are a number of factors that FOWLER 84 affect that association, thus reduce the predictive validity of this single risk factor (Turecki, 2005). Currently, the strongest risk factor for predicting suicide and suicide-related behavior is the history of suicide attempts. While some distinctive clinical and psychological features differentiate those who attempt suicide from those who die from suicide; most experts agree that a history of suicide attempt(s) is the greatest risk factor for future attempts, and death by suicide (Brown, Comtois, & Linehan, 2002; Cavanagh, Owens, & Johnstone, 1999; Joiner et al., 2005). Medically serious suicide attempts are strongly associated with the increased risk of mortality and repeated suicide attempts: a 5-year follow-up study found that individuals who made a single suicide attempt were 48 times more likely to die by suicide than the average person (Beautrais, 2004). In a recent Finnish epidemiological study of 18,199 cases of suicide attempt, the risk of repeated attempted suicide within 5 years was 30% and the risk of death by suicide was 10% (Haukka, Suominen, Partonen, & Lonnqvist, 2008). Suicide attempts confer considerable future risk, but the risk is far from absolute— calculating falsepositive pre ...
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School: Boston College


Running Head: Suicide Assessment


Suicide Assessment
Student’s Name
Course + Code

Suicide Assessment


Assessing the Client: Requirements to Better Evaluate the Suicidal State Of A Client
Suicide assessment of a client with suicidal ideas requires proper planning which
involves following a procedure that would help in ascertaining the cause and effect of the
tremendous grief that has triggered suicidal feelings. The first requirement is to obtain a
psychiatric evaluation form to undertake the suicidal assessment process (Nock, Deming,
Fullerton, et al., 2013). This evaluation form will help in obtaining crucial information from the
patient to provide an insight into the current and past medical history and mental state of the
client. From this information, it would be easy to identify the specific factor that is responsible
for the decline or rise in cases of suicidal behavior as observed in the client.
The next requirement is to address the immediate safety needs of the client before

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Tutor went the extra mile to help me with this essay. Citations were a bit shaky but I appreciated how well he handled APA styles and how ok he was to change them even though I didnt specify. Got a B+ which is believable and acceptable.

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