(Cao et al., 2020; Fulgniti et al., 2020; Steward et al., 2017). Epidemiological data suggest that although relatively rare in comparison to adults, at least 12% of all adolescents may experience suicidal ideation. Many of these youth exhibit symptoms of psychiatric diagnoses triggering psychosocial stressors, peer rejection, school problems, bullying and cyberbullying, and in some cases, high levels of family conflict (Bilsen, 2018). Accordingly, both the perceived burdensomeness and thwarted belongingness elements from Joiner’s theory appear to be prevalent in youth, particularly those with affective disorders and increased suicide risk. However, research has devoted less attention to the acquired capability component of the theory with respect to youth populations. This aspect presents a particular challenge, as acquired capability by its nature takes time to develop, and children attempting suicide have had less time to acquire the trait. There are also methodological challenges to studying acquired capability in youth populations. For example, psychological autopsy studies (Merelle, Van Bergen, Looijmans, Balt, et al., 2020) find that less than 25% of youth who die by suicide have made a previous attempt. These findings may result Three Step Theory (3ST) Although the interpersonal theory has made substantial improvements in our understanding of suicidal behavior, the truth is that suicidal behavior is a complex phenomenon and is influenced by a larger number of interacting variables than even the brightest human mind can integrate. This has led to more modern research approaches utilizing complexity science and machine learning in attempts to understand the interplay between more variables than are humanly comprehensible (Ribeiro et al., 2019). As these efforts continue, however, one major theoretical breakthrough in the field has been to narrow down the issue of suicide into one essential component: the transition from suicidal ideation into suicidal action. This issue is best exemplified by a recent “ideation-to-action” model proposed by Klonsky and May (2015), referred to as the “Three-Step Theory (3ST)." (3ST; Klonsky & May, 2015) The issue of ideation-to-action in suicidal behavior starts with the understanding that there are a substantial number of individuals who experience suicidal ideation, and yet only a small fraction of those individuals ever goes on to attempt suicide, and even fewer die by suicide. Ideation-to-action models attempt to understand this transition and what factors spur an individual to move from suicide contemplation into suicidal planning, preparation, and behavior. The first step in the 3ST (Step 1) posits that the individual first experiences a combination of psychological pain and hopelessness that leads to the development of suicidal ideation. This may be a function of various variables, including but not
from multiple factors. Firstly, family members, peers, service providers, and others who assist in psychological autopsy studies may have inaccurate knowledge of prior suicide attempts (which is entirely possible given that many suicide attempts by youth go unnoticed and/or unreported). Youth may also habituate to pain and self-destructive behaviors through other methods, such as non-suicidal self-injury (NSSI). Finally, psychological autopsy studies may not inquire fully about other experiences, such as abuse or other forms of physical trauma, which may increase one’s capacity to engage in serious self-injury. Although substantial research progress has been made in understanding youth suicidal behavior, especially at the theoretical level, more research is needed to determine the degree to which Joiner’s interpersonal model, and subsequent adult models, generalizes to youth suicide. Overall, the interpersonal theory of suicide has done much to advance the understanding of suicide and has garnered an impressive level of empirical support. However, the nature of science is to strive for the most accurate and predictive level of understanding possible, and additional advances building on the interpersonal theory continue to be made. exclusive to those factors outlined in the interpersonal theory of suicide. In this step pain can be derived from a variety of sources, but the feeling of hopelessness is necessary because it creates the perception that this pain will not fade. Step 2 of 3ST then posits that suicidal ideation escalates as psychological pain intensified and overwhelms feelings of interpersonal connection. In this case, interpersonal connectedness is viewed as one of the final safeguards against the desire for death, and if those bonds are overcome, risk for suicide becomes more severe. Finally, Step 3 of 3ST suggests that suicidal ideation can only be acted upon when an individual develops an acquired capability for suicidal behavior (from the interpersonal theory or suicide). It is only at this stage that suicidal behavior can occur. The 3ST has made substantial contributions to the theoretical basis of suicide and helps build an understanding of the process that patients may experience in the development of suicidal ideation (initial desire to die) and eventually into enacting suicidal behavior. Ongoing research continues to provide support for the 3ST model as well (Klonsky, Saffer, & Bryan, 2018). Overall, major progress continues to be made in enhancing our understanding of the causes of suicidal behavior; the better we can understand these causes, the better we can improve our suicide risk assessment and intervention efforts. The next section details suicide risk assessment, including ways in which these assessments have been enhanced by integrating the above- outlined theories of suicidal behavior.
THE FOUNDATIONS OF PSYCHOLOGICAL ASSESSMENT
● What’s going on [with this situation]? What would you like me to know? ● How has your life been going? Any changes lately? ● Is everything okay at home? What about at work (or school)? ● Have you been getting along with your family and friends lately? ● Have you been feeling any particular emotions lately? ● Have you consumed alcohol or used any other drugs? How often? ● Have things been going so badly that you started to worry that they might never get better? ● Have you felt like life is not worth living? How recently did you start feeling this way? ● Have you wanted to kill yourself? When did that feeling start, when was the last time you felt it? ● Have you made any efforts to prepare to die? Have you practiced how you might kill yourself, or gotten things ready to kill yourself? ● Have you ever tried to kill yourself before? How many times?
Now that key psychosocial risk factors and warning signs for suicidal behavior have been discussed, the next section will focus on psychological assessment. First, general psychological assessment considerations will be presented, followed by suicide-specific assessment strategies. Working with suicidal individuals can occur in various settings, some with ample time for formal assessment and some limited by time, space, and resources. This first section will focus on the basic elements of an assessment that can occur in any clinical setting, including those limited by time such as in schools and primary care offices. When any patient endorses suicidal thoughts and behaviors, further assessment is required; this approach serves as a triage to determine the need for a more comprehensive or expanded assessment, particularly in cases where imminent danger to self or others may be present. Key introductory assessment questions to solicit information from the suicidal individual can include:
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Book Code: PYCA1423
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