● What keeps you going? What are your reasons for living? What gives your life meaning? It is important to note that clinical assessment does not always begin with direct inquiry about suicidal thoughts or behaviors, and it is important to work on building a trusting relationship from the very start. Even after early development of a therapeutic relationship, beginning with direct questions about suicidal thoughts and behaviors can be off-putting and lead to less disclosure. Discussing home, work, and/or school, Expanded assessment in clinical practice While some clinicians may practice in settings where triaging risk is the focus, other clinicians provide ongoing direct services in outpatient settings. In outpatient settings where services are typically ongoing, an expanded assessment is necessary to ensure the safety of the patient, as well as provide the foundation for developing an effective treatment plan. Additionally, the comprehensive nature of the assessment and the development of a plan around the information obtained during the assessment may protect the clinician in the event of subsequent litigation (Barnett, 2020). Assessment of individuals with risk for suicidal ideation or behavior must be as comprehensive as the patient’s risk factors are complex. Evidence- based tools are often useful as a starting point and to periodically track data on progress, but should not be the sole factor in any decision-making process for planning interventions. The approach described here draws from various clinical professions. For example, Standard 5 of the NASW Standards for Social Work in Health Care Settings offers the following interpretations on comprehensive assessment for guidance: “In the assessment process, social workers may find standardized instruments helpful in identifying and responding to patient concerns. Such instruments are viewed as starting points in the development and refinement of an individualized, comprehensive assessment” (NASW, 2016, p. 25). Assessment is an ongoing activity, not a onetime event; this applies to suicide risk assessment as well. During the reassessment process, the clinician and at-risk individual (and, if appropriate, members of the patient support system) can revisit the needs, assets and priorities identified in the initial assessment and discuss the patient’s emerging concerns. When initiating the assessment process, a comprehensive assessment may include any number the following coverage areas: ● Behavioral and mental health status, including current level of functioning, coping style, crisis management skills, substance use history, and risk of suicide or homicide.
in the case of youth, is less threatening and serves as a nice transition into the inquiry process. It is also important to note that the assessment should end with an evaluation of protective factors; this provides some breathing room for the individual after discussing the more sensitive aspects of suicidal thoughts and behaviors, and it also sets the framework for developing a treatment plan (Stanley, Brown, Brenner, Galfalvy, Currier et al., 2018). ● Physical and cognitive functioning. ● Psychosocial-spiritual well-being, including ability to fulfill social roles. ● Cultural values, beliefs and practices. ● Patient strengths, protective factors, and points of resilience. ● Employment, educational or vocational history, including challenges, goals and objectives. ● Living arrangements, including suitability and safety of the home environment. ● Family composition, structure, and roles. ● Language preferences and proficiency levels. ● Degrees of literacy, including health, behavioral health, and financial literacy. ● Risk of abuse, neglect or exploitation of or by the patient, and underlying causes for such mistreatment. ● Social supports, including formal and informal support systems. ● Need for economic or other psychosocial resources, supports, and services. ● Ability to navigate relevant service systems (educational, employment, health care, housing, legal, nutritional, social services, or transportation systems). ● Life-span planning (which may include advance care planning, anticipation of caregiving responsibilities, permanency planning for minor children, retirement planning, or other domains). ● Patient’s perceptions of changes needed to improve her or his situation. ● Identification of barriers to adherence to the plan of care. Assessment processes should, to the extent possible, be customized for vulnerable populations, including children, people with severe and persistent mental illness, immigrants and refugees, people with substance use disorders, survivors of violence or trauma, people who are homeless, and people with physical or cognitive disabilities.
THE ROLE OF THERAPEUTIC ALLIANCE IN CLINICAL ASSESSMENT
Starting with the assessment, the need to approach each patient with the goal of developing a therapeutic alliance cannot be overstated. The therapeutic alliance has been defined in a number of ways, but most importantly it has been described as “a moderating variable without which no therapy would succeed” (Roth & Fonagy, 2005, p. 477; Fluckiger, Del Re, Wampold, & Horvath, 2018). In fact, taking a therapeutic approach to assessment is not a novel idea and has even been used in more formal psychological testing venues (Mihura, Roy, & Graceffo, 2017). One of the core tenets proposed by the Aeschi Working Group, a small international consortium of suicidologists originally based in Aeschi, Switzerland, is the belief that without a strong therapeutic relationship, psychotherapists cannot expect to be successful in their work with suicidal Clinical suicide risk assessment tools A number of clinical assessment tools have been studied over the last few decades, and evidence continues to grow in support of the utility of these measures in suicide-risk detection and prevention. These assessment tools, as noted above, are only one part of a comprehensive assessment to determine suicide risk and should be used in conjunction with a thorough
individuals (Jobes, Piehl, & Chalker, 2018). The basis of the Aeschi model is that the patient and the treating clinician form a shared understanding of the patient’s suicidality. While the clinician may have expertise in assessment and intervention, the patient is the only true expert of his or her suicidal experience. Only by developing an effective therapeutic relationship can the clinician gain insight into the patient’s experience and work jointly toward successful outcomes. An effective therapeutic relationship is equally essential at the assessment stage. Clinicians can anticipate that especially suicidal youth will have trouble reporting their experience without some sense of alliance and should question the validity of data gathered during an assessment that does not have the benefit of a therapeutic alliance. psychological history, assessment of current mental and physical health, and sound clinical judgement regarding the suicide risk factors previously covered. One relatively new measure shows some positive results. The Modular Assessment of Risk for Imminent Suicide (MARIS)
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