Table 4: Joiner Approach Risk Categories Risk Rating Description Low
• No symptoms of suicidal ideation. • Non-multiple attempter with ideation that is limited in intensity and duration; no/mild plans or preparations for an attempt; and no/few risk factors. • Multiple attempter with no other risk factors. • Non-multiple attempter with moderate-severe suicidal desire/ideation, no/mild plans and preparations for an attempt, and two or more risk factors. • Non-multiple attempter with moderate-severe plans and preparations. • Multiple attempter plus one other risk factor. • Non-multiple attempter plus moderate-severe plans and preparations for an attempt, and one or more risk factors. • Multiple attempter plus two or more risk factors. • Non-multiple attempter plus severe plans and preparations for an attempt and two or more risk factors. • Multiple attempter plus severe plans and preparations for an attempt.
Moderate
Severe
Extreme
Note . Adapted from “Scientizing and Routinizing the Assessment of Suicidality in Outpatient Practice,” by T. E. Joiner, Jr., R. L. Walker, M. D. Rudd, and D. A. Jobes, 1999, Professional Psychology: Research and Practice , 30(5), pp. 1-7; and “Routinized Assessment of Suicide Risk in Clinical Practice: An Empirically Informed Update,” by C. Chu, K. M. Klein, J. M. Buchman-Schmitt, M. A. Horn, C. R. Hagan, and T. E. Joiner, 2015, Journal of Clinical Psychology , 71(12), pp. 1186-1200.
The presence or absence of a history of multiple prior attempts is an important variable in the Joiner system and is emphasized with a separate categorization of risk. Rudd, Joiner, and Rajab (1996) explored the relationship among suicide ideators, single attempters, and multiple attempters across several categories, and they determined that “multiple attempters presented a more severe clinical picture and, accordingly, elevated suicide risk compared to [single] attempters and ideators” (p. 541). Further, according to the Joiner risk assessment model, attempt status (i.e., whether the individual has attempted once [single attempter] or more than once [multiple attempter]) should be considered along with several risk factors in order to determine an individual’s risk category. Risk factors from Joiner’s model of suicidal behavior, the Interpersonal Theory of Suicidal Behavior include: ● Capability for suicide (e.g., non-suicidal self-injury, fearlessness about death). ● Thwarted belongingness. ● Perceived burdensomeness. ● Hopelessness. ● Family history of suicidal behavior. ● Recent stressful life events. ● Impulsivity. ● Presence of acute indicators of risk (agitation, social withdrawal, sleep disturbance, severe affective states, weight loss). Case study 4 Samantha is a 20-year-old white female who presented for therapy after the break-up of a long-term relationship. During intake, she noted that she wanted help for her “serious abandonment issues” and stated that she often “jumped from one relationship to another.” Samantha noted that she “can’t be alone” and that she has suffered from these problems over the past 5 years. She had no prior treatment history but meets criteria for borderline personality disorder. Samantha had no history of engaging in self-injurious behaviors and denied current and past suicidal ideation. Discussion According to the Joiner model, Samantha would be considered to be at low risk because she has no past or current suicidal symptoms. In this case, the Joiner model would recommend taking the following actions:
(IPTS; Joiner, 2005; Van Orden, et al., 2010; Chu et al., 2017) Once a decision about acquired capability has been made, the decision-tree interview should be conducted. Resolved plans or preparations that are clear and with high intent, combined with any other significant findings, result in at least moderate risk. Even without resolved plans or preparation, elevation of suicidal desire or ideation combined with two or more other significant findings result in at least moderate risk. Perhaps the most compelling aspect to this assessment approach is that every element is backed up by ample empirical data for the resulting clinical decisions (Joiner et al., 2009; Chu et al., 2015). Joiner and colleagues also offer clinicians possible intervention actions to take depending on the patient’s risk category and explain how to appropriately document these actions (see Box 2). Notably, safety intervention can take a variety of forms from provision of crisis hotline numbers, to generation of helpful activities to cope with suicidal ideation, to higher levels of care and/or hospitalization. Intervention activities will be discussed in further detail later on in the course. Finally, as before, the final step in suicide risk assessment in the Joiner model is, after assigning risk level and developing an intervention plan, appropriate documentation. Examples of documentation of the assessment and intervention level can be found in Box 2.
BRIEF CASE STUDIES
● Tell the patient something along the lines of: “In the event that you begin to develop suicidal feelings, here’s what I want you to do: First, use the strategies for self-control that we will discuss, including seeking social support. Then, if suicidal feelings remain, call [the emergency call person]. If, for whatever reason, you are unable to access help, or if you feel like things just won’t wait, call 911 or go to the emergency department.” ● Give additional emergency numbers, including 1-800-273-TALK. ● Consider creating a safety plan (see Intervention section). ● Continue to monitor risk in subsequent sessions. ● Document activities in progress notes.
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Book Code: PYCA1423
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