Discussion This note covers the risk factors and recent and past suicide behaviors, summarizes a mental status examination, and provides a risk/benefit consideration of the various courses of actions. The note provides a “thinking out loud” approach to the reasons for the clinical decision. Joiner and colleagues would suggest the following documentation if using their risk assessment: Suicide risk was assessed according to Joiner et al. (1999) and determined to be [low/moderate/severe/extreme] due to … [e.g., ideation, plans, preparations, etc.]. Action taken: [e.g., safety plan, emergency numbers, consulted with supervisor, etc.]. Risk will continue to be monitored (Chu et al., 2015, p. 1200).
The recommendation of inpatient treatment was not welcomed by Mr. Moore. It was explained that this assessor was prepared to contact the authorities if Mr. Moore declined to be evaluated at the hospital. Mr. Moore indicated that he would rather “choose” going to the hospital over having the courts or police involved. The results and recommendations of this evaluation were shared with both the referring therapist and this evaluator’s supervisor; both were in agreement. The patient was escorted under constant observation to the hospital assessment center. A copy of this note was provided to staff there.
FOUNDATIONS FOR A STRONG ASSESSMENT WITH YOUTH
The previously discussed suicide risk assessment frameworks are relevant to at-risk individuals at all ages. However, there are some additional factors that can help clinicians when assessing at-risk youth. In addition to working toward a therapeutic alliance during the assessment process, clinicians should be aware of several other elements that may increase the likelihood of eliciting the most accurate information essential for sound suicide assessment. Shea (2002) summarized key points when asking adolescents about suicide: ● Significance of hesitancy : Any hesitancy on the part of the patient may suggest that he or she has had some suicidal thoughts, even if the hesitancy is followed by denial of these thoughts. ● Follow-up of answers : Answers such as “No, not really” often indicate that suicidal ideation has occurred, but the patient may believe the clinician is not interested in these thoughts if the patient has not seriously considered acting on them. Follow-up is important. ● Body language : Clinicians should pay attention to body language that may indicate deception or anxiety (e.g., fidgeting, change in tone of voice, or lack of eye contact). Follow-up may include “This seems to be difficult for you to talk about. How are you feeling right now?” ● Active listening : Shea (2002, 2004) recommends against note taking during the suicide risk assessment. This allows the clinician to attend to the patient’s responses fully and be aware of any nonverbal clues. It also indicates to the patient that the clinician is interested in his or her narrative. Of course, assessment almost always requires careful documentation. As a compromise, clinicians can summarize with the patient his or her narrative after the interview. During this time, the clinician can document the assessment while also reviewing the accuracy of the information with the patient. ● Clinician self-awareness : It is critical for clinicians to avoid any evidence of their own personal discomfort during the assessment interview. Behaviorally, this may be exhibited by nervous habits such as looking away from the patient, shaking feet, constantly moving, clicking pens, and rapid or pressured speech. These may increase a patient’s anxiety and interfere with a more accurate reporting of symptoms. Clinicians should periodically administer a “self-check” during the assessment to gain insight into their own feelings about what is being shared. Taking the assessment slowly may help mask any clinician discomfort. ● Clinician commitment : Clinicians should specifically make every effort to avoid appearing hurried. Individuals with suicidal ideation, and borderline personality disorder in particular, may be thrown into a state of emotional dysregulation when feeling rushed (Linehan, 1993; Selby et al., 2013). To help a patient manage his or her anxiety, clinicians should convey that they are interested in helping the patient take the time necessary to most accurately sort out and describe his or her experiences.
Several additional key points are important to consider when working with youth: ● Confidentiality : Confidentiality limitations may make disclosure of behaviors difficult. It is the clinician’s ethical obligation to inform, and the adolescent and parents’ right to know, about the limits of confidentiality prior to conducting any interviews. One of the best strategies for managing issues of confidentiality is to develop a strong relationship with both the adolescent and the parents. When adolescents know that information such as safety concerns about self- injury or potential for suicidal behavior may be shared with their parents and other adults, they may have difficulty in disclosing important information. Again, developing a strong therapeutic relationship may help reduce an adolescent’s underreporting and improve help-seeking behaviors. ● Interpersonal connections : Strengthening interpersonal connections is a developmental marker of adolescence and their ability to talk about interpersonal experiences, and to do so in an interpersonal context, may be underdeveloped. Prompts such as “I know this is not easy to talk about, but we have time, so let’s think a bit more about what that was like for you” may help indicate to the adolescent that he or she has time to think about how he or she feels and that the clinician is truly interested in that experience. ● Reassurance : Because youth often have misconceived ideas about what may happen if they report suicidal thoughts or behaviors (e.g., they will be “in trouble,” they will be hospitalized, or they will be subjected to mood-altering medication and physical isolation from others), it can be helpful to talk about the adolescent’s fears of disclosing how he or she really feels. Sometimes setting the record straight can reduce anxiety and increase the adolescent’s comfort in sharing sensitive information. ● Team approach : Emphasize a team approach to managing the crisis. If the adolescent were able to manage his or her own suicidal experience effectively, it is likely that the adolescent would not be in the present assessment situation. But while the clinician may serve as an expert in managing the crisis or implementing effective interventions, the adolescent is the expert of his or her suicidal experience (Michel & Jobes, 2010), so it is imperative that clinician and patient work together to develop the plan with the greatest likelihood of reducing suicide risk. ● Encouragement : Clinicians should always model hopefulness. It is easy at times to hear the tragic stories shared by individuals and feel sympathetic. Empathetic clinicians may even come to appreciate why the adolescent would want to die. It is critical, however, that clinicians never overtly share that thought. It is certainly acceptable to show empathy by saying something like “That sounds awful.” However, these expressions and the conclusion of the clinician’s response to the youth’s narrative should always be summarized with an expression of hope, as in this example: “As awful as that experience must have been for you, and even though you have tried very hard to move beyond it without much success, I want to encourage you and let
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