Clinician : That may be true, and I think you’re starting on the right path. I have some thoughts about a treatment approach that may help you with this. Following the initial interview, the clinician is concerned about the frequency with which Hannah was thinking about suicide, as well as the fact that she had previously engaged in self- injury, although it appears that she has stopped engaging in that behavior. While her risk for suicide is deemed moderate, the clinician’s assessment is that if he could get her into an intensive outpatient program, she would be able to work on the issues in her life that lead her to feeling down, depressed, and suicidal. Prior to discharge from the youth crisis center, the clinician is able to locate an outpatient therapist who can see Hannah in two days and will have the availability to see her frequently while her risk remains moderate. With the clinician’s help, Hannah completes a safety plan (described in greater detail later in the course). She agrees to talk with her mother, who has accompanied her to the crisis center, about some of the struggles she is having. The clinician expresses his concerns, reviews the safety plan with the mother, and discharges Hannah home with an appointment in two days with the outpatient therapist. Discussion This case displays many of the challenges that arise during the assessment of suicide risk in youth and adolescents. The clinician pays careful attention to the youth’s frequency and severity of suicidal ideation, interpersonal experiences with family and friends, potential presence of hopeless feelings, and coping skills. Although the youth has never attempted suicide before, and does express some feelings of hopefulness, the youth has also contemplated some potential suicide methods (e.g., taking her mother’s prescription pills or hanging herself) and has a history of NSSI. Accordingly, the clinician appropriately deems the patient to be at moderate risk for suicidal behavior and provides an appropriate intervention safety plan. Of course, don’t forget to document the decisions and plan as soon as possible! and the Ask Suicide-Screening Questions (ASQ) as useful tools for suicide assessment. Soon, in order to avoid missed detection, hospitals may use machine learning to discover whether a patient who has engaged in non-suicidal self- injury or a suicide attempt will attempt suicide in the near future (MHSOAC, n.d.). Researchers at the University of California, Berkeley, have teamed up with the U.S. Department of Veterans Affairs to train a “deep learning network” to study medical records in order to classify patients at risk for suicide (Eddy, 2019).
guess I could look it up online. Everyone has something to hang themselves. I have a few belts. Hannah : Do you think you would have the chance to do either of those things? Hannah : Well, my mom doesn’t come home from work until after 6:00 p.m., so I could probably do something after school one day. Clinician : Have you made any plans for a suicide attempt? Hanwnah : No. I really don’t think I’d do it. I just think about it from time to time. Clinician : When you think about suicide, how afraid are you? Hannah : Oh, man, I get scared just thinking about it sometimes. That’s probably why I stop thinking about it. Clinician : Has anything particularly stressful happened to you lately? Hannah : Not really. It’s just the same junk with kids at school. I want friends, but then they are annoying. Clinician : Do you feel hopeless about your future? Hannah : I’m still young, and next year I graduate. If I’m able to keep my grades up, maybe I can get away from some of the drama. Clinician : When you feel bad, how do you cope? Hannah : I used to cut myself on the leg, but then I realized that if it scarred, people might notice that in the summer, so I stopped. Now I just drown it out with music. Clinician : It sure sounds like there are things for you to be hopeful about, and you are starting to adapt some new coping strategies. That suggests to me that you are a pretty resilient young woman. What do you think of that? Hannah : I guess now that I hear myself say it, maybe you’re right. I am managing a bit better, but sometimes it seems there is still a long way to go. California suicide risk assessment According to MHSOAC’s Striving for Zero: California’s Strategic Plan for Suicide Prevention 2020-2025 (The Plan; n.d.), “best practices in suicide risk assessment and management use a collaborative and transparent approach to assessing for suicide risk” and to supporting “delivery of additional services, referral, or safety planning” (p. 47). The Plan emphasizes the importance of “the use of a standardized decision-making process to routinize risk designations based on suicide attempt history, the severity of current symptoms of suicide risk, and the integration of risk factors” (p. 73), and specifically mentions the Columbia- Suicide Severity Rating Scale (C-SSRS), the Patient Health Questionnaire (PHQ9 and PHQ9A; for use in healthcare settings), California early intervention California’s Know the Signs initiative maintains a website called Suicide Is Preventable . In addition to describing the signs that indicate a person’s vulnerability to suicide, the site offers advice under the headings Find the Words (how to start a conversation,
what to say, and what not to say) and Reach Out (resources). The website is listed in the Resources section at the end of the course.
Clinical intervention and risk prevention for suicidal behavior When mental health providers are dealing with individuals who are suicidal, it is imperative that they be aware of the legal implications related to the seriousness of suicidal thoughts. There are times when patients will need to be protected from themselves through hospitalization. At times, hospitalization
even may be involuntary. It is critical that clinicians be aware of the need for professional documentation of their decision- making process when dealing with patients who are at risk for suicide. This section reviews various issues related to commitment and documentation issues. et al., 2019). In this situation, the clinician has an ethical responsibility to ensure the patient’s safety (Obergi, 2017). Therefore, it is good practice to know and understand the applicable state statutes where one practices regarding options and obligations concerning involuntary treatment. Most states offer an option of pursuing involuntary commitment if a patient
Commitment criteria and imminent risk Experiencing elevated intent to act on a suicide plan is perhaps the primary cause for concern in suicide crisis evaluations of high-risk individuals (Jordan & Samuelson, 2016). An important clinician concern is deciding when to hospitalize a suicidal patient. This is especially the case when a patient reports elevated “intent” to act on suicidal thoughts or plans (Jordan
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