designing a treatment and intervention plan. A person-in- environment approach to assessment broadens the lens of assessment from individual psychology to environmental factors or larger social systems that can influence symptoms (Silverman et al., 2015). These other social systems include family, friends, social services, work, politics, religion or spirituality, education, legal systems, community organizations, immigration and acculturation issues, and informal networks. Some clients can describe their social support systems in detail, including their strengths and weaknesses; however, some cannot. For more information about the client’s social systems, the clinician can ask broad questions like the following (Silverman et al., 2015): Suicide Assessment Some clients may become so severely depressed that they may experience thoughts of suicide. According to SAMHSA (2022), 12.3 million adults had serious thoughts of suicide in the year prior. Of those, 3.5 million developed plans for suicide, and 1.7 million acted upon those plans. Hispanic or Latino adults acted upon their suicidal thoughts or plans at a higher rate than White or Asian adults (SAMHSA, 2022). CDC data on trends suggests that the rate of completed suicide peaked in 2018, after a continuous 19-year, 35% increase, and then decreased by 5% over 2019 and 2020. This decrease in 2020 was despite the increased risk factors presented by COVID-19 (Curtin & Ahmad, 2021). While death by suicide may have decreased slightly, the experience of suicidal ideation in the week of June 24–30, 2020, during the height of the COVID-19 shelter-in-place orders, increased (Czeisler et al., 2020). Czeisler et al. (2020) reported that in 2020, two times as many adults experienced suicidal ideation within the month prior than in 2018. The process of screening and assessment matters. As part of the assessment process, clinicians should explore current thoughts of suicidal ideation and past suicide attempts, as well as emotions that lead to vulnerability, with the client in a way that emphasizes the foundation of a strong therapeutic alliance, supports patient autonomy as much as feasible, and limits the triggering of shame (Bryan, 2021; Knapp, 2019; Ford et al., 2021). Screening tools should guide a meaningful discussion rather than asking, “You’re not thinking of harming yourself, are you?” (Ford et al., 2021). Screening and assessment typically utilize one of three screening instruments, the Columbia Suicide Severity Rating Scale, Columbia_Protocol.pdf (Posner et al., 2011), and the Ask Suicide Screening Questions tool (screening_ tool_asq_nimh_toolkit.pdf (nih.gov), which utilizes four questions to screen in approximately 20 seconds (Horowitz et al., 2020), and the Beck Scale for Suicide Ideation (Beck et al., 1979; Andreotti et al., 2020). These instruments are available in both adult and youth versions. They should not be used as the only source of information but rather as a foundation to have a meaningful discussion about mental well-being, risky behaviors, relationships, and purpose and meaning in a way that moves towards treatment. The American Psychiatric Association guidelines on initial assessment of suicide risk advise clinicians to evaluate the client (Silverman et al., 2015): • Current suicidal ideas, plans, and intent. • Prior self-harm, suicidal ideas, plans, and attempts, including those that were aborted. • Psychiatric and trauma history. • Mood, level of anxiety, hopelessness, and impulsivity. • Psychosocial stressors include lack of unemployment, social support, terminal medical diagnosis, and personal or relationship problems.
• What are the positive influences in your life? • Where do you go for support? • Where would you like to go for support but cannot right now? • How many friends do you have? • Do you ever ask them for help when you are troubled? • Who is your closest friend? • Tell me about your relationship with your family members. • Who do you get along with the best? • Which family member(s) do you not feel close to? • Are you religious? • Do you attend church? Clinicians need to recognize signals or warning signs of suicidal ideation and suspicious behavior during the assessment because some information is not accessible through direct questioning (Knapp, 2019). Some signals can be direct, such as a client sharing suicidal ideation, or indirect, such as a client stating that life is meaningless without her boyfriend. Sometimes, clients take behavioral action, such as buying excessive amounts of sleeping pills. Sometimes, their behaviors are indirect, such as giving away possessions. Clinicians should ask their clients directly about thoughts of suicide. For example, a clinician can ask, “Are you thinking of committing suicide?” or “I’ve noticed some changes in your behavior that concern me. Are you thinking that suicide may be a possibility?” When a client expresses suicidal ideation, the clinician should reflect on the client’s statements and assess three main areas: (1) Is the client’s proposed method of suicide a lethal method? (2) Does the individual have the means available to commit suicide? Moreover, (3) does the client have a specific plan and timeframe to complete the suicide? • How has that helped (or not helped)? • Are you having any legal problems? Note that the DSM-5-TR replaced the language “plan for committing suicide” with the more sensitive and less stigmatizing language of “a specific suicide plan, or a suicide attempt” (American Psychiatric Association, 2022). It is important to note that the American Academy of Pediatrics (AAP) recommends that clinicians also question children and adolescents directly about suicidal ideation (Sisler et al., 2020). Screening instruments most frequently utilized with children and adolescents are the Patient Health Questionnaire for Adolescents and the Beck Depression Inventory (Patra & Kumar, 2023). The Columbia Suicide Severity Rating Scale (C-SSRS) is also available in a pediatric version (Posner et al., 2011). Additionally, clinicians should ask specific questions about the child or adolescent’s fantasies. Some risk factors for suicidal ideation in children and adolescents are pathologic Internet use, learning of another’s suicide online, and bullying (Sisler et al., 2020). Adolescents with a family history of suicide, increased agitation, personal mental health problems, and a recent stressful life event are at higher risk of suicide (Sisler et al., 2020). For more information about assessing suicide risk, please see the Resources section. Shifts in treatment have moved from treating suicidal thoughts as a symptom of mental illness or depression to targeting suicidal thoughts directly (Clay, 2022), including the Collaborative Assessment and Management of Suicidality (CAMS; Swift et al., 2021) and dialectical behavior therapy (DBT) and DBT-informed interventions (Clay, 2022). Treatments may include keying in on the vulnerabilities of emotional dysregulation and cognitive rigidity (Rudd et al., 2015). CAMS is a six- to eight-session evidence-based intervention that targets suicide directly.
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Book Code: PCIL1525
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