Suicide Potential

Suicide is a serious public health issue both at the global level and in the United States. Globally, the World Health Organization indicates that there were 1,000,000 deaths by suicide in 2000, and projects that there will be 1.5 million suicide deaths in the year 2025. Additionally, the overall rate of suicide in the world has been steadily increasing since 1950. In the United States, according to the American Association of Suicidology, there were approximately 31,000 deaths by suicide in 2003 and, although there are no solid data identifying the actual number of suicide attempts, this organization estimates that there are at least 25 attempts for every suicide death.

Efforts to address the incidence and prevalence of suicide and suicidal behavior, while initially focused on developing standardized methods for prediction, have focused more recently on the identification of suicide potential through the assessment of salient risk factors and clinical indicators of suicidality. This entry provides an overview of the identified suicide risk factors and characteristics that counselors need to be aware of in their clinical work with suicidal individuals.

Treating the Potentially Suicidal Individual

Clinicians are urged to consider the issue of the interpersonal context of the assessment of suicide potential even before they complete the assessment of risk factors and potential indicators, as recent work in this area has suggested that suicidal clients often perceive the assessment process as impersonal and dehumanizing. Moreover, both theory and research suggest that the validity of assessment information is related to the quality of the interpersonal relationship from the client’s perspective. Thus, clinicians working with suicidal individuals should acknowledge the importance of considering the assessment process from the client’s point of view. Adherents to this perspective consider the suicidal individuals—not the counselor—as the experts in their suicidality. Additionally, suicidality is viewed as the central clinical problem in these models, as opposed to being addressed as a symptom of some underlying psychopathology. Regardless of the approach to the assessment of suicide potential (e.g., standardized assessment measures, clinical interview, or a combination), a greater focus on collaboration and a therapeutic assessment approach to suicide risk assessment will serve to increase the reliability and validity of information accrued through the process.

With the importance of the therapeutic relationship in mind as the backdrop for identifying information relevant to the assessment of suicidal potential, there are two different approaches for identifying risk factors and clinical indicators. The first approach is the top-down or clinician-focused model embedded in the Suicide Assessment Checklist (SAC) developed by James Rogers and his colleagues, and the second is the horizontal model reflected in the Collaborative Assessment and Management of Suicidality (CAMS) protocol developed by David A. Jobes and his colleagues.

Suicide Assessment Checklist (SAC)

In this model, the clinician prompts for information and completes the assessment protocol from what is typically an “expert” position. The SAC identifies a number of status and clinical variables that have been shown in the literature to be related to increased suicide potential. The status variables include the following:

  • Previous psychiatric history (implying a psychiatric diagnosis). Diagnoses specifically linked to greater suicide potential include:
    • Depression
    • Bipolar depression (especially with psychotic features)
    • Anxiety disorders
    • Schizophrenia
    • Post-Traumatic Stress Disorder
    • Personality disorders (especially borderline personality disorder)
  • Drug and alcohol use
  • Prior suicide attempts
  • Males at higher risk
  • Ages 15 to 35 and 65 and older at higher risk
  • Suicide survivor status
  • Marital status. Divorced, separated, or widowed at higher risk
  • Presence of a suicide plan including:
    • An identified method
    • Method access
  • Making final plans
  • The presence of a suicide note
  • Dependent children in the home. Serving as a protective factor

Similarly, clinical risk factors identified in the SAC model include the following:

  • Worthlessness
  • Hopelessness
  • Social isolation
  • Depression
  • Impulsivity
  • Hostility
  • Intent to die
  • Environmental stress
  • Lack of a future time perspective

The SAC provides for a quantitative summary assessment of suicide risk based on the identification of the status variables and ratings on the clinical risk factors. In general, higher scores are interpreted as indicating greater risk. However, the application of strict cutoff scores is discouraged, and clinicians are prompted to integrate the SAC information with their clinical experience in making final intervention decisions.

The SAC provides a structured approach for the assessment and documentation of factors related to increased suicide potential. However, there are a number of important clinical constructs that are not taken into account in this model. Neither does it specifically promote a strong working alliance. The following approach includes these additional clinical constructs while fostering a horizontal or collaborative interpersonal context.

Collaborative Assessment and Management of Suicidality (CAMS)

The CAMS model integrates a variety of approaches in the process of assessing and intervening with suicidal clients including attention to the behavioral, cognitive, psychodynamic, humanistic, existential, and interpersonal aspects of the suicidal experience of the client. The CAMS protocol prompts the client, in collaboration with the counselor, to provide a self-assessment of the following constructs that have been shown to be related to increased suicide potential:

  • Psychological pain
  • Stress
  • Agitation
  • Hopelessness
  • Self-hate
  • Reasons for living
  • Reasons for dying

Within the CAMS model, clients not only identify their level of distress on a variety of clinical variables, but also specify which aspects are the most troubling for them. Similarly, reasons for living and reasons for dying are rank ordered in terms of importance, leading to the development of targeted interventions. In addition to the risk factors identified in the SAC, the CAMS model also identifies the following four specific risk factors:

  • Suicide rehearsal (i.e., practicing suicide-related behaviors)
  • Relationship problems
  • Legal problems
  • Health problems

Currently, there is no research demonstrating the relative efficacy of these approaches. However, taken together, the status variables, risk factors, and clinical constructs incorporated in these two models provide a relatively comprehensive outline of the most salient indicators of suicide potential. Nonetheless, as important as familiarity with these factors is to accurately accessing the suicide potential of a client, it is equally important to understand the impact of the interpersonal context on the assessment process. Assessment and intervention are uniquely intertwined when responding to suicidal crises, and the quality of the information gathered in the process will be a function of the counselor’s ability to engage the client collaboratively and on an existential level.

References:

  1. Jobes, D. A., & Drozd, J. F. (2004). The CAMS approach to working with suicidal individuals. Journal of Contemporary Psychotherapy, 34, 73-85.
  2. Rogers, J. R., Lewis, M. M., & Subich, L. M. (2002). Validity of the Suicide Assessment Checklist in an emergency crisis center. Journal of Counseling and Development, 80, 493-502.
  3. Westefeld, J. S., Range, L. M., Rogers, J. R., Maples, M. R., Bromley, J. L., & Alcorn, J. (2000). Suicide: An overview. The Counseling Psychologist, 28, 445-510.

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