A number of competencies or skills are required for adequately working with suicidal individuals. Cramer et. al. (2013) examined a number of resources including the AAS Core Competencies (2010) and other resources. This list is adapted from those resources.
Manage Attitudes and Reactions Towards Suicide and Suicidal Clients
This competency involves self-awareness about your attitudes surrounding suicide. Do you feel suicide is always right, always wrong, is it a grey area? Under what circumstances is it appropriate or not to intervene?
Secondly, how do you respond to someone who is suicidal. Are you calm and in control, can you get there with additional training? If you don’t feel this is something you can handle, having a list of referrals for highly suicidal clients can help.
There is no attitude training program that I know of. This is something that can only be properly built through self-reflection. Understanding your own beliefs, however, is a form of building this competency so that you can respond in a way congruent with your values.
Assess Attitudes Towards Suicide
A number of tools exist to assess attitudes towards suicide. These includes the Attitudes Towards Suicide questionnaire (Diekstra & Kerkhof, 1988) and Understanding of Suicidal Patient (Samuelsson, Asberg & Gustavsson, 1997) scale.
Develop and Maintain a Therapeutic Alliance with Client
A strong therapeutic alliance is essential for client change. Standard skills like active listening, displaying warmth, empathy, and unconditional positive regard come into play.
Recognizing the conflict between the client’s desire to end their psychological pain and your desire to prevent suicide will help the client feel heard. Understanding a model of suicidality and being able to express that to the client helps ensure you’re both on the same page.
Finally, Bordin (1979) identifies three elements making up the “working alliance”: common goals decided between the clinician and client, tasks to be completed and the development of a bond between the clinician and the client.
Build Therapeutic Alliance with Clients
While elements like flexibility, confidence, and trustworthiness are associated with a positive therapeutic alliance (Ackerman & Hilsenroth, 2003) they are difficult to build outside of reflection and supervision.
Elements like Reflection, Interpretation, and Active Listening can be improved by reviewing counselling textbooks (especially video-taped sessions), roleplaying and continuing education in empathy and active listening.
A number of tools are in use to assess the working alliance. The Working Alliance Inventory (Horvath & Greenberg, 1989) is a 36-item tool that focuses on the three elements of the therapeutic alliance. It is available in both therapist and client versions.
Know and Elicit Evidence-based Suicide Risk and Protective Factors
Key to effective suicide risk assessment is the understanding of exactly what factors put someone at risk (risk factors), including what factors constitute elevated baseline risk (for instance a historical sexual assault), what factors increase acute risk (intoxication) and what elements represent a suicide attempt may be imminent (obtaining access to lethal means, putting final affairs in order.)
Understanding suicide protective factors and reasons for living allows one to put in place elements to reduce risk. Finally, understanding suicide-specific language is important in being able to accurately describe a client’s suicidal behaviour.
Understand Suicide Risk and Protective Factors
There is a strong evidence base for suicide risk factors and protective factors. The American Association of Suicidology formed a consensus group to assess the evidence for suicide risk and developed a list of suicide risk and protective factors.
I’ve written a blog post on the elements differentiating suicide attempts from ideators in a youth population.
Suicide specific language can be developed by reading journal articles such as De Leo et al’s (2006) study “Definitions of Suicidal Behavior” or Silverman et. al’s 2007 “Rebuilding the Tower of Babel.”
Beyond evaluation built in to workshops and regular feedback and supervision (from peers or actual supervisors), tools like the Suicide Intervention Response Inventory can help us assess our level of suicide intervention skill.
Identify Current Suicide Plan and Suicidal Intent
Being able to identify the current suicide plan and suicidal intent involves assessing the number, intensity and length of suicidal thoughts, as well as the presence and intensity of suicidal intent.
Additionally being able to understand the suicide plan (and accessibility of that plan) as well as the perceived lethality are important elements in this competency.
The CASE Approach (Shea, 2009) offers one avenue to assessing the suicide plan and intent. Additionally using a structured tool like the DCIB Risk Assessment helps a clinician or telephone crisis worker cover elements relevant to risk.
There are no existing tools that specifically cover a clinician’s exploration of suicidal intent but there are a number of tools the clinician can use with the client to assist them. These include:
Cutter (1999) includes a chapter in his book The Suicide Prevention Triangle discussing a number of assessment measures for suicide and suicidal intent.
Determine Level of Risk
Determining the level of risk means compressing all of the available information to express it in a simple fashion (e.g. Low, Medium, High, Extreme/Imminent) so that decisions about treatment and current status may be made.
This is a process that requires professional, clinical judgement and should only be performed with appropriate clinical supervision and close monitoring until these skills are mastered.
Training and experience in the Collaborative Assessment and Management of Suicidality (CAMS) approach is one structured method for building competency in suicide risk by completing a number of risk areas and assisting in the building of a treatment plan (see the next section, “Develop a Treatment Plan”)
In my opinion, assessing one’s currently level of skill in suicide risk estimation is something that can only be done by a third party. As the saying goes, we don’t know what we don’t know.
Common methods in hospitals include Grand Rounds and patient consults, while in community settings consultation with supervisors, as well as outside supervision with a supervisor well-trained in suicidality.
Develop a Treatment Plan
Developing a treatment plan includes elements such as designing a suicide safety plan, restricting access to lethal means, gaining buy-in from the client about actions to take to preserve safety in the short, medium and long-term and monitoring suicide risk.
Other activities to protect safety can include beginning counselling or therapy (or returning there if treatment had stopped), a referral to a psychiatrist or other physician for medication.
For those who work in managed care, a book like the Suicide and Homicide Risk Assessment and Prevention Treatment Planner can help you design treatment plans that meet the stringent requirements of HMO and insurance companies.
Assessing your treatment plans is another activity that requires expert opinion, but something like the Ontario Medical Association’s Key Elements to Include in a Coordinated Care Plan (2014) can give you some ideas as to where weaknesses may exist.
Notify and Involve Others
This competency involves understanding when it is appropriate to notify other individuals. For instance, family and friends, other treatment providers, physicians and pharmacists.
Learning your state or province’s laws on informed consent are an important part of developing this competency. Further down the page, “Understand the Law Around Suicide” may help as well. Where homicide risk may be present, see my article on homicide risk assessment.
Framing communication not as an attempt to subvert the client’s autonomy, but rather to help those close to them better help them may reduce resistance to communication.
Additionally, allowing the client to know each individual who was contacted, what they said, and what was put in their treatment plan or case notes (if anything) helps the client see you have their best interests at heart.
Workshops on the legal ramifications of suicide may allow you an opportunity to assess how your current practices work and to develop new ones.
The Counseling on Access to Lethal Means (CALM) course includes a component on involving parents and other independent verifies of information which is an important element in clinical decision making.
Checking in with your clients on a regular basis to see how they feel about decisions you’ve made, beyond a good practice in the therapeutic relationship, is also a good way to develop your intuition by finding out if the client is willing or interested in allowing you to speak with others around them.
Document Risk, Treatment Plan and Clinical Decisions
Risk assessment and treatment planning is useless without proper documentation, for a number of reasons. First, it allows you to monitor the level of risk over time and ensure you haven’t missed anything. Second, it allows collaboration with colleagues and communication of risk information with preciseness. Finally, it reduces legal liability in the event of a client’s suicide.
Ballas (2007) includes an article on documenting suicide risk assessments, and I have an article on document suicide risk here on my blog. The British Columbia Ministry of Children and Family Development has written a policy and practice consideration guide providing additional guidance.
By comparing your existing suicide risk assessments and case notes against the expert examples included in the above resources you can assess your weaknesses.
Understand the Law Around Suicide
You should be familiar with the law regarding suicide in your state, province or country. For instance, what is the process to get someone committed? When can you breach confidentiality? What are your obligations for recordkeeping related to suicide case notes?
This is an entirely individual process. In Ontario, the Ontario Hospital Association has produced a guide to Mental Health and the Law which will assist you in developing the necessary knowledge and decision-making. Continuing education may be available from your local Social Workers organization as well.
Review of your practice by a lawyer who specializes in mental health may help you avoid embarrassing and expensive legal complications and ensure you’re well protected in the future.
Engage in Debriefing and Self Care
Debriefing and self-care are critical to ensuring your continued success as a practitioner, regardless of your professional standing or position. Working with suicidal clients in any capacity can be extremely stressful and feelings of incompetence or failure can easily appear, even in situations where the client suffers no adverse outcomes.
Ensuring regular supervision (including your own psychotherapy if necessary) while working with suicidal clients is helpful. Seeking out additional supervision or clarification of legal or practice issues can be helpful. Regular self-care (sleeping enough, eating healthy, taking time for hobbies, etc.) is always helpful.
Questionnaires are available, including the Maslach Burnout Inventory-General Survey (MBIGS), the Burnout Measure (BM), the Shirom-Melamed Burnout Measure (SMBM), and the Oldenburg Burnout Inventory (OLBI) for topics like burnout, they can help assess your current level of functioning and give you an awareness if you are beginning to have trouble.
Ackerman, S.J., Hilsenroth, M.J. (2003) A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Review. 23(1):1-33
American Association of Suicidology. (2010). Core Competencies for the Assessment and Management of Individuals at Risk for Suicide. Accessed May 14, 2015 from http://www.suicidology.org/Portals/14/docs/Training/RRSR_Core_Competencies.pdf.
Ballas, C. (2007) How to Write a Suicide Note: Practical Tips for Documenting the Evaluation of a Suicidal Patient. Accessed on May 15, 2015 from http://www.psychiatrictimes.com/articles/how-write-suicide-note-practical-tips-documenting-evaluation-suicidal-patient.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice, 16(3), 252–260.
Cramer, R.J., Johnson, S.M., McLaughlin, J., Rausch, E.M., Conroy, M.A. (2013) Suicide Risk Assessment Training for Psychology Doctoral Programs: Core Competencies and a Framework for Training. Training and Education in Professional Psychology. 7(1):1-11. doi: 10.1037/a0031836.
Cutter, F. (1999). The Suicide Prevention Triangle. Triangle Books.
De Leo, D., Burgis, S., Bertolote, J.M., Kerkhof, A.F.F.M., Bille-Brahe, U. (2006) Definitions of Suicidal Behavior: Lessons Learned from the WHO/EURO Multicentre Study. Crisis. 27(1).4-15. DOI 10.1027/0227-5910.27.1.4
Diekstra, R.F.W., Kerkof, J.F.M. (1988) Attitudes Toward Suicide: Development of a Suicide Attitude Questionnaire (SUIATT). Current Issues of Suicidology. (1988) 462-476
Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36(2), 223 – 233
Ontario Medical Association. (2014) Platt, Katherin. Key Elements to Include in a Coordinated Care Plan. Accessed on May 14, 2015 from https://www.oma.org/Resources/Documents/CoordinatedCarePlan_June2014.pdf
Samuelsson, M., Asberg, M., & Gustavsson, J.P. (1997). Attitudes of psychiatric nursing personnel towards patients who have attempted suicide. Acta Psychiatrica Scandinavica, 95, 222-230
Silverman, M. M., Berman, A. L., Sanddal, N. D., O’Carroll, P. W. and Joiner, T. E. (2007), Rebuilding the Tower of Babel: A Revised Nomenclature for the Study of Suicide and Suicidal Behaviors Part 2: Suicide-Related Ideations, Communications, and Behaviors. Suicide and Life-Threat Behavi, 37: 264–277. doi: 10.1521/suli.2007.37.3.264