SCL1201 - SECTION 7: CONDUCTING A SUICIDE ASSESSMENT: SCENARIO ANALYSIS
Scenario 1
James is a 44 year-old Caucasian male police officer. He has come to see you for a fitness for duty exam following several big changes in his life. First, he has just received a demotion at work, from Staff Sergeant of first watch, to Beat Officer of the night watch, due to a run in with his superior officer and a number of job performance problems that have been building over the last 8 months. These job performance problems included a suspension for showing up at work intoxicated. Second, he has just been separated from his wife of 16 years, and has had to move back in with his parents, since he cannot afford to pay child support and maintain a residence of his own. His wife has been threatening to move to another state with their two children. She has filed a restraining order against him, since he made statements to her with implied threats of violence if she would not allow him to see his kids. What risk factors can you identify for this client based upon the information given? What are the factors that would determine if you would consider a 1013 involuntary hospitalization for this client? What third parties, if any, do you think may be useful to contact as part of this assessment process? What concerns do you have, if any, about how to approach the topic of suicidality with this client? If suicidality is determined to be present, what steps might need to be considered first in stabilizing this client and keeping him safe?
Scenario Question One
What risk factors can you identify for the client in our scenario, based upon the information given?
There are a number of risk factors that can be readily identified from the information given in this scenario. Let's look at each. First, the client is almost certainly in a period of acute turmoil from the multiple areas of stress. It may be a wise idea to see if there are somatic disturbances - such as sleep or appetite problems - present in the client. This would create an additional source of stress, and decrease resistance to suicide.
Second, the client has had a significant life loss, with the separation from his wife and the loss of contact with his children. The degree to which this is perceived to be upsetting to the client must be determined in the course of the assessment, but it is certainly an area that must be examined.
Next, there are indications that the client may be abusing alcohol. This must be evaluated further to see how severe a problem it may represent. It must also be determined whether it has contributed to the marital problems, and to problems with judgment and impulse control, as may be evident by the need for the client's wife to secure a restraining order. The client, of course, may have problems with impulse control and judgment apart from alcohol abuse, a factor that must also be evaluated.
The client's current career problems must also be evaluated. If the client's identity is deeply tied to his career, his demotion, and the unraveling of his career track may be a serious blow to his identity and self-esteem.
It may also be fruitful to evaluate whether this client has had repeated exposure to violent and disturbing events. If this is an officer who has been involved in traumatic work situations, it may have an effect on his willingness to consider suicide. It may decrease his resistance, due to his becoming desensitized to the idea of violence, or it may increase his resistance, due to exposure to the effects of the events upon the survivors. In either event, this is important assessment information.
It may also be a good idea to evaluate this client's current support system in some detail. Two areas where support might be expected - at his work and in his marital relationship - are experiencing problems. If there are limited sources of support in other areas, this may create an increased level of risk.
Finally, this is an individual who is familiar with the use of weapons, and has ready access to those weapons. This represents one of the most important risk factors in this scenario. Police officers are among the groups of people who have elevated rates of suicide. One of the contributing features is the ready availability of weapons.
This concludes our analysis of question one. How well did you do in identifying he areas of risk for this client?
Let's move on to examining question two.
Scenario Question Two
What third parties, if any, do you think may be useful to contact as part of this assessment process?
There are several third parties that may be helpful to contact in this case. It may be helpful to gather information from the client's workplace concerning the exact nature of the job problems. It may be helpful to talk to the client's estranged wife to gather more information about their relationship woes, as well as another perspective on client's ability to utilize relationships for support. Client's parents may also have information about this client's current mood and functioning, as well as his current level of alcohol use.
This is not to say that this client would be willing to sign a release of information to allow a clinician to talk to any of these third parties. He may not wish for anyone at his workplace to be aware of his counseling. He may fear that his estranged wife may use information about his seeking help in their various legal struggles.
It may be more likely that this client would be willing to allow the clinician to talk to his parents. He may have confided in them about his workplace problems, and they may know his wife and children, and be able to give some perspective on the client's problems in these areas. It may also be helpful to ask the client if he has ever seen a mental health clinician prior to this meeting. The client may have been referred to a clinician through his work, and prior information may be available about his ability to utilize treatment.
It is important that the evaluating clinician use good sense when deciding how hard to push the client to allow third party contact. The client will be making important decisions about whether to trust the evaluating clinician, which will in turn have a direct impact on the quality of the information gathered in the assessment.
It is also important to be aware of other potential third party contacts that may be identified by the client in the course of the assessment session. The client's most trusted confidante may be a fishing partner, an old friend from high school, a great-uncle - someone the clinician might not readily think of including in the assessment process.
This ends our analysis of question two. Let's move on to our next question.
Scenario Question Three
What concerns do you have, if any, about how to approach the topic of suicidality with this client?
While it is unfair to stereotype any groups of people to the detriment of viewing each person as a unique individual, there are certain factors that must be taken into consideration when deciding how to approach this client about a topic as sensitive as suicidality. This client has self-selected into a profession that is paramilitary in structure, authoritarian in nature, and historically oriented towards "machismo" attitudes.
While it is completely possible that this client is entirely different from any stereotype of a police officer, it is probably wise for the clinician to enter into a discussion of emotional material more cautiously than with a client from a less "machismo" culture. The client's capacity for tackling the affective components contained in the assessment must be evaluated with care as the clinician proceeds.
Based upon the evidence, it might also be wise for the clinician to be prepared to respond to some issues related to control as the topic of suicide is raised. The client exhibits several areas where he seems to be struggling with control problems. It may require a delicate combination of gentleness and firmness to direct the client through such a potentially painful assessment process. The clinician is likely to know quite early in the assessment process whether either of these areas will be problematic.
This completes our analysis of question three. Let's move to the last of our questions.
Scenario Question Four
If suicidality is present, what steps might need to be considered first in stabilizing this client and keeping him safe?
When a client is suicidal, and he/she works in a profession in which weapons are used, the first consideration will almost always be concerned with what to do with those weapons, particularly during any period of time when the client may be more actively suicidal. Depending upon the level of imminent risk, it may be necessary for the clinician to push the client to arrange a shift in his/her work structure so that weapons are not immediately available.
This sets up some difficult dilemmas in treatment planning. Our client in this scenario has already experienced a loss in his career track. A recommendation to move to a desk job where weapons aren't needed may create additional stress and resistance. This topic would need to be addressed very carefully.
The other question that would need to be addressed immediately would be the matter of the client's alcohol use. A depressed client, with major life losses, the ready availability of a weapon, and good judgment and reasoning clouded by alcohol is a dangerous combination. The client would need to be directed to a position of remaining sober until stability can be achieved.
Along a similar vein, the clinician will need to see if the client's depression is sufficient to cloud his reasoning and judgment even without the alcohol. If so, another early step might be to refer the client for an evaluation for antidepressant medication.
If the level of suicidality is serious enough, of course, the clinician has the obligation to put aside all other considerations and direct the client - voluntarily or involuntarily - to a safe and secure environment. Without further information, the need for hospitalization cannot be determined in this scenario, but the clinician must always be prepared to consider it when information points in that direction.
There are many other steps that might need to be considered here - always based upon the information that is gathered in the course of the assessment process. Again, this training is designed to present an overall framework for this process. The clinician will need to use his/her professional skills to fill out that framework to work with individual clients.
Suicide Assessment Scenario 2
Will A., is a 16 year old adolescent male who will be turning 17 in two weeks, and whose mother has brought him in for oppositional and defiant behaviors, as well as use of marijuana, alcohol, and psychedelic mushrooms pursuant to the death of his father. Will has had a recent history of engaging in extremely risky behaviors, the most severe of which was stealing a car and spending a couple of days in juvenile detention, where he was physically assaulted by another inmate. He has been becoming increasingly sullen and silent at school and home, and has been drawing “tattoos” on his arm with a Swiss Army knife and ink from a ballpoint pen. One of the drawings became infected and led to a trip to the emergency room. Will tells his clinician that he and his mother are going to be moving to very rural and isolated part of the state in order to be closer to Will’s maternal grandmother, a woman with a history of on again off again alcoholism that has led to repeated conflicts with Will’s mother. During the session, Will tells his counselor that she is the first counselor he has ever trusted, and wishes he could continue the counseling with her, even if it was only “using Skype or something like that.” What risk factors can you identify for this client based upon the information given? What are the factors that would determine if you would consider an involuntary hospitalization for this client? What third parties, if any, do you think may be useful to contact as part of this assessment process? What concerns do you have, if any, about how to approach the topic of suicidality with this client? If suicidality is present, what steps might need to be considered first in stabilizing this client and keeping him safe?
Scenario Question One
What risk factors can you identify for the client in our scenario, based upon the information given?
There are a number of risk factors that can be readily identified from the information given in this scenario. First, this client has experienced a major loss and appears to have several other secondary signs and symptoms pursuant to this period of loss. It must be determined whether his response to this loss is profound enough to generate the kind of despair that may lead to a suicidal gesture. Given that this is a teen-aged boy, the risk must be considered higher simply due to his age and sex, with the attendant increased risk for impulsive behaviors.
Second, the client is demonstrating poor decision making and is engaging in a variety of risky behaviors. This increases the concern about impulsiveness as a driving force.
Next, there are indications that the client is abusing a number of substances This must be evaluated further to see how severe a problem it may represent. It must also be determined whether the use of substances is adding further contributions to problems with judgment and impulse control. Additionally, at least one of the substances, alcohol, is a depressant and it may deepen the client's already present depressed mood.
The client's self-harming behaviors may also indicate an increased level of risk. While the drawing of tattoos on his arm is not as severe a symptom of self-injurious behaviors as self-cutting might be, it still represents a willingness to hurt himself and should not be taken lightly.
It may also be fruitful to evaluate the client's experience of being in detention, including any traumatic incidents that occurred while locked up, as well as the client's sense of self now that he has had the experience of entering the legal system. It may increase the client's internal sense of hopelessness and loss of control.
It may also be a good idea to evaluate this client's current support system in some detail. His mother may not be at a good place in terms of providing support to him if she is also experiencing a major loss in her life. If there are limited sources of support in other areas, this may create an increased level of risk.
Finally, it must be determined whether the means to commit suicide is readily available to this client. If there are weapons in the house or medications that might be used in a suicide attempt, then the level of risk must be considered to be increased.
This concludes our analysis of question one. How well did you do in identifying he areas of risk for this client?
Let's move on to examining question two.
Scenario Question Two
What third parties, if any, do you think may be useful to contact as part of this assessment process?
There are several third parties that may be helpful to contact in this case. It may be helpful to gather information from the client's mother and grandmother. They may be able to provide additional information about the client's experience and a history of his behavioral regression. They may also be able to provide some information about the client's access to means for a suicide attempt.
This would also allow the clinician to assess the emotional resources of these important support parties for the client, and to assess whether the mother and grandmother have been able to manage their own grief process.
It is also important to be aware of other potential third party contacts that may be identified by the client in the course of the assessment session. The client's most trusted confidante may be a teacher or a coach, and it may be possible to strengthen those supportive relationships.
This ends our analysis of question two. Let's move on to our next question.
Scenario Question Three
What concerns do you have, if any, about how to approach the topic of suicidality with this client?
With a teenager who has been engaging in impulsive behaviors using poor decision making, it can be daunting to broach the topic of suicide, as a clinician would not want to provide the client with ideas that were not already present in the mind of the teenager.
It may be helpful to approach the topic somewhat more peripherally in this circumstance, addressing the self-harm behaviors as a means of gathering information about the client's relationship with himself: does he experience anger at himself that is translated into self-harming behaviors, or is he angry at the world and the loss of his father?
Like in the first scenario, it might also be wise for the clinician to be prepared to respond to some issues related to control as the topic of suicide is raised. The client exhibits several areas where he seems to be struggling with control problems. It may require a delicate combination of gentleness and firmness to direct the client through such a potentially painful assessment process. The clinician is likely to know quite early in the assessment process whether either of these areas will be problematic.
This completes our analysis of question three. Let's move to the last of our questions.
Scenario Question Four
If suicidality is present, what steps might need to be considered first in stabilizing this client and keeping him safe?
As in the first scenario, the most important consideration will be in determining if the means for a suicide attempt is present and taking steps to remove easy access to those means. This may need to be done with regard to two separate households: his mother's residence that his grandmother's residence.
Next, there will need to be considerable time spent in establishing a well considered, well-planned transition strategy, with a safety plan to address the risk factors that have been established.
While it may be tempting for this clinician to be flattered about this client's feeling that a trusting relationship has been established, it is difficult to assess in a first session whether this is a sincere statement of fact, or an attempt at manipulation on the part of the client. A warm transfer of this case will be essential.
As in the first case, if the level of suicidality is serious enough, of course, the clinician has the obligation to put aside all other considerations and direct the client - voluntarily or involuntarily - to a safe and secure environment for further assessment and planning. Again, without further information that would come in the interaction between client and clinician, the need for hospitalization cannot be determined in this scenario, but the clinician must always be prepared to consider it when information points in that direction.
There are many other steps that might need to be considered here - always based upon the information that is gathered in the course of the assessment process. Again, this training is designed to present an overall framework for this process. The clinician will need to use his/her professional skills to fill out that framework to work with individual clients.
Suicide Assessment Scenario 3
Laura Y. is a mental health clinician specializing in work with adolescent girls. For the past year, she has been working with Natalie M., a sixteen year old with a history of acting out behaviors, self-mutilation and dramatic, but not life threatening, suicidal gestures. Natalie is currently living with her aunt, after a history of domestic violence between her mother and her father escalated to the point where her mother feared for her life and went into hiding, keeping her location hidden from everyone and not having contact with Natalie. Her father also went into hiding to avoid prosecution, but has been seen from time to time by Natalie at her school, where he comes to try to force Natalie to tell her where her mother is living. One afternoon, Natalie calls Laura to tell her that she is pregnant, and she thinks she has been for about a month. In order to avoid the potential repercussions within her family, she ran away with the future father, a seventeen year old boy from her school. After a week on the streets, the boy left her for a former girlfriend who comes from a family with money. Natalie asks for Laura's help in handling the situation, and says she is afraid to show up at Laura’s office because her father might look for her there. What risk factors can you identify for this client based upon the information given? What are the factors that would determine if you would consider an involuntary hospitalization for this client? What third parties, if any, do you think may be useful to contact as part of this assessment process? What concerns do you have, if any, about how to approach the topic of suicidality with this client? If suicidality is present, what steps might need to be considered first in stabilizing this client and keeping her safe?
Scenario Question One
What risk factors can you identify for the client in our scenario, based upon the information given?
There are many risk factors that can be readily identified from the information given in this scenario. First, the client potentially in a state of crisis on several fronts. The first of these is the purported pregnancy with all that may entail from that. Please note that this is a self-report from a potentially unreliable reporter, so it must not be taken as an absolute fact.
Second, the client has major family concerns, including exposure to abuse, violence, and stalking behaviors on the part of her father, with a significant amount of unpredictability. The current relationship with her boyfriend must be examined for any signs of difficulties of the same sort, as children who grow up in abusive families are sometimes drawn into relationships that re-create the same problems.
Next, this client has a confirmed history of self-harming behaviors and suicidal gestures, although mild in nature. It can be difficult to predict whether suicidal gestures will move from mild to serious and under what circumstances. If the current stresses create a rupture to client's relationship with her boyfriend, it may create an increased motive for client to engage in additional suicidal gestures. And even a suicidal gesture that is not intended to be fatal can go wrong, particularly in the absence of active adult support.
The client's current living situation presents additional risks on this front, and furthermore creates obstacles to conducting an involuntary hospitalization even if the need for one is determined.
This concludes our analysis of question one. How well did you do in identifying he areas of risk for this client?
Let's move on to examining question two.
Scenario Question Two
What third parties, if any, do you think may be useful to contact as part of this assessment process?
There are several third parties that may be helpful to contact in this case. Certainly client's aunt would be a party that the clinician would want to contact. If the aunt is the official care taking adult, it would be important to exchange information, if there is a release to do so or if the aunt has been granted care taking authority.
Because the client is underage and is at risk, it would also be important to contact the department of family and child services in client's county of residence. It is likely, given the circumstances, that appropriate notifications would have been made and that a case would be open. If an active case worker is assigned, the case worker could facilitate some of the further steps that might need to be taken. In any event, the circumstances also warrant a report from the clinician as a mandated reporter.
As in our previous case, there may also be some other supportive parties who could provide some information about the client's prior and current status and experiences. However, because this client is a minor, it would be up to the person with legal guardianship to provide permission for those contacts to occur. If the mother retains that legal authority - and she is in hiding from her ex-husband - then this becomes a serious impediment to gathering information from other sources.
This ends our analysis of question two. Let's move on to our next question.
Scenario Question Three
What concerns do you have, if any, about how to approach the topic of suicidality with this client?
Because this client has a prior history of self-harming behaviors and mild suicidal gestures, it is likely that the topic of self-harm and suicide will already have been addressed earlier in the course of treatment. The clinician may be able to reference those earlier discussions and use them to scale the degree of suicidality that is currently present.
This completes our analysis of question three. Let's move to the last of our questions.
Scenario Question Four
If suicidality is present, what steps might need to be considered first in stabilizing this client and keeping him safe?
This scenario represents our most difficult set of circumstances with regard to stabilization and safety. Without the client being present and in front of the clinician, it is difficult to establish any definitive stabilization plan.
The first order of business is to attempt to persuade the client to meet somewhere where the circumstances are a little better able to be controlled. This should be done with an eye towards working collaboratively with the department of family and children's services, as they would possess the authority and the resources to provide more stable and secure environments for managing this difficult situation.
This means that the clinician must use the strength of the therapeutic relationship effectively to invite and motivate this client to connect up with the resources that will help keep her safe. The good news here is that the client has called. If there was no established therapeutic relationship and no inclination to move towards a less chaotic set of circumstances, the client would probably just have disappeared.
There are other steps that might need to be considered here - always based upon the information that is gathered in the course of the assessment process. Again, this training is designed to present an overall framework for this process. The clinician will need to use his/her professional skills to fill out that framework to work with individual clients.
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References
Action Alliance for Suicide Prevention, http://actionallianceforsuicideprevention.org/
American Association of Suicidology, http://www.suicidology.org/resources/facts-statistics
CDC, Suicide Facts at a Glance, https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf
ENR, Clinical Practice Guideline: Suicide Risk Assessment, https://www.ena.org/practice-research/research/CPG/Documents/SuicideRiskAssessmentCPG.pdf
Mental Health America, http://www.mentalhealthamerica.net/suicide
NIMH, https://www.nimh.nih.gov/health/statistics/suicide/index.shtml
SAMHSA, http://www.integration.samhsa.gov/clinical-practice/screening-tools
Suicide Awareness Voices of Education, http://www.save.org/about-suicide/
World Health Organization, Suicide Data,
http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/
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