Suicide, for most, is a devastating outcome that has ripple effects on families, friends, colleagues, communities and societies. Just last year in Singapore, 378 lives were lost to suicide, and for every death by suicide, there were another six attempts.
Ninety per cent of the of individuals who commit suicide have a diagnosis of a serious mental health disorder. Suicide attempts also often occur soon after a visit to a health care professional. Mental health clinicians, therefore, bear both the heavy responsibility and precious opportunity to effectively identify and prevent suicide.
Suicide is a complex phenomenon, determined by multiple intra- and inter-personal experiences of suffering and desperation intersecting at one point in the life of the individual. Individuals who are suicidal are often desperate for relief, for connection and to escape suffering. Most of the time, they are ambivalent about dying and a high percentage of suicide attempts are impulsive acts. If clinicians are prepared and are able to perform a sensitive and thorough enough suicide assessment during a client’s visit, we have the opportunity to save lives.
The relational suicide assessment (Flemons & Gralnik, 2013) offers clinicians a helpful framework for making safety decisions by engaging clients in an exploration of their risks and resources in the context of their personal history and interpersonal relationships.
The basis of the approach is an interview process that is grounded in empathy. Carl Rogers (1980) has referred to empathy as “temporarily living in the other’s life, moving about in it delicately without making judgments. It includes communicating your sensings of the person’s world as you look with fresh and unfrightened eyes at elements of which he or she is fearful”. This means that the clinician must be prepared to use empathy to enter the client’s experiential world. Empathetic statements are interspersed throughout the interview to maintain the bond and keep the client from feeling interrogated.
Questions are asked around intra- and inter-personal risks and resources within four domains of suicidal experience: disruptions and demands, suffering, troubling behaviors, and desperation. There is an appreciation that a question is not only a request for information, but also sends the client in a particular direction, in search of an answer that is, in part, shaped by the question itself. For example, asking clients, “how hopeless about the future are you?” can lead the client down a path of inquiry that is very different from asking them, “how hopeful are you?”. This means that questions are not only data-gathering tools but are also opportunities for therapeutic intervention. The interview is made as informal and flowing as possible with the clinician always listening out for possibilities of safety, even where there is risk i.e. Is there a way to experience suicidality in a safe way? Is there a way to be suicidal and still be safe?” Throughout the assessment, the clinician not also listens to what the client is saying but also pays close attention to how the client is interacting as a way to corroborate their responses.
Over the course of the interview, a safety decision is allowed to emerge by juxtaposing, i) a recognition of risks with an appreciation of resources, ii) professional knowledge with information garnered from the client, and iii) the clinician’s emotional response with knowledge of the “facts”.
As far as possible, a safety plan is collaboratively co-constructed with the client based on the risks and resources identified in the assessment. The safety plan should cover the following areas.
- Identify ways for involving helpful and resourceful significant others with permission e.g. phone, joint session.
- Work out how significant others and patient will limit or prevent access to various means of making an attempt.
- Explore temporary alternatives to the patient’s troubling behaviours.
- Identify safe havens.
- Consider enlisting the patient’s workplace or school in reducing workload or in granting a leave of absence.
- Determine (if warranted or appropriate) if the patient would consider initiating, resuming or continuing relevant treatment.
- Identify and list personal, professional, and emergency resources, complete with phone numbers.
If hospitalization is deemed necessary, the clinician can strive to preserve the relationship with the client by emphasizing the current necessity of the hospital for protecting his or her safety.
For many clinicians, the responsibility of effectively identifying and preventing suicide can be an anxiety-provoking and emotionally-laden process. The relational assessment framework offers us a way to use our own experience to join with our clients, to strive for an empathic appreciation of their risks and resources, to consider these within the context of personal history and interpersonal relationships, and, through this process, to develop a sense of both their danger and potential for safety. We may take heart in hoping that client who can be kept safe today may still choose to stay alive tomorrow.
D. Flemons, & L. M. Gralnik (2013). Relational suicide assessment: Risks, resources, and possibilities for safety. New York, NY: W.W. Norton & Company.
Masters in Clinical Psychology at University College London (UCL) and the National University of Singapore (NUS)
MSPS, Registered Psychologist