“You will not fail to see that I am suffering under a depression of spirits which will [not fail to] ruin me should it be long continued” -Edgar Allan Poe {{Jamison, 1993 #18}.
Depression, left untreated, eventually leads to suicide. In the United States, suicide is the 11th leading cause of death, accounting for approximately 30,000 deaths with an age adjusted rate of 10.7 per 100,000 persons (Gaynes et al., 2004). Most clinicians have seen suicidal patients throughout their careers. Researchers have reported that professional psychologists has a 1:5 or 1:7 chance of losing a client to suicide; for psychologist trainees, a 1:6 ratio has been reported. To date, there is no known formalized training program for beginning or experienced clinicians designed to teach suicide assessment skills, nor is there a recognized model for treating suicidal thoughts and feelings in a systematic way (Rosenberg, 1999). Furthermore, the current literature fails to accurately define what it meant by “suicide ideation” or “suicide attempt”. O’Carroll et al describes in their research how one clinician can say to the other that they have hospitalized a client due to suicide attempt. The other clinician often wonders what that means. Does that mean the client actively attempted deliberate self-harm warranting medical attention, attempted self-harm but did not warrant medical attention, or ideated a plan for an attempt and was intent on acting on that plan. Eg pg 238 on senate asking the question and responding. Reasons for intent, how many came to the hospital how many didn’t, how many died. Basic terms are not uniform among clinicians (O’Carroll et al., 1996).
David Rudd has provided a conceptual framework based on clinical summaries and assessment tasks consistent with existing standards of care but not dependent on psychotherapeutic orientation. This framework is divided into three categories: practical skills, self-image, and interpersonal relationship (Rudd, 1998).
One of the essential goals to achieve treatment success is to emphasize psychodynamic approaches to developmental issues and the therapeutic relationship. A strong therapeutic alliance is essential to positive outcome treatment with a depressed client (Klein et al., 2003).
Several studies have noted a difference between single and multiple attempters (Joiner & Rudd, 2000; Joiner, Walker, Rudd, & Jobes, 1999; Rudd, Joiner, Jobes, & King, 1999; Walker, Joiner, & Rudd, 2001). It has been postulated that previous suicide attempts sensitize one to subsequent suicide-related thoughts and behaviors. These individuals with a history of multiple attempts display behavioral and cognitive styles distinct from those of non-multiple attempters. There is also evidence that crisis intensity is related to negative life events for non-multiple attempters but not for multiple attempters (Walker et al., 2001). These same authors have stated that clients fall into three types of groups when assessing suicidality: suicide ideators, single attempters, and multiple attempters (Joiner et al., 1999).
The difference between them is the elevated risk in multiple attempters because of type, chronicity, and severity of psychopathology. The authors also go on to define seven domains of factors in assessing suicide risk. These are:
1. Previous suicidal behavior
2. Nature of current suicidal symptoms
3. Precipitant stressors
4. General symptomatic presentation, including hopelessness
5. Impulsivity and self-control
6. Other dispositions (e.g. history of abuse, environmental factors, substance abuse, etc)
7. Protective factors (e.g. suicidal writing, social support)
A history of previous suicidal behavior is an important domain for risk assessment.
In addition to these domains, the authors have narrowed down two main factors to summarize suicidal symptomatology risk: “resolved plans and preparation” and “suicidal desire and ideation”.
Resolved plans and preparation is defined as the following symptoms: a sense of courage to make and attempt, a sense of competence to make an attempt, availability of means to and opportunity for attempt, specificity of plan for attempt, preparations for attempt (seeking gun, pills, etc), duration of suicidal ideation, and intensity of suicidal ideation. Their view is that if the client shows such symptoms, they are in pernicious, moderate risk.
The suicidal desire and ideation factor defines the following symptoms: reasons for living, wish to die, frequency of ideation, wish not to live, passive attempt, desire for attempt, expectancy of attempt, lack of deterrents to attempt, and talk of death and/or suicide. These symptoms are clinically noteworthy but are considered minimal risk, unless the client has had previous suicidal attempts (Joiner et al., 1999).
References:
Gaynes, N. B., West, S. L., Ford, C. A., Frame, P. S., Klein, J., & Lohr, K. (2004). Screening for suicide risk in adults: A summary of the evidence for the United States preventative services task force. Annuals of Internal Medicine, 140(10), 822-835.
Jamison, K. R. (1993). Touched with fire.New York: Free Press Paperbacks. p.18
Joiner, T. E., & Rudd, M. D. (2000). Intensity and duration of suicidal crises vary as a function of previous suicide attempts and negative life events. Journal of Counseling and Clinical Psychology, 68(5), 909-916.
Joiner, T. E., Walker, R. L., Rudd, M. D., & Jobes, D. A. (1999). Scientizing and routinizing the assessment of suicidality in outpatient practice. Professional Psychology: Research and Practice, 30(5), 447-453.
Klein, D. N., Santiago, N., Vivian, D., Schwartz, J. E., Vosisano, C., Blalock, J., et al. (2003). Therapeutic alliance in depression treatment: Controlling for prior change and patient characteristics. Journal of Counseling and Clinical Psychology, 71, 997-1006.
O’Carroll, P. W., Berman, A. L., Maris, R. W., Moscicki, E. K., Tanney, B. L., & Silverman, M. M. (1996). Beyond the tower of babel: A nomenclature for suicidology. Suicide and Life-Threatening Behavior, 26(3), 237-252.
Rosenberg, J. I. (1999). Suicide prevention: An integrated training model using affective and action-based interventions. Professional Psychology: Research and Practice, 30(1), 83-87.
Rudd, M. D. (1998). An integrative conceptual and organizational framework for treating suicidal behavior. Psychotherapy, 35(3), 346-360.
Rudd, M. D., Joiner, T. E., Jobes, D. A., & King, C. A. (1999). The outpatient treatment of suicidality: An integration of science and recognition of its limitations. Professional Psychology: Research and Practice, 30(5), 437-446.
Walker, R. L., Joiner, T. E., & Rudd, M. D. (2001). The course of post-crisis suicidal symptoms: How and for whom is suicide “cathartic”? Suicide and Life-Threatening Behavior, 31(2), 144-152.
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