"I'm afraid I could actually do it," said the 31-year-old woman. Abigail (not her real name) was referring to ending her own life. She had been struggling with depression for years and was on the verge of suicide. Medicines had only helped her minimally. Her idea was undisputed and her plan was clear.
These were terrifying words for me, and I held my breath for weeks and was afraid of a call from her husband who announced that Abigail had committed suicide. A short hospital stay had stabilized Abigail's life somewhat, but she was exhausted. After her discharge from the hospital, her husband and I worked together to draw up a safety plan to ensure that he was not a widower and that both of her children were motherless.
I have seen many clients like Abigail during my career as a licensed professional consultant. The treatment of suicide patients is a common event in therapy. There is little data available on the percentage of suicide patients that a general practitioner doctor could have. However, most of the numbers suggest that up to half of the average case numbers of customers are on the worrying side of the suicide risk continuum. This percentage is, of course, much higher among doctors working with certain population groups or disorders who have been shown to have an increased risk of suicide. Abigail fell into one of these risk categories. In 2006, a meta-analysis by Stefania Aegisdottir and colleagues published in The Counseling Psychologist showed that clinicians cannot assess the risk very well. That is shocking.
Research is equally worrying, showing that about a quarter of us will suffer the loss of a client through suicide during his career, but many (if not most) of us are ill-prepared to deal with the risk of suicide. In a 2013 study by Cheryl Sawyer and colleagues of 34 master's-degree counseling students, 15% said they had no confidence at all and 38% said they had little confidence in their ability to assess the risk of suicide, while only 3% said they did not feel fully competent for dealing with suicide risk.
However, the problem does not only exist with doctoral students. In spring 2017 I presented a workshop for the annual conference of my state professional association. The workshop focused on assessing the risk of harming yourself or others. I asked the around 85 participants whether they regularly work with suicidal clients. Every hand went up. I then asked if they felt that their training had adequately prepared them for assessing the risk of suicide. Only two people in the entire group said they felt prepared.
This answer is in line with an article entitled "Psychologists Need More Training in Suicide Risk Assessment" published in April 2014 in the Monitor on Psychology. The article, which included a report organized by the American Association of Suicidology (AAS) and a task force summit, says in part: "After three years of study, the AAS task force called for … accreditation organizations, state regulatory agencies and a new state and federal legislation to require suicide-specific training for psychiatric professionals. "The article goes on to say:" Many psychology students are only trained in suicide statistics and risk factors, not in clinical methods for carrying out meaningful suicide risk assessments. "
Something is wrong. Not only does it seem that psychiatric professionals are under-trained in this area, some researchers even ask whether the low level of education we receive has any effectiveness. Robert Cramer and colleagues, who wrote about suicide risk assessment training for postgraduate psychology programs in 2013, stated that "no existing training methods were specifically studied in traditional training environments and samples for clinical or advisory psychology."
Although the fifth edition of the Diagnostic and Statistical Handbook for Mental Disorders addresses suicide risks through diagnosis, it does not provide risk assessment tools for physicians. Given the picture I painted, how can it be that in 2020 we don't have a clear standard – often referred to as best practices – for assessing suicide risk?
Review
To find out what blind spots the consulting profession might have, I try to imagine what people will say about our field in 50 or 100 years. After all, it's easy to look into the past and spot our mistakes and oversights. Development psychologist Jerome Kagan wrote in Three Seductive Ideas (2000): “If you had lived in Europe at the end of the 15th century, you would have believed that witches cause illness… and that the pursuit of sexual pleasure depletes and guarantees a man's life energy the exclusion from heaven. "
These ideas sound ridiculous today. If you are under 30 years old, the following facts from the recent past sound just as ridiculous to you:
If you were a mental health person in the 1930s, "idiot" and "idiot" were formal classifications of what we now call lagging development. They also believed that ice water baths and jumping on a person's chest could cure schizophrenia.
If you were practicing in the 1950s, common treatments for depression included prefrontal lobectomies. Some doctors literally set up patients and performed these barbaric procedures in 10-15 minutes each.
When you practiced therapy in 1970, you believed that homosexuality was a mental illness. A few years ago, some people believed in praying homosexuality out of one person (one of the milder techniques used in so-called "conversion therapy").
In the early 1980s, hardly anyone had heard of AIDS, stalking, Munchausen syndrome through proxy or autism.
When I was in graduate school in the mid-1980s, none of my master or doctoral professors mentioned what we now refer to as "evidence-based" therapies. Cognitive behavioral therapy was pioneering, but most of us described ourselves as “versatile,” and after our surveillance sessions were satisfied, we all basically did what we thought was right.
The lack of accuracy in the area of mental health does not end here. When I was a regular lecturer at the FBI Academy in the 1990s, I received calls from across the country to various law enforcement consulting applications. A call came from a sheriff's department. Five officers had been involved in a shootout, and the departmental process required an assessment of fitness for duty. The sheriff asked me to do the assessments, so I started examining this facet of risk assessment and found that there were no standards of suitability for the service in this area. It was just a clinician's verdict. It's hard to believe, is it?
Apparently we still have a lot to learn. I hope that in the not too distant future the therapists will say: "Do you remember the time when there was no standard for the assessment of suicide risk? Unbelievable!"
Risk assessment tools
It would be easy to confuse the lack of a standard with the lack of tools. We have many tools. Commonly used evaluation tools include the Beck scale for suicidal thoughts, the reasons for the inventory, the suicide probability scale, the suicide intention scale and the SAD PERSONS scale, to name just a few. However, there is very little data that clearly shows that one instrument is better than another or that assessment instruments are effective at all.
An exception is the Beck scale for suicidal ideas, which is as well researched and validated as any instrument available. However, there is still no assumption that clinicians use "evidence-based" assessments. Does that sound a little crazy to someone other than me?
In a 2016 article in the Journal of Psychopathology and Behavioral Assessment, Keith Harris, Owen Lello, and Christopher Willcox identified a number of issues with standard practice of suicide risk assessment, but again there is no consensus in this area. The authors noted that "a task force from the American Association of Suicidology … and other experts have called for improved teaching guidelines for a valid risk assessment. The results of this and related studies reveal weaknesses in the current assessment and conceptualization of suicide risk and fear that some clinical trainers and practitioners are unfamiliar with the limitations of popular tests. There is a clear and current need to update core competencies for accurate assessment and risk formulation. "
How do we know that our reviews are effective?
I have never lost a client to suicide, and it would be tempting to assume that this indicates that my suicide risk assessment and intervention system is effective. However, there are several factors that are not related to my competence and can lead to the same result. For example, clients who come to counseling may simply be more motivated to live than those who do not. In such cases, any suitable therapist might have been effective.
There may be other factors in my clinical work that are the cause of my happy success. In other words, maybe I did something else that works (maybe a good relationship or social support), but I'm not aware that this actually helps, unlike my suicide assessment and intervention. And of course I could have been wrong if I had taken any risks at all. These potential false alarms could mean that my customers didn't kill themselves because they weren't really suicidal at first. And there are only three options.
That is why we need research and standardization. The standardization corresponds to the recognized research format. My students often start comments and questions with "I think …" or "I feel …". I never let that happen. I don't care what we think or feel. What do we know? That is what research – evidence-based practice – helps us to answer.
I understand that my words can be difficult to hear. Before evidence-based therapies became an ethical standard, we all did what we thought was right about mental health. Every challenge for our practice was associated with a defensive stance, and I was one of the clinicians who adopted this stance. We had or believed (just like my students) that our methods worked because our customers seemed to be getting better. We were certain that we were right, and maybe we were right, but we had nothing specific to base our assumptions on. This seems obvious in retrospect, but the idea was new to us at that time.
Some of our customers may have seemed better, but they weren't. Your desire for improvement may have masked symptoms, and we also know that we want to please customers. They could easily have presented their cases in a brighter light than they should. In other cases, they may have been temporarily better, but regressed after therapy was discontinued. We can easily interpret our positive feelings about our work as proof that it is effective. Could we now make similar mistakes in suicide risk assessment?
A perfect example of this is contracts without damage. One of the things that clinicians seem to largely agree on is that using harmless contracts – also known as security contracts – brings benefits to our suicidal customers. However, years of attempts to validate the effectiveness of no harm contracts have yielded nothing. M. David Rudd, Michael Mandrusiak and Thomas Joiner Jr. stated in an article from 2006 in the Journal of Clinical Psychology: In the session: “Non-suicide contracts suffer from a variety of conceptual, practical and empirical problems. Above all, they have no empirical support for their effectiveness. “A 2005 article by Jeane Lee and Mary Lynne Bartlett reported the same thing. In other words, the one thing almost all of us do has no data to prove its effectiveness.
What we risk
When dealing with clinical issues, I find it helpful to consider what I would say if I sit in front of my admissions committee's ethics committee or if I am being tried in court by an enemy lawyer. How hard would it be for a lawyer to find 10 clinicians who would suggest that I made the wrong decision? If you can only say, "I thought that was a good idea," you have a very weak defense.
In such cases, we risk losing a lawsuit and possibly blaming, suspending, or revoking our licenses. The more important risk, however, is that we make our customers fail and they lose their lives if we could have served them better.
A standard approach
Of course, I'm not the first to notice this problem. Among other things, AAS regularly focuses on the development of reliable and valid procedures for assessing suicide risk. So far, however, the solutions have been elusive. A number of research studies have attempted to address the problem. James Christopher Fowler summed up in a 2012 article in psychotherapy when he wrote: “We don't yet have evidence-based diagnostic tests that can accurately predict suicide risk at an individual level without an excessive number of false positives Predictions is created. ”This summary brings us back to where we started.
Through years of research, I have limited what we know about risks in my assessment process to a three-factor risk model and five risk components in order to assess the effectiveness of the risk assessment. I don't assume that my work is original or that my system is better than another. I only suggest that what I present here is in line with what we know and that it can serve as a starting point for collecting evidence and establishing a best practice standard.
Three-factor model: The three-factor model suggests that customers in three global areas are at risk or protected from risks: presentation of factors, personal factors and protective factors.
Presenting factors include diagnoses (e.g. depression), loneliness, divorce, previous attempts, suicidal thoughts, and other situational factors that increase the risk of suicide for clients.
Personal factors include pessimism, weak problem-solving skills, and minimal coping skills that increase the risk of suicide for clients. Actuarial data is included here. It has been shown that some population groups, such as B. African American women have a very low risk of suicide, while others are statistically very high (e.g. Indians, male Caucasian adolescents, the elderly).
Finally, protective factors balance presentation and personal factors. This would include healthy relationships, strong social support networks and religious commitment.
Moffatt's HM4: The risk assessment model I use takes all three factors into account. My HM4 model consists of five examination components: hope, method, means, motivation and mitigating circumstances.
The research is clear. People without hope are at high risk. Sometimes this is called "future orientation". Regardless of this, the question is: "What should my customer look forward to tomorrow, next week or next year?" If the answer is "nothing", I'm worried.
Method refers to your own plan. The more specific and clear the method, the more concerned I am. "I sometimes think the world would be better if I didn't wake up," is a vague plan. "I kept collecting my mother's medication. I hid it in my room and I plan to take it all at once when everyone is going to work and school." It's a very precise plan.
Means have to do with the tools to be used and the ability to carry out the method of dying by suicide. One of the children in my practice once said he wanted to kill himself. His method was to invent a robot that would kill him in his sleep. His method was clear, but the means to carry out this plan were completely unrealistic. Even if he could have invented such a robot, the likelihood that he could carry out this plan without drawing his parents' attention was minimal. On the other hand, adolescents and adults often have much more realistic means and due to freedom of movement and access to weapons, drugs and other resources, suicide attempts are much more likely to be successful.
Motivation refers to the degree of desire to enforce and complete suicide. Fortunately for us as consultants, most of our clients don't want to die. Her motivation is low, even though her emotional pain is high. That is why suicide hotlines work. People are so motivated to find a solution (with little motivation to accomplish suicide) that they call a complete stranger to seek help.
Finally, mitigating circumstances are issues that are so important that they override the other evaluation areas. Mitigating circumstances can either increase or decrease the risk of suicide. My concern for a high-risk client could be overshadowed by the person's religious beliefs about suicide or their desire to avoid harm to their children, spouse, or parents. "I couldn't do that to my children," I've heard many times from high-risk customers. "My uncle committed suicide and devastated my father's family" is another. Readers may recognize that hope is a mitigating factor, but it is so important that it has its own place in my model.
Rating from Abigail
Abigail's risk was clear. She was at high risk for gender, age, and diagnostic population. she had thought about suicide for a long time; and she had a clear plan. She had had emotional pain for many years and, what frightened me the most, she had little hope that anything could ever get better. Her efforts to improve and others to help her had been unsuccessful. She had bought a poison to have available when she wanted to kill herself (method) and it was currently in her possession (medium). I'm sure she was motivated to get through because getting the poison wasn't easy. She was ready to work hard to prepare for her own death, so I had little confidence that she would not get through.
Among several mitigating factors in Abigail's case was that she loved her children and did not want to leave them. She was also certain that her religion did not allow suicide, and she feared "an eternity in hell" if she killed herself. It also worked in her favor that she had at least enough hope to meet our deadlines. She was willing to at least try to let me help her, although she wasn't sure if it would get her anywhere. She came to therapy several times a week and was ready to trust that life could improve. Eventually, she followed medication for her depression and continued to do business in life.
Abigail is still alive and although she sometimes has problems, she reports that she is better, that her depression has been treated, and that she (now a grandmother) finds some happiness in life for her grandchildren.
Conclusions
If I take a critical look at our profession, it is unintentional. I don't think we know anything about suicide and risk assessment. On the contrary, there is tons of data on statistics, risk factors, ratings, etc. I attended a fantastic suicide risk assessment training session at the 2018 American Counseling Association conference. The session was full, the moderators were fabulous, and the information provided was very helpful, but the nature of the workshop showed that we lack clear standards. Almost all of us seem to be asking the same question: What are we doing?
Without a standard for suicide risk assessment, clinicians are exposed to two very serious risks. The first and most important thing is that non-standardization can put our customers at risk of harming themselves. Just because we have individualized systems that we believe will work doesn't mean they work. The second problem is self-protection in the event of a lawsuit or complaint against us on our licensing bodies. The existence of best practice standards would allow us to defend ourselves.
Although there is currently no standard assessment for the risk of suicide, this is not beyond our reach. In the 1990s, the medical community began to investigate the use of a research-based protocol in heart care in the emergency room. Malcolm Gladwell described this process in his 2007 book Blink. Doctors rejected the simple three-question protocol and were incredulous that anyone would suggest that such a simple tool could offer better triage than their work experience. However, the data showed that the protocol was superior in saving lives. The protocol is standard in the medical field today. The same process can be achieved in our area, but it depends on the willingness of our profession to study it and to accept the results.
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Gregory K. Moffatt is an experienced, licensed professional advisor of more than 30 years and dean of the College of Social and Behavioral Sciences at Point University in Georgia. His experience spans three decades of working with children, trauma and abuse, as well as a variety of other experiences, including working with schools, businesses, and law enforcement. He also writes the monthly Voice of Experience column for CT Online. Contact him at [email protected].
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