Suicide Assessment

Given the isolating nature of suicidal ideation and actions, it is all too easy for clinicians conducting a suicide assessment to find themselves developing tunnel vision, becoming overly focused on the client’s individual risk factors—hopelessness, presence of a plan, too-easy access to weapons or other lethal means, a history of trauma or previous attempts, and so on. Such topics are critically important to explore; however, the danger posed by these and other risks can’t be fully appreciated without considering them in relation to the person’s resources for safely negotiating a pathway through the suicidal thoughts and urges—protective beliefs, stories of resilience, exceptions to prevailing problems, past successes and current skills, and strategies for responding to internal and external stressors. And these intrapersonal risks and resources must, in turn, be understood in context—in relation to the interpersonal risks and resources contributed by the client’s significant others. 

Several years ago, I teamed up with Dr. Len Gralnik, a professor of psychiatry at Florida International University, to create a balanced, relational approach to suicide assessment.  We developed the Risk and Resource Interview Guide (RRIG) as a means of organizing assessment conversations with suicidal clients. Modeled on the semi-structured interview guides used by ethnographic researchers, it distills an extensive sociological and epidemiological research literature, as well as our 50+ years of combined clinical experience, into essential topics of inquiry arrayed within four domains of suicidal experience: Disruptions and Demands, Suffering, Troubling Behaviors, and Desperation.

Knowing what questions to ask a suicidal client is essential, but, to avoid his or her feeling interrogated, it is just as important to know how to ask questions and how to intersperse empathic statements throughout the interview. Beyond this, clinicians need to know how to use the information they gather to assist them in making a safety decision and, when it is warranted, how to collaborate with the client in developing a safety plan. All this and more can be found in our book, Relational Suicide Assessment: Risks, Resources, and Possibilities for Safety, published by W. W. Norton. Included in the book is what we call the Backpocket RSA—a compendium of three guides that you can access during the assessment process: the RRIG assists you in conducting an interview that is comprehensive and extemporaneously interactive; the safety plan construction guide helps you keep in mind all necessary details when developing a  detailed safety plan with the client; and the case note construction guide offers suggestions for what you should be sure to include when documenting what transpired during the assessment.