Second, the number of potential risk and protective factors of which counselors should be aware is overwhelming. Granello (2010b) reported 75-plus factors, we have a list of 25 (J. Sommers-Flanagan & Sommers-Flanagan, 2017), and even Cramer and colleagues (2013) lamented, “It would be impossible for clinicians to be familiar with every risk factor” (p. 6). Jobes (2016) referred to suicidology as “a field that has been remarkably obsessed with delineating countless suicide ‘risk factors’ (that do little for clinically understanding acute risk)” (p. 17).
Third, prominent suicide researchers have concluded that efforts to categorize client risk are ill advised (McHugh et al., 2019; Nielssen et al., 2017). For example, even the most commonly identified symptom of suicide, suicidal ideation, is a poor predictor of suicide in clinical settings; this is because suicidal ideation occurs at a very high frequency, but death by suicide occurs at a very low frequency. In one study, 80% of patients who died by suicide denied having suicidal thoughts when asked directly by a general medical practitioner (McHugh et al., 2019). Even the oft-cited risk factor of a previous suicide attempt has only a small statistical relationship to death by suicide. In a review of 17 studies examining 64 unique suicide prediction models, Belsher and colleagues (2019) reported, “These models would result in high false-positive rates and considerable false-negative rates if implemented in isolation” (p. 642).
To summarize, this suicide competency includes a deep dialectic. Clinicians absolutely must be aware of suicide risk factors, warning signs, and protective factors. Granello (2010b) recommended that counselors keep a list of relevant risk factors and warning signs on their desks. However, as Belsher et al. (2019) noted, risk and protective factors and warning signs—or any checklist or instrument—should not be used in isolation; an overemphasis on checklists impedes development of the therapeutic relationship, and the statistical reality is that suicide is not predictable and risk categorization is typically inaccurate. This competency can be boiled down to four parts, some of which form a dialectic:
1 Competent practitioners should have knowledge of evidence-based suicide risk and protective factors.
2 Competent practitioners are aware that evidence-based suicide risk and protective factors may not confer useful information during a clinical interview.
3 Instead of relying on checklists of suicide risk and protective factors, competent practitioners collaboratively identify and explore client distress and then track client distress back to individualized factors that increase risk and enhance protection.
4 Competent practitioners use skills to collaboratively develop safety plans that address each client’s unique risk and protective profile.
Although risk and protective factors do not provide an equation that tells clinicians what to do, knowing and addressing each unique individual’s particular risks and strengths remains an important competency (Granello, 2010b).
Competency 4: Focus on Current Plan and Intent of Suicidal Ideation
Asking directly about suicide and collaboratively exploring suicidal ideation, suicide planning, and suicidal intent are essential to competent suicide assessment. However, as noted for the previous competency, when asked about suicide, many clients or patients who will go on to die by suicide deny suicidal ideation (McHugh et al., 2019). Simply asking directly about suicide is not enough. Competent practitioners have clinical skills for asking about suicidality in ways that make it easier for clients to be open and honest.
Several important tasks are linked to this competency (and described in Chapter 3). These tasks include the following:
1 Use effective listening skills to show empathy and develop rapport.
2 Use sophisticated clinical interviewing skills to discuss suicidality with clients in ways that make it easier for them to disclose suicidal thoughts.
3 Collaboratively explore the frequency, intensity, duration, and termination of suicidal ideation.
4 Identify what distracts clients from a preoccupation with suicide and other ways to decrease the frequency, intensity, and duration of suicidal ideation.
5 Be able to use subjective suicide rating scales with clients.
6 Ask directly—using a collaborative style—about client plans, suicide methods, previous attempts, and behaviors related to suicide preparations.
Competency 5: Determine the Level of Risk
As discussed previously, accurately determining client suicide risk is probably impossible. Nevertheless, there are situations and contexts in which employment responsibilities will require you to make your best estimate of client suicide risk. However, because your specific suicide predictions may be incorrect, avoiding over-confidence, consulting with others, and collaborating with clients is recommended.
Sometimes so-called high-risk clients (based on traditional risk and protective factors) can be managed using a detailed safety plan and close in-home monitoring. Historically, these clients were hospitalized—often involuntarily. Although sometimes it is the only option, hospitalization is not an especially effective treatment for suicide, and the period after hospitalization is a time of heightened suicide risk (Large & Kapur, 2018).
Tasks associated with this competency include the following:
1 Recognize that because your ability to accurately categorize risk is limited, no matter the risk level, you should collaboratively establish a treatment plan to maximize client safety. This will likely involve safety or crisis planning (Bryan & Rudd, 2018; Stanley & Brown, 2012).
2 Expand your knowledge of the client (Granello, 2010b). Obtain previous medical/mental health records as well as collateral information from friends, family, or other supportive contacts (Wheeler & Bertram, 2019). This will require client consent; in some circumstances, you may need to breach confidentiality (e.g., when clients are suicidal and refuse treatment, when you have a duty to warn family about elevated risk, or when youth have suicidal ideation or make suicide gestures).
3 When clients will not collaborate on safety planning, or when you are setting mandates, categorize risk using “phraseology such as low, moderate, high, and extreme risk” (Cramer et al., 2013, p. 7). Most experts advise against using a no-risk category.
Competency 6: Develop and Enact a Collaborative Evidence-Based Treatment Plan
Suicide treatment planning should be strengths based and collaborative whenever possible. However, sometimes clients are unable to collaborate. They may be agitated, impulsive, lethargic, unengaged, and/or only minimally responsive. On other occasions, clients will flat out resist your collaboration efforts. When clients are unable to contribute to safety or treatment planning, risk is likely higher, and you will need to take the lead in safety planning.
When clients report suicidal ideation, short-term safety planning is recommended. Two short-term safety planning protocols have evidentiary support. These are Stanley and Brown’s (2012) safety planning intervention and Bryan and Rudd’s (2018) crisis response plan.
Longer term treatment planning is an important part of this competency. As Linehan (1993; Linehan et al., 2012) has discussed, sometimes clinicians need to be bold and direct. She typically speaks frankly, saying things like “We may have to go through hell together.” Her purpose is to show her commitment to the treatment process