Kevin J. Drab, M.A., M.Ed., LPC, CAADC, CEMDRT, NBCCH
Behavioral Counseling & Training Company
418 Stump Road, Suite #208, Montgomeryville, PA 18936
Tel: (215) 527-2904 e-mail: email@example.com
Defining Some Terms
Death caused by self-directed injurious behavior with any intent
to die as a result of the behavior.
Note: The term “committed” suicide is discouraged because it
connotes the equivalent of a crime or sin. The CDC has also
deemed “completed suicide” and “successful suicide” as
unacceptable. Preferred terms are “death by suicide” or "died
A non-fatal self-directed potentially injurious behavior with any
intent to die as result of the behavior. A suicide attempt may or
may not result in injury.
The act of setting out on an obviously fatal course without
directly committing the act upon oneself. Indirect suicide is
differentiated from legally defined suicide by the fact that the
actor does not pull the figurative (or literal) trigger.
Examples of indirect suicide include a soldier enlisting in the
army with the express intention and expectation of being
killed in combat.
Another example would be "suicide by cop” in which a police
officer is provoked into using lethal force against them.
High risk-taking behaviors and unhealthy lifestyles may reflect
an intent to die. Studies have suggested that many more auto
accidents are some form of indirect suicide than believed.
Suicide attempts or gestures and self-harm where there is no
result in death. It is a non-fatal act in which a person
deliberately causes injury to him/herself or ingests any
prescribed or generally recognized therapeutic dose in excess.
Studies have found that about half of those who commit
suicide have a history of parasuicide.
Self-harm (SH) or deliberate self-harm (DSH):
The intentional, direct injuring of body tissue most often done
without suicidal intentions. The person's primary intention is to
relieve unbearable emotions, sensations of unreality, or
feelings of numbness by injuring their body.
Include cutting, whereby the cut is not deep enough to cause
significant blood loss, or taking a non-lethal overdose of
Suicidal gestures are typically done to alert others of the
seriousness of the individual's clinical depression and suicidal
ideation, and are usually treated as actual suicide attempts by
hospital staff. Some suicidal gestures do lead to death, despite
the individual not having the intention of dying.
Any interpersonal action, verbal or nonverbal, stopping short of a
directly self-harmful act, that a reasonable person would
interpret as communicating or suggesting that a suicidal act or
other suicide-related behavior might occur in the near future.
Thoughts of suicide. These thoughts can range in severity from a
vague wish to be dead to active suicidal ideation with a specific
plan and intent. Although most people who undergo suicidal
ideation do not commit suicide, some go on to make suicide
Some individuals habitually think of suicide, or use thoughts of
suicide when in stressful situations, to enable them to feel
better and more in control of a situation (in that they always
have an escape).
A friend or family member who has experienced the suicide
death of someone they cared about. Grief following a suicide is
always complex. Survivors don't "get over it." Instead, with
support and understanding they can come to reconcile
themselves to its reality.
A retrospective reconstruction of the life history of the decedent,
which involves the examination of physical, psychological and
environmental details of the decedent's life in order to more
accurately determine the mode of death and get a better
knowledge of the death process and the victim's role in hastening
or affecting his own death.
This may be done for clinical purposes, used to settle criminal
cases, estate issues, malpractice suits, or insurance claims.
Interventions designed to stop suicidal behavior before it occurs.
These interventions involve reducing the factors that put people
at risk for suicide and suicidal behaviors. They also include
increasing the factors that protect people or buffer them from
being at risk.
At least 1 in 5 mental health professionals loses a patient to
suicide, yet many report receiving little or no support from
colleagues, supervisors or administrators.
More People Die By Suicide Than Homicide
Every 17 minutes someone dies by suicide; Every 42 seconds
someone attempts suicide
More than 32,000 Americans commit suicide each year (men
three times as often as women), making it the 9th leading cause of
death among adults, and the 3rd leading cause of death among
adolescents and children.
Annually over 200,000 individuals attempt, but do not
succeed, in killing themselves (women three times as often as
The actual incidence of suicides in this country is very
probably highly underreported for a variety of reasons, and, in
any case, does not include those who have killed themselves
As many as 50% of suiciders are intoxicated with alcohol or
other drugs. Alcohol abuse is a major factor that has been found
in the history of at least one fourth of all suicides examined.
Clinicians in Difficult Position
Surveys across clinical disciplines consistently show #1
greatest fear is prospect of losing a client to suicide.
Many clinicians have strong – often aversive – feelings toward
suicidal clients that may interfere with effective clinical care
and their willingness to address the topic.
Countertransferential fear and anxieties mostly rooted in not
being able to ultimately control the life-threatening behaviors
With managed care restricting admissions and lengths of
hospital stays, we must find ways to form a deeper outpatient
engagement and a meaningful interpersonal connection
with a suicidal client.
If we truly hope to succeed with any suicidal client, we must
first find a way to be “empathic of the suicidal wish,” thereby
opening the door to connecting and collaborating without
necessarily endorsing suicide as a means of coping with pain
-- Jobes (2006), p.37
We learn the deepest and most effective lessons
from our suicidal clients, and experience!
Suicidal individuals are neither hopeless, nor abnormalities of
the human condition. Looking deeply into ourselves we find
the places which could lead us to where they are.
Most people with suicidal tendencies have lost track of making
their lives viable and respond well to thoughtful clinical care.
Ambivalence is a common factor in the suicidal process.
Individuals can be ambivalent even when they are carrying out
a suicidal act.
Most literature on suicide focuses on unpleasant internal
states. Yet, relationships, role responsibility, and issues related
to self are much stronger factors in suicidal ideation and intent.
Observations on Suicidal Behavior
1. Asking about or exploring the possibility of suicide does not
create suicidal ideation, and, in fact, generally brings relief and
hope to the person for whom no one has asked that question
2. Most people kill themselves because they decide to kill
3. Even up to the actual process of killing themselves, the
majority are still ambivalent about their decision – a very
important tool for the intervening clinician!!!!
4. It is important to realize that suicide ‘works’ at some level; it
produces a solution to intense personal pain (“psychache”). As
life ends, the pain ends.
5. Most suicidal people don’t want to die, they want to end
their psychological pain and suffering.
6. Acceptance of the effectiveness of suicide is an important
first step in a clinician’s understanding of why suicide is
relatively common. We humans are a solution-oriented
7. Not a single piece of research has shown that the presence
of any collection of risk factors can accurately predict the
imminent dangerousness of a client. Nor have we found any
instrument which can reliably identify or predict suicidal risk.
8. Risk factors are not necessarily causes of an event, but are
merely associated in some way, e.g., high correlations of a
variable (such as age or illness) with suicidal behavior does
not prove cause and effect.
9. It is very likely that suicide-vulnerability is the result of
certain, as of yet undetermined, combinations of biological,
sociological, psychological, situational and existential
variables that seem associated with suicide risk.
10. Most suicidal people have psychological problems, social
problems, and poor methods for coping with pain – all
things that mental health professionals are usually well-trained
11. Individuals move in and out of periods of suicidal risk,
sometimes for brief periods, sometimes for moderate or
long periods, as their life circumstances fluctuate.
12. In order to commit suicide numerous conditions have to
exist, and even when individuals appear at high risk very
few actually kill themselves.
In the suicidal state there is a pervasive feeling of helplessness-hopelessness:
‘There is nothing I can do except to commit suicide and there is
no one who can help me with the pain that I am suffering.’
Underlying all of the emotions - hostility, guilt, shame - is the
emotion of impotent ennui, the feeling of helplessness-hopelessness.
Shneidman’s Ten Commonalities of Suicide (1985)
1. The common stimulus is unendurable psychological pain (i.e.,
2. The common stressor in suicide is frustrated psychological
3. The common purpose of suicide is to seek a solution.
4. The common goal of suicide is cessation of consciousness.
5. The common emotion in suicide is hopelessness-helplessness.
6. The common internal attitude toward suicide is ambivalence.
7. The common cognitive state in suicide is constriction.
8. The common interpersonal act in suicide is communication of
9. The common action in suicide is egression (i.e., escape).
10. The common consistency in suicide is with life-long coping
Research has found that the following protective factors can
counterbalance suicidal vulnerabilities:
having social supports
being cognitively flexible
obtaining treatment (especially psychotropic medications)
being a younger female
being physically healthy
They conclude that suicidal outcome is not only a joint
product of risk, vulnerability, and psychiatric disorder, but also
counterbalanced by protection, competency, and resilience.
Malone, et al. conclude that nonsuicidal depressed individuals
had no previous history of suicide attempts, had greater
survival and coping beliefs, feared social disapproval and
had more moral objections.
Might we conclude from this that clinicians should spend more
time doing the things that inoculate depressed individuals
against suicide (e.g., instilling hope for the future, social
supports, teaching coping skills, exploring moral objections to
suicide as well as reasons for living) rather than just assessing
and attempting to prevent risk?
THE ART OF SUICIDE ASSESSMENT
“Currently, the major bottleneck in suicide prevention is not
remediation, for there are fairly well-known and effective
treatment procedures for many types of suicidal states; rather
it is in diagnosis and identification.”
– Edwin Shneidman, father of modern suicidolgy.
Suicide Prediction refers to the foretelling of whether suicide
will or will not occur at some future time, based on the presence
or absence of a specific number of defined factors, within
definable limits of statistical probability
Suicide (risk) Assessment refers to the establishment of a clinical
judgment of risk in the very near future, based on the weighing
of a very large mass of available clinical detail. Risk assessment
carried out in a systematic, disciplined way is more than a guess
or intuition – it is a reasoned, inductive process, and a necessary
exercise in estimating probability over short periods.
SUICIDE: A MULTI-FACTORIAL EVENT
Access To Weapons
COMPONENTS OF SUICIDE ASSESSMENT
• Appreciate the complexity of suicide / multiple contributing
• Conduct a thorough psychiatric examination, identifying risk
factors and protective factors and distinguishing risk factors
which can be modified from those which cannot
• Ask directly about suicide; The Specific Suicide Inquiry
• Determine level of suicide risk: low, moderate, high
• Determine treatment setting and plan
• Document assessments
Demographic male; widowed, divorced, single; increases with age; white
Psychosocial lack of social support; unemployment; drop in socio-economic
status; firearm access
Psychiatric psychiatric diagnosis (es); comorbidity
Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease;
hemodialysis; systemic lupus erthematosis; pain syndromes;
functional impairment; diseases of nervous system
hopelessness; psychic pain/anxiety; agitation; psychological
turmoil; decreased self-esteem; fragile narcissism &
impulsivity; aggression; severe anxiety; panic attacks; agitation;
intoxication; prior suicide attempt
thought constriction; polarized thinking; rigidity
Trauma sexual/physical abuse; neglect; parental loss; traumatic events
Genetic & Familial family history of suicide, mental illness, or abuse
Areas to Evaluate in Suicide Assessment
Comorbidity; Affective Disorders; Alcohol / Substance
Abuse; Schizophrenia; Cluster B Personality disorders.
History Prior suicide attempts, aborted attempts or self harm;
Medical diagnoses; Family history of suicide /
attempts / mental illness
Coping skills; personality traits; past responses to
stress; capacity for reality testing; tolerance of
Acute and chronic stressors; changes in status; quality
of support; religious beliefs
Past and present suicidal ideation; plans, behaviors;
intent; methods; hopelessness; anhedonia; anxiety
symptoms; reasons for living; associated substance
use; homicidal ideation
Gathering and analyzing data from a variety of sources,
including documentation, testing and other evaluations (e.g.,
medical work-up), referral sources, individuals who know the
patient, and interviewing the patient.
However, the primary source of information must always be
the patient because it is from their internal world that suicide
is conceived as the correct answer.
Screening for Suicide Risk
To be done either through initial use of symptom-based
assessment tools or including questions about suicidal
ideation within the first 5-10 minutes of a clinical interview.
Examples of reliable, quick measures commonly used:
Beck Hopelessness Scale (Beck & Steer, 1988)
Beck Scale for Suicide Ideation (Beck & Steer, 1991)
Behavioral Health Monitor (Kopta & Lowry, 2002)
Brief Symptom Inventory (Derogotis & Savitz, 1999)
Columbia-Suicide Severity Rating Scale (C-SSRS) (Posner, K., et
al. 2008) http://www.cssrs.columbia.edu/docs/C-SSRS_1_14_09_Baseline.pdf
Outcome-Questionnare-45.2 (OQ-45.2) (Lambert,
Burlingame, et al., 1996)
Suicide Risk Categories
I. Baseline – Absence of an acute (i.e., crisis) overlay, no
significant stressors not prominent symptomatology. Only
appropriate for ideators and single attempters.
II. Acute – Presence of acute (i.e., crisis) overlay, significant
stressor(s) and or prominent symptomatology. Only
appropriate for ideators and single attempters.
III. Chronic high risk – Baseline risk for multiple attempters.
Absence of an acute (i.e., crisis) overlay, no significant
stressors not prominent symptomatology.
IV. Chronic high risk with acute exacerbation – Acute risk
category for multiple attempters. Presence of acute (i.e.,
crisis) overlay, significant stressor(s) and/or prominent
(from: Rudd, et al. 2001)
Collaborative Assessment & Management
of Suicidality (CAMS) method
• Developed by Dr. David Jobes (2006).
• A specific clinical approach and a philosophy of working with suicidal
• The CAMS approach conceptualizes the assessment and treatment of
suicidal patients in a fundamentally different way than current
• CAMS is inherently designed to help shift clinicians’ attitudes and
approaches by changing our conceptualization of suicide as a clinical
problem and thereby changing how we assess and treat this problem.
• Focused on keeping clients out of inpatient hospital settings.
• Clients are immediately engaged in the clinical assessment of their
suicidal risk, and then the management of their own outpatient
safety and stability.
• Within CAMS approach, formation of a strong and viable clinical
alliance is central.
• CAMS is designed to fundamentally optimize the client’s
• CAMS approach does not focus on alleviating problems like
depression, but rather concerns itself with suicidality. By
maximizing alliance and motivation CAMS assists the client to
develop coping and problem-solving skills to make suicide an
CAMS process of care has three distinct phases:
1) Initial “index” Assessment /Treatment Planning
2) Clinical Tracking
3) Clinical Outcomes
The core multipurpose tool used in all phases of the CAMS is the
Suicide Status Form (SSF).
Note: see examples of SSF in your handouts packet.
Use of the SSF within CAMS enables both parties to examine and
work with the client’s suicidality in a relatively objective
CAMS approaches the assessment and treatment of suicidal
clients in a fundamentally different way then current
In the conventional approach the client is a passive recipient of a
reductionistic diagnostic process which views suicide as a
symptom of some central psychiatric illness which will be treated
with traditional therapy and medications.
• With CAMS suicidality is understood as the central clinical problem
• While not ignoring psychiatric illness, CAMS emphasizes the
importance of broader underlying issues, e.g., psychological
suffering, that are suicide-specific.
• Most critically, the CAMS relational dynamic is one of collaboration,
where the client – who is the expert of his or her own experience –
is engaged as an active collaborator in clinical care.
Key features of Collaborative Clinical Effort
• On an equal basis – even in seating arrangement (if feasible)
• Empathetic and nonjudgmental listening
• Reassuring and affirmative
• Direct, respectful questions and suggestions
• Shift conversation to need to more deeply explore client’s
pain and suffering using SSF.
INTERVIEWING THE PATIENT
Motivational Interviewing (is an example of
knowledge/skills which provide effective tools to the
interviewer, such as:
• avoiding argumentation and direct “heavy”
• expressing empathy through reflective listening;
• supporting self-efficacy and optimism;
• rolling with resistance;
• identifying discrepancies between the client’s goals
or values and their current behavior.
Section A: (Client fills out with Clinician’s
• Psychological Pain
• Stress – pressure
• Agitation – perturbation, emotional urgency
• Rating overall risk of suicide at this point in time.
• Suicide thoughts related to self and others.
• Reasons for Living (RFL) and Reasons for Dying (RFD).
Section B: (Clinician fills out with Client’s guidance)
This is clinician’s assessment section, including suicide plan,
preparation, rehearsal, history of suicidality, current intent, etc.
Possible contributing factors such as history of impulsivity,
interpersonal isolation, relationship problems, substance abuse,
health problems, shame, etc.
Section C: (Clinician fills out with Client in collaboration)
Suicide Specific Treatment Plan which includes primary
Section D: The clinician’s postsession evaluation of client.
Includes MSE, Diagnoses, Assessed Overall Suicide Risk Level,
and case notes.
Common Errors of Suicide Interventionists
1. Superficial reassurance.
2. Avoidance of strong feelings.
3. Inadequate assessment of suicidal intent.
4. Passive rather than active, structuring responses.
5. Sidesteping the issue – don’t ask, don’t tell.
6. Keeping a secret.
7. Leaving the person alone.
8. Feeling responsible for saving the person.
9. Being shocked, morally outraged, angry or disgusted.
10. Giving advice.
11. Not listening!!!!
Things to do:
1. Ask questions and be direct in your conversation.
2. Listen, using all your clinical skills, providing empathetic
support through reflection, warmth, nonjudgmental
responses, paraphrasing, feedback, etc., as well as continually
assessing for signs and symptoms telling you what is going on
in the patient’s mind.
3. Take any suicidal complaint seriously.
4. Be confident, encouraging and optimistic.
5. Act definitively by carrying out some tangible task such as
arranging a referral, one-on-one monitoring, contract for
safety, medication, etc.
• All interventions are ultimately aimed at helping the patient
to find the answer to the question: “what needs to change in
you to make suicide a much less desirable option for you in
the future?” Clinician and client must systematically
eliminate the reasons for dying and work to develop, infuse,
and increase more reasons for wanting to live.
• A person in a suicide crisis needs emotional and physical
support, direction in thought and feeling, guidance to
effective action, reassurance, and advice when indicated.
• The critical component, in my view, for any good intervention
is your relationship with the client.
General Guidelines for Practice and
1. Establish a clear treatment plan with the client as to how
suicidal thoughts, feelings, and behaviors will be managed on
an outpatient basis.
2. Closely monitor and document ongoing suicidality until it
3. Consider and use all appropriate modalities (e.g., various
therapies: CBT, DBT, EMDR, Behavioral Activation Therapy,
journaling, exercise, couples counseling, bibliotherapy),
vocational counseling, medication, etc.
4. Routinely seek professional consultation and document such.
5. Document the resolution of suicidality; monitor for any
• Learning Warning Signs (“prodromals”) - Identifying thoughts,
emotions and behaviors which are or could lead to suicidal
• Coping/Crisis Card - List of different strategies (internal and
external behaviors) client can use in case of a crisis situation.
On card, smart phone, or other immediately available form.
• Developing a Hope Kit – aid to reminding individual why they
want to live – can be written (such as gratitude lost), or
something like a box filled with life-affirming items and
meaningful mementos that instill a sense of hope. Anything
that reminds client of why struggle to live is worth fighting for.
Note on Contracting for Safety!!!
The concept of contracting for safety (also known as no-suicide
contracts or agreements, no-harm contracts, and suicide prevention
contracts), although a popularly accepted method for managing
suicidal patients for more than 30 years, has no scientific evidence to
support its effectiveness.
At times, contracting is often the primary factor in clinical decision-making,
justifying a lower level of intervention or concern.
The ultimate focus of suicide contracting is not on the safety
agreement itself but on the process it engenders to engage staff and
patient in a dynamic, meaningful relationship for identifying patient
needs, encouraging disclosure of distress, and assuring consistent
support and appropriate interventions.