Thursday, May 17, 2012


I live in a coastal city. To get to and from...well, just about anywhere...I have to go over a major bridge. Sitting in rush hour traffic, there is plenty of time to notice all the billboards and signs. And although I've driven over the bridge countless times, I am always struck by one sign in particular.

I suppose it's four signs, actually: one on each side of both the Northbound and the Southbound levels (one is above the other). The signs read "Desperate? Depressed? Call the Samaritans" (a suicide prevention organization and "helpline"). 

Usually, when I notice these signs, I shudder and look away. Working with potentially suicidal clients, I don't like to think in too much detail about possible scenarios - especially what I've been told about this particular bridge. However, I appreciate the fact that it would be impossible to make it onto the bridge without seeing one of these signs - at least everyone who considers this path is offered one last chance to reconsider.

I imagine there are some people on the verge of suicide who do give the world one last chance to support them. I suspect that these people are the ones who are ambivalent about death - who may not see it as a positive thing, but may not see another way out. These may be the same people that hint to other people, or even seek treatment, when they are considering suicide. However, as I was reminded in a training today, ambivalence and desperation are not always present immediately prior to suicide (for example, when someone is approaching the bridge). Instead, having made the decision to commit suicide, many people experience relief and become more cheerful. The desperation has already ended.

When I worked with my first chronically suicidal client in outpatient therapy, my supervisor provided me with some of the best advice I've gotten on this subject. He acknowledged what I already knew - that this client ticked all the boxes for high suicide risk - while also reassuring me that I couldn't take on the responsibility of "saving" him. His life, or death, was in his hands, not mine. I could make sure that he knew help was available, and how to access it. I could work with him to build motivation to live. And I could assess frequently for risk and need of hospitalization. But I couldn't take on the sole responsibility of keeping him alive.

The second part of his advice dealt with how to assess someone who was suicidal at baseline. Given that he always had thoughts of suicide, and had a standing (lethal) plan, but denied intent, and had already been hospitalized and releases, what would tip me off if he became more acutely suicidal? A marked brightening of affect. Increased energy, improved mood, enthusiasm. Lightness.

I couldn't look for depression or desperation, which were always present. Instead, the real risk would come when and if he suddenly seemed to improve. This could be a dangerous sign that he had found a "solution" to his problems, and was feeling relief because everyone would soon be over.

Fortunately, I never had to experience that eerie mental status change with him. However, my agency's current risk assessment policies were developed after a suicide on the inpatient unit, presaged by sudden improvement in mood and program compliance. The take-home message: beware of sudden improvement in risky clients! 

How do you assess for suicide, particularly in high-risk clients? 

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