Assessing and Treating Suicide Risk: A Case Study

In this case study, “Frank,” a 17-year-old high school junior, attempted suicide a week earlier by ingesting his mother’s prescribed medication for arthritis. Upon intake, we learned that Frank has been experiencing a slow decline in functioning over the past two years since the divorce of his parents. He explained that the divorce did not come as a surprise because his parents never got along and always argued. The client reported that he could not think of one time when his family was together without his parents verbally fighting (Alonzo & Gearing, 2018).

Determining Risk

Warning signs may present as behavioral, cognitive, and/or emotional changes in an individual prior to active suicidal ideation and behaviors (Rudd et al., 2006). Based on Frank’s self-report during his intake, the warning signs that are present in the case example include increased social withdrawal, a sense of being trapped and feeling hopeless, and increased irritability. He also reported that his grade began “slipping,” which can be a behavioral warning sign for youths. Among other emotional and cognitive changes, Frank reported that he became increasingly concerned that he was a burden and disappointment to his mother after his parent’s divorce.

One of the major risk factors present in the case example is the combination of Frank’s age and gender, such that adolescent males are more likely to complete suicide than their female counterparts (Canetto & Sakinofsky, 1998; CDC, 2015). Additionally, the client presents with the risk factors of family history of depression and suicide, as noted by the client’s report that his paternal grandfather experienced depression and attempted suicide, Frank’s experience of depressive symptoms, and family conflict with a dysfunctional household environment prior to his parent’s divorce. Frank’s father’s unsupportive remark about having “no room in his life for any more stress or sadness” is also a concerning risk factor because research shows that lower perceived parental support predicts lifetime suicidality among adolescents, even after controlling for peer supports (Alonzo & Gearing, 2018).

The protective factors, which can help mitigate risk factors, that are present in this case example include the client’s sense of obligation and responsibility to his mother, his strong bond with his brother, and familial support from his mother. Additionally, Frank has access to mental health support through his school guidance counselor and as a client with our outpatient clinic. Additionally, it would be helpful to explore Frank’s individual coping mechanisms, any religious or spiritual protective factors, and other caring adults or peer supports that Frank has so that we can bolster his protective factors.

Regarding what else I would need to know to help me determine the client’s current level of risk, I would refer to the Columbia-Suicide Severity Rating Scale (C-SSRS) for guidance. For one, we will want to know if the client wants to die or if he hopes that overdosing would mean he would go to sleep and never wake up. Does he wish to be dead? We would then need to explore the client’s non-specific active suicidal thoughts. Based on the client’s methodical collection of his mother’s medication, we know that the client did exhibit active suicidal ideation with a specific plan and intent. I would want to know whether he would attempt again given the chance, as well as what other methods of suicide he has considered.

From there, we would need to explore the intensity of his suicidal ideation, including frequency, duration, controllability, deterrents, and reasons for ideation. For instance, what situations seem to trigger suicidal thoughts, how often do those situations occur, and what has stopped him from attempting in the past? Lastly, we would need to discuss his history of suicidal behavior, including any previous aborted and interrupted attempts, as well as non-lethal self-injurious behaviors.

Based on the intake, we know that the client had taken preparatory actions before attempting suicide a week ago, including collecting pills and writing farewell letters. Frank indicated that his depressive symptoms have been increasing and his functioning has been declining over the past two years, all of which indicates that Frank is currently at a moderate level of risk. Depending on his responses to whether he would attempt again given the chance, he may be at severe risk and would then benefit from in-patient treatment. Given the available information, however, I believe the client presents a moderate level of risk for suicide.

Impact of Personal Values and Beliefs

Despite attempting to follow professional ethics, my personal values, beliefs, and expectations could impact my assessment of this client. For instance, my expectations for a supportive family, even after parental divorce, may overemphasize the protective potential of the client’s perceived and actual parental support. As such, it is important to listen to the client’s perceptions during the intake to best gauge his individual sense of support.

Additionally, I would expect and hope that his parents would come together to support Frank in whatever way they can, but it is possible that the conflict between his parents could be compounded by this event and they may not be able to collaborate altogether. If I assumed that there would be immediate collaboration and then a family meeting turned into an explosive argument, the client could be severely negatively impacted. As such, it could be helpful to meet with the parents alone before bringing the family together for a session or meeting.

It is also important to stay mindful about one’s own beliefs and judgements related to suicide, specifically. If a client feels what they are discussing is being judged, they are less likely to feel safe enough to be honest and vulnerable. On the other hand, putting one’s own experiences onto a client could also be detrimental. For instance, I have Major Depressive Disorder but my experience with this mental illness is different from others. Each person has unique experiences. It is important, therefore, to remain mindful about self-disclosure so as not to make someone feel like their experience is abnormal in comparison to my own, which could then skew the assessment. Ultimately, it is important for me as a social worker to introspect and stay mindful of my judgements and expectations when working with clients.

Impact of External Factors

According to Alonzo and Gearing (2018), there are sociodemographic risk factors that can negatively impact children and adolescents, such as low socioeconomic status, low educational achievement, and sexual orientation. Additionally, if the client is a Person of Color, then the stress of discrimination and microaggressions could further compound depressive symptoms. It would be important to keep these risk factors in mind when assessing the client through the person-in-environment lens. That would also mean striving for cultural humility to ethically support and collaborate with clients. The case vignette does not indicate Frank’s race, socioeconomic status, or sexual orientation, but it would be important to know if any of these identities put the client at higher risk for stressors, such as being the recipient of discrimination and bullying.

Engagement and Treatment

I would work to engage this client in treatment by working to build rapport and approaching discussions about suicide and symptoms of depression with nonjudgement and empathy. This is particularly important considering Frank was hesitant to follow up on his initial mental health referral for fear of being judged as “crazy.” Additionally, I would work to involve the family in the client’s treatment, particularly when it comes to safety planning. For instance, Frank’s chosen means of suicide was overdosing on his mother’s prescription medicine, and so part of making the environment safe would be to have her lock up medications. Additionally, it would be important to determine if there are firearms in either the father’s or mother’s homes. If so, we would collaborate on gun safety, such as locking up guns, making sure they are unloaded, and keeping ammo in a separate area from the guns.

Although there is limited research on interventions for suicidal ideation and behaviors in youths, cognitive-behavioral therapy (CBT) is one of the few evidence-based practice(s) that shows promising efficacy for at-risk youths (Alonzo & Gearing, 2018; Brown et al., 2005). Therefore, I would suggest using CBT with this client. Additionally, it may be beneficial to incorporate a psychopharmacological intervention, such as antidepressants, alongside CBT. Lastly, safety planning should be incorporated into treatment. Safety planning, when applied as a form of brief intervention, has been shown to help mitigate suicide risk (Stanley & Brown, 2012).

The treatment strategies that we would utilize when creating a safety plan, which is always important when working with a client who has experienced suicidal ideations, would be to help the client identify warning signs within themselves, promote and build internal coping skills, develop a list of social contacts (people or places) that may help distract the client from a crisis, create a list of loved ones to contact in moments of crisis, provide contact information for professional support, such as a suicide hotline, and work to make the client’s home environment safe, as discussed earlier. Also, some of the CBT skills learned throughout treatment, including problem-solving, relaxed breathing techniques, and negative thought blocking, could be added to the client’s safety plan as it is revisited and revised (Ackerman, 2021).

In short, a combination of CBT, medication, and utilizing safety planning would likely be beneficial to Frank, especially if we are also able to collaborate constructively with his parents throughout the treatment process. This treatment plan, however, may need to be adjusted if Frank’s risk increases from moderate to severe, in which case in-patient care may be more beneficial for short-term safety purposes.

References

Ackerman, C.E. (2021). 25 CBT Techniques and Worksheets for Cognitive Behavioral Therapy. Positive Psychology. Retrieved from https://positivepsychology.com/cbt-cognitive-behavioral-therapy-techniques-worksheets/

Alonzo, D. & Gearing R.E. (2018). Suicide assessment and treatment: Empirical and evidence-based practices. (2nd ed.). Springer Publishing Company.

Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. Jama, 294(5), 563–570.

Canetto, S. S., & Sakinofsky, I. (1998). The gender paradox in suicide. Suicide and Life-Threatening Behavior, 28(1), 1–23.

Centers for Disease Control and Prevention. (2015). Suicide prevention: Youth suicide. Retrieved from https://www.cdc.gov/violenceprevention/suicide/index.html

Rudd, M. D., Berman, A. L., Joiner, T. E., Jr., Nock, M. K., Silverman, M. M., Mandrusiak, M.,…Witte, T. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life-Threatening Behavior, 36(3), 255–262.

Stanley, B., & Brown, G. K. (2012). Safety planning intervention: a brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264