Summary: Training and experience in suicide risk assessment can support the alleviation of anxiety and building of confidence for clinicians. Confidence is more commonly associated with assessments conducted by students, but not necessarily reflective of accurate assessment of suicide risk.
Notes: SRAA recognise and acknowledge that suicide risk assessment inherently requires an assessment of psychosocial needs, underpinning the drivers of suicidality, rather than a prediction per se. Regardless, in representing the research accurately, language that evaluates ‘suicide risk’ is used.
Suicide is a serious public health concern, with almost one million people around the world taking their own lives each year (World Health Organisation, 2012). The majority of people who die by suicide have come into contact with mental health clinicians shortly prior to their death (Regehr et al., 2006). In working with vulnerable and suicidal individuals in which the stakes are extremely high and the outcomes often uncertain, clinicians are subject to ongoing personal and professional challenges, anxiety and self-doubt.
A certain level of anxiety and self-doubt is both inevitable and necessary in this critically important area of practice. Clinicians should always hold some level of concern regarding their assessment of suicidality, and in their attempts to balance perceived versus actual level of suicide risk. Clinicians’ concern, uncertainty and caution is not reflective of an ineffective appraisal. Rather, it supports reflection and professional and personal growth, allowing for constant improvement and development with each client.
Nevertheless, anxiety and uncertainty regarding one’s own knowledge and skills in working with suicidal individuals, including limited understanding of associated medico-legal issues, presents barriers to the effective assessment of suicidality (e.g., Regeher, 2016).
Below we have reviewed two studies that illustrate some of the barriers to effective suicide assessment, both of which speak to the need for ongoing and in-depth training in this domain. In particular, these studies highlight the importance of understanding the legal and ethical obligations in the suicide assessment and management process, which will ideally ease anxiety in this key area of clinical practice.
Recent Research on Barriers to Effective suicide assessment:
A recent study by Regehr et al. (2016) examined professional judgment within the context of suicide risk assessment. The researchers sought to identify factors influencing clinical confidence. Participants, both final year social work students and experienced social workers, were required to assess simulated patients presenting with suicidal ideation. Specifically, participants were asked to judge whether the client was at imminent risk for suicide and whether the client required a hospital admission. Following each decision, participants were required to rate their level of confidence in their decision.
Results revealed highly divergent clinician views regarding whether the person’s suicide risk warranted hospitalisation, highlighting the need for ongoing training in working with suicidal clients.
Specifically, Regehr et al. (2016) found that a large number of students rated their decision with high confidence, relative to the experienced clinicians. Qualitative analyses demonstrated that these students appeared to make their judgements quickly and did not believe they needed more time to further assess the patient’s suicidality, suggestive of overconfidence in their judgments. Students were less likely to reflect on their own emotional responses in their decision making process, relative to experienced clinicians.
Conversely, qualitative analysis found that experienced clinicians who indicated they were highly confident in their assessment of suicidality adopted a more considered approach. For instance, unlike their student counterparts, they tended to reflect on what they could have done better. They reflected that they experienced varied emotional states, with some indicating they felt confident and others indicating they felt anxious. However, these emotional states did not appear to impact clinicians’ self-appraisal of their ability to make an effective decision regarding the client’s suicide risk. Consistently, experienced clinicians were comfortable in reflecting on their emotional responses and how this impacted their confidence in their appraisal of suicidality.
For experienced clinicians who indicated low confidence levels in their appraisal of suicidality, uncertainty appeared to be associated with lack of experience or training with the patient represented in the simulation (e.g. working with younger clients). Students who indicated low confidence levels reported that their anxiety was more broadly related to a lack of skills and knowledge.
Implications for Clinicians
Overall, the results of Regehr et al.’s (2016) study highlight the inevitable nature of uncertainty in this area of clinical practice and the need for further training, regardless of skill level, but particularly in recognising how internal states can influence decision making for clinicians. Further, results suggest that overconfidence in the face of such uncertainty is not only undesirable, but may not reflect the evidence presented by the client. Ultimately, these findings indicate that clinicians, both inexperienced and experienced, should adopt a considered and cautious approach to suicide risk assessment, highlighting what we would deem a ‘logical’ conclusion, that clinicians should continue to pursue regular training and supervision with respect to suicide risk assessment and management.