Addressing Concealed Suicidality: A Flexible and Contextual Approach to Suicide Risk Assessment in Adults

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https://doi.org/10.1007/s10879-021-09493-9 ORIGINAL PAPER

Addressing Concealed Suicidality: A Flexible and Contextual Approach to Suicide Risk Assessment in Adults

Jay Nagdimon¹ · Christopher McGovern² · Michael Craw¹

Accepted: 4 March 2021 / Published online: 17 March 2021

Abstract

Concealed suicidality can be a major impediment for clinicians conducting a suicide risk assessment. Client minimization and denial of suicidal thoughts can lead clinicians to undertreat and under-monitor clients experiencing a suicidal crisis. Five recommendations are given to address potential weak areas of suicide assessment with adults including routinized processes and a reliance on assessment instruments that may underestimate risk when individuals have no prior attempts or significant mental illness. Specifically, the authors highlight the importance of continued training and education in suicide assessment, how considering the context of the assessment can heighten one’s sensitivity to concealment of suicidal ideation and how different assessment instruments and interview techniques, when chosen with care, can increase the candor of client expression. The authors also recommend attending to clinician anxiety both as a way of maintaining rapport as well as a method of identifying clues that the assessment is not producing accurate information. Finally, application of recommendations is demonstrated through case vignettes.

Keywords Suicide · Assessment · Risk

Introduction

From 1999 through 2018 the rate of suicide in the United States increased by 35%, rising from 10.5 deaths per 100,000 people to 14.2 deaths per 100,000 people (Hedegaard et al., 2020). Currently suicide is the 10th leading cause of death in the U.S. for all ages (Centers for Disease Control Preven- tion, 2018). Efforts to contain and reverse this trend have brought greater awareness to the importance of identifying and assessing individuals at risk for suicide. A critical factor to consider when conducting suicide risk assessments is a client’s potential reluctance to disclose thoughts of suicide. Such reluctance is not uncommon. A study involving Australian adults found that only 25% of individuals reported they had disclosed their suicidal ideation to a

psychologist, 24% to a medical doctor and 13% to a psy- chiatrist (Calear & Batterham, 2019). Within the entire sam- ple 58% of individuals reported they had not disclosed their suicidal ideation to any healthcare professional suggesting that revealing suicidal ideations is a particularly concerning disclosure for many individuals (Calear & Batterham, 2019).

When examining low disclosure rates to healthcare professionals it is important to note that a large portion of suicide decedents had contact with a healthcare provider prior to their death. Recent studies suggest that 80% of suicide decedents had contact with primary care services in the year preceding their death and 44% had contact in the prior month (Stene-Larsen & Reneflot, 2019). Contact rates remain high when looking at mental health service engagement, with 50% of decedents having had contact six months prior and 21% of decedents having had contact one month prior to their death (Stene-Larsen & Reneflot, 2019). Fur- thermore, disclosure of suicidal thoughts to medical professionals remains low even in facilities where medical support is available and screening for mental health problems including suicidal ideations occurs (Berman, 2018). Overall, the literature suggests that concealed suicidality directly contrib- utes to missed opportunities for intervention.

* Jay Nagdimon N3473@lapd.online

1 Los Angeles Police Department, Behavioral Science Services, 221 N. Figueroa St. #650, Los Angeles, CA 90012, USA

2 Department of Psychological Sciences, Case Western Reserve University, 11220 Bellflower Road, Cleveland, OH 44106, USA

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When preparing to work with clients who may be apprehensive about disclosing suicidal ideation, it is important to consider what factors might impede disclosure. Results from several studies have shown that fear of forced hospitalization and medication are common reasons for concealing suicidal thoughts and behaviors (Hom et al., 2015; Sheehan et al., 2019). In a study of 874 participants, 67% cited fear of hospitalization and 48% cited opposition to taking psychiatric medication as specific reasons for not wanting to disclose suicidal ideations to a psychologist or counselor (Hom et al., 2017a).

Perceived public stigma can be another barrier to self- disclosure of suicidal ideations (Hom et al., 2017a); Sheehan et al., 2019). Fears about being seen as weak (62%) and being judged (48%) are commonly cited reasons for concealing suicidal ideations (Hom et al., 2017a). Stigmatization fears brought on by gender role conflict may disproportion- ally affect men employed in professions noted for adhering to traditional male gender norms, such as military service members and law enforcement officers (Heath et al., 2017;

Hom et al., 2017b). In a study examining perceptions of mental illness stigma in police departments, 62% of officers believed that most of their peers would expect to experience discrimination if they disclosed a history of mental illness (Stuart, 2017). Fifty-nine percent of officers also agreed their peers would perceive treatment for mental illness as a sign of personal failure (Stuart, 2017).

Individuals belonging to certain cultural groups may also be vulnerable to increased stigmatic pressure to conceal thoughts of suicide (Byrow et al., 2020; Wolf et al., 2016).

In collectivist cultures where a higher value is placed on the family than the self, an individual may feel pressure to protect the family image by not disclosing mental illness (Augsberger et al., 2015; Yu et al., 2018). Overall, studies on mental health engagement in first responders, military service members and various cultural groups indicate that clinicians need to be extra vigilant and flexible when conducting clinical interviews with individuals who may be more likely to conceal suicidal ideations due to stigmatic pressure (Choudhry et al., 2016; Heath et al., 2017; Karaffa & Koch, 2016). Suggestions of how to address stigma-related concerns will be described in Recommendations 3 and 4.

Client-centric factors are not the only source of potential barriers to self-disclosure. Clinician discomfort when approaching the topic of suicide can further complicate a risk assessment, especially with clients who are already hesitant to disclose thoughts of suicide. Evidence suggests feeling uncomfortable when working with suicidal clients is correlated with decreased odds of conducting a suicide risk assessment during the first appointment (Roush et al., 2018). In addition, the presence of psychosocial risk factors of suicide, which should prompt further querying into current ideations, are sometimes ignored when a clinician feels

unprepared to address an affirmative response (Jahn et al., 2016; Roush et al., 2018). Avoiding a more comprehensive assessment can be especially deadly when a client is already apprehensive about disclosing thoughts of suicide.

Through clinical vignettes the current effort attempts to highlight potential indicators of incomplete or inaccurate client disclosure during a clinical suicide risk assessment.

In addition, the authors will give recommendations on how to address such situations, stressing the importance of taking a flexible, contextually-sensitive approach to suicide risk assessment.

Recommendations

Recommendation 1: Attend to Clinician Anxiety The authors recommend that clinicians monitor their interviewing style and methods when conducting suicide risk assessments and notice how any experience of anxiety influ- ences the tone, timing, and content of interview questions.

Clinician anxiety and stress may arise from the humanitarian concern for the safety of their client and the psychological suffering that fuels suicidality. Additionally, clinician anxiety may involve a concern for one’s professional reputation (which can be especially pronounced in group and institutional settings) and potential legal ramifications should a client take his or her own life (Jobes, 2017).

Feelings of incompetence when treating a suicidal client may be a primary driver behind clinician anxiety. Find- ings from a study of 289 mental health practitioners suggest that clinicians who perceive their suicide training as inadequate will experience greater discomfort and greater fear of negative outcomes when working with a suicidal client (Jahn et al., 2016). These concerns about competency and the anxiety they generate can have a detrimental effect on rapport-building and impede self-disclosure by the client.

Clinician discomfort can manifest in a nervous therapeutic presentation and narrowed clinical approach. For example, after a client acknowledges suicidal ideation, an anxious clinician may reflexively ask about suicide attempt planning. A client noticing the rapidity with which the follow-up question is asked may respond with psychological reactance, alarmed by the thought that the clinician is preparing to hospitalize them (Borden, et al., 2017).

Steve, a police detective, requested counseling for marital difficulties. The treating clinician conducted a psychosocial assessment which included asking about a history of suicidal thinking or behavior. As the assessment proceeded, the psychologist felt the therapeutic alliance was being established. When the client reported an episode of past suicidal ideation

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with intent, the psychologist noticed a rise in their own anxiety as they felt pressure to determine the contemporary level of suicide risk. The psychologist abruptly advanced the assessment to ask about current suicidal feelings. As he did so, he noticed a distant and searching expression from the client. The psychologist real- ized that his anxiety had caused him to lose focus of the moment by moment unfolding of the session which was perceived negatively by the client. The psychologist worked to repair the relationship by asking about the client’s changed expression and any unspoken concerns he might have. As a result, the client revealed a close family member who had been involuntarily hospitalized numerous times and who now has negative feelings towards mental health professionals. With the client’s experiences and current concerns revealed, the psychologist was able to re-establish rapport and sensitively returned to the assessment for current risk.

Anxiety may also affect how clinicians frame the inquiry into suicidal ideations. Negatively framing questions about suicide (e.g., “No thoughts of suicide?”) can be an uncon- scious consequence of a clinician’s anxiety about receiving an affirmative response. One study reviewing video record- ings of 83 clinician-posed questions about suicide found that 75% of questions communicated a biased expectation towards a negative response (McCabe et al., 2017). Though a natural response to anxiety, a negatively phrased question may indicate to the client that the clinician is uncomfortable exploring the topic of suicide, further reinforcing disclosure barriers such as feelings of stigma.

High levels of anxiety can also influence clinicians to doggedly assess for suicidal ideation to minimize the possibility that such feelings exist, even after client denials. It can be helpful for clinicians to seek a second opinion when uncertainty exists around the validity of a risk assessment.

Professional consultation can be used as a second “pair of eyes” reviewing both the assessment and the client’s reactions, assuaging any anxiety that suicidality has gone unde- tected or that the clinician did not conduct a comprehensive evaluation.

Recommendation 2: Seek Out New Assessment Instruments and Training

The authors recommend that clinicians seek out contemporary suicide risk assessment instruments and clinical interviewing techniques, and pursue training opportunities regarding the theoretical etiology, identification and treatment of suicidality. Given the heterogenous presentation of suicidality we do not recommend a specific instrument or theoretical approach. Rather, we believe expand- ing one’s clinical toolbox with several instruments and

conceptualizations of suicide is important for enhancing clinician comfort and confidence when conducting suicide risk assessments. Additionally, having multiple clinical tools and techniques to choose from permits clinicians to adopt a flexible approach to risk assessment, which is crucial when trying to accurately assess risk for a client who is reluctant to disclose suicidal ideations.

Foundationally, clinicians should strive to understand theoretical conceptualizations that attempt to subsume various pathways to suicide under a cohesive structure. Such understanding can guide clinicians to explore specific types of psychosocial stressors and cognitive schemas which may underlie concealed suicidal ideation. With theory-informed exploration, the basis for probing questions regarding psychological pain, thoughts of death and thoughts of suicide can be compassionately elicited. For example, the Inter- personal Theory of Suicide (Van Orden et al., 2010) posits that suicidality stems from either thwarted belongingness or perceived burdensomeness in the presence of an ability to inflect lethal self-harm (Acquired Capacity). The assessment for suicide then can explore recent losses or romantic break- ups in addition to the cognitive appraisal that one’s death is worth more than one’s life. The theory further describes how the capability for suicide develops over time through a process of habituation to painful stimuli or repeated trauma exposure which provides an additional avenue for assessment.

Refinement of the theoretical and practical skills needed to develop a flexible approach to suicide risk assessment requires that clinicians continue education in suicidology after graduate training. Graduate level training is often insuf- ficient to fully develop competence in working with clients experiencing suicidal thoughts and behaviors (Montague et al., 2016). A survey of 59 graduate students enrolled in clinical psychology programs across the U.S. found that only 20% of students reported receiving focused clinical super- vision on suicide assessment (Mackelprang et al., 2014).

Furthermore, over 55% of students indicated they did not feel confident in their ability to effectively assess for suicide risk (Mackelprang et al., 2014).

Suicide-focused training can help fill competency gaps left by inadequate graduate level training (Mirick et al., 2020; Montague et al., 2016). In a survey of 60 mental health professionals, 71% of participants reported positive changes in the way they inquired about suicide after attending a one day continuing education course on suicide (Mirick et al., 2020). Another 63% reported greater feelings of competency in managing suicidal risk, while 48% also felt they were now better able to build stronger therapeutic alliances with clients having thoughts of suicide (Mirick et al., 2020). Another study by Wakai et al., (2020) found that 89% of mental health professionals who had attended a suicide assessment training endorsed always asking new

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clients about suicide while only 64% of untrained professionals reported the same.

Recommendation 3: Consider How the Context of the Assessment Can Influence Self‑Disclosure of Suicidal Ideation and Planning

The authors recommend that clinicians give considerable attention to the context of the assessment and how that may influence a client’s level of comfort and degree of candor.

The challenge of accurately assigning risk is further com- plicated by the potential for misleading or incomplete disclosure of suicidality. Contextual factors can help mark the presence of potential disclosure barriers, which require more careful exploration. For example, fear of negative work consequences may be an especially salient disclosure barrier for police officers (Stuart, 2017).

Paying attention to contextual markers of possible concealed ideation is especially important given that common screening tools place endorsement of suicidal ideation as the gatekeeper question for further inquiry (Berman, 2018). Even in unstructured interviews, denial of suicidal thoughts can prompt clinicians to prematurely move on from the topic. In this way individuals who are motivated to keep their suicidal thoughts hidden can easily mislead clinicians by denying the existence of suicidal ideations in response to these gatekeeper questions. Additionally, the clinical tendency to overweight suicidal ideation as a predictor of future suicidal behavior can cause other equally significant risk factors to be mini- mized in the face of denied ideation. A retrospective chart review of 157 suicide decedents who died within 30 days of their last clinical assessment looked at this tendency (Ber- man, 2018). Berman (2018) found that 56% of decedents had denied suicidal ideation during their last assessment, with two-thirds doing so within two days of their death. However, the profile and prevalence of suicide risk factors between decedents who had endorsed suicidal ideations and those who had denied ideation were remarkably similar. Furthermore, there is evidence that many of these denials likely reflect attempts to hide suicidality rather than a true absence of ideation. Contextually, the proportion of patients who denied suicidal ideation was highest in situations where denial of ideation was integral to clinicians’ decisions to discharge or admit the individual to the hospital (Berman, 2018). Taken together these findings highlight an important roadblock to accurate suicide assessment. Many suicidal individuals may deny ideations when asked by a clinician, but the absence of endorsed ideation does not mean absence of ideations or risk. To address this issue, the authors recommend that any denial of suicide be treated at least initially as a neutral find- ing until contextual factors influencing the assessment have been considered and explored.

In preparation for recognizing and querying hidden suicidality, clinicians need to be familiar with commonly cited reasons and contexts for denying suicidality. Individuals fre- quently cite fear of forced treatment (medication and possible hospitalization) and fear of stigmatization as significant motivators for concealing suicidal ideations from clinicians (Blanchard & Farber, 2020; Hom et al., 2017a). However, motivators for concealing suicidality do not influence eve- ryone equally.

Person specific contexts, such as cultural identity, occu- pation, and reason for referral can increase the pressure these motivators place on an individual as they grapple with the decision to speak openly about their thoughts of suicide. For example, pilots disclosing thoughts of suicide are likely to be “grounded” if the assessing mental health professional believes they are a danger to themself or others. As a result, pilots may be more likely to conceal mental health issues and thoughts of suicide compared to the general population (Parker et al., 2001). Military service members and medical doctors may also find fear of negative job consequences to be especially salient motivators to conceal suicidality (Hom et al., 2017b; Stuart, 2017).

When surveyed nearly 40% of physicians reported concerns about licensure would make them apprehensive to seek out formal care for a mental health condition (Dyrbye et al., 2017).

During a suicide risk assessment gender role conflict and cultural factors may inhibit help-seeking behavior and may contribute to the decision not to reveal suicidal ideation. For men, seeking mental health care can trigger experiences of gender role conflict as such behaviors are often seen as incongruent with traditional male gender norms. As a result, men are likely to experience increased stigma-related motivators for concealing suicidality when engaging with mental health services (Loganathan & Foo, 2019; Rasmussen et al., 2018). The experience of gender role conflict when seeking mental health care may be especially salient for men belonging to cultures that ascribe high importance to traditional male norms. For example, Latino men scoring high on measures of machismo report greater negative attitudes towards seeking mental health care (Davis & Liang, 2015). Evidence also suggests that adherence to traditional male gender norms confers increased risk for experiencing gender role conflict and subsequent disengagement with mental health services among African American men (Cadaret & Speight, 2018).

Finally, it should be noted that gender role conflict can transcend traditional societal expectations related to sex and gender identity. Women identifying with aspects of masculine culture can experience gender role conflict and the diminished mental health help seeking behaviors that come along with it (McDermott et al., 2018).

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A variety of other cultural factors can heighten the fear of negative outcomes from disclosing suicidal thoughts. Reli- gion, societal norms, and cultural experiences with systemic racism can increase feelings of apprehension when engaging with a mental health care provider (Alhomaizi et al., 2018; Burkett, 2017). For example, practitioners of various religious faiths may view mental illness as a spiritual problem (e.g. loss of faith in God, possession by the Devil, or punishment for sin) which can be a source of shame or embarrassment. Consequently, seeking professional mental health treatment may be stigmatized as it signals a personal failure (Alhomaizi et al., 2018). There is also a body of research indicating that experiences of inequity caused by racial discrimination has cultivated mistrust in the mental health care system among under-represented groups (Maura

& de Mamani, 2017). A qualitative study of 17 Black men and women experiencing depression found a majority of participants were reluctant to engage in treatment because they believed they would experience discrimination and that white providers would not understand their experiences (Campbell & Long, 2014). Still, Sue (1998) cautions that clinicians should not be hasty when attributing indications that a client is not being forthcoming to cultural differences.

Exploration of concealed suicidality should be approached with sensitivity and in collaboration with the client to guard against erroneous assumptions.

The following vignette considers the intersection of law and significant suicide risk. In a large midwestern state all law enforcement officers must obtain a “carry card” in order to legally carry a firearm as part of their official powers.

State law requires the removal of the privilege when an officer is hospitalized for suicidal thinking or planning. Once that card is removed it can only be reinstated through a court proceeding. In practical terms, an officer who admits to significant suicidal ideation and is hospitalized would be without a job upon discharge from inpatient treatment.

John, a 34-year-old Caucasian police officer, had been arguing with his fiancé about the amount of alcohol he consumed. His fiancé said that his behavior was intolerable and that she was going to move out. Fear- ing that he had just lost his girlfriend and future wife, he called the Employee Assistance Program’s helpline offered by his employer. The clinician who spoke with the client assessed the client to be at high risk for suicide and directed him to go to the nearest emergency room. John was initially admitted for observa- tion due to his level of alcohol intoxication and was subsequently involuntarily admitted to the psychiatric inpatient unit within the hospital. The hospitalization and the resulting loss of his carry card put his job in jeopardy. Having contacted his employer about the loss of the carry card, John was put on administrative

leave until he was both cleared to return to work by a physician and had his carry card reinstated. Meanwhile word of his hospitalization traveled across his department with many officers feeling that he was betrayed by the Employee Assistance clinician. In their minds the clinician should have recommended that a friend come over and stay with him until he sobered up – a solution that John himself suggested both over the phone to the clinician and subsequently to other officers.

Any stigma involving failure or personal weakness may be compounded by concerns regarding professional consequences. The above vignette highlights not only the potential complications that some individuals might experience after revealing suicidal ideation, but it also illuminates how fears of unwanted treatment spreads through work groups and social circles. “Institutional memory” can involve not only policies and procedures, but significant events experienced by employees. Such situations can have far-reaching effects, influencing attitudes and perceptions of employees beyond immediate co-workers to include employees in separate departments as well as entirely separate workplaces.

Concealed suicidality may be uncovered through rapport building, a step-wise series of questions leading to a query about painful emotions and desires for escape or relief, or direct inquiry about possible concealment. The authors believe that upon repeated denials, it is reasonable to refrain from further questions about suicide otherwise the clinician risks the client taking offense at not being believed or that their denials were dismissed in favor of the clinician’s own suspicions. Research conducted by the Aeschi Working Group has demonstrated the importance of taking a person-center approach when working with a suicidal client. Cultivation of the therapeutic alliance, which begins at first assessment (Jobes, 2017), has been correlated with decreased suicidal ideation over the course of psychotherapy (Gysin-Maillart et al., 2017). If a clinician remains uncon- vinced of the absence of suicide risk, a treatment plan that emphasizes the timely reduction of psychological pain and the enhancement of social support can be an important bul- wark against suicide planning.

Recommendation 4: Attend to Indications of Minimization of Suicidality

Clinicians must attend to subtle and not so subtle indicators that the suicide risk interview is not producing accurate information. Apart from a suspiciously abrupt denial, clients may present with caginess (“maybe I could”), resist- ance (“I’m not going to tell you”), or hostility (“why do you care?”). It is likely necessary to reset the tenor of the interview by focusing attention on improving the therapeutic

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alliance and establishing trust. While some clients may fear immediate hospitalization, others are negatively provoked by the power differential between therapist and client (Pet- tyJohn et al., 2020). It may be important for the therapist to directly address the client’s concerns regarding the outcome of the assessment and whether the therapist will act in what the client agrees to be his or her best interest.

Of additional interest is the mismatch between the clinician’s observations of the client (watery eyes or crossed arms, or voice tones which are hostile, offended, or irrev- erent) and their denial of suicide ideation. As opposed to challenging the discrepancy, the authors recommend a more patient approach, sensitive to what may be conflicting feelings within the client (whether to be honest or deceive the person who is trying to help) by asking what the client is feeling at the moment. This question could be followed up by a normalizing statement that many people, in circumstances similar to theirs, might have a mixture of feelings about how much to reveal to a therapist and what the pros and cons of doing so would be.

Francine was asked by her supervisor to attend an intake with an employee assistance psychothera- pist. She initially resisted the request but eventually agreed and appeared for her appointment. The client said that her supervisor was worried about her because she was seen crying in the women’s bathroom. She said the experience of being observed crying was

“humiliating” and that she was just momentarily upset because she found out her fiancé, despite his denials, was still in contact with a former girlfriend. She said she called off the marriage since this was her third relationship that involved a romantic partner lying to her. The client’s presentation was guarded. In response to a question about suicidal feelings the client simply replied no and stared at the clinician. The emotional tone of the moment and the brevity of the response suggested to the clinician that the client was reluctant to fully disclose her feelings. The clinician changed her approach to focus on the history of the relationship and the positive emotional moments between the couple. She asked about and reflected feelings of hurt, betrayal and loss. The client’s demeanor softened, and her eyes became tearful. The clinician made a statement that many people in her situation might have thoughts of ending their life. The client acknowledged having those thoughts but sought to reassure the clinician that she had no intention of carrying them out.

She said the experience had caused her to think about not wanting to live but said she knew she would never go through with it.

In the above vignette the clinician was attuned to her mis- givings about the client’s responses. While she could have

simply assumed that the forcefulness with which the client denied suicidal ideation reflected resoluteness, she felt the context of the referral, the client’s description of feeling humiliated when observed crying and the unusual stare that accompanied the denial suggested that further exploration was necessary. Moreover, changing to a less direct approach that first focused on feelings served to establish the basis for a normalizing comment about suicidal thoughts, which was conducive to more candid self-disclosures by the client.

There are substantially more subtle indicators that the information shared by the client represents only a partial truth or a fabrication. It may be that the client says that they were “only joking” or contend that they were misunderstood, and that other people were overreacting to a transient expression of hopelessness (McClay et al., 2018). In the authors’

experience, given the circumstances of an assessment and the motivators for concealment, these statements are fre- quently deflections.

Simon, an aerospace engineer, was asked to present himself for an evaluation by his work supervisor after Simon’s ex-girlfriend reported that he had sent a series of alarming text messages. The ex-girlfriend sent screenshots of the conversation to the supervisor which read that Simon had threatened suicide because, he claimed, he could not live without her. When Simon presented late the following day, he said that he was drunk when he wrote the texts and was only trying to re-establish the relationship. He said that he was not

“seriously” suicidal.

While the client’s explanation in the above vignette is plausible, the circumstance of the referral combined with the knowledge that true feelings can emerge when intoxicated caused the therapist to continue to explore the client’s feelings. He asked about the client’s reactions to the possible breakup, the client’s concerns about his employment and what actions the therapist might take if he was suicidal. With reasonable reassurance the therapist persuaded the client that it was safe to acknowledge that his feelings were as expressed in the text message.

In some circumstance clients will admit to having suicidal thoughts but deny intention. Undoubtedly this is true and accurate for many people. However, some clients will make this distinction with a searching look directed at the therapist. The client gauges the impact of the admission, signal- ing a possible attempt to mislead the therapist or divine their reaction as opposed to merely sharing their inner experience. In this situation, the observant therapist will direct the client’s attention to their behavior and note that they seem more interested in the therapist’s reaction than in describing their full range of thoughts about suicide. While this must be a gentle confrontation, it is clinically important to address not just the stated content, but potential concerns that frame

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or constrict the client’s presentation of suicidal thinking and planning.

By considering the indicators of conscious misdirection the clinician can, in some cases, simply reassure the client of their genuine desire to be helpful. However, in other circumstances the clinician can offer a clear explanation about the importance of candor in the interview and note that forth- rightness is needed to create an effective treatment plan. In this type of discussion, a better understanding of the client’s own goals for a happier life is crucial to enhance the client’s motivation and interest in cooperation. Lastly, in the context of a mandated evaluation, it may be necessary to explain the purpose of the interview and the choices presented to the therapist if they are unable to estimate risk with some degree of confidence. In many of these situations an incomplete risk assessment might result in a psychiatric evaluation at a hospital emergency room or a report to the mandating agency or legal body that the evaluation could not be completed.

Recommendation 5: Consider Strengths and Weaknesses of Suicide Risk Assessment Instruments

Clinicians may choose to use suicide risk assessment self- report inventories and screening instruments as one way to mitigate feelings of stigma and shame. For some, the absence of direct, personal inquiry about suicide and the seemingly impersonal nature of a computer screen or the completion of a written form may feel more comfortable.

While the use of screeners is helpful in the identification of an individual for whom an in-person evaluation is warranted, the use of these and general suicide risk assessment instruments come with an important caveat: their effectiveness is ultimately limited to those people willing to acknowledge suicide feelings. In recent years an attempt has been made to bypass conscious denial and misdirection with the use of the Implicit Association Test, however its unique contribution to risk prediction beyond self-report and clinician assessment is still being established (Glenn et al., 2017; Harrison et al., 2018) and its application is unclear in a clinical setting where a reluctant client must be told of the test’s purpose.

Another shortcoming of risk assessment instruments is that the endorsement of past suicide attempts or the presence of a psychiatric diagnosis are considered to be substantial components of suicide risk. The Suicidal Adult Assessment Protocol (SAAP) places greater weight on a prior suicide attempt than it does on family history of attempts or deaths by suicide (Fremouw et al., 2005). When the client is experiencing their first episode of suicidality, assessment instruments that are so weighted may underestimate the true risk of suicide. This is problematic considering research indi- cates 59% of suicide decedents died on their first attempt (Bostwick, et al., 2016). Pre-screened occupational groups

such as police officers, with an absence of historical risk factors, may be particularly susceptible to false-negative results and an under-estimation of suicide risk on assessment instruments.

How a client will experience an assessment should also be considered when selecting assessment tools. A client’s pre-existing feelings of stigma regarding suicide may be accentuated by the power differential that exists in a psy- chotherapeutic setting. The Suicide Status Form IV (Jobes, 2016), which can be used both initially and as an on-going risk assessment tool, recognizes this and seeks to increase the client’s candor by collaboratively completing the assessment and interactively exploring the client’s answers.

Finally, clinicians should not administer suicide risk assessment instruments in isolation for risk management considerations (Borden et al., 2017). There are appropri- ate occasions for the use of structured suicide instruments, however, the clinician should think through which approach best fits the context and clinical presentation and what other assessment techniques can supplement the choice of a risk assessment instrument. Clinicians should describe this thoughtful process in their clinical documentation.

Frank has been in an unhappy marriage for many years with strong feelings of rejection from his spouse. As a result, he became interested in and pursued a female colleague at work. His repeated requests were rebuffed by his colleague and a complaint was filed against him. His employer changed his work location while the complaint was being investigated. The change was questioned by his wife and Frank admitted to attempt- ing to have an affair. The ensuing argument became heated. Frank retrieved a firearm and threatened suicide. His wife convinced him to put the gun away and at the time she did not arrange a mental health assessment for her husband. Approximately one week after the incident, Frank’s wife contacted his employer about the situation, including a description of the argument. Frank’s supervisor insisted Frank submit to an evaluation by a mental health professional. During the assessment, Frank appeared to minimize the threat to use his gun and denied that the behavior was an actual suicide attempt. The client was given a Beck Hope- lessness Scale and a SAAP. The client denied feeling hopeless and the client’s responses on the SAAP placed him in the minimal risk range. However, upon shifting to a more interactive instrument, the Suicide Status Form IV, the client began to express his feelings of emotional pain and now, with the prospect of divorce a real possibility, he described a sense of futil- ity about his life and his prospects for future happiness.

By the point in the assessment where he was to rate his degree of suicidal feelings, he ventured to say it

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was a 3 on a 5-point Likert scale. After this selection the clinician chose to return to the night of concern.

He used the Behavioral Incident technique (Shea, 2017) in which the client admitted the gun was not only drawn, it was placed under his chin and his finger was on the trigger. The clinician also sought to vali- date the client’s feelings of rejection and to elicit the brief, but significant thought that he was unlovable as a person. The initial interview led to a mutually agreed upon treatment plan to preserve his life and address his clinical issues.

In the above vignette the clinician recognized that the circumstance of the referral (by the client’s immediate supervisor) might cause the client to feel anxious about fully disclosing his thoughts and feelings. The clinician chose to augment his standard assessment instruments with one that encouraged therapist-client interaction in the hope of building rapport and trust. Recognizing the stigma associ- ated with suicidality and the client’s apparent minimization of his emotions and risky behavior, the clinician chose to use a specific interviewing technique (Behavioral Incident) to obtain greater clarity about what happened after the client’s wife confronted him. The risk assessment revealed that suicide risk reduction strategies should feature prominently in the client’s treatment plan along with coping strategies should his wife chose to leave him.

Conclusion

Suicidal feelings are common enough that all clinicians must be trained in how to assess their severity. Through early training and clinical experience clinicians may adopt a standard format of assessment questions and/or instruments. Given the idiosyncratic etiology of suicidality, the dynamics between the individual and the therapist, and environmental considerations involving the context of the assessment, some interviewing techniques and instruments may produce more information and accuracy than others. A flexible approach that is client-centered and contextually sensitive helps avoid the possibility of deception or minimization by the client and will produce a more accurate assessment of the client’s suicidal state of mind.

Declarations

Conflict of interest Dr. Nagdimon, Mr. McGovern, and Dr. Craw de- clare that there is no conflict of interest involved in the production of this manuscript.

Research involving Human and Animal Participants This manuscript does not contain any studies with human participants or animals performed by any of the authors.

Informed Consent This article does not contain any studies with human participants performed by any of the authors.

References

Alhomaizi, D., Alsaidi, S., Moalie, A., Muradwij, N., Borba, C.

P., & Lincoln, A. K. (2018). An exploration of the help-seeking behaviors of Arab-Muslims in the US: A socio-ecological approach. Journal of Muslim Mental Health, 12(1).

Augsberger, A., Yeung, A., Dougher, M., & Hahm, H. C. (2015). Fac- tors influencing the underutilization of mental health services among Asian American women with a history of depression and suicide. BMC Health Services Research, 15(1), 542. https:// doi.

org/ 10. 1186/ s12913- 015- 1191-7

Berman, A. L. (2018). Risk factors proximate to suicide and suicide risk assessment in the context of denied suicide ideation. Suicide and Life-Threatening Behavior, 48(3), 340–352. https:// doi. org/

10. 1111/ sltb. 12351

Blanchard, M., & Farber, B. A. (2020). “It is never okay to talk about suicide”: Patients’ reasons for concealing suicidal ideation in psychotherapy. Psychotherapy Research, 30(1), 124–136. https:// doi.

org/ 10. 1080/ 10503 307. 2018. 15439 77

Borden, K. A., Sommers-Flanagan, J., & Shaw, S. L. (2017). Suicide risk assessment: What psychologists should know. Professional Psychology: Research and Practice, 48(2), 98–106. https:// doi.

org/ 10. 1037/ PRO00 00106

Bostwick, J. M., Pabbati, C., Geske, J. R., & McKean, A. J. (2016).

Suicide attempt as a risk factor for completed suicide: Even more lethal than we knew. The American Journal of Psychiatry, 173(11), 1094–1100. https:// doi. org/ 10. 1176/ appi. ajp. 2016. 15070 Burkett, C. A. (2017). Obstructed Use: Reconceptualizing the mental 854 health (help-seeking) experiences of Black Americans. Journal of Black Psychology, 43(8), 813–835. https:// doi. org/ 10. 1177/ 00957 98417 691381

Byrow, Y., Pajak, R., Specker, P., & Nickerson, A. (2020). Percep- tions of mental health and perceived barriers to mental health help-seeking amongst refugees: A systematic review. Clinical Psychology Review, 75, 101812. https:// doi. org/ 10. 1016/j. cpr.

2019. 101812

Cadaret, M. C., & Speight, S. L. (2018). An exploratory study of attitudes toward psychological help seeking among African American men. Journal of Black Psychology, 44(4), 347–370. https:// doi.

org/ 10. 1177/ 00957 98418 774655

Calear, A. L., & Batterham, P. J. (2019). Suicidal ideation disclosure:

Patterns, correlates and outcome. Psychiatry Research, 278, 1–6.

https:// doi. org/ 10. 1016/j. psych res. 2019. 05. 024

Campbell, R. D., & Long, L. A. (2014). Culture as a social determi- nant of mental and behavioral health: A look at culturally shaped beliefs and their impact on help-seeking behaviors and service use patterns of Black Americans with depression. Best Practice in Mental Health, 10(2), 48–62.

Centers for Disease Control and Prevention. CDC WISQARS: Leading causes of death reports, 1999–2018. Retrieved from: https:// webap pa. cdc. gov/ sasweb/ ncipc/ leadc ause. html.

Choudhry, F. R., Mani, V., Ming, L. C., & Khan, T. M. (2016). Beliefs and perception about mental health issues: a meta-synthesis. Neu- ropsychiatric disease and treatment, 12, 2807–2818. https:// doi.

org/ 10. 2147/ NDT. S1115 43

Davis, J. M., & Liang, C. T. H. (2015). A test of the mediating role of gender role conflict: Latino masculinities and help-seeking attitudes. Psychology of Men & Masculinity, 16(1), 23–32. https://

doi. org/ 10. 1037/ a0035 320

(9)

Dyrbye, L. N., West, C. P., Sinsky, C. A., Goeders, L. E., Satele, D.

V., & Shanafelt, T. D. (2017). Medical licensure questions and physician reluctance to seek care for mental health conditions.

Mayo Clinic Proceedings, 92(10), 1486–1493. https:// doi. org/

10. 1016/j. mayocp. 2017. 06. 020

Fremouw, W., Tyner, E., Strunk, J., & Mustek, R. (2005). Suicidal Adult Assessmentprotocol–SAAP. American Psychological Association.

Glenn, J. J., Werntz, A. J., Slama, S., Steinman, S. A., Teachman, B. A., & Nock, M. K. (2017). Suicide and self-injury-related implicit cognition: A large-scale examination and replication.

Journal of Abnormal Psychology, 126(2), 199–211. https:// doi.

org/ 10. 1037/ abn00 00230

Gysin-Maillart, A. C., Soravia, L. M., Gemperli, A., & Michel, K. (2017). Suicide ideation is related to therapeutic alliance in a brief therapy for attempted suicide. Archives of Suicide Research, 21(1), 113–126. https:// doi. org/ 10. 1080/ 13811 118.

2016. 11622 42

Harrison, D. P., Stritzke, W. G. K., Fay, N., & Hudaib, A. R. (2018).

Suicide risk assessment: Trust an implicit probe or listen to the patient? Psychological Assessment, 30(10), 1317–1329. https://

doi. org/ 10. 1037/ pas00 00577

Heath, P. J., Seidman, A. J., Vogel, D. L., Cornish, M. A., & Wade, N.

G. (2017). Help-seeking stigma among men in the military: The interaction of restrictive emotionality and distress. Psychology of Men & Masculinity, 18(3), 193–197. https:// doi. org/ 10. 1037/

men00 00111

Hedegaard, H., Curtin, S. C., Warner, M. Increase in suicide mortal- ity in the United States, 1999–2018. NCHS Data Brief, no 362.

Hyattsville, MD: National Center for Health Statistics. 2020.

Hom, M. A., Stanley, I. H., & Joiner, T. E., Jr. (2015). Evaluating factors and interventions that influence help-seeking and mental health service utilization among suicidal individuals: A review of the literature. Clinical Psychology Review, 40, 28–39. https:// doi.

org/ 10. 1016/j. cpr. 2015. 05. 006

Hom, M. A., Stanley, I. H., Podlogar, M. C., & Joiner, T. E., Jr. (2017a).

“Are you having thoughts of suicide?” Examining experiences with disclosing and denying suicidal ideation. Journal of Clini- cal Psychology, 73(10), 1382–1392. https:// doi. org/ 10. 1002/ jclp.

22440

Hom, M. A., Stanley, I. H., Schneider, M. E., & Joiner, T. E. (2017b).

A systematic review of help-seeking and mental health service utilization among military service members. Clinical Psychol- ogy Review, 53, 59–78. https:// doi. org/ 10. 1016/j. cpr. 2017. 01. 008 Jahn, D. R., Quinnett, P., & Ries, R. (2016). The influence of training

and experience on mental health practitioners’ comfort working with suicidal individuals. Professional Psychology: Research and Practice, 47(2), 130. https:// doi. org/ 10. 1037/ pro00 00070 Jobes, D. A. (2016). Managing suicidal risk, A Collaborative Approach

(2nd ed.). Guilford Publications.

Jobes, D. A. (2017). Clinical assessment and treatment of suicidal risk: A critique of contemporary care and CAMS as a possible remedy. Practice Innovations, 2(4), 207–220. https:// doi. org/ 10.

1037/ pri00 00054

Karaffa, K. M., & Koch, J. M. (2016). Stigma, pluralistic ignorance, and attitudes toward seeking mental health services among police officers. Criminal Justice and Behavior, 43(6), 759–777. https://

doi. org/ 10. 1177/ 00938 54815 613103

Loganathan, N., & Foo, F. M. (2019). Relationship between gender role conflict and attitude towards seeking professional psychological help. Polish Psychological Bulletin, 50(4), 352–356.

Mackelprang, J. L., Karle, J., Reihl, K. M., & Cash, R. E. (2014).

Suicide intervention skills: Graduate training and exposure to suicide among psychology trainees. Training and Education in Professional Psychology, 8(2), 136–142. https:// doi. org/ 10. 1037/

TEP00 00050

Maura, J., & de Mamani, A. W. (2017). Mental health disparities, treatment engagement, and attrition among racial/ethnic minorities with severe mental illness: A review. Journal of Clinical Psy- chology in Medical Settings, 24(3–4), 187–210. https:// doi. org/

10. 1007/ s10880- 017- 9510-2

McCabe, R., Sterno, I., Priebe, S., Barnes, R., & Byng, R. (2017).

How do healthcare professionals interview patients to assess suicide risk? BMC Psychiatry, 17(1), 1–10. https:// doi. org/ 10. 1186/

s12888- 017- 1212-7

McClay, M. M., O’Connor, S. S., Groh, B. N., Baudino, M., Venanzi, L., Shields, A., & Nicolson, S. (2018). Denial of suicide attempt among hospitalized survivors of a self-inflicted gunshot wound.

Psychiatric Services, 69(6), 657–663. https:// doi. org/ 10. 1176/

appi. ps. 20170 0130

McDermott, R. C., Smith, P. N., Borgogna, N., Booth, N., Granato, S.,

& Sevig, T. D. (2018). College students’ conformity to masculine role norms and help-seeking intentions for suicidal thoughts. Psy- chology of Men & Masculinity, 19(3), 340–351. https:// doi. org/

10. 1037/ men00 00107

Mirick, R. G., Berkowitz, L., Bridger, J., & McCauley, J. (2020).

Changes in practice following a continuing education training on suicide assessment and intervention: Training participants’

perspectives. Journal of Teaching in Social Work, 40(1), 31–47.

https:// doi. org/ 10. 1080/ 08841 233. 2019. 16856 24

Montague, K. T., Cassidy, R. R., & Liles, R. G. (2016). Counselor training in suicide assessment, prevention, and management. VIS- TAS Online, 65, 1–15.

Parker, P. E., Stepp, R. J., & Snyder, Q. C. (2001). Morbidity among airline pilots: the AMAS experience. Aviation Medicine Advisory Service. Aviation, Space, Environtal Medicine, 72(9), 816–820.

PettyJohn, M. E., Tseng, C.-F., & Blow, A. J. (2020). Therapeutic util- ity of discussing therapist/client intersectionality in treatment:

When and how? Family Process, 59(2), 313–327. https:// doi. org/

10. 1111/ famp. 12471

Rasmussen, M. L., Hjelmeland, H., & Dieserud, G. (2018). Barriers toward help-seeking among young men prior to suicide. Death studies, 42(2), 96–103. https:// doi. org/ 10. 1080/ 07481 187. 2017.

13284 68

Roush, J. F., Brown, S. L., Jahn, D. R., Mitchell, S. M., Taylor, N.

J., Quinnett, P., & Ries, R. (2018). Mental health professionals’

suicide risk assessment and management practices. Crisis, 39(1), 55–64. https:// doi. org/ 10. 1027/ 0227- 5910/ a0004 78

Shea, S. C. (2017). Uncovering a patient’s hidden method of choice for suicide: Insights from the Chronological Assessment of Suicide Events (CASE Approach). Psychiatric Annals, 47(8), 421–427.

https:// doi. org/ 10. 3928/ 00485 713- 20170 708- 01

Sheehan, L., Oexle, N., Armas, S. A., Wan, H. T., Bushman, M., Glover, L., & Lewy, S. A. (2019). Benefits and risks of suicide disclosure. Social Science & Medicine, 223, 16–23. https:// doi.

org/ 10. 1016/j. socsc imed. 2019. 01. 023

Stene-Larsen, K., & Reneflot, A. (2019). Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scandinavian Journal of Public Health, 47(1), 9–17. https:// doi. org/ 10. 1177/ 14034 94817 746274 Stuart, H. (2017). Mental illness stigma expressed by police to police.

The Israel Journal of Psychiatry and Related Sciences, 54(1), 18–23.

Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53(4), 440–448. https:// doi.

org/ 10. 1037// 0003- 066x. 53.4. 440

Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E., Jr. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575–600. https:// doi.

org/ 10. 1037/ a0018 697

Wakai, S., Schilling, E. A., Aseltine, R. H., Blair, E. W., Bourbeau, J., Duarte, A., & Welsh, A. (2020). Suicide prevention skills,

(10)

confidence and training: Results from the Zero Suicide Work- force Survey of behavioral health care professionals. SAGE Open Medicine, 8, 2050312120933152. https:// doi. org/ 10. 1177/ 20503 12120 933152

Wolf, K. M., Zoucha, R., McFarland, M., Salman, K., Dagne, A., &

Hashi, N. (2016). Somali immigrant perceptions of mental health and illness: An ethnonursing study. Journal of Transcultural Nurs- ing, 27(4), 349–358. https:// doi. org/ 10. 1177/ 10436 59614 550487

Yu, S., Kowitt, S. D., Fisher, E. B., & Li, G. (2018). Mental health in China: Stigma, family obligations, and the potential of peer support. Community Mental Health Journal, 54(6), 757–764. https://

doi. org/ 10. 1007/ s10597- 017- 0182-z

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