As has been the case in other areas of clinical practice, there has been a movement over the last several years to identify core competencies and establish practice guidelines in suicide risk assessment and management. The American Psychiatric Association (2003) published practice guidelines for suicide risk assessment and, more recently, the American Association of Suicidology (AAS) teamed with the Suicide Prevention Resource Center (a federally funded entity, www.sprc.org) to identify and disseminate core competencies in suicide risk assessment (2005). Both documents emphasize that all clinicians, regardless of practice setting or focus, need to have basic skills in suicide risk assessment and management. More often than not, the general topic of suicide risk assessment and management is integrated into other courses in the clinical training curriculum such as introduction to psychotherapy or crisis intervention. Seldom does suicide risk take center stage in a stand alone course, although the literature could easily .ll an entire semester, not to mention much needed supervised clinical exposure with at-risk patients. As both the APA guidelines and the AAS/SPRC core competencies illustrate, the assessment and management of suicide risk demands a complex blend of skills and abilities, all requiring speci.c attention, training and supervised experience. In short, the identi.ed core competencies and guidelines identify basic, entry-level skills for clinical practitioners.
It’s more complex than simply knowing what questions to ask a patient. Most, if not all psychologists are aware of appropriate questions in cases that present suicide risk. As the AAS/ SPRC core competencies demonstrate, however, creating a context for accurate risk assessment is among the most challenging of clinical tasks. It’s essential that the environment created and managed by the clinician provide the patient a sense of safety and comfort that encourages he or she to disclose and discuss in detail feelings permeated by ambivalence. In contrast to other clinical problems, ambivalence is the operative word in suicide risk assessment and management. Accordingly, very minor aspects of the patient-clinician interaction can nudge ambivalence in one direction or the other, encouraging or discouraging a patient to be forthcoming about suicide plans, access to method, preparation or rehearsal and intent. As a critical element, all clinicians need to recognize and understand the importance of the therapeutic alliance and the in.uence of clinician attitudes and approach. Much of this emphasis originated with work done by the Aeschi group (www.aeschiconference.unibe.ch/), noting the vital importance of a patient-centered approach to the assessment and treatment of suicidality.
In today’s environment of limited inpatient and residential treatment alternatives, it is simply impossible to avoid encountering suicidal patients in outpatient practice. The literature bears out the impossibility of screening suicidal patients out of a targeted clinical practice (e.g. Rudd, 2006; Rudd, Joiner, Rajab, 2004). The core competencies identi.ed include the following categories: attitudes and approach to risk assessment, theoretical models for understanding suicide, collecting accurate assessment information, formulating risk, developing a plan for treatment, managing ongoing care, and understanding legal and regulatory issues related to suicide risk assessment and management. The training program developed is a full-day workshop and, obviously, the current context will not allow a detailed discussion of each competency, but we would like to highlight a few of the more salient points here and some emerging empirical work. The link for the complete curriculum is: www.sprc.org/featured_resources/trainingandevents/training/clincomp.asp.
Although far from perfect, the core competency curriculum provides a clear foundation for entry-level training, establishing boundaries within which training faculty and programs can navigate. It makes it clear what are essential elements of training, eliminating debate and competing interpretations of the literature. There is plenty of room to expand and emphasize different clinical skills depending on the particular interests and expertise of faculty. Regardless, though, basic training in the core competencies helps ensure that clinicians are well prepared for one of the most challenging and anxiety-provoking tasks in clinical practice. Also of importance, the current structure of the curriculum lends itself to ef.cient and effective integration into existing training models, recognizing that training programs are already challenged to .nd room for all areas mandated by APA. Let me encourage you to visit the web sites listed and become familiar with the core competencies in the assessment and management of suicide risk.
American Association of Suicidology (2005). Assessing and managing suicide risk: Core competencies for mental health professionals. Washington DC: AAS.
American Psychiatric Association (2003). Practice guideline for the assessment and treatment of patients with suicidal behaviors. Washington DC: American Psychiatric Press.
Rudd, M.D. (2006). The assessment and management of suicidality. Sarasota, FL: Professional Resource Press.
Rudd, M.D., Joiner, T.E., & Rajab, H. (2004). Treating suicidal behavior. New York: Guilford.