September, 2020. For several years, the Journal has featured content on suicide risk assessment and management, including a particularly valuable series of publications by Hal Wortzel and colleagues in the journal’s Law and Psychiatry column. These articles are available for a time-limited period with free access to full-text, posted on the journal’s homepage, in a collection titled “Treatment of the Suicidal Patient.”1 The material covers a wide range of content, including a model for therapeutic risk management, using structured interviews, stratifying risk by severity, safety planning, suicide risk formulation, a therapeutic risk management model, a chain analysis of suicidal ideation and behavior, and much more.
In clinical psychiatry, suicide assessment (ie, assessing for the risk of self-directed violence) is a top priority, perhaps the highest priority in our work, demanding every ounce of our knowledge and skill. And we know a great deal about risk factors for suicide, the result of intensive research over decades. But how many times have we heard, or have we said, that even though we know many statistically significant risk factors that have emerged from studies of large populations, we cannot be as sure as we’d like to be about the degree of risk of the individual patient who sits across from us in the consultation room. Digesting the rich wisdom in this collection, however, equips us to have heightened confidence that we can, at least most of the time, help guide the high-risk patient back from the brink.
I sometimes use a simplistic “Four S” concept regarding suicide: it is (1) Serious, (2) Stigmatized, (3) Scary, and (4) Solution, mainly to emphasize the fourth, that for many suicidal patients, death by suicide may seem like the only solution left to “turn off” unbearable suffering. Understanding this helps us refrain from the natural, caring, and human impulse to advise the patient to look on the bright side—because, as different as things may look to us, for the patient there just may not be any “bright side.” At the Menninger Clinic, we teach a strategy developed by Jobes and colleagues2 called the Collaborative Assessment and Management of Suicidality (CAMS), that encourages the clinician to “mentalize” and imagine being in the patient’s shoes in the moment. This validation—that suicide may seem inviting because it is the only solution left—can be a first step to help the patient feel understood.
In our COVID-19 world today, stress is at an all-time high and suicide rates are rising. People are losing their jobs, families are being evicted, people are fighting to get health care, and people are dying from the pandemic. In such circumstances, suicide (self-directed violence) is not the only worry—another is the potential for other-directed violence to erupt. Just as there are those at risk for suicide, others are at risk to become violent toward others, and this is another high-stakes concern that we don’t know enough about how to predict and how to prevent. In the July issue of the Journal, Wortzel and colleagues tackled the topic of “Therapeutic Risk Management for Violence: Clinical Risk Assessment,” and in this issue of the journal, they continue this focus with “Therapeutic Risk Management for Violence: Augmenting Clinical Risk Assessment with Structured Instruments.” In these times of social unrest, these words of wisdom and advice are welcome indeed. Readers can access these publications with free access to full-text for a limited time on the journal’s homepage, in another collection titled “Therapeutic Risk Management for Violence.”3
JOHN M. OLDHAM, MD
1. Collection of columns and articles on “Treatment of the Suicidal Patient”. Available at: https://journals.lww.com/practicalpsychiatry/pages/collectiondetails.aspx?TopicalCollectionId=3
. Accessed September 1, 2020.
2. Jobes D. Managing Suicidal Risk: A Collaborative Approach, 2nd ed. New York, NY: Guilford Press; 2016.
3. Collection of columns and articles on “Therapeutic Risk Management for Violence”. Available at: https://journals.lww.com/practicalpsychiatry/pages/collectiondetails.aspx?TopicalCollectionId=15
. Accessed September 3, 2020.