Staff Voices - Review of "The Assessment and Management of Suicidality"
Assessing and treating suicidal clients is one of the most anxiety-producing professional challenges faced by mental health providers. Doing so conjures up fears about competence, risk management, and the time demands that come with working with suicidal clients. While there is a wealth of literature to guide mental health professionals in this area, it can be difficult to find a resource that covers theory, assessment, and treatment in a concise form. Recently, I discovered a resource that should be a part of every mental health provider’s library: The Assessment and Management of Suicidality, by M. David Rudd. Dr. Rudd is a renowned scholar in the area of suicidality and is a prolific researcher and author. However, his straightforward and simply written pocket resource for this challenging work may be one of his greatest contributions.
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In the introduction of the book, Dr. Rudd puts forth his goals for the book: to emphasize the importance of being precise and specific when discussing suicide with patients and others; to emphasize the importance of using an empirically-grounded framework to guide suicide assessment; to point out the need to be direct and predictable with the suicidal client; and to highlight the need for thorough, clear, and consistent documentation.
By focusing on the importance of specific terminology in Chapter 1, Dr. Rudd clearly demonstrates through the use of scenarios that people define suicidal behavior differently. In other words, what one mental health professional would call “suicidal” may not be interpreted as such by the next mental health professional. However, he proposes definitions that clarify terms for the reader, and he makes the excellent point that certain factors (e.g., intent, both subjective and objective) speak to whether a behavior is suicidal or not. Dr. Rudd recommends using specific terminology in talking with clients, other professionals, and in documentation.
Chapter 2 summarizes Dr. Rudd’s Fluid Vulnerability Theory (FVT) which he has written about extensively in other publications. In summation, FVT considers an individual’s chronic, or baseline level of risk and his/her acute level of risk to determine overall risk for suicide. He proposes that all individuals have a baseline level of risk for suicide that is based on a personal history of unchanging variables such as family and personal history of suicide attempts. On the other hand, acute risk is comprised of precipitants to suicidality, the nature of the client’s suicidal thinking, and his/her symptomatic presentation. If a person has a history of two or more suicide attempts, then that person is considered to be chronically at moderate risk of suicide at least, with their overall level of risk possibly being higher depending on their acute risk factors. On other hand, single attempters and those who have not attempted suicide do not display chronic risk and their overall risk for suicide is based on their acute risk factors in the absence of chronic risk.
In Chapter 3, Dr. Rudd discusses the importance of the therapy relationship and encourages the reader to do some self-exploration about his/her own personal theory about why people die by suicide and other questions that influence how one might work therapeutically with a suicidal client. Next, he reviews critical points to remember when building a therapy relationship, and he actually gives some examples of how one might word questions and reflective statements. These are extremely helpful and may be useful for therapists who are less experienced or particularly anxious about working with suicidal individuals.
Chapters 4 and 5 return to assessment and offer specific recommendations about how to assess the nature of suicidal thinking, other risk factors, and protective factors. Chapter 4 contains a diagram which condenses valuable information about understanding the client’s suicidal thoughts into a flowchart-like tool. Once the reader has read the corresponding sections in the body of the text, this flowchart is a nice quick reference for proceeding into questions about the nature of suicidal ideation. Chapter 5 also has a reference table which clearly and succinctly describes particular areas of risk such as predispositions to suicidality, precipitants to suicidality, different aspects of symptom presentation, hopelessness, and protective factors.
In Chapters 6 and 7, the reader will learn how to use the information presented in earlier chapters to formulate an overall risk category. Again, Dr. Rudd has put a wealth of information into a table to help guide the process of categorizing a client’s acute level of risk. In addition, there is also a complete suicide risk assessment form which contains the information needed to assess and document the client’s risk level. This form includes risk factors, protective factors, a mental status exam, and a risk rating based on acute and chronic risk. It also includes a space for diagnosis and plan. This suicide assessment form would suffice as the clinical note in some cases. A very important part of Chapter 7 is Dr. Rudd’s discussion of the utility of no-suicide contracts and his suggestion that the Commitment to Treatment Statement be used instead. This is described as an agreement between the client and the provider that states the roles, expectations, and responsibilities of both the client and the therapist. The Crisis Response Plan is also introduced in this section. The Crisis Response Plan outlines steps that the client will take if he/she becomes suicidal, and specific examples of coping behaviors are provided. A final important part of Chapter 7 is a table that outlines appropriate responses by the therapist for various risk levels.
In the next two chapters, Dr. Rudd discusses documentation and consultation. He writes about documentation from the standpoint of “open” and “closed” risk markers. Open markers are areas of risk that have been identified by the therapist and these become “closed” once they are addressed in therapy. Dr. Rudd points out that malpractice claims are often based on the presence of unaddressed open markers for suicide risk. In reference to consultation, the reader learns about the importance of staying connected as a mental health provider. In other words, Dr. Rudd clearly points out that consulting with our colleagues is critical. He also notes that consultation should be documented.
The final chapter in The Assessment and Management of Suicidality is a reminder of the reality that there are no assessments or treatments that will completely assure mental health professionals that their clients will not die by suicide. Accepting a limited amount of control in this regard is a necessary part of working with this population. However, while we cannot completely control the outcome when working with suicidal clients, by using an empirically-grounded process in assessment and treatment we ensure that we are giving them the best that the field has to offer.
In summary, Dr. Rudd’s The Assessment and Management of Suicidality offers a wealth of information about working with suicidal clients—information that will be valuable for both junior and senior mental health professionals. Drawing from his own work and additional important information from the suicide-related literature, he has created a skillfully written and organized publication that is a “must read” and “must own” for mental health professionals.
Assessing and treating suicidal clients is one of the most anxiety-producing professional challenges faced by mental health providers. Doing so conjures up fears about competence, risk management, and the time demands that come with working with suicidal clients. While there is a wealth of literature to guide mental health professionals in this area, it can be difficult to find a resource that covers theory, assessment, and treatment in a concise form. Recently, I discovered a resource that should be a part of every mental health provider’s library: The Assessment and Management of Suicidality, by M. David Rudd. Dr. Rudd is a renowned scholar in the area of suicidality and is a prolific researcher and author. However, his straightforward and simply written pocket resource for this challenging work may be one of his greatest contributions.
Read more "Staff Voices" entries
Visit the CDP's Blog
In the introduction of the book, Dr. Rudd puts forth his goals for the book: to emphasize the importance of being precise and specific when discussing suicide with patients and others; to emphasize the importance of using an empirically-grounded framework to guide suicide assessment; to point out the need to be direct and predictable with the suicidal client; and to highlight the need for thorough, clear, and consistent documentation.
By focusing on the importance of specific terminology in Chapter 1, Dr. Rudd clearly demonstrates through the use of scenarios that people define suicidal behavior differently. In other words, what one mental health professional would call “suicidal” may not be interpreted as such by the next mental health professional. However, he proposes definitions that clarify terms for the reader, and he makes the excellent point that certain factors (e.g., intent, both subjective and objective) speak to whether a behavior is suicidal or not. Dr. Rudd recommends using specific terminology in talking with clients, other professionals, and in documentation.
Chapter 2 summarizes Dr. Rudd’s Fluid Vulnerability Theory (FVT) which he has written about extensively in other publications. In summation, FVT considers an individual’s chronic, or baseline level of risk and his/her acute level of risk to determine overall risk for suicide. He proposes that all individuals have a baseline level of risk for suicide that is based on a personal history of unchanging variables such as family and personal history of suicide attempts. On the other hand, acute risk is comprised of precipitants to suicidality, the nature of the client’s suicidal thinking, and his/her symptomatic presentation. If a person has a history of two or more suicide attempts, then that person is considered to be chronically at moderate risk of suicide at least, with their overall level of risk possibly being higher depending on their acute risk factors. On other hand, single attempters and those who have not attempted suicide do not display chronic risk and their overall risk for suicide is based on their acute risk factors in the absence of chronic risk.
In Chapter 3, Dr. Rudd discusses the importance of the therapy relationship and encourages the reader to do some self-exploration about his/her own personal theory about why people die by suicide and other questions that influence how one might work therapeutically with a suicidal client. Next, he reviews critical points to remember when building a therapy relationship, and he actually gives some examples of how one might word questions and reflective statements. These are extremely helpful and may be useful for therapists who are less experienced or particularly anxious about working with suicidal individuals.
Chapters 4 and 5 return to assessment and offer specific recommendations about how to assess the nature of suicidal thinking, other risk factors, and protective factors. Chapter 4 contains a diagram which condenses valuable information about understanding the client’s suicidal thoughts into a flowchart-like tool. Once the reader has read the corresponding sections in the body of the text, this flowchart is a nice quick reference for proceeding into questions about the nature of suicidal ideation. Chapter 5 also has a reference table which clearly and succinctly describes particular areas of risk such as predispositions to suicidality, precipitants to suicidality, different aspects of symptom presentation, hopelessness, and protective factors.
In Chapters 6 and 7, the reader will learn how to use the information presented in earlier chapters to formulate an overall risk category. Again, Dr. Rudd has put a wealth of information into a table to help guide the process of categorizing a client’s acute level of risk. In addition, there is also a complete suicide risk assessment form which contains the information needed to assess and document the client’s risk level. This form includes risk factors, protective factors, a mental status exam, and a risk rating based on acute and chronic risk. It also includes a space for diagnosis and plan. This suicide assessment form would suffice as the clinical note in some cases. A very important part of Chapter 7 is Dr. Rudd’s discussion of the utility of no-suicide contracts and his suggestion that the Commitment to Treatment Statement be used instead. This is described as an agreement between the client and the provider that states the roles, expectations, and responsibilities of both the client and the therapist. The Crisis Response Plan is also introduced in this section. The Crisis Response Plan outlines steps that the client will take if he/she becomes suicidal, and specific examples of coping behaviors are provided. A final important part of Chapter 7 is a table that outlines appropriate responses by the therapist for various risk levels.
In the next two chapters, Dr. Rudd discusses documentation and consultation. He writes about documentation from the standpoint of “open” and “closed” risk markers. Open markers are areas of risk that have been identified by the therapist and these become “closed” once they are addressed in therapy. Dr. Rudd points out that malpractice claims are often based on the presence of unaddressed open markers for suicide risk. In reference to consultation, the reader learns about the importance of staying connected as a mental health provider. In other words, Dr. Rudd clearly points out that consulting with our colleagues is critical. He also notes that consultation should be documented.
The final chapter in The Assessment and Management of Suicidality is a reminder of the reality that there are no assessments or treatments that will completely assure mental health professionals that their clients will not die by suicide. Accepting a limited amount of control in this regard is a necessary part of working with this population. However, while we cannot completely control the outcome when working with suicidal clients, by using an empirically-grounded process in assessment and treatment we ensure that we are giving them the best that the field has to offer.
In summary, Dr. Rudd’s The Assessment and Management of Suicidality offers a wealth of information about working with suicidal clients—information that will be valuable for both junior and senior mental health professionals. Drawing from his own work and additional important information from the suicide-related literature, he has created a skillfully written and organized publication that is a “must read” and “must own” for mental health professionals.