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

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.

Six strategies to help reluctant patients to disclose their suicidal thoughts.

“…For example, a patient may admit to suicidal thoughts and plans but falsely deny the possession of a firearm (Richards et al, 2021). Other patients may downplay past statements about suicide by, for example, falsely claiming that they were only joking, or claiming that others overreacted by taking their suicidal comments out of context (Nagdimon et al, 2021).…”

Effect of enhanced informed consent on veteran hesitancy to disclose suicidal ideation and related risk factors

“…Lack of disclosure of suicidality results in missed opportunities for clinical intervention (Nagdimon et al., 2021). Research suggests that approximately half of patients experiencing SI had denied it in previous interviews (Obegi, 2021), and SI denial is even greater among veterans with approximately three‐quarters of suicide decedents having denied SI at their last healthcare visit (Denneson et al., 2010).…”