by Douglas Flemons and Leonard M. Gralnik
W. W. Norton, 2013
Review by Beth Cholette, Ph.D. on Nov 19th 2013
Like the authors of this book, I am a mental health professional (a psychologist) working in a student counseling center. Also similar to the authors, I am frequently confronted with student clients who present with thoughts of suicide, and determining whether these thoughts might result in an actual suicide attempt is a regular part of my job.
I was eager to draw on the expertise of authors Douglas Flemons, a family therapist, and Leonard M. Gralnik, a psychiatrist. Their relational approach to suicide assessment (RSA) focuses on assessing lethality not as a separate component of the clinical interview, but rather as part of an overall collaborative conversation between the therapist and the client. The authors are influenced by solutions-oriented work in that they view their approach not only as a means to assess for suicide but also as a strategy for weaving in possibility-focused language, thus identifying both sources of hope and potential resources throughout the process.
The authors cite a 2005 study (p. 9) which lists over 75 risk factors for suicide. Based on their own research, Flemons and Gralnik identify 21 what they called "risk descriptors," or classifiers that they have found to contribute to an individual's suicidality. They further group these 24 topics into the following broad categories:
1. Disruptions and Demands--includes stressors which can lead to a sense of hopelessness
2. Suffering--mental/physical symptoms which may contribute to feelings of desperation
3. Troubling Behaviors--may include social isolation, increased substance use, or self-harm
4. Desperation--includes feelings of hopelessness and intent/willingness to act
Chapter 3, "Risks and Resources," details how the authors inquire about these factors during the relational suicide assessment. To illustrate, they incorporate use of direct quotes, brief session excerpts, and more lengthy case scenarios. Generally, I find these type of hands-on examples to be extremely helpful, but unfortunately, the formatting felt choppy and confusing here. The awkward presentation of the various "Resources (for example, empathically connecting, managing anxiety) make them extremely easy to overlook--which is regrettable given the merit of this information.
The subsequent chapter, "Safety," was more straightforward and thus more readable. Although client examples were still utilized, these were confined to specific sections. However, one of the things that stood out for me the most from this chapter was the importance of therapists relying on intuition or "gut" feelings. Of course, the authors emphasize that it takes years of clinical experience to develop this sense, but they maintain that this professional judgment is an invaluable part of deciding whether a safety plan is even needed for a given client. Specific guidelines are also given for how to construct safety plans with clients who do need them.
The final chapter is "RSA in Action," or a complete review of the method using a single client example (somewhat helpful but also a bit tedious, at least for a more experienced therapist). The Appendix, "The Backpocket RSA," basically includes the same Risks/Resources charts that have been used throughout the book. Personally, I found these charts (which are formatted as four separated four-part graphs) cluttered and confusing rather than helpful.
In the end, Relational Suicide Assessment was somewhat of a disappointment. Although I am a psychologist with almost twenty years of experience in college mental health, I still expected to benefit from the expertise of the authors. And while Flemons and Gralnik did provide some effective conceptualizations, I did not find the overall format of their book to be practical. Perhaps this manual would be most useful as a training tool for newer therapists, as a beginning clinician might have more patience for distilling the valuable information from this work.
© 2013 Beth Cholette
Beth Cholette, Ph.D., is a clinical psychologist who provides psychotherapy to college students.