Managing Suicidal Risk: A Collaborative Approach

David Jobes, a leader in the field of suicidology, has provided the reader with a psychological approach to the suicidal patient. There are many useful aspects of Managing Suicidal Risk, including an emphasis on the importance of risk assessment that takes into account the patient's perception of his or her own psychological pain, important symptoms such as agitation and hopelessness, and specific elements of a suicide inquiry. Jobes has developed a suicide assessment form, entitled the Suicide Status Form, that has multiple categories that can assist a clinician in organizing an approach to suicide assessment. The categories include a patient's self-rating, clinician inquiries into multiple clinical areas, a mental status exam, a traditional multiaxial diagnoses, and assessment of overall risk.

Jobes states that the application of this form will lead to a determination of suicide risk. Furthermore, the application of this form is based upon the premise of suicidality as the core problem. The reader needs to understand that this focus has limitations. It is known that suicide occurs across the entire spectrum of psychiatric diagnoses. In fact, 90% to 95 % of patients who commit suicide have a major psychiatric syndrome. Suicidality can occur in the context of an acute depressive illness, a schizophrenic episode, or the end stage of alcoholism. The approach to suicidality among these patients very much requires an inclusion of a biological approach. I would certainly agree that a unitary approach is unwise in the treatment of a patient who is experiencing suicidal impulses. However, the exclusion of the biological treatment of a depressive disorder is unwise.

In the preface, Jobes accurately portrays the current status of suicide assessment in terms of the limitations of suicide scales and the inability to predict suicide. Jobes's approach and characterization of the suicidal patient appears to have its application in the treatment of suicidality as a component of personality disorders. The therapeutic alliance is a critical aspect of the management of these patients. Working with the patients on their coping styles and helping them understand what suicide means to them can be a critical asset in their treatment. Although Jobes gives important admonitions about the application of suicide contracts, his approach very much embodies positive aspects of a suicide contract, that is, the necessity of building a strong therapeutic alliance. Having patients take some responsibility for their suicidality is not only important but may be necessary in the management of the chronically suicidal patient.

In addition, he offers useful interviewing strategies, such as having the patient sit by the interviewer's side. This empathetic approach has been discussed previously by Leston Havens ( 1 ). Of course, this type of suggestion would need to take into account character styles of certain patients who may find physical closeness uncomfortable. The risk management section is one of the stronger parts of the book, in terms of reminding the clinician of the need to document risk on a timely and regular basis. Clinicians can learn a lot about understanding suicide risk by reading this book. Whether or not they choose to use a form, it has to be their own choice. A form is not recommended by this reviewer, but rather a structured approach, which one can glean from Jobes's work. Furthermore, clinicians need to understand that 60% to 70% of persons who commit suicide have an affective disorder that is best treated by a combination of medication and psychotherapy.