Suicide Risk Assessment: Examining Influences on Social Workers' Professional Judgment

Background:  Every year, approximately 1 million people die from suicide, resulting in a worldwide mortality rate of 16 per 100,000, or one death every 40 seconds (World Health Organization, 2011). High risk populations include those who suffer from a major mental disorder; youth in special education, child welfare and juvenile justice settings (Chavira, Accurso, Garland, & Hough, 2010; Farand, Chagnon, Renaud, & Rivard, 2004; Pilowsky & Li-Tzy, 2006); women who are victims of violence (Garcia-Moreno, Jensen, Ellsberg, Heise, & Watts, 2005; Haarr, 2010); and individuals facing extreme social conditions (Canada, 2005; Harris & Barraclough, 1997; Kessler, Berglund, Borges, Nock, & Wang, 2005; Kirmayer et al., 2007; World Health Organization, 2007).  Given these high risk populations, it is not surprising that a US national survey revealed that 92% of social workers had worked with suicidal clients (Feldman & Freedenthal, 2006). 

Professional judgment in complex clinical situations such as the assessment of suicide risk encompasses a multifaceted cognitive understanding of the substantive issues, technical expertise, and emotional awareness (Epstein & Siegal, 2008; Eraut, 1994; Schon, 1987). Experts reflect on previous similar experiences and selectively apply this knowledge to the problem at hand (Cheetham & Chivers, 2005; Ruch, 2002), actively using critical thinking and tacit knowledge to find creative solutions (Cheetham & Chivers, 1998; Eraut, 2002; Schon, 1983, 1987). However, clinical experience may allow not only for the acquisition of knowledge, but may also include exposures that lead to physiological stress, trauma response and burnout that can potentially negatively influence decision-making.  This experimental design study investigated the degree to which the previous work-related experiences of workers and their pre-existing emotional state influence professional judgment regarding acute risk in patients presenting with suicidal ideation. 

 Methods:  Thirty-seven MSW students and 34 experience clinicians assessed two simulated patients, portrayed by standardized patients presenting with suicidal ideation, an older chronically depressed woman, and an adolescent in crisis.  Through random assignment, half the participants interviewed one client first and the other half interviewed the other client first to control for order effects.  After indicating their professional judgment regarding the need for hospitalization, participants completed three standardized suicide risk assessment measures. Pre-test measures addressed previous work experiences and current levels of post-traumatic stress, generalized stress and burnout in participants.

Results: This study revealed significant variations in clinical judgments of social workers assessing suicide risk.  While scores on standardized risk assessment measures were the strongest predictor of judgments regarding the need for hospitalization in order to ensure the safety of patients, other influences included clinician age and levels of post-traumatic stress symptoms. 

Implications:  Social workers and organizations that employ them should be aware of possible individual influences on professional judgments related to suicide risk. Social work education programs should ensure that training and supervision includes sensitizing students to their decision-making processes in this critical area of mental health practice.