FACTORS CONTRIBUTING TO THE DECISION MAKING PROCESS FOR SOCIAL
WORKERS WHEN WORKING WITH YOUTH EXPRESSING SUICIDAL
IDEATION
A Project
Presented to the faculty of the Division of Social Work
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
by
Kimberly Alison Utz
SPRING
2014
FACTORS CONTRIBUTING TO THE DECISION MAKING PROCESS FOR SOCIAL
WORKERS WHEN WORKING WITH YOUTH EXPRESSING SUICIDAL
IDEATION
A Project
by
Kimberly Alison Utz
Approved by:
____________________________________, Committee Chair
Dr. Francis Yuen, DSW, Professor
____________________________________
Date
ii
Student: Kimberly Alison Utz
I certify that this student has met the requirements for format contained in the University
format manual, and that this project is suitable for shelving in the Library and credit is to
be awarded for the project.
__________________________, Graduate Coordinator
Dale Russell, Ed.D., LCSW
Division of Social Work
iii
___________________
Date
Abstract
of
FACTORS CONTRIBUTING TO THE DECISION MAKING PROCESS FOR SOCIAL
WORKERS WHEN WORKING WITH YOUTH EXPRESSING SUICIDAL
IDEATION
by
Kimberly Alison Utz
This study aims to identify the frequency of utilization of various decision making factors
for social workers when working with youth expressing suicidal ideation. Review of
current literature reveals the following factors were found to be important to the decision
making process: ethics, agency policy, assessment tools, colleague support, professional
experience, and clinical insights, specifically the therapeutic relationship with the youth
and intuition. The purpose of the study was to measure the significance of these factors
in relation to the decision making process. A questionnaire survey was distributed to
school social workers and interns as well as mental health professionals at a community
health center. The researcher had hypothesized that the utilization of past experience and
intuition would be identified as most important to the decision making process. Findings
indicated that these factors were identified as important in individual questionnaire items
iv
but not in an overall analysis of most important factors. Results also revealed that the
utilization of the therapeutic relationship and collaboration with colleagues to be
important to the decision making process. These findings demonstrate a need for further
training in the formation of the therapeutic relationship and promotion of positive
working environments, in which colleagues feel comfortable seeking support from each
other. Another finding of note, was a lack of importance placed on the involvement of
law enforcement in the decision making process, which marks an area for further research
into the professional relationship between social workers and law enforcement.
____________________________________, Committee Chair
Dr. Francis Yuen, DSW, Professor
____________________________________
Date
v
TABLE OF CONTENTS
Page
List of Tables…………………………………………………………………………… ix
List of Figures…………………………………………………………………………… x
Chapter
1.
STATEMENT OF THE PROBLEM………………………………………….... 1
Background of the Problem…………………………………………….. 2
Statement of the Research Problem…………………………………….. 5
Purpose of the Study……………………………………………………. 5
Theoretical Framework…………………………………………………. 6
Normative Decision Theory…………………………………….. 6
Rational Comprehensive Model……………….……………….. 7
Intuitive Decision Theory………………………………………. 8
Definition of Terms……………………………………………………... 9
Assumptions…………………………………………………………….. 10
2. REVIEW OF THE LITERATURE…………………………………………….. 11
Suicide and the Mental Health Profession……………………………… 11
Decision Making Factors in Social Work………………………………. 13
Ethical Decision Making………………………………………... 14
Agency Policies and Assessment Tools………………………… 16
vi
Colleague Support………………………………………………. 21
Professional Experience………………………………………… 25
Clinical Insights…………………….…………………………... 26
Summary……………………………………………………………….. 29
3. METHODOLOGY…………………………………………………………….. 31
Study Design………………………………………………………….... 31
Sampling Procedures……….…………………………………………... 32
Data Collection Procedures…………………………………………….. 33
Instrument………………………………………………………………. 33
Data Analysis…………………………………………………………… 34
Protection for Human Subjects…………………………………………. 35
4. STUDY FINDINGS……………………………………………………………. 37
Overall Findings………………………………………………………… 38
Specific Findings……………………………………………………….. 39
Professional Experience and Intuition………………………….. 39
Colleague Support, Therapeutic Relationship, and Past
Experience………………………………………………………. 45
Qualitative Data Findings………………………………………………. 47
Summary………………………………………………………………... 48
5. DISCUSSION………………………………………………………………….. 50
Summary of Study…………………………………………………….... 50
vii
Analysis of Findings Related to the Researcher’s Hypotheses…. 51
Past Experience, Colleague Support, and Therapeutic
Relationship…………….………………...…………………….. 53
Analysis of Qualitative Findings……………………………….. 55
Implications…………………………………………………………….. 55
Recommendations……………………………………………………… 57
Limitations……………………………………………………………… 58
Conclusion……………………………………………………………… 59
Appendix A. Cover Letter ………………...………........………………………. 60
Appendix B. Decision Making Study When Working With Youth Expressing
Suicidal Ideation ….………………………….…………………... 61
References………………………………………………………………………. 65
viii
LIST OF TABLES
Page
1.
Important variables contributing to decision making between those with
less/more than 7.5 years of experience ……………………….…….………….. 46
ix
LIST OF FIGURES
Page
1. Frequency distribution of importance of past experience….………….....……... 40
2. Frequency distribution of importance of intuition…………….….………...…... 41
3. Distribution of variables selected as most important from vignette……..……....42
4. Distribution of variables selected as most important from vignette 2 …..............43
x
1
Chapter 1
STATEMENT OF THE PROBLEM
Suicide and suicidal ideation are very tangible issues that occur with clients in the
social work profession. It is rare for a social worker not to have worked with a client
who expresses suicidal ideation. Suicidal ideation can be unsettling and daunting. There
are so many factors that contribute to the client’s emotional, psychological, physical,
social, and economic state. Is the client serious about taking his/her own life? Does the
client have a plan? Does the client have the means to commit suicide? Are there
protective factors in the client’s life? Does the client have a support system? As a social
worker, making a decision about what to do when a client presents with suicidal ideation
is no easy task. There are numerous paths to take with the client’s survival as the
ultimate goal, but how does a social worker choose which is the correct route to take that
will be most beneficial for a specific client?
The inspiration for this study came from experience as a social work intern at the
Youth and Family Resource Center (YFRC) of a middle school in the Sacramento City
Unified School District (SCUSD). Multiple Screen for Youth Suicide Risk (SYSR)
(Thompson, Herting, Randell, & Eggert, 2004) assessments were performed at this site,
which is the requirement of SCUSD when a student presents with suicidal ideation. The
assessment measured the level of suicide risk and depressive and protective factors. Each
student that presented with suicidal ideation elicited a strong response from the school
2
social workers. The social workers perseverated on the assessment and behaviors of the
students because the assessment does not give direct guidelines for actions to take once it
has been completed. They needed validation that they had made the right decision after
doing the assessment. Decision making was left to the discretion of the social workers to
determine what actions would be most beneficial for the student at that time. It is here
that my interest was sparked to discover what factors play an important role in the
decision making process of social workers when working with suicidal youth. At the
school, law enforcement, the student’s parents or guardians and the results of the SYSR
(Thompson et al., 2004) were contributing factors into decision making, but I also was
interested in the influence of other factors, such as professional judgment, intuition and
ethics. Thus this study was created to identify and measure the frequency of factors
contributing to decision making factors of social workers when working with suicidal
youth.
Background of the Problem
According to the Center for Disease Control (2014), suicide is the third most
common cause of death for youth between the ages of 10-24. Suicide attempts are more
common during adolescence than in any other period of life. Suicidal ideation is rarely
demonstrated before puberty. The incidence of fatal suicide increases steadily through
adolescence and peaks in the early to mid-20’s, while nonfatal suicide attempts peak at
around age 16. Fatal suicide therefore is more of an adult act, but suicidal ideation begins
to appear majorly during adolescence (Shaffer, 2004). A majority (52.5 percent) of social
workers have come into contact with clients with nonfatal and/or fatal suicidal behavior
3
(Jacobson, Ting, Sanders, & Harrington, 2004). The school setting is an arena where
many social workers come into contact with youth with suicidal behavior because of the
unparalleled access to at-risk youth. Mental health services are received in schools more
than in any other sector, including psychiatric hospitals and residential facilities (Rones
& Hoagwood, 2000). In a study of 399 school social workers done by Singer and Slovak
(2011), 88 percent reported working with suicidal youth in the past two years. Further
support of the commonality of suicidal ideation and the unique access of service
providers to youth expressing suicidal ideation will be reviewed in Chapter 2 of this
document.
SCUSD has recognized the commonality of suicidality in youth and requires the
utilization of the SYSR when a youth presents with suicidal ideation. The SYSR is an
evidence-based, intermediate assessment to evaluate a student’s current risk of suicide. It
is also used to ascertain if a referral needs to be made for an in-depth assessment. It
evaluates direct suicide risk factors, while gathering information about related factors,
such as depression, and protective factors. The SYSR takes about 20-30 minutes and
involves a series of 22 questions read aloud with which the student responds by giving a
number (0-6) corresponding to a color-coded scale. The questions are grouped into the
following categories: Related Suicide Risk Factors, Direct Suicide Risk Behaviors,
Related Suicide Risk Factors and Protective Factors. A post interview process is
completed by the interviewer summarizing and ranking the suicide risk factors of the
student. Although the intent of this assessment is to guide social workers in making
decisions, as was stated earlier, decision making is left to the social worker’s discretion
4
when working with these students. Risk level is determined by the assessment, not direct
guidelines for action. Social workers are left to utilize other factors to determine the
course of action to protect the life of the student that is contemplating suicide (Thompson
et al., 2004).
The Adolescent Services program at CommuniCare Health Centers also provides
services to youth expressing suicidal ideation. CommuniCare Health Centers is a
Federally Qualified Health Center providing health services to those in need in Yolo
County at 5 community clinic sites and outreach programs. Services offered at
CommuniCare Health Centers include primary medical and dental health care, behavioral
health services, substance abuse treatment, health education, and support services. The
youth receiving mental health services from the Adolescent Services program are often
referred by probation and schools. A significant number of youth in this program have
had past issues with substance abuse, especially alcohol and marijuana. These
depressants amplify the possibility for these youth to have suicidal ideations.
The Adolescent Services program at CommuniCare follows the policy in the
Adolescent services: Welcome packet and policy and procedure manual (n.d.), which
states “If a counselor believes a client is actively suicidal, that counselor will need to do
everything possible to protect that client from harming themselves.” This policy is vague
and does not provide action steps for the clinician when a youth is presenting with
suicidal ideation. Therefore the clinicians must rely on other factors to make decisions
on what the best route of service would be for the youth.
5
Statement of the Research Problem
As illustrated by the policies of SCUSD and Communicare decision making when
working with youth expressing suicidal ideation rests upon implementation of various
factors not outlined by the agency or guided by the assessment tool. It is very common to
come into contact with youth expressing suicidal ideation in this field, but what factors
contribute to the decision making process of social workers when working with suicidal
youth? Numerous elements contribute to the course of action that will be taken by a
social worker when this situation presents. From a review of relevant literature, which
will be further explained later in this document, the following factors were found to be
important to the decision making process: ethics, agency policy, assessment tools,
colleague support, professional experience, and clinical insights, specifically the
therapeutic relationship with the youth and intuition. From experience at SCUSD and
conversations with social workers and other clinicians working with youth, it is
hypothesized that professional experience and intuition are the factors most utilized in the
decision making process. The assessment tool is necessary to determine risk but not
sufficient because social workers must still utilize other factors to make decisions.
Purpose of the Study
The purpose of this study is to identify the frequency of specific factors that
contribute to the decision making process of social workers when working with youth
presenting with suicidal ideation. Extensive review of literature and consultation with
service providers in school and agency settings help limit the focus of this study to the
following three factors: organizational policy and procedures, clinical suicide assessment
6
tools, and professional judgment. The study will assess the extent to which these factors
contribute to the decision making process when social workers are working with suicidal
youth. Study findings will contribute to the development of the knowledge base and
effective practice models for social workers in serving this high risk youth population.
Theoretical Framework
The theoretical framework for this study follows three theories/models of decision
making: normative decision theory, the rational comprehensive model, and intuitive
decision theory.
Normative Decision Theory
Normative decision theory involves a rational process of gathering information to
analyze the problem from different angles. The consequences of each alternative are
assessed and the alternative which best meets current needs is chosen (Simon, 1983).
This approach compensates for human fallibility by providing a way to break complex
problems down into smaller parts and linking choices to norms existing outside of
decision problems to ensure rationally and internally consistent decisions. This model
reflects the decision maker’s values, perspective, and understanding of the situation. It
provides a mathematical structure in which the smaller components that the problem has
been broken down into can be manipulated allowing the individual to process the impact
of different alternatives. Due to the fact that the model reflects the individual’s personal
understanding of the problem, this model of decision making provokes increased insight
into the problem. This model is particularly strong in the analysis and recommendation
of alternative pathways to decision making (Brennan, 1995).
7
In relation to decision making of social workers when working with youth
presenting with suicidal ideation, this model reinforces that there are numerous factors
that play into the decision making process. The utilization of these factors in making a
decision allows the social worker to analyze the alternative actions that could be taken to
best help the youth. Depending on the characteristics of the specific case, the social
worker assesses the severity of the situation at hand and decides among different
alternatives, such as contacting law enforcement or the youth’s parents or guardians,
reaching out to colleagues for collaboration or relying on personal intuition. From the
social worker’s perspective on the situation, the alternatives of the decision are analyzed
and the best alternative is chosen.
Rational Comprehensive Model
The rational comprehensive model also analyzes the alternatives in decision
making. The advantages and disadvantages of each alternative are addressed and ranked
in order of importance. The alternative which is assessed as the most advantageous to
goal attainment is chosen (Hostovsky, 2006). The rational comprehensive model
objectively focuses more in depth on the problem, goals, values and objectives of the
situation. It takes into account a wide variety of variables related to the problem from
which the best solution can be determined and ranks them after all information has been
considered.
For social workers working with youth expressing suicidal ideation, this model
would be an ideal form of decision making because it creates a complete image of the
situation at hand. Just as the alternatives are analyzed in the normative model, they are
8
also ranked in this form of decision making, which mirrors the process of social workers
as they decide the actions to take when working with the youth at hand. Unfortunately,
the meticulousness of this model can be overly complex, time-consuming, and often not
conducive to the situations and immediacy of the instances when a youth is presenting
with suicidal ideation. The model also assumes that all the details of the problem and
alternatives are easily known by the social worker, when this is often far from the reality
of the situation.
Intuitive Decision Theory
Intuitive decision theory more appropriately describes decision making in social
work because decisions are made on an impromptu basis with inconclusive or partial
information. People choose what seems to offer the best solution to their problem and
such solutions are tried out one at a time (Forkby & Hojer, 2011). Decision making in
social work is often limited by ambiguity, incomplete and contradictory information.
This theory best encapsulates social work decision making because it is realistic in its
requirement of information in accordance with the resources available and immediacy of
the situation at hand. It also demonstrates the manner of many social work decisions
where multiple alternatives will be tried, but one at a time.
When social workers are working with youth expressing suicidal ideation, it is
often a crisis situation where decisions must be made quickly but effectively. A
significant portion of the information related to the problem may be messing, yet
decisions and actions must be taken one at a time to ensure safety of the youth. This
theory also acknowledges that appropriate resources may not be available when making
9
decisions. For example, this deficiency of resources can occur when law enforcement is
contacted, but does not immediately respond or does not deem that the youth is truly a
danger to themselves. The social worker is still required to make a decision in this
situation that represents an alternative to his/her first choice of action.
Definition of Terms
Decision making: Decision making refers to the choices professional social workers have
to make when a youth presents with suicidal ideation. These decisions may involve
organizational policy and procedures, clinical suicide assessment tools, and professional
judgment.
Suicidal ideation: thoughts, feelings, and behaviors related to dying by taking one’s own
life. Suicidal ideation may range from fleeting to intrusive thoughts, planning and
gathering materials in preparation for suicide, and self-injury with suicidal intent.
Ethics: values in action (Yuen, personal communication, April 3, 2014) i.e. National
Association of Social Workers Code of Ethics, guide to the everyday professional
conduct of social workers.
Agency Policy: principles and procedures put in place by an organization, agency, or
school to be followed by all employees as the standard with which to accomplish
everyday professional tasks.
Assessment Tools: evaluative implements used to measure a specific characteristic or
quality. In this study, assessment tools refer to implements that measure the level of risk
of suicidality in youth.
10
Colleague Support: the collaboration of social workers with co-workers and supervisors
in the same working environment in an effort to obtain advice, guidance, or reassurance.
Professional Experience: the knowledge obtained from the cumulative years of
experience in a relevant field of social work.
Therapeutic Relationship: the professional connection and rapport between social
workers and their clients.
Intuition: the instinctive, guttural understanding or feeling that a person has about a
situation without conscious reasoning.
Assumptions
This study assumes that rates of suicidality in Sacramento and Yolo County
mirrors the national trend. The assumption is that suicidality among youth in this area is
as big of an issue as the data for the national trend suggests. This also implies that
working with youth expressing suicidal ideation is a main task of mental health
professionals and school social workers in this area. It assumes that social workers
encounter youth expressing suicidal ideation as frequently as those in other areas of the
country.
11
Chapter 2
REVIEW OF THE LITERATURE
Decision making in social work when working with a youth expressing suicidal
ideation is a complex and difficult process that is often met with insufficient information,
time constraints and procedural pressure. Suicidal ideation among youth is first
described in this review to acknowledge its prevalence and the likelihood for social
workers to come across this challenge in their practice. Decision making factors are then
discussed as they relate to the research problem of this study. From reviewing current
literature and practice experience the following factors were deduced as important to the
decision making process: ethical decision making; agency policies and assessment tools;
colleague support; professional experience; and clinical insights, including intuition and
therapeutic relationships.
Suicide and the Mental Health Profession
According to the Center for Disease Control (2014), suicide is the third most
common cause of death for youth between the ages of 10-24. Approximately 4,600
young lives are lost as the result of suicide each year. According to the CDC’s most
recent figures from 2010, 8.5 percent of youth (ages 1-18) deaths were suicides, with 49.5
percent of those deaths caused by suffocation (National Center for Injury Prevention and
Control, 2010). Among youth, the number of suicides is greater for males than females.
12
Males are more likely to die from suicide than females, with 81% of reported suicides in
2011 being males (Center for Disease Control and Prevention, 2014).
More young people survive suicide attempts than actually die. Females are more
likely to attempt suicide with an estimated 10.1 percent of girls having attempted suicide
before the age of 19 compared to 3.8 percent of boys (Lewinsohn, Rhode & Seeley
1996). A nationwide survey performed by the CDC of high school students in both
private and public schools found that 16% of students reported seriously considering
suicide, 13% had created a plan and 8% reported actually attempting. This study also
found that Hispanic youth were more likely to report attempting suicide than their peers.
Approximately 157,000 youth age 10-24 is seen by Emergency Departments across the
country for self-inflicted injuries (Center for Disease Control and Prevention, 2014).
Suicide attempts are more common during adolescence than in any other period of life.
Suicidal ideation is rarely demonstrated before puberty. The incidence of fatal suicide
increases steadily through adolescence and peaks in the early to mid-20’s, while nonfatal
suicide attempts peak at around age 16. Fatal suicide therefore is more of an adult act,
but suicidal ideation begins to appear majorly during adolescence (Shaffer, 2004).
A majority (52.5 percent) of social workers have come into contact with clients
with nonfatal and/or fatal suicidal behavior (Jacobson, Ting, Sanders, & Harrington,
2004). The school setting is an arena where many social workers come into contact with
youth with suicidal behavior because of the unparalleled access to at-risk youth. Mental
health services are received in schools more than in any other sector, including
psychiatric hospitals and residential facilities (Rones & Hoagwood, 2000). In a study of
13
399 school social workers done by Singer and Slovak (2011), 88 percent reported
working with suicidal youth in the past two years. Research demonstrates that school
staff members from multiple disciplines have received minimal professional training in
suicide prevention, intervention and postvention (Christianson & Everall, 2008; Reis &
Cornell, 2008). Effectiveness and confidence in work with suicidal youth is impacted by
the quality and amount of training received by school social workers (Debski, Spadafore,
Jacob, Poole, & Hixson, 2007; Reis & Cornell, 2008; Singer & Slovak 2011).
Decision Making Factors in Social Work
In social work, decisions involving youth with suicidal ideation are often made in
less than ideal circumstances. Information can be insufficient, unreliable, conflicting or
missing, but ultimately very influential decisions must be made in a stressful
organizational and political context that can immensely impact the lives of clients. Gray
and Gibbons (2007) provide a comprehensive depiction of the reality of decision making:
In reality, problem solving is never a structured linear process of decision making;
people are not always available for consultation and may not always give good
advice; clients often do not understand the situation they are in; there is always
the potential for unintended or unforeseen outcomes; and it may not always be
possible to get all sides of the story. In reality, all we can do is work with the
incomplete information we have and do the best that we can. Although we are
expected to justify our actions drawing on available knowledge and research
(evidence), including agency policy and relevant ethical codes, ultimately ethical
decisions are subjective and relational and depend very much on the situations in
14
which they occur. They are complex. There are no right answers, only choices,
and we are responsible for, and have to be able to live with, the decision or
choices we make. (p. 225)
Although this is an accurate description of the realities that social workers face, there are
factors of decision making that can be relied on for support and guidance through this
powerful and unpredictable challenge.
Ethical Decision Making
The social work Code of Ethics presents a moral guideline under which social
workers practice. When a youth presents with suicidal ideation, often an ethical dilemma
can arise by creating a conflict between two principles within the Code of Ethics: respect
for the client’s autonomy and self-determination; and the duty to prevent harm. Social
workers agree to respect clients’ autonomy and self-determination when practicing with
clients. Autonomy refers to the right of the clients to make their own decisions and
choices within their lives. The Code of Ethics also prescribes that social workers prevent
harm when practicing with clients (NASW Code of Ethics). When it comes to suicidal
ideation, it is often difficult to adhere to both of these principles. The social worker is
forced to make a decision about which principle to follow, which will hopefully ensure
the client’s vitality.
Rothman (2005) presents a case study that depicts such an ethical dilemma. Two
clients are presented. Client A is a 19-year-old African American male, who is
employed, intends to go to college and has support within his community. He has
recently broken up with his girlfriend and is threatening to kill himself. The social
15
worker assesses his suicidal risk and determines that the threat is designed to elicit his exgirlfriend’s sympathy rather than end his life. But, noting his prospects and supports, the
social worker chooses to call the police and have the client hospitalized. Client B is a 40
year-old female who has experienced numerous physical, psychological and sexual
traumas throughout her life. She suffers from severe depression, panic attacks, bulimia
and self-mutilation. She has a history of multiple suicide attempts, hospitalizations, and
treatments. Most recently, she was found unconscious in a park. She states that she
wants to be allowed to die. The social worker, assessing her history, decides to try to use
motivational strategies but does not detain her from committing suicide. Client B
commits suicide. In this scenario, the social worker violates Client A’s autonomy, but
not Client B’s autonomy. The social worker has made a decision to analyze and assess
risk for each client on an individual basis. “Because both the obligation to selfdetermination and to the prevention of harm are given similar weight in the Code of
Ethics…and ‘harm’ is not clearly defined, absolutist and relativist positions would lead
the worker to different courses of action” (Rothman, 2005, p. 149). The author goes on
to discuss the ambiguity surrounding the definition of harm in society, which influences
the social worker to use his/her personal values to determine action in this case
(Rothman, 2005).
Discrimination is also examined. Discrimination can be seen with both clients in
the case scenario. Client A experiences discrimination by the restriction of his selfdetermination when the worker decides to detain him to prevent harm. Client B
experiences discrimination in the worker’s judgment of her quality of life with her past
16
history of trauma and severe mental illness. Again, both clients are assessed on an
individual basis which variably affects their autonomy and prevention of harm (Rothman,
2005).
Linzer (1999) furthers the analysis of this ethical dilemma. The author presents a
case of a 78 year-old woman, living in a nursing home, has refused to eat or drink and has
approached the social worker in assisting her in obtaining extra sleeping pills to commit
suicide. Linzer (1999) discusses the dilemma between client autonomy and harm. He
speaks of how client self-determination can be circumscribed when it may be harmful to
the client or others or when a mental illness such as depression diminishes mental
capacity to make decisions. Preservation of life or nonmaleficence is also questionable in
this case, because of the lack of clear definition of harm. Again harm holds an
ambiguous meaning. To the patient, harm is continuing to live when she desires to die.
To the social worker, harm is the effect of the suicide on the patient and others
surrounding the situation. Linzer (1999) works with this dilemma by concluding that the
social worker’s best plan of action is to assist the client in making an informed decision
by utilizing his/her knowledge and skill in counseling, family dynamics, grief and issues
of control and autonomy. The social worker must make sure that the client is aware of
the consequences of her decision for herself and others but also must be prepared to
accept the choice of the client (Linzer, 1999).
Agency Policies and Assessment Tools
Another factor related to decision making involves adherence to agency policies
and procedures as well as the utilization of required assessment tools. Studies have
17
demonstrated that the best intervention when a youth is expressing suicidal ideation is a
risk assessment. Risk assessments are utilized by agencies to standardize service
interventions and provide some predictability. Items determined to be included in a risk
assessment are developed through empirical research that demonstrates a statistical link
between the items and the circumstances of the case. Suggested areas to be addressed in
an assessment include: presence of suicidal thoughts, plans and behaviors; presence of
psychiatric symptoms associated with suicidality, such as impulsivity and hopelessness;
prior suicidal behavior; current and past mental health treatment history; family history;
current stressors; and strengths and protective factors (Stokes & Schmidt 2012). Davis
and Brock (2002) also recommend assessing the youth’s conception of death and the
response that suicidal ideation elicits from the youth’s support network. Risk is thus
determined by considering a multitude of factors including the presence of a plan,
availability of means and availability and accessibility of social support. The data
obtained from the risk assessment is used to determine preventative intervention tactics
(Granello & Granello, 2007).
In an exploratory study on suicide intervention strategies, researchers examined
the interventions that took place after the administration of risk assessments with youth in
three school districts in Colorado. The study determined that the interventions varied
depending on where the youth’s suicidal ideation rated on a continuum from low risk to
high risk. For youth that were at low risk, each youth was made to sign a No Harm or
Safety Contract and safety requirements and resources were shared with the student and
parents. At the moderate level of risk, parents were asked to come to the school to
18
participate in safety planning, youth were asked to sign a No Harm or Safety Contract,
and if it was deemed appropriate the youth was transported, either immediately or on
delay, to the emergency room, an inpatient facility or an outpatient facility. Those youth
that were at high risk for suicide were transported immediately to the emergency room,
an inpatient facility or an outpatient facility. Procedures were in place at each school
district for follow-up and monitoring depending on the level of risk expressed (CrepeauHobson, 2013).
Shaffer (2004) discusses the decisions of a clinician when working with an
adolescent who has made a nonfatal suicide attempt. The author analyzes the factors that
can contribute to a clinician’s determination to hospitalize the adolescent, keep the
adolescent under observation or discharge the adolescent to outpatient care. These
factors require an analysis of the events, cognitions and emotions that led to the suicidal
behavior and that may still be present. In deciding to hospitalize the adolescent, the
clinician should assess both the features of the suicide attempt and the adolescent‘s
mental state. The severity of the features of the attempt should be determined through
analyzing the motives of the specific action made by the adolescent, such as ingestion
and cutting, to end his/her life. Cutting is often seen as a less severe, but if the
adolescent’s motive in cutting was to cause fatality, then the clinician must take this into
account in making decisions regarding treatment. Other indications of severity include
presence of preparatory activities, such as writing a note, making a will or giving away
possessions; amount of effort into getting materials for the suicide attempt; and whether
any active steps were made to avoid discovery, shown by where and when the attempt
19
took place. The most common features present when an adolescent commits suicide are
restlessness, agitation and activation. The author also notes the importance of getting a
third party’s perspective, often a family member, to establish a history of behavior and to
determine environment and protective factors. Finally, the author evaluates the value of a
safety contract made with the youth. A safety contract conveys to the adolescent that
they are being taken seriously and gives an opportunity to the clinician to analyze and
rehearse with the adolescent how he/she will respond if they again encounter the stressors
that contributed to the suicide attempt. Conversely, studies of individuals that have
made multiple attempts indicate that nearly a third had previously signed safety contracts
(Shaffer, 2004).
In a study of the acceptability of intervention techniques, Eckert, Miller, DuPaul
and Riley-Tillman (2003) presented three intervention techniques to a group of 211
school psychologists. The three intervention techniques included: curriculum-based
programs presented to students; in-service presentations to school staff; and school-wide,
students’ self-report screening programs. The curriculum-based programs and staff inservice training were rated as significantly more acceptable than the screening program.
The screening program was also deemed to be significantly more intrusive than the other
two interventions. The results from this study indicate that staff needs more training of
the beneficial effectiveness and directness of the school-wide screening programs in the
assessment of suicidal risk. Studies of safety contracts also revealed the need for more
training in managing of suicidal students to alleviate the stress of the situation (Davidson
20
& Range, 2001; Debski, Spadafore, Jacob, Poole, & Hixson; Reis & Cornell, 2008;
Singer & Slovak, 2011).
Standardized assessment tools and agency policies can be beneficial to
consistency in decision making (Corby, 2003). On the other hand, assessing risk is
difficult and complex with no guarantee that the assessment will be accurate (Granello &
Granello 2007). There is also no evidence to assure that acting on the data obtained from
the assessment will actually reduce the risk for suicide (Large, Ryan & Nielssen, 2011).
The assessment tools themselves can promote error for a litany of reasons. Studies have
identified that assessment tools often tend to focus on a specific event or incident in the
client’s life which in turn neglects to identify chronic problems that are the root of the
client’s struggle (Daniel, 2000; Platt, 2006). Both Cradock (2004) and Holland (1999)
focus on the tendency of assessment tools to negate the complexity of clients’ lives,
which is an ineffective way to properly assess clients’ situations.
Parada, Barnoff and Coleman (2007) performed a study to analyze the use of
professional agency within the agency-imposed limitations and restrictions of child
welfare workers. Professional agency is defined by the researchers as the ability of child
welfare workers to utilize their social work knowledge, skills and clinical judgment in
making decisions in their everyday practice. Research findings revealed that although
many agency protocols and restrictions were in place, child welfare workers were still
able to utilize their professional agency to make appropriate clinical decisions. Decisions
were commonly made through the utilization of both the assessment tools and
professional. Participants in the study shared that assessment tools were often used after
21
the social worker had already made a decision regarding the case. They saw the tool as a
guideline to articulate and clarify the issues and concerns that needed to be address and
utilized the tool to corroborate the decisions they had used their professional agency to
already determine. Participants also spoke to the limitations of assessment tools. The
majority of the time, child welfare workers would go beyond the questions of the
assessment to gather a more complete picture of what is happening for the family. The
assessment tools were limited to an individualistic focus that excludes social, political,
economic and cultural contexts which would give a deeper analysis of the struggles faced
by the family (Parada, Barnoff & Coleman 2007).
Colleague Support
Another factor that research has determined to be important to the decision
making process in social work is collaboration with colleagues, supervisors and other
social workers. A study of child welfare workers done by Torbjörn Forkby and Staffan
Höjer (2011) in Sweden found that decision making regarding placing teens in residential
care was a collective process that involved negotiations between different entities with a
coordinating social worker in the middle. The study involved 29 participants in 8 focus
groups about the decision making process. The participants held a variety of positions
within the child welfare field. Two questions were posed at the start of each focus group:
“what discussions are currently taking place in your organization about the placement of
young people and the purchase of care, and what factors are influential in deciding where
to place any particular teenager?” (Forkby & Höjer, 2011, p.163). The study found that
decisions were made in a collaborative group setting that relied on collective memory of
22
the members of the group. Collective memory, as defined by the authors, is a
collaboration of anecdotes of experience from each member that first comes from the
individual but then becomes a shared asset of the group for future decision making. The
social workers in the study saw collective memory as a repository of numerous years of
experience that could be drawn from to understand the present. In this specific study
collective memory contained facts about each residential treatment facility, the
enrollment process, knowledge of staff behavior with the children, and anecdotes of
children who had gone to different facilities. The social workers with more experience
were seen as important members in facilitating and mediating the use of the collective
memory in decision making (Forkby & Höjer, 2011).
A study of 22 critical care nurses done by Marshall, West and Aitken (2013)
determined that nurses preferentially collaborated with colleagues for information to
assist in making decisions in uncertain situations. The study utilized concurrent verbal
protocols, retrospective probing and focus groups to gather information. It was
determined that the nurses placed greater emphasis on the person they sought information
from rather than the information itself. Key features contributed to who they chose to
collaborate with. These features include: experience, clinical role, trust and
approachability. Combined, the authors deduced that these features contribute to the
clinical credibility of the individual who information is sought from. Nurses’ statements
were analyzed to reveal that clinical experience equated with knowledge. They would
deliberately seek out someone with similar or superior experience when faced with
uncertainty. Clinical role was another determining factor in who to ask for support.
23
Nurses related that they would seek out a supervisor or someone with superior experience
than themselves. Again knowledge was equated with years of experience, but also
supervisory role. Trustworthiness was another factor in identifying who to approach for
information. Trust was seen in two ways. The first coincided with the length of
experience held by an individual. Trust was also seen when an individual maintained a
similar style of practice. Finally, approachability was a factor in seeking support. This
meant that nurses would only ask for help from those perceived as friendly or open to
supporting others. In this study, experience and clinical role were the most important
factors in choosing a colleague for collaboration (Marshall, West, & Aitken, 2013).
A symposium done in Australia focusing on risk assessment and management in
clinical mental health practice also determined the importance of collaboration in the
decision making process. The symposium consisted of 120 members of the University of
South Australia’s Mental Health and Substance Abuse Research Group and the South
Australian Department of Health’s Acute Unit Matters. Participants were all front-line
mental health clinicians and practitioners. The day was based upon two themes: risk
assessment with less than desirable outcomes and risk assessments with positive
outcomes. One of the practice recommendations that arose from the symposium involved
the use of collaboration between mental health social workers, psychiatrists, nurses and
doctors in determination of treatment. Risk management and assessment can often
engender strong emotional reactions and anxiety in the clinician. The clinician takes on a
sense of responsibility for a potentially suicidal client and the therapeutic relationship
becomes one of rescue. Consultation and support can assist in rational decision making
24
rather than emotive impulsive decisions in an effort to reduce the clinician’s personal
distress. Collaboration with colleagues acts as a rationalizing tool so response to a client
crisis benefits the client (Deuter, et al., 2013).
Ingram (2013) discusses emotions, decision making and supervision. The author
establishes that emotions and decision making often maintain an uneasy balance because
of the conception of rationality in decision making. Lazarus and Lazarus (1994) state
that rationality is commonly defined as being concerned with the maximum potential of
success with the minimum potential for loss with the focus on logic and factual evidence.
This definition negates other factors of decision making such as equality, kindness,
fairness and justice. It also demonstrates that the rationally right thing to do can be very
different from one individual to the next depending on the meaning of success. Studies
of coping behaviors for mental health social workers working with clients with suicidal
behavior have shown that sources of support, such as supervisors, administrators, family
and friends, are also significant in reducing secondary traumatic stress (Kleepsies &
Dettmer, 2000; Ting, Jacobson,& Sanders, 2008).
Ingram (2013) cites multiple studies that recognize the importance of
collaboration with colleagues in the decision making process through supervision with an
experienced clinician. A clinician’s emotional response to a client is a natural human
process that requires the clinician to actively reflect about his/her practice to create
awareness and acknowledgement for these emotions and feelings. Ingram (2013) argues
that supervision is a key time to gain support from a senior colleague and practitioner not
only in the functional areas of practice but also as a way to critically reflect on the
25
content of the practice. Hawkins and Shohet (2000) view supervision as allowing social
workers to step back from their practice as to not internalize all of their emotional
responses.
Professional Experience
Objective knowledge can only go so far in social work; rather secondary forms of
experiential knowledge utilize the social worker’s experience that has been transformed
into cultural, practical and practice knowledge. This personal experience base enables
social workers to filter a situation through their own thinking process that is influenced
by past experience. From here, social workers are able to determine relevant information,
infer patterns of meaning and validate the individual’s experience in the world (Stokes &
Schmidt, 2012).
Parada, Barnoff and Coleman (2007) discuss the use of professional experience
in the decision making as one of the key findings of a study done on decision making
with child welfare workers. The utilization of assessment tools and adherence to strict
protocols are the required procedures for decision making in this field. The researchers
found that workers who were new to the field were more likely to stringently abide by the
protocols than those who had more professional experience. The new workers would
follow the protocols with such reverence for fear of making an error. Those with more
experience reported that they had developed their own style of working within the system
which involved the use of practice wisdom that was more attuned to the complexities of
making decisions.
26
A study of child protection workers in British Colombia analyzed the factors
utilized in decision making in child welfare cases. The study used a factorial survey with
case vignettes in which 327 participants assessed the vignettes for risk, service provision
and importance of client contact. The study determined that there is not a clear causal
relationship between the decisions made and the source of knowledge from which the
decisions were made. The research suggests that although standardized assessment tools
are often required to make decisions, the workers made decisions based on their own
experiences and character. Decisions were not purely made on the utilization of an
objective assessment tool but rather with the integration of that empirical knowledge with
both procedural and experiential knowledge as well (Stokes & Schmidt, 2012).
Clinical Insights
Clinical insights are gained through practice experience. The clinical insights
about intuition and therapeutic relationships are discussed here.
In the study done by Parada, Barnoff and Coleman (2007), child welfare workers
associated the use of intuition in decision making with the amount of experience held by
a worker. Participants recounted a feeling that they would obtain when working with a
family. This was also referenced as a guttural feeling that the worker would develop
from interviewing the family and observing their interaction. Participants agreed that the
more experience a worker had, the faster he/she could make intuitive decisions.
Although these decisions are made following the personal feeling of the worker, they are
made with the cognizance that they have to be able to be rationalized in the framework of
agency guidelines.
27
Intuition can be defined in a multitude of ways depending on the nature of its
utilization. In social work, intuition can be seen as the absence of deliberation. It is a
relatively quick way to decide making sense of limited information through the
recognition of patterns and filling in gaps. O’Sullivan (1999) classifies professional
intuition in social work decision making, as a skill which is not taught but rather acquired
through experience. Intuition can also be described as an implicit store of knowledge
used to interpret the client’s unique situation and make decisions that are in accordance
with the organizational and societal context (Zeira & Rosen, 2000).
Ambady (2010) identifies intuition in thin slice judgments. The author defines
thin slice judgments as “accurate impressions that predict certain ecologically valid
outcomes from brief observations of behavior” (Ambady, 2010, p. 271). These
judgments have been proven to be remarkably accurate despite the short experience of
behavior and potentially distracted conditions. Intuition is identified as the primary
reason that these judgments are accurate because of the nonverbal manner of
communication through which they are made. In this sense, intuition relies on tacit,
implicit knowledge that make verbal explanations and reasoning unnecessary.
Furthermore, these judgments are more accurate when they are made without
deliberation. The involvement of cognitive processes in decision making
overcomplicates that which was already intuitively known (Ambady, 2010).
The power of the therapeutic relationship with a client has also been determined
by research as beneficial to the decision making process. Many studies confirm the
importance of the therapeutic relationship with a client as an effective practice tool to
28
gain client trust in future interventions. Lee and Ayon (2004) emphasize the role of a
positive client relationship as the primary prerequisite for assessment and intervention
with youth, especially involuntary and resistant clients. In their study, they found a
significant correlation between the therapeutic relationship and improvements in the
youth’s physical and emotional care, discipline and parental coping. Platt (2008) further
supports the value of the therapeutic relationship. Despite the continuous direction
toward procedural and standardized social work, skilled workers will continue to be
successful because of their ability to evoke positive rapport with clients. In a study done
by Stokes and Schmidt (2012) of child welfare workers, the therapeutic relationship was
determined to be integral in decision making as evidenced by the importance social
workers delineated to home visits and client contact when making decisions about the
child’s placement. The researchers argue for more training in foundational relationship
building skills in social work school curriculums and agencies to ensure that these skills
are integrated into future decision making.
Participatory practice with both youth and parents can also be an effective means
of decision making. The basis of participation is solid when it begins with trust in the
therapeutic relationship between the youth and the social worker (Gallagher, Smith,
Hardy & Wilkinson, 2011). Too often, studies have found that youth experience constant
changes in social workers, leaving them to be distrustful of the helping powers that the
relationship could entail. The frequent changes can cause resentment in youth, who also
reported workers being rarely available, slow to return phone calls, and lacking in follow
through on requests and promises (Cashmore, 2002). Ideally, a long term, continuous
29
relationship will foster a therapeutic relationship built on trust and efficacy that will
benefit the implementation of future interventions. Through the increased bond of the
therapeutic relationship, youth can be involved in the decision making process to identify
his/her unique needs (Gallagher, Smith, Hardy & Wilkinson, 2011).
Summary
Working with clients expressing suicidal ideation is a prevalent challenge for
social workers. Suicidal ideation is most common in adolescence while fatal suicide
mostly occurs with adults over the age of 24. The commonality of a social worker to
encounter a client expressing suicidal ideation is most likely during the adolescent period.
The school setting is an arena where many social workers come into contact with youth
with suicidal behavior because of the unparalleled access to at-risk youth. Mental health
services are received in schools more than in any other sector, including psychiatric
hospitals and residential facilities (Rones & Hoagwood, 2000). In a study of 399 school
social workers done by Singer and Slovak (2011), 88 percent reported working with
youth with suicidal ideation in the past two years. Mental health professionals who work
with youth in community programs are also commonly confronted with the suicidal
ideation from their clients, because they share the commonality with school social
workers of the age group that most often presents the challenge of this issue.
Most research that has been done on working with clients who are expressing
suicidal ideation has focused on the utilization of assessment tools required by agencies.
This research has failed to recognize other important factors that play into the decision
making process. Among these are ethical considerations, the utilization of professional
30
experience and clinical insight, as well as support sought from colleagues. When a social
worker is faced with working with a youth expressing suicidal ideation, there is a lack of
a comprehensive study which describes the factors that play an important role in the
decision making process.
31
Chapter 3
METHODOLOGY
The purpose of this study is to identify the frequency of specific factors that
contribute to the decision making process of social workers when working with suicidal
youth. Extensive review of literature and consultation with service providers in school
and agency settings helped limit the focus of this study to the following three factors:
organizational policy and procedures, clinical suicide assessment tools, and professional
judgment. The study assessed the extent to which these factors contribute to the decision
making process when social workers are working with suicidal youth. Study findings
contribute to the development of the knowledge base and effective practice models for
social workers in serving this high risk youth population.
This chapter will outline the methodology of this research study in terms of study
design, sampling procedures, data collection procedures, instruments, data analysis, and
protection of human subjects.
Study Design
This is a cross-sectional questionnaire survey of human service practitioners in a
school district and community health center in Northern California. A 38-item
questionnaire consisting of close and open-ended questions was distributed to social
workers, marriage and family therapists, and masters and bachelor’s level interns. The
questionnaire aimed at identifying the frequency with which the factors of organizational
32
policy and procedures, clinical suicide assessment tools, and professional judgment
contribute to their decision making process when working with youth expressing suicidal
ideation.
Sampling Procedures
Purposive sampling was used in this study. Participants were selected on the criteria
that they all currently work with the targeted population of youth expressing suicidal
ideation in a professional setting. The sample will consist of three subdivisions. The
first subdivision (Sample 1) consists of school social workers and coordinators of the
Youth and Family Resource Centers (YFRC’s) in the Sacramento City Unified School
District (SCUSD). Participants from Sample 1 have been trained in the utilization and
analysis of the Screen for Youth Suicide Risk (Thompson et al, 2004) assessment tool as
the protocol for the SCUSD when a student presents with suicidal ideation. The second
subdivision (Sample 2) consists of social workers and marriage and family therapists in
the Adolescent Services Department at Communicare Health Centers in Yolo County.
Participants in Sample 2 follow the policy in the Adolescent Services: Welcome packet
and policy and procedure manual (n.d.), which states “If a counselor believes a client is
actively suicidal, that counselor will need to do everything possible to protect that client
from harming themselves.” The third subdivision (Sample 3) is comprised of interns in
SCUSD. The interns are students at California State University working on their
bachelor’s or master’s degree in social work or a degree in marriage and family therapy.
These subdivisions were chosen to allow for comparisons to be made between
professionals and interns at a school district and those at a community agency.
33
Data Collection Procedures
Data was collected in the form of a questionnaire distributed by the researcher.
Data was collected from Sample 1 during the November 2013 monthly meeting of school
social workers at the SCUSD office. Questionnaires were distributed to the social
workers at this time to give to the Youth and Family Resource Center coordinators and
then returned to the researcher. Data was collected from Sample 2 during a November
2013 weekly staff meeting of social workers in the Adolescent Services Program at
Communicare Health Center. Data was collected from the interns at SCUSD at a January
2014 monthly training attended by all interns at the SCUSD office.
Instrument
Based on the review of the literature and guided by the purpose of the study, a
questionnaire was created. The 38-item questionnaire (Appendix B) consists of closeended questions on demographics, social work experience and 2 case vignettes. The case
vignettes describe two fictional youth presenting with suicidal ideation. The researcher
included specific behavioral and psychosocial details in each vignette to indicate severity
of suicidal risk. In the first vignette, the fictional youth displays common symptoms of
depression, including loss of sleep and appetite, and a decrease in grooming habits. This
youth is also experiencing peer conflict at school and has made comments to her brother
about preparing for her death. The second vignette includes more psychosocial factors
related to the fictional youth, including substance abuse, poverty, an incarcerated parent,
and potential gang involvement.
34
The vignettes are followed by ten close-ended questions aimed at assessing the
importance decision making factors, such as a suicide risk assessment, intuition and
practice experience, when working with the youth described in the vignette. Two openended questions ask participants to provide any additional decision making factors they
would use when working with the youth in the vignette.
The instrument used in this study holds content validity. The construction of the
instrument was guided by the purpose for this study and informed by relevant literature
on suicidality and decision making. The knowledge behind the construction of the
instrument developed out of the most current view and understanding of the topic from
the literature, as well as consultation with professionals working with youth. Reliability
was not established for this tool since it was only distributed once for the purpose of this
study.
Data Analysis
A total of 42 questionnaires were collected. All questionnaires collected were
complete and therefore 42 questionnaires were used for data analysis. The Statistical
Package for Social Science (SPSS) was used for data analysis. Basic descriptive statistics
were used to provide detailed descriptions of the respondents, including gender,
ethnicity/race, education, current agency, and years of professional experience with
youth. Inferential statistics including chi square and independent t-tests were used to
determine whether there were significant differences among various variables.
Specifically, independent t-tests were utilized to determine significant differences
between years of professional experience of respondents with the level of importance
35
indicated for each factor of the decision making process identified on the questionnaire.
One-sample (Pearson’s chi-square) goodness-of-fit test was performed on respondents’
views on the importance of experience and intuition for each of the vignettes.
Protection for Human Subjects
The Protocol for Protection of Human Subjects was submitted and approved by the
Research Review Committee of the Division of Social Work at California State
University, Sacramento as exempt research. No risk is involved in this questionnaire
because it asks about everyday professional activities. This study is determined to be
exempt under 45 CFR 46.101(b)(2) or (3). The study only involves survey procedures. It
does not involve children. It was recorded in a manner in which no human subjects can
be identified. Any disclosure will not “place subjects at risk of criminal or civil liability
or be damaging to the subjects’ financial standing, employability, or reputation” as stated
on the Human Subjects Regulation Decision Chart found on the Department of Health
and Human Services website
(http://www.hhs.gov/ohrp/policy/checklists/decisioncharts.html#c4).
Implied consent is sufficient for this study due to the fact that this is an exempt study
involving adult respondents. A cover letter was distributed to participants prior to
distribution of the questionnaire (Appendix A). Participants were informed of the
anonymity, confidentiality, and voluntary nature of the study in the cover letter. Privacy
and safety were also mentioned in the cover letter. All questionnaires were anonymous at
the time of distribution and thereafter. No names were present on the questionnaires.
Participation was completely voluntary. Participants were informed that they could
36
discontinue participation at any time without prejudice. The researcher was not present
when participants were filling out the survey. Upon completion of the questionnaire,
participants returned completed questionnaires into a sealed box in the meeting room
which was be picked up by the researcher after all questionnaires were completed. To
ensure confidentiality, paper questionnaires were kept in a locked filing cabinet owned by
the researcher at all times except for when it is being analyzed. Once entered into SPSS,
data was saved on a password protected flash drive owned by the researcher. Data was
only accessed by the researcher and her thesis advisor, Dr. Yuen. Data will be retained
for 3 months after completion of the study and then destroyed.
37
Chapter 4
STUDY FINDINGS
This chapter summarizes the findings of a questionnaire survey on the decision
making process of working with youth presenting with suicidal ideation by service
providers. The survey was completed by school social workers, marriage and family
therapists, and interns from Sacramento City Unified School District and CommuniCare
Health Centers. Participants were chosen on the basis of their contact with youth
presenting with suicidal ideation. The purpose of this study was to identify the frequency
of specific factors that contribute to the decision making process of social workers when
working with youth presenting with suicidal ideation. Extensive review of literature and
consultation with service providers in school and agency settings helped to limit the focus
of this study to the following three factors: organizational policy and procedures, clinical
suicide assessment tools, and professional judgment. The study assessed the extent to
which these factors contribute to the decision making process when professionals work
with youth presenting with suicidal ideation. A 38-item questionnaire (See Appendix B)
was distributed to participants. The questionnaire consisted of close-ended questions on
demographics, social work experience and 2 case vignettes. The case vignettes describe
two fictional youth presenting with suicidal ideation. The vignettes are followed by ten
close-ended questions aimed at assessing the importance decision making factors, such as
utilization of a suicide risk assessment, intuition and practice experience, when working
38
with the youth described in the vignette. Two open-ended questions ask participants to
provide any additional decision making factors they would use when working with the
youth in the vignette.
Analysis of the data collected from this study is presented and supported through
various charts, graphs and tables. The chapter begins with an overview of overall
findings, including sample size and demographic information. Specific findings are then
presented, comprising of significant patterns, discrepancies, and relationships found.
Following, are the results of the qualitative data collected and concluding this chapter is a
brief summary of the overall analysis of findings.
Overall Findings
In total, 42 questionnaires were collected. Of the participants, 38 indicated their
current agency affiliation, while 4 did not select an agency. Thirty-two (76.2%)
participants were affiliated with Sacramento City Unified School District and 6 (14.3%)
participants were with CommuniCare Health Centers. The participant sample comprised
of 38 (90.5%) females and 4 (9.5%) males. Of the participants, 45.2% (19) reported that
their race/ethnicity was White, 23.8% (10) were Hispanic or Latino, 9.5% (4) were
Black/African American, 9.5% (4) were Asian, and the remaining 12% (5) of participants
selected other races including American Indian/Native American and Native Hawaiian or
Other Pacific Islander. Two participants did not select a race/ethnicity.
Participants were also asked to indicate their level of education and number of
years of professional experience with youth. The sample was divided into 22
professionals and 19 interns. Of the professionals, 14 had their Master of Social Work, 3
39
were Licensed Clinical Social Workers, and 5 had their Master of Marriage and Family
Therapy. The intern sample was comprised of 7 Master’s level social work interns and
12 Bachelor’s level social work interns. Twenty-eight participants indicated the number
of years of professional experience with youth, which ranged from less than 1 year to 22
years. The mean number of years of professional experience was 8.54 years and the
median was 7.50 years.
Specific Findings
The primary purpose of this study was to identify the frequency of specific factors
that contribute to the decision making process of social workers when working with
youth presenting with suicidal ideation. This section will focus on the findings relevant
to the researcher’s hypotheses as well as factors that demonstrated statistically significant
relationships.
Professional Experience and Intuition
The researcher had hypothesized from experience working with youth presenting
with suicidal ideation and extensive review of relevant literature that the utilization of
professional experience and intuition in professional practice would be the strongest
variables contributing to the decision making process. One-sample (Pearson’s chisquare) goodness-of-fit test was performed on respondents’ views on the importance of
experience and intuition for each of the vignettes. Findings indicate statistically
significant emphases (p<.05) on experience [vignette one (2= 24.9, df=4, p<.01);
vignette two (2= 16.2, df=4, and p<.01)] and on intuition [vignette one (2= 18.8, df=3,
and p<.01); vignette two (2= 10.4, df=3, and p<.05)]. These findings reject the null
40
hypotheses and support the alternative hypotheses that both experience and intuition are
significant factors in the decision making process.
Frequency distributions of participants’ responses to the two vignettes also
demonstrate that experience and intuition are highly valued in the decision-making
process. Frequency distributions from individual items in the questionnaire are
demonstrated in Figure 1 for professional experience and Figure 2 for intuition. Figure 1
indicates that 47.6% (20) of participants for the first vignette and 34.1% (14) of
participants for the second vignette placed high importance on the utilization of past
experience in the decision making process. These frequencies demonstrate that the
majority of participants utilize past experience in the decision making process.
Vignette #1
Vignette #2
47.6%
50.0%
45.0%
40.0%
34.1%
35.0%
29.3%
30.0%
25.0%
20.0%
26.8%
23.8%
16.7%
15.0%
10.0%
7.1%
4.9%
4.8% 4.9%
5.0%
0.0%
Not Applicable
Least Importance Low Importance
Moderate
Importance
High Importance
Figure 1. Frequency distribution of importance of past experience
Figure 2 (see below) demonstrates that 50.0% (21) of participants for the first
vignette and 34.1% (16) of participants for the second vignette placed high importance on
41
the utilization of intuition in the decision making process. These frequencies support that
the majority of participants utilize their intuition in the decision making process.
Vignette #1
Vignette #2
60.0%
50.0%
50.0%
38.1%
40.0%
30.0%
26.2%
20.0%
10.0%
28.6%
31.0%
16.7%
4.8% 4.8%
0.0%
Least Importance
Low Importance
Moderate Importance
High Importance
Figure 2. Frequency distribution of importance of intuition
The importance of experience and intuition are reflected by the responses to their
respective items within the questionnaire. However, in an overall analysis of what
participants identified as most important in the decision making process for each vignette,
past experience and intuition were not commonly selected. Figure 3 (see below) presents
the frequencies of the variables participants identified as most important in their decision
making process specific to vignette 1. From Figure 3, it can be seen that past experience
and intuition were not among the most important factors identified by participants. The
42
utilization of past experience and intuition were both only selected by 1.2% (1) of
participants. Other factors, such as reaching out to colleagues for support and utilizing a
suicide assessment tool were individually selected by a greater majority, 23.2% (19), of
participants for this vignette.
I will respecet the
youth's autonomy as
stated in the Code of
Ethics., 3.7%
I will utilize my
intuition., 1.2%
I will utilize my past
experience with suicidal
clients., 1.2%
I will inform law
enforcement., 2.4%
I will inform the
youth's
parents/guardians.,
12.2%
I will follow
my duty to
prevent harms
as stated in the
Code of
Ethics., 8.5%
I will utilize my
training on suicide
intervention., 9.8%
I will utilize my
therapeutic relationship
with the youth., 14.6%
I will reach out to
colleagues/supervisor
for support., 23.2%
I will utilize a suicide
risk assessment tool.,
23.2%
Figure 3. Distribution of variables selected as most important from vignette 1
Figure 4 presents similar findings corresponding with the second vignette as
Figure 3. Again, the utilization of intuition and past experience were not commonly
43
chosen with 2.4% (2) and 4.9% (4) of participants, respectively. Reaching out to
colleagues/supervisor for support was also commonly chosen by participants (22%) in
response to the second vignette. Utilization of the therapeutic relationship was another
popularly chosen decision making factor as 18.3% (15) of participants made this
selection.
I will follow my duty
to prevent harms as
stated in the Code of
Ethics., 12.2%
I will respecet the
youth's autonomy as
stated in the Code of
Ethics., 3.7%
I will inform law I will inform the
youth's
enforcement., 1.2%
parents/guardians.,
4.9%
I will utilize my
intuition., 2.4%
I will reach out to
colleagues/supervisor
for support., 22.0%
I will utilize my
training on suicide
intervention., 14.6%
I will utilize a suicide
risk assessment tool.,
15.9%
I will utilize my past
experience with
suicidal clients.,
4.9%
I will utilize my
therapeutic
relationship with the
youth., 18.3%
Figure 4. Distribution of variables selected as most important from vignette 2
44
Furthermore, in selecting factors that were of least importance, participants
selected the utilization of past experience in 16 (20.8%) cases for the first vignette and 12
(14.8%) cases for the second vignette. Nine (11.7%) participants selected intuition as
least important to the decision making process for the first vignette and 10 (12.3%)
selected for the second vignette.
The researcher recoded data related to level of education and level of importance
for the utilization of past experience and intuition for both vignettes. Participants were
separated into professional or intern based upon the level of education selected. Rank of
importance was recoded to important or not important dependent on responses to each
specific questionnaire item. This recoding was done to determine through Pearson chisquare analysis if the number of interns surveyed in this study impacted the results found
for these factors. None of the tests comparing interns and professionals with level of
importance produced statistically significant differences. The comparison of participants
and level of importance of intuition for the second vignette did reveal a pattern of
difference in which 40.96% of interns indicated that intuition was not important to the
decision making process compared to only 21.1% of professionals selecting this option.
Due to one of the cells having less than 5 cases, the researcher employed the Fisher's
Exact Test outcome which indicated a p value of .153. Although this result is not
statistically significant, the data does display a distinct variation between interns and
professionals related to the importance of intuition.
Of further note, 28.6% (22) of participants for the first vignette and 35.8% (29) of
participants for the second vignette chose informing law enforcement as least important
45
to the decision making process. These numbers indicate that a substantial number of
participants do not view law enforcement as important to the decision making process
when working with youth expressing suicidal ideation.
Colleague Support, Therapeutic Relationship, and Past Experience
Several factors were found to have statistically significant relationships. The
researcher compared the years of experience of each participant with different factors
related to decision making. As stated earlier, the mean years of experience indicated by
28 participants was 8.54 years and the median was 7.5 years. Table 1 (see below)
displays the statistical data from independent t-tests that compared years of experience
with various factors. As can be seen in the table, the factors that provided statistically
significant information were the same for both vignettes. There is a statistically
significant difference between those with more than 7.5 years of experience and those
with less than 7.5 years of experience in regards to reaching out to colleagues/supervisor
for support. Those with less than 7.5 years of experience are more likely to reach out to
colleagues/supervisor for support than those with more than 7.5 years of experience (see
Table 1). There is also a statistically significant difference between those with more than
7.5 years of experience and those with less than 7.5 years of experience in relation to the
utilization of the therapeutic relationship when working with youth expressing suicidal
ideation. Participants with more experience are more likely to utilize their therapeutic
relationship with a youth than those with less experience (see Table 1). In addition, there
is a statistically significant difference between those with more than 7.5 years of
experience and those with less than 7.5 years of experience in the utilization of past
46
experience. Participants with more experience indicated that the utilization of past
experience was more important in the decision making process than participants with less
experience.
Table 1
Important variables contributing to decision making between those with less/more than
7.5 years of experience
Variables
I will reach out to
colleagues /supervisor for
support.
t
3.045
df
26
p
.005*
I will utilize my therapeutic
relationship with the youth.
-2.110
26
.045*
I will utilize my past
experience with clients
expressing suicidal ideation.
-3.001
26
.006*
I will reach out to
colleagues /supervisor for
support.
2.787
26
.010*
I will utilize my therapeutic
relationship with the youth.
-2.590
26
.016*
I will utilize my past
experience with clients
expressing suicidal ideation.
* Statistically significant, p<.05
-3.068
25
.005*
Vignette 1
Vignette 2
47
Qualitative Data Findings
The questionnaire included two open-ended questions asking participants to
specify any other factors that would be important to the decision making process in
relation to each vignette. Of the sample, 19 participants responded to the open-ended
questions. All 19 respondents provided supplementary decision making factors for the
first vignette and 14 provided supplementary decision making factors for the second
vignette. Responses were recorded into an excel spreadsheet for content analysis. From
which, the researcher was able to identify common terms and themes from the
participants’ responses.
In relation to the first vignette, 15 participants responded with an answer that
indicated the need for more details on various aspects regarding the youth. For example,
respondents indicated the need for the youth’s mental health history, prior suicide
attempts, and family/friend relational factors. Four respondents placed importance on the
results of the assessment tool to provide guidance for decision making, especially in
regard to informing law enforcement. Three respondents identified cultural competence
as a variable in decision making. One respondent indicated, “The other crucial element
in this scenario is cultural competence, especially since Hmong beliefs about mental
health are very unique. Unless I had a good rapport with this student/family, I would
definitely seek out a Hmong mental health professional.”
The majority of responses (7) corresponding with the second vignette identified
information on the youth’s home environment as another variable affecting the decision
making process. These responses indicated a variety of aspects related to the home
48
environment, such as level of support at home, access to firearms, and mother’s
involvement. Four respondents identified other psychosocial factors as other variables
related to the decision making process. Included in these factors are substance abuse and
gang involvement.
Summary
This study yielded 42 participants unevenly split between SCUSD (32) and
CommuniCare Health Centers (6), with 4 individuals not identifying an agency. The
researcher hypothesized that the utilization of past experience and intuition would be the
factors indicated most important by participants in the study. Although these factors
were ranked highly in individual questionnaire items, they were not chosen in an overall
analysis of most important factors. Factors that emerged as of high importance included
reaching out to colleagues/supervisor for support, utilization of a suicide risk assessment
tool, and utilization of the therapeutic relationship with the youth.
In comparison of years of experience, the researcher found that those with more
experience were more likely to involve their past experience and the therapeutic
relationship in the decision making process. Those with less experience indicated that
they were more likely to reach out to colleagues/supervisor for support than those with
more experience. From this study it can be deduced that overall the therapeutic
relationship and collaboration with colleagues were important factors to the decision
making process.
Finally, the qualitative findings from this study revealed a need for more detailed
information about the youth described in each vignette. Participants indicated the desire
49
to know more about various psychosocial factors involved in the systems of the youth.
These factors included knowing mental health history, past suicide attempts, and level of
familial involvement.
50
Chapter 5
DISCUSSION
Findings from this study contribute to the limited research that has been done on
factors related to the decision making process when working with youth presenting with
suicidal ideation. From an extensive review of relevant literature, the researcher found
that most literature about working with clients with suicidal ideation focused on suicide
assessment tools. This study adds specific knowledge identifying the frequencies of
other factors that contribute to the decision making process such as ethical
considerations, the utilization of professional experience and clinical insight, as well as
support sought from colleagues. In this section findings are discussed and compared to
relevant literature. Implications for the social work profession and recommendations for
future study are explored. Finally, limitations of this study are identified.
Summary of Study
This study rendered numerous important findings that can be related to relevant
literature. In this chapter, first, the findings related to the researcher’s hypotheses will be
analyzed. Next, the findings related to reaching out for colleague/supervisor support, the
utilization of the therapeutic relationship, and the utilization of past experience will be
discussed. Finally, the results of the qualitative data will be examined.
51
Analysis of Findings Related to the Researcher’s Hypotheses
The researcher hypothesized that the utilization of past experience and intuition
would be the factors indicated most important by participants in the study. Although
these factors were ranked highly in individual questionnaire items, they were not chosen
in an overall analysis of most important factors. The researcher speculates that these
factors were not chosen as the most important in the decision making process for
numerous reasons.
An initial explanation of the importance of these factors looks at the nature of
intuition and past experience in professional practice. Intuition and past experience are
latent and implicit variables. When analyzed individually participants demonstrated that
these factors were important to the decision making process, but in an overall analysis of
factors their importance was not high. This finding can be explained by the latent nature
of the two factors. When analyzed among other more tangible factors, intuition and
experience become hidden by the more apparent nature of these other factors, such as the
therapeutic relationship and colleague support. Participants may have ranked other
factors as most important because of their more obvious, outward nature (Yuen, personal
communication, March 27, 2014).
In regard to past experience, the researcher asked interns to complete the
questionnaire. Interns were both masters and bachelor’s level in the social work field.
Of the sample (n=42), 19 participants were interns and 10 of the interns identified the
number of years of professional experience with youth. Nine out of the ten interns that
shared their years of experience had less than 3 years of experience. The limited years of
52
experience indicated by the interns may have impacted their responses to the decision
making factors in the survey, especially the utilization of past experience.
It was found in the study that those with less experience are less likely to rely on
their past experience in the decision making process. The findings from a study done by
Parada, Barnoff, and Coleman (2007) support this finding. The researchers found that
those with limited experience were more likely to strictly adhere and abide by the agency
protocols and assessment tools, whereas those with more experience had developed their
own style of working that relied on the use of practice wisdom that was more attuned to
the complexities of making decisions.
The number of interns surveyed may have also impacted the level of importance
placed on intuition in the current study. Findings from this studied indicated that interns
indicated that intuition was not an important factor in decision making process almost
twice as many times (40.9%) than professionals (21.1%). O’Sullivan (1999) classifies
professional intuition in social work decision making, as a skill which is not taught but
rather acquired through experience. Intuition can also be described as an implicit store of
knowledge used to interpret the client’s unique situation and make decisions that are in
accordance with the organizational and societal context (Zeira & Rosen, 2000). Lack of
experience can impact the level of confidence the interns placed on the use of their
intuition in the decision making process and therefore it was ranked with low importance.
Another possible explanation for the level of importance of intuition in this study
is the ambiguity that surrounds the definition of the term. Intuition can be defined in a
multitude of ways dependent on the nature of its utilization. There is potential that
53
participants were unclear about the implied definition of intuition and therefore did not
place importance on the factor. The researcher still views intuition as a key factor in the
decision making process despite the findings of this study. Ambady (2010) defines
intuition as judgments made based on short experience of a client’s behavior in
potentially distracted conditions, which is a realistic interpretation of many decisions
made in social work. Often times, decisions need to be made with partial information in
a short period. Although the findings of this study do not support the importance of this
factor, further exploration of the involvement of intuition in the decision making process
may reveal different findings.
Past Experience, Colleague Support, and Therapeutic Relationship
Significant findings in this study identified three factors as being important in the
decision making process in relation to the number years of professional experience
identified by participants. These factors include past experience, reaching out to
colleagues for support, and the therapeutic relationship.
In comparison of years of experience, the researcher found that those with more
experience were more likely to involve their past experience and the therapeutic
relationship in the decision making process. Past experience with youth presenting with
suicidal ideation can positively inform the decision making process in a future situation.
Stokes and Schmidt (2012) discuss how objective knowledge can only go so far in social
work; rather secondary forms of experiential knowledge utilize the social worker’s
experience that has been transformed into cultural, practical and practice knowledge.
This personal experience base enables social workers to filter a situation through their
54
own thinking process that is influenced by past experience. Social workers are able to
determine relevant information, infer patterns of meaning and validate the individual’s
experience in the world.
Those with less experience indicated that they were more likely to reach out to
colleagues/supervisor for support than those with more experience. Collaborating with
colleagues serves multiple purposes. First it acts as a way to tap into the past experience
and practical knowledge of colleagues that may are different from the experience of the
individual. Forkby and Höjer (2011) called this past experience collective memory,
which consists of a collaboration of anecdotes of experience from each member that first
comes from an individual, but then becomes a shared asset of the group that can be drawn
from to understand the present. When working with a youth with suicidal ideation,
reaching out to colleagues to support in the decision making process can provide advice
for action steps that a colleague used in the past as well as a differing perspective from
someone outside of the case. The clinician working with the youth presenting with
suicidal ideation often takes on a sense of responsibility for the client and the therapeutic
relationship becomes one of rescue. Consultation and support can assist in rational
decision making rather than emotive impulsive decisions in an effort to reduce the
clinician’s personal distress. Collaboration with colleagues acts as a rationalizing tool so
response to a client crisis benefits the client (Deuter, et al., 2013).
Additionally, from this study it can be deduced that the therapeutic relationship is
an important factor of the decision making process. Many studies confirm the
importance of the therapeutic relationship with a client as an effective practice tool to
55
gain client trust in future interventions (Cashmore, 2002; Gallagher, Smith, Hardy &
Wilkinson, 2011; Lee & Anyon, 2004; Platt, 2008; Stokes & Schmidt, 2012). Fostering a
significant level of trust in building the relationship with a client is incredibly beneficial
to future assessment and interventions, especially when suicidal ideation is involved.
Participants with more experience valued the therapeutic relationship more than those
with less experience revealing a potential need for more training and importance placed
on the therapeutic relationship in social work curriculum and agency training.
Analysis of Qualitative Findings
The qualitative findings from this study revealed a need for more detailed
information about the youth described in each vignette. Participants indicated the desire
to know more about various psychosocial factors involved in the systems impacting the
youth. These factors included knowing mental health history, past suicide attempts, and
level of familial involvement. The researcher foresaw this response when the decision
was made to utilize vignettes. There is always a need to know more information about
clients and the psychosocial systems and relationships that impact their lives. The more
information known assists in making relevant decisions to help clients meet their specific
needs. The supplementary factors identified by participants presented important
information that would help with the decision making process, including the client’s
mental health and suicidal history.
Implications
Findings from this study expand the limited knowledge of the decision making
process when working with youth expressing suicidal ideation. Implications for social
56
work derived from this study include further training in factors related to decision making
and suicidality, and an increase in agency environments that promote colleague
collaboration.
One of the factors related to decision making that proved to be most important in
this study was the utilization of the therapeutic relationship when working with youth.
The therapeutic relationship is an integral, yet understated, dynamic when working with
clients. The researcher argues for more training in foundational relationship building
skills in social work school curriculums and agencies to ensure that these skills are
integrated into future decision making. If more time is spent building the therapeutic
relationship, more meaningful interventions can be made in the future, especially during
critical times of crisis.
Training in suicide intervention is another important factor consequent of this
study. From relevant literature review, it was found that suicide is a common issue seen
in the social work field, especially with adolescents. Training on prevention,
intervention, and postvention would only prove to be beneficial to the social workers who
frequently come across this issue. Increased training in social work school curriculums
and agencies would potentially increase the level of confidence and capability of social
workers encountering this delicate issue.
A final factor found to be important in this study is collaboration with
colleagues/supervisor for support when working with a youth expressing suicidal
ideation. The researcher suggests that strong promotion of an agency environment of
collaboration would be advantageous to all staff. Collaboration provides support,
57
emotional regulation, and collective knowledge that has proven to be one the major
factors affecting the decision making process. Agencies should be welcome to and
encourage colleague collaboration and provide an open environment in which staff feels
comfortable in doing so. Examples of promotion of this open atmosphere include
holding staff/team building events to increase staff’s connection with each other, holding
frequent staff meetings to provide a forum for collaboration and consultation, and
developing an agency model focused on team treatment, rather than model that involves
isolation of social worker and client.
Recommendations
Recommendations were determined from the discussed findings of this study.
These recommendations involve further study on certain factors pertaining to the decision
making process. These factors are intuition and involvement of law enforcement.
Further study on the nature of intuition would be beneficial to further define and
understand the different interpretations of this factor. As stated earlier, although findings
of this study do not support intuition as a key factor in the decision making process, the
researcher still regards intuition as a guiding element in making decisions. Future study
could explore how the term is interpreted and utilized by social workers in different
settings to determine its level of impact in decision making.
Another factor warranting further study is the level of importance of involvement
of law enforcement in the decision making process. Law enforcement is the most direct
path with which to refer youth to a higher level of care when they are actively suicidal.
This study found that social workers were very unlikely to inform law enforcement when
58
making a decision involving a youth presenting with suicidal ideation. Knowledge of the
reasoning behind these findings and further exploration on levels of trust, confidence in
ability, and other factors pertaining to the professional relationship between law
enforcement and social workers would be beneficial in understanding these findings.
Limitations
There are four noteworthy limitations when discussing the findings of this study:
the aim of the study, geographic location, validity and reliability, and uneven distribution
between community agency and school district. This study aimed to explore the
frequency of different factors of the decision making process of social workers who
encounter youth expressing suicidal ideation. The study did not determine factors
associated to this process, but rather described the frequencies with which school social
workers and mental health professionals rate various factors related to decision making.
Therefore other factors may be associated with the decision making process that are
outside the realms of the current study.
Secondly, the geographic location of the research limits the inference of its
results. The geographic range of the participating social workers, mental health
professionals, and interns provides a representation of the greater Sacramento area and
Yolo County, therefore limiting the study’s generalizability to other areas of the state or
nation.
The validity and reliability of the measuring instrument is limited. The measuring
tool was self-constructed by the researcher and therefore has not been utilized prior to the
experiment. The tool only holds content validity from the extensive review of relevant
59
literature and personal experience of the researcher. It does maintain any other reliability
or validity measures.
Finally, the distribution of participants between CommuniCare and SCUSD is
uneven. There is a great underrepresentation of participants from CommuniCare. The
researcher was unable to compare responses from the two entities due to the uneven
distribution.
Conclusion
The factors contributing to the decision making process when social workers
encounter youth expressing suicidal ideation were explored in this study. Responses to
the questionnaire yielded important findings that provided appropriate implications and
recommendations for the social work field. The researcher’s original hypotheses about
the importance of past experience and intuition were supported by study findings in the
individual questionnaire items, but not as in an overall analysis of important factors.
Instead significant factors included the utilization of the therapeutic relationship and
collaboration with colleagues/supervisor for support in making decisions involving youth
expressing suicidal ideation. These findings support the implication for further training
in therapeutic relationship skills and overall suicide prevention, intervention and
postvention, as well as the promotion of colleague collaboration in agency environments.
The researcher also determined from this study that further exploration of the factors of
intuition and involvement of law enforcement would be beneficial to the knowledge base
of the social work field.
60
Appendix A
Cover Letter
You are invited to participate in a study on the factors that contribute to the decision making
process of social workers when working with youth expressing suicidal ideation. This is a thesis
research project by Kimberly Utz for her Master of Social Work Study at CSUS. You were
selected as a possible participant because of your professional experience and expertise in
working with youth in your agency. The findings from this study will be analyzed and used to
further knowledge on the decision making process of social workers when working with youth
expressing suicidal ideation.
If you decide to participate, you will be asked to complete a written questionnaire that describes
your opinion on the factors involved in decision making when working with youth expressing
suicidal ideation. This questionnaire will only be administered once and should take
approximately 30 minutes.
Any information obtained in this study will be treated as confidential. No information will be
disclosed and only group information will be included in the report.
Your participation is completely voluntary. Should you choose to participate, you may
discontinue participation at any time without prejudice.
This research project studies your everyday professional activities and will not put you at any
risk. The return of your completed questionnaire implies your understanding of the nature of
this study and consent to participate.
If you have any questions, please do not hesitate to contact the researcher, Kimberly Utz, or her
thesis advisor, Dr. Francis Yuen.
Thank you for considering this request.
61
Appendix B
Decision Making Study When Working with Youth Expressing Suicidal
Ideation
Decision making refers to the choices that you as a professional working with youth have to make
when a youth presents with suicidal ideation. These decisions may involve your agency’s
policies, the Code of Ethics, standardized assessment tools, professional experience, etc.
Basic Demographics
1. Gender:
Male
Female
Other
2. Race/Ethnic Group (Please check all that apply):
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other __________________
3. Current agency:
Sacramento City Unified School District
Communicare Health Centers
Experience
4. Please check one:
MSW
Other Master’s ________________________
LCSW
Bachelor’s ____________________________
MFT
Other _______________________________
5. Number of years of professional experience with youth:____________________
Decision Making Factors
Please read the following vignettes and answer the following questions.
Vignette #1:
Amy is a 12 year old Hmong girl in 7th grade. She has been receiving counseling services from
you because of peer conflict at school. Amy’s mother came to you to express concerns about
Amy’s mental health. At home, her mother had noticed a change in Amy’s behavior. She no
longer put effort into her appearance. She was not sleeping or eating as much as she used to and
62
was very stressed about schoolwork. Her younger brother had reported that Amy had been
making comments to him about preparing for when she was not with the family anymore.
On the following scale, please rank the degree of importance (least to most) of each statement in
the decision making process when working with the youth described in the vignette.
0-Not Applicable 1-Least Importance 2-Low Importance 3-Moderate Importance 4-High Importance
6. I will inform law enforcement.
0
1
2
3
4
7. I will inform the youth’s parents/guardians.
0
1
2
3
4
8. I will reach out to colleagues/supervisor for support.
0
1
2
3
4
9. I will utilize a suicide risk assessment tool.
0
1
2
3
4
10. I will utilize my therapeutic relationship with the youth.
0
1
2
3
4
11. I will utilize my past experience with suicidal clients.
0
1
2
3
4
12. I will utilize my training on suicide intervention.
0
1
2
3
4
13. I will utilize my intuition.
0
1
2
3
4
14. I will respect the youth’s autonomy as stated in the Code of Ethics.
0
1
2
3
4
15. I will follow my duty to prevent harm as stated in the Code of Ethics.
0
1
2
3
4
16. Of items 6-12, which TWO factors are most important in the decision making process with
the youth described in the vignette:
6
7
8
9
10
11
12
13
14
15
17. Of the items 6-12, which TWO factors are the least important in the decision making process
with the youth described in the vignette:
6
7
8
9
10
11
12
13
14
15
18. Are there any other factors that you think are important to the decision making process?
______________________________________________________________________________
______________________________________________________________________________
Vignette #2:
Michael is a 15 year old African American male entering high school. He lives with his mother
and 5 siblings in a two bedroom apartment in an area known for gang violence. His father is
incarcerated. He is receiving counseling and drug education services because he was caught in
middle school smoking marijuana. Michael’s teacher has come to you with a poem he wrote
63
about his future. The poem speaks of morbidity and ends with “dying sooner rather than later is
the best answer.”
On the following scale, please rank the degree of importance (least to most) of each statement in
the decision making process when working with the youth described in the vignette.
0-Not Applicable 1-Least Importance 2-Low Importance 3-Moderate Importance 4-High Importance
19. I will inform law enforcement.
0
1
2
3
4
20. I will inform the youth’s parents/guardians.
0
1
2
3
4
21. I will reach out to colleagues/supervisor for support.
0
1
2
3
4
22. I will utilize a suicide risk assessment tool.
0
1
2
3
4
23. I will utilize my therapeutic relationship with the youth.
0
1
2
3
4
24. I will utilize my past experience with suicidal clients.
0
1
2
3
4
25. I will utilize my training on suicide intervention.
0
1
2
3
4
26. I will utilize my intuition.
0
1
2
3
4
27. I will respect the youth’s autonomy as stated in the Code of Ethics.
0
1
2
3
4
28. I will follow my duty to prevent harm as stated in the Code of Ethics.
0
1
2
3
4
29. Of items 14-23, which TWO factors are most important in the decision making process with
the youth described in the vignette:
19
20
21
22
23
24
25
26
27
28
30. Of the items 14-23, which TWO factors are the least important in the decision making process
with the youth described in the vignette:
19
20
21
22
23
24
25
26
27
28
31. Are there any other factors that you think are important to the decision making process?
______________________________________________________________________________
______________________________________________________________________________
Clinical Insights and Practice Wisdom
On the following scale, please rank how much you agree (Strongly Disagree to Strongly Agree)
with the following statements.
0-Not Applicable 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree
32. The suicide risk assessment tool is very useful and effective.
0
1
2
3
4
64
33. Erring on the side of caution is a good practice.
0
1
2
3
4
34. Over reporting, on suicidal ideation that may not be real, is a
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
37. Suicide talk among youth can be seen as a way to seek attention.
0
1
2
3
4
38. I fear that I will lose the trust of my client if I report his/her
0
1
2
3
4
concern when working with youth.
35. Over reporting can harm others perception of my professional
competence.
36. My practice wisdom and clinical insights are more effective than
the suicide risk assessment tool.
suicidal ideation.
Thank you for your participation!
65
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