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https://www.infirmiere-canadienne.com/blogs/ic-contenu/2025/04/28/modele-narratif-de-crise

Structured approach acknowledges dynamic nature of suicidal ideation and behaviour

By Matias Gay
April 28, 2025

Nurses frequently encounter individuals in crisis, including those contemplating suicide. Traditional suicide risk assessments categorize risk into chronic or acute based on individual factors. However, these assessments often overlook the complexities of suicidal thoughts and behaviours.

This article discusses the limitations of current approaches and proposes using the Narrative Crisis Model  (NCM) to enhance nurses’ decision-making in suicide risk assessment (Galynker, 2017). Developed by psychiatrist Igor Galynker, the NCM offers a structured approach that acknowledges the dynamic nature of suicidal ideation and behaviour (Galynker, 2017).

Limitations of traditional suicide risk assessments

Current suicide risk assessments primarily focus on static risk factors, such as past suicide attempts or psychiatric diagnoses, which do not capture the fluid nature of suicidality. Studies indicate that suicide risk is not a fixed state but fluctuates based on situational and emotional factors (Borges et al., 2012). Static assessments lack the capacity to adapt to these shifts, thereby potentially missing signs of escalating risk.

Another limitation of traditional assessments is their neglect of the individual’s subjective experience and emotional narrative. This oversight restricts health-care providers from fully understanding the motivations driving suicidal thoughts (Galynker, 2017). The absence of a personalized approach can lead to interventions that may not adequately address underlying distress.

Additionally, individuals often underreport suicidal ideation due to stigma or fear of involuntary hospitalization, forcing clinicians to rely on observable behaviours alone (Stone, Holland, & Bartholomew, 2018). Without direct disclosure, traditional assessments can fail to capture the depth of internal distress, leaving at-risk individuals without adequate support.

Introduction to the Narrative Crisis Model

The Narrative Crisis Model (NCM), developed by Galynker, provides a dynamic framework that helps clinicians understand the progression of suicidal thoughts and behaviours. Unlike static risk-based assessments, the NCM emphasizes the fluctuating nature of suicidality and integrates the individual’s evolving psychological state with external stressors (Galynker, 2017). The model includes four key components: trait vulnerabilities, stressors, the suicidal narrative, and the suicide crisis syndrome. These elements collectively enable health-care providers to better understand suicide risk holistically and intervene effectively during high-risk periods (Galynker, 2017).

Trait vulnerabilities

Trait vulnerabilities refer to longstanding characteristics that increase an individual’s baseline risk for suicidality, including factors such as childhood trauma, impulsivity and chronic hopelessness (Fawcett et al., 1990). Rather than treating these traits as isolated risk markers, the NCM contextualizes them within the individual’s current experience. This allows health-care providers to anticipate how these vulnerabilities may contribute to heightened risk during crises and facilitates proactive intervention.

Stressors

Stressors encompass external events or internal experiences that can trigger suicidal thoughts in vulnerable individuals, such as job loss or relationship breakdowns (Hendin et al., 2001). The NCM emphasizes understanding the subjective meaning of these stressors for each patient, offering deeper insight into what drives their crises. This approach helps identify how situational pressures exacerbate vulnerabilities, moving the individual closer to acute risk.

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Suicidal narrative

A core feature of the NCM, the suicidal narrative involves the individual’s internalized story about their life, often marked by distorted beliefs and a sense of hopelessness. Unrealistic life goals, unmet expectations, and perceived failures contribute to a narrative of inadequacy and social defeat (O’Connor et al., 2012). As stressors build, this narrative intensifies, fostering despair. By exploring and challenging this narrative, health-care providers can help patients reframe their story, reducing the risk of progression toward crisis.

Suicide crisis syndrome

The suicide crisis syndrome (SCS) is an acute psychological state that often signals imminent suicide risk. Characterized by feelings of entrapment, affective disturbance and loss of cognitive control, SCS reflects the culmination of interactions between trait vulnerabilities, stressors, and the suicidal narrative (Galynker, 2017). SCS is a critical focus in NCM assessments as studies have shown that it reliably predicts near-term suicide risk (Yaseen et al., 2019). Recognizing SCS enables clinicians to intervene during high-risk moments, providing timely support, and reducing the likelihood of suicide.

Practical applications for nurses

The NCM framework offers actionable strategies for nursing professionals to improve suicide risk assessments:

• Training and education: Nurses should receive training to recognize the stages of the suicidal narrative, identify SCS and understand trait vulnerabilities that impact suicide risk. Empirical evidence demonstrates that education focused on SCS and the suicidal narrative improves assessment accuracy (Galynker, 2017).
• Utilization of assessment tools: The use of specific assessment tools such as the Suicide Crisis Inventory can help nurses evaluate SCS components, even in patients reluctant to disclose ideation (Galynker et al., 2017). These tools capture subtle signs of psychological distress, enhancing nurses’ ability to detect individuals at high risk.
• Person-centred care and therapeutic engagement: A key aspect of the NCM is building a therapeutic alliance through empathetic, person-centred communication. By exploring patients’ subjective experiences, nurses can better understand the emotional landscape of suicidality, identifying feelings of hopelessness, perceived burdensomeness, and social isolation central to the individual’s crisis (Joiner, 2005).
• Continuous monitoring and flexibility: Given the fluctuating nature of suicide risk, nurses should engage in ongoing assessment, monitoring shifts in the patient’s narrative and SCS signs. Reassessing risk factors in response to changing emotional states or new stressors ensures that care plans remain responsive to the patient’s evolving needs.

Results and Implications

Implementing the NCM in clinical settings has shown promise in improving suicide prevention outcomes. For instance, Mount Sinai Beth Israel hospital in New York reported a 40% reduction in readmission rates and no suicide deaths after incorporating SCS-focused assessments into practice (Galynker, 2017). Similarly, Northshore University in Chicago experienced significant reductions in readmissions and a complete absence of suicide deaths following their adoption of the NCM (Galynker, 2023). These outcomes underscore the NCM’s efficacy in recognizing acute risk, enhancing timely intervention, and reducing suicide-related hospital readmissions.

The NCM has been successfully integrated into various clinical contexts, including inpatient and outpatient facilities in Norway, Israel and Taiwan, with consistently positive outcomes (Galynker et al., 2023). In these settings, clinicians have observed that the model enhances decision-making, allowing more accurate admission and discharge judgments in emergency care scenarios. This widespread success highlights the practical utility of the NCM in delivering comprehensive, individualized suicide risk assessments across diverse environments.

Conclusion

The Narrative Crisis Model (NCM) represents a significant advancement in understanding and assessing suicide risk, particularly for nursing professionals working with patients at imminent risk of harm. Unlike traditional methods that rely on static risk markers, the NCM acknowledges suicidality’s dynamic and evolving nature by emphasizing the interplay between trait vulnerabilities, stressors, the suicidal narrative, and the acute state of SCS (Galynker, 2017). This multifaceted approach empowers nurses to develop nuanced, immediate understandings of risk, enabling more targeted and effective interventions (Yaseen, Cohen, & Galynker, 2014).

By adopting the NCM, nursing professionals can shift from reactive crisis management to proactive, empathetic care. This approach not only addresses immediate crises but also facilitates long-term narrative reconstruction, helping individuals move beyond crisis toward recovery and resilience. Ultimately, the NCM provides health-care providers with the tools to engage patients in a preventive and restorative therapeutic process, significantly enhancing suicide prevention efforts within nursing and advancing the field overall (Galynker, 2017).

References

Borges, G., Nock, M. K., Haro Abad, J. M., Hwang, I., Sampson, N. A., Alonso, J., ... & Kessler, R. C. (2010). Twelve-month prevalence of and risk factors for suicide attempts in the World Health Organization World Mental Health Surveys. The Journal of Clinical Psychiatry, 71(12), 1617–1628. doi:10.4088/JCP.08m04967blu

Fawcett, J., Scheftner, W. A., Fogg, L., Clark, D. C., Young, M. A., Hedeker, D., & Gibbons, R. (1990). Time-related predictors of suicide in major affective disorder. American Journal of Psychiatry, 147(9), 1189–1194. doi:10.1176/ajp.147.9.1189

Galynker, I. (2017). The suicidal crisis: Clinical guide to the assessment of imminent suicide risk. Oxford University Press.

Hendin, H., Maltsberger, J. T., Lipschitz, A., Haas, A. P., & Kyle, J. (2001). Recognizing and responding to a suicide crisis. Suicide and Life-Threatening Behavior, 31(2), 115–128. doi:10.1521/suli.31.2.115.21515

Galynker, I. (2022). Empirical support for the Narrative Crisis Model of suicide. In The Suicidal Crisis: Clinical Guide to the Assessment of Imminent Suicide Risk (2nd ed.). Oxford University Press.

Joiner, T. (2005). Why people die by suicide. Harvard University Press.

O’Connor, R. C., O’Carroll, R. E., Ryan, C., & Smyth, R. (2012). Self-regulation of unattainable goals in suicide attempters: A two-year prospective study. Journal of Affective Disorders, 142(1–3), 248–255. doi:10.1016/j.jad.2012.04.035.

Stone, D. M., Holland, K. M., Bartholow, B., Crosby, A. E., Davis, S., & Wilkins, N. (2017). Preventing suicide: A technical package of policies, programs, and practices. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. https://doi.org/10.15620/cdc.44275

Yaseen, Z. S., Cohen, L. J., & Galynker, I. (2014). Development of a screener for the suicide crisis syndrome: A pilot study. International Journal of Emergency Mental Health and Human Resilience, 16(1), 12–19.

Yaseen, Z. S., Hawes, M., Barzilay, S., & Galynker, I. (2019). Predictive validity of proposed diagnostic criteria for the suicide crisis syndrome: An acute presuicidal state. Suicide and Life-Threatening Behavior, 49(4), 1124–1135. doi:10.1111/sltb.12495

Matias Gay, RN, is clinical leader of the department of emergency mental health and addictions at the IWK Children’s Hospital in Halifax, N.S.

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