2019). However, despite such drastic progress in this area, there remains yet to be a clear, gold-standard online or virtual suicide risk assessment program or protocol. Therefore, while these Initiating a suicide-specific assessment inquiry Now that we have covered some basic information and options regarding clinical assessment and suicide risk assessment modalities, we will focus our attention on the suicide risk assessment process more specifically. It is common for clinicians who are new to assessing suicide risk to have some hesitation or anxiety about asking about suicidal behavior; suicidal thoughts and behavior can be upsetting and worrisome to learn about for any clinician, educator, or family member. However, it’s also important to recognize that being unwilling to inquire about suicidal behavior can be exceedingly dangerous and, in some cases, tragic. Therefore, if there is any concern for suicide risk, any reticence or anxiety on the part of the clinician must be overcome to ensure safety. Fortunately, any anxiety associated with conducting a suicide risk assessment will be reduced over time, and the more a clinician can respond to the at-risk individual with a calm demeanor and empathy, the more readily an intervention plan can be enacted. When conducting a suicide-specific inquiry, clinicians should use explicit language when asking patients about suicidal thoughts, for example: “Have you had thoughts about killing yourself?” (Chu et al., 2015). Blunt language may help elucidate the seriousness of the patient debate. Another advantage of the direct question is that the phrase “killing yourself” is not ambiguous; what is being asked is quite clear. Some clinicians may feel anxious about this and feel an impulse or desire to use more gentle language, but this impulse can result in reduced accuracy of assessment, so clinicians must withstand this impulse. The following general questions should be answered in the course of a suicide risk assessment: ● What are the suicide-relevant thoughts? Are they active or passive? ● When did they begin? ● How frequent are they? ● How persistent are they? Are they obsessive? ● Can you control them? ● Are there command hallucinations (i.e., with an external voice encouraging suicidal behavior)? One of the most common reports by patients is referred to as passive suicidal ideation. Passive suicidal ideation refers to desires for death in the absence of an active will to harm oneself, and even though this may be a less severe form of suicidal ideation, it should still be taken very seriously (Liu, Bettis, & Burke, 2020). Active ideation , on the other hand, refers to clear
emerging options continue to be studied, it is recommended to supplement any virtual or online methods with more traditional clinical assessment protocols.
thoughts and/or desires to harm or kill oneself. The presence of a suicide plan further increases the risk for suicide beyond ideation. How well the plan is thought out, its consideration of avoiding detection, and the lethality of the planned method all converge in the assignment of the risk level for suicide. A patient may not know that their planned method of suicide is not a great risk for imminent death (e.g., overdosing on three extra Zoloft); however, it is the patient’s perception of risk for death that should be ascertained. The patient’s level of ambivalence also should be assessed. Even up until the moment of death, many patients who die by suicide appeared to have debated the question of continuing to live or not (Bergmans, Gordon, & Eynan, 2017.) Less risk would be indicated by there being a greater number and ranking for reasons to live. The tension between the “living-or-dying” internal debate can create great anxiety, which in turn can confer greater risk for acting on suicidal thoughts (Bergmans et al., 2017; Deuter, Procter, & Evans, 2019). Hopelessness, as conveyed by patients’ belief that their situation cannot improve, should also be assessed at this juncture. Hopelessness has been shown to be a significant predictor of suicide risk (Ribeiro, Huang, Fox, & Franklin, 2018), though it is not necessarily an indicator of near-term suicide danger because, for many patients, hopelessness can exist for some period of time before suicidal action is taken (Qiu, Klonsky, & Klein, 2017). Now that the basic foundations of clinical and suicide risk assessment have been laid, two potential suicide risk assessment framework options will be discussed in detail. Two independent frameworks are presented so that clinicians and educators can select the framework that best fits the unique needs of their practice or educational setting. Both frameworks have established empirical evidence in improving suicide detection and intervention outcomes, and differences between the frameworks tend to be more stylistic, with each framework sharing some key strategies. Presented in no particular order of preference are: ● Framework #1: Five-Step Evaluation and Triage (SAFE-T; SAMHSA, 2017). ● Framework #2: Joiner’s Assessment Model (Joiner et al., 1999; Chu et al., 2015). Additional notes on intervention steps and safety plans, documentation, and assessment with youth will be covered. suicide and abuse, the patient’s psychiatric state of mind, the presence of drugs, and other confounders, such as insomnia. 2. Suicide inquiry : This suicide-specific inquiry should include specific questions about suicidal thoughts/ideation, suicidal plans, suicidal intent, and access to means. In general, patients will not spontaneously report suicidal ideation, but it has been shown that up to 70% of patients will report their intentions to attempt suicide to their friends and family members. To get patients to open up when asking about suicidal ideation, it is important that the clinician avoid asking leading questions (Kazim, 2017). An example of a wrong question to ask is, “You are not thinking about committing suicide, are you?” The correct question to pose is, “Have you ever tried to kill yourself or thought about suicide?” If this inquiry reveals no indications of any suicidal ideation, questioning may stop at that time. However, if the clinician is highly suspicious that the patient may have suicidal thoughts, but initially denies any suicidal thoughts, he or she may keep asking questions as many times as necessary until the incongruence is resolved. The clinician must ask questions
Suicide assessment framework option 1: Five-Step Evaluation and Triage (SAFE-T) Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) was developed in collaboration with the Suicide Prevention Resource Center (SPRC) and Screening for Mental Health (SAMHSA, 2017). The screening tool is the product of Screening for Mental Health, Inc. (SMH) and Suicide Prevention Resource Center in 2009 but remains one of the two screening tools recommended by SAMHSA in 2017.
Almost 3% of adults are assumed to experience thoughts of suicide at any specific time. The assumption is that the incidence of suicidal thoughts is much higher among adolescents. Five steps have been denoted key components of any suicide risk assessment: 1. Assessment of risk factors : Risk factors include various life events and circumstances, such as illness. The strongest predictor of suicide is the presence of a previous suicide attempt. Individual risk factors for suicide include major physical illness, chronic pain, and the presence of traumatic brain injury. Mental health disorders are also included in this category. This section should also include a family history of
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