Table 1: Nomenclature Describing Suicidal Behavior Instrumental
Potentially self-injurious behavior for which there is evidence that (a) the person did not intend to kill him- or herself and (b) the person wished to use the appearance of intending to kill him- or herself to attain some other end (e.g., to seek help, to punish others, to receive attention).
suicide- related behavior Suicide- related behavior
Potentially self-injurious behavior for which there is evidence either that (a) the person intended at some level (nonzero) to kill him- or herself, or (b) the person wished to use the appearance of intending to kill him- or herself to attain some other end. Suicide-related behavior comprises suicidal acts and instrumental suicide-related behavior.
Suicide plan A proposed method of carrying out a course of action that will lead to a potentially self-injurious outcome. Suicide threat Any interpersonal action, verbal or nonverbal, stopping short of a directly self- harmful act that a reasonable person would interpret as communicating or suggesting that a suicidal act or other suicide-related behavior might occur in the near future.
Suicidal ideation
Any self-reported thoughts of suicide (i.e., passive ideation) or engaging in suicide-related behavior (i.e., active ideation).
Non-suicidal self-injury
Self-inflicted injury that is engaged in without suicidal intent.
Note . Based on terms defined in Glenn et al. (2020) and Frey et al. (2020).
IDENTIFYING CLIENTS AT RISK: IT’S NOT SUICIDE PREDICTION
In a classic study attempting to identify which clients would complete suicide within 5 years based on known risk factors, Pokorny (1992) concluded “that we do not possess any item of information or combination of items that permit us to identify to a useful degree the particular persons who will commit suicide, in spite of the fact that we do have scores of items available, each of which is significantly related to suicide” (p. 127). Unfortunately, though the situation today is better, we still have a long way to go (Large et al., 2017). A recent examination of the predictive power of self-injurious thoughts and behaviors in the prediction of suicidal ideation and behavior came to a similar conclusion. “When considered in the context of the extremely low prevalence of suicidal thoughts and behaviors and the Warning signs of elevated suicide risk The following are general warning signs for potential suicidal behavior (National Institute of Mental Health [NIMH], 2018): ● Talking about feeling hopeless or having no purpose. ● Talking about feeling trapped or being in unbearable pain. ● Talking about being a burden to others. ● Increasing the use of alcohol or drugs. ● Acting anxious, agitated or reckless. ● Sleeping too little or too much. ● Withdrawing or feeling isolated. ● Showing rage or talking about seeking revenge. ● Displaying extreme mood swings. ● Talking about wanting to die. ● Looking for a way to kill oneself. In addition to these general behaviors, additional clinical warning signs are defined and arranged in the mnemonic acronym “IS PATH WARM?” (See Table 2). It is also important to note that, whereas depression and/or depressed mood are psychiatric problems associated with risk for suicide, they are not warning signs for suicide. So, for example, while a diagnosis of major depressive disorder may increase an individual’s risk for suicide, the diagnosis alone does not indicate that the individual may be suicidal. However, a number of the warning signs, such as hopelessness, withdrawal, and mood changes, are, in fact, symptoms of a depressive episode; therefore, noting changes in associated symptoms is necessary in providing ongoing care and supervision of those who are at heightened risk for suicide. Further information will be provided in subsequent sections to assist clinicians in differentiating general risk factors and warning signs from the most important factors in the upcoming suicide risk assessment section.
clinical demands that call for very short prediction timeframes, prior self-injurious thoughts and behaviors may not improve prediction much beyond chance levels” (Ribeiro et al., 2016, p. 234). Because of the challenges of predicting suicide outcomes, the provider’s primary task instead is to identify those persons most at risk for suicide, and then to appropriately respond to that immediate risk with proper assessment and treatment (Chu et al., 2015). It is important to remember that the notion of assessing risk should not be confused with actually predicting suicide. It also should be remembered that risk assessment, although imperfect, likely saves lives and should be done rigorously. Table 2: Warning Signs for Suicide: IS PATH WARM? Warning Sign Description Ideation Threats or talk of wish to hurt or kill self. Substance abuse Increasing alcohol or drug use. Purposelessness Expressing no reasons for living. Anxiety Agitation, restlessness, unable to sleep. Trapped Feeling that there is no way out. Hopelessness Self lacks value, others do not care, future is unchanging. Withdrawal From friends, family members; sleeping all the time; anhedonia. Anger Uncontrolled and excessive expressions of anger. Recklessness Acting recklessly; high-risk behaviors. Mood changes Dramatic shifts from typical mood state: ask to get more information. Note . Adapted from “Know the Warning Signs,” by the American Association of Suicidology, n.d. Retrieved from http://www.suicidology. org/resources/warning-signs
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