● Whether and when they have thought about suicide (ideation); ● Which actions they have taken to prepare for suicide, and when; and ● whether and when they attempted suicide or began a suicide attempt that was either interrupted by another person or stopped of their own volition. Whichever clinical assessment measure is utilized, it is important to make sure the requirements of the measure fit the needs of the setting with regard to length of administration, required background of the clinical assessor, and the intervention/ documentation requirements of the setting/agency. Furthermore, any clinical assessment can be further informed by the suicide risk assessment modalities that will be discussed further along in this section. For clinicians wanting to obtain a thorough assessment of both NSSI and suicidal behavior, it is recommended that the Self- Injurious Thoughts and Behaviors Interview (SITBI; Nock et al., 2007; Fox et al., 2020) be used. The SITBI is a well-validated, structured clinical interview consisting of five modules that assess self-injury, suicidal ideation and plans, and suicidal behavior. A major focus of the interview is about the form, frequency, and severity of self-injury, as well as the frequency and intensity of urges about self-injury. Participants respond to open-ended questions about the frequency, methods, and severity of self- injury, and then they rate the various functions of self-injury as it applies to their behavior using a Likert scale ranging from 0 (never) to 4 (frequently). Options for the functions of self- injury include escaping aversive feelings, generating feelings, communication with others, or to avoid activities or others. Participants also rate the extent to which they feel pain during self-injury, and to what extent their family, friends, or peers may have contributed to self-injurious behavior. Finally, participants also rate the likelihood that they will engage in self-injury in the future. The SITBI interview also assesses the dangerousness of self- injurious behaviors and if previous medical attention was
required for the behavior. The SITBI also consists of segments about the frequency, intensity, and duration of suicidal ideation in the past week through the past year, occurrence of suicidal plans and gestures, and detailed information about previous suicide attempts. Each of the five modules begins with an initial screening question, and if that initial question is endorsed, then the full module is included in the interview. This allows for skipping sections that are not relevant to an interviewee, thus reducing the total length of the interview. A particular advantage of the SITBI is that it includes a thorough assessment of suicidal ideation and behavior in addition to self-injury, a feature that is particularly useful given the high association between self-injury and suicidal behavior (Fox et al., 2020). The SITBI interview is freely available from the developer’s website (see the Resources section of this course) and comes in longer and shorter versions depending on assessment needs. With some time, preparation, and training, the interview can be integrated into a wide variety of clinical settings. Virtual Suicide Risk Assessment Measures . With regard to suicide-specific online measures, the field of virtual suicide assessment has boomed over the last few years. New improvements have been made with real-time monitoring of suicide risk (Kleiman, Turner, Fedor, Beale, Huffman, & Nock, 2017) and integrating virtual suicide monitoring into general hospital settings and emergency departments (Kroll, Stanghellini, DesRoches, et al., 2020). Numerous suicide risk assessment and safety planning apps have been studied, including: Virtual Hope Box (Bush, Smolenski, Denneson, et al., 2017), Stay Alive (Bakker, Kazantis, Rickwood, & Rickard, 2016), Suicide Safety Plan (de la Torre, Castillo, Arambarri, et al., 2017), and many others (Castillo-Sanchez, Camargo-Henriquez, Munoz-Sanchez, et al., 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 emerging options continue to be studied, it is recommended to supplement any virtual or online methods with more traditional clinical assessment protocols.
INITIATING A SPECIFIC-SUICIDE INQUIRY
● 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 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
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?
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Book Code: SWUS1524
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