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 Determining the level of intervention Regardless of which suicide risk assessment approach is utilized, it is always necessary for an interviewing clinician to establish the suicide risk level of an individual AND select the appropriate level of intervention necessary to keep the high-risk individual safe. While some completing this training may not have definitive clinical duties and responsibilities that require them to intervene with a patient, it is nonetheless important and potentially lifesaving to follow the same procedures outlined with regard to assigning risk level and appropriate level of intervention. Depending on the specific situation, determinations need to be made about the client’s ability to manage the situation. For example, it is often necessary for the therapist to take control when suicidality is related to certain risk factors such as high-risk psychiatric disorders (e.g., schizophrenia), prominent feelings of pain and a wish to escape, or risk that is acute. When the specific situation is related to a client’s personality disorder that presents with chronic suicidality and prominent feelings of anger, Jacobs and colleagues recommended giving the client more control and responsibility in managing the situation (Jacobs et al., 1999). Although clients with personality disorders may exhibit a clear predominating set of features, it also should be remembered that they can shift toward greater risk and always need to be
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; Fowler et al., 2017); and ● Framework #2 – Joiner’s Assessment Model (Joiner et al., 1999; Chu et al., 2015). fully evaluated. In such cases, the clinician should be ready to take more responsibility than was previously appropriate. If suicide risk is deemed high in these clients, the clinician needs to ensure that the individual is in an appropriately safe and secure environment. It is vital that the clinician organize reassessment within 24 hours. The clinician should make sure that contingency plans are in place for rapid reassessment if distress or symptoms escalate. Clinicians need to assess a client’s competence to enter into a treatment process when suicidal danger is acute. The client should be able to explain the risks and benefits for each treatment course considered. Given the extreme constriction that often is evident with suicidal clients, seeing alternatives may be quite a challenge for them. For example, clients experiencing a recent relationship break-up may be experiencing high levels of stress and suicidal ideation and may believe that the only solution left is suicide. They may have convinced themselves that they are “unlovable” and will never find love again because their partner has left them. If a client’s competence to consent to treatment is impaired or if the clinician judges that the client is at imminent risk for suicide, involuntary treatment (usually hospitalization) should be sought. 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 until any discrepancies between the assessment and the patient’s responses are addressed. 3. Determine intensity : In cases where the patient is having suicidal thoughts, the clinician should ask specific questions about the intensity and frequency of the suicidal thoughts as well as the degree to which the patient is prepared. Does the patient have a suicide plan? If a specific plan is described, the clinician should document that and document whether the patient has self-injurious or lethal plans. Additionally, the clinician should inquire about the method of suicide rehearsals, such as loading a gun, walking on a bridge to assess the height, or tying a noose. Whenever possible, the clinician should confirm findings with a family member or a close friend because patients are more likely to inform close relations of suicidal ideation than they are to tell a healthcare provider. 4. Assessment of protective factors : The clinician should inquire about existing protective factors against suicidal thoughts, such as strong family ties and friendships or the presence of a significant other. Additionally, religious belief, faith, and a sense of belonging can be used as protective factors. It is best to explore the patient’s reasons to die versus reasons to live. The presence of protective factors can help dampen the suicide risk in people with low or moderate
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. 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,
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 (Kazim, 2017): 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 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
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