● Perceived burdensomeness. ● Hopelessness. ● Family history of suicidal behavior. ● Recent stressful life events. ● Impulsivity, and ● Presence of acute indicators of risk (agitation, social withdrawal, sleep disturbance, severe affective states, weight loss). Once a decision about acquired capability has been made, the decision-tree interview should be conducted. Resolved plans or preparations that are clear and with high intent, combined with any other significant findings, result in at least moderate risk. Even without resolved plans or preparation, elevation of suicidal desire or ideation combined with two or more other significant findings result in at least moderate risk. Perhaps the most compelling aspect to this assessment approach is that every element is backed up by ample empirical data for the resulting clinical decisions (Chu et al., 2015; 2017). Joiner and colleagues also offer clinicians possible intervention actions to take depending on the patient’s risk category and explain how to appropriately document these actions (see Box 2). Notably, safety intervention can take a variety of forms from provision of crisis hotline numbers, to generation of helpful activities to cope with suicidal ideation, to higher levels of care and/or hospitalization. Intervention activities will be discussed in further detail later on in the course. Finally, the final step in suicide risk assessment in the Joiner model is, after assigning risk level and developing an intervention plan, appropriate documentation. Examples of documentation of the assessment and intervention level can be found in Box 2. The Joiner model is illustrated in the following case examples. First example: Samantha is a 20-year-old white female who presented for therapy after the break-up of a long-term relationship. During intake, she noted that she wanted help for her “serious abandonment issues” and stated that she often “jumped from one relationship to another.” Samantha noted that she “can’t be alone” and that she has suffered from these problems over the past 5 years. She had no prior treatment history but meets criteria for borderline personality disorder. Samantha had no history of engaging in self-injurious behaviors and denied current and past suicidal ideation. According to the Joiner model, Samantha would be considered to be at low risk because she has no past or current suicidal symptoms. In this case, the Joiner model would recommend taking the following actions: ● Tell the client something along the lines of: “ In the event that you begin to develop suicidal feelings, here’s what I want you to do: First, use the strategies for self-control that we will discuss, including seeking
social support. Then, if suicidal feelings remain, call [the emergency call person]. If, for whatever reason, you are unable to access help, or if you feel like things just won’t wait, call 911 or go to the emergency department.” ● Give additional emergency numbers, including 1-800-273- TALK. ● Consider creating a safety plan (see Intervention section). ● Continue to monitor risk in subsequent sessions. ● Document activities in progress notes. Second Example: Megan is a 37-year-old white female who presented for treatment of depression. She reported that she had been depressed her entire life. As a teenager, Megan abused alcohol and drugs, including amphetamines, marijuana, and LSD, and received inpatient substance use treatment at the age of 18. Shortly thereafter, Megan joined Alcoholics Anonymous and has not used alcohol or drugs since that time. Megan has attempted suicide twice, once by overdose and once by carbon monoxide poisoning, and cut herself in several locations while in substance use treatment. Megan was diagnosed with persistent depressive disorder and borderline personality disorder. She scored in the severe range on the Beck Depression Inventory (31) and reported frequent suicidal ideation but denied suicidal intent. Megan also reported difficulties in her romantic relationship and indicated that she had no close friends. In addition, she reported that she had been unable to maintain employment as a result of difficulty communicating with others. According to the Joiner model, Megan would be considered to be at severe risk because she is a multiple attempter and has current suicidal ideation and at least two additional risk factors (depression, borderline personality disorder, relationship difficulties, thwarted belongingness, employment difficulties). In this case, the Joiner model would recommend taking the following actions: ● Consult with colleague or supervisor before client leaves. ● Consider emergency mental health options with colleague/ supervisor (and offer to client). ● Create a safety plan. ● Give emergency numbers including 1-800-273-TALK . ● Schedule mid-session phone check-ins. ● Attempt to limit access to lethal means (ask about guns, pills, etc.) and document if client refuses. ● If client leaves, arrange for client to be accompanied/ monitored at all times until next appointment. ● If hospitalization is not warranted, get client’s permission to elicit help/support from family members. ● For minor clients, notify parents/guardians. ● Continue to monitor risk in subsequent sessions. ● Document activities in progress notes.
INTERVENTION - CLINICAL REFERRAL
For many professionals, the primary intervention for a patient at elevated suicide risk is referral to additional healthcare. While some professionals may have the ability to work with a suicidal patient utilizing the following clinical interventions, other professionals may not have the ability to directly intervene and will instead have to refer a patient for a higher level of care. Such referring clinicians can include educators, medical or dental professionals, physical and occupational therapists, religious and legal professionals, and it is important to emphasize that intervention via referral in these settings is just as important as direct clinical intervention done by mental healthcare workers. This is because the vast majority of suicidal patients are seen and interact in settings outside that of clinical mental health, and unless these individuals are pointed in the direction of direct intervention many will go on to engage in suicidal behavior without realizing help is available. Thus, someone working in a professional setting involving clinical referral, as opposed to direct care, should take the following steps for referral:
1. Gather suicide risk information. It’s okay to ask a patient about suicidal ideation or plans, doing so will not cause any harm (Bender et al., 2019), and asking can help a potentially suicidal patient open up about what they’ve been experiencing. 2. Using the suicide risk assessment in this course, a referring professional can get a sense of how elevated an individual’s risk is. While a referring clinician may not be responsible for making suicide risk decisions, they can occasionally have the potential to identify high risk cases. In the case of a high-risk patient expressing very intense suicidal ideation, suicide plans, and suicide intent, the professional should consider directing the individual to the hospital for further evaluation, or in extreme cases reaching out to local police for assistance in escorting the individual for further intervention. The referring clinician should not attempt to physically restrain or transport an agitated or potentially hostile suicidal individual, and even if the individual leaves, a professional can simply
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