Box 2: Taking Action and Documenting
Rate Risk (also use decision tree) Risk is: low □
low-moderate □
moderate □
moderate-severe □
severe □
extreme □
Take Action All the following actions can be taken by assessor: Low End of Risk Scale: • Regular monitoring. • Provide client with emergency numbers (1-800-273-TALK and local numbers).
• Provide client information about adjunctive treatment. • Encourage client to seek support from friends and family. • Tell the client: “If you begin to experience suicidal feelings and for any reason cannot get help, go to the closest emergency department or call 911.” • Document. Low to Middle of Risk Scale (take previous actions and also …) • Mid-week phone check-in scheduled for: ___________________________________________. • Means safety/restriction interventions (ask about removing guns, pills, ropes from the home or restricting access in other ways). • Complete safety plan form with client. • Complete a crisis card with client. • Consult supervisor within 24 hours. Above Middle of Risk Scale (take all previous actions and also …) • Frequent phone check-ins. • Arrange for client not to be alone (monitored by family member or friend). • Consult supervisor before client leaves. Severe or Extreme Risk • Voluntary or involuntary hospitalization. Consult if: unsure of risk level or actions taken, moderate to severe risk level or above, notable increase in symptoms. Suggested Documentation “Suicide risk was assessed according to Joiner et al. (1999) and determined to be [low/moderate/severe/extreme] due to … [e.g., ideation, plans, preparations, etc.]. Action taken: [e.g., safety plan, emergency numbers, consulted with supervisor, etc.]. Risk will continue to be monitored.” Note . Adapted from “Routinized Assessment of Suicide Risk in Clinical Practice: An Empirically Informed Update,” by C. Chu, K. M. Klein, J. M. Buchman-Schmitt, M. A. Horn, C. R. Hagan, and T. E. Joiner, 2015, Journal of Clinical Psychology, 71 (12), pp. 1186-1200; and “Scientizing and Routinizing the Assessment of Suicidality in Outpatient Practice,” by T. E. Joiner, Jr., R. L. Walker, M. D. Rudd, and D. A. Jobes, 1999, Professional Psychology: Research and Practice, 30 (5), pp. 1-7.
The presence or absence of a history of multiple prior attempts is an important variable in the Joiner system and is emphasized with a separate categorization of risk. In a classic study, Rudd, Joiner, and Rajab (1996) explored the relationship among suicide ideators, single attempters, and multiple attempters across several categories, and they determined that “multiple attempters presented a more severe clinical picture and, accordingly, elevated suicide risk compared to [single] attempters and ideators” (p. 541). Further, according to the Joiner risk assessment model, attempt status (i.e., whether the individual has attempted once [single attempter] or more than once [multiple attempter]) should be considered along with several risk factors in order to determine an individual’s risk category. Risk factors from Joiner’s model of suicidal behavior, the Interpersonal Theory of Suicidal Behavior (IPTS; Joiner, 2005; Van Orden, et al., 2010) include: ● Capability for suicide (e.g., non-suicidal self-injury, fearlessness about death).
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.
● Thwarted belongingness. ● 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).
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