Suicide Risk Assessment for Clinicians

I remember undertaking my first suicide risk assessment. It included a client that came to the organisation I worked with at that moment and I was scheduled to perform the intake session. 

Details were collected, substance use history documented, and finally we get to a triage type mini suicide risk assessment section (an area that asks the clinician to briefly detail past and current suicidality and thus determine the risk).

The client had lost his job, drank excessively, and described that he had some suicidal intent. To his absolute credit, he'd come for the intake from across town, a journey that also included a 45 minute walk. He was determined to get help.

I was a little shaken (though not visibly I'm told) when he'd described that he'd had the means (a shotgun) and has called off prior attempts to take his life. This man obviously was ambivalent towards dying.

I determined that he was a medium to high risk suicide client, and went to a colleague to consult. After consultation and my colleagues assistance in negotiating with the client, we set him up for counselling sessions, and determined his suicidality as medium risk.

So that's the extent of my initial contact with a suicidal client. After that, I'd familiarised myself with the literature, and have consulted with others about how to best approach these clients. And so I came across the SIMPLE STEPS Suicide Risk Assessment formulated by Dr Jason M. McGlothlin. In his book Developing Clinical Skills in Suicide Assessment, Prevention, and Treatment, he describes this assessment model for suicidal clients. 

In his interview with Rebecca Daniel-Burke of the American Counseling Association (ACA) he looked into these steps along with treatment options at greater length. It's those steps (similar but more expansive than the American Association of Suicidology's IS PATH WARM acronym to suicide risk assessment) that I'm going to list in this post.

The acronym is as follows:

S: Suicidal
I: Ideation

M: Method

P: Perturbation

L: Loss

E: Earlier Attempts

S: Substances

T: Troubleshooting

E: Emotional Diagnosis

P: Parents and Family

S: Stress and Life Events

Basically we want to ask, (1) Is the client suicidal? If they're younger clients you might want to look into what they actually know about the meaning of suicide, and their ideas about death. If the client tiptoes around this question you might want to probe them a little deeper, but what we need as clinicians is a thorough understanding as to whether the client shows any signs that they are or have been at risk of suicide.

Next we look at ideation. (2) What are the client's thought processes like around suicide? How are their thoughts structured? Measuring on an ordinal scale rather than numeral scale might be helpful. For example, does the client want to live and not die? Does the client not care whether they die, but they don't want to take their life? Does the client want to take their life? And, does the client want to take their life and they know how to?  We also look at the clients responses in a temporal way. For example, we might ask them: On a scale of 1 to 10 how likely are you to commit suicide in the next 72 hours? That gives us a sense of how serious the situation is for the client, and how far they're willing to take it.

Method looks at the means of completing suicide. (4) Does the client have access to the means in which they want to take their own life? Remember, we're not assessing for the lethality of of the means, but rather we're assessing the client. If the client thinks that their chosen method of suicide might be lethal (say, taking 7 valium) it's not up to us to determine whether it actually is lethal, but rather the clients intent and access to the means. Does the client have access to the valium? A gun? Bullets? Etc.

Perturbation is basically assessing the pain that the client's in. (5) What makes you want to take you life? This question of pain accompanies the question of how likely the client is to complete suicide using a scaling question. If we ask how likely are they out of 10 to complete suicide and they rate themselves a 3 or 4, then we could look at what it might take for them to reach a 5 or 6. Little steps in determining the client's level of pain might be the key to knowing how to proceed in being a helper.

Loss is next. (5) What's your experience around loss, both perceived and actual? What this question might serve with the assessment - though it could definitely (as with the others) be formulated in a different way - is to find what precipitating factors might serve the client in their thoughts of suicide. The clinician must keep in mind that perceived loss might actually be more debilitating than actual loss. Perceived loss refers to the anxiety around losing something. Whether it's a partner, job, health, or life, it's a loss that's not certain. It's an anxiety about what might be to come and thus there's no sense of closure. Contrast this to actual loss we see that there's the possibility of achieving a sense of closure and working on from there. Once we've understood the client's sense of loss we can begin to understand how this relates to their thoughts an potential actions towards suicide.

Looking for earlier attempts at suicide is next. (6) Have you attempted suicide in the past? This question can prompt the client to discuss the circumstances around any prior attempts. The more attempts the more potential to complete suicide. As the clinician gages the severity of prior attempts, how long ago, and the number of prior attempts, he or she could open a dialogue around the circumstances prior to attempting suicide and seeing how this might relate to treatment.

Substance use is next. (7) Are you currently on any substances or medications at the moment? That question attempts to understand whether the client's use of certain medications or substances (whether licit or illicit) might be contributing to his or her considerations towards suicide. Seeing whether the client is medicine compliant (i.e. actually taking their medications) might serve to find whether any prescriptions that might be helping them handle a diagnosed mental illness are actually serving their purpose. If not, then the clinician could see whether discussion around this might be useful with the client. Understanding the content and frequency of illicit or licit substance use with the client could also serve to gage what probable contribution this might have to the client's ideation. For example, if the client is using a depressant (e.g. alcohol) they could be more likely to commit suicide when they're in their low mood. Using illicit substances that alter brain chemistry and functioning could also increase the client's attempts towards completing suicide.

(8) How are your problem-solving skills? Understanding what a client's troubleshooting skills are like serves to determine the trajectory of suicidal behaviour. For example, if the client accidentally trips over and straight away thinks of suicide they could be more prone to actually completing suicide. When problem-solving skills aren't there then the brains capacity to think of other solutions to what could ultimately end in taking one's own life is compromised. Furthermore, knowing what immediately preceded the client's thoughts of suicide could assist to determine how adequate their problem-solving skills actually are. This could also be an area that the clinician and client could collaborate on in terms of a treatment context; to work on one's troubleshooting skills.

Emotions. These get us into a whole lot of trouble, and if handled suboptimally one could be headed towards a dark place. (9) What emotions are you experiencing when you feel suicidal? Working towards an emotional diagnosis assists the clinician in understanding what contributors could be at work in the intricacy of suicide. What's usually spoken of in this context is when the client's are experiencing a sense of worthlessness, helplessness, hopelessness, loneliness, and/or depression. If the client identifies with one or more of those factors, the clinician will be better equipped to know how to proceed.

Asking question about family history and suicidality or mental illness is also beneficial in the process of suicide risk assessment. (10) Have your parents, or anybody else in your family suffered with anything similar to what you're suffering through? Studies have found that parental depression can contribute to a number of negative outcomes including less than ideal parenting practices and children suffering from similar symptoms, symptoms that could lead to suicidal ideation. Genetic factors also contribute towards a number of diagnoses of mental illness. Therefore as a clinician progresses through an assessment, questions oriented towards understanding family history are essential.

Finally, we want to get a sense of the way stress and life events have contributed to the client's behaviours. (11) How have you been able to handle stress in the past? In a previous post I've detailed important ways that'll hopefully help a person overcome their negative ruminations. Clients that are so focused on the anxieties and stresses of life given certain life events haven't been able to manage their stress levels to the best of their ability. That way, when a clinician's enquiring about the client's stress levels he or she will get a sense of how the client normally reacts to life events. Being able to capture and slow these thoughts about various life events that are perceived negative might wok well in a therapeutic context.

So there we have it, a very valuable resource to aid with suicide risk assessment for the clinician!

Note: The SIMPLE STEPS model presented in this post is a summarised version of what's presented in the ACA interview with Dr. McGlothlin noted earlier

Images retrieved from:

http://religion.lilithezine.com/images/Suicide-03.jpg

http://www.psychotherapybrownbag.com/.a/6a010537101528970b0120a5fb4736970c-320wi

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http://siliconangle.com/files/2013/10/illegal-drugs.jpg

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