A number of competencies or skills are required for adequately working with suicidal individuals. Cramer et. al. (2013) examined a number of resources including the AAS Core Competencies (2010) and other resources. This list is adapted from those resources.
Manage Attitudes and Reactions Towards Suicide and Suicidal Clients
This competency involves self-awareness about your attitudes surrounding suicide. Do you feel suicide is always right, always wrong, is it a grey area? Under what circumstances is it appropriate or not to intervene?
Secondly, how do you respond to someone who is suicidal. Are you calm and in control, can you get there with additional training? If you don’t feel this is something you can handle, having a list of referrals for highly suicidal clients can help.
There is no attitude training program that I know of. This is something that can only be properly built through self-reflection. Understanding your own beliefs, however, is a form of building this competency so that you can respond in a way congruent with your values.
Assess Attitudes Towards Suicide
A number of tools exist to assess attitudes towards suicide. These includes the Attitudes Towards Suicide questionnaire (Diekstra & Kerkhof, 1988) and Understanding of Suicidal Patient (Samuelsson, Asberg & Gustavsson, 1997) scale.
Develop and Maintain a Therapeutic Alliance with Client
A strong therapeutic alliance is essential for client change. Standard skills like active listening, displaying warmth, empathy, and unconditional positive regard come into play.
Recognizing the conflict between the client’s desire to end their psychological pain and your desire to prevent suicide will help the client feel heard. Understanding a model of suicidality and being able to express that to the client helps ensure you’re both on the same page.
Finally, Bordin (1979) identifies three elements making up the “working alliance”: common goals decided between the clinician and client, tasks to be completed and the development of a bond between the clinician and the client.
Build Therapeutic Alliance with Clients
While elements like flexibility, confidence, and trustworthiness are associated with a positive therapeutic alliance (Ackerman & Hilsenroth, 2003) they are difficult to build outside of reflection and supervision.
Elements like Reflection, Interpretation, and Active Listening can be improved by reviewing counselling textbooks (especially video-taped sessions), roleplaying and continuing education in empathy and active listening.
A number of tools are in use to assess the working alliance. The Working Alliance Inventory (Horvath & Greenberg, 1989) is a 36-item tool that focuses on the three elements of the therapeutic alliance. It is available in both therapist and client versions.
Know and Elicit Evidence-based Suicide Risk and Protective Factors
Key to effective suicide risk assessment is the understanding of exactly what factors put someone at risk (risk factors), including what factors constitute elevated baseline risk (for instance a historical sexual assault), what factors increase acute risk (intoxication) and what elements represent a suicide attempt may be imminent (obtaining access to lethal means, putting final affairs in order.)
Understanding suicide protective factors and reasons for living allows one to put in place elements to reduce risk. Finally, understanding suicide-specific language is important in being able to accurately describe a client’s suicidal behaviour.
Understand Suicide Risk and Protective Factors
There is a strong evidence base for suicide risk factors and protective factors. The American Association of Suicidology formed a consensus group to assess the evidence for suicide risk and developed a list of suicide risk and protective factors.
I’ve written a blog post on the elements differentiating suicide attempts from ideators in a youth population.
Taking training such as Applied Suicide Intervention Skills Training (ASIST) or suicideCare can also help, as would programs like the AAS’s Recognizing and Responding to Suicide Risk training.
Suicide specific language can be developed by reading journal articles such as De Leo et al’s (2006) study “Definitions of Suicidal Behavior” or Silverman et. al’s 2007 “Rebuilding the Tower of Babel.”
Beyond evaluation built in to workshops and regular feedback and supervision (from peers or actual supervisors), tools like the Suicide Intervention Response Inventory can help us assess our level of suicide intervention skill.
Identify Current Suicide Plan and Suicidal Intent
Being able to identify the current suicide plan and suicidal intent involves assessing the number, intensity and length of suicidal thoughts, as well as the presence and intensity of suicidal intent.
Additionally being able to understand the suicide plan (and accessibility of that plan) as well as the perceived lethality are important elements in this competency.
The CASE Approach (Shea, 2009) offers one avenue to assessing the suicide plan and intent. Additionally using a structured tool like the DCIB Risk Assessment helps a clinician or telephone crisis worker cover elements relevant to risk.
There are no existing tools that specifically cover a clinician’s exploration of suicidal intent but there are a number of tools the clinician can use with the client to assist them. These include:
Cutter (1999) includes a chapter in his book The Suicide Prevention Triangle discussing a number of assessment measures for suicide and suicidal intent.
Determine Level of Risk
Determining the level of risk means compressing all of the available information to express it in a simple fashion (e.g. Low, Medium, High, Extreme/Imminent) so that decisions about treatment and current status may be made.
This is a process that requires professional, clinical judgement and should only be performed with appropriate clinical supervision and close monitoring until these skills are mastered.
Training and experience in the Collaborative Assessment and Management of Suicidality (CAMS) approach is one structured method for building competency in suicide risk by completing a number of risk areas and assisting in the building of a treatment plan (see the next section, “Develop a Treatment Plan”)
In my opinion, assessing one’s currently level of skill in suicide risk estimation is something that can only be done by a third party. As the saying goes, we don’t know what we don’t know.
Common methods in hospitals include Grand Rounds and patient consults, while in community settings consultation with supervisors, as well as outside supervision with a supervisor well-trained in suicidality.
Develop a Treatment Plan
Developing a treatment plan includes elements such as designing a suicide safety plan, restricting access to lethal means, gaining buy-in from the client about actions to take to preserve safety in the short, medium and long-term and monitoring suicide risk.
I have a blog post on designing suicide safety plans; additionally the Counseling on Access to Lethal Means course is helpful for learning how to reduce access, especially in young persons.
Other activities to protect safety can include beginning counselling or therapy (or returning there if treatment had stopped), a referral to a psychiatrist or other physician for medication.
For those who work in managed care, a book like the Suicide and Homicide Risk Assessment and Prevention Treatment Planner can help you design treatment plans that meet the stringent requirements of HMO and insurance companies.
Assessing your treatment plans is another activity that requires expert opinion, but something like the Ontario Medical Association’s Key Elements to Include in a Coordinated Care Plan (2014) can give you some ideas as to where weaknesses may exist.
Notify and Involve Others
This competency involves understanding when it is appropriate to notify other individuals. For instance, family and friends, other treatment providers, physicians and pharmacists.
Learning your state or province’s laws on informed consent are an important part of developing this competency. Further down the page, “Understand the Law Around Suicide” may help as well. Where homicide risk may be present, see my article on homicide risk assessment.
Framing communication not as an attempt to subvert the client’s autonomy, but rather to help those close to them better help them may reduce resistance to communication.
Additionally, allowing the client to know each individual who was contacted, what they said, and what was put in their treatment plan or case notes (if anything) helps the client see you have their best interests at heart.
Workshops on the legal ramifications of suicide may allow you an opportunity to assess how your current practices work and to develop new ones.
The Counseling on Access to Lethal Means (CALM) course includes a component on involving parents and other independent verifies of information which is an important element in clinical decision making.
Checking in with your clients on a regular basis to see how they feel about decisions you’ve made, beyond a good practice in the therapeutic relationship, is also a good way to develop your intuition by finding out if the client is willing or interested in allowing you to speak with others around them.
Document Risk, Treatment Plan and Clinical Decisions
Risk assessment and treatment planning is useless without proper documentation, for a number of reasons. First, it allows you to monitor the level of risk over time and ensure you haven’t missed anything. Second, it allows collaboration with colleagues and communication of risk information with preciseness. Finally, it reduces legal liability in the event of a client’s suicide.
Ballas (2007) includes an article on documenting suicide risk assessments, and I have an article on document suicide risk here on my blog. The British Columbia Ministry of Children and Family Development has written a policy and practice consideration guide providing additional guidance.
By comparing your existing suicide risk assessments and case notes against the expert examples included in the above resources you can assess your weaknesses.
Understand the Law Around Suicide
You should be familiar with the law regarding suicide in your state, province or country. For instance, what is the process to get someone committed? When can you breach confidentiality? What are your obligations for recordkeeping related to suicide case notes?
This is an entirely individual process. In Ontario, the Ontario Hospital Association has produced a guide to Mental Health and the Law which will assist you in developing the necessary knowledge and decision-making. Continuing education may be available from your local Social Workers organization as well.
Review of your practice by a lawyer who specializes in mental health may help you avoid embarrassing and expensive legal complications and ensure you’re well protected in the future.
Engage in Debriefing and Self Care
Debriefing and self-care are critical to ensuring your continued success as a practitioner, regardless of your professional standing or position. Working with suicidal clients in any capacity can be extremely stressful and feelings of incompetence or failure can easily appear, even in situations where the client suffers no adverse outcomes.
Ensuring regular supervision (including your own psychotherapy if necessary) while working with suicidal clients is helpful. Seeking out additional supervision or clarification of legal or practice issues can be helpful. Regular self-care (sleeping enough, eating healthy, taking time for hobbies, etc.) is always helpful.
Questionnaires are available, including the Maslach Burnout Inventory-General Survey (MBIGS), the Burnout Measure (BM), the Shirom-Melamed Burnout Measure (SMBM), and the Oldenburg Burnout Inventory (OLBI) for topics like burnout, they can help assess your current level of functioning and give you an awareness if you are beginning to have trouble.
Ackerman, S.J., Hilsenroth, M.J. (2003) A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Review. 23(1):1-33
American Association of Suicidology. (2010). Core Competencies for the Assessment and Management of Individuals at Risk for Suicide. Accessed May 14, 2015 from http://www.suicidology.org/Portals/14/docs/Training/RRSR_Core_Competencies.pdf.
Ballas, C. (2007) How to Write a Suicide Note: Practical Tips for Documenting the Evaluation of a Suicidal Patient. Accessed on May 15, 2015 from http://www.psychiatrictimes.com/articles/how-write-suicide-note-practical-tips-documenting-evaluation-suicidal-patient.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice, 16(3), 252–260.
Cramer, R.J., Johnson, S.M., McLaughlin, J., Rausch, E.M., Conroy, M.A. (2013) Suicide Risk Assessment Training for Psychology Doctoral Programs: Core Competencies and a Framework for Training. Training and Education in Professional Psychology. 7(1):1-11. doi: 10.1037/a0031836.
Cutter, F. (1999). The Suicide Prevention Triangle. Triangle Books.
De Leo, D., Burgis, S., Bertolote, J.M., Kerkhof, A.F.F.M., Bille-Brahe, U. (2006) Definitions of Suicidal Behavior: Lessons Learned from the WHO/EURO Multicentre Study. Crisis. 27(1).4-15. DOI 10.1027/0227-5910.27.1.4
Diekstra, R.F.W., Kerkof, J.F.M. (1988) Attitudes Toward Suicide: Development of a Suicide Attitude Questionnaire (SUIATT). Current Issues of Suicidology. (1988) 462-476
Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36(2), 223 – 233
Ontario Medical Association. (2014) Platt, Katherin. Key Elements to Include in a Coordinated Care Plan. Accessed on May 14, 2015 from https://www.oma.org/Resources/Documents/CoordinatedCarePlan_June2014.pdf
Samuelsson, M., Asberg, M., & Gustavsson, J.P. (1997). Attitudes of psychiatric nursing personnel towards patients who have attempted suicide. Acta Psychiatrica Scandinavica, 95, 222-230
Silverman, M. M., Berman, A. L., Sanddal, N. D., O’Carroll, P. W. and Joiner, T. E. (2007), Rebuilding the Tower of Babel: A Revised Nomenclature for the Study of Suicide and Suicidal Behaviors Part 2: Suicide-Related Ideations, Communications, and Behaviors. Suicide and Life-Threat Behavi, 37: 264–277. doi: 10.1521/suli.2007.37.3.264
The DCIB Suicide Risk Assessment follows the new standards of the National Suicide Prevention Lifeline (Joiner, et. al., 2007). The result of the research and expert consensus was the following core principles and subcomponents, listed below. If you prefer to watch, you can see a video below.
Components of the DCIB Risk Assessment
- Suicidal Ideation (Desire to kill self/others)
- Psychological Pain
- Perceived Burden on Others
- Feeling Trapped
- Feeling Intolerably Alone
- History of Suicide Attempts
- Exposure to Someone Else’s Death by Suicide
- History of/Current Violence to Others
- Available Means of Killing Self
- Currently Intoxicated
- Substance Abuse
- Acute Symptoms of Mental Illness (e.g. recent dramatic change in mood, out of touch with reality)
- Extreme Agitation (Increased anxiety, decreased sleep)
- Attempt in Progress
- Plan to Kill Self/Other (method known)
- Preparatory Behaviour
- Expressed Intent to Die
- Immediate Supports
- Social Supports
- Planning for the Future
- Engagement with Helper
- Ambivalence for Living/Dying
- Core Values/Beliefs
- Sense of Purpose
Example of DCIB Assessment
One suicide risk assessment example using the DCIB Standard comes from the Hospital Association of Southern California (HASC) and has also been adopted by the iCarol helpline management software. In the HASC example specific, concrete elements are given to determine the Low, Moderate or High Risk for each element.
Scoring the DCIB Assessment
If the majority of the elements in each category (Desire, Capability, Intent or Desire) are Moderate or High, the element is scored as present. The HASC example of the DCIB Risk Assessment is scored on the following 5-point scale:
- 5 – Suicide Attempt in Progress of Imminent
- 4 – Desire/Capability/Intent ALL Present regardless of buffers
- 4 – Desire/Intent or Desire/Capability with few/no buffers
- 3 – Desire/Intent or Desire/Capability or Capability/Intent with many buffers
- 3 – Capability alone / Intent alone with many buffers
- 2/1 – Desire alone, many buffers
- 0 – No Desire, Capability or Intent
Joiner, T., Kalafat, J., Draper, J., Stokes, H., Knudson, M., Berman, A.L., McKeon, R. (2007) Establishing Standards for the Assessment of Suicide Risk Among Callers to the National Suicide Prevention Lifeline. Suicide and Life Threatening Behaviour. 37(3). 353-365
The Samaritans are one of the most well-known suicide prevention organizations, helping individuals in distress via telephone, email and even through postal mail, over 5 million times a year (Pollack et. al. 2008) The Samaritans teach their volunteers the skills of active listening and the value of self-determination, and therefore most Samaritan organizations use no caller ID and only intervene in calls with suicidal individuals when they ask the person to do so.
Vining (1995) describes a simple suicide risk assessment tool used by at least one Samaritans branch in the past. Since that article was published 10 years ago, the Samaritans have moved to a standardized training known as Samaritans Initial Training (SIT) and are in the process of updating their suicide risk assessment training. A 2002 risk assessment presentation trained individuals on this particular assessment though.
Just to be clear: The Samaritans do not currently use or teach this tool.
A 2008 evaluation of the Samaritans (Pollack, et. al, p.56) service noted calls were coded on a 7 point scale, ranging from -3 to +3, where -3 indicated an abusive caller, fantasizer, and +3 being a suicide attempt in progress or imminent, and the levels in between being various levels of emotional distress.
Suicide Risk Assessment Tool
Part I. Chief Indicator of Immediate Risk
Imminent Sudden Death (Firearm, Hanging, Jumping) – 8
Imminent Slow Method of Suicide (Overdose, Cutting) – 7
Future Sudden Death Planned – 6
Future Slow Method of Suicide Planned – 5
Planning Suicide “Gamble” – 4
Planning Suicidal Gesture – 3
Definite Suicidal Thoughts – 2
Toying Vaguely with Idea of Suicide – 1
No Suicidal Thoughts – 0
Part II. Additional Risk Factors
Previous Suicidal Acts or Gestures – 4
Recent Broken Relationships / Isolation / Rejection – 3 (each)
No Hope / Loss of Faith – 3 (each)
Depressive Illness – 2
Dependence on Alcohol / Drugs – 2
Possession of Means of Suicide – 2
Putting Affairs in Order – 2
Finally the score on these two sets of items are scored based on the following criteria:
Score of 8+ or greater on Part I. or more than 20 in total = Imminent Risk
14-19 = High Risk
6-11 = Moderate Risk
1-5 = Low Risk
My Thoughts on the Tool
I wonder whether the depth of the suicide plan is really the best predictor of a later suicide attempt. Someone who believes that overdosing, if they believe it will kill them, is no less likely to attempt suicide than someone who plans to jump off a building. One may even argue that the suicide risk is lower with someone who plans to jump because they have less access to tall buildings than they do to medication.
The ambiguous wording in some of these items may also hamper reliability of the scale. A suicide gamble appears to be ambivalence regarding an actual suicide attempt, despite intent being present (for instance an overdose with the intent of dying), where a suicidal gesture lacks intent – the person merely wishes to express emotional pain but has no intent to die.
The fuzziness of “definite suicide thoughts” and “toying with the idea of suicide” is also problematic in evaluating use of the tool.
I question the predictive value of some of these risk factors, particularly given their contradiction with the AAS Consensus List of Suicide Risk Factors.
Certainly previous suicide attempts are well-correlated to an increase in baseline risk for suicide death (Suominen, et. al., 2004) but it is less clear whether “suicide gestures” (where a lack of intent is present) increase risk of dying by suicide.
Relationship breakdown (Wyder, Ward & De Leo, 2009), isolation (Roma, et. al., 2003) and rejection by parents or peers (Donath, et. al., 2014; Fotti, Katz, Afifi & Cox, 2006) show some predictive validity in determining suicide risk, and the presence of strong social support is a protective factor that reduces suicide risk. (Compton, Thompson & Kaslow, 2005)
Hopelessness has been well established as a risk factor to suicide attempts (Beck et. al., 1990), as has alcohol and drug use (Tondo, et. al., 1999).
On the other hand, someone who is intoxicated may attempt suicide where they would not have otherwise, in the absence of a dependence on drugs or alcohol. Will someone who is actively intoxicated be scored these two points? If so, I would argue given the impact of alcohol on impulsiveness and judgement that being actively intoxicated is a high-risk factor for a later suicide attempt.
Redesigning this Suicide Risk Assessment Tool
I can see why the tool was attractive; it provides a simple framework that can be performed on the phone by trained paraprofessionals like crisis line volunteers. On the other hand, if the risk factors that are being assessed are not empirically related to suicide risk, they run the risk of underestimating lethality.
Taking a look at the existing tool, a number of themes exist in the elements covered:
Presence of Suicide Plan
Imminent Sudden Death (Firearm, Hanging, Jumping)
Imminent Slow Method of Suicide (Overdose, Cutting)
Future Sudden Death Planned
Future Slow Method of Suicide Planned
Presence of Suicide Ideation (Suicidal Thoughts)
Planning Suicide “Gamble”
Planning Suicidal Gesture
Definite Suicidal Thoughts
Toying Vaguely with Idea of Suicide
Historical / Stable Risk Factors
Previous Suicidal Acts or Gestures
Dependence on Alcohol / Drugs
Acute Risk Factors
Recent Broken Relationships / Isolation / Rejection
Possession of Means of Suicide
No Hope / Loss of Faith
Immediate Warning Signs
Putting Affairs in Order
Historical vs. Dynamic
These categories indiscriminately cover both suicide risk factors and warning signs, as well as modifiable factors and non-modifiable factors. It’s important that a suicide risk assessment tool only assess those factors likely to be relevant to a suicide attempt.
Chief Indicator of Immediate Risk
I suggest collapsing the first four items under “Chief Indicator of Immediate Risk” referring to the suicide plan into one item, “Presence of Suicide Plan”, which I would score two points. Then I would include a self-reported timeline differentiating between 1 hour, 24 hours, one week, one month, or one year, in decreasing order of significance.
Next, I would remove “Planning Suicide Gamble” and “Planning Suicidal Gesture” entirely as these items are too vague as to be useful. I would collapse “Definite Suicidal Thoughts” and “Toying Vaguely with the Idea of Suicide” into one item, “Presence of Suicidal Thoughts.”
Additional Risk Factors
TI would begin by renaming “Previous Suicidal Acts or Gestures” to “Previous Suicide Attempts.” Suicidal gestures without intent are not predictive of death by suicide. (Nock & Kessler, 2006)
I would rename “Depressive Illness” to “Presence of Mental Illness.” While depression is the most common mental illness leading to suicide, other mental illnesses have also shown likelihood to die, with complex psychiatric history – defined as 3 or more diagnoses having the highest risk of suicide attempt. (Nock & Kessler, 2006)
I would rename “Dependence on Alcohol / Drugs” to “Presence of Substance Abuse”, and add “Currently Intoxicated” as a warning sign. Alcohol and drug abuse has been associated with later unplanned suicide attempts (Borges, Walter & Kessler, 2000), which agrees with (Kaplan, et. al., 2012) who notes a large portion of suicide attempts or deaths involve intoxication.
“Possession of Means of Suicide” is helpful as an acute risk factor and does not need changing.
“Recent Broken Relationships / Isolation / Rejection” can be kept, but perhaps changed to “Presence of Precipitating Event” with these items listed as examples. A precipitating event viewed as overwhelming by the individual commonly precedes a suicide attempt. (Maltsberger, et. al., 2003)
“No Hope / Loss of Faith” appear to cover the same factor, hopelessness. Hopelessness, as noted above, is predictive of later suicide attempts but I feel these items should be collapsed into one so as to avoid over-emphasis on this score.
Finally, “Putting Affairs in Order” is a noted warning sign of imminent suicidal behaviour but one that is elusive to study. I suggest renaming this to “Preparatory Behaviour” to cover the wide variety of preparatory behaviours (obtaining means, ensuring solitude, preventing rescue, and so on.)
One factor missing from the historical risk factors that correlates strongly with later suicide attempts is history of sexual abuse and/or rape. (Nock & Kessler, 2006)
New Suicide Risk Assessment Tool
Part I. Chief Indicator of Imminent Risk
Presence of Suicidal Thoughts 1
Presence of Suicide Plan 2
If present, is there a timeline for attempt?
Within several hours 6
Within one day 5
Within one week 4
Within one month 3
Within one year 2
Additional Risk Factors
Historical / Stable
Previous Suicide Attempts 4
Presence of Mental Illness 3
(3 or more?) 2
Presence of Substance Abuse 2
Previous Sexual Abuse / Rape 2
Acute / Dynamic
Possession of Means of Suicide 2
Recent Precipitating Event (Recent Broken Relationships / Isolation / Rejection) 2
Preparatory Behaviour (Putting Affairs in Order / Obtaining Lethal Means / Steps to Avoid Rescue) 3
Currently Intoxicated 3
Scoring the New Suicide Risk Assessment Tool
The existing score system can still be used to score the updated tool. It should take no more time to use or score this tool that and it would the previous one, and now each item is empirically associated with future suicide attempts.
Score of 8+ or greater than 20 in total = Imminent Risk
14-19 = High Risk
6-11 = Moderate Risk
1-5 = Low Risk
Beck, A.T., Brown, G., Berchick, R.J., Stewart, B.L., Steer, R.A. (1990). Relationship Between Hopelessness and Ultimate Suicide: A Replication with Psychiatric Outpatients. American Journal of Psychiatry. 147(2).
Borges, G., Walters, E.E., Kessler, R.C. (2000) Associations of substance use, abuse, and dependence with subsequent suicidal behaviour. American Journal of Epidemiology. 151(8). 781-789
Compton, M.T., Thompson, N.J., Kaslow, N.J. (2005) Social environment factors associated with suicide attempt among low-income African Americans: The protective role of family relationships and social support. Journal of Social Psychiatry and Psychiatric Epidemiology. 40:175–185. doi: 10.1007/s00127-005-0865-6.
Donath, C., Graessel, E., Baier, D., Bleich, S., Hillemacher, T., (2014) Is parenting style a predictor of suicide attempts in a representative sample of adolescents?. BMC Pediatrics. doi: 10.1186/1471-2431-14-113
Fotti, S.A., Katz, L.Y., Afifi, T.O., Cox, B.J. (2006) The associations between peer and parental relationships and suicidal behaviours in early adolescents. Canadian Journal of Psychiatry. 51(11):698-703.
Kaplan, M.S., McFarland, B.H., Huguet, N., Conner, K., Caetano, R., Giesbrecht, N., Nolte, K.B. (2012) Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System. Journal of Injury Prevention. doi:10.1136/injuryprev-2012-040317
Maltsberger, J.T., Hendin, H., Haas, A.P., Lipschitz, A. (2003) Determination of Precipitating Events in the Suicide of Psychiatric Patients. Journal of Suicide and Life Threatening Behavior.
Nock, M.K., Kessler, R.C. (2006) Prevalence of and Risk Factors for Suicide Attempts Versus Suicide Gestures: Analysis of the National Comorbidity Survey. Journal of Abnormal Psychology. 115(3). 616-623. doi: 10.1037/0021-843X.115.3.616
Pollack, K., Armstrong, S., Coveney, C., Moore, J. (2008) An Evaluation of Samaritans Telephone and Email Emotional Support Service. Nottingham University. Accessed May 10, 2015.
Roma, P., Pompili, M., Lester, D., Girardi, P., Ferracuti, S. (2013) Incremental conditions of isolation as a predictor of suicide in prisoners. Forensic Science International. 233(1-3)e:1-2. doi: 10.1016/j.forsciint.2013.08.016
Suominen K., Isometsa E., Suokas J., Haukka, J., Achte, K., Lonngvist, J. (2004) Completed suicide after a suicide attempt: a 37-year follow-up study. American Journal of Psychiatry. 161:563-564.
Tondo, L, Baldessarini, R.J., Hennen, J., Minnai, G.P., Salis, P., Scamonatti, L, Masia, M., Ghiani, C., Mannu, P. (1999) Suicide attempts in major affective disorder patients with comorbid substance use disorders. Journal of Clinical Psychiatry, 60(2), 63-69.
Vining, R.M. Assessing risk of suicide: Samaritans’ scoring system helps develop judgment (1995) British Medical Journal.
Wyder, M., WArd, P., De Leo, D. (2008) Separation as a suicide risk factor. Journal of Affective Disorders. 116(3) 208-213. doi: 10.1016/j.jad.2008.11.007
A safety plan is a written list of those activities that allow us to do three things:
- Recognize when a crisis is occurring
- Recognize who our supports are
- Make immediate next-steps for planning
Safety plans are not checklists, and they should not be used in place of having a real conversation. They help provide a sense of control and a reminder to suicidal individuals that they have resources to rely on.
Warning signs are anything that indicates a suicidal crisis might be coming. This are unique but some examples could be a change in physical or mental health status, a fight with someone, academic or occupational difficulties, financial problems, and anything else that will trigger your suicidal thoughts.
You can ask questions like:
- What do you think led you to feeling suicidal?
- How is today (or when you felt suicidal) different from yesterday?
- What things would have to change to take these suicidal feelings away?
Your support network is all of the resources you draw on to help yourself get through a crisis. They include internal supports, external supports, and peripheral supports. You can read more about this on my support network article.
- Future Hopes and Dreams
- Positive Value System
- Religion and Spirituality
- Past Experiences
- Listening to music
- Taking a hot bath
External supports are those friends and family who we’re close to, and can rely on when our internal supports just aren’t good enough.
- Boss / Colleagues
Peripheral supports are the professionals we move to when our external supports are not qualified.
- Counsellor / Therapist
- Crisis Lines
- Mobile Crisis Teams
- Information and Referral Services
- Social Service Agencies
Strategies for Reducing Risk in a Crisis
There are a number of steps a person can take depending on their level of suicide risk. The traditional model is a three-pronged approach.
Low risk focuses on active listening. By exploring with the person what led them to have these suicidal thoughts you can help them feel some catharsis and emotional relief. There is no need to be directive here, or even to offer resources unless the person wants them.
In medium risk situations it is important to focus on a collaborative safety model. This may include counseling on access to lethal means, referrals and follow up. This ensures that someone who might attempt suicide in the medium term is able to access enough support.
One important element about referrals: the referrals that have the best uptake are existing or past referrals, while the lowest rate of taking action is to new referrals. (Gould, et. al., 2012)
In high risk suicide situations we will focus on emergency referrals and unilateral intervention. Mobile crisis teams, hospitals and police will be the appropriate referrals at this stage.
In the case of a suicide attempt in progress, getting an ambulance will be of utmost priority.
Sample Safety Plan
Stanley & Brown (2008) wrote a safety plan and accompanying manual that can be used with adults, particularly veterans. It would require some changes to the wording for use with youth but the principles are the same.
Gould, M.S., Munfakh, J.L.H., Kleinman, M., Lake, A.M. (2012) National Suicide Prevention Lifeline: Enhancing Mental Health Care for Suicidal Individuals and Other People in Crisis. Journal of Suicide and Life Threatening Behavior. doi: 10.1111/j.1943-278X.2011.00068.x
Stanley, B., Brown, G.K. (2008) Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version. Department of Veterans Affairs.
Youth suicide represents a significant public health issue and one particularly important given that young people often have fewer tools to deal with their suicidal thoughts.
Suicide is the 4th leading cause of death for youth in Canada (Statistics Canada, 2011). There are between 50 and 200 suicide attempts per suicide death in adolescents (Schwartz, 2003).
This rate is higher than the estimated 25 attempts per suicide death in adults (McIntosh, 2012), which could be due to an underestimation of lethality, as Kartakis (1999) noted in an adult population, or because of an ambivalence, a desire not to die. Given youth often have trouble communicating their emotional needs either one could contribute.
The Role of Attitudes and Beliefs about Suicide
One study, by Lake, Kandasamy, Kleinman & Gould (2013) looked at the attitudes of adolescents towards the causes of suicidal behaviour and identified two distinct belief systems:
- Stress model, that believes that suicidal behaviour is the result of overwhelming stress
- Medical model, that believes suicidal behaviour is the result of mental illness.
This is backed up by Muehlenhamp & Gutierrez (2004) that found attitudes towards dying in a sample of high school students were associated with suicide attempts but not self-harm.
Youth who believed in the stress model were more likely to believe suicide was something that happened to everyone and that it was not treatable or curable. Assessing youth attitudes towards suicide may therefore represent an opportunity to intervene before suicidal thoughts begin.
Risk Factors for Adolescent Suicide
Taliferro & Muehlenkamp (2014) identify a number of risk and protective factors. Some of them are similar to adult risk factors while others are specific to youth.
- Alcohol and Drug Use (Cash & Bridge, 2009)
- Bullying Behaviour / Fighting
- Impulsiveness (Klonsky and May, 2010)
- Mental Health Issues
- Parental Substance Abuse
- Running Away from Home
- Self-Injurious Behaviour
- Victim of Childhood Abuse
In addition, a few risk factors were associated more suicidal behaviour in one gender than the other. In males, smoking (cigarettes or marijuana) and truancy were risk factors in males, while being victims of dating violence, having same-sex experiences and perceiving one’s self as being overweight were risk factors in females.
A Note on Impulsiveness
Impulsiveness has been noted in other sources (e.g. the Counseling on Access to Lethal Means course) as a risk factor in that youth can act on suicidal impulses before someone has a chance to intervene, however Klonsky & May (2010) revealed that it was not the impulsiveness that was the danger (when comparing youth who attempted suicide from youth who didn’t), but rather a poor ability to forsee the consequences for their actions.
Protective Factors for Adolescent Suicide
The following protective factors were identified as well:
- Academic Achievement (Borowsky, Ireland & Resnick, 2001)
- Enjoying School
- Parental and Non-Parental Connectedness (trusted adults)
- Supportive Friendships
- Involvement in Sports
- School Engagement and Safety
It’s important to note that liking school was more a protective factor for females, while feeling safe in school was more a protective factor for males.
Borowsky, I.W., Ireland, M., Resnick, M.D. (2001) Adolescent Suicide Attempts: Risks and Protectors. Journal of Pediatrics. 107(3). 485-493. doi: 10.1542/peds.107.3.485
Cash, S.J. and Bridge, J.A. (2009) Epidemiology of Youth Suicide and Suicidal Behaviour. Current Opinions in Pediatrics. 21(5). 613-619.
J.L. McIntosh. (2012) “USA Suicide 2009 Official Final Data” Accessed May 5, 2015 from http://www.isu.edu/irh/projects/ysp/downloads/2009NationalData-AAS.pdf
Kartakis, P. (1999) The Persistently Suicidal: Perceived Lethality, Intent and Hopelessness Among Multiple Attempters. MA Thesis, York University.
Klonsky, E.D., May, A. (2010) Rethinking impulsivity in suicide. Journal of Suicide and Life Threatening Behavior. (40)6. 612-9. doi: 10.1521/suli.2010.40.6.612
Lake, A.M., Kandasamy, S., Kleinman, M., Gould, M.S. (2010) Adolescents’ attitudes about the role of mental illness in suicide, and their association with suicide risk. Journal of Suicide and Life Threatening Behaviour. 43(6):692-703. doi: 10.1111/sltb.12052.
Muehlenkamp, J. J. and Gutierrez, P. M. (2004), An Investigation of Differences Between Self-Injurious Behavior and Suicide Attempts in a Sample of Adolescents. Journal of Suicide and Life-Threatening Behaviour, 34: 12–23. doi: 10.1521/suli.126.96.36.199769
Schwartz, M.W. (2003) The 5-minute Pediatric Consult. Lippincott Williams & Wilkins. pp 796.
Statistics Canada. Table 102-0561 – Leading causes of death, total population, by age group and sex, Canada, annual, CANSIM (database). Accessed May 7, 2015.
Taliaferro, L.A., & Muehlenkamp, J. J. (2014). Risk and protective factors that distinguish adolescents who attempt suicide from those who only consider suicide in the past year. Journal of Suicide & Life-Threatening Behavior, 44, 6-22.