The Joint Commission on Accreditation of Healthcare Organizations that accredits healthcare organizations in the US is often a requirement for state licensure or for receiving Medicare/Medicaid reimbursements.
One of the items in the Joint Commission accreditation is Goal 15.01.01, comprehensive suicide risk assessment. This involves screening of individuals who are at risk, and further assessment and intervention for those who have elevated risk.
There are three main types of screening:
- Indicated Screening – Individuals who appear to be at risk based on demeanor or appearance are subjected to a suicide risk assessment
- Selective Screening – Individuals who fall into certain high-risk categories (e.g. individuals with depression) are screened
- Universal Screening – All individuals presenting to an organization (hospital, community organization, doctor) are given a brief suicide risk screening
While indicated screening is the most common currently practiced, neither indicated nor selective screening is sufficient to meet the Joint Commission requirements. In a study of 8 Emergency Departments who implemented universal screening, the rate of detected suicidal ideation was doubled. (Boudreaux, et al., 2015)
The ED-SAFE study involves a decision support tool that involves a series of structured questions to assess suicide risk.
Decision Support Tool
- Question 1. Ex. Have you had recent thoughts of killing yourself? Is there other evidence of suicidal thoughts, such as reports from family or friends?
- Question 2. Do you have any intention of killing yourself?
- Question 3. Have you ever tried to kill yourself?
- Question 4. Have you had treatment for mental health problems? Do you have a mental health issue that affects your ability to do things in life?
- Question 5. Have you had four or more (female) or five or more (male) drinks on one occasion in the past month or have you used drugs or medication for non-medical reasons in the past month? Has drinking or drug use been a problem for you?
- Question 6. Recently, have you been feeling very anxious or agitated? Have you been having conflicts or getting into fights? Is there direct evidence of irritability, agitation, or aggression?
If the patient answers yes to any of the above questions, a referral to a mental health clinician should be considered. For comprehensive suicide risk assessment beyond this tool, consider the SAFE-T Tool.
Caring for Adult Patients with Suicide Risk
The Suicide Prevention Resource Centre has developed this handy suicide risk guide to help you implement suicide risk assessment screening into your emergency department or community organization.
Boudreaux, E., Allen, M., Goldstein, A.B., Manton, A., Espinola, J., Miller, I. (2015) Improving Screening and Detection of Suicide Risk: Results from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Effectiveness Trial. Society for Prevention Research 23rd Annual Meeting. Accessed Jun 28 2015 from https://spr.confex.com/spr/spr2015/webprogram/Paper23206.html
In the helping professions, including both client-facing roles (like therapy or case management) and other roles, the importance of being able to talk constructively with people is key.
Particularly in areas like nursing or case management where both physical/medical issues need to be taken care of, patients can feel overlooked or like they’re not taken care of, even when they’re instrumental issues (e.g. their medical problems or what brought them into the service) are being handled.
The core to making a person feel heard is to use empathy statements. These are statements that allow you to communicate in a way that makes the other person feel heard or understood.
An empathy statement has the following structure: an opening statement (often that references what the person has said), followed by an emotion, and sometimes a statement closer.
For instance, “When you say that nobody cares about you, it sounds like you’re feeling really alone.” The person may say, “Yeah, I do really feel alone, I might talk to one person a week”, that further explores the problem.
On the other hand, they might say “No, I’m not feeling alone at all, I’m more angry than anything”; this is okay! Now you know exactly what emotion they are experiencing.
DESC Model for Assertive Communication / WIN Statements
The DESC Model is one way to communicate assertively when you need something from someone, or you need them to know what you’re feeling. They also have the name “WIN” statement as a short way to remember them.
DESC stands for Describe, Express, Specify and Consequences:
- Describe the Situation – Say what behaviour the person is doing you wish to change
- Express Your Feelings – I feel ___________.
- Specify what you want – I want/prefer/need you to ___________.
- Consequences – Indicate what you and the person will gain if they give you what you’ve asked for
WIN Statements are a shorter version of this:
- When you ___________ I feel ___________; I need you to ___________.
Active Listening Training Resources
For more indepth training on active listening, you have a number of options: most crisis lines offer basic training sessions (linked here is the ContactUSA helpline accreditation standards) that cover emotional support and active listening, I have an article on building helpline skills that covers active listening, and most counselling courses cover this as well.
There are also private seminars that go over this, such as those offered by the Helplines Partnership in the UK.
Active Listening Barriers
There are some things that you want to avoid in active listening, things that get in the way of providing emotional support.
Interrupting can sometimes be because someone is speaking slowly, they’re speaking too quietly for you to hear them, because you need to get more information from them, or because you’re not sure if the sentence has ended due to a language barrier.
Unfortunately when you interrupt, this gives the person the perception that you don’t care, and that can be very invalidating – even if you knew what they were going to say. Simply practice waiting until the person has finished talking completely or asking them to speak up if you can’t hear them.
Why questions are common in our everyday speech, but their use in emotional support conversations can be very judgemental. Instead of saying “Why do you think nobody likes you”, say something like, “Tell me more about that” or “What makes you think that nobody likes you?”
Fixing / Offering Advice
Fixing, or offering advice is a very natural gesture that takes a lot of work to undo. Giving advice promotes dependence on you, which means if you tell them to do something and things go wrong, you’ll be blamed for it, and the person will be unable to make their own decisions.
We want to promote independence and empowerment by helping people to make their own decisions. Rather than making the decision for them, you can explore options with them, by asking “Have you thought about xyz?”, “Tell me how you’ve coped with this situation in the past”, and avoiding use of the word “should.”