Organizations like the Tema Conter Memorial Trust in Canada and Reviving Responders in the US have highlighted the skyrocketing rate of suicide among first responders, including police officers, paramedics and firefighters. In 2015, there were over 100 suicides by law enforcement officers in the US. (Kulbarsh, 2016) They note the high incidence of PTSD among law enforcement officers and the stigma that prevents them from seeking support.
One way to reduce law enforcement suicide is through police academy training that provides all officers with suicide awareness training. This helps reduce the stigma of receiving mental health support and gives police the opportunity to act as peer supporters for their colleagues.
Overview of Curriculum
The material below comes from the Basic Course for Police Officers authored by the New Jersey Police Training Commission (2016). This 262-page manual provides a complete review of the curriculum that police officers in that state learn during their 24 weeks at the Academy.
One of the instructional units is named “Suicide Awareness and Prevention for the Law Enforcement Officer”. The description is as follows:
The trainee will understand the causes, symptoms, warning signs and risks associated
with officer suicide, and will identify appropriate intervention and prevention strategies
to effectively deal with this issue.
The outcomes of this module are as follows. Once completed, the police recruit will be able to:
Identify demographics associated with law enforcement suicide
Know stressors that contribute to suicide
Explain risk factors associated with suicide
Identify warning signs associated with suicide
Understand suicide myths
Explain and apply the AID LIFE acronym for intervening with suicide
Identify obstacles to effective suicide intervention
Note professional resources helpful to an officer
Identify strategies to prevention law enforcement suicide
The content from these modules is summarized below, but I’ve added references where appropriate to back up the un-cited information. The goal is to provide added-value and confirm the veracity of the material.
Suicide is defined as the intentional taking of one’s own life (Stedman, 2016).
Demographics of Law Enforcement Suicide
There are more deaths to police suicide than in the line-of-duty (Kulbarsh, 2016)
The police officer life expectancy is less than the general population (Violanti, 2013)
The suicide rate is approximately 14 deaths per 100,000 (Badge of Life, n.d.) compared to 13 per 100,000 in the general population (AFSP, 2014)
Although the curriculum maintains that the divorce rate is higher among police officers, the opposite is actually true. The divorce rate is slightly lower, at 14.47% versus 16.96% for all professions over the lifetime (Roufa, 2015)
The rate of substance abuse is higher among police officers (Cross & Ashley, 2004)
Stressors Contributing to Law Enforcement Suicide
In addition to the normal stressors such as depression, anxiety, substance abuse and relationship issues, the curriculum identifies some specific job-related stressors. These include:
Discipline issues (internal affairs and/or
criminal investigations); and
Management issues (assignment – lack of promotion – supervision);
Retirement (loss of identity and sense of belonging).
Unfulfilled job expectations;
Risk Factors Associated with Law Enforcement Suicide
Warning signs, as defined by the AAS (n.d.) are items that represent an imminent, increased risk (active factors) rather than the stable historical factors that don’t necessarily represent increased risk. For instance, being a male does not itself mean someone is suicidal, but being a man does increase the chances someone will die.
The warning signs listed in the curriculum (reproduced verbatim below) represent a mix of risk factors and AAS-type warning signs.
Attitude of hopelessness and helplessness;
Unexplained changes in appetite, weight, appearance, and/or sleep habits;
Difficulty making decisions;
Previous suicide attempt;
Increase in the use of alcoholic beverages;
Overly aggressive or violent behavior;
Any changes in mood or behavior that are out of the ordinary, including a neutral mood;
Changes in work habits;
Behavioral clues of suicidal thoughts:
Giving away possessions;
Making a will;
Talking about a long trip;
Sudden interest or disinterest in religion;
Substance abuse relapse; and
Taking inappropriate duty-related and personal risks.
Anger / irritability; and
Concern expressed by family / friends / colleagues about a specific individual;
Identifying Common Suicide Myths
The myths that are discussed here include:
People who talk about suicide won’t attempt
Talking about suicide with someone does not reduce their risk
Warning signs are not present before a person dies by suicide
Suicidal individuals must have a mental illness
Suicidal individuals are beyond help
Suicidal individuals are committed to dying
See my article on suicide myths for a more complete discussion of these
AID LIFE for Suicide Intervention
AID LIFE is an acronym that is given in the training for a simple intervention procedure. The steps in AID LIFE are as follows:
A – Ask if the individual is thinking about suicide
I – Intervene immediately. Listen and let the person know they are not alone.
D – Don’t keep their suicidal thoughts a secret. Seek assistance
L – Locate help. This can include a supervisor, chaplain, physician, or other members of their support network. (Including crisis workers or the Emergency Room.)
I – Inform the Chain of Command. This can help get important resources like counselling in place.
F – Find someone to stay with the individual. (Dustin’s note: I’m actually not a big fan of this one, it shows up in the Marine Corps suicide awareness program as well; this is more important for high-risk, imminent suicide than it is for someone who may be low or moderate risk.)
E – Expedite. Get help now, rather than delaying it.
Obstacles to Effective Suicide Intervention
These obstacles are reproduced directly from the manual and include a variety of police-specific and more general obstacles to effective intervention with police officers who are struggling with suicidal thoughts.
Fear of stigma, isolation, humiliation, suspension, job loss;
Fear of change in duty status;
The police culture; (seeking mental health support may be perceived as a character weakness)
Denial that there is a problem; (by the officer, peer officers, supervisors, the command staff)
Reluctance of the officer to seek help for fear of the officer losing control of the situation;
The officer’s fear that confidentiality will not be maintained;
The officer’s distrust of management;
Supervisors and peers who protect or shield a troubled officer; and
Lack of knowledge by a troubled individual about the availability of counseling resources, and concern about being able to afford such services.
Professional Resources for Law Enforcement Suicide
Although this is a New Jersey Police manual, the resources presented are general enough to be a good reference. The resources that are recommended include:
Employer Assistance Program (EAP)
Faith-based support (e.g. Chaplain or Church official)
Hospital emergency room
Mental Health Counselling (in person or otherwise)
Peer Support (from another officer or supervisor)
Strategies to Prevent Law Enforcement Suicide
The following 4 strategies are generally recommended for preventing suicide by both law enforcement officers and the general public. They include:
Understanding the risk factors and warning signs of law enforcement suicide
Together for Life was developed by Psychologists as a comprehensive suicide prevention program in Montreal. This program includes a half-day training session for all officers, a confidential telephone helpline, a full-day training session in more in-depth techniques for supervisors and awareness materials. Mishara & Martin’s 2012 evaluation showed:
99% of those who attended the sessions said they would recommend the sessions to a colleague
84% of supervisors were aware of the program
Positive increases in knowledge of risk factors and warning signs, and how to intervene
A nearly 80% decrease in the rate of Montreal police suicides (versus no change in the rate of police suicides in other police services in Quebec)
Badge of Life: Psychological Survival for Police Officers (Levenson, O’Hara & Clark, 2010)makes “emotional self-care (ESC)” the focus of a series of training modules delivered to police officers, along with mental health screenings and the delivery of peer support by other officers and the use of Critical Incident Stress Debriefing (CISD).
Police Organization Providing Peer Assistance (POPPA) (Dowling, et. al., 2006) is a New York Police Department (NYPD) based program for preventing suicide. It combines a confidential helpline, support groups, printed suicide awareness and intervention materials distributed to all police officers, and tools to assess resiliency and stress. Applied Suicide Intervention Skills Training (ASIST) is also provided yearly.
American Association of Suicidology. (n.d.) “Warning Signs | American Association of Suicidology” Retrieved on September 4, 2016 from http://www.suicidology.org/resources/warning-signs
American Foundation for Suicide Prevention (AFSP). (2014) “Suicide Statistics — AFSP” Retrieved on September 4, 2016 from https://afsp.org/about-suicide/suicide-statistics/
Badge of Life. (n.d.) Police Suicide Myths. Retrieved on September 4, 2016 from http://www.badgeoflife.com/myths/
Cross, C.L. & Ashley, L. (2004) Police Trauma and Addiction: Coping With the Dangers of the Job. FBI Law Enforcement Bulletin. 73(10) Retrieved on September 4, 2016 from https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=207385
Dowling, F.G., Moynihan, G., Genet, B. & Lewis, J. (2006). A Peer-Based Assistance Program for Officers With the New York City Police Department: Report of the Effects of Sept. 11, 2001. American Journal Of Psychiatry: Official Journal Of The American Psychiatric Association, (1), 151. doi:10.1176/appi.ajp.163.1.151
Kulbarsh, P. (2016) “2015 Police Suicide Statistics” Officer.com. Retrieved on September 4, 2016 from http://www.officer.com/article/12156622/2015-police-suicide-statistics
Levenson Jr, R. L., O’Hara, A. F., & Clark Sr, R. (2010). The Badge of Life Psychological Survival for Police Officers Program. International Journal Of Emergency Mental Health & Human Resilience, 12(2), 95-101.
Mishara, B. L., & Martin, N. (2012). Effects of a comprehensive police suicide prevention program. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 33(3), 162-168. doi:10.1027/0227-5910/a000125
New Jersey Police Training Commission. (2016) Basic Course for Police Officers.
Roufa, T. (2015) “What is the Divorce Rate for Police Officers?” The Balance. Retrieved on September 4, 2016 from https://www.thebalance.com/what-is-the-divorce-rate-for-police-officers-974539
Stedman, T. (2016) Stedman’s Medical Dictionary (28th ed.). Philadelphia: Lippincott Williams & Wilkins.
There are a variety of sources related to Canadian suicide statistics, but no source effectively summarizes all of the statistics, with graphs and charts, and links back to the original citation. The purpose of this article is to provide the most up-to-date information on suicide by method, gender, province, age-range, and other characteristics. The most common source of data is Statistics Canada.
Suicide Rate in Canada
The overall rate for suicide in Canada is 11.3 per 100,000 based on the 2012 Statistics Canada data (released in 2015), for both genders. This is mostly unchanged from the 5 year average of 11.36 per 100,000. The next data will be released in 2017.
Although other countries may calculate suicide differently, Canada ranks approximately 70 for both sexes suicide, 70 for male suicides and 73 for female suicides (out of a total of 170 countries, where lower is better), based on 2012 data from the World Health Organization. (WHO, 2012)
Suicide by Age in Canada
The largest population of suicides in Canada are from men and women 45-59. All Ages data includes suicide of those of unknown age and those under 10.
Rate per 100,000 persons
% of Total
10 to 14
15 to 19
20 to 24
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85 to 89
90 and older
Chart, Suicide by Age in Canada
Suicide by Gender in Canada
In Canada, like most countries, male suicides outnumber female suicides. (Statistics Canada, 2012)
Age at time of death
Male per 100,000
Female per 100,00 people
90 and older
The chart below shows the gross number of suicides in order to demonstrate the male percentage of the total. (Statistics Canada, 2012)
10 to 14
15 to 19
20 to 24
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85 to 89
90 and older
Chart, Suicide by Gender in Canada
Suicide Attempts in Canada
Suicide attempts usually do not lead to suicide deaths. In the US, Han et. al. (2016) reported that in 2012, there were over 1.3 million suicide attempts and 39,426 suicide deaths, leading to a ratio of approximately 33 suicide attempts for every suicide death.
Statistics Canada (2016) notes a World Health Organization source that notes up to 20 suicide attempts for every suicide death.
Suicide Attempts by Gender in Canada
Females attempt suicide 1.5 times more often than males (Langlois & Morrison, 2002) Mustard, et. al. (2012) note that the rate of suicide attempts among women is 3 times that of men. Both sources are referred to in Statistics Canada (2016).
Suicide by Method in Canada
Suicide methods impact lethality, therefore it is important to understand the most common methods used to attempt suicide in Canada. Men are likelier to use more lethal means like hanging and firearm than women are (Bilsker & White, 2011) increasing their suicide lethality. 1998 data reveals the following gender breakdown by method for suicide (Langlois & Morrison, 2002)
Total Suicide Deaths
Total Poisoning Deaths
Jumping From High Place
Additionally, the following information is provided for poisonings (these numbers make up the total poisoning deaths number above):
Drugs and Medication
Motor Vehicle Exhaust
Other Carbon Monoxide
Chart, Suicide by Method in Canada
The above chart shows total poisoning deaths. The below chart breaks out poisoning into the various types:
Suicide by Province in Canada
Suicide in Canada has a distinct provincial impact, with northern territories having a higher rate of suicide and the Maritimes having a lower rate of suicide as compared to the provincial average. (Statistics Canada, 2016b)
Newfoundland and Labrador
Prince Edward Island
Chart, Suicide by Province in Canada
Youth Suicide in Canada
Youth suicide in Canada has been relatively stable for several years. Suicide is the 2nd leading cause of suicide in Canada for ages 15 to 34. (Statistics Canada, 2015a) Additionally, there are more suicide attempts in youth than adults, with Schwartz (2003) estimating between 50 and 200 attempts per youth suicide death.
It has been well-documented that the LGBT community has a higher rate of suicide than the general population.
Approximately 30% of suicide deaths and 28% of suicide attempts in Canada involve lesbian, gay or bisexual individuals. (LGB; Banks, 2003) The LGB population was estimated by Statistics Canada (2015c) at approximately 2%, though this is likely an underestimate.
The trans suicide rate is dramatically higher than the LGB rate. Between 20 and 40% of transgender individuals report suicide attempts, while a study of trans youth in Ontario reported that 35% had suicidal thoughts and 11% had a suicide attempt in the previous year. (Bauer, 2015)
Veteran/Military Suicide in Canada
Military member and military veteran suicide has increasingly been in the public consciousness. In 2012, the Canadian Forces had 10 suicide deaths by current members and 11 suicide attempts by current members according to a Global News article citing Department of National Defence data. (Minsky, 2015)
Given a strength of approximately 68,000 Regular Force members and 27,000 Reserve members, 10 suicides leads to a suicide rate per 100,000 of approximately 9.5, slightly lower than the general population rate of 13.1.
Bauer, G. R., Scheim, A. I., Pyne, J., Travers, R., & Hammond, R. (2015). Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health, 15(1), 1-15. doi:10.1186/s12889-015-1867-2
Banks, C. (2003) The Cost of Homophobia: Literature Review on the Human Impact of Homophobia On Canada. Community-University Institute for Social Research. Retrieved on August 27, 2016 from http://www.usask.ca/cuisr/sites/default/files/BanksHumanCostFINAL.pdf
Bilsker, D. & White, J. (2011) The silent epidemic of male suicide. BCMJ. 53(10) 529-534.. Retrieved on August 27, 2016 from www.bcmj.org/articles/silent-epidemic-male-suicide
Han, B., Kott, P. S., Hughes, A., McKeon, R., Blanco, C., & Compton, W. M. (2016). Estimating the rates of deaths by suicide among adults who attempt suicide in the United States. Journal Of Psychiatric Research, 77125-133. doi:10.1016/j.jpsychires.2016.03.002
Langlois, S & Morrison, P. (2012) Suicide deaths and suicide attempts. Health Reports. 13(2):9-21. Retrieved on August 26, 2016 from http://www.statcan.gc.ca/pub/82-003-x/2001002/article/6060-eng.pdf
Minsky, A. (2013, 4 Dec.) “For every suicide in the Canadian Forces, at least one attempt was recorded: documents”. Global News. Retrieved on August 27, 2016 from http://globalnews.ca/news/1009779/soldier-suicide-one-attempt-for-every-death/
Mustard, C., Bielecky, A., Etches, J., Wilkins, R., Tjepkema, M., Amick, B., Smith, P.M., Gnam, W.H. & Aronson, K. (2012). Suicide Mortality by Occupation in Canada, 1991-2001. Canadian Journal Of Psychiatry-Revue Canadienne De Psychiatrie, 55(6), 369-376.
Schwartz, M.W. (2003) The 5-minute Pediatric Consult. Lippincott Williams & Wilkins. pp 796.
Statistics Canada. (2015a) Table 102-0561 – Leading causes of death, total population, by age group and sex, Canada, annual, CANSIM (database). Accessed August 27, 2016.
Statistics Canada. (2015c) “Same-sex couples and sexual orientation… by the numbers” Retrieved on August 27, 2016 from http://www.statcan.gc.ca/eng/dai/smr08/2015/smr08_203_2015
Statistics Canada. (2016a) Table 102-0563 – Leading causes of death, total population, by sex, Canada, provinces and territories, annual, CANSIM (database). Retrieved on August 27, 2016 from http://www5.statcan.gc.ca/cansim/a47
Statistics Canada. (2016b) Navaneelan, T. Suicide rates: An overview. Retrieved on August 24, 2016 from www.statcan.gc.ca/pub/82-624-x/2012001/article/11696-eng.htm
World Health Organization (WHO). (2012) “GHO | By category | Suicide rates – Data by country.” Retrieved on August 27, 2016 from http://apps.who.int/gho/data/node.main.MHSUICIDE?lang=en
With text and chat services increasingly moving online, emotional support work – the core element of the work of crisis lines is needing to be adapted to work in new formats that require a change in your perspective and technique. On the telephone, there are a number of ways of providing a warm, genuine experience. For instance, your voice tone and pitch communicates a lot, as well as the speed in which you talk, whether you speak over the caller or let them lead, and so on. There is a lot of non-verbal communication that happens on the phone.
In contrast, online all you have is text. So many of the dimensions that are used to promote warmth, communicate empathy and demonstrate caring are simply absent. This makes it more difficult to build rapport with these visitors and be effective.
The elements of active listening, or the active listening process are the same, although of course it seems unusual to call it “listening” since you aren’t using your ears. There is still an effort made to be alert for and respond to communication, however. Some people prefer “emotional support” instead.
Chat and Text Length
Chat and text conversations tend to be longer than telephone conversations; an average telephone call may be 20 minutes while a crisis chat or text conversation will be 45-60 minutes. This is due to the time required for you to send a text, for the visitor to receive it, read it, decide what they’re going to write, and then write back. You may not send a lot of messages in this 60 minutes, but that doesn’t mean that you aren’t accomplishing a lot – which is reflected in the outcomes, often up to 30% reduction in subjective distress over an hour.
In the opening of a text-based conversation, it’s important to be warm and genuine. Your opening message should give your name, because the visitor doesn’t have anything else to go on. You may want or need to identify your organization as well. Finally, you’ll want to ask the visitor what brought them to text in.
An example of an opening message I could use on the ONTX Project is “Welcome to the ONTX Project. My name is Dustin, what’s going on in your life?”
Sometimes a visitor will text in with a lethality statement, something like, “I want to die.” This doesn’t necessarily change your opening, but it doesn’t hurt to acknowledge the suicidal feeling. “Welcome to the ONTX Project. My name is Dustin, it sounds like you’re really struggling. Did you want to tell me what’s been going on?”
Some visitors though, may need a bit of encouragement. If you ask a visitor how they’re feeling, they may reply “idk” (I don’t know) or “bad”, and not elaborate. Other visitors may be much more articulate and be able to explain what’s going on in their life.
If someone says “idk” or “bad”, usually my next move is to ask them what’s on their mind tonight. This is a gentle way of rewording the question that helps them feel more comfortable. Usually at this point they’ll begin talking, but if not my final option is “What were you hoping to get out of texting in tonight?”
I’ve never had a visitor respond with “idk” or other messages after this much encouragement but I would likely empathize with how difficult it’s been for them to text in before ending the conversation and inviting them to try us again when they’re more able to speak.
Because of a 140 character limit, some of these messages may need to be sent as a pair of messages on text.
Exploring the Issue
Exploring the issue that the visitor is texting in about can be challenging. Unlike the helpline, where you may need to take a while to establish rapport, visitors on text tend to jump right to their primary concern rather quickly. They don’t have the luxury of many messages back and forth.
If you’ve used the above Opening the Conversation ideas, you should be well into exploring the issue. This section should proceed just the same way as an offline conversation does, using all elements of the active listening process (open ended questions, paraphrasing and summarizing.)
You may notice that you need to ask more clarifying questions than usual, because with text and a lack of tone it’s easier for things to be misunderstood or misconstrued.
In an online environment, you have no voice tone to demonstrate empathy. For this reason it’s important to write out your empathy statements clearly in order to show that you have an idea what the visitor is going through. Clarifying and paraphrasing can help in rapport building as well, by demonstrating that you are paying attention. It’s important to recognize that clarifying, paraphrasing and other open and close-ended questions are not a replacement for pure empathy.
Empathy: You sound really alone.
Clarifying: You just lost your dog?
Paraphrasing: You’ve been having trouble since you lost your pet.
Note the difference, empathy highlights an emotion (alone) while clarifying and paraphrasing primarily on content without regard to an emotional undertone.
Suicide Risk Assessment and Intervention
Suicide risk assessment and intervention is a challenging topic over chat and text. The primary challenges in this environment include the difficulty collecting the amount of information required to perform a competent assessment in 140 characters and the lack of voice tone and body language.
Typically the first question asked on chat and text after confirming suicide thoughts are present is to determine if they’re at imminent risk. This is usually accomplished by asking something like “Have you done anything to kill yourself?” or “Have you taken any steps to end your life tonight?”
Chatters and texters will sometimes text in immediately after an overdose, and will readily reveal their level of danger but not until you ask. Sooner rather than later!
Next, I’ll ask the visitor what’s led them to feeling suicidal. This, when combined with an empathy statements, helps to begin exploring the visitor’s reasons for living or dying. For example, “You must be feeling so overwhelmed. Tell me what’s led you to feeling suicidal?”
Because visitors are using their cell phones, they can put their phone in their pocket, and then pull it out without thinking about the time that passes in a few minutes. It’s not uncommon that at the end of your 45-60 minutes, when it comes to winding up, the visitor doesn’t even realize that amount of time has passed. They find themselves feeling better, however, which is great news!
Winding up has to be deliberate, otherwise the visitor is unlikely to wind up in a decent time. Past experience has shown that crisis chats can last 3 hours or longer lacking a proper wind up. In order to initiate a windup, you simply have to give the visitor an opportunity to express anything else on their mind and then let them know that you have to go. For example,
“We’ve been talking for about an hour so we’ll need to wrap our conversation up soon. I’m wondering if there’s anything else on your mind that you haven’t shared yet.”
Or, more succinctly,
“We’re just coming up on 45 minutes of chatting so we’ll need to wind up soon. Was there anything else you wanted to share before we do?”
This cues the visitor that the conversation needs to end and lets them focus on any outstanding issues. For instance, you may be convinced of their safety and they may not be – and by pointing that out by replying “I don’t know what to do to avoid attempting suicide tonight” then you can spend your remaining 15 minutes implementing a comprehensive safety plan for that visitor. In this way, the windup can be a tool for you and the visitor.
The Crisis Triage Rating Scale (CTRS; Bengelsdorf, et. al. 1984) is a telephone triage tool that can be used for determining whether an individual in crisis requires psychiatric assessment. Turner & Turner (1991) determined that a cut-off score of 9 or lower necessitated admission. This was confirmed in a follow up study by Adeosun et. al. (2013)
The CTRS has three subscales:
Ability to Cooperate
Each category is rated from 1-3, so the entire scale is scored from 3-15 (with a lower score representing less functioning.) This copy of the CTRS from the Human Services and Justice Coordinating Committee lists the response guidelines:
Urgency of Response
Immediate response recommended
A. Dangerousness _____
See within 2 hours
B. Support System _____
See within 12 hours
C. Ability to Cooperate _____
See within 48 hours
Total Score: _______
See within 2 weeks
Community Use and Validation of the CTRS
The CTRS has been used in community organizations that have mobile crisis teams, for the purpose of assessing whether callers require inpatient admission to a hospital. This can help guide the often murky process of crisis assessment.
Bonynge & Thurber (2008) determined that the CTRS was accurate in determining the difference between inpatient and outpatient treatment but that with all the tools tested (the Crisis Triage Rating Scale, the Triage Assessment Form and the Suicide Assessment Checklist), the determination of exactly what inpatient treatment (Hospitalization in a psychiatric or substance abuse settings, partial hospitalization or crisis beds) is most effective.
Limitations of the Crisis Triage Rating Scale
Molina-Lopz et. al. (2016) note that the CTRS “requires knowledge of each patient’s social and family support system at the time of assessment, which can be especially difficult to gauge in aggressive, agitated, suspicious, isolated or non-cooperative patients” which is a reasonable criticism of the Support System subscale of the tool.
The criteria used for the Dangerousness subscale is also interesting, for each rating there are 3-4 criteria given. Because of the difficulty in evaluating these (e.g. “Expresses suicidal/homicidal ideas with ambivalence, or made only ineffectual gestures. Questionable impulse control”) the reliability of the CTRS may be suspect.
The CTRS can be downloaded from the Human Services and Justice Coordinating Committee here.
Adeosun, I., Adegbohun, A., Jeje, O., & Omoniyi, O. (2013). 1364 – Predictive validity of the crisis triage rating scale in the disposition of patients attending a nigerian psychiatric emergency unit. European Psychiatry, 281. doi:10.1016/S0924-9338(13)76409-5
Bengelsdorf, H., Levy, L., Emerson, R., & Barile, F. (1984). A crisis triage rating scale: Brief dispositional assessment of patients at risk for hospitalization. Journal Of Nervous And Mental Disease, 172(7), 424-430.
Bonynge & Thurber (2008). Development of Clinical Ratings for Crisis Assessment In Community Mental Health. Brief Treatment and Crisis Intervention. 8(4):304-312; doi:10.1093/brief-treatment/mhn017
Molina-López, A., Cruz-Islas, J. B., Palma-Cortés, M., Guizar-Sánchez, D. P., Garfias-Rau, C. Y., Ontiveros-Uribe, M. P., & Fresán-Orellana, A. (2016). Validity and reliability of a novel Color-Risk Psychiatric Triage in a psychiatric emergency department.BMC Psychiatry, 161-11. doi:10.1186/s12888-016-0727-7
Turner, P.M., Turner, T.J. (1991). Validation of the crisis triage rating scale for psychiatric emergencies. Canadian Journal of Psychiatry. 36(9):651-4
Suicides in prisons and jails are several times higher than the general population (Thigpen, Beauclair, Hutchinson & Zandi, 2010) for a variety of reasons: incarceration is stressful, mental health issues can be exacerbated in the corrections environment, and overcrowding and understaffing mean that suicidality can be hard to detect. This led to the development of the JSAT.
The JSAT, or Jail Suicide Assessment Tool (Carlson, 2002) is a semi-structured tool featuring 24 domains associated with suicidality, These categories explore supports in your life, physical health, mental health, suicidal thoughts and attempts, and more. This tool is NOT to be confused with the similarly named Jail Screening Assessment Tool, also abbreviated as JSAT.
Each domain or category in the JSAT features some sample words to help guide the answering of that question. For example, the category “Psychiatric treatment” includes the sample words “counseling, medication, compliance, hospitalization, diagnoses.
Components of the JSAT:
The 24 components of the JSAT can be clustered under five broad categories, Mental Health, Physical Issues, Personality and Emotional State, Social Supports and Other / Situational.
Depression (current signs)
Reality testing (current signs)
Self-harm history (could also be classified under Physical Health Issues)
Recent suicide signs
Physical Health Issues
Personality and Emotional State
View of death
View of suicide
Other / Situational
Scoring the JSAT
Each category is scored + (positive, lack of suicide risk), – (negative or risk of suicidality) or n (neutral). Additionally, the tool provides some ways of operationalizing these categories.
Looking at the category “Suicidal intention”, the category is described as “Resolution to act, lethal plan with available means.” To mark + (absence of risk) the prisoner must convincingly deny any intent to harm themselves, while to mark – (presence of risk) they must express a desire to die by suicide in the near future and/or have a lethal suicide plan with available means.
Time for Administration is between 30 and 120 minutes
Research Supporting the JSAT
There have been no research studies that I am aware of evaluating the JSAT in a corrections population. It was prepared for the Federal Bureau of Prisons based on a previous tool called the Prison Suicide Risk Assessment Checklist (PSRAC), which itself has not been evaluated either.
Evaluation of the JSAT
Although there is no published research review of the JSAT, the general principles of suicide risk assessment can be applied to confirm whether the JSAT is an effective tool for evaluating risk. The principles include:
Does the tool appear to measure what it claims to? (face validity)
Will the tool cover the important risk factors and warning signs of suicide? (content validity)
If two professionals complete the tool on the same prisoner in the same circumstances, will they reach the same conclusion? (reliability)
Can the completed tool be defensible in court if a suicide occurs? (documentation)
Let’s review each of these below.
Face Validity of the JSAT
The JSAT includes elements covering history of suicide attempts, current suicide warning signs, presence of depression, self-injury and substance abuse issues, social supports, view of suicide and many other risk factors.
On this basis the JSAT appears to be face valid for suicide – though I would question if all the elements are necessary in a comprehensive assessment. For example, “Cooperation” is identified as whether there is a good rapport between the interviewer and the client, as evidenced by a no-suicide contract. This is clearly not evidence-based (no suicide-contracts do not work), and rapport is not a suicide risk factor.
A minor criticism as well, some of the categories in the JSAT are oddly named. For instance, the criteria for the category Character is listed below:
“+” No indication of prominem character disorder traits.
“-“A diagnosed personality disorder; prominent, innexible. maladaptive character traits which cause significant functional impairment or distress.
Given the Character item explores the presence of a personality disorder (which is also not a major risk factor for suicide on its own outside of Borderline Personality Disorder) it makes much more sense to simply name it “Personality Disorder.”
Content Validity of the JSAT
Content validity explores whether the elements of an effective suicide risk assessment is covered. The acronym IS PATH WARM (Lester, Mcswain & Gunn, 2011), developed by the American Association of Suicidology (AAS) can be used to verify suicide warning signs.
Mapping the IS PATH WARM mnemonic onto the JSAT criteria we see the following matchup:
The presence of suicidal thoughts. This is covered by the JSAT category Suicidal Intention, which has as a risk factor “Expresses desire to commit suicide in the ncar future; has a lethal suicide plan with available means.”
Current or former substance abuse issues. This category is found in the JSAT as Chemical Abuse/Use where the risk factor is “Presently intoxicated or going through symptoms of withdrawal; recent history of drug or alcohol abuse”
Purposelessness is adequately covered by the JSAT category Hope. The risk factor is described as “no future orientation or life goals; cannot identify reasons to live.”
The JSAT category Mental Status is defined as “Significantly impaired orientation; disturbed mood/affect; thought content or form showing signs of psychosis; severe anxiety; severe agitation.”
Trapped does not appear to be represented in any of the JSAT categories.
See purposelessness above.
See Substance Abuse above.
See anxiety above.
Recklessness or impulsiveness is explored in the JSAT category Measured Reasoning, defined as “sudden destructive action toward self/others, impulsive. a hot-head.”
See Anxiety above.
Summary of JSAT Content Validity
Given the above, it appears the JSAT has adequate content validity for the risk factors of suicide, though some of them appear to be lumped together in multiple categories. A more effective tool would separate these categories to make sure the nuances are not overlooked.
Reliability of the JSAT
Reliability describes the ability for a tool’s consistency. This makes no claim to the correctness of the evaluation (known as validity), but rather that two people using the same tool with the same person will come to similar results.
Given the detailed operationalization, the reliability of the JSAT should be good. For instance, looking at “View of Death”, the risk and non-risk options are below:
“+” Convincingly expresses a desire to survive.
“-” Would welcome a natural death; can name good things that would occur as a result of dying
This is specific enough that two assessors should be able to come to the same conclusion.
Documenting a Jail Suicide Assessment
Would the JSAT stand up in court? This is often one of the most important elements of a risk assessment. Even if it is valid, if you can’t “show your work” and demonstrate that you have adequately considered all elements, you may be legally exposed in the event of a client suicide.
Obegi, Rankin, Williams, & Ninivaggio, (2015) explore the elements of a risk assessment required to stand up in court. They use the acronym CAIPS, which stands for:
Chronic and Acute Factors
Imminent Warning Signs
Chronic and Acute Factors / Imminent Warning Signs
The chronic and acute factors, and imminent warning signs of the JSAT have been adequately explored above.
One major problem with the JSAT is that a simple + or – sign will not provide the detail required to defend the presence or absence of a risk factor. For example, reviewing “View of Death” above, how does the clinician prove the client welcomes a natural death? What good things do they believe would occur upon their death?
Protective factors are explored fairly extensively in the JSAT, with Social Supports, Important Relationships, View of Death (which explores the idea of a perceived burden), Hope (future plans, reasons for living, hope for the future), Help Self (problem-solving ability and sense of control), Cognitive Themes (presence of optimism), and View of Suicide (beliefs or values that resist suicide).
The final element of the CAIPS element is the Summary Statement. This is the major element missing from the JSAT, as noted above. A detailed risk assessment requires both a discussion of the individual risk factors and warning signs, as well as an overall summary noting their risk and prescribing the appropriate interventions (e.g. removal of suicide means or surveillance.)
Case Study Using the JSAT
Brandy et. al. (2008) provide a number of suicide case studies, one of which is adapted here to demonstrate use of the JSAT. For more information see the original source.
49-year-old, single male who is in the county jail for attempted robbery
Noose discovered in his personal effects
Client is awaiting a 10 year prison sentence
Notes if he is sentenced to 10 years he would hang himself, making another noose if the first one was taken away
Cares deeply for his girlfriend and her children but feels they don’t care for him
Refused mental health support and had nothing to live for
An evaluation using the JSAT would result in negative (risk present) selections in at least the following categories:
Recent Suicide Signs
The most important elements here are the lack of supports, hopelessness and expressed intent to die. This client would be considered high risk for suicide given the lack of protective factors and should be restricted from accessing means for hanging.
Applying the DCIB Risk Assessment as an alternative risk assessment for confirmation, we note that this client is showing suicide desire, capability, intent and has a lack of protective factors.
Brandy L. Blasko , Elizabeth L. Jeglic & Stanley Malkin (2008) Suicide Risk Assessment in Jails, Journal of Forensic Psychology Practice, 8:1, 67-76, DOI: 10.1080/15228930801947310
Lester, D., Mcswain, S., & Gunn Iii, J. F. (2011). A TEST OF THE VALIDITY OF THE IS PATH WARM WARNING SIGNS FOR SUICIDE. Psychological Reports,108(2), 402-404. doi:10.2466/09.12.13.PR0.108.2.402-404
Thigpen, M.L., Beauclair, T.J., Hutchinson, V.A., Zandi, F. (2010) National Study of Jail Suicide: 20 Years Later. National Institute of Corrections. Accessed electronically on Mar 12 2016 from http://static.nicic.gov/Library/024308.pdf
Obegi, J. H., Rankin, J. M., Williams, J. J., & Ninivaggio, G. (2015). How to write a suicide risk assessment that’s clinically sound and legally defensible. Current Psychiatry, (3), 50.