SIMPLE STEPS Model for Suicide Risk Assessment

Introduction

The SIMPLE STEPS Model (McGlothlin, 2008) for suicide risk assessment provides a simple mnemonic similar to others like SADPERSONS (Patterson, et. al., 1983) or IS PATH WARM (from the American Association of Suicidology). Each of these is correlated with increasing suicide lethality and so this can be a useful short-hand to remember these items.

Suicide risk assessment on the crisis line is mostly concerned with imminent risk, and many suicide screeners designed for lay people may miss important variables in a goal to be simplistic; the SIMPLE STEPS model appears to avoid both of these traps, by providing an assessment tool simple enough to be used in the crisis line environment but comprehensive enough to be used by counsellors or therapists for ongoing monitoring of suicide risk.

Items in the SIMPLE STEPS Model

  • Suicidal – Is the individual expressing suicidal ideation?
  • Ideation – What is their suicidal intent?
  • Method – How detailed and accessible is their suicidal method?
  • Perturbation – How strong is their emotional pain
  • Loss – Have they experienced actual or perceived losses? (Relationships, material objects)
  • Earlier Attempts – What previous attempts has the individual experienced, what happened after those attempts?
  • Substance Use – Is the individual abusing drugs, alcohol, or other substances?
  • (Lack of) Troubleshooting Skills – Are they able to see alternatives or options other than suicide?
  • Emotions / Diagnosis – “Assessment of emotional attributes (hopelessness, helplessness, worthlessness, loneliness, agitation, depression, and impulsivity) and diagnoses commonly associated with completed suicide (e.g., substance abuse, mood disorders, personality disorders, etc.)” (McGlothlin, et. al., 2016)
  • (Lack of) Protective Factors – What is keeping this person safe from suicide? Who are their supports (internal such as personal values and external like people), resources and agencies
  • Stressors and Life Events – What has happened in their life to lead them to suicide?

Sharp readers will identify that these elements map very neatly onto the DCIB Model of Suicide Risk Assessment, but perhaps provide a better mnemonic in order to make sure that clinicians who do not have the DCIB in front of them are able to perform that assessment.

Validation of the SIMPLE STEPS Model

McGlothlin, et. al. (2016) used 13,000 calls over six years to a crisis line and correlated the SIMPLE STEPS items with the lethality risk present in that call. One limitation of this study is that it used self-reported (by the helpline worker taking the call) lethality rather than using another evidence-based risk assessment in order to compare with. I am satisfied that McGlothlin addressed this in his limitations section, where he noted the difficulty with using data collected in this manner.

References

McGlothlin, J. (2008). Developing clinical skills in suicide assessment, prevention and treatment.
Alexandria, VA: American Counseling Association

McGlothlin, J., Page, B., & Jager, K. (2016). Validation of the SIMPLE STEPS Model of Suicide Assessment. Journal Of Mental Health Counseling, 38(4), 298-307. doi:10.17744/mehc.38.4.02

Patterson, W.M., Dohn, H.H., Patterson, J. & Patterson, G.A. (1983). “Evaluation of suicidal patients: the SAD PERSONS scale.” Psychosomatics 24(4): 343–5, 348–9. doi:10.1016/S0033-3182(83)73213-5. PMID 6867245

Cite this article as: MacDonald, D.K., (2017), "SIMPLE STEPS Model for Suicide Risk Assessment," retrieved on July 21, 2017 from http://dustinkmacdonald.com/simple-steps-model-suicide-risk-assessment/.

 

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Level of Care Utilization System (LOCUS)

Introduction

The Level of Care Utilization System or LOCUS tool has been designed by the American Association of Community Psychiatrists (2009) to allow staff who work on inpatient hospital environments with patients with psychiatric problems (such as emergency departments, psychiatric sections of general hospitals or in psychiatric hospitals) to determine the level of care that an individual should receive.

The LOCUS provides for six levels, ranging from the least intense (recovery maintenance, such as seeing a case manager once a month and having access to a 24-hour crisis line if needed) to the most intense (medically managed residential services such as being a hospital inpatient.)

Parameters

The LOCUS is based on a set of parameters that an individual is scored along. The level of care is determined based on the mix of parameters that each client has. These parameters are:

  1. Risk of Harm
  2. Functional Status
  3. Medical, Addictive and Psychiatric Co-morbidity
  4. Recovery Environment
  5. Treatment and Recovery History
  6. Engagement and Recovery Status

In most of these domains there are a number of states that are used to code the domain. For instance, “Risk of Harm” has five potential states from Minimal Risk of Harm to Extreme Risk of Harm. The exception is 4. Recovery Environment which has two subcomponents, Level of Stress and Level of Support.

The LOCUS manual provides detailed coding instructions to allow an individual to be assessed in a reliable, repeatable way.

Levels of Care

For each Level of Care, the manual provides for four categories, Care Environment, Clinical Services, Supportive Systems, and Crisis Stabilization and Prevention Services.

Care Environment describes where services are delivered and what facilities might need to be available. Clinical Services describes the type and number of clinical employees (nurses, etc.) and the types of therapies or treatments available. Supportive Services includes client access to things like case management, outreach and financial support, while Prevention Services include mobile crisis, crisis lines, and other access to services.

Scoring

Each of the levels includes specific individual scores required for a level, and also a composite score. The Composite Score overrides the individual scores to determine which level an individual is placed at if the Composite Score results in a more intense level of care.

Composite Scores

  • Level 1 – 10-13
  • Level 2 – 14-16
  • Level 3 – 17-19
  • Level 4 – 20-22
  • Level 5 – 23 – 27
  • Level 6 – 28+

Level 1 – Recovery Maintenance and Health Management

  • Risk of Harm: 2 or less
  • Functional Status: 2 or less
  • Co-morbidity: 2 or less
  • Level of Stress: Sum of Stress and Support less than 4
  • Level of Support: Sum of Stress and Support less than 4
  • Treatment & Recovery History: 2 or less
  • Engagement & Recovery Status: 2 or less

Level 2 – Low Intensity Community Based Services

  • Risk of Harm: 2 or less
  • Functional Status: 2 or less
  • Co-morbidity: 2 or less
  • Level of Stress: Sum of Stress and Support less than 5
  • Level of Support: Sum of Stress and Support less than 5
  • Treatment & Recovery History: 2 or less
  • Engagement & Recovery Status: 2 or less

Level 3 – High Intensity Community Based Services

  • Risk of Harm: 3 or less
  • Functional Status: 3 or less
  • Co-morbidity: 3 or less
  • Level of Stress: Sum of Stress and Support less than 5
  • Level of Support: Sum of Stress and Support less than 5
  • Treatment & Recovery History: 3 or less
  • Engagement & Recovery Status: 3 or less

Level 4 – Medically Monitored Non-Residential Services

  • Risk of Harm: 3 or less
  • Functional Status: 3 or less
  • Co-morbidity: 3 or less
  • Level of Stress: 3 or 4
  • Level of Support: 3 or less
  • Treatment & Recovery History: 3 or 4
  • Engagement & Recovery Status: 3 or 4

Level 5 – Medically Monitored Residential Services

  • Risk of Harm: If the score is 4 or higher – the client is automatically Level 5
  • Functional Status: If the score is 4 or higher – most clients are automatically Level 5
  • Co-morbidity: If the score is 4 or higher – most clients are automatically Level 5
  • Level of Stress: 4 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Level of Support: 4 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Treatment & Recovery History: 3 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Engagement & Recovery Status: 3 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity

Level 6 – Medically Managed Residential Services

  • Risk of Harm: If the score is 5 or higher – the client is automatically Level 6
  • Functional Status: If the score is 5 or higher – the client is automatically Level 6
  • Co-morbidity: If the score is 5 or higher the client is automatically Level 6
  • Level of Stress: 4 or more
  • Level of Support: 4 or more
  • Treatment & Recovery History: 4 or more
  • Engagement & Recovery Status: 4 or more

Given that there are a number of nuances in the exact scoring it’s recommended that an individual read or receive structured training in administration of the LOCUS. The LOCUS manual also provides a decision tree (not shown) to assist in making your determinations and a determination grid (shown below.)

Level of Care Determination Grid

LOCUS Level of Care Determination Grid

Research

Although the LOCUS is widely used, research is surprisingly limited.

The initial study validating the LOCUS was Sowers, George & Thomson (1999). Their study examined scores on the LOCUS and correlated them to expert decisions to see if the LOCUS matched that decision-making; their results indicated that it performed well in this function.

Kimura, Yagi & Toshizumi (2013) reviewed the LOCUS by comparing scores on it to the Global Assessment Scale (GAS) scores, a similar tool and examining the change of scores from admission to discharge. They found it a sensitive and effective tool for clinical use in Japan.

Ontario Shores, a large mental hospital in Whitby, ON implements the LOCUS along with the RAI tools as well.

References

American Association of Community Psychiatrists. (2009) LOCUS Level of Care Utilization System for Psychiatric and Addictions Services, Adult Version 2010. Retrieved on January 18, 2017 from http://cchealth.org/mentalhealth/pdf/LOCUS.pdf

Kimura, T., Yagi, F., & Yoshizumi, A. (2013). Application of Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) to Psychiatric Practice in Japan: A Preliminary Assessment of Validity and Sensitivity to Change. Community Mental Health Journal, 49(4), 477-491. doi:10.1007/s10597-012-9562-6

Sowers, W., George, C., & Thomson, K. R. (1999). Level of care utilization system for psychiatric and addiction services (LOCUS): a preliminary assessment of reliability and validity. Community Mental Health Journal, (6), 545.

Cite this article as: MacDonald, D.K., (2017), "Level of Care Utilization System (LOCUS)," retrieved on July 21, 2017 from http://dustinkmacdonald.com/level-care-utilization-system-locus/.
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Interprofessional Education in Suicide Prevention

Introduction to Interprofessional Education

This is an essay I wrote in 2015 for the course HSRV 306 Critical Reflection for Practice at Athabasca University.

Interprofessional education (IPE) is defined as “the process, through which two or more professions learn, with, from and about each other to improve collaboration and the quality of service” (CAIPE, 1997) IPE has been practiced in various forms for decades (Smith & Clouder, 2010) but is most commonly associated with healthcare and the social sciences.

The advantage of interprofessional education is that it allows allied fields to benefit from “pooling together of expertise in teams [that] would make them more effective and efficient” (Illingworth & Cheivanayagam, 2007) than those professions working on their own. As there is much overlap in the work provided by professionals in social work, psychology and psychiatry this pooling together of resources has the potential to improve their skills and competencies.

One competency required by these professions is the ability to prevent suicide, which involves the interrelated skills of risk assessment and suicide intervention. How much an individual may need to intervene will differ depending on their role, with some professionals needing only to recognize the signs and refer them on, while others may be required to perform regular and comprehensive suicide risk assessment and intervention.

Suicide and Mental Health Professionals

The suicide rate in Canada has remained relatively steady in Canada for several years, with more than 3,000 individuals dying by suicide in Canada each year. (Statistics Canada, 2014) A 2002 meta-review demonstrated that many of these people visited physicians or nurses for physical health complaints before their death. (Luoma, Martin & Pearson, 2002) Whether or not these physical complaints were related to their mental health issues or not, an opportunity for suicide screening and subsequent referral was missed.

One study on suicide screening, focused on Emergency Departments in the United States found that when universal screening was implemented, requiring all patients to be screened for suicide regardless of their presenting problem, the rate of detected suicidal thoughts doubled. (Boudreaux, et. al., 2015) This demonstrates the importance of all healthcare professionals being competent in the basics of suicide screening.

Mental health professionals regularly treat suicidal clients, with Feldman & Freedmanthal’s 2006 study reporting 78% of social workers had provided service to a suicidal client in the previous year. While mental health professionals regularly work with suicidal clients they may lack the skills or confidence to respond appropriately.

Ruth et. al. (2006) conducted interviews with social work students, faculty and Deans and discovered that the majority of programs provided their social worker students less than 4 hours of education on suicide assessment during their graduate programs. This resulting lack of coverage left social work students feeling unconfident working with suicidal clients, and indeed scared of the possibility that a client will reveal suicidality, a fact noted by other researchers as well. (Osteen, Jacobson & Sharpe, 2014) This paralyzing fear may contribute to burnout or other negative professional consequences and ultimately make them less effective practitioners.

Interprofessional education has the potential to improve the care of suicidal clients by allowing professionals to take advantage of the best practices in education present in allied fields. By borrowing best practices from other helping professions the number of competent professionals may ultimately be increased and the number of suicides or potential suicides that are undetected may be reduced.

Potential drawbacks to adopting interprofessional education that have been documented in the literature include the costs of implementation (such as redesigning curriculums) and the possible loss of professional identity among different groups who learn the same skills (Smith & Clouder, 2010) Given that mental health care is already well-diffused (with each professional area like social work, psychology and psychiatry having specialties but ultimately all being able to provide counselling or therapy with training), this may be less of an issue in suicide prevention, which is currently practiced by volunteers all the way up to Psychiatrists and Psychologists holding doctorates.

Interprofessional Education in Physical and Mental Health

There are a number of approaches to education in mental health fields (social work and psychology) and physical health fields (nursing and non-psychiatric medicine), including best practices that have demonstrated improved knowledge transfer, satisfaction and skill within their respective professional programs.

Physical health professions include general medicine practiced by physicians as well as nurses, who are recognized as professionals in their own right (College of Registered Nurses of Manitoba, n.d.). Professional schools of nursing have a long history, stretching back to the early 1900s (Schekel, 2009), while the first medical school opened in Italy in the 9th century. (de Divitiis, Cappabianca, & de Divitiis, 2004)

Education of physicians and nurses has always emphasized hands-on treatment and “learning by doing”, but especially since the 15th century when the first cadaver dissections were performed for medical students. (Rath & Garg, 2006)

Current techniques used in medical and nursing education include case studies, where the signs and symptoms of an illness and a patient’s history are described in detail and a diagnosis or treatment is sought (Raurell-Torreda, et. al., 2015), and simulated patients who are specially trained actors that medical students interact with in order to experience conducting clinical interviews, assessment and diagnosis (Uys & Treadwell, 2014).

Both case studies and simulated patients have shown utility in general nursing and medicine according to Luebbert & Popkess (2015). Some studies have specifically explored their utility with suicidal patients, such as Norrish (2009) who used cases to teach suicide risk assessment skills to Omani medical students.

Techniques that have demonstrated effectiveness with Psychology and Social Work students on the other hand, include role-playing (Murdoch, Bottorff & McCullough, 2013) where students practice simulated complaints with each other in order to develop the skills of recognizing and responding to suicidal statements, and evidence-based lecture. (Scott, 2015)

Gate-keeper training programs that are designed to teach lay people the basic skills of recognizing the signs of suicide and referring individuals to trained professionals, for instance, QPR (Lancaster, et. al., 2014) have demonstrated effectiveness in increasing confidence and skill in both nursing (Bolster, Holliday, Oneal & Shaw, 2015) and social work students. (Sharpe, Frey, Osteen & Bernes, 2014)

While domain-specific education for nurses and physicians has begun to be developed, it lacks the exploration of knowledge-transfer and rigorous methodology necessary for it to be as effective as possible. One example of beginning nurses education is Kishi et. al. (2014), who had emergency room nurses in Japan completing a 1 day workshop. The workshop covered suicide risk assessment, management of the immediate suicidal crisis, referring patients to long-term resources, and attitudes towards suicidal patients. This workshop was taught using lectures and case studies, with a pre and post-test design on a scale measuring attitudes towards suicide (but not knowledge transfer or skill acquisition.) The lack of a knowledge-transfer component means these nurses are unable to demonstrate whether they learned anything or if they apply their training to their patients.

Other exercises in integrating suicide prevention into social work including Scott (2015) who developed a full-semester course for MSW students that taught suicide risk assessment, intervention, and public health interventions such as media guidelines around suicide. Luebbert & Popkess (2015) had students complete either a video-taped lecture or speak to a standardized patient after being exposed to material on suicide assessment and found that the group that worked with the standardized patient felt much more confident.

What is lacking in nursing and medical education is a focus on evidence-based practice in suicide prevention, an issue noted by nursing faculty (Kalb et. al., 2015) Additionally providing opportunities for hands-on practice through exercises like case studies, simulated patients, and roleplaying will allow for necessary deep knowledge transfer.

Conclusion

Suicide prevention is a field ripe for improvement by integrating the best practices from a variety of allied fields. Most notably, from nursing and general medicine the case study and simulated/standard patients may help social workers and psychologists reduce their fear of working with suicidal clients, while the strong evidence-based lecture, roleplaying and gate-keeeper training may give busy nurses and physicians an opportunity to develop suicide awareness and referral skills that will allow them to intervene to prevent death.

References

Bolster, C., Holliday, C., Oneal, G., & Shaw, M. (2015). Suicide Assessment and Nurses: What Does the Evidence Show?. Online Journal Of Issues In Nursing, 20(1), 1-1 1p. doi:10.3912/OJIN.Vol20No01Man02

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 Dec 10 2015 from https://spr.confex.com/spr/spr2015/webprogram/Paper23206.html

de Divitiis, E., Cappabianca, P. & de Divitiis, O. (2004) The “schola medica salernitana”: the forerunner of the modern university medical schools. Neurosurgery. 55(4);722-44

CAIPE (1996) Principles of Interprofessional Education. London: CAIPE.

College of Registered Nurses of Manitoba. n.d. “Standards of Practice for Registered Nurses: Nursing Practice Expectations” Accessed electronically from https://www.crnm.mb.ca/uploads/document/document_file_89.pdf?t=1438266260 on Dec 11 2015.

Feldman, B. N., & Freedenthal, S. (2006). Social work education in suicide intervention and prevention: An unmet need? Suicide and Life-Threatening Behavior. 36. 467–480

Illingworth, P. & Chelvanayagam, S. (2007) Benefits of interprofessional education in health care. British Journal of Nursing. 16(2):121-4

Kalb, K.A., O’Conner-Von, S.K., Brockway, C., Rierson, C.L. & Sendelbach, S. (2015) Evidence-Based Teaching Practice in Nursing Education: Faculty Perspectives and Practices. Nursing Education Perspectives. DOI: 10.5480/14-1472

Kishi, Y., Otsuka, K., Akiyama, K., Yamada, T., Sakamoto, Y., Yanagisawa, Y., Morimura, H., Kawanishi, C., Higashioka, H., Miyake, Y. & Thurber, S. (2014) Effects of a Training Workshop on Suicide Prevention Among Emergency Room Nurses. Crisis. 35(5):357–361 DOI: 10.1027/0227-5910/a000268

Lancaster, P.G., Moore, J.T., Putter, S.E., Chen, P.Y., Cigularov, K.P., Baker, A., Quinnett, P. (2014) Feasibility of a web-based gatekeeper training: implications for suicide prevention. Journal of Suicide and Life Threatening Behaviour. 44(5):510-23. DOI: 10.1111/sltb.12086

Luebbert, R. & Popkess, A. (2015) The Influence of Teaching Method on Performance of Suicide Assessment in Baccalaureate Nursing Students. Journal of the American Psychiatric Nurses Association. 21(2) 126-133. DOI: 10.1177/1078390315580096

Luoma, J.B., Martin, C.E. & Pearson, J.L. (2002) Contact with mental health and primary care providers before suicide: a review of the evidence. American Journal of Psychiatry. 159(6):909-16

Murdoch, N.L., Bottorff, J.L. & McCullough, D. (2013) Simulation Education Approaches to Enhance Collaborative Healthcare: A Best Practices Review. International Journal of Nursing Education Scholarship. 10(1):307-321. DOI: 10.1515/ijnes-2013-0027

Norrish, M. (2009) The effectiveness of a vignette approach to teaching suicide risk factors: An Omani perspective. Medical Teacher. 31:539-544. DOI: 10.3109/01421590902849511

Osteen, P. J., Jacobson, J. M., & Sharpe, T. L. (2014). Suicide Prevention in Social Work Education: How Prepared Are Social Work Students?. Journal Of Social Work Education, 50(2), 349-364. DOI: 10.1080/10437797.2014.885272

Rath, G. & Garg, K. (2006) Inception of cadaver dissection and its relevance in present day scenario of medical education. Journal of the Indian Medical Association. 104(6):331-3

Raurell-Torreda, M., Olivet-Pujol, J., Romero-Collado, A., Malagon-Aguilera, M. C., Patiño-Maso, J., & Baltasar-Bague, A. (2015). Case-Based Learning and Simulation: Useful Tools to Enhance Nurses’ Education? Nonrandomized Controlled Trial. Journal Of Nursing Scholarship. 47(1). 34-42 9p. DOI: 10.1111/jnu.12113

Ruth, B.J., Gianino, M., Muroff, J., McLaughlin, D. & Feldman, B.N. (2012) You Can’t Recover From Suicide: Perspectives on Suicide Education in MSW Programs. Journal of Social Work Education, 48(3). 501-516. DOI: 10.5175/JSWE.2012.201000095

Scott, M. (2015) Teaching Note—Understanding of Suicide Prevention, Intervention, and Postvention: Curriculum for MSW Students, Journal of Social Work Education, 51(1), 177-185

Scheckel, M. (2009). Nursing Education: Past, Present, Future. In Roux, G., & Halstead, J.A. (Eds.) Issues and Trends in Nursing: Essential Knowledge for Today and Tomorrow. (pp. 27-35).

Sharpe, T.L., Frey, J.J., Osteen, P.J. & Bernes, S. (2014) Perspectives and
Appropriateness of Suicide Prevention Gatekeeper Training for MSW Students, Social Work in Mental Health, 12:2, 117-131, DOI: 10.1080/15332985.2013.848831

Smith, S., & Clouder, L. (2010). Interprofessional and Interdisciplinary Learning: An Exploration of Similarities and Differences. In A. Bromage, L. Clouder, J. Thistlethwaite, & F. Gordon (Eds.) Interprofessional E-Learning and Collaborative Work: Practices and Technologies (pp. 1-13). Hershey, PA: . DOI: 10.4018/978-1-61520-889-0.ch001

Statistics Canada. (2014) “Suicides and suicide rate, by sex and by age group (Both sexes no.)” from CANSIM, table 102-0551. Retrieved electronically from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth66a-eng.htm on Dec 6, 2015.

Uys, Y., & Treadwell, I. (2014). Using a simulated patient to transfer patient-centred skills from simulated practice to real patients in practice. Curationis, 37(1), 1-6 6p. DOI: 10.4102/curationis.v37i1.1184

Cite this article as: MacDonald, D.K., (2016), "Interprofessional Education in Suicide Prevention," retrieved on July 21, 2017 from http://dustinkmacdonald.com/interprofessional-education-suicide-prevention/.
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Crisis Triage Rating Scale (CTRS)

IntroductionCrisis Triage Rating Scale (CTRS)

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:

  • Dangerousness
  • Support System
  • Ability to Cooperate

Scoring

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:

Score Urgency of Response CTRS Rating
Extreme/Severe 3-9 Immediate response recommended A. Dangerousness _____
High 10 See within 2 hours B. Support System _____
Medium 11 See within 12 hours C. Ability to Cooperate _____
Low 12-13 See within 48 hours Total Score: _______
Non-Urgent 14-15 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.

Download CTRS

The CTRS can be downloaded from the Human Services and Justice Coordinating Committee here.

Bibliography

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

Cite this article as: MacDonald, D.K., (2016), "Crisis Triage Rating Scale (CTRS)," retrieved on July 21, 2017 from http://dustinkmacdonald.com/crisis-triage-rating-scale/.

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Jail Suicide Assessment Tool (JSAT)

Introduction

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.

Picture by Michael Coghlan
Picture by Michael Coghlan

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.

Mental Health

  • Psychiatric treatment
  • Mental status
  • Depression (current signs)
  • Reality testing (current signs)
  • Self-harm history (could also be classified under Physical Health Issues)
  • Recent suicide signs
  • Suicidal intention
  • Character

Physical Health Issues

  • Physical health
  • Physical pain
  • Chemical abuse/use

Personality and Emotional State

  • Hope
  • Help self
  • Cognitive themes
  • Coping resources
  • Measured reasoning
  • View of death
  • View of suicide

Social Supports

  • Important relationships
  • Social Status:

Other / Situational

  • Legal status
  • Institutional adjustment
  • Cooperation
  • False presentation

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:

Ideation

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.”

Substance Abuse

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

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.”

Anxiety

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

Trapped does not appear to be represented in any of the JSAT categories.

Hopelessness

See purposelessness above.

Withdrawal

See Substance Abuse above.

Anger

See anxiety above.

Recklessness

Recklessness or impulsiveness is explored in the JSAT category Measured Reasoning, defined as “sudden destructive action toward self/others, impulsive. a hot-head.”

Mood Change

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
  • Protective Factors
  • Summary Statement

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

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).

Summary Statement

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:

  • Important Relationships
  • Legal Status
  • Hope
  • Cognitive Themes
  • Recent Suicide Signs
  • Suicide Intention

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.

Bibliography

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

Carlson, D.K. (2002) Jail Suicide Assessment Tool. Federal Bureau of Prisons. Accessed electronically on Mar 12 2016 from http://www.usmarshals.gov/prisoner/assessment_tool.pdf

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.

 



Cite this article as: MacDonald, D.K., (2016), "Jail Suicide Assessment Tool (JSAT)," retrieved on July 21, 2017 from http://dustinkmacdonald.com/jail-suicide-assessment-tool-jsat/.

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