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 June 24, 2018 from http://dustinkmacdonald.com/jail-suicide-assessment-tool-jsat/.

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Is the SAD PERSONS Scale dangerous?

The SAD PERSONS scale was first developed in 1983 by Patterson, Dohn, Patterson & Patterson to teach medical students clinical suicide risk assessment skills. In that first publication, students taught the tool – which features 10 risk factors for suicide that are added up, “demonstrated a significantly greater ability to accurately evaluate and make recommendations for disposition of a low-risk and a high-risk patient” compared to controls who rated both patients as high risk for suicide.

SAD PERSONS Risk Factors

The risk factors of the SAD PERSONS scale are below:

  • Sex – Men die by suicide 3x as often as women (see my article Understanding and Preventing Male Suicide)
  • Age – Suicide rates rise with age in the US; in Canada they tend to peak in middle age
  • Depression – Depression is the most common diagnosed mental illness in those who die by suicide (Isometsä, 2014)
  • Prior History – The greatest predictor of future suicidal behaviour is past suicidal behaviour (May, Klonsky & Kline, 2012)
  • Ethanol Abuse  – Substance abuse disorders are the second most common disorder (behind mood disorders) in suicide deaths, and those who are acutely intoxicated are at 5-10x greater risk (Conner, 2014)
  • Rational Thinking Loss – The inability to think clearly can raise a person’s acute suicide risk
  • Support System Loss – Along with No Significant Other, lacking a support system can be a risk factor
  • Organized Plan – The more detailed someone’s suicide plan is, the more likely they may be to attempt
  • No Significant Other
  • Sickness – Physical health issues can increase suicidality

Scoring and Types of Risk Factors

Each factor that is present increases the score by 1, with higher scores indicating increased risk to die by suicide.

Some of these factors (sex, age, prior history of suicide, no significant other) are historical or static risk factors while some (depression, ethanol abuse, rational thinking loss, support system loss, organized plan) are dynamic risk factors and at least one, sickness could fit into either one.

Research Evidence

Since 1983, we’ve learned a lot about suicide. It’s important that suicide risk assessment tools be validated and show an ability to predict suicide. Juhnke (1994) reviewed some of the early history of the tool and found that although it was used regularly in clinical settings, the research evidence supporting it was limited.

More recently, Warden, et. al. (2014) reviewed a number of studies on the SAD PERSONS scale and found that none of the studies that explored its ability to predict suicide showed that it was able to do so.

Finally, Saunders, et. al. (2013) noted that the SADPERSONS scale misses so many suicidal individuals that it may be harmful. Given the lack of research support for the scale, it would be wise to explore alternate tools.

Alternative Risk Assessment Tools

Bibliography

Conner, K. R., Bagge, C. L., Goldston, D. B., & Ilgen, M. A. (2014). Alcohol and Suicidal Behavior. What Is Known and What Can Be Done. American Journal Of Preventive Medicine, 47(Supplement 2), S204-S208. doi:10.1016/j.amepre.2014.06.007

Isometsä, E. (2014). Suicidal Behaviour in Mood Disorders–Who, When, and Why?. Canadian Journal Of Psychiatry, 59(3), 120-130.

Juhnke, G. A. (1994). SAD PERSONS Scale review. Measurement & Evaluation In Counseling & Development (American Counseling Association), 27(1), 325.

May, A. M., Klonsky, E. D., & Klein, D. N. (2012). Predicting future suicide attempts among depressed suicide ideators: A 10-year longitudinal study. Journal Of Psychiatric Research, 46946-952. doi:10.1016/j.jpsychires.2012.04.009

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

Saunders K et al. The sad truth about the SADPERSONS Scale: An evaluation of its clinical utility in self-harm patients. Emerg Med J 2013 Jul 29 [e-pub ahead of print]. (http://dx.doi.org/10.1136/emermed-2013-202781) – See more at: http://www.jwatch.org/na31829/2013/08/02/sad-performance-sadpersons-scale#sthash.YsRHmKja.dpuf

Warden, S., Spiwak, R., Sareen, J., & Bolton, J. M. (2014). The SAD PERSONS Scale for Suicide Risk Assessment: A Systematic Review. Archives Of Suicide Research, 18(4), 313-326 14p. doi:10.1080/13811118.2013.824829

 

Cite this article as: MacDonald, D.K., (2016), "Is the SAD PERSONS Scale dangerous?," retrieved on June 24, 2018 from http://dustinkmacdonald.com/is-the-sad-persons-scale-dangerous/.

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Developing Core Competencies for Suicide Risk Assessment

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.

Bibliography

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



Cite this article as: MacDonald, D.K., (2015), "Developing Core Competencies for Suicide Risk Assessment," retrieved on June 24, 2018 from http://dustinkmacdonald.com/developing-core-competencies-for-suicide-risk-assessment/.

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DCIB Suicide Risk Assessment

Introduction

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 Desire

  • Suicidal Ideation (Desire to kill self/others)
  • Psychological Pain
  • Hopelessness
  • Helplessness
  • Perceived Burden on Others
  • Feeling Trapped
  • Feeling Intolerably Alone

Suicidal Capability

  • 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)

Suicidal Intent

  • Attempt in Progress
  • Plan to Kill Self/Other (method known)
  • Preparatory Behaviour
  • Expressed Intent to Die

Buffers/Connectedness

  • 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

Bibliography

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

Cite this article as: MacDonald, D.K., (2015), "DCIB Suicide Risk Assessment," retrieved on June 24, 2018 from http://dustinkmacdonald.com/dcib-suicide-risk-assessment/.

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Evaluating a Samaritans Suicide Risk Assessment

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

Scoring

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.

Predictive Validity

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
Depressive Illness
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
Hopelessness 2

Warning Signs
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

Bibliography

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



Cite this article as: MacDonald, D.K., (2015), "Evaluating a Samaritans Suicide Risk Assessment," retrieved on June 24, 2018 from http://dustinkmacdonald.com/evaluating-a-samaritans-suicide-risk-assessment/.

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