Risk for Self-Harm

Assessment and
management of suicide risk

Suicide in the U.S.

11th leading cause of death in the population
overall
About 33,000 suicides annually
14-16,000 of these occur while in treatment

Suicide Risk Assessment

There are no reliable quantitative measures to assess suicidal
risk, which leaves the clinician with guided clinical judgment.

Assess when
Beginning treatment (intake)
There is a significant clinical change (increased distress, crisis, or
sudden improvement with depressed clients)

An accurate assessment is largely dependent on the clinicians

ability to gain private information from the client.
An unstable or poor therapeutic relationship is a risk factor for
completion.

Risk assessment involves a multidimensional assessment of

several factors, including:
Risk factors (predisposing factors, short-term factors, precipitating event)
Specific suicide inquiry (ideation, intent, plan, means)
Protective factors (current resources, commitment to safety plan)

Suicide Risk Assessment

The Threshold Model describes how different types of risk and
protective factors interact to produce a threshold for suicidal
behaviour for the individual. The different types of factors are:
Long term/predisposing risk factors that can be present at birth or
soon after birth: these identify people who are in at-risk groups (i.e. race)
Short term risk factors that can develop later in life: these may predict
when someone is most likely to commit suicide (i.e., unmarried)
Precipitating risk factors which occur due to crisis, a recent life event,
or access to a method of committing suicide: these allow a more
immediate assessment of risk (i.e. recently lost job)
Protective factors that may be long or short term: these can offset risk

Mental Health Trust, British National Health Service

Suicide Risk Assessment: Demographics

Age
Highest risk is elderly white men (also 6x more likely to complete)
Rate increases each year of age

Ethnicity

Caucasians and Native Americans at highest risk

Other ethnic groups have similar, low risk levels
Highest risk: Caucasian men, 66% of all suicides.
Lowest risk: African-American women.

Gender
Women attempt more often, at a ratio of 3:1
Men complete more often, at a ratio of 4:1

Geography
Highest risk nations are soviet bloc (Top 5: Belarus, Lithuania,
Russia, Kazakstan, Latvia) and southeast Asian nations (Japan,
South Korea, Sri Lanka)
Highest risk states are Central Mountain (Nevada, Montana,
Wyoming, etc.) and Alaska

Suicide Rate 2005-2010

Completions per 100,000

12

Females - Lifespan Suicide Risk by Ethnicity and Age

(2005-2010)

10
8
6
4
2
0
10-14 yrs 15-19 yrs 20-24 yrs 25-34

35-44

45-54

Am Indian/AK Native - Females

Asian/Pac Islander - Females

Hispanic - Females

White - Females

55-64

65-74

Black - Females

CDC (2013) http://www.cdc.gov/injury/wisqars/index.html

75-84

85+ yrs

Suicide Rate 2005-2010

Completions per 100,000

60

Males - Lifespan Suicide Risk by Ethnicity and Age Cohort

(2005-2010)

50
40
30
20
10
0
10-14 yrs 15-19 yrs 20-24 yrs 25-34

35-44

45-54

Am Indian/AK Native - Males

Asian/Pac Islander - Males

Hispanic - Males

White - Males

55-64
Black - Males

CDC (2013) http://www.cdc.gov/injury/wisqars/index.html

65-74

75-84

85+ yrs

Suicide Risk Assessment

Teens have a lower rate than every group except
children
But, suicide is their third leading cause of death,
following MVA and homicide (2nd leading cause of death
for young adults).
Whereas suicides accounted for 1.4% of all deaths in the U.S.
annually, they comprised 12% of all deaths among 15-24-yearolds

Although rates vary somewhat by geographic location,

within a typical high school classroom, it is likely that
three students (one boy and two girls) have made a
suicide attempt in the past year.
Most adolescent suicide attempts are precipitated by
interpersonal conflicts. The intent of the behavior
appears to be to effect change in the behaviors or
attitudes of others.
American Association of Suicidology, 2010)

Adolescent Suicide Ideation

Percentage of U.S. High School Students Reporting Considering, Planning, or

Attempting Suicide in the Past 12 Months, by Sex, United States, 2009

Suicide Risk Hispanic Adolescents

18% of Hispanic adolescents have reported seriously
considering attempting suicide in the last 12 months - a
proportion higher than reported by their Non-Hispanic
classmates.
Hispanic female high school students reported a higher
percentage of suicide attempts (14%), than White NonHispanic (7.7%) or Black Non-Hispanic (9.9%) female
students.
Thus, although rates of completed suicide among youth
are lower than those for Non-Hispanics, school-aged
Hispanic youth self-report higher rates of feeling sad or
hopeless, of thinking about suicide, and of attempting
suicide.
American Association of Suicidology (2010)

Suicide Risk Assessment

Low socioeconomic
status
Living alone
Divorced/widowed
Unemployed
Lack of structured
religion
Gay/lesbian
Attempt 6x/2x more
frequently

Immigrant
Veteran

Prior suicide attempts

Family history of suicide
Recent exposure to suicide
(friend/media)
5% of adolescent suicides are
part of clusters

Anniversary of important loss

Hx of impulsive, violent, or
reckless behavior
33% of completers have EtoH
in their system.

Family of origin violence

Victim of physical/sexual
abuse
Domestic violence

SUICIDE RISKS IN SPECIFIC DISORDERS

Condition

RR

Prior suicide attempt 38.4

Eating disorders
23.1
Bipolar disorder
21.7
Major depression
20.4
Mixed drug abuse
19.2
Dysthymia
12.1
Obsessive-compulsive 11.5
Panic disorder
10.0
Schizophrenia
8.45
Personality disorders
7.08
Alcohol abuse
5.86
Cancer
1.80
General population

1.00

%/y

%-Lifetime

0.549

27.5

0.310
0.292
0.275
0.173
0.143
0.160
0.121
0.101
0.084
0.026

15.5
14.6
14.7
8.6
8.2
7.2
6.0
5.1
4.2
1.3

0.014

0.72

A.P.A. Practice Guidelines (2003)

Suicide Risk Assessment

Medical/Physical
Decline in physical functioning/recent
illness (especially terminal illness)
Traumatic Brain Injury
Risk appears continually high

Epilepsy
Temporal lobe epilepsy

Chronic Pain

Loss Factors
Decrease in vocational
status/unemployed
Loss of significant relationship
Recently divorced/widowed
Sense of rage/victimization

Loss of freedom due to legal status

Recent Humiliation, shame, guilt
Most adolescent suicides are
precipitated by interpersonal problems,
and may be attempts to gain affection,
revenge, etc.

Cognitive Features that Contribute to

Risk
Loss of executive function
Thought constriction (tunnel vision)
Polarized thinking/perfectionism
Closed-mindedness
Inability to adapt to a dependent role
Negative attitude towards help seeking

Clinical Factors
Intense, distressing affective states
Low self-esteem, high self-hate
Hopelessness, poor coping
Helplessness, sense of being trapped
Recent increase/uncharacteristic sub.
abuse
Recent increase/uncharacteristic
recklessness
Currently Psychotic
Unstable or poor therapeutic
relationship

Suicide Risk Assessment

Availability of weapons!
Suicide is often an impulsive response to an acute stressor

Rate of lethality:

Guns - 85%
Suffocation (Drowning, hanging, CO2) 66-75%
Blunt trauma (jumping from buildings, trains) ~ 33%
Other means (pills, poisoning, etc.) 1-2%

The top three methods do not allow for back out.

Ratios of attempted to completed suicides for youth are estimated to
range between 100 to 1 and 200 to 1 (compared to 25 to 1 for adults,
and 4 to 1 for seniors).

Suicide completers are more than 2X more likely to have a gun

in the home than attempters.

Suicide Risk Assessment - Inquiry

Clients will rarely volunteer suicidal ideation - they have to be
asked directly
Timing and clinical skill have a lot to do with how successful this
assessment is.

Develop rapport first, through empathic listening

Discuss presenting problem and attempt to fully understand the

meaning of the problem to them, the history of the problem, as
well as the difficulty theyre experiencing.
Dont forget to inquire about coping history, how theyre coping with the
problem as well as how theyve coped with it in the past.

Pay attention to history, present risk factors (all the factors

covered in a good clinical interview mental health, physical
health, social support, substance abuse, etc.).
Despite the presence of absence of risk factors, all assessments should include a direct
inquiry

Suicide Risk Assessment - Inquiry

Four biggest factors predicting suicide:
Ideation
Intent
Plan & Means
History

Intent and plan are the two most dangerous

factors by far.

Strategies to elicit disclosure

Behavioral Incident
What did you do after you thought about ____

Shame Attenuation
-Sometimes people who are really overwhelmed think about hurting themselves.
Do you ever feel that way?

Gentle Assumption
Tell me about another time you cut yourself.

Symptom Amplification
Would you say you think about this every couple of hours? Every hour?

Denial of the Specific

Have you ever thought of overdosing?

Normalization
Some of the people I work with - who are going through similar problems
sometimes they find themselves wishing they werent alive. Do you ever feel that
way?
Shea, 2002

Suicide Risk Assessment - Inquiry

Clients will rarely volunteer ideation, they typically have to be asked directly.
The inquiry should follow:
The establishment of rapport
Discussion of the presenting problem (client should demonstrate that they are
comfortable expressing themselves with you).
It can be useful to follow expressions of distress with the inquiry.

Some possible lead in questions include:

Whats _________ been like for you?

Do you find yourself feeling hopeless?
Desperate?
Is it hard to face each day?
Overwhelmed? Do you feel life is a burden?

Normalize ideation before asking, and begin with general open-ended

questions and transition to more specific questions.
Often, people that are having a really hard time, like you are, they often wish
they werent here anymore. Do you ever have thoughts like that? Do you
sometimes feel its not worth going on?
If they say no, ask why, and document

Do you ever think about hurting yourself/ending your life?

Assessment Ideation Inquiry

If they disclose current ideation, explore it further.

View the ideation as a legitimate attempt to cope

When you think about ____, what do you imagine?

Consider the following elements of the ideation:

Frequency, duration, intensity, time of occurrence
Active or passive
How intense, or overwhelming are these thoughts? (SUDS)

Understand the function of the ideation (soothing, revenge,

attention/affection from others, etc.)
Is there something in your life right now that you think is contributing to these
thoughts?
This may sound like an odd question, but how might it help you to think about
dying?
When you think about (not being here, dying, etc.), what do you imagine it will be
like? What will happen to these problems youre struggling with?
Do you ever think about your funeral? Who would go? How do you imagine
others would react?

Assessment Intent and Plan Inquiry

Intent and plan are two most serious indicators
Planning activities or rehearsals
When you imagine dying, how do imagine it happening?
Consider passive vs. active means

Have you taken any steps to put this plan into action?
Have you gotten the things you will need?
Have you ever walked yourself through it/practiced doing it?
Have you thought about saying goodbye to others? What steps have you
taken to say goodbye?
Have you told anyone? If not, why not? If they dont know, how did you keep
it from them?
Look for rituals/rehearsals, preparations, gambles, attempts to keep it secret.

Do you have any intention of following through on these plans?

On a scale of 1 to 10, 1 being I definitely wont follow through on these
thoughts, 10 being I definitely am going to, where are you? (SUDS)
If not, why not? What prevents you from killing yourself?

How likely are you to die from that, do you think?

How confident are you that you can keep yourself safe?
(SUDS)

Suicide Risk Assessment - Inquiry

Always ask about prior suicide attempts (ask
even if they deny current ideation)
Have you ever tried to hurt yourself in the past?
Get information on number of previous attempts, time
since last attempt (greatest risk in the first 30 months
after 5150 discharge)
Consider:

Lethality of method
Impulsive vs. planned
Rescued/saved by others
Attempts to avoid discovery

How do you feel about the fact that you survived?

Disappointed by survival?

Suicide Risk Assessment

Archinard, Heynal-Reymond, & Heller (2000):
59 patients admitted to Geneva University Hospital after a
suicide attempt are assessed for risk by the psychiatrist.
The psychiatrists facial expressions are recorded and coded.
The Psychiatrists ratings correctly classify the re-attempters
(10 in 24 months) 22.7% of the time.
The psychiatrists facial expressions distinguish them
correctly over 80% of the time.

The moral of the story? If you feel nervous, you

probably should.
Use structured risk assessment, but listen to your clinical
instincts as well.

Interventions to foster safety

Suicidality is often an acute reaction to stressors, a
permanent solution to a temporary problem.
90% of those who survive a nonfatal attempt do not go on to die by
suicide (Owens, British J Psych, 2002; review of 90 studies of repetition
of self-harm)

The purpose of intervention is to assist the individual in

navigating the crisis.
Suicidal behavior and ideation is an attempt to cope with
circumstances in which the individual feels helpless and
hopeless.
I have no way to cope with this pain
My situation is not going to get better

However, exploring their situation further typically reveals

ambivalence about suicide itself.

Interventions to foster safety

Highlight ambivalence
Although youre thinking about killing yourself, you havent. Whats kept you
going?
Despite being really overwhelmed, it seems that the fact that youre seeking help
today shows that theres a part of you that still hopes or believes that things can
get better.

Reframe ideation as an attempt to cope

You know, when you talk about what it would feel like to die, it seems that you
really imagine that you would finally stop feeling all this pain. If we could find a
way for you to find peace again, would you still want to die?

Reduce Hopelessness by instilling hope

Have you ever gone through a really difficult time before? Did you get through it?
How?
I know this feels really overwhelming right now, but this is a problem we deal with
a lot, and we know a lot about helping people overcome it.

Reduce Helplessness by fostering adaptive coping

Recognize and praise them for the positive strategies theyre using already
Develop safety plan . . . . Which is really a coping plan.

Interventions to foster safety

Remove means
Typically best to enlist a family member, friend
Even if plan does not include firearms, remove them anyway.
Important to know current medications and potential lethality.

Remove drugs/alcohol
Again, family members or friends can be helpful

Increase social support

Identify people/activities that can be distractions
Identify people that can be emotional supports (in distress)
Provide hotline/warmline numbers

Decrease social stress

Have client identify problematic relationships and consider ways to avoid
them

Interventions to foster safety

Increase supervision and monitoring
Increase session frequency
Utilize phone contacts/check-ins
Enlist family members or friends to help
Explain what will happen if they do not follow through with follow-up: I will call the
police, and they will come to your house to do a safety check

Provide concrete affect-regulation strategies

Cognitive techniques, active coping statement
DBT toolbox
Medication/psychiatric support

If there are adaptive steps they can take to solve the problem, it may be
useful to encourage them (for example, identifying openings if they lost a
job).
How willing are you to try these strategies? Is there anything were leaving
out?
On a scale of 1 to 10, how committed are you to keeping yourself safe?

Interventions to foster [your] safety

Document
Risk determination
Elements of inquiry: ideation, intent, plan
Include SUDS intent rating

Protective factors (very important!)

Include reasons for living
SUDS commitment to safety

Interventions taken to insure safety

Referrals to hotlines, elements of safety plan

Results of follow up contacts, and ongoing assessment of ideation and intent.

Demonstrate repeated assessment of ideation/intent unless client is consistently
no/low risk.
Re-assess if there are future crisis, distress, etc.

At this point, contracts for safety are contraindicated. Legally useless, and
potentially dangerous due to their tendency to lull clinicians into a false
sense of security.
Always consult! Peer consultation is proving to be a legal expectation within
the standard of care (supervisees, of course, consult supervisors).
Document consultations.

When to treat outpatient:

Low intent
Willingness to commit to safety and follow up
Available social support and coping resources
Can inhibit impulsivity (no substance abuse, brain
injury, history of recklessness etc).
Stable living situation
Strong therapeutic relationship
Patient has chronic suicidal ideation and/or self-injury
without prior medically serious attempts

A.P.A. Practice Guidelines (2003)

Hospitalization might be required:

After a suicide attempt or aborted suicide attempt
In the presence of suicidal ideation with:

Psychosis
Major psychiatric disorder
Past attempts, particularly if medically serious
Possibly contributing medical condition (e.g., acute neurological disorder, cancer,
infection)

Lack of response to or inability to cooperate with partial hospital or outpatient

treatment
Limited family and/or social support, including lack of stable living situation
Lack of an ongoing clinician-patient relationship or lack of access to timely
outpatient follow-up
In the absence of suicide attempts or reported suicidal ideation/plan/intent,
but evidence from the psychiatric evaluation and/or history from others
suggests a high level of suicide risk and a recent acute increase in risk
E.g. Previous attempts and current crisis

A.P.A. Practice Guidelines (2003)

Hospitalization Indicated:
In the presence of suicidal ideation with:
Specific plan with high lethality
High suicidal intent

Patient is psychotic
Recent attempt was violent, near-lethal, or premeditated
Precautions were taken to avoid rescue or discovery
Distress is increased or patient regrets surviving
Patient is male, older than age 45 years, especially with new onset of
psychiatric illness or suicidal thinking
Patient has limited family and/or social support, including lack of stable
living situation
Current impulsive behavior, severe agitation, poor judgment, or refusal of
help is evident
Patient has change in mental status with a metabolic, toxic, infectious, or
other etiology requiring further workup in a structured setting

A.P.A. Practice Guidelines (2003)

CALM Protocol
If you are faced with an imminent emergency (for example, the
client is attempting self-harm in front of you), contact 911
immediately.
If you identify suicidal ideation and significant intent:
If you are under clinical supervision, you must contact your supervisor to consult
immediately.
If you are unable to reach your clinical supervisor, contact members of the
executive team until you reach someone.
If you are licensed, you are still encouraged to consult with peers.

Ask CALM staff or law enforcement to sit with client if

necessary to maintain safety.
Contact a support person to assist with supervision, coping, or
transportation

CALM Protocol
If hospitalization is determined to be unnecessary:
Develop a safety plan with client: remove means, identify and remove triggers or other
stressors, develop coping strategies (affect regulation/soothing, positive self-talk,
distraction, supportive people to contact/hotlines), increase contact and supervision.
Additional support may include hotlines: 211
Teens: 1-877-YOUTHLINE /800-852-8336 /800-843-5200/Child Abuse counseling (800) 422-4453
General Suicide Hotlines 1-800-273-TALK/1-800-SUICIDE
Post-Partum Depression 1-800-PPD-MOMS/PEP Warmline (805) 564-3888/Sp. 852-1595

If hospitalization is determined to be necessary:

Encourage voluntary hospitalization, which can be conducted through the emergency

room. Consider whether client can be transported safely (by a family member or friend do
not allow clients to transport themselves).
If a client refuses voluntary hospitalization, seek an assessment.

For Children, contact Safe Alternatives for Treating Youth (SAFTY) 1-888-334-2777
For Adults, call 911.

If a client refuses to participate in your assessment or

safety planning and/or leaves, contact 911.