Texas ZEST Toolkit Creating a Suicide Safe Care Center

Suicide Risk Assessment

Goal 4: All children and adults within the public mental health system who are
identified as potentially at risk during a suicide screening will receive an
evidence-informed suicide risk assessment. This suicide risk assessment
should include all of the core components of an effective risk assessment.

Rationale

Behavioral health centers play a critical role in recognizing and intervening with individuals
at risk of suicide. In a 2008 study of a crisis hotline (Mishara, Chagnon, Daigle, et al., 2007a),
callers were not asked about suicide about half of the time (723 out of 1431 calls). Of the
474 who reported suicidal ideation, 46% were not asked about access to lethal means or
means availability. Questions about prior attempts were only asked of 104 callers. Similar
findings from other settings suggest that provider behavior may not always mirror best
practices in suicide risk assessment (Bongar, Maris, Berman, & Litman, 1998; Coombs, et. al,
1992). Agency policies should identify and support a risk assessment based on the most
current research evidence.

Determining the level of risk for an individual at risk of suicide can be one of the most
challenging and stressful tasks for mental health providers. While individual safety is the
primary goal, individuals deserve to receive treatment in the least restrictive environment
possible, so a risk assessment must strive to weigh both the benefits and negative
consequences of various intervention approaches. Research and expert consensus does lead
to the suggestion of some core best practices in suicide risk assessment.

Engagement in the Risk Assessment

There are a variety of factors that can impact the quality of a suicide risk assessment,
including stigma, societal or cultural attitudes, and clinical discomfort. Individuals may be
unwilling to disclose information on ideation, intent, plans, or behaviors because they do
not want an attempt thwarted or are wary of the potential response of the Research on risk
assessments conducted over a national crisis hotline have identified some of the core
characteristics of helpful interactions as reported by the person at risk (Mishara, Chagnon,
Daigle, et al., 2007b). Approaches that were tied to good outcomes included the
demonstration of empathy, respect as well as the use of a supportive approach and
collaborative problem-solving. The assessor should approach the interaction as a
collaboration, focused on working together to determine what to do next. Providers need to
be aware of any direct or indirect communication to the individual that they are
uncomfortable with a discussion of suicide, prefer negative responses to questions, or are
shocked by the information they share.
Texas ZEST Toolkit Creating a Suicide Safe Care Center

The CASE Approach, developed by Shawn Shea, provides a strategy for enhancing the
quality of the information gathered from an individual during a suicide risk assessment. Dr.
Shea posits that:

Real Suicide Intent = Stated Intent + Reflected Intent + Withheld Intent

Dr. Shea points out that the more strongly the individual’s actual intent, the more likely
he/she is to withhold his/her true intent. The individual’s reflected intent may be the most
important component for determining real suicide intent. Reflected intent is “the quality and
quantity of the patient’s suicidal thoughts, desires, plans, and extent of action taken to
complete the plans.” (Shea, 2009, p. 3). Shea posits that it is the amount of time spent
thinking, planning, preparing and practicing for an attempt may be the strongest indicator
of imminent risk of a suicide attempt.

The CASE Approach is a best practice interviewing strategy designed to maximize the
likelihood that the assessor is gathering valid information about the stated and reflected
intent and to minimize withheld intent. The CASE Approach draws on research to identify
strategies to raise the issue of suicidality in a way that minimizes shame and stigma, as well
as ways of formulating questions to maximize validity. Training on the CASE Approach can
be obtained through the Training Institute for Suicide Assessment and Clinical Interviewing.
A resource for guidance on training providers in the CASE Approach can be found at Shea
and Barney, 2007 and Shea, Green, Barney, et. al., 2007.

Core Components of a Risk Assessment

A comprehensive risk assessment should include the following information gathered from
the individual and his/her natural supports (adapted from SAMHSA SAFE-T and JCAHO B-
SAFE):
 Suicide Inquiry - Current and previous suicidal thoughts, plans, behavior, and intent
 Warning signs – characteristics that are temporally related to the acute onset of
suicidal behaviors (hours to a few days)
 Risk factors – characteristics that statistically put an individual at increased risk
 Protective factors – characteristics that statistically indicate lower risk
 Determine risk level – develop appropriate treatment plan to address risk in least
restrictive environment
 Documentation - document risk level, rationale, treatment plan, and follow-up.

Inquiry Around Suicide

The Texas Department of State Health Services is recommending the use of the Columbia
Suicide Severity Rating Scale (C-SSRS) to insure a comprehensive, evidence-based
assessment of current and previous suicidal thoughts, behaviors, intent, and plan. If the C-
SSRS is not used to structure the risk assessment, the assessment should include
information on the following, both in the present and past:
 Suicidal thoughts, including intensity, duration, controllability, reasons
Texas ZEST Toolkit Creating a Suicide Safe Care Center

 Suicidal behaviors, including interrupted attempts, aborted attempts, and

preparatory behaviors
 Any thoughts about methods or specific plan(s) and intent to act on thoughts
 Intention to act on thoughts and intention to act on plan (if present)

Warning Signs

Potential warning signs include:

 Talking about or making plans for suicide
 Expressing hopelessness about the future
 Displaying severe/overwhelming emotional pain or distress
 Feeling intolerably alone
 Feelings of helplessness
 Perception of being a burden to others
 Making arrangements to divest responsibility (e.g., for children, pets, elderly parents)
 Showing worrisome behavioral cues or marked change in behavior, particularly in
the presence of other warning signs, including significant:
o Withdrawal from or changing in social connections/situations
o Recent increased agitation or irritability
o Anger or hostility that seems out of character or context
o Changes in sleep (increased or decreased)

Risks Factors

Risk factors alone do not predict suicidal behavior; however they indicate characteristics
that have shown a statistical relationship with an increased risk for suicide. They should be
used in combination with warning signs and other elements of the risk assessment.

Potential risk factors include:

 Family history of suicide
In general, there is
 History of previous attempts; previous self-harm
consensus that it is the
behavior
combination of warning
 Access to firearms or other lethal means
signs and potentiating risk
 History of mental illness (mood disorders, anxiety,
schizophrenia) or factors that increases a
 History of trauma (physical or sexual abuse, person’s risk of suicide
victimization by peers) (Jacobs et al., 1999).
 Alcohol or substance abuse
 Physical illness, especially new or worsening symptoms and/or chronic pain
 Impulsivity or poor self-control
 Recent losses – personal, physical, financial
 History or current bullying (for youth)
 Frequent/persistent family conflict (for youth)
 Recent discharge from psychiatric hospital
Texas ZEST Toolkit Creating a Suicide Safe Care Center

 Barriers to help

Some risk factors are immutable, but the assessor should consider these statistics in the
overall assessment of risk. Some demographic characteristics that are related to increased
risk are being male, elderly, and widowed, divorced or single marital status, particularly for
men. Adolescents and young adults are also at increased risk, as are individuals who are
lesbian, gay, or bisexual.

Protective Factors

Protective factors are those that reduce the risk of suicide. Recognizing strengths and
resiliency during the risk assessment can foster hope and set the stage for interventions to
build upon these protective factors and reduce future risk. Protective factors should not
supersede the importance of significant warning signs, however, and should only be one
component of the comprehensive risk assessment.

Example protective factors:

 Strong connections to family and community; positive social support
 Adept skills in problem solving and coping
 Optimism for the future
 Sense of responsibility to family; children in the home (except when postpartum
psychosis or depression); pregnancy
 Spirituality
 Constructive use of leisure time (enjoyable activities)
 Access to effective physical and behavioral health care; positive therapeutic
relationship
 Fear of death and dying; ambivalence towards living/dying

Measures for Suicide-Specific Assessment

Various suicide-specific measures have been developed to assess for suicide risk across
populations. Some individuals, especially adolescents, have been found to more openly
share information related to suicidal thoughts, behaviors, and risks through self-report
instruments, so these tools can be helpful components of the risk assessment. The most
common evidence-supported measures are described below.

Columbia Suicide Severity Rating Scale (C-SSRS)

The Columbia Suicide Severity Rating Scale (C-SSRS) is a tool to measure suicidal
ideation and behavior, as well as the intensity of ideation and predicts suicide risk
across treatment and research settings (Posner, et al, 2011). It has been widely used
and is available at no cost. The Risk Assessment version includes a checklist of
protective and risk factors, to be used in conjunction with information about suicidal
ideation and behavior. Training is necessary to administer the measure, but not
restricted to mental health professionals.
Texas ZEST Toolkit Creating a Suicide Safe Care Center

The Collaborative Assessment and Management of Suicidality (CAMS)

The Collaborative Assessment and Management of Suicidality (CAMS) is a therapeutic
framework that can be utilized at the stage of assessment and within the course of
clinical treatment (for more information, see Workforce Competency). The Suicide
Status Form (SSF) is used during the initial session by both the individual and a
clinician to understand the details of the person’s suicidality, including risk and
protective factors and the person’s current sense of safety. The SSF is helpful for
outlining the course of intervention and is used to track symptoms throughout
treatment (Jobes, 2009).

The Beck Scale for Suicide Ideation (SSI)

The Scale for Suicide Ideation (SSI; Beck, et al., 1979) is a brief 21-item scale that
assesses the person’s current intensity of attitudes, plans, and behaviors to commit
suicide. The SSI examines the duration and frequency of ideation, the sense of control
over an attempt, the number of deterrents, and the amount of planning involved into a
contemplated attempt (Brown, 2002). This scale is appropriate for both inpatient and
outpatient settings, can be conducted through interview or self-report, and requires
some interviewer training.

Beck Depression Inventory (BDI)

Both the Beck Depression Inventory (BDI; Beck & Steer, 1988) and the Beck Depression
Inventory II (BDI-II; Beck, Steer & Brown, 1996) are moderate cost, self-report scales of
depression symptoms with a suicide item that outlines ratings one through four, from
passive suicidal ideation to strong intent to commit suicide. Individuals who rate at
least a two, or report thoughts of suicide but no intent, were 6.9 times more likely to
commit suicide. Research also supports that the measure can be useful to tracking
suicidal ideation overtime and for assessment purposes (Brown, 2002).

Beck Hopelessness Scale (BHS)

The Beck Hopelessness Scale (BHS; Beck & Steer, 1988) is another brief, self-report
measure that has been shown to predict suicide in both inpatient and outpatient
psychiatric clients and is one of the most widely used scales for hopelessness (Brown,
2002). The BHS has 20 true-false questions assessing positive and negative thoughts
about the future over the course of the past week. This tool is of medium cost and is
available in Spanish.

Documentation

Determining Risk Level

Determining and documenting risk level is a critical component of the risk assessment. No
study has identified one specific risk factor or set of risk factors that specifically predicts
suicide or suicide behavior; therefore, the determination of risk level will depend on careful
consideration of the information gathered in the assessment and the clinical judgment of the
assessor. The determination of the best setting of care and course of treatment should
Texas ZEST Toolkit Creating a Suicide Safe Care Center

consider not only the level of risk, but also the benefits and potential risks to the individual.
While a more restrictive care setting may be necessary to safeguard against potential self-
harm, there may also be negative effects from this course of treatment that must be weighed
in the decision, such as disruption of employment, disruption of therapeutic alliance, and
increased family conflict. When possible, the provider should collaborate with the individual
in understanding and weighing different treatment options.

Considerations for Each Risk Level:

Risk Level Suicidality Risk/Protective Factors

Urgent/  Suicidal thoughts with intent to act One or more risk factors likely to be
High in past 30 days (C-SSRS Item 4) present; extra concern for
 Ideation with plan and intent in psychiatric diagnoses with severe
past 30 days (C-SSRS Item 5) symptoms, including psychosis;
 Any suicide behavior in past 90 recent discharge from psychiatric
days (C-SSRS Item 6) inpatient unit; lack of family and/or
social support; lack of engagement in
care; intent with lethal means
Emergent/  Suicidal thoughts with method in Absence or presence of risk and
Moderate past 30 days (but no plan or intent; protective factors may play stronger
C-SSRS Item 3) role in overall risk
 Suicidal thoughts with intent to act
(but no plan) at worst ever (C-SSRS
Item 4)
 Suicidal thoughts with specific plan
and intent at worst ever (C-SSRS
Item 5)
 Any suicide behavior at worst ever
(C-SSRS Item 6)
Low  Wish to be dead in past 30 days (C- Modifiable risk factors, strong
SSRS Item 1) protective factors; available social
 General thoughts of killing self support
without thoughts of methods (C-
SSRS Item 2)

Information on the potential interventions and monitoring to be considered at each level of

risk can be found in the Pathways to Care and Safety Planning chapters.

Key Resources and References

Action, A. O. (2001). Practice parameter for the assessment and treatment of children and
adolescents with suicidal behavior. Journal of the American Academy of Child and
Adolescent Psychiatry, 40(7 SUPPLEMENT), 24s-51s.
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American Psychiatric Association (2003). Practice Guidelines for the Assessment and
Treatment of Patients with Suicidal Behaviors. Available at
http://www.psychiatryonline.com/pracGuide/pracGuideTopic_14.aspx

Bongar, B., Maris, R. W., Berman, A. L., & Litman, R. E. (1998). Outpatient standards of care
and the suicidal patient. Risk management with suicidal patients, 4-33.

Brim, C., Lindauer, C., Halpern, J., Storer, A., Barnason, S., et. al. (December, 2012). Clinical
Practice Guideline: Suicide Risk Assessment. Emergency Nurses Association.
Available at http://www.ena.org/practice-
research/research/cpg/documents/suicideriskassessmentcpg.pdf.

Coombs, D. W., Miller, H. L., Alarcon, R., Herlihy, C., Lee, J. M., & Morrison, D. P. (1992).
Presuicide attempt communications between parasuicides and consulted
caregivers. Suicide and Life-Threatening Behavior, 22(3), 289-302.

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 Behavior, 37(3),
353-365.

Joint Commission on Accreditation of Healthcare Organizations (2007). A Resource Guide

for Implementing the 2007 Patient Safety Goals on Suicide. Available at
http://www.aha.org/content/00-10/JCAHOSafetyGoals2007.pdf

Mishara, B. L., Chagnon, F., Daigle, M., Balan, B., Raymond, S., et al. (2007a). Comparing
models of helper behavior to actual practice in telephone crisis intervention: A silent
monitoring study of calls to the U.S. 1-800-SUICIDE network. Suicide and Life-
Threatening Behavior, 37, 291-307.

Mishara, B. L., Chagnon, F., Daigle, M., Balan, B., Raymond, S., et al. (2007b). Which helper
behaviors and intervention styles are related to better short‐term outcomes in
telephone crisis intervention? Results from a silent monitoring study of calls to the
US 1–800‐SUICIDE network. Suicide and Life-Threatening Behavior, 37(3), 308-321.

National Suicide Prevention Lifeline (2007). Suicide Risk Assessment Standards Packet.
Available at
http://www.behavioralhealthlink.com/Downloads/Documents/LethalityPacket.pdf

Shea, S. C. (2009). Suicide assessment: Uncovering suicidal intent: A sophisticated art.

Psychiatric Times, 26, 1-6. Retrieved from
http://www.suicideassessment.com/pdfs/PsychiatricTimesArticleparts1-2PDF.pdf

Shea, S. C. and Barney, C. (2007). Macro training: A how-to primer for using serial role-
playing to train complex clinical interviewing tasks such as suicide assessment.
Psychiatric Clinics of North America, 30, e1-e29.
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Shea, S. C., Green, R., Barney, C., et al. (2007). Designing clinical interviewing training
courses for psychiatric residents: A practical primer for interviewing mentors.
Psychiatric Clinics of North America, 30, 283-314.

Substance Abuse and Mental Health Services Administration (2009). Suicide Assessment
Five-Stage Evaluation and Triage (SAFE-T): Pocket Card for Clinicians. Available at
http://store.samhsa.gov/product/Suicide-Assessment-Five-Step-Evaluation-and-
Triage-SAFE-T-/SMA09-4432