How do you conduct suicide assessments

[edieb]

Does anybody on here have any links or references which demonstrate how to-do thorough, legally-sound suicide assessments (e.g., better than "are you suicidal or homicidal", measuring hopelessness, etc) I looked on Amazon.com and bought some books but it appears they expect you to spend 30 minutes on each patient, which just isn't reasonablie

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[bostongal109]

I believe, to do a legally sound suicide assessment you need specific training on this. It's about the wording, how much you can really say about their risk, and demonstrating the effort you put into fully understanding their needs and risks. So, in short, a "legally sound" assessment will typically be longer than 30 minutes unless the person is just flagrantly suicidal (like if they present in the context of a suicide attempt). You need to do a thorough interview with the client, understanding their current mental status, risk and mitigating factors, previous behaviors/psychiatric history,etc. I like to use Phillip Resnick's suicide and risk assessment as a guide (it's a little outdated but still helpful http://www.fmhac.net/Assets/Documents/2007/Resnick Suicide and Violence 2007.pdf). Then, I personally believe, you need to demonstrate effort made to substantiate the history, so calling providers and/or family, getting emergency records from previous hospitalizations, calling the area's crisis team for information on the client.

I would definitely read about it, but ultimately you need training, and if in the meantime this situation presents itself you can call a crisis team as they are trained to do this, and it relieves you of the burden. Also- nothing is ever "legally sound" when it comes to estimating risk, but you can CYA but putting in the effort.

And just for reference: I do these multiple times a week, and have for many years, so I think I've gotten the system down pretty well. I allow 3 hours per patient, but if the stars align, I can do it in 2. An hour to interview them, an hour for record review/collaterals (I typically already am given their records), and a quick dictation, And an hour to talk to insurance, if needed, and set up next level of care.

 

[pny32]

I would recommend look at Dr. Joiner’s Risk Assessment which is available on his lab’s website: http://psy.fsu.edu/~joinerlab/resources.html in addition to using the BSS ideation questionnaire. It provides a nice guideline for things you should be asking.

It’s important to do a thorough suicide risk assessment and to initiate safety planning/provide resources even if they don't outwardly appear suicidal. Beyond CYA, you're providing an opportunity for the patient/research subject to discuss thoughts and feelings. You should be looking at passive and active SI, access to lethal means, plans, etc. You should also be assessing for a change from baseline - have things been more stressful for that person in the last week or so? Have they been experiencing agitation or insomnia? Things like that.

Usually it takes me between 20-30 minutes for each research subject and, typically, I initiate safety planning with everyone because they all have a pretty serious disorder or history.

 

[Rivi]

You probably already stumbled on this, but I really like Shea's book:
http://www.amazon.com/The-Practical-Suicide-Assessment-Professionals/dp/0615455646

Perhaps giving clients with suspected SI the Beck Suicide Scale, which can help you make a decision and they can complete in 5-10 minutes before the session.

Also, I like this post on how to document:
http://thelastpsychiatrist.com/2006/09/how_to_write_a_suicide_note.html

I don't think anyone suggests spending 30 minutes on SI alone. It is hard to find the balance between thoroughness and expediency, but there is probably a way to take the core components and utilize them efficiently.

 

[KillerDiller]

I second the recommendation for Shea and the CASE approach.

 

[PsychBiker]

My favorite psychiatrist spends 20 seconds getting a patient to sign a suicide contract... so that's an option.

 

[Therapist4Chnge]

"No harm contracts" are dicey at best. In combination with treatment plan they can be helpful, though only if used correctly and with a clear understanding of the limitations and appropriateness.

 

[DynamicDidactic]

like a boss

With regard to your question though, the two risk assessment protocols I like the most are the Columbia Suicide Severity Rating Scale with the accompanying Risk Assessment page (http://www.cssrs.columbia.edu/scales_practice_cssrs.html) and the University of Washington Risk Assessment and Management Plan (http://depts.washington.edu/brtc/files/UWRAMP.pdf). I think the UWRAMP has the edge because it includes a place to document clinical decision making regarding risk management (because it's not enough to just do assessment). These do not reduce the amount of time needed, though. It takes as long as it's going to take. If you want to be doing risk assessment and management such that what you do may actually prevent suicide, then you're going to have to invest the time to do it.

CSSRS - whack
UWRAMP - much better

Here is something in the making
http://behavioraltech.org/products/ssn.cfm

I think the bigger issue is assessment alone is rather useless without the overarching context of actually preventing suicide. As most of us probably have experienced, the most common method of dealing with suicidal clients is hospitalization. Yet there is zero evidence showing that hospitalization decrease suicide. If anything we have good evidence showing that hospitalizations don't help at all.

 

[smalltownpsych]

like a boss


CSSRS - whack
UWRAMP - much better

Here is something in the making
http://behavioraltech.org/products/ssn.cfm

I think the bigger issue is assessment alone is rather useless without the overarching context of actually preventing suicide. As most of us probably have experienced, the most common method of dealing with suicidal clients is hospitalization. Yet there is zero evidence showing that hospitalization decrease suicide. If anything we have good evidence showing that hospitalizations don't help at all.

Might be because one key point of both the assessment and treatment of suicidality is rapport. Involuntary holds and the adversarial approach of many systems can really inhibit that. Also, being hospitalized can exacerbate environmental stressors and it can increase avoidance conditioning. But the whole system is geared to hospitalize as that is the "safer" option from a risk management standpoint. Just a few thoughts about what I deal with when doing ER consults.

 

[irish80122]

I taught a class on suicide online last summer and I have my lectures on suicide assessment online. They can be found at the following links:

Assessment video 1:
Assessment video 2:

As you can see in those videos, the primary tools I use are Fremouw's SAAP and Jobes' SSF-III. Both are very good measures (as are the ones suggested above).

I am not a lawyer, but from what I have gathered from numerous presentations doing a defensible suicide assessment is less about the measure you select (so long as it is defensible) and more about spending the time to get all the information, documenting your decision including what factors led to your decision about risk, and then doing appropriate follow-up whether it be hospitalization or creating a safety plan

Safety plan video:

I hope that helps some!

 

[Therapist4Chnge]

I am not a lawyer, but from what I have gathered from numerous presentations doing a defensible suicide assessment is less about the measure you select (so long as it is defensible) and more about spending the time to get all the information, documenting your decision including what factors led to your decision about risk, and then doing appropriate follow-up whether it be hospitalization or creating a safety plan.

This is 100% in line with what I was taught during training and have seen in professional practice.

What a licensing board/judge/ethics committee/etc. will be considering is if the treating clinician(s) was/were adequate in their care of the individual. Assessment, documentation, treatment, and follow-up are all important aspects of care. The quality of a treatment plan should *not* be judged by the end result, as a certain % of patients will attempt and complete their suicide, regardless of the treatment plan.

 

[smalltownpsych]

This is something that continues to be said in treatment settings, but I know of zero data that actually supports it. It ultimately only serves to make providers feel pessimistic and lessen the likelihood that they will take up strategies that HAVE been shown to be effective in preventing suicide and suicide attempts. Believing that suicide is preventable is one of the culture shifts that has enabled places like the Henry Ford system to be able to shift their care and reduce suicides dramatically within the system. It is also at the core of the Zero Suicide Approach, which was born out of the success of Henry Ford and other systems.

I agree to an extent, but in the real world, are we responsible for people who continue to use substances and become suicidal? Many people want me to "fix" these people but they are not asking for help.

 

[smalltownpsych]

To an extent, yes we are responsible for providing the very best care that we can. Saying "oh, they'll just do it no matter what I do" in no way makes us strive to do better. I would argue that it does the opposite and makes us complacent. The spirit of a Zero Suicide framework is not to blame clinicians. Rather it is to shine a light on how the system overall is doing in preventing these outcomes, place the responsibility on the system, and continue to try to refine and enhance care to do better.

Great points. The frustration that many clinicians have is with the system overall and the tendency for the responsibility to fall solely on our shoulders. Being able to advocate for systemic change more effectively is part of why I became a psychologist and have been teaming up with other community members along these lines.

 

[FLpsychstudent]

We also use Joiner et al. 1999. You ask mostly about suicidal ideation (including frequency/types of thoughts, desire, intent, etc.), then plans/preparation, prior history, and there are a few other risk factors (e.g., severity of psychopathology, hopelessness, etc.) that can play a role. You can categorize their risk and their are actions laid out for each risk level (e.g., safety planning, coping strategies, resources, means restriction, check ins). It can take really however long you make it, I have had anywhere between less than 5 mins to an hour for people who are less willing to engage in the assessment or prevention. Not sure exactly the legal terms but I feel like this system allows you to feel comfortable that you have taken the appropriate actions depending on the risk level.

 

[DynamicDidactic]

I agree with @psycscientist. As a psychologist we take on the responsibility of preventing suicide. At the same time, we actually cannot control the actions of our clients. However, to conflate the two is erroneous. I also want to underscore psycscientist's point, that we have zero evidence saying that a certain % of patients will attempt and complete their suicide, regardless of the treatment plan. To me, it seems that something can be done for everyone to prevent suicide. However, to empirically prove so and to implement it is very difficult.

 

[PsyDr]

Necro bump!

 

[psych.meout]

Necro bump!

 

[Therapist4Chnge]

Childhood right there! My best friend had a Sega Master System and I had a Nintendo...so we rocked out. Kids these days don’t understand the importance of games like AB.

 

[Justanothergrad]

Man, give me AB and golden axe any day..