In my previous post, I outlined suicide risk factors. In this post, I will describe a few specific methods for evaluating risk.
One way in which to assess risk is to use mnemonics. Each letter in the mnemonic represents an area to evaluate. The higher the level, the higher the risk of suicide. The great thing about mnemonics is that they are easy to remember. Keep in mind that evaluating clients for suicidal intention is emotionally intense, so the more information you have at your fingertips, the better.
ISPATHWARM
Ideation
Substance abuse
Purposefulness
Anxiety
Trapped
Hopelessness
Withdrawal
Anger
Restlessness
Mood change
SLAP
Specificity of plan
Lethality of proposed method
Availability of method
Proximity of helping resources (such as supportive friends and family)
The more specific the plan, and the more lethal the method, the higher the risk. The closer the proximity of helping resources, the lower the risk.
SAD PERSONS
(1 pt each)
Sex (male)
Age (older)
Depression
Previous attempts
Alcohol abuse
Rational thinking loss
Social supports lacking
Organized plan
No spouse
Sickness
Total up the points: 3-4 close follow up; 5-6 strong consideration for hospitalization; 7-10 hospitalization or commitment
General Tips
Please keep in mind that none of these tools are exact formulas, but rather different ways to think about and assess risk. It is important to remember that supervision and consultation are essential.
In addition…
If the client mentions previous attempts, use this opportunity to get some very specific information about said attempts. You’ll want to know the nature and quality, what method was used, what happened afterwards, did someone find them, what were their reactions after revival, how do they feel about still being alive, etc. If you don’t do this at this point, be sure to go back and do it later. Keep in mind that ¾ of those who commit suicide had previous attempt(s). The greater the lethality of the previous attempt, the higher the risk.
If you hear the terms “helplessness,” “hopelessness,” “worthlessness,” or “guilt,” be sure to ask about them. How hopeless is it? Are you thinking of hurting yourself? It is important to ask the appropriate questions to uncover the frequency and intensity of these types of thoughts.
In general, it is very important to explore ideation, to calmly and directly assess it. This lets clients know that you are not afraid of the subject, which means they are more likely to be honest and disclose more fully. Be sure to ask multiple times in different ways because clients don’t always reveal suicidal ideation when first asked. It is also important to normalize the experience for clients by saying something like, “many people have had the thoughts at some point.” If client acknowledges suicide thoughts or feelings, then make sure you understand the duration and intensity as well as the context in which they occur.
Ask how in control they feel over their moods- can a client exert internal control over suicidal ideation? At risk are those who fear losing control or who have a history of losing control.
Intent is also important to determine. Determine the extent to which they intend to carry out their plan. Scaling questions can be useful for this. Be sure to explore their reasons for living, because this can go a long way toward mitigating risk. And remember, the most intent client is the one who doesn’t ask for help, so be vigilant with regard to depressive symptoms and other risk factors.
In my next post, I will discuss how to make a decision about a suicidal patient and what to document.
Yours in the Joy of Knowledge,
Dr. Barbara LoFrisco
Source: personal communication, Dr. Caroline Wilde, November 13, 2013
