suicude assessment ways

suicude assessment ways While we cannot predict future behavior with certainty, clinicians can make
a reasonable judgment regarding the degree of present danger. A thorough
assessment of all aspects of suicidality—ideation, behavioral rehearsals of
lethal actions, prior attempts, and past and current intentions—will inquire
into risk factors, warning signs, and protective factors. These can be embedded
in a more complete biopsychosocial investigation. In doing so, it is useful
to cover as many of the following content areas as possible:
Reasons for living and reasons for dying: “What would have to happen
to make you want to kill yourself?” “List all those things that are
keeping you alive.”
Sense of hope and future orientation: “Do you think things will get
better?”
Likelihood of past circumstances repeating themselves in the future:
“What is the same or different about this episode compared with
prior episodes?”
Insight into current and/or chronic problems: “How do you understand
what is happening to you?”
Current and past use of alcohol and other drugs, including prescription
and over-the-counter medications (since these, of course, can
impair reality testing, information processing, and judgment): “What
role does alcohol play in your management of your problems?” “How
does alcohol make things better or worse?”
Imminent versus chronic risk for self-destructive thoughts and
behaviors: “Are these thoughts and/or feelings overwhelming or
frightening to you, or are they familiar?”
Presence of a support network: “How important are your friends/
family/teammates?” “To whom are you closest?” “To whom can you
confi de?” “What role does spirituality and/or religion play in your
life?” “Who can you count on in an emergency?”
Prior exposure to suicidal behavior (family, friends, etc.): “Do you know anyone who has died by suicide or made a suicide attempt?”

Development of social skills (e.g., peer pressure resistance) and cognitive
skills (e.g., problem solving): “How well do you negotiate what
you need from others?” “Are you able to say no when you don’t want
to go along with what others are doing?” “What kinds of situations
and relationships are diffi cult for you to manage?”
History of impulsivity and aggression: “Have you gotten into trouble
with the law?” “Are you prone to make snap judgments or fl y off the
handle without much warning?”
Sleep patterns and sleep hygiene: “Have you noticed any diffi culties
with falling asleep, staying asleep, or waking up earlier in the morning
than you intend?”
Instrumental, psychological, and interpersonal messages contained
in suicidal behaviors, including acting-out behaviors: “What did
you hope would happen after the last attempt?” “Did this current
attempt give you any relief from your distress?” “What would be the
best outcome from this current episode?”
Suicidal patients may be reluctant to explore their suicidality without fi rst
feeling assured that the clinician is well versed and comfortable with the topic.
Such assurance can be conveyed by discussing the topic in a calm and nonjudgmental
manner, knowing the range of self-injurious and self-destructive
behaviors, and understanding the motives behind suicidal behaviors. Demonstrating
comfort with the subject of suicide helps build trust and a therapeutic
alliance, which are critical to the treatment outcome.
It is not unusual for clients to deny suicidal thoughts when asked outright,
due to the ongoing stigma associated with suicide and the fear of unknown
consequences when admitting to suicidal ideation (“They might send me to
the hospital or kick me out of school”). Therefore, if there’s any indication at
all of suicidal material, the clinician must go beyond the initial “no” response,
and explore further.
One way to gently introduce the topic is by inquiring into the client’s general
state of well-being and then proceeding to issues of ideation, intent, and
planning as noted above. A potential sequence might start as follows: “How
bad have you been feeling?” “Does it seem as though things will change for the
better?” Depending upon the responses, the clinician might then advance: “Do
you see much point in going on?” “Have you been feeling like a burden to others?”
“Do you wish you were dead?” “What does suicide mean to you?” “Have
you thought about a particular way to end your life?” “Do you have access to a
method to do this?” “Have you tried this out?” “Have you imagined or engaged
in ‘rehearsals’ for a planned suicide?” “Does anything make these feelings get
better or worse?” “How likely do you think you would be to harm yourself?”
“Under what set of circumstances?” (Davidson, 1999; Goldman, Silverman, & Alpert, 1998).•

If the student does acknowledge some suicidal content, it’s vitally important
to understand the context, the “who, what, when, where, why, and how”
of the circumstances that engendered it. For example: “Where were you when
the thought occurred?” “Who was present?” “What happened?” “When did
it start?” “How long did it last?” “Why do you think it occurred when it did?”
“How did you deal with it?” “Did you act on it?” “Would you act on it next
time?” (Barrios, Everett, Simon, & Brener, 2000). The answers will allow the
clinician to answer the ultimate questions of “Why now?” and “Is it likely to
happen again?”
Finally, in assessing lethality, the clinician should weigh the character of
any ideation (Was it serious? Pervasive? Fleeting? Disturbing? Distressing?
Comforting? Relieving? Familiar? Logical? Paranoid?) and its possible progression
(Did it go from a thought to a wish, desire, or intent? Did it go from a
thought to a plan?) (Silverman, 2005). If there was an actual attempt, the clinician
additionally needs to consider the following: Was the attempt intended
to end a life? Was it instrumental in nature (a behavior to accomplish some
specifi c end rather than self-destruction or death)? Did it appear to be a “cry
for help”? Did the student plan to be rescued? Did the attempt involve lethal
methods? Did the student use coping behaviors learned from others? Does the
student have accurate knowledge of lethal means—amounts, dosages, accessibility,
time frames, etc.? Is there a pattern to the behavior? How does the
student feel now? (Berman, Shepherd, & Silverman, 2003; Silverman, 2005a).
All of the above can then be interpreted in context along with the quality
of the therapeutic interaction (e.g., degree of cooperation, presence of anger,
demeanor); conduct of the interview (eye contact, verbal interchange, ability
to track the sequence of questions, level of distress/anxiety); and physical
attributes (attention to personal grooming, how the student sits in a chair)
(Silverman, 2005a).