Procedures for Assessment of Suicide Risk
***Counselors-in-training are highly encouraged to seek consultation with supervisors or instructors if there is immediate concern regarding a client.
Although there is much information to gather, there are no shortcuts to suicide assessment. Risk assessment requires directness, intentional questioning, and careful listening. The essential skills and conditions of counseling (empathy, reflections, restatements, attending, active listening, etc.) are important in suicide assessments and intervention.
Information that is gathered during assessment should be documented (See Ethical and Legal Aspects
Knowing when a suicide assessment is necessary
There are recommendations that counselors conduct suicide risk assessments on all clients presenting for therapy (Laux, 2002). It is common practice that suicide ideation is assessed through intake forms and intake interviews
Specifically, clients presenting with depression or depressive symptoms
or in states of crisis should be questioned for suicidal ideation. If using depression inventories
, special attention should be given to questions related to suicidal thoughts (such as question 9 on the Beck Depression Inventory).
As the client tells his/her story, the counselor should be listening (and looking) for the presence of risk factors
and protective factors
. As the number of risk factors increases particularly in the absence of protective factors, suicide risk increases and should be questioned.
As a counselor attends to the client, language that reflects feelings of hopelessness and despair should be noticed and explored. For instance, it is paramount to ask for elaboration on statements such as “I can’t go on anymore.” “I want to end it all.” “I wish I were dead.” “This is hopeless, I don’t see any way out of this situation.”
In truth the first intervention for suicide is the assessment, in other words assessment begins the process of suicide intervention.
The point is to assess for risk AND leverage (information that can be used to intervene).
Questions to guide Suicide Assessments
Either as part of an intake assessment, or based on information you have gathered indicating that a suicide assessment is in order, the starting point is:
- Ask directly if the client has thoughts of suicide. “Have you thought of committing suicide?”
- “Are you thinking of killing yourself?” In this case, subtlety is counterproductive.
If the answer is anything but a confident “No”, then assessment should proceed.
Even in cases when a client answers by saying “No”, continued exploration and discussion of what the client has said or presented that may be related to suicidal ideation is warranted.
- Have there been previous attempts? (When, surrounding circumstances, rescuer?)
For example: “When?” “How often?” “What happened?” “What was going on in your life at the time?” If attempts were made, then exploration of method and rescuer should be explored.
If the client indicates having thoughts or having made attempts in the past, even if there is no current ideation, past experiences should be thoroughly explored.
If the client does not answer questions about suicide, the answers are vague, or if the client conveys that he/she has entertained thoughts of suicide then…
- Are the thoughts pervasive or intermittent? When was the last time the thought occurred to the client? Do these thoughts typically occur in times of crisis?
- Is there a specific precipitating event?
Even if answers to these questions continue to be vague or seem to be more intermittent, ideas of how the person might commit suicide need to be explored.
- Is there a plan? What are the details of the plan? How extensive is the plan?
Examples: “How have you thought of killing yourself?” “When would you carry out the plan?” “Do you have a date and time?” “Where would you be?” “Who would you want to find you?”
- What is the lethality of the means/method?
- Is there access to the identified means?
Examples: “If you were to commit suicide, how would you do it?” “Do you have the pills?” “Where are they?” “What type of pills would you take?” “What type of gun?” “Where would you get the gun?” “Do you have bullets?” “Where is the gun? The bullets?” “Do you have a rope/cord?”
The previous questions have related specifically to suicide ideation. In addition, questions that assess for risk and protective factors are explored. All of this information aids in determining risk and subsequent interventions
- Is the client using drugs or alcohol?
- What are the client’s social supports?
- Does the client have a religious or spiritual affiliation?
- How is the client discussing suicide and potential aftermath? Do fantasies seem to be positive or painful?
- Is the client able to see any alternatives to suicide?
- How does the client respond to challenges to distorted thinking?
The Use of Assessment Instruments
Various instruments have also been used assessing for suicide risk. These include assessments such as the Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974) and the Beck Depression Inventory (Beck & Steer, 1987) and the BDI-II (Beck, Steer, & Brown, 1996) that were not specifically designed to measure suicide ideation, but what is measured correlates with suicide ideation and can therefore be helpful.
In addition, there have been instruments developed specifically to assess for suicide ideation. These instruments include:
- Beck Scale for Suicide Ideation (BSSI) (Beck, Kovacs, & Weissman, 1979)
- Suicidal Ideation Scale (SIS) (Rudd, 1989)
- Suicide Behaviors Questionnaire (SBQ) (Cole, 1988)
- Reasons for Living Inventory (Linehan, Goodstein, Nielsen, & Chiles, 1983)
- Suicidal Ideation Questionnaire (Reynolds, 1987)
Some of the above instruments have also been validated for use with adolescent or college populations. In addition, there are instruments that have been specifically developed for these populations.
- College Student Reason for Living Inventory (Westefeld, Cardin, & Deaton, 1992)
- Suicidal Ideation Questionnaire – junior high version
- Multiattitude Suicide Tendency Scale – for adolescents (Orbach, Milstein, Har-Even, Apter, Tiano, & Elizure, 1991)
- Fairy Tales Test (Life and Death Attitude Scale for the Suicidal Tendencies Test (for children 10 and younger) (Orbach, Feshbach, Carlson, Glaubman, & Gross, 1983)
The use of suicide assessment instruments can be helpful, but should not replace the assessment interview. There are also times (due to the emotional and cognitive state of the client) when administration of a test would not be prudent.
*For a discussion on suicide assessment instruments, see Brems, 2000 and Westefeld, Range, Rogers, Maples, Bromley, and Alcorn, 2000).