1. Zero Suicide: Train, Identify, Engage Preparing QMHA’s for Risk Assessment & Intervention Rich Roell, MSW, LCSW Program Coordinator Washington County Crisis Team – Hawthorn Walk-in Center Lifeworks Northwest

2. Risk Screening training for non-QMHP’s

3. Context
This training was developed to provide guidance & support to staff who are now assessing for risk of harm using the Columbia-Suicide Severity Rating Scale (C-SSRS).

4. The Columbia Suicide Severity Rating Scale (C-SSRS) questions
1) Have you wished you were dead or wished you could go to sleep and not wake up?
2) Have you actually had any thoughts of killing yourself?
If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6.
3) Have you been thinking about how you might do this?
E.g. “I thought about taking an overdose but I never made a specific plan as to when where or how I would actually do it….and I would never go through with it.”
4) Have you had these thoughts and had some intention of acting on them?
As opposed to “I have the thoughts but I definitely will not do anything about them.”
5) Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
  6) Have you ever done anything, started to do anything, or prepared to do anything to end your life?
Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.

5. Context The C-SSRS is part of two organizational priorities:
Utilized as part of the Zero Suicide Initiative.
Used to screen all incoming clients and those receiving services at the Certified Community Behavioral Health Centers (CCBHCs).

6. Context
Staff who historically were not asking questions specific to suicide are now required to ask about ideation & intention, and to assist with getting the appropriate supports in place for the client;
This has created apprehension for some of our staff members.

7. Staff Concerns Here are some of the concerns staff voiced:
What happens if they answer yes?
If I ask them about suicide, it will put the idea in their head.
I am now responsible for someone that wants to kill them self, I don’t feel prepared for this.
I’m responsible if this doesn’t end well.

8. The Columbia-Suicide Severity Rating Scale (C-SSRS)

9. The C-SSRS
The C-SSRS is a suicidal ideation rating scale created by researching at Columbia University to evaluate suicidality.
The scale rates an individual’s degree of suicidal ideation.
The scale identifies behaviors which may be indicative of an individual’s intent to complete suicide.
An individual exhibiting even a single behavior identified by the scale was 8 to 10 times more likely to complete suicide.

10. C-SSRS & LifeWorks NW process
Process and Practice
Currently, all clients calling our Intake Department are receiving a C-SSRS screening.
Enrolled CCBHC clients are screened at each visit or once per week.

11. When to ask C-SSRS Questions
At every visit, but not required more than once per week.
Involve your client in deciding when you will ask the question. For example, if you regularly meet the client in the community you could say, “I need to ask you this question at each appointment. Would you rather I ask it at the beginning, or should we set aside time later in the appointment for this?”

12. Assessing for Risk
Now that you have completed the C-SSRS with the client and get an affirmative answer to the question(s) posed, what do you do?
Don’t panic. You don’t have to do this alone!
Thank the client for sharing the information & and assure them you’ll be working with others to help keep them safe.
3) Begin a conversation so that you can gather more information about their specific plan or intent.

13. Gathering Information
The reason for gathering additional information is to determine what the immediate plan should be. Questions to consider: 1. How long has the client been thinking about this? E.g. Have you been thinking about this for a while or did it just begin last night? 2. Does the client have a specific plan? E.g. Have you thought of ways to do this? Or, have you gone as far as developing a plan for how you will do this?

14. Gathering Information
Questions to Consider: When is the person planning to do this? Someone who says they are going to end their life if their partner/significant other breaks up with them in the future needs a different response than someone who says they are planning to do it immediately that same day.

15. Gathering Information
Question to Consider: Does the person have the means? If the client reports a plan to shoot themselves, you might ask if they have access to a gun. If the person doesn’t have a gun, doesn’t know where to get a gun, and doesn’t have the money to purchase a gun, their risk is lower than someone who has a gun at home.

16. Gathering Information
How lethal is the person’s plan? A person who plans to shoot themselves is likely more lethal than a person who plans to overdose on five Trazodone tablets.

17. Gathering Information
We always take suicidal threats seriously despite the lethality and immediacy of the plan. The reason for gathering information is to formulate how high the risk is, plan our intervention, and communicate with the rest of the client’s team.

18. Gathering Information
What if the person always says they are suicidal?
Don’t assume their risk is low because of chronic suicidal thoughts.
Ask if anything has changed lately. Maybe something has changed to increase their risk.
Be familiar with their safety plan and work with your supervisor or the client’s QMHP about how to respond to the client’s ongoing thoughts.

19. Gathering Information
Substance Abuse: Does the person abuse substances or are they currently intoxicated? People who use alcohol or other substances are significantly more likely to take their own lives.

20. Gathering Information
Question to Consider:
Do they want help keeping themselves safe?
(Your problem solving will be more effective if they have agreed they want our help).
E.g. “I’m concerned about your safety. Can I help you think through some strategies to help you stay safe?”

21. Make a Plan Immediate Concern
If the client has an immediate plan to hurt themselves, or has already done something to hurt themselves, you will need to take immediate action, including possibly taking them to an emergency room or calling 911.

22. Make a Plan Immediate Concern
An example of an immediate concern is the client discloses, or you suspect, they have already taken an overdose. Another example is that you are driving a client and they threaten to jump out of the car.
It is important to consult with your supervisor, but you may need to take immediate action before you have a chance to consult.

23. Current Risk Managers:
Make a Plan
Immediate Concern
You should call a risk manager if you cannot reach your supervisor. Risk manager phone numbers are listed on the home page of IRIS. Risk managers are available 24/7.
Current Risk Managers:
James Gurule:
Susan Dale:
Mark Lewinsohn:

24. Imminent (but not immediate) Concern
Make a Plan
Imminent (but not immediate) Concern
If the client has a plan to hurt themselves that day or the next, you need to take action but you have more time.
Remember, as long as the client is with you, they are safe. If you can, keep the client with you and involve them in developing a plan.

25. Make a Plan Imminent Concern
Explain to the client that you want to help keep them safe and need to consult with your supervisor or their clinician. Make sure the client will be safe while you consult. For instance, you might ask someone to keep an eye on them while you consult or you might consult while the client is with you.

26. Make a Plan Imminent Concern
You can explore ideas with the client about what might keep them safe – stay with a friend, have family assist, etc.
Help facilitate an appointment for the client to meet with a QMHP for further safety planning. Help them plan for safety until that appointment.

27. Concern is Not Imminent
Make a Plan
Concern is Not Imminent
If the client isn’t planning on hurting themselves or ending their life in the near future, there is even more time for planning. A good example of this would be a client who says they plan to kill themselves on their birthday, which is two months away.

28. Make a Plan
Once it is clear that there is no imminent concern, either share this information with the client’s clinician or facilitate the client sharing this information themselves. It is your role to communicate any information you have to the QMHP, and it’s the QMHP’s role to meet with the client to work on safety.

29. Make a Plan The Client is Vague
If you don’t get clear answers when you try to gather more information, it is important to consult fairly quickly with a QMHP, preferably someone who knows the client.
This is where the client’s history becomes important – is this their usual behavior?? Have they made attempts before?

30. Make a Plan
The Client is Vague With the knowledge you and the QMHP have about the client, plus asking a few more questions of the client or their collaterals, the team will likely be able to develop a clearer picture of this person’s risk and take appropriate steps.

31. Assessment aides
There are many assessment tools to help with suicide risk. Here are two; they are brief and easy to remember.
S-specificity: detailed plan
D-dangerousness: how lethal was their attempt
L-lethality: how lethal was their means
I-intent: did they think they would die
A-availability: what is their access to means
R-rescue: did they aid in their own rescue
P-proximity: how close/available are helping resources
T-timing: how recent was their attempt M

33. Closing thoughts by Karen Micciche, Intake Department Manager….
At first, we were all scared.
The C-SSRS is like this beautiful net we are casting out to provide support. It’s a good thing.
Once we started doing this, it wasn’t bad at all!

34. What would you do?
You meet with your client Steve and ask him the C-SSRS questions. Steve responds “yes” when you ask him if he has wished he was dead or wished he would go to sleep and not wake up. Steve further elaborates and shares he has been ‘stockpiling’ his sleep aid medications for this purpose.
What do you do next?

35. What would you do?
You are meeting with Maggie prior to her first job interview in several years. During your drive with Maggie to her potential new employer, you ask her the C-SSRS questions. Maggie responds yes when asked, Has she had any actual thoughts of killing herself.
Do you proceed to job interview with Maggie?

36. What would you do?
You meet with Tom for your regular skills training session. Tom indicates that he wishes he were dead. Tom regularly reports this status to all his team members. In your opinion, Tom is always suicidal.
How do you move forward with Tom?

37. Putting It Into Practice
You will now be working in groups. Read through the vignettes and as a group, determine your next action steps.

38. Vignette example Text Message
A QMHA is working with a 16 year old female client in the youth addictions program. The QMHA sees the client about one time per week for mentoring services. The client is currently in treatment for cannabis and alcohol use disorders. She has no prior history of suicide attempts, and has endorsed sporadic thoughts of suicide without a clear plan. She has a history of cutting, but has not cut in about a year.
It is 6:30 PM and the QMHA is just leaving the office for the night when she receives a text message from the client stating,
“I just got in another big fight with my mom and left the house. I am tired of all her negativity. I seriously feel like jumping off the Burnside Bridge.”
What additional questions might the QMHA ask?
What actions, if any, should the QMHA take?

39. Debriefing the Vignettes
Have you dealt with similar situations?
Would you have completed similar actions steps?
Is there something different you would have done?
Please keep in mind that each issue will be dynamic and fluid. The key being there needs to be some action. Consultation is a key to increase making a right answer.

40. In Closing Take all threats seriously.
Please remember, a supervisor or clinician should help assess the situation to ensure safety for all. You should never place yourself in harm’s way. It may be difficult, but remain calm. Help facilitate support on behalf of your client, advocate for their needs.
Please check in with your program supervisor or manager for protocols in dealing with these situations. Know your resources & responsibilities. M

41. Completed Suicides of Lifeworks NW clients

42. Thank you!!
Rich Roell, MSW, LCSW