1. Lifeline Safety Assessment Model
Updates on the
Lifeline Safety Assessment Model
Shye Louis, M.Ed, Coordinator – Best Practices in Suicide Prevention
National Suicide Prevention Lifeline
National Crisis Center Conference
October

2. Disclaimer
The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services.

3. Overview What are the Lifeline Risk Assessment Standards?
Why develop a new assessment?
What is the new Safety Assessment and how did Lifeline develop it?
Impact for staff and for consumers
Q&A

4. National Suicide Prevention Lifeline
Over 160 crisis centers nationwide
Linked via TALK or 800-SUICIDE
Extensive back-up system ensures all calls are answered
Both phone and chat based services
Centers must adhere to Lifeline established standards
Over 2 million calls answered in 2017

5. Background: Lifeline Process
IDENTIFY BEST PRACTICES
STANDARDS, GUIDELINES & POLICIES
IMPLEMENT
TRAINING & T.A.
EVALUATION

6. Lifeline Risk Assessment Standards
Lifeline Suicide Risk Assessment Standards (SRAS) (2006)
Require three prompt questions
Are you thinking of suicide?
Have you thought about suicide in the last two months?
Have you ever attempted to kill yourself?
Full suicide risk assessment
Suicidal Desire
Suicidal Capability
Suicidal Intent
Buffers/Connectedness

7. Lifeline Imminent Risk Guidelines
Policy for Helping Callers at Imminent Risk of Suicide (2011)
Focus on
Active Engagement - make reasonable efforts to collaborate with callers at imminent risk to better secure their safety
Active Rescue - take all action necessary to secure the safety of a caller and initiate emergency response with or without the caller’s consent if unwilling/unable to take action
Collaboration with other community crisis and emergency services

8. Why Review SRAS? Decade passed since development
Is SRAS consistent with developments in field?
Two policies (SRAS/IR) that really need to be one guideline
Must address crisis center feedback
So many risk factors what to do with them
Are some elements more important than others?
Concerns regarding rote check off approach
Continued requests for scale to predict risk

9. Lifeline Committee Guidance
Maintain the Lifeline four core principles – desire, intent, capability, buffers
Provide guidance not just on WHAT to ask but WHY and HOW
Develop model based on hotline call flow that
Emphasizes connection to the caller
Focuses on safety at its core
Emphasizes safety and prevention over prediction

10. About Assessment of Risk
Cannot predict who will die by suicide
Risk factors, warning signs, drivers
Use of scales
BUT
Many more people think about suicide than make an attempt
Limited knowledge on what moves people from ideation to action
We do know that the time between ideation to attempt can often be short

11. Ideation to Action Deisenhammer et al. (2009)
Interviewed 82 patients three days after suicide attempt
47.6% (N=39) reported that the period between the first current thought of suicide and attempt was 10 minutes or less.
Those patients in which this process had taken longer showed a higher suicidal intent
Millner, Lee and Nock (2016)
Interviewed 30 patients that had recently attempted suicide
Noted onset of suicidal ideation and selection of method often occurred years prior to an attempt
However, majority of proximal steps down the pathway to suicide occurred within a week and most within 12 hours of the attempt
Many also reported absence of SI until just before attempting

12. Ideation to Action (contd.)
Short time span underscores
Role crisis hotlines play
Need to focus on safety for now
Need for preventative measures – safety plan to be in place for all those at risk

13. Model Emphasis Phase 1: CONNECT Attention to connection
Early and direct focus on suicide – past and present
Assess if an attempt is already in progress
Safety formulation from the start

14. Model Emphasis Phase 2: LISTEN TO THE NARRATIVE CLARIFY PLAN
Attention to connection
Gather information to formulate safety
Pay attention to drivers of suicidality
CLARIFY
Fill in the gaps
Desire, Intent, Capability, Buffers
PLAN
Focus on safety and prevention
Use all information gathered to develop safe plan
Develop safety plan regardless of risk status

15. Updated Emphasis on Safety Considerations
The contents of the table below will be familiar to crisis centers as the four core principles of the Lifeline Risk Assessment Standards. Crisis centers within the Lifeline network are required to develop a risk assessment that includes all subcomponents contained above – but, as mentioned earlier in this paper, what to ask callers, when to ask, and most importantly HOW to ask about these elements can be difficult to determine and the need to ask about every component is not always necessary.

16. Model Emphasis
Phase 3:
OFFER FOLLOW-UP
WRAP UP THE CALL

17. Consistent with leading approaches
Assessment and Management of Suicide Risk (AMSR)
Pisani, Murrie, and Silverman (2016)
Consistent with the Lifeline perspective on moving away from a formulation based strictly on risk labels
Stress prevention over prediction and a formulation of risk that is “anchored in the clinical context and patient population in which the assessment occurs”
Risk formulation should lead directly to intervention strategies anchored in context and time
ASIST 11
Risk is reframed as threats to safety
Focus on Safety-for-Now

18. Strategies for Safety Addresses the connection between WHAT to assess
HOW to assess it
WHY you’re assessing it
and the “SO WHAT” – how does the crisis counselor use that information to collaborate with the caller to address the need for safety?

19. Example What: Psychological Pain
How: “If your current situation didn’t change, could you tolerate the way you feel? (one of several sample questions available to crisis counselors)
Why: Psychological Pain is a strong contributor to suicidal desire
Strategies for Safety:
Listen and validate feelings, allow the person's pain to be heard
Collaborate with the person at risk to discuss internal coping strategies that can help de-escalate negative feelings and self- soothe
Explore the feeling of pain and clarify desire to die:
"It sounds like what you are describing is not so much wanting to die, as it is wanting and needing this pain to end.“
If the desire is more for the pain to end then death, the crisis counselor can highlight this as a need to stay safe for now until additional ways to relieve some of the pain can be put into place

20. Safety Assessment Tool
Online safety assessment resources provide:
Brief skill based modules to highlight core content and demonstrate effective interviewing techniques
Videos, sample prompts/questions, counselor tips, summary of WHY, literature, data sources, printable tip sheets

21. https://projects.invisionapp.com/share/QCI3K E58NM5#/screens/323232818

22. Discussion
How will the revised approach better serve individuals at risk?
How might operations feel different on both the crisis center side and for the caller at risk?

23. Questions
SARAH
We will now turn to questions.
Q&A!

24. Contact Info
Shye Louis Coordinator – Best Practices in Suicide Prevention