1. Assessment of Risk of Suicide: Interview
Establishment of the Therapeutic Relationship
Countertransference
Explicit intent vs Implicit intent
Acute vs Chronic Risk
Suicide Risk Assessment Areas
Protective Factors
Warning Signs
Methods of doing a Suicide Risk Assessment

2. Signs of Depression
Persons who are considering suicide often show signs of depression, anxiety, low self-esteem, and/or hopelessness, such as:
Appearing sad or depressed most of the time
Clinical depression: deep sadness, loss of interest, trouble sleeping and eating—that doesn’t go away or continues to get worse
Feeling anxious, agitated, or unable to sleep
Neglecting personal welfare, deteriorating physical appearance
Withdrawing from friends, family, and society, or sleeping all the time
Losing interest in hobbies, work, school, or other things one used to care about
Frequent and dramatic mood changes
Expressing feelings of excessive guilt or shame
Feelings of failure or decreased performance
Feeling that life is not worth living, having no sense of purpose in life
Talk about feeling trapped—like there is no way out of a situation
Having feelings of desperation, and saying that there’s no solution to their problems

3. Symptoms of Depression
Their behavior may be dramatically different from their normal behavior, or they may appear to be actively contemplating or preparing for a suicidal act through behaviors such as:
Performing poorly at work or school
Acting recklessly or engaging in risky activities—seemingly without thinking
Showing violent behavior such as punching holes in walls, getting into fights or self-destructive violence; feeling rage or uncontrolled anger or seeking revenge
Looking as though one has a “death wish,” tempting fate by taking risks that could lead to death, such as driving fast or running red lights
Giving away prized possessions
Putting affairs in order, tying up loose ends, and/or making out a will
Seeking access to firearms, pills, or other means of harming oneself

4. Therapeutic Relationship
Interviews are typically the main method of compiling data; thus, a therapeutic relationship must be established rapidly
Clinician comfort level with suicide may influence a patient’s willingness to share
Clinician’s willingness to ask about factors that may influence level of risk evaluated

5. Questions to Consider What is your comfort level?
Think about your experiences; what may influence your reactions?

6. Therapeutic Relationship
Countertransference
Definition: Redirection of a clinician’s feelings towards a client emotionally
Potential Issues:
Anxiety-Avoidance
Hopelessness
Contempt
Disdain
Hostility
When understood and used consciously, countertransference may help a clinician gather important data

7. Implicit vs Explicit Intent
Implicit Intent: Estimated by patient’s current and past behavior and understanding lethality of means chosen
Explicit Intent: Patient’s stated intent or what the patient says during the interview
If any discrepancies between the two are discovered, discuss them with the patient

8. Acute vs Chronic Risk
Chronic Risk: Likelihood of a future attempt based on the patient’s background factors and history. Establishes a baseline of risk.
Acute Risk: Level of current risk based on intent and risk

9. Structuring an Assessment Interview
3 Main Components:
Gather information related to risk factors, protective factors, and warning signs
Collect information related to suicide ideation, desire, intent, behaviors, and planning
Create a clinical formulation of risk, based on the information gathered

10. Risk Assessment Areas Predisposition to suicide
Static factor evaluated through previous history of the patient. Represents a chronic risk.
Stressors or Precipitants
Stress of issues may differ from patient to patient. Rating methods may help quantify the amount of stress an issue is to an patient.
Symptomatic Presentation
Baseline rate of suicidal behavior of people with affective disorders is very low, making it difficult to identify those with high risk. However, there have been predictors identified by research, such as substance abuse or low self-esteem
Hopelessness
Hopelessness is often a primary motivator in suicide attempts; thus, hopelessness ought to be assessed and monitored carefully

11. Rating Methods Examples:
Examples include 1-10 rating scales
Quantifies and clarifies patient response
Allows for comparisons over time and helps identify change
Can improve communication
Stressors may be perceived with different levels of stress to each patient
Examples:
On a scale of 1 to 10, 1 being ____ and 10 being ____....
How would you rate the severity of your hopelessness?
How would you rate your intent to kill yourself right now?
How would you rate the severity of the thoughts to kill yourself?
How would you rate your hopefulness about the future?
How would you rate your ability to seek help if you feel very suicidal?

12. Monitoring Hopelessness
Majority of suicidal patients consider it a primary motivator
Consider monitoring frequency, duration, and severity over time through quantification methods
Determine primary cause
Determine coping mechanisms in treatment plan

13. Assessment of Suicidal Thinking
Frequency
Intensity
Duration
Specificity and plans
Availability of means
Active behaviors
Explicit intent
Deterrents
Patient resistance may decrease if remote episodes are discussed first. Cultural factors must also be taken into consideration.

14. Previous Suicidal Behavior
Dimensions of each previous episode of suicidal behavior must be assessed. Can indicate ideas of increased risk when chronic risk has been identified.
Frequency
Context
Perceived lethality
Opportunity for rescue
Identifiable preparation for death

15. Assessing Self-Control
Perceived sense of control
Objective identifiers
Impulsive/self- destructive behaviors
Coping methods
Impulsivity as a result of a long-standing problem or personality trait is a significant risk factor, as suicide attempts are often triggered by specific environment stressors

16. Protective Factors Social support
Skills in problem solving, coping and conflict resolution
Sense of belonging, sense of identity, and good self-esteem
Cultural, spiritual and religious beliefs
Identification of future goals
Constructive use of leisure time
Active participation in treatments
Children present in the home
Pregnancy
Life satisfaction
Intact reality testing
Fear of social disapproval
Fear of suicide or death
Absence of potentiating risk factors and warning signs

17. Other possible methods include:
Methods of doing a Suicide Risk Assessment
Interviews are the most common way of assessing risk, and should be used when possible
Other possible methods include:
Phone calls
Video chat
If a high level of suicide risk is determined via these methods, and immediate treatment is deemed necessary, get the individual to call 911 or go to the ER

18. What could be some significant suicide factors?
Brainstorm!
What could be some significant suicide factors?

19. Assessment of Risk of Suicide: Determining Risk of Suicide
Risk factor areas
Predisposition to Suicide
Stressors and Precipitants
Symptomatic Presentation
Presence of Hopelessness
Nature of Suicidal Thinking
Previous Suicidal Behavior
Impulsivity and Self-Control
Protective Factors
Suicide Risk Assessment Tools

20. Suicide Risk Assessment Tools
Many questionnaires have been developed to measure aspects of suicidality
Different tools have different aims and approaches
Content collected through the questionnaire is typically more important
No consensus on which tool is more effective
Potential issues:
High false-positive rate
Stable variables
Predictive validity
Lack of generalizability

21. What are some ways of describing various levels of risk?
Brainstorm
What are some ways of describing various levels of risk?

22. Assessment of Risk of Suicide:
Appropriate Actions and Referrals for Various Levels of Risk
Quantification of Risk
Categories of Risk
Intent Levels
Correlation to Risk Level

23. Appropriate Actions Similar cases may require different responses
Formulate a treatment plan based on determined suicide risk, risk and protective factors, and suicidality
Follow up on the patient, and reassess for any changes that might be necessary
Ensure that all aspects of the treatment plan and its reasoning is documented

24. Assessment of Risk of Suicide: Documenting the Assessment
What to document:
Suicide risk areas
Predisposition factors
Protective and risk factors
Availability to lethal means
Safety plan and treatment
Rationale for any decisions made