ASSESSING RISK

The prediction of suicide is fraught with difficulty, and the level of accuracy is likely to be low. It is therefore advisable to take all suicidal thoughts seriously. Assessment of suicide risk requires a biopsychosocial assessment of the patient, including details of their suicidal thoughts, intent, plans, personal and demographic risk factors and a comprehensive mental state examination (Cole-King et al 2013).

Asking about suicidal feelings, thoughts, plans and behaviours

There is no evidence that asking about suicidal feelings causes harm. In fact, research indicates that it may help to reduce suicidal ideation (Dazzi et al 2014; Berman 8c Silverman 2017).

Asking someone about suicidal thoughts and feelings (CMH 2019) can show that you care and are taking their feelings seriously. You will also demonstrate that talking about suicide is not taboo and hopefully make it easier for them to talk about the subject. Ask simple, direct questions and encourage them to be honest about how they are feeling.

See https://www.mind.org.uk/media-a/2904/support-someone-who- feels-suicidal-2017.pdf,

https://www.rethink.org/advice-and-information/carers-hub/suicidal-

thoughts-how-to-support-someone/.

Goodpractice point

Remember that every contact with someone who could be suicidal is an opportunity to reduce their risk and engage them in process of recovery. Risk assessment should be the start of a therapeutic response or intervention, not a stand-alone process.

There is a tendency for clinicians to focus on predicting the probability of suicide despite little evidence supporting the utility of this approach (Chan et al 2016; Quinlivan et al 2017; Steeg et al 2018). The goal of risk assessment is not to predict the likelihood of suicide but to assess the person’s needs and use this information to plan for safety and treatment. Hawton (2017) recommends we use a process of progressive questioning to gather relevant information to inform a risk formulation that leads to an individualised intervention.

Your first goal is to start an open and honest conversation. There isn’t a single right way to ask about suicide; generally, it’s worth being direct. Most people will value your honesty and may even be relieved to be able to have a conversation they or their loved ones may have felt unable to have. Open-ended questions tend to facilitate this rather than a string of closed questions (which will naturally be in your mind to ask if you are conducting a risk assessment as you want to gather important information). Any risk assessment will involve some closed questions, e.g. when discussing a person’s last suicide attempt or their access to means, but try to begin with an open-ended question and then explain that you need to gather information. For example

So you keep a rope ... could you tell me a bit more about how that helps you? (After this initial exploration I may then ask ‘would you be willing to tell me where the rope is? Does anyone else at home know where you keep it?’ (These are all closed questions.)

I would also round off such a discussion with a statement like ‘Thank you. I imagine this isn’t easy to talk about. I really appreciate your honesty’ (if this is how you feel). ‘Is there anything you haven’t told me that I really should know?’

Some people find it hard to talk about their suicidal thoughts and may initially be reluctant to share them with you. Be aware of your own and the potentially suicidal person’s voice and body language. If the person delays responding or if their response to a question is simply “Alright” or “OK”, it might indicate that perhaps the person is not quite as “alright” as they claim (Cole-King et al 2013).

Do’s

  • • make sure you are unlikely to be interrupted (this is especially important if you are talking on the phone and the person is at home);
  • • discuss limits of confidentiality;
  • • ask about suicide in a way that feels natural to you and that signals you are prepared to hear any answer;
  • • phrase the questions in a way that allows for a range of answers;
  • • use direct language such as “suicide”, “killing yourself” or “ending your life”;
  • • listen and be non-judgemental; listen with empathy, not sympathy;
  • • validate the person’s feelings;
  • • make sure you record your assessment, concerns and actions in line with your service’s policy and procedures;
  • • contact the local mental health crisis team if the client appears to be at high risk;
  • • emphasise that there is help available and agree a plan.

Don’ts

  • • promise absolute confidentiality;
  • • use indirect or infantilising language, such as “doing something silly”;
  • • shy away from important questions;
  • • phrase the question negatively, e.g. “You’re not thinking of killing yourself, are you?” Research has shown that when the question is phrased negatively, patients are more likely to deny suicidal feelings (McCabe et al 2017). They may see it as implying the clinician’s preferred answer (Table 2.2).

Table 2.2 What to cover in a risk assessment

Twelve areas to assess

Sample questions

1. Suicidal intent2 thoughts-frequency, intensity, duration and persistence

How often do you think about suicide?

How long have you been having suicidal thoughts? When did you last think about suicide?

Have your suicidal thoughts got worse?

2. Degree of planning (internet research; learning about method; looking for place and time). The more detailed and specific the greater the risk.6

Have you thought about what you might do?

Do you have a plan to end your life? If so, how would you do it? Where would you do it?

(if yes) Is this something you’ve ever rehearsed?

Have you made any preparations towards this plan or any other arrangements?

Do you have a timeline in mind for ending your life?

Is there something (an event) that would trigger the plan?

(Continued)

Twelve areas to assess

Sample questions

3. Degree of preparation (putting affairs in order; e.g. stockpiling tablets suicide notes, changes to will). How detailed is the plan: have they thought about when, where and how?

Have you taken any steps to prepare for killing yourself, such as writing a suicide note, giving things away or going to specific locations?

Have you done anything to begin to carry out the plan?

4. Access to lethal means

Do you have the... (drugs, rope) that you would use? Where is it right now?

Do you have access to means of killing yourself?

5. Previous self-harm or suicide attempts.'

If someone has a history of multiple attempts explore their most dangerous, when they most wanted to die or the most recent attempt.

Any regret/remorse over current/previous attempt.

How lethal were the attempts?

Have you ever made a suicide attempt?

  • - Did you self-rescue or not?
  • - What did you hope would happen?
  • - Did you want to die?
  • - How did you feel afterwards?

Have you ever tried to hurt yourself (e.g. cutting self, overdosing)?

What other risk-taking behaviour have you been involved in?

6. Mental state associated with their suicide mode, including features of depression and agitation, guilt and shame.

Observation of appearance and behaviour, speech, mood, insight

Can you describe to me what you feel like when you are at your most suicidal?

Do you have

  • - racing thoughts,
  • - irritability,
  • - restlessness and
  • - impulsivity?

7. Perception of the future and any sense of hopelessness

What are your thoughts about the future?

What do you think needs to happen for you to feel better?

8. Drug and alcohol use

Do you use drugs or alcohol? Have you ever used drugs or alcohol before attempting suicide?

  • 9. Risk factors
  • • male
  • • 40-44 years
  • • under mental health services
  • • history of self-harm

о in criminal justice system о bereaved or affected by suicide о living in areas of higher socioeconomic deprivation о unemployed (Samaritans 2017; Centre for Mental Health Report 2019)

(Explore psychosocial factors in the person's life and circumstances)

Twelve areas to assess

Sample questions

10. Reasons for dying, e.g. to end their suffering or perceived burden on others (Joiner et al 2002)

What makes you think of suicide (e.g. worries, fears, loss)?

Do you feel like you are a burden to anyone or that others would be better off without you?

11. Reasons for living and protective factors, including children being present at home, religious engagement, fear of death, active participation and commitment to treatment and use of effective problemsolving or coping skills.

What reasons do you have for living?

Is anyone aware that you think about suicide (family, friends, professionals)?

Can you talk to family and friends?

Do you feel anyone cares about you?

12. How do they try to manage their suicidal thoughts? (distraction, suppression, thinking about reasons for living such as the impact on loved ones).

Ability to resist acting on their thoughts of suicide or self-harm.

What helps you to not think about harming yourself or suicide?

What stops you from going through with it when you have strong urges but manage not to act on them? (explore exceptions).

What stops you acting on these thoughts?

a It is critical to distinguish explicit or subjective intent - the patient's stated intent and motivation (what they actually tell us) from implicit or objective intent (based on previous history, lethality of the method and inferences drawn from other knowledge of the suicidal act). It is worth revisiting this on risk assessments - gently probing later in the interview to elicit more disclosure.

b Patients who report suicide plans should be asked about the plan in detail, including the chance of rescue, preparations for and rehearsal of the suicide attempt. Interventions to reduce the risk of suicide should then be targeted towards eliminating or minimising these various factors (Welton 2007). c Suicidal ideation at patients' worst time in their lives may better predict suicidal behaviour than current suicidal ideation (Becketal 1999).

Goodpractice point

Document the date, time and the key aspects of your assessment: “If you did not document it then you did not ask it”.

The suicide mitigation approach

Dr Alys Cole-King is a Consultant Liaison Psychiatrist and the co-founder and Clinical Director of Connecting with People, a social enterprise which provides suicide and self-harm awareness and response training throughout the United Kingdom. Cole-King has evolved a very practical model for risk assessment which is then recorded using a continuum of risk. The key to a compassionate suicide mitigation approach is the emphasis on collaboration rather than direction (Cole-King &Lepping 2010) (Table 2.3).

Table 2.3 Evidence-based risk factors and “red flag” warning signs (Cole-King et al 2013)

Demographic and social

Personal background

Clinical factors in history

Mental state examination and “red flag” warning signs

Demographic factors

Family history

Current mental illness

Hopelessness

Gender and age: male, younger men and very elderly (but recent increase in middle-aged men)

Marital status: separated > divorced > widowed > single > married

Unemployment: initially high risk, decreases after three months until after about one year, then higher again Profession: farmers, veterinarians, doctors (female) and dentists

Economic class (high and low income)

Ethnic group: minorities (e.g. Black or Asian women); refugees.

Suicide

Mental illness, particularly alcoholism and bipolar affective disorder

Repeated relapses, recent admission/discharge from psychiatric unit; recent relapse in mental illness.

Self-neglect

Agitation

Depressive symptoms, especially anhedonia and insomnia

Severe anxiety and panic

Post-traumatic stress disorder

Perception of the future as persistently negative and hopeless: of particular concern if only able to see one to two hours into the future Negative thoughts, helplessness, guilt, “I’m a burden”, “nothing to live for”

Sense of “entrapment”

Sense of shame, especially if severe and/or if in conflict with underlying religious or spiritual beliefs

Life events

Personality disorder

Previous self-harm

Suicidal ideas and plans

Significant threat or loss, e.g. health event, bereavement of partner or close family Childhood adversity

No memory of being special to any adult when growing up

Bullying or abuse Relationship instability Redundancy Unemployment

Personality traits of impulsivity, aggression, liability of mood Sudden unexplained changes in behaviour or uncharacteristic behaviour

Especially high-suicide- intent attempt, superficial cutting, recent increasing intent of repeated self-harm

The risk of a “completed” suicide remains raised for many years after a high- suicide-intent act

Especially if omnipotent and compelling, recently worsened and associated with distress Suicide plans/preparations, e.g. will, goodbye note/text/email, internet search for methods; lethality of method; possible rescue/treatment Unable to distract themselves from suicidal thoughts

Note: the method can easily change from low to high lethality

Social capital (lack of)

Social isolation and living alone

Recent loss of attachment

Perception of lack of social support/confidants

Institutionalisation, e.g. prison

Recently leaving armed forces

Major relationship instability

Recently bereaved

Loss of privilege

Use of suicide-promoting websites.

Substance misuse Precipitated by loss of interpersonal relationships Especially if:

high level of dependency; long history of drinking; binge drinking; depressed mood; poor physical health; poor work record in past four years

(peak age 40-60 years)

Chronic medical illness (one in ten of “completed” suicides)

Especially if accompanied by chronic pain, functional disability or incurable cancer; cardiovascular disease; dialysis; gastrointestinal disease; genitourinary disease in men; epilepsy (especially early onset); multiple sclerosis; dementia; neurological illness after cerebral trauma.

Psychotic phenomena

Distressing phenomena; persecutory delusions; nihilistic delusions; command hallucinations perceived as omnipotent.

Cognitive functioning

Delirium

Low IQ

Access to lethal means

Poor problem-solving skills

Medication

Insight

Firearms

Poisons (available to, e.g., dentists, farmers, anaesthetists)

Suicide hotspots

Low IQ

Poor coping skills

“Overthe counter” and prescribed (consider issuing weekly prescriptions)

Note the addictive effect of different medications

High premorbid functioning and fear of deterioration Early stage of illness

There are three other forms of risk which are usually assessed alongside risk to self:

  • • risk to others;
  • • risk from others;
  • • risk of self-neglect.

All of these may be linked to increased risk of suicide or mortality. Domestic abuse or partner violence (especially when severe or persistent) is a strong risk factor for suicide and attempted suicide (Devries et al 2011; Munro 8c Aitken 2020). The distress, sense of entrapment and hopelessness arising from domestic abuse can cause victims to feel that suicide is “the only way out” (O’Connor 8c Knock 2014). As suggested in Part 1 with regard to substance abuse, clinicians or practitioners assessing anyone who is experiencing partner violence or suicidality should be alert for both (Salvatore 2018). Wu et al (2012) found levels of clinician-appraised risk of self-neglect, but not of suicide or violence, predicted mortality among people receiving a risk assessment in secondary mental health service. Selfneglect can occur across the lifespan but is more common in older people.

In addition to assessing what people say, we need to consider what they may not be telling us, and the potential for someone to talk risk-to-self up or down. When we are assessing risk, we may not know the person well. This can make it difficult to pitch our sense of whether someone may be talking suicide up or down. Equally when we do know someone who has survived many suicide attempts, we may under-estimate their risk. In either instance it is always important to keep an open mind.

There are many reasons why people may talk suicide “up” or “down”.

Reasons for talking suicide “down” include: [1]

  • • ambivalence and fear you will carry it out unless you are stopped;
  • • desperation for help;
  • • desire for help or hospital admission.

Management of high-risk individuals

The more serious the suicidal thoughts and planning and the greater the lack of protective factors, the more the clinician will need to “direct” rather than “co-create” support to keep the patient safe. In this situation, support is more likely to include professional intervention, with a possible admission to hospital. Once the crisis has dissipated, however, a longer- term, suicide mitigation safety plan can be created in collaboration with the patient to help address any future crisis (Cole-King et al 2013). If a high level of risk is established, ensure safety with 24-hour support through the crisis team of the local mental health service. Consider grounds for assessment and detention under the Mental Health Act if the person refuses and, if necessary, break confidentiality and contact their closest relative. It may not be advisable for the person to be alone and you may want to consider getting help with removing suicidal means (Table 2.4).

Table 2.4 When to signpost or contact a GP, ED; phone 111 (NHS) or the police (999)

Risk level of suicide

General public/other agencies

Mental health professional

Risk not imminent

GP

Address directly with patient; discussion in supervision and MDT, and review risk regularly

Urgent/out-of-hours

111 (free and open 24/7)

Crisis service3

Risk imminent (24-48 hours) esp. if in public place; others at risk or person non- compliant with their own safety

999 Police

999 Police

Acted on and in need of medical attention

Ensure the individual goes to ED or call 999 Ambulance

Ensure the individual goes to ED or call 999 Ambulance

a Most crisis teams will accept referrals from GPs and primary mental health services; internally from mental health teams and EDs. They would aim to see a patient face to face within four hours and ideally would be trying to contact them within an hour.

Goodpractice point

Risk needs to be continually reviewed as suicidality fluctuates and risk levels can change within a short time frame, so any SFI should include a regular review of risk.

Clinicians can rate the client s wish to live and their wish to die, with the idea that high wish-to-die ratings accompanied by low wish-to-live ratings are especially potent risk factors for eventual suicide (Brown et al 2005). CAMS uses a Likert scale (1-5) in which the patient is asked at every session to rate key psychological dimensions associated with suicide risk and their overall belief that they will kill themselves (Jobes 2006,2016).

Clinicians can also gain useful and important information from third parties such as family, friends and colleagues. This can be critical supplementary information in patients who you consider may be underreporting or not fully disclosing their risk.

  • [1] shame; • strong desire, determination or resolve to die by suicide; • fear of involuntary detention. Reasons for talking suicide “up” include: • a history of invalidation leading to escalated communication ofneeds through self-harming behaviour or threats of self-harm;
 
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