Ethics and Risk Management: Suicide Risk Assessment

Robin Weill, Ph.D.

 

Florida State University (FSU) has established an empirically-based set of guidelines to be used as a standard of care for suicide (Cukrowicz, Wingate, Driscoll, & Joiner, 2004). By focusing on the variables identified as most predictive of completed suicides, the approach offers clinicians a straightforward guide to conducting suicide assessments. The result of the suicide assessment is to suggest levels of intervention based on the assessed risk. The FSU standard of care includes these elements: Empirically supported suicide risk assessment, a suicide decision-tree procedure for determining level of risk of suicide, actions to take for specific categories of suicide risk, and legal responsibilities. We at the University of Houston Psychology Research and Treatment Center (PRSC) have adopted this approach, and I will summarize it here briefly. Forms the PRSC has created to support the use of this model will posted when the new ADPTC website is completed. The article that presents the guidelines, entitled “A Standard of Care for the Assessment of Suicide Risk and Associated Treatment: The Florida State University Psychology Clinic as an Example,” is available to psychology clinic directors by emailing Dr. Joiner at joiner@psy.fsu.edu.

An evidence-based method for assessing suicide must systematically assess known risk factors for suicide. Cukrowicz and colleagues (2004) note that the variables most associated with completed suicide are current suicidal ideation, resolved plan, and preparations. (Joiner & Rudd, 2000; Rudd, Joiner,& Rajab; 1996; Cukrowicz et al, 2004). Other predictors include previous suicidal behavior (i.e. previous attempts, lethality, etc), the nature of the current suicide symptoms (plan, preparation, etc), precipitant stressors, general symptomatic presentation, impulsivity and self-control, and predisposition to suicidal behavior (Cukrowicz et al, 2004; Joiner, Walker, Rudd, & Rajab, 1999). These are assessed along with protective factors. The clinician assigns one of five levels of risk, based on the presence of the assessed risk factors (Nonexistent, Mild, Moderate, Severe, Extreme). Recommended interventions are provided for each level. Clear guidelines are provided for crisis scenarios. Finally, legal issues of foreseeability and causation are addressed through the formulation and documentation of the assessment and intervention plan, including documentation of consultation.

The clinician's primary method for determining the client's level of risk is the Suicide Assessment Decision Tree (Joiner, Walker, Rudd, & Jobes, 1999) copied with permission here.

Clinicians at the PRSC use a form for implementing the FSU model with clients who demonstrate suicidal risk. This includes 1) a Risk Assessment checklist , a graphic of the decision tree, and Risk Categories checklist. The risk assessment checklist includes the following domains with check boxes for items within each of these: Previous Suicidal Behavior (BSS 20), Nature of Current Suicidal Symptoms (Resolved Plans and Preparations and Suicidal Desire and Ideation), General Symptomatic Presentation , Precipitant Stressors (in last 6 months), Other Predispositions to Suicidal Behavior, Impulsivity, Protective Factors, Some other risk factors , the graphic of the decision tree, and check boxes for the level of risks (Nonexistent, Mild, Mild-to-Moderate, Moderate, Severe, Extreme), definitions for these levels with the recommended intervention indicated by that level of risk, and example coping plan for clinicians to use with clients. We also have a note format for student clinicians to use for documenting this assessment and response. This Suicide Assessment note is set as a template in our electronic records system (Titanium).

The FSU article also recommends the use of a modified version Cognitive Behavioral Analysis System of Psychotherapy (CBASP; Jehle & McCullough, 2002, cited in Cukrowicz, et al, 2004) as an easy to learn and implement treatment for suicidal behavior. We have not yet systematically incorporated CBASP training here at PRSC.

References
Cukrowicz, K.C., Wingate, L.R., Driscoll, K.A., Joiner, T. (2004). A Standard of Care for the Assessment of Suicide Risk and Associated Treatment: The Florida State University Psychology Clinic as an Example. Journal of Contemporary Psychotherapy, Vol. 34, No. 1, Spring, 447"453.

Joiner, T., & Rudd, M.D. (2000). Intensity and duration of suicidal crises vary as a function of previous suicide attempts and negative life events. Journal of Consulting & Clinical Psychology, 68, 909-916.

Joiner, T., Walker, R., Rudd, M. D., & Jobes, D. (1999). Scientizing and routinizing the outpatient assessment of suicidality. Professional Psychology: Research & Practice, 30, 447"453.

Jehle, P.J. & McCullough, Jr., J.P. (2002). Treatment of chronic major depression using the Cognitive Behavioral Analysis System of Psychotherapy. Journal of Contemporary Psychology, 32, 263-271.

Rudd, M. D., Joiner, T., & Rajab, M. H. (2001). Treating suicidal behavior. New York: Guilford.