Risk Assessment

If there is one thing we need to be unfailingly conscientious about as therapists, it is risk assessment. While it is of course not possible to prevent all harm to or by our clients, nobody wants to be second-guessing themselves (or have others second-guessing) about whether we did everything we could to ensure our clients' safety. Therefore, it's good to have a system in place for assessing risk. At the minimum, risk should be assessed at the beginning and end of treatment, periodically throughout (e.g., when doing treatment plan updates), and whenever there is a change in a client's mental status.

It takes some practice to get comfortable asking about and talking about risk issues. I made the following "cheat sheet" for my students, and decided to share it here as well. It includes questions to ask to assess five categories of risk: suicidality, non-suicidal self-injury, homicidality, hallucinations, and substance abuse.

Of course, these are just my ways of approaching assessment. Different clinicians may have different styles, and therefore use different wording. If there are things that you've found particularly effective, or if there are other mnemonics you use to remember what to ask, please share a comment below!

Suicidality

• Assess past suicidality
• “Have you ever thought about suicide?”
• “When was that?”
• “What was going on in your life that led you to consider suicide?”
• “Did you ever act on those thoughts?”
• When
• What method
• Did it lead to medical or psychiatric hospitalization?
• “Has anyone in your family ever attempted suicide?”
• Assess current suicidality?
• “Are you having any thoughts of suicide now?”
• “When did you have those thoughts most recently?”
• “When did the thoughts start?”
• “How frequent are they?”
• “Do they feel intrusive or obsessive? Can you stop them or control them?"
• Passive SI = Wanting to die without planning to take action
• Active SI = Plan or intent to end one’s own life
• Assess for a Plan: “Do you have a plan for what you would do?” (acronym: SLAP; P=plan)
• Specificity
• Lethality
• Violent/irreversible methods are most lethal
• Likelihood of rescue
• Accessibility
• Assess Intent
• “Do you think you would act on it?”
• “What will you do if the thoughts become more intense, and you’re feeling more likely to act on them?” (is the patient able to convincingly contract for safety)
• Assess Meaning/Motivation: “What seems appealing about dying?”
• Relief (from distress, psychological or physical pain, unbearable circumstances)
• Revenge (to hurt/punish someone else, or punish oneself)
• Rebirth or Reunion (to escape the current unsatisfactory life through rebirth into a better life; reunion with others who have died)
• High Risk BehaviorPreparation – obtaining supplies to implement plan, writing a suicide note, arranging finances/giving away belongings
• Rehearsal – going through the motions, starting the plan but stopping before the lethal gestureLosses or anticipated losses of relationships or reason for living
• Mood change, including marked brightening of mood

Non-Suicidal Self-Injury

• “Have you ever thought about other ways of hurting yourself or causing yourself pain, like cutting or burning yourself?”
• “Have you ever acted on those thoughts?”
• When, and when most recently
• What did you do
• How often
• Assess potential lethality
• “Did you ever hurt yourself badly enough to need medical attention?”
• Location on body
• Severity (e.g., depth of cut, proximity to blood vessels)
• Assess whether self-injury is:
• Compulsive
• Habitual and repetitive
• Ego-dystonic
• E.g., hair pulling, skin picking, severe nail biting, purging
• Impulsive
• Episodic
• Gratifying
• A reaction to events
• Ego-syntonic
• E.g., cutting, burning, suicide attempts, substance abuse, including laxative/diuretic

Homicidality

• “Have you ever thought about harming someone else?”
• “Have you ever gotten into a physical fight or attacked someone?”
• When, and when most recently
• Frequency
• How
• “Did the other person require medical attention?”
• “Have you ever been arrested?”
• “Have you ever thought about killing someone?”
• Past homicidal ideation:
• When, and when most recently
• “Have you ever acted on those thoughts?”
• How
• “Did the other person require medical attention?”
• Outcome (legal, social, psychological)
• Current homicidal ideation: “Are you having thoughts like that now?”
• Toward whom
• Assess plan (SLAP), intent and ability to contract for safety
• Duty to Warn (Tarasoff): providers must notify the intended victim if s/he is in imminent danger

Hallucinations

• “Have you ever seen or heard something other people couldn’t see or hear?”
• What
• When
• How often
• Is it persistent, intrusive, obsessional
• Assess whether it is a thought or a perceptual disturbance
• “Does the voice seem like it’s inside or outside of your head?”
• “Is it more like picturing something, or seeing a picture?”
• Content
• “Is it one voice, or multiple voices? What does it say?”
• Are there Command Auditory Hallucinations (CAH)?
• Do the voices tell the patient to do something?
• Do the voices command the person to harm self or others?
• Are the visual hallucinations of a violent or scary nature?
• Is the content mood congruent or incongruent?

Substance Use/Abuse

• “Do you currently use any kind of drugs or alcohol?”
• What, how often, how much
• How (method, e.g. smoking, snorting, IV)
• Any negative consequences
• “Have you used any (or any additional) substances in the past?”
• What, how, how often, how much
• Any negative consequences
• “What made you decide to stop using this/these substance(s)?”
• Assess for substance abuse/dependence
• Purpose: “What does (the substance) do for you?” (e.g., social use; lower inhibitions; numbness; euphoria )
• CAGE:
• “Have you ever felt you should CUT DOWN on your use?”
• “Have you ever felt ANNOYED by other people criticizing your use?”
• “Have you ever felt GUILTY about your use?”
• “Have you ever used first thing in the morning (to get over a hangover)?” (EYEOPENER)
• Tolerance: “Have you had to use progressively more of the substance to get the same result?
• Withdrawal: “Have you experienced any kind of side effects when you stopped or cut back on your use?”
• “Have you ever needed detox or other treatment for substance abuse?”

Useful Mnemonics on Suicidality

Continuing my series on suicide, the training I had this week also made me remember a few very useful things I learned in social work school about suicide. Both have handy mnemonics (hence this post's title).

First, for assessing suicidality, remember SLAP:

S - Suicidal ideation

L - Lethality

A - Accessibility

P - Plan

Unfortunately, they couldn't put it in the actual sequence of assessment (well I supposed they could, but "slap" sounds better than "spla" (or God forbid, "splat"). Basically, when it comes to suicide, you first want to know if they have thoughts about it (and no, asking if someone is thinking about suicide does NOT plan the idea - they've done plenty of research to disprove this myth!) - Suicidal ideation. If they do have thoughts, you want to know if they have a Plan. If they have a plan, you want to know if the means are Accessible, and how readily (something that's in the house? something they know where to buy?). Then you want to consider its Lethality (i.e., likeliness they could survive if they act on it). 

However, it's probably more important to consider intent - not part of the acronym, but for my money, more crucial than lethality. After all, if someone has a lethal plan they'd never act on, they are at less risk than someone with an ostensibly less lethal plan they have every intention to act on. Plenty of people die by "less" lethal means, sometimes even when they only intended the act as a so-called "cry for help." It's Russian roulette. 

The second mnemonic has to do with people's motivation for attempting/committing suicide. These factors help us recognize serious suicidality, and better understand our suicidal clients. They are the 3 R's:

Relief

Rebirth/Reunification

Revenge

Relief is perhaps the most obvious. People who think about suicide are typically in pain - mental, physical, or both. They may have lost hope of ever feeling better while living, so they begin to consider whether they might be "better off dead." Even people who think there is no form of existence after death may think that at least their pain will end. If it starts to seem worth it - that's a big sign of risk.

Many people do believe in some form of existence after death, however. Therefore, they may not only think their current pain will end, but also think that they will get a better life instead - i.e., Rebirth. That includes both reincarnation (rebirth into a body on this earth), and "rebirth" as transition into some other form of existence (e.g., heaven). An idealized image of a better life can be a powerful motivation for suicide. Even more powerful, perhaps, can be an image of Reunification - getting to see and be with loved ones, both people and pets, that have died. This motivation is a major reason why recent loss is a risk factor for suicide.

Finally, sometimes the motivation for suicide can be less about oneself, and more about someone else. Sometimes people develop a fantasy about how other people will feel and react if they die, most notably loved ones. Suicide can seem like the ultimate way of getting the "last laugh" - causing pain without the possibility of retaliation. 

While none of these things are...pleasant...to think about, they are all important, because most of us work with clients who already have risk factors for suicide. What other things do you keep in mind when you think about suicidality? 

Desperate?

I live in a coastal city. To get to and from...well, just about anywhere...I have to go over a major bridge. Sitting in rush hour traffic, there is plenty of time to notice all the billboards and signs. And although I've driven over the bridge countless times, I am always struck by one sign in particular.

I suppose it's four signs, actually: one on each side of both the Northbound and the Southbound levels (one is above the other). The signs read "Desperate? Depressed? Call the Samaritans" (a suicide prevention organization and "helpline"). 

Usually, when I notice these signs, I shudder and look away. Working with potentially suicidal clients, I don't like to think in too much detail about possible scenarios - especially what I've been told about this particular bridge. However, I appreciate the fact that it would be impossible to make it onto the bridge without seeing one of these signs - at least everyone who considers this path is offered one last chance to reconsider.

I imagine there are some people on the verge of suicide who do give the world one last chance to support them. I suspect that these people are the ones who are ambivalent about death - who may not see it as a positive thing, but may not see another way out. These may be the same people that hint to other people, or even seek treatment, when they are considering suicide. However, as I was reminded in a training today, ambivalence and desperation are not always present immediately prior to suicide (for example, when someone is approaching the bridge). Instead, having made the decision to commit suicide, many people experience relief and become more cheerful. The desperation has already ended.

When I worked with my first chronically suicidal client in outpatient therapy, my supervisor provided me with some of the best advice I've gotten on this subject. He acknowledged what I already knew - that this client ticked all the boxes for high suicide risk - while also reassuring me that I couldn't take on the responsibility of "saving" him. His life, or death, was in his hands, not mine. I could make sure that he knew help was available, and how to access it. I could work with him to build motivation to live. And I could assess frequently for risk and need of hospitalization. But I couldn't take on the sole responsibility of keeping him alive.

The second part of his advice dealt with how to assess someone who was suicidal at baseline. Given that he always had thoughts of suicide, and had a standing (lethal) plan, but denied intent, and had already been hospitalized and releases, what would tip me off if he became more acutely suicidal? A marked brightening of affect. Increased energy, improved mood, enthusiasm. Lightness.

I couldn't look for depression or desperation, which were always present. Instead, the real risk would come when and if he suddenly seemed to improve. This could be a dangerous sign that he had found a "solution" to his problems, and was feeling relief because everyone would soon be over.

Fortunately, I never had to experience that eerie mental status change with him. However, my agency's current risk assessment policies were developed after a suicide on the inpatient unit, presaged by sudden improvement in mood and program compliance. The take-home message: beware of sudden improvement in risky clients! 

How do you assess for suicide, particularly in high-risk clients? 

The Role of Identity in Athlete Suicide

Following the suicide of long-time NFL great Junior Seau earlier this month, news media focused on the question of whether playing football - or, more specifically, suffering concussions - could involve brain trauma that might ultimately lead to clinical depression, and even suicide.

However, an alternate possibility discussed on WBUR's Radio Boston today seems more compelling to me. The program asked: what happens when athletes can no longer participate in their sport, for whatever reason? After all, the athlete role can take on immense personal significance, becoming a pivotal part of a person's identity. When injury, health, other obligations, or retirement in the case of professional athletes, removes the person from the athlete role, it is often experienced as a significant loss - not only of an enjoyed activity, or a social network, but of one's identity.

Many people experience such a loss in youth. A large percentage of kids play sports in high school. Many will experience an injury that sidelines them, temporarily or permanently, and these kids - who are in the process of defining themselves anyway - struggle with who they are without their sport(s). Beyond this number, the majority of high school athletes won't go on to play at the college level, and the majority of college athletes won't go on to play at the professional, national or world levels. At some point in young adulthood, the vast majority have to grieve the loss of their athlete identity, and find a way to define themselves separate from sport. Fortunately, young adulthood is a time for developing our identities, and this loss, while devastating, does not usually push people to the point of suicide - identity is still developing, and therefore, alternate identities are available.

We can only imagine that, for those exceptional few who do go on to more advanced levels, instead of developing an alternate identity - an understanding of who they are separate from sport - the athlete identity crystallizes into their core sense of self. Unfortunately, the human body does not continue to perform at an elite level indefinitely - at some point, every athlete reaches the point where they can no longer be competitive at the same level.

Of course, some will find ways to continue their involvement in sports - they play in recreational leagues, become coaches or commentators. However, I imagine the loss would be more profound the more advanced people go in their athletic careers. For example, a football start like Junior would lose not only a central part of his identity, but also the social roles of teammate, role model, and celebrity, not to mention the income and lifestyle. If you've spent 20 years in the NFL, and college, high school, and perhaps middle school teams before that - if you're in your 40s and have known no other life - what does it feel like to retire from football? An immense void, I suspect. Some are able to redefine themselves, while others are not. Suicide is an extreme response to the latter eventuality.

That raises the question of how loss of identity or role may factor into suicide more generally. We know that older adults are at greater risk for suicide, and loss of role, functioning, and/or identity is likely a key reason. What about other groups? How do you understand identity issues in depression and suicide?

Motivation or Manipulation?

As much as our profession values self-determination (i.e., everyone having the power and freedom to make their own choices in life), we're also put in the position of trying to prevent or minimize damage (to our clients or others) from destructive choices. It's an ethical dilemma.

We try to rationalize our way out of the dilemma by saying that we defer to clients' self-determination only in very specific circumstances: when it's life-or-death (suicide, homicide, or complete inability to care for self), or when a vulnerable population may be harmed (children, the elderly, persons with disabilities - including individuals whose psychosis is interfering with safety).

There seems to be no end of debate about the moral and legal nuances involved here, but that's not what I want to focus on. What I'm thinking about today is the way I intervene differently according to the risk involved.

Motivational Interviewing (MI) is considered best practice for substance abuse, as well as other "problem behaviors." Essentially, it assumes that people often enter treatment with some ambivalence - that part of them sees the behavior as a problem and wants to change it, while another part is comfortable with the behavior and doesn't want to change it. MI tries to strengthen the first part of the ambivalence, for example by "developing discrepancy" (i.e., highlighting the divergence between the behavior and the client's values and goals), and selectively reflecting "change talk" (i.e., highlighting things clients say from the first part of the ambivalence, while purposefully not reflecting back things that come from the second part of the ambivalence).

Part of the justification for this approach, from the perspective of self-determination, is that the clinician is following the client's lead by encouraging movement toward a change that the client has said s/he wants (at least partially), drawing on the client's self-identified motivators (e.g., goals and values). For this reason, I like MI as an approach...when there's time to do it without the problem becoming lethal.

On the other hand, I have a high-risk client who is teetering on the edge of suicidality. He isn't actively suicidal...at least, not today. As a result, he doesn't meet hospital level of care. However, he's holding onto the idea of suicide as a back-up plan, just in case things get worse, or don't get better. He's also severely depressed, and therefore not particularly verbal. He's not spontaneously coming up with any "change talk," and only occasionally reveals motivations in either direction. (I assume ambivalence because he is still alive, in spite of persistent SI).

I could wait and see - wait for change talk to come - but that feels too risky for me. I'm trying to develop some discrepancy - something that matters to him that's incongruent with suicide. The only thing, so far, is concern about his suicide damaging his children.

In trying to build some commitment to life, I admit I stooped to what felt like manipulation - elaborating on how his suicide might harm the kids (the only motivator he's identified), asking about what he'd be sad to miss (alas, even walking his daughter down the aisle at her wedding is not a good reason to live, in his mind), and even trying to cast doubt on his idealized image of going to heaven (shamelessly capitalizing on the Catholic belief that people can't go to heaven if they commit suicide, in spite of my personal belief to the contrary).

Yes, definitely seeming more like manipulation than motivation. Yet, that's what it took for me to feel like I'd done everything I could to keep him alive for another week. There are no guarantees, of course, but I'm cautiously optimistic because what he got out of all that was the (baffling, to him) sense that I care what happens to him, even after death. Maybe knowing that will be enough.