The figure above outlines the standards for assessment of suicide risk used by crisis call centers in the network of the National Suicide Prevention Lifeline. The four columns represent four areas of assessment: suicidal desire, capacity, intent and protective factors.
- Suicidal ideation – killing self and/or others, fantasies, imaginal rehearsal, habituation
- Psychache/Feeling Trapped – extreme distress diminishes ability to problem solve
- Burdensomeness – “my death is worth more than my life”
- Feeling alone – thwarted belongingness
A prospective study of 1,958 outpatients found that hopelessness, as measured by the Beck Hopelessness Scale, was significantly related to eventual suicide. A scale cutoff score of nine or above correctly identified 94.2% of the people who eventually died by suicide, thus replicating a previous study with hospitalized patients. Researchers determined that the high-risk group identified by this cutoff score was 11 times more likely to die by suicide than those whose cutoff score was lower, and thus, the Beck Hopelessness Scale appears to be a sensitive indicator of suicide potential.
Desire for suicide alone is a necessary but not sufficient condition
for suicide risk.
- History of suicide attempt, particularly multiple suicide attempts increase the risk for suicide significantly. These behaviors represent that the individual has a certain fearlessness when facing death and that self-harm is a primary way of coping
- History of/current violence to others may indicate that he or she is capable of self-inflicted violence and comfortable with violence means
- Exposure to/impacted by someone else’s death by suicide. Grief and trauma caused by another’s suicide might make a person more vulnerable. Sometimes when someone close dies by suicide, a person may consider suicide because of the contagion effect (copycat). Others will not have considered suicide before their loved one died and because of this experience, this option has entered their consciousness.
- Availability of and familiarity to lethal means
- Current intoxication
- Tendency toward frequent intoxication
- Acute symptoms of mental illness – agitation, insomnia, recent dramatic mood change; command hallucinations (hearing a voice telling one to kill oneself); extreme rage
Aaron Beck investigated the validity and reliability of the Suicidal Intent Scale as a measure of the seriousness of a suicide attempt. All of the 194 people who had died by suicide had higher scores on the scale than the 231 people who had a suicide attempt. In addition, 19 people who attempted suicide and then reattempted suicide within one year of discharge had greater suicidal intent than attempters who did not.
- Plan – to hurt self or others
- Expressed intent to die – ambivalence
- Some studies have documented a low association between intent and lethality of method
NOTE: Buffers can be strong protectors for suicidal people, they also can be easily faked by someone who has a strong intent to die. If people are claiming that they “would not take their life because they couldn’t hurt _________” but all the other signs of suicide risk are present, still consider that person in a heightened state of risk.
- Perceived immediate supports (can the person list five people to call, who can help the person remove the lethal means? Who will take the person to the ER?)
- Planning for future – long term and short term
- Engagement with helper – openness and disclosure; clinicians sense of collaborative connection
- Joiner, T., Kalafat, J., Draper, J., Stokes, H., Knudson, M. Berman, A. & McKeon, R. (2007). Establishing standards for the assessment of suicide risk among callers to the National Suicide Prevention Lifeline. Suicide and Life Threatening Behavior, 37 (3):353-365.
- Beck, R., Morris, J. & Beck, A. (1974). Cross validation of the suicide intent scale. Psychological Report, 34(2). 445-446.
- Joiner, (2008). Practical and usable clinical skills. Presentation at the 2008 Bridging the Divide: Suicide Awareness and Prevention Summit. Regis University, May 22, 2008; Denver, CO.